key: cord- -sbieo s authors: oni, tolu; micklesfield, lisa k.; wadende, pamela; obonyo, charles o.; woodcock, james; mogo, ebele r. i.; odunitan-wayas, feyisayo a.; assah, felix; tatah, lambed; foley, louise; mapa-tassou, clarisse; bhagtani, divya; weimann, amy; mba, camille; unwin, nigel; brugulat-panés, anna; hofman, karen j.; smith, joanne; tulloch-reid, marshall; erzse, agnes; shung-king, maylene; lambert, estelle v.; wareham, nicholas j. title: implications of covid- control measures for diet and physical activity, and lessons for addressing other pandemics facing rapidly urbanising countries date: - - journal: global health action doi: . / . . sha: doc_id: cord_uid: sbieo s at the time of writing, it is unclear how the covid- pandemic will play out in rapidly urbanising regions of the world. in these regions, the realities of large overcrowded informal settlements, a high burden of infectious and non-communicable diseases, as well as malnutrition and precarity of livelihoods, have raised added concerns about the potential impact of the covid- pandemic in these contexts. covid- infection control measures have been shown to have some effects in slowing down the progress of the pandemic, effectively buying time to prepare the healthcare system. however, there has been less of a focus on the indirect impacts of these measures on health behaviours and the consequent health risks, particularly in the most vulnerable. in this current debate piece, focusing on two of the four risk factors that contribute to > % of the ncd burden, we consider the possible ways that the restrictions put in place to control the pandemic, have the potential to impact on dietary and physical activity behaviours and their determinants. by considering mitigation responses implemented by governments in several lmic cities, we identify key lessons that highlight the potential of economic, political, food and built environment sectors, mobilised during the pandemic, to retain health as a priority beyond the context of pandemic response. such whole-of society approaches are feasible and necessary to support equitable healthy eating and active living required to address other epidemics and to lower the baseline need for healthcare in the long term. in rapidly urbanising low-and middle-income countries (lmic), the realities of large overcrowded informal settlements, a double burden of infectious and non-communicable diseases (ncds), malnutrition and the precarity of livelihoods [ ] have raised added concerns about the potential impact of the covid- pandemic. control measures implemented in these settings include closing of national and state/county borders, and schools, restricted movement (including frequency of shopping), working from home, provision of water in informal settlements for hand hygiene, physical distancing and the banning of large gatherings. these measures have been shown to slow down transmission, buying healthcare systems preparation time [ ] . however, there has been less of a focus on the indirect impacts of these measures on health behaviours and consequently health risks, particularly in the most vulnerable. these restrictions have the potential to impact ncd risk factors such as dietary intake and physical activity behaviours [ ] , by limiting access to healthy foods and to environments conducive to physical activity. while many of the interventions to curb the pandemic are intended to be temporary, they have exposed existing inequities in disease vulnerability and access to care. the amplification of these inequities is resulting in poorer disease outcomes and negative impacts on livelihoods among the poor and marginalised. this debate piece will describe how the implementation of restrictions to limit the spread of the pandemic may impact diet and physical activity behaviours, as well as their determinants. we also reflect on the experiences from mitigation interventions mobilised by several governments to respond to this pandemic, and the potential for these to be leveraged beyond covid- in order to retain health as a priority. with the implementation of measures to prevent further spread of covid- infections, lmics are experiencing two inter-related pandemics. our public health response to the covid- pandemic may be exacerbating behaviours such as unhealthy food consumption, physical inactivity and sedentary behaviour. these aforementioned behaviours are considered the key drivers of obesity epidemic globally, and obesity is a risk factor for adverse outcomes of covid- infection [ ] . external dimensions of the food environment include the availability, price, vendor and product properties, and promotional information. by comparison, personal dimensions of the food environment are the accessibility, affordability, convenience and desirability of food sources and products. these food environment exposures, which vary considerably between and within high-, middle-and lowincome countries, influence food choices, dietary habits, and food security [ , ] . the covid- -related closures of national borders threaten food supply especially in countries already facing food insecurities and those largely dependent on food imports. as a result, maintaining adequate food production, import, storage and transportation can be precarious for both external and personal dimensions of the food environment. the dynamics of purchasing and consumption of healthy food in this context, driven by limited access to fresh foods and refrigeration, has highlighted the growing wealth inequality within countries. for many, the new reality of shelter-in-place measures has resulted in an increase in cooking and eating at home. on one hand, this presents an opportunity for preparing more healthy meals at home. however, a lack of nutritional knowledge and cooking skills, increased snacking behaviour, unavailability and increased costs of healthy foods [ ] , and the lack of guidelines to ensure nutritional quality of food parcels to the poor [ ] may result in a shift to more unhealthy processed food consumption. this is particularly important for lower-income households without the means, or in some cases, the access to refrigeration, to stock up on fresh food supplies. in addition, school closures result in interrupted access to food for children from households that depend on school-feeding programmes, adding to the financial burden and household food insecurity. these measures are also resulting in a staggering loss of jobs and livelihoods that further impact on people's ability to afford healthy foods. the predominance of the informal economic sector and absence of robust social safety schemes in lmics further compound food affordability. in these circumstances, without social welfare measures, the most vulnerable are left with no choice but to defy social distancing measures to avoid hunger. covid- control measures inevitably disrupt routine daily activities and may have positive or negative consequences on physical activity behaviours. stay-at-home orders and curfew measures result in reduced travelling, which in many cases includes walking, potentially reducing the opportunity for physical activity. reduced regular physical activity alone, or compounded by unhealthy eating may result in an increased risk or worsening of chronic conditions such as obesity, diabetes, hypertension and cardiovascular disease [ , ] , which are increasing in prevalence in lmics [ ] . these are the very conditions that have also been associated with an increased risk of hospitalisation and death from covid- [ ] . some evidence from other emergencies suggests that the deleterious effects of physical inactivity and sedentarism that begin during an outbreak may continue for some time after the end of the outbreak [ ] . conversely, this new reality may encourage more physical activity as people seek respite from being stuck at home, particularly if the reduction in traffic makes built environments more conducive to physical activity in public spaces. as such, it would be important to mitigate indirect negative consequences to encourage safe physical activity. while doing this at home would be ideal, it is important to recognise that for the majority of the urban poor, particularly in the context of informal settlements [ ] , this will not be practical. furthermore, outdoor physical activity has been associated with greater enjoyment and increased likelihood of achieving the recommended levels of physical activity [ ] . this highlights a critical need for guidelines on safe physical activity outdoors at the different alert levels of pandemic response. many governments in lmics have implemented measures to minimise covid- risk while working to address underlying social inequities that further increase vulnerability to disease. in so doing, the emergency has highlighted the possibility of previously considered impossible or unfeasible actions [ ] . we note the following reflections from these pandemic responses that could be applied to current and future epidemics and pandemics to support equitable access to healthy diets and physical activity: ( ) wide-ranging multisectoral action to reduce inequalities is possible at pace when there is social and political will. the response to the covid- pandemic has seen unprecedented multisectoral action compared to responses to the ongoing obesity pandemic. of note, governments have led coordination of multisectoral responses, removing bureaucratic processes that could hinder support for vulnerable communities. for example, in kenya, the ministry of agriculture has partnered with county governors to aggregate information on the volumes and prices of staples and nutritious foods in order to ensure affordability [ ] . county governors have also prioritized identifying vulnerable families to ameliorate food insecurity [ ] . beyond this pandemic, mapping access to nutritious foods and governing their equitable distribution can be utilised to improve dietary behaviours, especially for the urban poor. the implementation of riskcontainment strategies has also required effective partnerships at the community level, with community health volunteers and grassroots organizations constituting the last mile of distribution of health information, rapid testing, healthy food and other supplies. beyond an acute emergency response, continued collaboration with these same partners can ensure that physical activity and healthy diets remain accessible. in another example of government-led strategies to support food security, the state commissioner for agriculture in nigeria established makeshift neighbourhood food markets in schools in lagos which were closed due to the lock down [ ] . in a megacity where fresh food markets are often centralised in large markets, like mile market [ ] , this intervention brought fresh food supplies closer to neighbourhoods to mitigate the impact of the closure of centralised markets and movement restrictions across the city. in jamaica, with the closure of international borders and the sudden loss of the demand for food from the tourist industry, the government introduced community-based cashless farmers markets and distribution of fixed priced 'vegetable baskets' though community organizations to reduce the waste of perishable agricultural items and help support this sector [ ] . larger food manufacturers also increased capacity for fruit preservation though production of purees and manufactured new fruit blends [ ] . beyond this pandemic, it would be important to reflect on and evaluate the experience of these endeavours to inform longer term strategies to make fresh foods more locally available within neighbourhoods. ( ) covid- has revealed significant flaws in our existing urban infrastructure. these flaws include economic systems that reduce resilience to food insecurity, and streets that prioritize motorised traffic, making physical activity for leisure or travel unsafe. understandably, the majority of emergency mitigation responses have focused on food security. however, some settings such as bogota, colombia have created new space for walking and cycling [ ] while the jamaican ministry of health and wellness has shifted focus to television and social media-based exercise programmes [ ] . given that physical distancing measures are likely to be recommended for some time, contextually relevant research to encourage and support safe accessible physical activity for all should inform recovery plans related to the built environment. ( ) there is a need for public health interventions jointly to reinforce democracy, the rights of the individual and the collective good. in the context of acute response to emergencies, varying approaches have been adopted including extensive tracing using big data and deployment of the police to enforce movement restriction measures. if rights are side-lined, these measures potentially compromise data privacy and individual rights if applied in a discriminatory manner. this highlights the importance of a rights-based approach to public health, recognising that the right to health is dependent upon other human rights (such as food, housing, information and participation) and that even well-intended enforcement could bring harms. a rights-based approach could similarly be applied to addressing the obesity pandemic. for example, governance of urban space could ensure that organizations charged with enforcing lockdown measures are thoroughly oriented in equitable governance approaches, and partner with community stakeholders to improve access to neighbourhood resources including safe spaces for physical activity. additionally, it can include collaboration with key actors to facilitate access to space for urban agriculture for the poor. while the impacts of these interventions are yet to be evaluated, these examples hint at the potential for whole-of-society approaches to building stronger systems for health and lower the baseline need for healthcare. in the long term, it is vital that the economic, political, food and built environment sectors mobilised during the pandemic are encouraged (and governed) to retain health as a priority. societies that support and enable healthy eating and active living are vital to reduce vulnerability to covid- and other diseases and pandemics in the long term. urban health research in africa: themes and priority research questions how will country-based mitigation measures influence the course of the covid- epidemic? fact sheet on noncommunicable diseases. geneva: world health organization world health organization. covid- and ncds concepts and critical perspectives for food environment research: a global framework with implications for action in low-and middle-income countries nutrition amid the covid- pandemic: a multi-level framework for action pmbejd media statement: food prices and public health messages in a time of covid- food aid parcels in south africa could do with a better nutritional balance physical inactivity and cardiovascular disease at the time of coronavirus disease (covid- ) covid- related school closings and risk of weight gain among children opensafely: factors associated with covid- -related hospital death in the linked electronic health records of million adult nhs patients physical activity and sedentary behaviour among children and adolescents living in an area affected by the great east japan earthquake and tsunami for years slum health: arresting covid- and improving well-being in urban informal settlements does participating in physical activity in outdoor natural environments have a greater effect on physical and mental wellbeing than physical activity indoors? a systematic review covid- )-inducedre-imagination: things we knew but could do nothing about until we could and did state seeks to ensure food security in covid- war joho sets aside sh million to help cushion residents of mombasa from cessation order lagos holds makeshift food markets in schools thursday mile market booming sales at kingston and st andrews farmers markets agriculture and fisheries. agri ministry collaborates with tru-juice to process excess produce bogotá expands bike lanes to curb coronavirus spread jamaica moves encourages home exercise to led the conceptualisation, initial drafting, and the overall drafting process of the manuscript.lkm and pw co-led drafting of significant components of the manuscript and overall drafting process.coo, jw, em, fao, fa, lt were responsible for drafting and editing of subsections of the manuscript.lf, cmt, db, aw, cm, nu, abp, kjh contributed to the editing and finalisation of the manuscript.js, mtr, ae, msk, evl, njw contributed to final edits of the manuscript. no potential conflict of interest was reported by the authors. not applicable. in urban populations with inadequate access to sanitation, food and physical activity, and growing obesity and ncd burden, covid- control measures can widen health inequities. addressing the pandemic while mitigating this vulnerability calls for a rights-based approach to governance of urban space. multisectoral government covid- responses in these cities to address social inequities highlight the feasibility of economic, political, food and built environment sectors, mobilised during the pandemic, to support healthy eating and active living. key: cord- - hede cz authors: nowak-wegrzyn, anna title: food allergy : learning from the past, looking to the future date: - - journal: ann allergy asthma immunol doi: . /j.anai. . . sha: doc_id: cord_uid: hede cz nan food allergy : learning from the past, looking to the future the year is full of surprises, high hopes, and disappointments. due to the epidemic of covid- , many international and domestic meetings were canceled and travel plans ruined, casting a shadow over the allergy community. yet, there are exciting developments to celebrate. at the end of january , the us food and drug administration issued approval for the first drug for peanut oral immunotherapy (oit), giving hope to many -to -year old children with peanut allergy and their caregivers. the us food and drug administration's decision regarding another commercial product in development, peanut patch immunotherapy, is expected in the fall of . the availability of peanut oit raises many crucial questions. how do we identify the most favorable candidates for this treatment? should the diagnosis of peanut allergy be confirmed with an oral food challenge before initiating oit? how long should oit continue? how safe is peanut oit and how much protection over peanut avoidance does it provide? how frequently should we evaluate desensitization to peanut doses exceeding the maintenance dose? what effects on quality of life does oit have? going forward, emerging allergen-specific strategies (eg, modified peanut vaccines) and biologic drugs beg the question of standardization of clinical trial reporting of outcomes and safety parameters. these are only some of the questions that need to be answered to fully comprehend the risk-to-benefit ratio of novel therapies for food allergy. the annals food allergy issue tackles many of these questions. i want to highlight the invited articles from this timely themed issue. capucilli et al performed a comprehensive pubmed literature search of reviews and clinical articles discussing peanut or other food-related allergic reactions, accidental exposures, or anaphylaxis pertinent to avoidance diet or comparative with oit trials. they found that peanut remains a leading allergen associated with accidental ingestions responsible for food-related reactions, both mild and severe. however, interventions such as emergency treatment plans can significantly decrease the risk of accidental anaphylaxis. in addition, patients may overestimate anaphylaxis risk from inhalation or through skin contact. they concluded that considering the increased risk of anaphylaxis during the first year of oit, peanut avoidance remains a viable option for long-term peanut allergy management and should be discussed with all patients with food allergy seeking novel therapies. wee chong et al delve deep into the different phenotypes of food-induced anaphylaxis. they proposed that food-induced anaphylaxis has pathophysiology that differs from anaphylaxis induced by other triggers and also that within food-induced anaphylaxis, there might be different endotypes. they observed that many patients with food allergy experience a typical pattern of symptoms after food allergen exposure, both during supervised oral food challenges as well as at large. they proposed integrating datasets from different cohorts and applying unbiased machine learning analyses as an effective tool to characterize specific food allergy endotypes in a similar way to asthma. they postulate this as an important area for future research to gain better accuracy in predicting patients at the highest risk of severe food-induced anaphylaxis. mcwilliam et al reviewed prevalence and natural history of tree nut allergy. tree nuts are important triggers of food-induced anaphylaxis, yet tree nut allergy remains relatively understudied, thus limiting the understanding of tree nut allergy prognosis. tree nut allergy prevalence estimates range between less than % and %, and little is known about its resolution with age, which has been estimated from small studies to be between % and %. considering the increasing nutritional importance of tree nuts as health foods and their importance as anaphylaxis triggers, tree nut allergy deserves much in-depth research. fear of deadly food-induced anaphylaxis is every caregiver's nightmare, despite relatively low risk compared with other causes of death. dorris provided insights from the us fatal food-induced anaphylaxis voluntary registry. the cases captured in this registry ( cases per year on average over the past decade) are at the lower limit of the broad estimate of to cases per year of fatal foodinduced anaphylaxis in the united states. the registry is limited by reliance on public media searches and self-reporting, which might result in inaccurate estimates. in this registry, % were male patients with an average age of years (range, - years). foods reported to have caused fatality included peanut (accounting for % of the cases), tree nuts, cow's milk, shellfish, fish, wheat, and unknown. delayed or no epinephrine use and underlying asthma were confirmed as risk factors for fatality. shaker provided a timely and critical update on the stock epinephrine law that was signed by president obama in . he explored the tangible benefits of this legislation, the limitations, and future directions. this is a must-read, not only for those interested in public policy but also for all of us dedicated to keeping patients with food allergy safe. as intramuscular epinephrine remains the first line of treatment for anaphylaxis of all causes, dreborg and kim shared their perspective on the importance of needle length in the epinephrine autoinjectors. with shorter needles, the injection may be delivered into the subcutaneous tissue instead of the muscle tissue, thus resulting in slower systemic absorption and longer time to achieve serum peak concentration. with longer needle lengths, there is a risk of intraosseous or periosteal injection. they concluded that future research should consider not only the length but also the variation in pressure needed to release the needles in a way that ensures reliable and safe intramuscular delivery. upton and bird in a continuing medical education review focused on the special aspects of oral food challengesdthe most important diagnostic procedure in food allergy. they provided practical insights and clinical pearls regarding challenging infants, adults, patients with food proteineinduced enterocolitis syndrome, alpha-galedelayed anaphylaxis, and cofactors. finally, in a pro-con debate, clinicians with extensive practical experience in food allergy confronted their views on the utility of performing skin testing with fresh foods, with emphasis on specials insights as well as potential caveats. , in summary, the food allergy theme issue of the annals is full of contemporary and clinically relevant articles as well as cutting-edge directions in food allergy research that will satisfy the most discerning reader. anna nowak-wegrzyn, md, phd * ,y * department of pediatrics, allergy and immunology new york university langone health new york, new york y department of pediatrics, gastroenterology and nutrition icer report for peanut oit comes up short food reactions during avoidance: focus on peanut reaction phenotypes in ige-mediated food allergy and anaphylaxis prevalence and natural history of tree nut allergy fatal food anaphylaxis: registering a rare outcome the stock epinephrine law: five years later and counting epinephrine autoinjectors: the needle length matters oral food challenges: special considerations pro: skin prick testing with fresh foods con: skin testing with fresh foods olsztyn, poland anna.nowak-wegrzyn@nyulangone.org key: cord- - ofi mg authors: wei, yuwa title: human rights issues date: - - journal: issues decisive for china&#x ;s rise or fall doi: . / - - - - _ sha: doc_id: cord_uid: ofi mg contemporary china is plagued by a wide range of human rights related issues and problems. in addition to those arising in the areas of religious toleration, judicial practice, treatment of labor and forced abortion, which were extensively reported by the media in the past, some newly emerged problems concerning human rights violation are much more alarming, due to the size of population affected and the degree of challenge caused to the public’s psychological endurance and confidence in the social ethnics and administration of the nation. most of all, these problems concern nearly every chinese citizen’s well-being and impact on their personal prosperity, as well as the prosperity of the nation as a whole. these problems are mainly associated with failures in environmental protection, food safety, and medical security. first white paper on human rights being released in , the white papers of the following years were arranged as a series sequentially informing the progress made and the actions taken in human rights promotion in each year. nevertheless, it is an undeniable fact that contemporary china is plagued by a wide range of human rights related issues and problems. in addition to those arising in the areas of religious toleration, judicial practice, treatment of labor and forced abortion, which were extensively reported by the media in the past, some newly emerged problems concerning human rights violation are much more alarming, due to the size of population affected and the degree of challenge caused to the public's psychological endurance and confidence in the social ethnics and administration of the nation. most of all, these problems concern nearly every chinese citizen's wellbeing and impact on their personal prosperity, as well as the prosperity of the nation as a whole. these problems are mainly associated with failures in environmental protection, food safety, and medical security. achieving modernization has been the core economic objective and a solemn promise of the chinese government. urbanization has been a major means of reaching this goal. this course has been accelerated since the s with an average urban population growth rate of more than . %. nowadays, the number of urban population has reached . million, account for . % of the total population of the nation. in the meantime, china has scored an extraordinary gdp growth rate ranging from the lowest . % to the highest % between and . if these are to be seen as modernization or development, the modernization or development droughts and storms, deforestation, desertification, etc., affected more than two billion people and the economic toll multiplied compared with the previous decades. this trend has an even acuter presentation in china. in the past three decades, china experienced extraordinary economic growth, accompanied by rapid industrialization and urbanization. the emergence of many city clusters has resulted in centralized and condensed population in urban areas. the economic development, together with urbanization, has generated substantial environmental problems. nowadays, china is facing nearly all of the world's ecological challenges including climate change, desertification, deforestation, declining water resources, acid rain, soil erosion, air and water pollution and biodiversity loss. apart from increasingly frequent natural disasters caused by climate change, air and water pollution has become a paramount concern to the general public, which is acutely perceived in their daily life. as mentioned in the beginning of this section, the cost of environmental degradation in china is massive and profound, from people's lifespan to economic toll. the link between environment and human rights can be established on basis that physical environment is a precondition for living a life of dignity and worth. good environment is a pre-requisite for the enjoyment of fundamental human rights. in china, for a long time, human rights violations and environmental degradation have not been treated by central and local governments as related issues and addressed in a coherent and integrated way. it has become evident that environmental protection and human rights are prima facie interrelated, interconnected, and mutually responsive, since they both serve the purpose of improving and sustaining the well-being of humanity. human well-being has a basic requirement for safe food, clean air and drinking water, safe shelter and protection from diseases. human activities such as rapid industrialization and urbanization result in environmental degradation including rising of sea levels, air and water pollution, drought, flooding, which in turn, affects people at a large number. at the international law level, the vital role that environment plays in guaranteeing individuals' fundamental human rights has been recognized at a much earlier time. the stockholm declaration of , nairobi declaration of , world charter for nature of , earth summit of , johannesburg conference on sustainable development of , un conference on sustainable development of have all acknowledged the interdependence between environment and human rights by conveying the message that environment may lead to long term impact on humanity and violation of human rights. the human rights council in its resolution / of march and resolution / of march focused specifically on human rights and climate change, pointing out that environment change impairs and undermines directly and indirectly the effective enjoyment of human rights. traditional international environmental laws commonly address environmental issues through creating and determining rights and obligations between states. human rights laws, on the other hand, place individuals' rights at the center of the focus. the establishment of the linkage between human rights and environment enables individuals victimized by environmental degradation to seek remedy on human rights violation ground, which traditional environmental laws gives little focus. it is unfortunate that in china's priority agenda, both human rights protection and environment protection have given way to economic development for quite a while. the link between environmental damage and human rights violation has not been articulately addressed either. indeed, it is a high time for china to adopt a comprehensive, human rights based approach to formulate environmental policies for clarifying human rights obligation in environment protection and for identifying and promoting good practice in environment management. there are signs that current central government shows the interest in considering human rights law enforcement as a means of achieving the purpose of environment protection. "environment protection" have become hot words in china's political life since the th national congress of the communist party of china (nov. - , ) . in his keynote report in the opening ceremony, hu jin tao, the president of china by then, emphasized the term "ecological civilization" for fifteen times. his successor, the current president xi jin ping, in his speeches at the national people's congress and at the chinese people's political consultative conference , called for environment protection and pointed out that protecting environment is as important as protecting productive forces. with the initiative from top leaders, the governments of all levels have become more and more mobilized to change their focus and give particular importance to environment protection. although the areas like beijing, hebei and shanxi are still frequently blanketed by hazardous smog and problems caused by environmental degradation and climate change are still acute, people are more willingly to adopt an optimistic attitude when speaking likely environmental improvement in the coming decades. nowadays, with the growth of economic prosperity, common chinese people enjoy an ever-abundant supply of food products and are keen to broaden their dining experiences. in today's china, eating occupies nearly all occasions and businesses. visitors to china are likely to find that eating is arranged as a highlight for them by the hosts. some research suggests that the current food consumption pattern in china even poses as an exception to engel's law, that is: as the income of an average chinese family rises, the proportion of income spent on food increases, rather than decreases. some other research finds that in fact, the share of chinese households' income spent on food fell from over half in the s to about one-third nowadays. nevertheless, one-third of household income being spent on food is still spectacularly excessive, compared with . % in the u.s., . % in the u.k., and . % in singapore. while all levels of the population take any possible opportunities to indulge with feasts, disturbing facts concerning food safety emerge. this article concerns itself with some of the most severe problems associated with food safety in china, which mainly refer to the cases involving deliberate contamination of food for profits. these include problems such as manufacturing and trading imitation food (e.g., selling pork as beef), processing and selling contaminated food, adding chemical additives into food products for improving visual appeal, taste, or simply for falsely increasing nutritional value (e.g., adding melamine into baby formula to inflate the protein levels), and producing and trading tainted food (e.g., profiting from recycled oil mainly dredged up from restaurant gutters). worst of all, the above problems are not sporadic but are widespread and rampant, and in some cases, systematic. it needs to be borne in mind that the above issues are the most severe ones and only account for a small part of the avalanche of food scandals. here, incidents relating to sanitation or foodborne illness outbreaks caused by negligence in manufacture and service processes are not taken into account, though they are also serious problems. the right to safe food is a basic human right for all individuals. in addition, safe food should be regarded as an issue of national security for the reason that toxic food poses a serious threat to public health, which in turn leads to destructive social and economic consequences, and eventually has an adverse impact on the national interests of a country. it is high time for the chinese to review their policies and strategies in dealing with social issues, including social justice, equal distribution, anticorruption and clean governments, social ethics and public morality, and public psychology. regulation is surely a necessary instrument to control illegal conduct. however, given the fact that policies and laws are always watered down or compromised in implementation, it is thus particularly important for policy makers to take all the above issues into consideration when shaping the nation's regulatory infrastructure for food safety. when serious food problems have a devastating impact on a large proportion of the population, it is necessary to assess the situation from a human rights perspective while searching for solutions. this section examines china's food safety issues in connection with human rights awareness in the country. it investigates the social, political and cultural causations of the food scandals, and explores possible solutions. before the s, under the planned economy, food problems that arose from manufacturing were extremely rare and the regulatory focus was on sanitation occurring in the service and consumption processes, where the food safety administration was part of the duties of the sanitation and anti-epidemic departments. although it appeared that a legal framework was largely put into place, the food industry was, in fact, less effectively regulated, due to the loose context of the laws and the gaps between the laws and their practice. the situation has deteriorated since the beginning of the new millennium with the introduction of the practice of quality inspection exemption or the regime of self-inspection by enterprises themselves, an initiative launched to reduce the operational costs of food enterprises. the self-inspection regime was a result of the administrative authorities exercising their supervisory powers in an abusive manner while in the discharge of their quality control duties concluding with the imposition of unnecessary and excessive burdens on food producers. however, instead of disciplining administrative conduct, the policy makers opted for a compromise by abolishing food quality inspection. research has shown that the managerial costs in chinese firms are chiefly caused by defects inherent in the governance of these firms. without fundamental improvements in the corporate governance system, xu, supra note . see, for detailed discussions on managerial costs and corporate governance in chinese firms, yuwa wei, "directors' duties under chinese law -a comparative review", ( ) university of the costs are likely to continue to inflate. later instances of food safety crises have proven that those who maintain the argument that relaxation in quality control can reduce food companies' operational costs are simply barking up the wrong tree, where the most likely result is noncompliance. it took the government years to realize that giving enterprises free rein in regards to food quality control was an unwise decision. it was at least partly responsible for the current culpable culture in the food industry. in the aftermath of a series of food scandals, policy and regulatory mechanisms have been introduced as the main crisis control efforts. on the current law imposes full responsibility on food producers and manufacturers to ensure that their products meet safety standards throughout each process, including purchase of raw materials, production, storage, package, transport and delivery. in addition, they need to faithfully record the safety management throughout the whole course. however, china's experiences reveal that without fierce scrutiny, the industry is unlikely to comply with such requirements. under the current regime, the supervision and administration are given to local governments at or above the county level, who formulate annual plans for food safety and undertake food sampling inspection. specific branches of government, including the departments of agriculture administration, quality supervision, industrial and commerce administration, and the food and drug administration carry out the routine work of food sampling inspection. ( ) china, § ( ) , an english version is available at <www.fdi.gov.cn/ _ _ _ _ .html>. the section states: "the food producers and traders shall, in accordance with laws, regulations and food safety standards, carry out productive and operational activities, establish and improve the food safety management system and adopt efficient management measures to ensure food safety. the food producers and traders shall be responsible for the safety of produced and trade food themselves as well as society and the public, and also bear social responsibility." ibid, at § . ibid, at § . persons with direct responsibility in the above mentioned governments are subject to disciplinary punishment comprising of the recording of serious demerits, demotion, dismissal or expulsion, in the event of a failure to perform their supervisory and administrative duties, particularly where the failure causes a serious social effect. the same penalties are imposed directly on persons responsible for the above mentioned government branches, in the case where negligence is committed, daily supervision and inspection of food samples are omitted, abuse of power occurs, or favouritism is shown in the supervisory and administrative processes. from the above overview of the new regulatory regime, a few inadequacies can be identified. first, the legal (regulatory) framework is far from comprehensive. the supervisory model of food safety mapped out in the new laws can be summarized as: relying mainly on the segment-based approach, supplemented by a categorybased approach. in other words, the administration of food quality is undertaken by multiple inspection and administrative agencies, exercising their authorities in different stages of food production and services and targeting different types of foods. such an arrangement poses a potential risk in regards to conflict of powers, though the new laws allude to the benefits of efficient coordination among these agencies by identifying their authorities and duties in different stages of production and services. given the gaps in the existing laws, it is very likely that china will encounter further challenges in food supervision caused by its inefficient administrative system. speaking from a broader perspective, china is not the only country that has applied a multi-agency approach to food supervision and administration. the united states and japan have also adopted a scheme of assigning duties of food administration to multiple governmental agencies and departments. however, their comprehensive and detailed stipulations on division of responsibilities, quality standards, transparency and public scrutiny have ensured effectiveness of the system and smooth coordination among the agencies. moreover, it is noteworthy that even in countries such as the united states, there are increasing calls for combining their multiple agencies into a single agency to further the operational efficiency. it is therefore necessary for china to improve its food safety administration system to further enhance its regulatory regime on the one hand, and to rationalize the administrative chains and procedures in food supervision on the other. second, the current legal regime does not provide sufficient remedies for victims of food safety, nor does it effectively encourage consumer and community participation in food safety control. the laws have introduced monetary remedies for consumers consisting of damages and a fine of ten times that of the commodity's value. however, the accused are liable for the fine only where evidence shows that they have produced defective products and are at fault. what is more outrageous is that the onus of proof is on the consumers in such cases. the amount of ten times the value of the goods has already been criticized as being too insignificant to be a deterrent. the requirement that consumers need to prove the culpability of producers in making defective foods renders it nearly impossible for the consumers to benefit from the fine, not to mention the conceivable negligible impact that the provision has on food producers. third, the regulatory regime has loopholes and demonstrates too much leniency towards liable producers and traders, as well as those administrative personnel who fail to discharge their duties or show favoritism. among government staff of relevant departments, only those directly responsible for administrative negligence or abuse of powers that result in serious social impact may face disciplinary action. criminal penalties imposed on food producers for breaches of the law are also weak. moreover, no single criminal penalty is available to penalize delinquent public servants. the criminal law of china only punishes the conduct of producing for instance, in the u.s., the powers of food administration are divided amongst the u.s. department of agriculture, the food and drug administration and the environmental protection agency. see chamus burnside-savazzini, "training in an integrated food safety system: focus on food protection officials", food safety magazine (april/may ), <www.foodsafetymagazine.com/ article.asp?id= &sub=sub >. the people's congress of the people's republic of china, supra note , § . the food safety law does not address the issue of burden of proof. hence, the rules of general law apply, rendering that the burden of proof lies upon he who brings the claim. see tonghai liu, "on the shortcomings of the foot safety law and some suggestions on improvement", blog of tonghai liu on legal study net (october , ), <http://wq.zfwlxt.com/ newlawyersite/blogshow.aspx?itemtypeid=fdf ea- b- - ea- bfb &itemid= de f - bd- f - bdc- f e &user= >. the people's congress of the people's republic of china, supra note , § . and selling foods causing serious food poisoning and diseases, and the conduct of producing and selling foods mixed with toxic or harmful non-food substances. it can thus be observed that the scope of application of the criminal law provisions is limited to offences occurring in food production and sale. this leaves the conduct of processing, packaging, storing and transporting defective or harmful foods unpunished. furthermore, the amounts of the penal fines provided in the criminal law are even less than those stipulated in the food safety law, and are subject to a higher threshold in application. finally, the most essential issue to be addressed by the chinese is the enforcement of the laws. according to a survey carried out by the national survey research center at renmin university of china in , % of people interviewed attributed the cause of food scandals to administrative inefficiency and supervisory failure. in the meantime, judicial failure to rigorously implement food laws has cast a further shadow over effective law enforcement in the future. it is reported that courts are reluctant to support consumers' claims for damages up to or times the amount of the commodity price provided for in the law of the people's republic of china on the protection of consumer rights and interests and the food safety law of the people's republic of china . many manufacturers also promise the criminal code of china states: "whoever produces or sells food that does not confirm to hygiene standards in a manner that is sufficient to cause a serious food-poisoning accident or any serious disease caused by foodborne bacteria shall be sentenced to fixed-term imprisonment of not more than years or criminal detention, and concurrently or independently be sentenced to a fine of not less than half of the sum obtained through sale and not more than twice of that. if the offence causes serious harm to human health, the offender shall be sentenced to fixed-term imprisonment of not less than years and not more than years, and concurrently be sentenced to a fine of not less half of the sum obtained through sale and not more than twice of that. if the consequences are especially serious, the offender shall be sentenced to fixed-term imprisonment of not less years or life imprisonment, and concurrently be sentenced to a fine of not less than half of the sum obtained through sale and not more than twice of that or confiscation of property." a person who knowingly mixes the food to be produced or sold with toxic and harmful non-food stuffs is subject to the same penalties. : "when any manufacturer produces any food not conforming to the food safety standards or sells any food knowing its nonconformity with the food safety standards, the customer can demand the manufacturer or the seller to pay a penalty times of the paid amount, in addition to the compensation for the loss thereof." the amount of the compensation provided for in article of the law of the people's republic of china on the protection of consumer rights and interests is up to two times upon occurrence of fraud. junhai liu, the deputy president of china consumer association pointed out that due to judges' misunderstanding of legal reasoning, consumers' that an amount of compensation of up to times the amount of the commodity price will be paid to consumers upon violation of food safety. however, such claims are likely to be rejected by courts. some judges insist that such an amount appears to be punitive and thus does not have legal basis in contractual relations. the stance of courts in such cases renewed the public's suspicion of judicial corruption. the worst scenario concerns events involving arrest and conviction of consumer advocates. the zhao lianhai case is a typical example. zhao lianhai was a man who became an activist after his son experienced kidney problems linked to contaminated baby formula. he was convicted of inciting public disorder by setting up a web site to help other parents with sick children share information, seek compensation, and organize protests. it is clear that despite legislative efforts, tackling the food safety problem is an overwhelming challenge. compared to assessing legislative improvements, evaluating law enforcement in china presents a far more demanding task and is entangled with a number of social, political, economic and cultural issues. more discussions on enforcing food safety law in china will be carried out in section iii of this article. in summary, much work needs to be done to develop an efficient and effective food safety regulatory regime. this is not a mere legal task, but a social project involving reform of the administrative culture, a change in the business environment and transformation of the perception of the right to safe food for the public. human rights are rights inherent to all human beings, and they are inalienable and fundamental. the international community has reached a common understanding on the universality of human rights. for promoting and protecting human rights and fundamental freedoms of individuals, governments are obliged to act in certain ways or to refrain from specific acts. the most common universal human rights claims for compensation provided in the above provisions are rarely supported by courts in the past. see social and cultural rights , the right to food is recognized as part of the right to an adequate standard of living. the rome declaration on world food security and world food summit plan of action reaffirms everyone's right to "have access to safe and nutritious food, consistent with the right to adequate food and the fundamental right of everyone to be free from hunger" and describes food security as: "[w]hen all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life." it is therefore clear that as a part of human rights, the right to food is inalienable and indivisible from other fundamental rights including the right to life, the right to health, the right to know, ( - nov. , rome) . here, "right to know" is a term used in environmental law, referring to the legal principle that the individual has the right to know the chemicals to which they may be exposed in their daily living. it comprises two aspects -community right to know (environmental hazard information) and workplace right to know (workplace hazard information). nowadays, the term is used in the field of human rights in reference to the right of access to information concerning citizens' human rights, or their rights under freedom of information laws. for instance see sandra coliver, the justifiable to say that the right to food incorporates at least the following dimensions: availability, accessibility and adequacy. in other words, food must not only be available as a resource and affordable in order for people to be able to satisfy their dietary needs, but must also be safe for human consumption and free from contaminants. everyone must have access to food that is not only nutritionally adequate, but also free from harmful substances, so that it does not endanger people's lives or health. the states parties to the international covenant on economic, social and cultural rights have agreed to assume the obligation to progressively realize the right to adequate food. the responsibility is interpreted by the committee on economic, social and cultural rights as comprising three types of obligations: respect, protect and fulfil/facilitate. a state government must not interfere with individuals' efforts to access food. it must also protect its people from infringement of their right to adequate food by others. the government should help those who do not already enjoy the right to food by creating opportunities for them to provide for themselves. in the case where people are unable to enjoy the right to food due to events out of the individuals' control (natural disaster for example), the government ought to provide food to them directly. china is a signatory of the universal declaration of human rights and a contracting party of the international covenant on economic, social and cultural rights , the convention on the elimination of all forms of discrimination against women and the united nations convention on the rights of the child . china also signed the international covenant on civil and political rights but has yet to ratify it. the government of china is under international obligation to facilitate a pre-warning system regarding threats to the right to adequate food, and to improve coordination between different government and food safety agencies, as well as improve their accountability. violation of the right to food refers right to know: human rights and access to reproductive health information (article -university of pennsylvania press, london-philadelphia, ) ; and jacqueline klosek, the right to know (praeger, westport, ) . article of the universal declaration of human rights states: "everyone has the right to freedom of opinion and expression; this right includes freedom to hold opinions without interference and to seek, receive and impart information and ideas through any media and regardless of frontiers." jean ziegler, "what is the right to food?", right to food (august , ) <www.webcitation. org/ cmsst c>. not only to shortage of food, lack of infrastructure, mal-distribution and inadequate access to food, but also to protection from contaminated and harmful food. most of the recent food scandals in china involve rampant violations of the right to food in the dimension of adequacy -provision of food for safe consumption. while immoral and illegal conduct of individuals and enterprises is ultimately responsible for the outbreak of food safety crises, the government is accountable for inefficiencies in monitoring the enterprises and disciplining personnel in charge of administrating the food industry. as the most populated country on the earth, the chinese government has always paid great attention to food issues and regarded provision of enough food to the people as the first priority. after decades of effort, china has mostly solved the problem of feeding its people. however, new problems associated with agriculture and food have arisen since the commencement of market oriented reforms. it is reported that due to accelerated industrialization and urbanization, arable land has been shrinking and farmland capacity has declined. this constitutes a threat to china's future food security. the government has introduced the national land consolidation plan ( ) ( ) ( ) ( ) ( ) that aims to increase the effective area of arable land by . million hectares before , though the enforcement of the plan faces challenges such as lack of mechanisms for protection of cultivated land and inefficiencies in the management of land tenure rights. it appears that china has made a significant effort to achieve food sufficiency in the country. food availability and accessibility have been a top agenda item for the government in the past and will continue to remain a central issue in the future. the adequacy aspect received far less attention. the recent outbreak of food scandals is chiefly a result of a lack of oversight within the food industry. this can be partly attributed to the understaffing of supervisory authorities, partly to the misfeasance, malfeasance, nonfeasance and unprofessionalism of administrative officers. it is noteworthy that administrative personnel's unsupportive attitude and behavior towards businesses has been the cause of changes in inspective practice, resulting in a switch of models from official inspection to enterprise self-inspection. under the enterprise self-inspection regime, the working manner of administration is even more unprofessional. for instance, in the recycled buns case, when doing their sample inspection, the governmental inspectors, once arriving at a food factory or workshop, would only come into the administrative office and wait for the factory managerial staff to provide the samples to be examined. it is no surprise that they did not get any clues over the years. in one of the clenbuterol contaminated pork s z gu and y j zhang, "food security in china", in sun honglie and shidong zhao (eds.), area studies -china: regional sustainable development review (vol. , ) incidents, the problematic pigs were sold from henan pig farms to jiangsu province and had to go through several checkpoints conducted by the trade bureau, health inspection station, veterinary station, etc. however, some inspectors acted as middlemen between pig sellers and slaughterhouses for a commission of rmb yuan per pig, which caused wide dissemination of the contaminated pork and pork products. the recycled buns case showed workers in a filthy workshop "recycling" buns by throwing the stale buns into a vat, adding water and flour, and repackaging them to be sold anew. the clenbuterol contaminated pork case involves pig farmers feeding pigs with pig feed mixed with clenbuterol used to make the pigs have leaner bodies, which sell for a higher price. other food scandals involve melamine-contaminated baby milk; pork sold as beef after it was soaked in borax; rice contaminated with cadmium, arsenic-laced soy sauce; popcorn and mushrooms treated with fluorescent bleach; bean sprouts tainted with an animal antibiotic; and wine diluted with sugared water and chemicals. the alarming fact is that most of the food related offences were first discovered and disclosed by journalists, and not the personnel in charge of the surveillance authorities, or even the police or national security authority. it is inexcusable for administrative agencies to claim that ill-training, poor quality equipment and understaffing are the main causes for such an appalling incidence of food scandals in the country, since journalists are by no means in a position to be better trained and better equipped than food inspection agencies or police. as a matter of fact, detection and disclosure of food safety problems is not the expertise of journalists, nor their major business. respect for human rights is becoming a universal principle of good government. this is because many human rights require activity on behalf of government. these activities relate to the duties to respect, protect and fulfil human rights in order to provide the conditions necessary for prosperity and well being of individuals. a good government is committed to protection of the rule of law. hence, it is the state government's responsibility to make good laws and to establish able, professional and corruption-free administrative institutions, with a public service team to guarantee the implementation of the laws. although china's government is quick in making legislative efforts to curtail misconduct in the food industry, it needs to demonstrate its determination and capability of ensuring that the laws are fully abided by and it is accountable for building a law enforcement agency comprised of highly motivated, dedicated, well-trained law enforcers. a typical national food control system comprises the following components: food law and regulation, food control management, inspection services, laboratory services and information, education, communication and training. the capacity of food safety control in a nation is demonstrated by effectiveness, efficiency and sustainability. in china's case, apart from legislative efforts, much needs to be done in the following aspects: law enforcement involves certain members of society acting in an organized manner to promote adherence to the law by investigating and punishing persons who violate the rules and norms governing that society. the enforcement of the law consists of a system comprised of the courts and procuratorates, the judicial and public security agencies, and the administrative agencies, with their descending hierarchy of departments, bureaus, sub-bureaus, and stations. with regard to enforcement of food laws and regulations, administrative mechanisms play a more substantial role, compared with other enforcement instruments. the key is to enhance food control management. this involves development of food control strategies, implementation of risk analysis, operation of a food control program, securing funds and allocating resources, and development of emergency response procedures. development and implementation of food control strategy is concerned with defining food control objectives, identifying priorities of competing interests relating to public investment, state economic interest, food import and export, farmers and producers. an integral, effective food control strategy is particularly important to china, since it will improve the coherence of multiple existing administrative agencies in the country and reduce confusion, duplications of effort, inefficiencies in performance and waste of resources. for the time being, a crucial task china food and agriculture organization of the united nations and world health organization, assuring food safety and quality: guidelines for strengthening national food control systems (joint fao/who publication) - (rome ), <ftp://ftp.fao.org/docrep/fao/ /y e/ y e .pdf>. see food and agriculture organization of the united nations and world health organization, supra note , at . ibid. faces is to consolidate its food control policy at the macro-level by standardizing food quality certification, management, and rating, and in the meantime, to improve the market price system. a market entry certification system should also be put in place. another important task to deal with is to establish a uniform food safety risk analysis scheme to ensure compliance with food regulations and standards. unlike developed countries, the food safety problems in china occur in every stage from food production to service, typically consisting of contamination of raw food materials, cross contamination in manufacture, improper storage and preservation, and unhygienic practices in services. this requires a wide-ranging risk analysis system capable of identifying risk factors at every stage and of providing solutions. in doing so, there is the need to coordinate the risk assessment activities currently exercised by different administrative agencies and to develop a comprehensive scheme for food safety risk assessment, in which a professional team comprising food researchers, toxicological analyzers, pathological analyzers and inspectors play an essential role. attention should also be paid to food safety risk communication improvement. insufficient food risk communication in the past was chiefly responsible for a crisis in customer confidence with china's food industry. until this point, no substantial improvement has been made in this regard. in summary, the flaws of this situation can be attributed to a lack of government guidance, silence on the part of scientific academia, and unreliability of entrepreneurs. addressing this issue, the minister of health recently announced that a plan for food safety risk communication was in development and the press was expected to continue to play a leading role in this aspect. however, without access to channels for obtaining scientific information, the press's capacity for publishing fair and accurate reports is considerably undermined. it is therefore necessary to base risk communication on a system of interactive exchange of information and opinions among all stakeholders, including risk assessors, risk managers, consumers, industries, the academic community and other interested parties. this requires the government to allocate sufficient funds to finance and staff risk communication institutions of various specialities. china has more than million farmers and more than , food production companies. hence, to some, the food production system seems too vast to see world health organization/food and agriculture organization of the united nations, "about risk analysis in food", <www.who.int/foodsafety/micro/riskanalysis/en/>. allow for meaningful inspection at all stages of the food production process. however, the establishment of a national database for food supervision and inspection and a platform for food safety risk assessment enabling all interested parties to follow the development of food safety will absolutely make a difference to china's food industry. by the end of , the ministry of health formed the expert committee for national food safety risk assessment, which was a significant step toward improvement of china's food safety control. it is also reported that the state council of china has revealed its intention to establish a database of food companies' safety records. according to the plan, companies with poor safety records will be blacklisted and publicized, and will be subject to punishment. better regulation mechanisms, legal and standard systems, as well as technical support systems will also be introduced to improve the overall food safety management level. now, the world is waiting to see how well the plan will be realized. improving inspection services for food safety control is another key element for enhancing the food safety control system in china. food inspection service is a means of ensuring that the food supply is safe for consumers and meets legislative requirements. it is also an instrument for decreasing hazardous intoxicants in foods, including pathogenic bacteria, viruses and parasites, chemical contaminants and mycotoxins. the primary duty of the food safety inspection service is to inspect food manufacturing, processing and handling facilities, importing/exporting of foods and the monitoring of a company's facilities for compliance with the national legal and regulatory requirements. in some countries, the food inspectorate also conducts the functions of investigating food poisoning and injury cases and fraudulent marketing practices, as well as handling consumer complaints. of individual inspectors and the quality of their work. it is thus important to make sure that inspectors have detailed guidance and rules to follow when discharging their responsibilities. their powers and the procedures to be followed should be well defined. inspectors should receive up-to-date training in the new technologies used in processing and manufacturing, including what is required for the control of these technologies in order for them to function at maximum effectiveness and to assure proper performance. they must also be able to evaluate the performance of equipment and instruments used in production to guarantee that they are appropriately controlled and monitored. the impotence of china's food safety inspectorate has been widely reported and acutely recognized by consumers. it is officially perceived that the food safety inspection administration suffers from insufficient resources, a lack of qualified personnel, and deficient coordination among layers of governments and among various institutions, particularly among those administrative agencies at the provincial level and below. apart from the above-mentioned vices, three more factors must be taken into account: corruption, shirking and laziness. china's public services have long suffered from a number of bureaucratic problems such as authoritarianism, routinism, elitism, corruption, shirking of responsibility, deceit, laziness, formalism, red tape, nepotism, seeking special privilege, overstaffing, duplication, ineffectiveness, and over-centralization. upon close study, one can discern that corruption, shirking and laziness are the most prominent problems that induce or exacerbate the other problems. these deep-rooted problems penetrate the food safety inspection system and eventually take their toll on public confidence in the food industry. the government of china has pledged to enhance the ability of the inspectorate. in its food safety decision june , , the state council announced that it planned to take years to improve the nation's food safety and food control management. according to the state council's statement, food safety will become a measure of local governments' performance in their annual assessments, in the hope that incorporating food safety as one of the evaluation criteria will make local governments and officials aware of their responsibilities. however, given the institutional decline, erosion of authority of the central government, and loss of control over local agencies and agents in the era of the market economy, effectively rooting out corruption in the food safety administration will certainly demand much greater efforts based on resolute determination. to a certain extent, it represents a social problem and needs to be tackled on a broader scale. to curtail food safety problems on a broader scale, it is necessary to promote general respect for universal human rights in the society. from this point of view, improvement of food safety can be seen as a social project. in the past three decades, in making the transition from a planned economy to a market economy, china placed much emphasis on economic gains and profitability. along with gdp growth, extreme utilitarianism, fickleness and mammonism have become more and more evident and have turned into a driving force in chinese people's daily life. the food safety outbreaks are merely typical consequences of the erosion of social morality and business ethics. food safety outrages spark a new round of calls to promote public morality and human rights. many chinese have come to realize that without a morally healthy social environment, mere economic prosperity does not guarantee a successful society and true advancement. in contrast, it may only carry with it the seeds of corruption and decay. to bring changes to the broader system, the general public needs to step out from their family-centred tradition and self-interested sphere, and endeavor to shape a society where individual equality is upheld, respect for others' human rights is generally aware of, and public interests are greatly valued. the construction of such a society requires the combined efforts of the government, private sectors and the community. while the government is accountable for formulating policies and initiatives, facilitating state agencies and mechanisms, and allocating resources, the business sector and the community are expected to participate in shaping a good society by promoting sustainable business practices, interacting with the government and influencing the policies of governance. it is worth noting that the constitution of china only implicitly addresses citizens' rights to safe food. article provides that "the state . . . promotes health and sanitation activities of a mass character, all for the protection of the people's health"; and article states: "citizens of the people's republic of china have the right to material assistance from the state and society when they are old, ill or disabled." compared with some nations that incorporate the right to healthy food into their constitutions, china is much behind in providing constitutional safeguards for food security. given the challenge of tackling food problems, it may be necessary for china to introduce provisions to protect food safety in the constitution. in the case of combating food safety problems, the food industry shares responsibility with governmental agencies in achieving the objectives of a national food control strategy. involving the industry in national food control activities might be instrumental in overcoming potential problems. the food industry is responsible for the implementation of rules regulating agriculture, food manufacturing and processing practices, as well as a food quality and safety system. the industry should also be obliged to educate and train all employees in food handling and make sure that they understand general food quality and safety system. it can also provide information to consumers through food labeling and advertising. in china's case, the food industry may need to go through a long journey to correct its practices which may also involve a change in the business culture. as members of the community, consumers have a right to quality and safe food and also have responsibilities to prevent food related health hazards. consumers need to understand there is no such thing as an absolutely safe food supply. the right to food for consumers also requires a responsibility to play a role in food control. consumers can actively contribute to food safety control by providing valuable information to the authorities, usually by complaining about product deception and poor quality and by reporting injury and illness caused by food. the authority then needs to provide them with a channel to let their dissatisfaction be known. consumer organizations are expected to play an important role in representing the consumer in the development of a national food control strategy and also in bringing the concerns of consumers to the attention of policy makers and the industry. the chinese government needs to take proactive action in order to ensure that consumers are heard and taken into account. in summary, combating food safety problems depends on a combination of mechanisms including training, business ethics education, administration and supervision, public scrutiny, civil litigation and penal punishment. in other words, combating the food safety problem require a collective effort from the entire nation. the government is certainly accountable for all mandatory activities necessary to ensure the quality and safety of food, including enacting food regulations, operating food inspectorates, organizing analytical services, and enforcing rules. the participation of other stakeholders and interested parties including the industry, consumers, communities and even the society as a whole, is equally crucial. the battle will happen across a gamut of fields involving governmental conduct, social ethics, public relations, business practice, and consumer culture. the medical insurance system of a state directly affects its people's key human rights, namely the right to life and the right to health. the notion of modern medical insurance can be traced back to the introduction of the sickness insurance program in in germany. the antecedents of similar kinds existed in the form of charity or welfare in some civilizations, such as friendly societies organized by european trade guilds, fraternal organizations, the english poor law , the prussian common law , and the civil war pension program . the sickness insurance program in germany came as a result of the medical reform movement and a series of political debates and compromises afterwards. the sickness insurance act was enacted in to facilitate the program. the law allowed the largest segment of workers to benefit from access to public health care through insurance funds. in the event of accidental injury, illness or old age, workers were entitled for minimum indemnity for medical treatment and sick pay for up to weeks. this initial system was financed by workers and employers, with the employers contributed one third, while the workers contributed two thirds to insurance funds. in germany passed the accident insurance act covering serious and fatal accidents occurring on the job in certain industries. the act went a step further by placing the entire cost of the liability on the employers. the significance of the german health insurance program introduced in the s lay in that it was for the first time in history that a national health insurance system was institutionalized. following the german practice, industrialized countries commonly introduced social security programs in the following decades, i.g., the uk the medical insurance program as an indispensable part of the modern social security system has carried human societies into a new era where the government of a country provides economic assistance to persons faced with unemployment, disability, or agedness for the purpose of advancing the benefits of the members of the community as a whole. the key feature of the scheme is: it is imposed and controlled by the government. before the introduction of social security schemes, the dominant mode of support for people unable to provide for themselves was charitable relief proffered by benevolent societies, sometimes with financial help from the authorities. social security comprises two arms: social assistance and social insurance. the rationale behind modern social security programs is the necessity to maintain social and economic justice. with industrialization, social security has gone through a change from charity to a state responsibility. guaranteeing a certain amount of social well-being and economic security to every individual member in the community has become a duty of a modern state. nowadays, social security has emerged as a human right enshrined in the universal declaration of human rights, which states: after the establishment of the socialist state in , as part of the social welfare or security package china introduced a state funded, central planned health care system, which provided a universal coverage of health care to the chinese population. an innovative feature of the system was the operation of the so call barefoot doctors at health clinics at the village and township level, which served the mass rural citizens accounting for three quarters of the total population. this system was held up as a model for providing universal health care in the developing world in the s by the world health organization (who) and inspired who to launch the "health for all by a.d." program. under this scheme, public health in china improved dramatically, with the citizens' life expectancy increasing from to years, infant mortality decreasing from to per live births. the system operated in china for nearly years until the market oriented medical reform took place in the s. as a result, china's health care program has experienced a change from a scheme performing universal social welfare function to a model that is a mixture of free market and medical insurance. however, the reform turns to be a failure which makes china's health care scheme one of the least equitable systems in the world. care reforms ciency and abuse. its sustainability posed a challenge to the leadership in the post-mao era, which had an economic reform scheme at the top of the agenda. by the s, the administrative and financial support for the health care was removed from the national agenda through decentralization before a nationwide health insurance system was provided. with local governments having little incentive to promote local healthcare, individuals of rural areas and urban non-salaried residents primarily relied on out-of-pocket spending for medical and health services. in the meantime, prices for provision of medicines, diagnostic tests, surgical implants, and specialized care were deregulated. as a direct impact, many chinese were in short of medical services and supplies since they simply resolved to not seeking medical help. it was reported in , about % of the chinese people refused to see a doctor when ill and % of those refused to go to hospital, mainly out of financial concerns. there was still worse to come. after the collapse of the previous model, no strategy was adopted to mitigate the lack of integration and coordination in the later medical system. due to a lack of reliable local clinics, people had to wait in long queues for basic health care, with no scheduled appointments and little privacy. after all the inconvenience, what they could receive was usual a very brief face to face consultation of a few sentences or a couple of minutes. during this period, health care was seen "as a consumption activity rather than a fundamental right of the people or a responsibility of the state". indeed, this unsustainable, reactionary approach had to be subject to review and amendment. as a result, in , the new cooperative medical scheme (ncms) for rural population, mainly funded by the government, was launched. since , a health insurance scheme for urban non-salaried residents, especially for children and old people has been implemented. although china's health care system has appeared to get back on the track of government subsidy since the mid- , it is far from offering accessible, affordable, equitable and quality health care services with a universal coverage. some believe that the current health care reform is unlikely to solve the fundamental problems of accessibility, affordability, equity and quality. as long as the buck-passing polity does not fully change and the health policy process is still influenced by interested groups, the problem of dis- see jason shafrin, "an olympic post: the history of the chinese healthcare system", healthcare economist (august, ), available at <http://healthcare-economist.com/ / / page/ />. parity inherent in china's health care system will continue to affect the country's social environment. the worst part of china's health care system is the rampant medical corruption stemming from the medical reform over the past decades, particularly in the period between the mid- s and the mid- s. the usual scenario is that doctors and other staff expect to be paid extra fees (usually in the form of "red envelops" ) to perform operations and take kickbacks from pharmaceutical firms and medicalequipment suppliers. the practice is so prevalent that an unsullied doctor nearly does not exist. almost all practitioners and medical staff tell the same story as the defence of their unclean hands -low salary or underpayment. whistle blowers also tell that doctors have economic income targets allocated by hospitals and hospital administrators for them to meet and exceed. only upon completion of their quotes, they are paid benefit bonuses which can be much higher than their basic salaries. in other words, they are under pressure to charge patients extra fees and to recommend patients to go through unnecessary but expensive tests and procedures as well as purchase expensive medicines. nonetheless, such excuses are not sound enough to defeat professionalism and patients' human rights. besides, on many occasions, they are free to make a choice. for instance, a surgeon or a nurse can always hold up professional dignity by declining a red envelop because it is commonly given privately. moreover, nothing can justify their procurement of briberies and kickbacks from pharmaceutical companies or health care companies. facing a choice between campaigning for improving income or work environment and becoming corrupt, chinese doctors have had less difficulty in choosing to compromise their professional morality in the first place. moreover, nothing can defend the corruptive and negligent conduct of the personnel in governments and the health care system, which have caused further spread of epidemics such as aids. a nation has every reason to become alarmed when seeing medical profession to be infested by the epidemic of corruption. the governments and citizens all have a responsibility to trace the deep root of the phenomenon in their society, culture, policy and ethics in order to find the cures. access to quality health care services is a basic right in a civilized society. it is essential to one of the core human rights -human right to health. the human right to health care means that hospitals, clinics, medicines, and doctors' services must be accessible, available, acceptable, and of good quality for everyone, on an equitable basis, where and when needed. hence, universal access, availability, acceptability, dignity, non-discrimination, accountability, and transparency should be the fundamental principles upon which a health care system is built. many countries have upheld health care as a basic human right in their laws. unfortunately, the failure of the health care scheme has deprived many chinese citizens this right for more than two decades after the medical reform. this renders china's medical reform a truly disgraceful story. when people are deprived their access to hospital and health care services, their human rights, including their rights to health, life and information are potentially compromised and threatened. china is a contracting party to the international covenant on economic, social and cultural rights (icescr) and the united nations convention against corruption (uncac), a signatory of the international covenant on civil and political rights (iccpr). it is thus under treaty obligation to protect individuals against corrupt acts of third parties. though corruption and abuse of the health care scheme committed by practitioners and professionals in hospitals, insurance companies and suppliers of medical and health care goods and services impact on patients' human rights, the guilty individuals are not in direct breach of the uncac. instead, the uncac is directed primarily at member states rather than non-state actors. hence, it is the obligation of the chinese government to prevent corruption involving governments, industries, companies and individuals in fight against corruption and to raise public awareness of the matter. due to the fact that corruption has invaded into every corner of the chinese society, citizens have faced an unfavorable physical and social environment. fraud in project approvals and failure to apply emission control measures are responsible for the human right to health means that everyone has the right to the highest attainable standard of physical and mental health, which includes access to all medical services, sanitation, adequate food, decent housing, healthy working conditions, and a clean environment. xiangming zhou, a study of the health care right (phd thesis, jilin university, ) . see part ii -articles and uncac. rising pollution in the country. some professions including teachers, doctors, lawyers and those safeguarding consumptive goods are not only important to people's lifestyle and well-being and society's progress, but also play a social role in which trustworthiness is an expectation in every tradition. in china, these professions, because of the rampage of the unethical performance conducted by a majority of the people in the trades, have definitely failed to honor their part of social compact with society, which in turn exacerbates human rights related problems. it is a high time for china to review the ethical conduct of these key professions. the chinese government has an obligation to protect citizens' human rights to health, access to healthy food, safe drinking water, clean air, and a healthy environment. in discharging this obligation, effective mechanisms combating corruption in various forms need to be established in order to sustain the country's social stability and economic prosperity. china -pig farmers told to drug livestock china, fear of fake eggs and 'recycled' buns history of universal human rights -up to ww sourcebook: human rights & good governance (asialink project on education in good governance and human rights office of the united nations high commissioner for human rights a reflection on the circumstances of contemporary chinese social moral ideal from an academic point of view, it is perceived that china's medical reform in the s and s was basically a buck-passing strategy. in a joint report in , both who and the state council of china admitted that china's medical reform was overall unsuccessful. nevertheless, this system was costly and prone to ineffi- the barefoot doctors are the medical practitioners who had only basic health care training and lived in the community they served health care system reform in china: issues, challenges and options (cema working papers , china economics and management academy see the declaration of alma-ata privatization and its discontents-the evolving chinese health care system see who, supra note governing health in contemporary china three prescriptions for treating the symptoms of the medical reform', china youth daily chian's health care reform: not just a policy failure, carengie endonwment for international peace an envelope with cash inside if the government is really serious, all the chinese doctors and drug companies will be found guilty because no drug manufacturer or doctor is innocent. if doctors are to be laid off for receiving hongbao, then every chinese doctor will be laid off. but then who will take care of the patients? if the benefit bonus is fully deducted, the doctor only receives the basic salary part. people usually refer the basic salaries when speaking their salaries consequences of a stalled response: epidemic among blood donors in central china sourcebook: human rights & good governance. asialink project on education in good governance and human rights china's environmental crisis social insurance and allied services public health and human rights: evidence-based approaches privatization and its discontents-the evolving chinese health care system training in an integrated food safety system: focus on food protection officials. food safety magazine historical summary of workers compensation laws (olr research report food safety and public morality, china culture and media daily network evidence on the impact of sustained exposure to air pollution on life expectancy from china's huai river policy article /university of pennsylvania press, london/philadelphia committee on economic, social and cultural rights (twentieth session, ) general comment no. on the right to adequate food the vienna conventions on the law of treaties: a commentary suhe meng's opinion: confidence crisis is the biggest challenge to china's food products, caixin net earth summit ( ) rio declaration on environment and development shrinking arable land threatens grain security, china daily national wide investigation into problematic buns, food safety face trust crisis fifteen organizations share responsibilities in food safety supervision and administration: weak supervision and administration cause frequent problems, cctv half-hour economy assuring food safety and quality: guidelines for strengthening national food control systems workingmen's insurance in europe markets adapt to china's changing diet mcgill_queen's university press, montreal hannah b ( ) how corruption blights china's health care system china food safety, it ain't working and we told you so food safety and effective supervision by the government area studies -china: regional sustainable development review health care system reform in china: issues, challenges and options (cema working papers , china economics and management academy governing health in contemporary china. routledge, london/new york human rights council ( ) human rights council resolution / on human rights and climate change meanings of environment terms international legal instruments addressing good governance (report of united nations human settlements programme) the german sickness insurance programme - : its relevance for contemporary american health policy the right to know: your guide to using and defending freedom of information law in the united states china, fear of fake eggs and 'recycled' buns the right lists tells how to envisaging china's human rights development, people's daily online ping: protecting environment is as importance as protecting productive forces, xinhua news agency (the news center of the national people's congress of china and the chinese people's political consultative conference managing economic reforms in post-mao china studies on issues concerning food safety in criminal law, legal study news of the capital city www on the shortcomings of the foot safety law and some suggestions on improvement equity in health and health care: the chinese experience a comparison of the health systems in china and india (rand, information and interdisciplinary subjects series chian's health care reform: not just a policy failure, carengie endonwment for international peace universal coverage of health care in china: challenges and opportunities (world health report social security of labour in the new indian economy ?cn=c national people's congress of the people's republic of china ( ) criminal law of people's republic of china national people's congress of the people's republic of china ( ) the law of the people's republic of china on food safety glossary of statistical terms: social security schemes human rights approach to environmental protection people's congress ( ) the constitution of the people's republic of china rayner m, history of universal human rights -up to ww chinese baby formula activist sentenced to / years in prison for incitement, the washington post state council information office of the people's republic of china ( ) human rights in china state council of the people's republic of china ( ) trial regulations of the people's republic of china on food hygiene state council of the people's republic of china ( ) decision of the state council on some issues concerning further enhanced product quality state council of the people's republic of china ( ) the regulation on the implementation of the food safety law of the people's republic of china reflections on china's food safety administration the national bureau of statistics of china: the urbanization population rate achieves multilateral trade negotiations on agriculture -a resource manual/sps and tbt agreements module , national food control systems: components and operation the decision of the state council about further strengthening food safety un secretary-general's high-level panel on threats ( ) challenges and change, a more secure world: our shared responsibility united nations ( ) the declaration of the united nations conference on the human environment the future we want united nations environment programme ( ) nairobi declaration on the state of worldwide environment united nations environment programme universal declaration of human rights international covenant on economic, social and cultural rights united nations general assembly ( b) international covenant on civil and political rights convention on the elimination of all forms of discrimination against women draft world charter for nature convention on the rights of the child what are human rights? www.ohchr.org/en/issues/pages/whatarehumanrights.aspx usda -economic research service ( ) percent of consumer expenditures spent on food, alcoholic beverages and tobacco that were consumer at home, by selected countries three prescriptions for treating the symptoms of the medical reform directors' duties under chinese law -a comparative review world meteorological organization, timely access and response to accurate early warnings are crucial for minimizing impacts of natural disasters johannesburg declaration on sustainable development and plan of implementation of the world summit on sustainable development: the final text of agreements negotiated by governments at the world summit on sustainable development a study of china's legal system for food safety a study of the health care right chinese vs. western perspectives: understanding contemporary china food safety becomes national priority, china daily what is the right to food? right to food key: cord- - zerjwa authors: roos, yrjö h. title: water and pathogenic viruses inactivation—food engineering perspectives date: - - journal: food eng rev doi: . /s - - -z sha: doc_id: cord_uid: zerjwa water is an essential component of food structures and biological materials. the importance of water as a parameter affecting virion stability and inactivation has been recognized across disciplinary areas. the large number of virus species, differences in spreading, likelihood of foodborne infections, unknown infective doses, and difficulties of infective virus quantification are often limiting experimental approaches to establish accurate data required for detailed understanding of virions’ stability and inactivation kinetics in various foods. furthermore, non-foodborne viruses, as shown by the sars-cov- (covid- ) pandemic, may spread within the food chain. traditional food engineering benefits from kinetic data on effects of relative humidity (rh) and temperature on virion inactivation. the stability of enteric viruses, human norovirus (hunov), and hepatitis a (hav) virions in food materials and their resistance against inactivation in traditional food processing and preservation is well recognized. it appears that temperature-dependence of virus inactivation is less affected by virus strains than differences in temperature and rh sensitivity of individual virus species. pathogenic viruses are stable at low temperatures typical of food storage conditions. a significant change in activation energy above typical protein denaturation temperatures suggests a rapid inactivation of virions. furthermore, virus inactivation mechanisms seem to vary according to temperature. although little is known on the effects of water on virions’ resistance during food processing and storage, dehydration, low rh conditions, and freezing stabilize virions. enveloped virions tend to have a high stability at low rh, but low temperature and high rh may also stabilize such virions on metal and other surfaces for several days. food engineering has contributed to significant developments in stabilization of nutrients, flavors, and sensitive components in food materials which provides a knowledge base for development of technologies to inactivate virions in foods and environment. novel food processing, particularly high pressure processing (hpp) and cold plasma technologies, seem to provide efficient means for virion inactivation and food quality retention prior to packaging or food preservation by traditional technologies. viruses are intracellular, foreign, genetically structured particles of biological macromolecules which use biological functions of host cells to replicate, i.e., no replication occurs outside host cells. in other words, viruses are not organisms or living cells, although they contain genetic material providing viruses with an ability to replicate using their specific host cells. properties of viruses, replication, and inactivation are significantly different from those of pathogenic microorganisms in foods. microorganisms are individual living cells which use food materials as their growth medium. viruses outside their host cells, however, exist as inactive virions, i.e., as particles with complete infective functions. virions present biological mechanisms for entering their specific hosts' cells, where an infection causes the host cells to reproduce viral dna or rna and then release a large number of virus copies for spreading as new virions. moreover, viruses do not change organoleptic properties of contaminated foods [ , ] , and quite often, the source of virus contamination and spread is unidentified [ ] . a food engineering and safety concern is the retention of virus infectivity and infection risks within the food chain. viruses vary in size which is typically around nm but the sizes among approximately classified virus species [ ] may vary significantly from to above nm. obviously, optical microscopes may not detect individual virions and images are typically obtained by electron microscopy. the genome of a virus is structured either in dna or rna sequences which with nucleoprotein are surrounded by a protein capsid. a number of viruses produce a lipid bilayer as an envelope around the capsid. such envelope consists of phospholipids and proteins from cell membranes of their host cells. the small size, concentration, and a tiny infective dose of virions besides the need of host cells for reproduction of viral material result in challenges in studies analyzing virus survival and infectiousness in food, water, and the environment [ ] . viral inactivation studies often employ surrogate viruses to follow virus stability and inactivation. on the other hand, virus infections often result in serious illnesses which may be transmitted via the food chain, including food handling, premises and packaging, or even the food itself. bivalve mollusks (shellfish) and fresh produce (hand-picked berries, fruits, vegetables), for example, are minimally processed foods which are often contaminated by viruses and, therefore, important sources of foodborne infections [ ] . multiplication of viruses occurs by production of viral genomes by virus-specific host cells. that is a viral dna or rna, or a number of genomes may be detected outside host cells after a particular treatment, but virus extraction and analytical methods to find whether the virion has remained active and infectious are limited [ , ] . such lack of methodology and unique multiplication route results in a significant difference between studies of viral and microbial stability, loss kinetics, or retention of nutrients and biologically active substances in food. furthermore, bacteria growth or loss kinetics may be derived from numbers of growing cells following a treatment or sampling from surfaces while chemical analytical methods allow detection and studies of degradation kinetics of nutrients or other molecules in food. likewise, one may find viral dna or rna in food or water, contact surfaces, food handling areas, and employees. the existence of viral genomes outside cells, however, does not confirm viability of virions when host cells become available. for such reasons, studies of infective virus concentrations must use plaque assays (e.g., [ , ] ) or require cell cultures (e.g., [ ] ) to reproduce viral genomes besides extraction of a sufficient number or concentration of virions from a contaminated source [ ] . because of such challenges and large variation in experimental data, transmission routes of viruses as well as factors affecting viability of virions are poorly understood. transmission pathways of viral infections and data of their importance to food safety are of high value in food engineering. foodborne transmissions of many nonenveloped virions causing gastroenteric viral illnesses have well-established links to contamination of ready-to-eat food by an infected food handler [ , ] . foodborne transmission of enveloped influenza viruses is also a possibility, although airborne spreading from infected carriers via surfaces, including foods and packaging, is a recognized risk, particularly at food handling and processing facilities [ , ] . according to fao and who [ ] , major foodborne viruses cause infections in the gastrointestinal tract. such viruses are typically transmitted in feces or vomitus. noroviruses (nov) and hepatitis a virus (hav) are known as the most common foodborne causes of viral gastroenteritis along with rotaviruses, enteroviruses, and astroviruses [ , , , ] . determination of an infective dose may present difficulties. the highly infective human norovirus (hunov) has an infective dose of to genome copies or to virions [ ] . one may note that g of infected stool may contain > hunov virions [ ] . a large number of other viruses may show transmissions via food or water allowing them to replicate in the human intestine. illness, however, may occur only after virions migrate to other organs, such as the liver or even the central nervous system (enterovirus). many virions survive food processing and even sars-cov and highly pathogenic avian influenza (hpai) virus have been documented to show foodborne transmission [ , , ] . jalava [ ] concluded in her analysis of initial transmissions of sars-cov- (covid- ) that respiratory transmission was likely. she found food as an unlikely route. poor ventilation was taken into account, but working practices, the cold chain, and possible condensation of aerosol particles or droplet settling on surfaces thereby leading to direct contamination and transmission via food or packaging contamination was not considered. an infective viral contamination of a food is always a risk of a likely cause of an infection. in food engineering, there is a need to understand effects of treatments on virions as well as effects of food properties and storage conditions, including water activity, a w , on virions. that is not the presence of viral genomes in foods as such, but the infective load of viruses, i.e., number of virions, is essential in understanding processing needs and food safety. unfortunately, no rapid methodology for the detection of foodborne transmissions or virions in foods or food package headspace has been developed. stability of viruses seems to depend strongly on whether they have a non-enveloped (naked) capsid (e.g., enteroviruses) or enveloped capsid (e.g., influenza and coronaviruses) [ ] . most viruses causing gastroenteritis show excellent stability in fresh products and may remain active throughout product shelf life and even several months in shellfish (bosh et al., ). moreover, chilled and frozen storage of foods can preserve viruses for months or years. on the other hand, numerous antiviral compounds are naturally present in various foods, as was reviewed by bosch et al. [ ] and galanakis [ ] . such compounds may inactivate the spike proteins of viruses and disable their entry into host cells. in food processing, viruses are effectively destroyed by temperatures > °c which rapidly damage virus capsids. free chloride and ozone cause strong damage to nuclei acids of viruses besides harmful effects on the capsid [ ] . virus stability and transmission routes are universal environmental issues which have a direct implication on food safety. food industry has a need for information on viral stability throughout the food chain as well as understanding of viral degradation kinetics in various surroundings, including foods. conversely, food engineers have developed technologies for food processing and preservation which require understanding of effects of electric fields, light and radiation, pressure, ph, phase and state transitions, temperature, and other physicochemical parameters on bioactive substances, nutrients, and microorganisms. one example of high relevance of such technologies to virions' stability is dehydration by spray drying which uses aerosols and droplets of food liquids to produce stable particles. besides physicochemical surroundings of virions in such food processing, water may significantly affect stability and degradation kinetics of virions [ ] . here, we summarize studies reporting on virus survival and degradation kinetics with critical evaluation of the importance of known data to understanding losses of virus infectivity in normal circumstances, and particularly as affected by water from a food engineering and safety perspective. furthermore, we emphasize virion stability and kinetics of loss of virion infectivity, including data for influenza a and sars (severe acute respiratory syndrome) virions, and discussion of the new sars-cov- (covid- ) virion stability. the overall benefits of general food engineering to studies of virions survival and stability are due to similarities in requirements with existing food processing treatments and preservation technologies which often aim at reducing microbial survival and growth without compromising food safety, nutritional value, and sensory pleasure. classification and general properties of most common food-related pathogenic viruses are given in table . pathogenic viruses of significant concern to food safety are listed by fao and who [ ] as those that: & cause a high incidence of foodborne viral disease, based on currently available data (enteric viruses) & cause severe disease including significant mortality worldwide (pandemic) & have the potential for foodborne transmission and to pose a significant threat to public health (pandemic) viral transmissions are strongly related to the presence of water either as a transmission medium or with a structural and stabilizing function [ ] . according to fao and who [ ] , food hygiene guidelines, which have been optimized for prevention of bacterial infections, may not be effective for viruses. foods may become contaminated by infective viral material through (i) human sewage and feces; (ii) infected food handlers; and (iii) animals for zoonotic viruses [ ] . on the other hand, these transmission routes seem to primarily apply to direct contamination of food and inclusion of virions as part of the food. several other routes of viral transmissions in modern food supply chain need to be considered. such routes include food surfaces and packages, food manufacturing and distribution, food service establishments, and supermarkets [ ] . viral infections can be transmitted directly from contaminated foods, from the environment, and directly in aerosols and droplets emitted by infected hosts (table ). food contamination often occurs via soil, water, and other direct routes as well as from infected persons or animals. some enteric viruses, such as human norovirus (hunov) and enteroviruses may also transmit via aerosols and feces. the working environment is another important source for infections among employees, particularly at healthcare facilities [ ] and also at refrigerated food premises, particularly at meat processing plants. food engineers have skills and potential to respond and model aerosol composition and dehydration effects on virions' survival in emission and environment as well as during food processing and in manufacturing facilities. pathogenic viruses may also be assumed to adhere strongly and subsequently survive on personal protective equipment (ppe) and protective clothing of employees depending on hydrophilic-hydrophobic as well as electrostatic properties of materials [ ] . according to van doremalen et al. [ ] , sars-cov- virions were more stable on plastic (half-life > h, virus viability > h) and stainless steel than on aerosols and copper (half-life ≈ h) or cardboard (half-life > h). such survival times are sufficient for virions stabilization by dehydration and effective release of concentrated, infective virions to result in secondary transmissions by dusting or direct contact from plastic (including polyester, pet, clothing) and other surfaces, including clothing. traditional food preservation using acidification, dehydration, or temperature control may not be sufficient to control foodborne viral infections, mainly because of highly resistant enteric viruses [ , ] . on the other hand, spreading of influenza viruses, including pandemic influenza a and coronaviruses, in food is also possible [ , ] . according to zuber et al. [ ] , enteric virions need to survive the enzymatic and extreme ph conditions of the gastric system which reflects their high resistance to many common food preservation and processing treatments. likewise, enveloped virions of pathogenic viruses, e.g., influenza a virions have been shown to remain infective in frozen meat [ ] and there is a possibility for survival of the new sars-cov- on meat surfaces [ ] . enveloped viruses are transmitted rather in fluids, respiratory droplets, blood, and tissue [ , ] but their virions are more sensitive to environmental conditions and variations in humidity. foodborne transmission of viruses is a potential risk in the case of enteroviruses but also other pathogenic viruses, and their spreading within the environment is wellrecognized [ ] . a summary of common foodborne viral infections is given in table . enteric viruses can also be airborne, bloodborne (including vector-borne), or sexually transmitted. traditionally microbial food safety is linked to gastroenteritis and bacteria transmitted directly from food. loss of virions infectivity often relates to loss of capsid essential functions for introducing the viral genome to a host cell to initiate a viral infection [ ] . most foodborne virions have no envelope, and infectivity is retained well in conditions outside host cells [ , ] . many such virions demonstrate good resistance to extreme ph values (acid and alkaline), and virions may remain infective after drying, radiation, and other food preservation treatments [ , ] . the essential parts of an infectious virus are the integrity of the genome and capsid protein at minimum [ ] . any treatment of food against pathogenic viruses must ensure sufficient loss of viral infectivity, i.e., numbers of infective virions need to decrease by several logarithmic cycles. enteric viruses are common in water and environment. butot et al. [ ] showed that viruses were not likely to contaminate bottled water. their study showed that enteric viruses, hav, hunov, and rotavirus (rv) were adsorbed and remained on polyethylene terephthalate (pet) bottle surfaces and thereby retained infectivity at the pet surfaces even for d at room temperature. such attraction of viruses on hydrophobic surfaces emphasizes the importance of hydrophobic properties of nonenveloped virions to stability and loss of infectivity. enteric viruses show interactions with many food components. according to sánchez and bosch [ ] , enteric viruses attach to foods by ionic and hydrophobic interactions, van den waals forces, interaction with receptors (e.g., hunov attachment to carbohydrates), and uptake into bivalve mollusk and vegetable tissues. hav has been shown to retain infectivity at °c for d, and acidification is not a sufficient means to reduce hav infectivity [ ] . the sars-cov- outbreak in / has shown that viral transmissions are complex and foodborne transmission of covid- is also a possibility [ ] . conversely, foodborne viral infections are not limited to viruses infecting human gastric track but rather to any infecting viruses, including common influenza virus (table ) . virions in respiratory transmissions are often emitted from infected carriers as aerosols and droplets. droplet nuclei in aerosols are below μm in size. such droplets dropping from the height of . m take over min while large droplets > μm are not inhaled and settle on surfaces within a few seconds (weber and stillianakis, ) . particles resulting from coughing, sneezing, and speaking vary over the range of to μm and interestingly correspond to droplet sizes in spray drying. most particles are too large for inhalation (weber and stillianakis, ) and they settle on surfaces and cause droplet contamination in surroundings. a considerable number of up to , aerosol particles/cough over a size range of . μm to μm may be expelled during coughing. the number of emitted particles is often higher for influenza patients than for healthy persons [ ] . in some cases, small numbers between and virions may result in an infection [ ] and an aerosol infection dose may be taken as - copies of the viral genome [ ] . employees are often an important source of direct and indirect virions transmissions. in manufacturing plants, aerosol particles are formed during coughing, sneezing, and speaking. zayas et al. [ ] found that during coughing of healthy individuals, % of droplets were less than μm in size. they also reported a large variation in droplet size and high emitters included an ex-smoker and a person older than years. an outlier was involved in high intensity sports which may imply that virus spreading may become enhanced during activities with strong physical requirements, including such tasks in working environments. although not statistically significant, older individuals seemed to emit larger droplets than younger persons [ ] . harper [ ] found that a low temperature and low relative humidity enhanced survival of several viruses, although poliovirus showed enhanced stability at a high humidity. the most important factors affecting the stability of virions in the aerosol state are temperature, ph, relative humidity, water content, size of the aerosol particle, composition of the suspending medium, sunlight exposure, air quality, and virus type [ ] . at high relative humidity, surface alteration of the virion has been reported, whereas at low relative humidity, virus inactivation appears to be mediated by the removal of structural water molecules. when dried on environmental fomites, hav and rotavirus are more resistant to inactivation than enteric adenovirus, astrovirus, and poliovirus. the hydrophobic lipid bilayer is likely to provide strong hydrophobic properties to enveloped viruses. the envelope is often covered by glycoproteins which may also provide some hydrogen bonding capability. we assume that such structure enhances retention of water molecules in virions to support viral activity and it provides virions with protection against activity loss during release from host cells and spreading. moreover, mannose-specific lectins of many plants, including garlic and leek, were found to show antiviral activity against coronavirus sars-cov [ ] . keyaerts et al. [ ] presumed that such lectins interfered with the glycans of spike proteins during entry and release of virions at host cell membranes. in general, inactivation of virions is possible by damaging the genome, the protein coat, or the lipid bilayer and the associated glycoproteins [ ] . routes of inactivation according to zhang et al. [ ] are illustrated in fig. . thermal processing provides an effective means for virus inactivation [ ] although fat, protein, and sugars may improve stability of virions against thermal treatments [ , , ] . many studies have shown that temperatures above °c are more effective in killing viruses than lower temperatures [ ] . according to sánchez [ ] industrial blanching of vegetables at °c for - s may reduce hav infective virions by [ , ] . interestingly virions seem to be less sensitive to thermal degradation than virus genomes both in simple (e.g., water) and complex (e.g., food) matrices. one may conclude that the complete virus structure provides protection to virus genome and loss of infectivity in food benefits from the shorter processing time of virion inactivation than may be suggested by genome degradation. enteric viruses, such as hav and parvovirus, as noted by sánchez and bosch [ ] , show higher thermal stability than most other viruses. despite challenges in determination of viability of virions and particularly in detecting virions infectivity, a number of studies have addressed virions survival in foods (e.g., [ , , ] ). in general, many viruses cannot be cultured in vitro and studies of virus stability often use surrogates to achieve data on loss of infectivity [ , ] . according to sánchez and bosch [ ] , stability of viruses in foods is dependent on virus type, temperature, ph, relative humidity, water content, sunlight exposure, and type of food. they also pointed out that the type of surface, for instance, the presence of crevices and hairlike projections in berries, may shield the viruses against environmental modifications and also the presence of natural antiviral compounds in the food itself may reduce risks of infections. viruses are expected to occur in fresh foods primarily on surfaces, e.g., on surfaces of fresh and frozen berries, but inactivation occurs rapidly on hands. butot et al. [ ] found that uv-c light ( - nm) was effective in reducing hav and murine norovirus (mnv) on fresh and frozen blueberries, raspberries, and strawberries. they, however, noted that the surface properties of the product as well as ice formation on surfaces may affect reduction of viruses. uv-c light treatments are effective only on product surfaces. virion inactivation on metal surfaces is highly dependent on metal type. a comprehensive research and statistical analysis of pre- published data on influenza virus persistence in various environments was carried out by irwin et al. [ ] . they reported half-lives of virus concentrations in water, air, feces, and fomites at various temperatures as well as in aerosols varying in temperature and rh. data were screened from relevant studies but only studies provided sufficient details as most published data suffered a lack of virus concentrations at a minimum of two time points. influenza virus h n had the shortest half-life of . min in paper tissue transfer to hands at °c and - % rh. longest half-lives of . and . h were found for influenza virus h n on eggshell and latex surfaces, respectively, at ambient temperature and humidity. an increase in temperature typically led to a shorter half-life. the use of heat treatments has been most effective means for nov inactivation [ , ] . alteration of capsid protein was considered as the main target of heat inactivation. most foodborne viruses are inactivated during > min heat treatment in boiling water but typical pasteurization temperatures around > °c may require up to min for virus inactivation [ ] . bioactives require stability in food or pharmaceuticals and their retention, for example, in drying operations is of much interest. spray drying involves aerosols and droplet sprays where bioactives often become protected. bioactive and other components in formulations migrate during atomization and spray drying within a hydrophilic or hydrophobic phase or toward interfaces depending on their affinity [ ] . lowering of water activity often improves stability of bioactives and nutrients in foods. dehydration of foods also seems to improve virion stability, and loss of infectivity may require substantially longer treatment times [ ] . moreover, atomization in spray drying results in a significant air-water interface area which may allow virions adhesion at droplet interfaces. spray drying often uses sufficient pasteurization of liquid foods prior to atomization, as is required for virion inactivation and reduced infection risks. weber and stilianakis [ ] recognized the crucial role of water in inactivation of influenza viruses. water is essential in maintaining the structure of the lipid bilayer of the envelope. according to cliver [ ] , enteroviruses may become inactivated by drying, which is not true for hav and hunov. furthermore, enveloped viruses due to their hydrophobic properties tend to accumulate on droplet surfaces rather than remain inside droplets as was assumed by marr et al. [ ] . interestingly, envelopes of virions (genome and capsid) contain - % lipids by weight that originate from host cell lipids [ ] . although nonenveloped viruses rely less on lipid structures, their hydrophobic entry to target cells requires hydrophobic surface properties. virions survival at various rh conditions in aerosols may vary although survival may increase at high rh and low temperature [ ] . both rh and absolute humidity (ah, mass of water in unit volume of air) have been suggested as key factors affecting virus stability [ ] . dehydration from aerosols and droplets at a low rh may increase virion stability, e.g., at room temperature where smallest -μm droplets dehydrate in milliseconds and droplets up to -μm in less than min [ ] . droplets larger than μm are also likely to settle on surfaces from . m height in s [ ] where subsequent dehydration may become considerably delayed. however, the equilibrium water content of emitted particles in aerosols approach the equilibrium vapor pressure of water in the surrounding air, and the final droplet size and water content become dependent on droplet composition and rh [ ] . dehydration affects the droplet size and it seems that virus inactivation occurs more slowly than dehydration of aerosol particles to an equilibrium size and water vapor pressure [ ] . one may also assume that aerosol droplets contain primarily proteins and nacl. therefore, dehydration occurs rapidly to . a w as nacl approaches saturation concentration and other components have a minor effect on final droplet a w due to their large molecular size. at an equilibrium of % rh ( . a w ), aerosol droplets retain approximately % of their initial diameter [ ] . obviously, the reduced size and water content have a significant effect on virions' gravitational settling, fate, and lifetime [ ] . marr et al. ( ) correctly noted that aerosol droplets became saturated during dehydration and subsequent crystallization of nacl could enhance viral degradation. they also showed that the settling time of a -μm particle during dehydration could change from approximately min up to h as a result of decreasing particle diameter. interestingly, marr et al. [ ] concluded that temperature and rh were the most important parameters affecting virus stability. that is because temperature as an intrinsic factor was seen to control inactivation of viral macromolecules while rh was claimed to be an extrinsic factor controlling evaporation. it is, however, important to note that dehydration controls water activity and the physicochemical properties of both droplet and viral components. indeed, lin and marr [ ] reported that virion inactivation at intermediate % rh levels was a result of solute concentration-induced damages to virions structure. they also noted that an intermediate-rh peak in virion inactivation occurred both in enveloped and nonenveloped structures. such high sensitivity of virions to inactivation at intermediate rh levels over to % rh [ , ] suggests that rh control during dehydration may be used to maximize virions' inactivation during dehydration. on the other hand, thermal processing prior to liquid dehydration in food manufacturing is often sufficient to reduce risks of foodborne infections. spontaneous rapid dehydration of aerosols at food manufacturing sites may retain virions' infectivity, and contamination from aerosols and droplets remains as a risk for food chain-related infections. low temperature drying can provide a high retention of sensory and nutritional food quality, but such food treatments also mean low inactivation levels of enteric viruses. butot et al. [ ] found that heating for min at °c was required to inactivate hav in freeze-dried berries. obviously, such harsh treatment results in loss of the superior sensory quality and flavor retained during freeze-drying to dried products. hav has been reported to show higher rate of decay at % rh than at % rh on nonporous surfaces during h at °c while survival can be higher at % rh than at % rh during d at °c [ ] . survival of viruses seems to depend on species and types of surfaces besides storage rh. nacl concentrations of ≥ % could be used for inactivation of hunov and hav in traditional korean foods [ ] . enteric viruses, however, can be assumed to retain infectivity in dehydration of fruits and vegetables [ ] , and data on hav infections have confirmed that many viruses retain infectiousness in drying [ ] . there is also some evidence that glassy structures form in dehydration of aerosols and droplets which may contribute to virion inactivation due to reduced rate of drying at intermediate rh conditions, but enhanced retention of infectivity at low rh conditions [ , ] . a decrease in temperature often reduces rates of chemical and biological changes, which may result in increased stability of virions. furthermore, conformational changes of macromolecules, solidification of lipid components, and other physicochemical properties of viral components may affect increased virion stability at decreasing temperatures [ ] , although differences in stability mechanisms of enveloped and nonenveloped structures are likely. chilled temperatures ( - °c ) during food storage in most studies have stabilized enteric viruses for a period exceeding product shelf life [ ] . that is often a period of days or longer. thermal and environmental factors affecting virion stability are summarized in table . lipids in influenza virions appear solid at and below °c while liquid state of lipids dominates above °c [ ] . chilling of contaminated foods seems to improve virion stability [ , ] . mullis et al. [ ] found that a bovine coronavirus could retain infectivity on lettuce surfaces with a d-value of - days at °c. virions showed a higher resistance with a d-value of days in a fecal suspension at the same conditions. mullis et al. [ ] suggested that dehydration on the lettuce surfaces could reduce infectivity. the findings of mullis et al. [ ] showed that enveloped corona viruses may retain infectivity on food surfaces for a sufficiently long period of time to result in transmission and infection in humans. marr et al. [ ] noted that ph effect on thermal stability at temperatures below and above °c suggested that temperature affected influenza virus stability at a molecular level. such conclusion also implied that differences in temperature could alter virus degradation mechanisms and kinetics. freezing was not found by butot et al. [ ] to reduce viability of a number of viruses. several studies have confirmed stability and retention of infectivity of virions during frozen storage of foods, particularly in frozen berries and shellfish [ , ] . sánchez and bosch [ ] concluded that freezing does not ensure an adequate reduction of enteric viruses if present in foods. on the other hand, there are variations in virus survival in foods depending on food composition. a higher decay rate has been found in blueberries, raspberries, and strawberries which was assumed to result from a lower ph [ ] . however, one also needs to take into account the extent of freezing which depends on food composition (e.g., [ ] ). the extent of food freezing and virion stability at various frozen storage conditions has not been considered in studies addressing stability of virions at low temperatures. berries are well known to have a higher unfrozen water content because of their high content of small sugars. on the other hand, virions may be found on product surfaces, but leaking of cellular fluids with sugars may affect the extent of freezing and virion stability during frozen storage. the survival of hav and virions of other enteric viruses in frozen foods suggest that virions need to be inactivated prior to freezing to ensure food safety even after long frozen storage periods. freezing and frozen storage in general seem ineffective in killing viruses [ ] . water activity, a w , is a well-recognized parameter in understanding food stability, but a w is not often used as a virus stability parameter. virions need no nutrients and virions have shown good stability in water. enteric viruses may survive several months in water and high a w foods, such as yoghurt and cheese [ ] . as enteric viruses in water were found to accumulate at pet surfaces [ ] , it suggested some hydrophobic interactions of nonencapsulated virions and virions' affinity to hydrophobic surfaces. cook et al. [ ] produced a comprehensive review on effects of heat, ph, and water activity on the survival of hav and hev (hepatitis e) viruses in food. their review, however, covered the effects of rh on virus stability rather than a w of foods. it should be noted that most studies of effects of water on virion stability have observed the environmental rh rather than the equilibrium water vapor pressure, i.e., a w , of the viral material. according to sánchez and bosch [ ] , surface alteration of virions at high rh and loss of structural water molecules at low rh contribute to virus inactivation. at high rh conditions, water may protect nonenveloped viruses in aerosols while enveloped viruses often exhibit improved stability at low rh [ ] . lin and marr [ ] reported that the high dose of solutes at intermediate rh conditions decreased dehydration as well as led to a higher level of virion inactivation. food materials often carry viral material on surfaces rather than as a contamination inside food. some virions of enteric viruses may contaminate food and their infectivity can become dependent on a w . that is, the water vapor pressure of the virion can be assumed to be at equilibrium with the vapor pressure of water within the food. surprisingly, a small number of studies have reported the effects of rh in closed containers on virus survival. stine et al. [ ] found that hav and feline calivirus (fcv) retained activity well at low rh conditions (mean rh - %). on the other hand, virions were more resistant in a complex food matrix than in water or simple solutions [ ] . indeed, a few studies have followed stability of hunov surrogates and hav in real food materials. data of bozkurt et al. [ ] and lee et al. [ ] confirmed enhanced retention of virus infectivity on wooden surfaces and real foods. virions tend to show higher sensitivity to water and temperature at intermediate rh conditions. prussin et al. [ ] showed that infectivity of bacteriophage phi (surrogate for influenza virus and other enveloped viruses) decreased significantly with increasing temperature over the range of to °c and to % rh. sánchez and bosch [ ] considered water as a medium that facilitated transmissions, but dehydration reduced such function. enteric viruses have been shown to be resistant against dehydration and they may remain infectious several months in dried food or feces [ ] . kim et al. [ ] stored hav, mnv (hunov surrogate), and ms bacteriophage over a range of rh ( , , and % rh) and temperatures ( , , , and °c) on stainless steel or coated wooden surfaces. they found that virion inactivation increased with temperature at all rh, and inactivation was significantly more rapid on stainless steel than on coated wood. kim et al. [ ] considered more rapid dehydration as a possibility for the difference although they noted that virus inactivation was also dependent on the type of the metal surface. one may note that significant differences in thermal conductivity, water condensation, and a w of the surface material can have an effect on loss of virus activity during storage. furthermore, it is likely that wood approached the a w corresponding to equilibrium relative humidity (erh) differently from stainless steel or other metals. metals, indeed, may exhibit surface condensation which can increase local and thereby a w of virions. other metals, such as copper, may also contain metal ions which may accelerate chemical reactions and physicochemical changes, including oxidation. all viruses studied by kim et al. [ ] showed retarded inactivation at % rh on both surface materials. casanova et al. [ ] in their study of effects of rh on sars-cov surrogates considered the maillard reaction as one possible reason to explain their finding of more rapid viral inactivation at % rh than at or % rh. they, however, stored viruses suspended in cell culture media dispensed as -μl droplets on stainless steel surfaces. obviously, dehydration and oxidation which may accelerate on metal surfaces were also considered as factors affecting loss of virions activity. the high level of virion inactivation at intermediate rh conditions [ ] suggested that virions' infectivity is likely to reduce rapidly on intermediate moisture foods. relative humidity has an impact on virus survival in aerosols and droplets, as rh affects rates of dehydration of droplets containing virions. the study of casanova et al. [ ] used two enveloped coronaviruses, transmissible gastroenteritis virus, tgev (alphacoronavirus ), and mouse hepatitis virus, mhv (murine coronavirus) on stainless steel surfaces at and °c and , , and % rh. such conditions were relevant for understanding virus stability in biological material at food manufacturing and handling facilities as well as effects of a w on virions. according to marr et al. [ ] , stability of influenza viruses has shown either a decrease in stability with increasing rh or u-shaped relationship showing lowest stability at intermediate rh conditions. one may also assume that the hydrophobic lipids in enveloped viruses enhance virions' sensitivity to organic solvents and the envelope may have an impact on retention of infectivity at various a w conditions as well as affinity to varyingly electrostatic as well as hydrophobic or hydrophilic surfaces [ ] . casanova et al. [ ] showed a significant retention of mhv and tgev infectivity at % rh (fig. ) . although d-values were > days at and °c and % rh, more rapid loss of infectivity occurred at % rh than at % rh at °c for mhv. a trend of d-values decrease with increasing temperature and rh was observed. d-values of - h at °c and % rh suggested that large numbers of virions of pandemic viruses may remain on surfaces for a sufficiently long time for spreading and infections. d-values of to months at % rh and to days at rh of and % at °c suggested that cold temperatures in food manufacturing and storage facilities can significantly enhance viral transmissions. furthermore, virions may retain activity on contaminated food packages in cold distribution chains. the high rates of infections of the new covid- at meat plants in several countries could be explain with the retention of infective virions at low temperature and high rh conditions. it should be noted that virions of these enveloped viruses are unlikely to exist inside food materials, as contamination is limited to aerosols, droplets, and surfaces. inactivation of viruses involves degradation of genomes and inactivation of virions. most studies have addressed degradation of genomes primarily using surrogates as detection of pathogenic viruses presents a number of analytical and safety challenges [ , ] . an early study of bidawid et al. [ ] investigated inactivation of hav in milk and cream. inactivation was determined in skim milk ( % fat), homogenized milk ( . % fat), and cream ( % fat). inactivation was followed at , , , , , , , and °c, but log reduction in titer at °c occurred within . min. their data up to °c showed that hav inactivation occurred more rapidly in skim milk than in fat-containing products. there are no studies on effects of food structure on virus inactivation, but it seems that dispersed particles provide a hydrophilic-hydrophobic interface for adhesion of viruses. foodborne virions seem to adhere on surfaces in food structures and it is expected that surfaces may enhance their stability. moreover, virions accumulate on surfaces during transmissions and they also need surface attraction during adhesion on outer target cell membranes to cause a subsequent infection. enveloped virions are often found on water-air interfaces [ , ] . nonenveloped enteric viruses migrated on hydrophobic walls of pet water bottles [ ] , but information on nonencapsulated virions' assembly in dispersions is limited. an arrhenius plot of reported inactivation kinetics data of bidawid et al. [ ] is shown in fig. . the results of bidawid et al. [ ] suggested that the activation energy, e a , was fairly similar around kj/mol for all dairy products over the temperature range from to °c. above °c e a for skim milk showed a strong nonlinearity increasing e a to around kj/mol suggesting a change in inactivation mechanism. the inactivation of hav occurred significantly more rapidly in skim milk than in homogenized . % fat milk. inactivation was also more rapid in the % fat cream. such difference may have resulted from homogenization as the overall interface area may be assumed to be larger in the homogenized . % milk than in cream. the change in activation energy above °c suggested that rapid denaturation of capsid proteins resulted in rapid hav inactivation [ ] . cliver [ ] noted that high temperatures of °c and above were detrimental to capsids of virions. bertrand et al. [ ] analyzed kinetic data of thermal genome degradation or viral inactivation summarizing findings published in original papers. they applied firstorder reaction kinetics to the data, i.e., viral inactivation or genome degradation was assumed to follow the relationship of equation ( ) . the weibull model was reported to fit better to inactivation kinetics data of enteric viruses [ ] . lee et al. [ ] studied hav and hunov surrogates (murine norovirus, mnv, and bacteriophage, ms ) loss kinetics in digestive glands of oysters, and surface of cut, fresh peppers. they used "virus survival" models to assess kinetic data obtained during incubation at , , , and °c at both and % rh. a linear model ( ), weibull distribution model ( ) , and a biphasic model ( ) were fitted to virus inactivation data. the temperature range covered by lee et al. [ ] found little variation in virus inactivation at the two different rh conditions. they reported less rapid virus inactivation in oysters than in peppers. the biphasic model fitted well to experimental data. relative humidity (%) d value (hours) °c fig. effect of temperature and relative humidity (rh) on enveloped mouse hepatitis virus (mhv) and transmissible gastroenteritis virus (tgev) inactivation on stainless steel surface, as derived from data of casanova et al. [ ] food eng rev where t is time, c t is concentration at time t, c is concentration at t = . n t and n correspond to c t and c but referring to the number of viruses, d is decimal reduction time, b and n are scaling parameters, f is first fraction surviving, and b and b are slopes of the first and second phases, respectively. bertrand et al. [ ] used time for first log reduction (tfl value) of genome degradation or viral inactivation as a universal kinetic criterion. tfl value was analogous to d-value, i.e., decimal reduction time, commonly used in thermal processing, but limited to the first log decrease. the tfl value represented a larger rate constant than would be found for subsequent d-values. the weibull model could provide a corresponding applicability. the weibull model takes into account an initial concavity that was shown by the decrease in viral concentration. it appeared that log tfl decreased linearly with increasing temperature, but the relationship showed a steeper slope for data above °c than below °c . although their data covered enteric, foodborne viruses and bacteriophages, they provided an overview of viral loss kinetics at normal ambient and common food processing temperatures. figure shows tfl values at °c derived from the data of bertrand et al. [ ] for common enteric viruses. bertrand et al. [ ] classified materials as "simple" and "complex" matrices, which represented high water content and a w materials, such as water or a simple solution, or a more complex, real food type materials, respectively. such classification followed common findings that virions' inactivation occurs more rapidly in water than in food materials. these findings agreed with the data of bidawid et al. [ ] for dairy liquids. the tfl at °c was longer than was suggested by the data of bidawid et al. [ ] for hav in milk and cream. an interesting finding was that log (tfl) had similar slope values for all virions, but only the slopes below and above °c were different. another variation was the intercept, α , at t = °c. in other words, the effect of temperature on the log (tfl) was not virus specific while each virus had an individual α and corresponding log (tfl). such temperature dependence supported the earlier assumption of liu [ ] suggesting that virion inactivation followed thermal kinetics of chemical degradation reactions. bertrand et al. [ ] concluded that the universal temperature dependence allowed a "worst case" virus to be selected as the most persistent risk for evaluation of thermal inactivation. one should note that such worst case needs to be validated for being sufficient to inactivate the most resistant and infective virions. the authors did not consider infective doses, which can vary significantly among virus infections. sánchez [ ] in her review concluded that pasteurization at °c for min or at °c for min seemed to be more effective against hav inactivation than short-time pasteurization ( . °c for - s), but such thermal treatments were not sufficient for complete virion inactivation. she also noted that normal cooking of shellfish was not sufficient to inactivate hav unless the shellfish internal temperature reached - °c for . min which compromised sensory quality. the results of bertrand et al. [ ] indicated that the tfl value at temperatures < °c was several days and extended to several months at °c (fig. ) . such levels of genome degradation or virion inactivation suggested that enteric viruses often remained infective in fresh foods until consumed or to the end of product shelf life in agreement with numerous studies on stability of enteric viruses in foods [ ] . that is washing and other forms of cleaning are essential in reducing infection risks. a further support on virus infectivity in contaminated foods is seen from the fairly low activation energies which apply to virion inactivation below °c (fig. ) . conversely, thermal treatment at temperatures > °c, preferably > °c, are required for efficient virion inactivation. even then the "worst case" treatment for tfl can be up to h, although for most virions d-value (tfl) for inactivation could be less than a few seconds. food-related studies of viruses are limited to potential foodborne transmissions and illnesses spreading in the food chain. studies involving highly infective pandemic viruses have significant challenges in laboratory experiments but could be valuable for understanding possible other than foodborne spreading routes. moreover, data for enveloped viruses may differ from mainly nonenveloped, gastric viruses. although casanova et al. [ ] dispensed virions in cell culture media on stainless steel surfaces, they used saturated salt solutions and controlled temperature conditions to maintain constant temperature and rh. their data can be used to derive dvalues and activation energies for coronaviruses. such data are also important examples of effects of water and temperature on inactivation of enveloped pandemic viruses. the data of casanova et al. [ ] showed that relative humidity had only a minor effect on mhv and tgev activation energy. as shown in fig. , the activation energy at the higher rh conditions varied little between the two viruses, although tgev seemed to have a larger difference at % rh. it should be noted that the data of casanova et al. [ ] similar to other studies of virion inactivation showed large variations and standard deviations. the data for both strains at % humidity suggested that inactivation mechanisms of virions at lower and higher temperatures were different and such variation was more pronounced at low rh (fig. ) . one possible factor reducing activation energy below °c is solidification of the lipid components of the envelope. furthermore, dehydration of structural components of the virion may be expected to result in conformational changes in proteins and other component macromolecules. unfortunately, there are no available data on the effect of cooling-reheating cycles on loss of infectivity of enveloped viruses to address lipid solidification and changes in macromolecular conformation. however, inactivation of virions at higher temperatures for the development and stability of vaccines is commonly addressed. thermal degradation may follow first-order kinetics, although non-linearity in plotting logarithmic concentration against time is often reported [ , , ] . liu et al. [ ] considered denaturation of the sars coronavirus as a temperature-dependent rate problem. their analysis of kinetic data for sars coronavirus inactivation showed a significant temperature dependence, particularly below °c . accordingly, the exponential increase in virion stability suggested sars coronavirus stability to extend over several days or weeks at low temperatures. the activation energy obtained was kj/mol in fairly good agreement with temperature dependence of inactivation of enteric viruses. liu [ ] estimated that sars-cov could have a lifetime of h at °c while at °c sars-cov could remain infective over d. conversely, inactivation of sars-cov at temperatures approaching °c could occur within min [ ] . madani et al. [ ] reported an activation energy of . kj/mol for inactivation of a flavivirus (alkhumra hemorrhagic fever virus, ahfv) over a temperature range of to °c showing a corresponding activation energy for the loss of infectivity. according to marr et al. [ ] , similarities in mechanisms of thermal degradation of influenza virus may apply over a range of systems, including aerosols, droplets, surfaces, and bulk culture medium. studies reporting kinetic data with temperature dependence of virus inactivation have often a limited temperature range below °c, and very little data are available on the impact of water content on thermal inactivation. this is particularly true for influenza and other enveloped viruses. modified atmosphere technology or packaging (map) may significantly improve the shelf life of many fresh foods, but it may not inactivate hav [ , ] and perhaps neither other viruses when food grade and safe gases are used. map and other novel processing treatments, such as hpp, pulsed electric fields (pef), pulsed light, cold plasma, or uv light, are used primarily for fresh or high a w foods. both hpp [ , ] and cold plasma [ , ] may provide means for virion inactivation besides thermal processing. according to li et al. [ ] , hpp could damage hunov capsid which explained virus inactivation. hav contamination is common in seafood, and a number of studies have reported effects of hpp or uv light treatment during shellfish depuration [ , ] . kingsley and co-workers as reviewed by kingsley ( ) have investigated effects of hpp on various nonenveloped enteric viruses in foods. kingsley ( ) noted that enteric viruses as nonencapsulated viruses need to become inactivated as a result of changes in protein conformation. that conclusion was made as enteric viruses have no lipid-specific component, and hpp is not effective in braking covalent bonds of nucleic acids. according to sánchez [ ] , hpp treatments at > mpa are effective in hav inactivation. uv-c light treatments or pulsed uv light have also reduced hav contamination in fruits, vegetables, and other foods. as in other stability studies, virus inactivation in hpp and uv light treatments has been found to depend on the chemical surroundings of the viruses, i.e., food composition, ph, etc. [ ] . studies of pulsed electric fields, ultrasound, and other emerging technologies' effects on viruses have been very limited. irradiation using gamma rays is also possible, but a high dose of gamma rays is required even in aqueous suspensions to effectively degrade virions [ ] . novel processing technologies would be applicable pretreatments prior to thermal processing, freezing, dehydration, and other food preservation to ensure virus inactivation and ensure minimal losses in food quality. moreover, combined processes in the control of foodborne infections may show more useful in reducing infection risks. on the other hand, refrigerated temperature in caliciviruses hpp treatment has been unexpectedly found to enhance loss of virion infectivity (kingsley, ) . hpp treatment parameters for virion inactivation also seem to vary substantially among various virus species. virions in food, water, and the environment are infective macromolecular bioparticles. several nonenveloped, enteric viruses contaminate fresh products, but pathogenic enteric viruses have a high resistance against virion inactivation. thermal processing exceeding common protein denaturation temperatures is often detrimental to genomic material and sufficiently efficient to reduce infective virion numbers and ensure food safety. moreover, virions are structured to protect their genome outside infected cells. loss of virus infectivity is a result of physicochemical changes and chemical reactions. such changes and reactions include, for example, dehydration, hydrogen bonding, hydrophobic interactions, electrostatic changes, and molecular conformations. consequently, virus inactivation needs to be considered in a similar context as loss of nutrients or bioactive substances. virion inactivation, however, needs to take into account virion stability in aerosols and droplets besides survival in food and surfaces. little is known on effects of water on virions' stability or loss of infectivity. dehydration of virions in aerosols and droplets has similarities with spray drying but it may affect both virion stability and loss of infectivity. kinetics of losses of virions infectivity suggest differences in inactivation mechanisms at lower temperatures below common pasteurization temperatures and higher temperatures applicable to pasteurization and thermal processing. activation energies are little affected by virus strains which, however, show large differences in thermal processing needs. novel food processing technologies provide additional means to control viral food safety. hpp and cold plasma treatment are examples of new technologies which may be used in food pretreatment without compromising food quality prior to subsequent food preservation. inactivation of murine norovirus- and hepatitis a virus on fresh meats by atmospheric pressure plasma jets the impact of temperature on the inactivation of enteric viruses in food and water: a review 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/cjag. sha: doc_id: cord_uid: lz chxab covid‐ has imposed a series of unique challenges on the food retail and food service sectors in canada. almost overnight, the roughly % of the food dollar that canadians have been spending on food away from home has shifted to retail. the impacts of the covid- outbreak on the food retailing sector in canada are significant and, to a great extent, unexpected. the impacts fall into two major categories, the first being the actual impacts of public health on individuals, on employees in retail and food service, and on individuals throughout the rest of the supply chain, and the second being the dramatic change in what and where people want to buy their food. although there is an immediacy to the impacts of covid- on the food retail and food service industries, there is a remarkably uncertain projection for the future in a world where the sars-cov- virus is manageable and we go back to "normal" life. the new "normal" is unlikely to be the same for the retail/food service level of food markets as life was in january . in canada, for example, over the period - , household expenditure share on food away from home increased from % to %. revenues generated by different industrial categories of retail trade and food service (figure ) illustrate the significant increase in revenues in food service and drinking places (deflated dollars), whereas food and beverage stores, convenience stores, and beer, wine, and liquor store revenues remain relatively flat across the period from to . both food retail and food service sectors are significant in terms of employment within canada. as seen from data in figure , the share of employees in food retail declined from a peak of . % of . million employees in to % of million employees in . the share of food service employees, on the other hand, increased from % of total employees in to . %, on average, over the period - . brown ( ) reported that, as of april , % of , canadian respondents had shopped for groceries online (with % regularly). these numbers were up from % of survey respondents from months earlier. in , statistics canada reported an increase in food service and drinking places that report e-commerce sales from . % of businesses in to . %. although canadians had awareness of the sars-cov- virus elsewhere in the world, the first report of a presumptive case of covid- in canada occurred on january , , in toronto. the virus began to get more serious attention from the public as states of public emergency were declared by individual provinces (march - ). with the shutdown of schools and eventually other nonessential services, heightened concerns were felt throughout the country. the recommendations/orders to stay home immediately changed the way individuals looked at food purchases. first of all, everyone (both children and adults) became housebound (with the exception of essential workers). second, people realized that they personally were vulnerable, to disease and to loss of employment, and that food habits needed to change-for example, eating three meals a day at home, changing the frequency of "shopping" trips, and being faced with the unavailability of certain places where they had traditionally shopped. at terrific speed, the following changes were felt in the food retail and food service system: . eating and drinking places were closed with the exception of takeout or delivery options. . there was a surge in the demand for online grocery shopping that caused the existing infrastructure to struggle (evidenced by websites that crashed or operated extremely slowly and by long turnarounds in delivery time options from between and days to days or more). the shutdown of sit-down restaurant dining switched food purchases to grocery stores. this significantly changed the volume and types of foods purchased at grocery stores without the stores having time to adjust their supply chains. in some notable cases, the shopping behavior resulted in shortages of products in grocery stores (e.g., toilet paper), which exacerbated people's concerns and may have increased stockpiling behavior. actions taken by food service, food retail, and government in response to the declaration of public emergency status and the changes in consumer behavior that ensued included the following: . distribution of food service excess foods to centers feeding vulnerable people and to food banks (with higher usage due to the sudden unemployment of major sectors of the population) (harvey, ). . grocery store chains and supermarkets hired more employees to deal with online orders and distribution, provided additional support to employees, and raised wages (wilson, ) . . grocery store chains changed their just-in-time inventory management strategies to be able to deal with uneven shortages throughout their largely national distribution networks, in some cases avoiding distribution centers completely (canadian grocer, ). . grocery store chains develop strategies to deal with older and more vulnerable shoppers, including specific shopping hours for the vulnerable group only and targeting the vulnerable group first for grocery delivery. . grocery store chains installed protective plastic shields to protect cashiers and adopted customer management strategies to maintain safe distances between customers; food service delivery systems adopted no-contact food drop off to reduce contact between customer and delivery person (shah, ) . . grocery store chains attempt to deal with the surplus of certain foods arising from reduced demand from food service through diversion to consumer-ready retail products. short-term problems arise due to "transportation shortages caused by an overwhelmed trucking industry, processing and packaging challenges, a sharp decline in bulk customers due to the mass closures of restaurants and bakeries, and inconsistent distribution to stores" (shaw, ) . . regulatory rules related to labeling and food packaging began to be adjusted to facilitate product processing for retail as opposed to bulk processing for food service (health canada, ) . further adjustments to regulatory policy are recommended by some analysts, including relaxation of some antitrust measures related to retailers collaborating on supply logistics (keogh, ) . . food retailers step up in response to request for aid from food banks and shelters (e.g., loblaw company ltd., a, b; metro inc., ; opinko, ). . the competition bureau signaled that it will generally refrain from exercising scrutiny in circumstances where there is a clear imperative for companies to be collaborating in the short term to respond to the pandemic (competition bureau, ). it is difficult to predict exactly what might happen in the food service and food retail sectors as canada recovers from the economic and public health effects of this covid- outbreak. once states of emergency are lifted, then food service will likely reopen, and the question of how long it might take for people to be comfortable eating in restaurants again remains open. income elasticities of demand for food-away-from-home purchases are considered to be more elastic than similar elasticities for food-at-home purchases. from table , the potential impact of the covid- outbreak on potential food expenditures in total and by segment can be illustrated. a base of the food expenditure levels is used to translate percentage expenditures into dollars. an assumption of a % impact on disposable income in and a % impact on disposable income in is used as the shock to the system. the above numbers assume that restaurants are allowed to open again in and that the income effects are distributed across the years rather than being captured in one or two quarters of . the results highlight the shift between food away from home and food at home (even in the absence of restaurant closures) arising from the oppositely signed income elasticities. food retailing and food service sectors are both important economically in canada. prior to the covid- crisis, the food retailing sector has been evolving to higher sales through supermarkets and convenience stores, and the food service sector has been growing considerably, taking food market share away from food retailing. actions taken under the states of emergency imposed to deal with the pandemic in canada have changed the reality of food purchasing and the confidence people have in the ability of the food retail system to maintain consistent food and grocery availability. some reactions by the public, such as increased online purchasing with grocery delivery, will likely be maintained after the pandemic restrictions are over. there are uncertainties about how the public will react after states of emergency are lifted in terms of restaurant visits and the types of foods that will be purchased through food retail. amazon leads online grocery shopping in canada: survey. canadian grocer grocers respond to food shortage fears amid covid- outbreak competition bureau statement on competitor collaborations during the covid- pandemic canadian food banks struggle to stay open, just as demand for their services skyrockets. globe and mail temporary suspension of certain labelling requirements for foodservice products due to covid- covid- : rules of game must be changed to ensure supply of food loblaw provides $ million donation to get food and health essentials to canada's most vulnerable president's choice children's charity funds $ million response to vulnerable kids missing school-based hunger programs due to covid- closures covid- -metro demonstrates together we can with a commitment to give $ million to help communities in need; encourages customers to come together and donate too save-on-foods launches $ -million campaign to feed kids during covid- pandemic. lethbridge herald grocery chains install checkout shields, raise wages in response to coronavirus pandemic. global news b.c. farms dumping milk because of problems getting it to the store walmart hires workers amid covid- how to cite this article: goddard e. the impact of covid- on food retail and food service in canada: preliminary assessment key: cord- -tvt gtn authors: li, dan; de keuckelaere, ann; uyttendaele, mieke title: fate of foodborne viruses in the “farm to fork” chain of fresh produce date: - - journal: compr rev food sci food saf doi: . / - . sha: doc_id: cord_uid: tvt gtn norovirus (nov) and hepatitis a virus (hav) are the most important foodborne viruses. fresh produce has been identified as an important vehicle for their transmission. in order to supply a basis to identify possible prevention and control strategies, this review intends to demonstrate the fate of foodborne viruses in the farm to fork chain of fresh produce, which include the introduction routes (contamination sources), the viral survival abilities at different stages, and the reactions of foodborne viruses towards the treatments used in food processing of fresh produce. in general, the preharvest contamination comes mainly from soli fertilizer or irrigation water, while the harvest and postharvest contaminations come mainly from food handlers, which can be both symptomatic and asymptomatic. foodborne viruses show high stabilities in all the stages of fresh produce production and processing. low‐temperature storage and other currently used preservation techniques, as well as washing by water have shown limited added value for reducing the virus load on fresh produce. chemical sanitizers, although with limitations, are strongly recommended to be applied in the wash water in order to minimize cross‐contamination. alternatively, radiation strategies have shown promising inactivating effects on foodborne viruses. for high‐pressure processing and thermal treatment, efforts have to be made on setting up treatment parameters to induce sufficient viral inactivation within a food matrix and to protect the sensory and nutritional qualities of fresh produce to the largest extent. foodborne viruses are overall excreted in high numbers in human feces, and they are transmitted by the fecal-oral route. the most frequently linked viruses with foodborne outbreaks, and as such identified as the foodborne viruses with the highest priority worldwide are norovirus (nov) and hepatitis a virus (hav) (fao/who ) . fresh produce has been identified as an important vehicle for the foodborne transmission (bassett and mcclure ; fao/who ) . vegetable row crops (such as leafy greens) and fruits were responsible for % and %, respectively, of nov foodborne outbreaks in the u.s. ( to ) (hall and others ) . concerning fresh produce outbreaks, nov was identified as the top cause of outbreaks ( %), according to a comprehensive survey of outbreaks with identified food sources in the u.s. ( to ) (dewaal and bhuiya ) . epidemiologic evidence linking foodborne outbreaks with virus contaminated fresh produce are available in the literature (table ) . frequently identified fresh produce items that were implicated ms submitted / / , accepted / / . authors li, de keuckelaere, and uyttendaele are with laboratory of food microbiology and food preservation, faculty of bioscience engineering, ghent univ., coupure links , b- , ghent, belgium. direct inquiries to author li (e-mail: dan.li@ugent.be). in these outbreaks are soft red fruits (including raspberries and strawberries) and leafy greens (such as salads). the overview of the peer-reviewed outbreak investigation literatures gives only a narrow view on the relevance of fresh produce as a vehicle for foodborne viruses, since not every foodborne outbreak is reported in peer-reviewed publications. mostly the reported outbreaks are from north america or europe. in order to determine a basis to identify possible prevention and control efforts, this article reviewed the transmission routes and viral persistence of foodborne viruses (mainly novs and hav) during the farm-to-fork chain of fresh produce, as well as the effect of treatments used in food processing of fresh produce on viruses. since it still remains impossible to determine the viral infectivity of human novs and most wild-type hav strains, the detection of foodborne viruses relies mainly on molecular methods, exclusively reverse transcriptase-quantitative polymerase chain reaction (rt-qpcr). in order to understand the stability of human novs, surrogates that share pathological and/or biological features with human novs (for example, feline calicivirus [fcv] , murine norovirus [mnv] , and tulane virus [tv] ) have been used (cromeans and other ; wang and others ; arthur and gibson ; mormann and others ) . for hav, only a laboratory-adapted variant hm can be propagated and therefore has been used in the survival and inactivation studies (shimasaki and other ). foodborne viruses in fresh produce . . . all foodborne outbreaks linked to the same kind of lettuce and the same supplier suggesting contamination at farm-level. lettuce was believed to be contaminated with multiple nonzoonotic pathogens leading to the speculation that human fecal matter may have been the source of contamination, possibly via contaminated water ethelberg and others ( ) mixed raw vegetables enteric viruses such as novs and hav follow the fecal-oral transmission route. as both human nov and hav are currently believed to be nonzoonotic viral pathogens, the primary cause of contamination is contact with (residue of) infected and shedding people. a person infected with nov can shed up to viruses (rt-pcr) per gram of feces (atmar and others ) . a person infected with hav can excrete to particles/g of feces during infection (sanchez ). next to the high viral load during shedding and the low infectious dose, also environmental persistence facilitates water-and foodborne spread of nov and hav. hence in this section, next to the causes of the contamination of fresh produce, also environmental persistence will be included during each of the stages of the farm-to-fork production chain. the life cycle of a plant starts with a seed. viral outbreaks have not yet been linked to sprouted seeds. nevertheless, to understand whether viral-contaminated seeds could also pose a threat to human health, wang and others ( ) investigated the persistence of hav and human nov surrogates mnv and tv on alfalfa seeds during storage and on sprouts after a -d germination period. it was reported that hav, mnv, and tv remained infectious on the surface of the alfalfa seeds after d. following a -d germination period, viruses were located in all tissues as well as in sprout-spent water sampled on several occasions (wang and others ) . as such, good agricultural practices (gap) during production of seeds and appropriate control measures to prevent cross-contamination due to reuse of water during germination should also focus on enteric viruses as a possible contaminant. similarly, although specific foodborne outbreaks due to fresh produce linked to viral-contaminated soil are missing, proof of the concept has been demonstrated in a study by wei and others ( ) . attachment of mnv was observed upon contact of lettuce with spiked treated sludge and manure. hence, viral presence in soil may increase the risk of fresh produce contamination (wei and others ) . as nov and hav are generally strictly confined to humans as their sole hosts, application of animal manure to the soil as fertilizer does not contribute to viral contamination of the produce. however application of manure or slurry contaminated with excrements of human origin, or the proximity of a latrine may pose a risk. a second source of viral contamination of the soil is the application of sludge. sludge originates from the process of waste water treatment and, hence, might contain high loads of pathogens (viruses, bacteria, and so on) present in waste waters. concerning the persistence of enteric viruses in soil, temperature, and moisture are primary factors influencing persistence. overall, both relatively short-term ( d) persistence of poliovirus in soil in ohio in summer (tierney and others ) and long term persistence (ࣙ mo) of coxsackievirus in soil in winter in denmark (damgaardlarsen and others ) of enteric viruses in (amended) soils have been observed. more detailed reviews are available in the literature (rzezutka and cook ; . intentional application of water at the farm stage includes the use of water for irrigation, the use of water to dissolve and apply chemicals (such as fungicide, insecticide) to the produce, and the use of water for cleaning of equipment. links to a major outbreak in the czech republic in ( ill persons) specifically linked to hav-contaminated frozen strawberries due to irrigation with sewage can be found (leggeÄm ) . viral foodborne outbreaks due to possible contamination as a result of vegetable or fruit spraying with insecticides and fungicides mixed with contaminated water were not found in the literature. however, the relevance of these transmission routes for viral pathogens has been proven during experimental field studies (cheong and others ; brassard and others ) and by the use of qmra others b, ) . viral contamination of plants by means of irrigation water may occur in ways, either by direct contact, like by spray or splash, or through internalization into the tissue via the root system of the plant. in studies in which plants are grown in viral-contaminated hydroponic solution, high contamination levels of enteric viruses in edible plant tissue have been demonstrated, such as contamination levels exceeding log gc/plant for hav and mnv have been found in all portions of both green onion and spinach plants, including the edible portions (hirneisen and kniel a) . transfer of organisms from water to produce surfaces via irrigation is influenced by irrigation method and the type of produce. irrigation method is an important factor as choosing an optimal strategy can minimize the contact of irrigation water with the above-ground portion of the crop and, hence, lower the risk of viral contamination. in a field study by stine and others ( b) no viral contamination of lettuce was detected when grown using subsurface drip irrigation practices, while the use of furrow irrigation led to contaminated lettuce. crops irrigated with sprinkler and furrow systems may have a higher chance of direct contact with viruses and are, hence, considered to be more hazardous for fresh produce crops such as lettuce . concerning the influence of produce type, leafy vegetables such as lettuce, with high water retention capacity and in close contact with the ground, are identified to be especially vulnerable to viral contamination through irrigation (hamilton and others ) . presence of enteric viruses has been demonstrated in all sorts of waters generally used for irrigation of produce. as such, novs have been detected in ground water wells in the united states (fout and others ) , korea (cheong and others ; park and others ) , and italy (gabrieli and others ); in canal waters in the united states (kayed ) ; in reclaimed wastewater, and in river water samples all over the world as in poland (kozyra and others ) , in the netherlands (westrell and others ) , in japan (haramoto and others ) , and in south africa (mans and others ) . sources of irrigation water can be generally ranked by the microbial contamination hazard: in order of increasing risk these are potable or rain water, groundwater from deep wells, groundwater from shallow wells, surface water, and finally raw or inadequately treated wastewater (pachepsky and others ) . the omnipresence of enteric viruses in these waters can be explained by (i) the recalcitrance of enteric viruses such as novs toward wastewater treatments, as viruses have been detected in both influent and effluent waters (da silva and others ; sidhu and toze ; battistone and others ), (ii) the deficient state of current sewage systems and the omnipresence of viral contamination sources such as leaking septic tanks, latrines, combined with a higher potential for transport in soil (hijnen and others ) , and (iii) the high persistence of enteric viruses in these waters. in general, mean inactivation rates of viruses in fresh water are less than log per day, indicating that viruses can persist in freshwater sources for prolonged periods (rzezutka and cook ) . persistence of surrogate virus mnv- has also been observed in reconstituted pesticides (verhaelen and others b) . with time, the ratio of infectious particles to genomic copies (molecular detection) has been observed to decrease and, as such, this ratio is partly depending on the "age" of contamination (de roda husman and others ). the persistence of enteric viruses in water is known to be affected by temperature, virus association with solids, exposure to light (uv), and the presence of indigenous microbiota. these are all factors that are known to be substantially different from one geographical location to another (john and rose ; bosch and others ) . generally a faster die-off rate is observed on fresh produce than on or in soil which is considered as a more protective environment from solar radiation and desiccation (choi and others ) . however, enteric viruses can persist for several days on fresh produce during preharvest conditions. as such, a d-value of . d was observed for mnv- on semisavoy spinach during a persistence study in greenhouse biocontrol chambers (hirneisen and kniel c) . while an inactivation rate (k d ) as low as . , . , and . per day (corresponding to a d-value of , , and d) was observed for hav on cantaloupe, lettuce, and bell peppers, respectively, during a persistence study in a controlled environment chamber mimicking relevant growing condition in the united states and central america (stine and others a) . all in all, these limited studies suggest that enteric viruses persist longer than enteric bacteria and may persist from the time of contamination (such as by means of irrigation) to harvesting (stine and others a) . persistence can depend on crop type and even crop variety (e.g., survival of mnv- and tv on semisavoy spinach versus smooth spinach mentioned by stine and others a; carratala and others ; hirneisen and kniel c) . since the surface texture and structure of vegetables may play an important role in the attachment and persistence of viruses. as such, the rougher or more irregular the surface of produce, the longer viruses are able to persist (stine and others a; hirneisen and kniel c) . there has been evidence for biphasic inactivation of viruses on crops during preharvest conditions (petterson and others ) . an important implication of the biphasic inactivation is the possibility for virus accumulation on the crop surface over subsequent irrigations due to the presence of a persistent subpopulation of viruses that decay slowly (petterson and others ) . this higher persistence of this subpopulation could be a result of their location in a more protective niche such as stomata, complex wax structures, or cuts. also, the location of inoculum on the abaxial (lower) leaf surfaces has been observed to result in higher decimal reduction times (d-values) compared to viruses present on adaxial (upper) leaf surfaces (hirneisen and kniel c) . in this stage food handlers are identified as critical point or hot spots for the transmission of foodborne viruses. food handlers in this context include field harvesters, production plant workers, professional chefs and caterers, but also nonprofessionals such as those cooking at home, or at a youth camp preparing food. the risk of contamination posed by an infected food handler can depend on personal factors specific to a food handler, including, for example, phase of clinical infection which impacts the degree of virus-shedding, personal hygiene habits, and a variety of behavioral factors such as the willingness to work when feeling ill (mokhtari and jaykus ) . note that this transfer by infected food handlers can involve both symptomatic as well as asymptomatic food handlers, as also asymptomatic food handlers can shed similar high loads of virus particles (ozawa and others ) . for instance, up to % of analyzed feces samples of asymptomatic food handlers working at a none-outbreak-related facility in japan tested positive for nov (okabayashi and others ) . the harvesting of fresh produce can be either manual or mechanical. as such, contamination can take place due to contaminated food handlers and/or contaminated surfaces. food handlers' hands can also get contaminated by the produce and serve as a vehicle for further contamination. this was observed in a study on hand hygiene of pickers of green bell peppers in mexico where the workers' hands were not contaminated before work ( / ), while . % ( / ) of the pickers' hands were contaminated with novs after h of work (leon-felix and others ) . during harvesting, food handlers such as fruit pickers have been suspected as the source of contamination in several reported viral soft red fruit outbreaks (table ) . to assess to which extent food handlers and contaminated food contact materials contribute to the introduction and spread of foodborne viruses, transfer experiments are available in the literature that encompass all of the possible transfer combinations with hands, produce, food contact materials as either donor surface or acceptor surface (reviewed in kotwal and cannon ) . in short, mean transfer rates of infectious viruses ranging from % to % and . % to . % have been found for contact of contaminated finger paths (dry conditions) with lettuce ( enteric viruses have the potential to persist on hands for the better part of a work shift, as in a study by mbithi and others ( ) a biphasic reduction curve was observed, resulting in a mere . to . log reduction h after inoculations of hav on human hands. this illustrates the potential risk when infected food handlers are employed in a food processing/handling environment. once surfaces are contaminated, these surfaces can function as reservoir for further contamination events, and this for prolonged periods of time, as the relative persistence of enteric viruses in the environment is high. as such, the half-life of hav on stainless steel under different conditions (t ࣘ °c and rh < %) was at least d (sattar and others ) . surrogate mnv- has been observed to remain infectious after d on several surfaces (stainless steel, ceramic, rubber, wood, glass, plastic) at room temperature (kim and others ) . exceptionally, it has been found that copper could effectively inactivate mnv- by destroying the viral capsid massively (warnes and others ) . on inanimate surfaces, the most important factors that affect virus stability are the type of virus and surface, relative humidity, moisture content, temperature, composition of the suspending medium, light exposure, and presence of antiviral chemicals or biological agents (bosch and others ) . foodborne viruses in fresh produce . . . next to these influencing factors, the presence of food residue has been observed to increase the persistence and the resistance of enteric viruses towards chemicals (takahashi and others ) . after harvest the produce is cooled at the farm or immediately after entering the postharvest processing or distribution stage, depending on the locally available infrastructure. in the case of raspberries, postharvest processing can consist of the production of individual quick-frozen (iqf) raspberries or raspberry puree. for the production of iqf raspberries, raspberries are frozen after which manual sorting can take place. the presence of nov shedders is realistic considering the high prevalence of nov infections in a community. transmission through contaminated hands is hence realistic since the presence of nov contamination on the hands of infected individuals has been confirmed during clinical trials (liu and others ) . since washing is one of the typical processing units in the production process of fresh-cut lettuce, risks concerning washing practices will be discussed for lettuce. in the processing of lettuce toward fresh-cut leafy greens, the produce is cut, washed, and spindried before packaging with or without protective atmosphere. this washing process has the potential to reduce the microbial load of the incoming fresh produce but has also the potential to be a direct source of contamination and a vehicle for spreading localized bacterial and viral contamination (cross-contamination) when sanitizers are used inadequately or are lacking (holvoet and others ). as such, in a recent outbreak in korea the use of contaminated ground water during the processing of cabbage kimchi was identified as the source of viral contamination (cho and others ) . viral transfer from contaminated fresh produce to washing water (without sanitizers) has been documented for both lab-scale and industrial-scale washing units (baert and others ; casteel and others ; holvoet and others ) . persistence of enteric viruses in wash water has been shown to amply exceed common working hours (ࣙ h, °c) (baert and others ) endorsing the potential risk for cross-contamination. in-depth study on the consequence of a contaminated wash bath for the processing of several batches of lettuce and resulting quantitative data of transfer rates is available (holvoet and others ) . next to the washing process, cross-contamination by contaminated machinery (such as by cutters), contaminated surfaces, and leftovers from a previous contaminated batch is also a possibility. at the level of caterers and professional food handlers the same risk factors exist as at the processing level. the bare-hand contact with food is likely the most prominent way of transmission (hall and others ) . therefore, a "no bare hands" rule was included in the u.s. food and drug administration's model food code and has been already adopted by many states. such legislation is not commonly found in other parts of the world. however, while gloves may provide an important barrier against food contamination, it has to be noted that they cannot be used as a stand-alone hygienic measure. the combination of hand washing with an extra intervention measure-hand gloving and hand gloving/disinfectant-is advised to prevent virus spread during food preparation (stals and others ) . in addition, infected food handlers can also indirectly contaminate the food by contaminating the environment. besides, cross-contamination with naturally contaminated fresh produce or other food commodities such as seafood is also a risk factor. for example, the cross-contamination of salad by seafood was identified as the probable cause of an outbreak of nov illness in (griffin and others ) . this section will focus on treatments applicable to fresh produce that allow the retention of fresh-like organoleptic properties and the data will focus on effect of processing on the viral load of fresh produce. special attention will be reserved for the novfresh produce commodities frequently linked to viral foodborne outbreaks, lettuce and raspberries. however, as frozen raspberries are frequently linked to viral outbreaks, leading to the recommendation to heat frozen berries before consumption, as in several north european countries, both freezing and heat treatment will also be included in this section. low-temperature storage immediately upon harvest is recommended to preserve the quality of fresh produce, primarily by lowering the respiration and metabolism rates. ideal storage temperatures for berries and leafy greens are to °c and to °c, respectively (efsa biohaz panel a,b). temperature has been identified as the major factor influencing virus persistence. however, in contrast to bacterial pathogens, maintaining the cold-chain cannot be considered as a mitigation strategy for viral pathogens on fresh produce, as persistence of enteric viruses is higher at low temperatures, and decay rates generally increase with increasing temperatures (rivm ). in table , log reduction data are presented for the persistence of enteric viruses or their surrogates on soft red fruits and leafy greens. next to temperature, persistence has been found to depend on other factors: type of fresh produce (croci and others ; verhaelen and others ) , different environmental factors, such as relative humidity (rh), presence of feces, and aggregation (konowalchuk and speirs ) , and the virus type (rzezutka and cook ) . the presence of fecal material strongly enhances virus persistence (escudero and others ) . the effect of rh is less unambiguous given that mnv and ms persisted better at low rh, while hav persisted better at higher rh in a study by kim and others ( ) . in a recent study it was suggested that absolute humidity (ah, a measure of the actual amount of water vapor in a particular sample of air) rather than rh (the ratio of the actual amount of water vapor present in a sample to that amount that would be needed to saturate that particular sample) is the critical factor for keeping nov infectious. the data also suggested that when the atmosphere was not entirely saturated (as % rh), low ah values (below . kg water/kg air) are favorable to nov persistence. this possibly explains the seasonality of nov infections since low winter ah conditions ( . % of the day with ah < . kg water/kg air) in a temperate climates as in paris, france provides favorable conditions for keeping human nov infectious (de la noue and others ). since the shelf-life of fresh produce, and especially for casestudies lettuce and raspberries, is short, only a low reduction in the numbers of infectious viral particles is expected when stored at cold temperatures. overall, persistence of enteric viruses can be expected during the time between purchase and consumption. in case of fresh-cut lettuce, modified-atmosphere packaging (map) is generally adopted. map is a food-packaging method in which the proportions of carbon dioxide, nitrogen, and oxygen in a sealed container are different from those in the normal (ambient) air to enhance the food's shelf life. next to functions such as the control of the respiration and reduction of enzymatic browning reactions, map conditions have also been designed to reduce the growth of spoilage microorganisms and pathogens. however, in a study on the persistence of hav in packaged lettuce, a modified atmosphere did not influence the persistence when incubated at °c. even a slight improvement in virus persistence on lettuce was observed in the presence of high co levels ( % co , % persistence) at room temperature (rt) compared to when stored in bags with normal atmospheric conditions ( % persistence) (bidawid and others ) . map is also applied on berries, however mainly on berries intended to ship fresh for long distances, and not applied in final consumer packages (efsa bio-haz panel a). next to map packaging, the antiviral activity of active packaging material consisting of silver-infused polylactide (pla) films has also been explored on virally contaminated vegetables. however, the efficiency of active packaging based on silver depends very much on the food type, on environmental factors, and on the pathogen. for instance, on paprika no antiviral activity of the packaging towards fcv was observed, while reductions > . log were observed for fcv on lettuce (martinez-abad and others ). by far, the most popular method for storing berries is freezing. in the largest european raspberry producing countries serbia and poland, the majority of raspberries (> % and > %, respectively), is exported frozen (djurkovic ) . freezing, however, has no pronounced influence on the viral load of fresh produce as no reduction was noted of mnv- surrogate on frozen onions and spinach after mo of storage (baert and others a) , and frozen storage for mo had limited effects on hav and rv persistence in berries and herbs (butot and others ) . cryostability of nov (gii. ) to freezing and thawing was also observed in a recent study by richards and others ( ) . in general, freezing is actually used as a method for long-term storage of fecal and lysate stocks of enteric viruses in research. also, during outbreak investigations, according to the cdc updated nov outbreak management and disease prevention guidelines, food samples strongly suspected as the source of an outbreak of acute gastroenteritis should be stored frozen at − °c before analysis for optimal preservation (hall and others ) . in conclusion, enteric viruses such as nov and hav are expected to persist during the shelf-life (up to mo and more) of frozen fruit and vegetable products and have been implicated in several foodborne outbreaks due to frozen berries (table ) . vacuum freeze-drying is the reference process for manufacturing high-quality dehydrated products to maintain the color, flavor, and most types of antioxidants. the production of freeze-dried produce involves preliminary freezing of fresh produce, followed by placing the produce under reduced pressure with sufficient heat to sublimate ice. in the study of butot and others ( ) , an optimized freeze-drying treatment decreased the hav infectivity and the human nov rna presence on strawberries, raspberries, blackberries, blueberries, parsley, and basil with varied effects ( . to . log reduction). next to temperature, ph has been identified as a principal determinant for the growth of bacteria on fresh produce. berries have a relative acidic internal ph varying between . and . , depending on the berry species (knudsen and others ) . however, enteric viruses are engineered to survive stomach acid and, hence, longterm persistence (mnv- , refrigeration temperatures) has been observed in acid conditions such as fruit juices (> d besides the removal of dirt, foreign materials and tissue fluids from cut surfaces, washing, rinsing, and spraying are used to reduce the microbial load on fresh produce, while allowing the retention of fresh-like organoleptic properties. often chemical sanitizers are added to the wash solution in order to maintain the water quality and to increase the reducing effect of the treatment. in this part, efficiency of general washing practices and effect of chemical sanitizers will be discussed. however, comparing the outcome of different studies is not always relevant as several process parameters concerning the experimental set-up, such as treatment time and doses, produce:water ratio, organic load, ph of washing water, and type of produce and virus, can have an influence on the effectiveness of decontamination treatments (gil and others ). an experimental set-up that mimics industrial practices as realistic as possible should be the intention. generally, washing results in ࣘ logarithm decrease (tenfold decrease) in the quantity of viruses detected ( others ). minor adaptations to the classic washing step by immersion such as use of bubbling (fraisse and others ) or warm water ( °c) (lukasik and others ; butot and others ) , or the inclusion of hand rubbing (lukasik and others ) did not significantly improve viral reduction on the produce. household practices such as the addition of salt ( . % nacl), liquid dishwashing detergent ( . %), or use of the consumer-oriented produce wash fit (procter and gamble, contains ethanol, sunflower oil, glycerin, potassium hydroxide, and grape fruit oil) did not have any significant added value for reducing the viral load on strawberries in a study by lukasik and others ( ) . in table , a selection of available reduction data is given when using tap water or the commonly used chlorine and peroxyacetic acid (paa) solutions. hypochlorite is, despite its corrosive nature, the most commonly used sanitizing agent and widely applied in food processing. chlorine preparations are available as solid (calcium hypochlorite: ca(clo) ), aqueous solution (sodium hypochlorite: naocl), and chlorine gas (cl ). chlorine solutions can be either applied by immersion of the food or by spraying. after application of a sanitizer, in spray or in the form of a bath, rinsing or a final wash of the fresh produce in potable water is compulsory to remove any residual chemical and/or by-products. in order to maximize the efficacy of chlorine disinfection, the concentration of free chlorine (fc), the ph (ideal ph to ), and the organic load (cod level) of the wash water must be controlled. generally applied chlorine dosages and contact times by produce processors are to ppm (mg/l) for a maximal contact time of to min, leading to typical log reductions of to logs for bacteria and viruses on fresh produce (casteel and others ; predmore and li ; goodburn and wallace ). the effectiveness of chlorine in virus inactivation on produce can vary according to the virus under study (butot and others ; fraisse and others ) and according to the type of produce (butot and others ) . in spite of the rather modest viral reductions on fresh produce obtained using chlorine, chlorine is much more effective for inactivation of viral pathogens in suspension (wash water) than for removal of these pathogens from fresh produce (dawson and others ) . this reasoning also applies to bacteria. hence, despite the general idea that sanitizers are used to reduce the microbial population on the produce, their main effect is maintaining the microbial quality of the water (gil and others ). hence, the use of wash water sanitizers is highly valuable to reduce cross-contamination from one contaminated crop/batch to the other crops/batches present in the washing bath. the drawback for the use of chlorine is that this biocide is highly corrosive for the stainless steel surfaces commonly used in the food industry, and its efficacy is negatively influenced by the organic load of the wash water. also, the formation of by-products in the wastewater, such as trihalomethanes (thms), has been frequently cited as the downside of using chlorine and is the reason for the continuous search for new alternatives for disinfection (fraisse and others ) . these by-products are formed by reaction of the chlorine disinfectant with organic matter in the wash bath. despite the occurrence of the formation of thms in the process wash water, no residue can be found in vegetable tissue after rinsing with tap water (lopez-galvez and others ; gomez-lopez and others ). when good practices are applied (hence control of cod, fc, and regular refreshing of washing water), chlorinebased sanitizers such as chlorine gas, sodium hypochlorite, and calcium hypochlorite can be safely used to wash fresh produce, in spite of the formation of thms in the water. as such, suggestions that the industry should move away from this traditional disinfection agent are unreasonable (gil and others ) . another chlorine-containing disinfectant used in food production and processing is chlorine dioxide (clo ). advantages of clo in comparison to the classic chlorine-containing disinfectants is that no formation of thm compounds occurs in the presence of organic matter (lopez-galvez and others ); and this sanitizer is little affected in its effectiveness by ph and the presence of high amounts of organic matter (hirneisen and others ) . however, application of clo in the united states is restricted for use in washing whole fruits and vegetables and, hence, not permitted for disinfection of fresh-cut fruits and vegetables (hirneisen and others ) . other restrictions for the use of chlorine dioxide are that it must be generated on site due to its instability and that it can be explosive when concentrated. concentrated solutions of sodium chlorite are on the market, for example, carnebon (intl. dioxide inc., clark, n.j., u.s.a.) and oxine (bio-cide intl., inc., norman, okla., u.s.a.), that upon acidification generate "stabilized chlorine dioxide" (lukasik and others ) . however, the effectiveness of clo at the recommended low concentrations for usage by the fda (max. mg/l or ppm), is rather low (only about log reduction) for fcv and hav, even at the rather extensive contact times ( min) tested by butot and others ( ) . next to chlorine-containing solutions other chemical agents have been tested for their effectiveness in reducing the viral load of fresh produce during washing: peroxyacetic acid solutions (paa) (equilibrium mixture of hydrogen peroxide and acetic acid) (as in allwood predmore and li ) . next to chemicals, also the antiviral properties of natural biochemical substances such as grape seed extract (gse) in wash water (li and others ; su and d'souza ) and sprays of essential oils (azizkhani and others ) have been explored. each of these tested substances has its own merits, limitations, and drawbacks. the effects of some promising combinations of different chemicals or inactivation strategies have been studied on fresh produce. as such, the use of the combination of the surfactant sds ( ppm) and chlorine ( ppm) enhanced the efficiency of virus removal and inactivation (mnv) resulting in a reduction of up to log for lettuce, strawberries, and raspberries ( min, rt) (predmore and li ) . also, a synergism was reported between the use of vaporized h o and uv light on lettuce (xie and others ; li and others ) . in conclusion, good practices for the washing of fresh produce require the use of a sanitizer. sanitizers (such as chlorine or paa), however, are generally more effective in viral reduction in suspension (wash water) than on surfaces such as on fresh produce (dawson and others ) as only marginal reductions of the viral load are obtained on fresh produce ( to log ). even the introduction of multiple washing steps performed in series (baert and others b) , extended contact times (xie and others ) , or the use of increasing concentration of disinfectants (butot and others ) , will not necessarily lead to significantly higher reductions of the viral load of fresh produce. similar to bacteria, viruses can be located in protective sites on the produce, such as the stomata or the cut edges, not accessible during washing procedures and most decontamination processes. as such, the use of sanitizers during the wash process is primarily to maintain the microbial quality of the wash water and hence to limit the possibility of cross-contamination. nonetheless, reporting of the effectiveness of the sanitizer under study in reducing the viral load in the resulting wash water is not always included. however, the latter is important to judge the utility for any sanitizers as mitigation strategy for cross-contamination. good practices are also required to limit internalization of pathogens by avoiding influx of potentially contaminated wash water into the produce. therefore, a higher temperature of the washing solution than the temperature of the produce is demanded, as if the reverse is true, air bubbles inside the fresh produce will shrink upon contact with the cold water, resulting in a partial vacuum causing wash water to enter the tissue through pores, channels, or punctures (holvoet ). in this section the effect of radiation, both nonionizing and ionizing radiation, and high-pressure processing (hpp) will be discussed as nonthermal inactivation treatment options for enteric viruses in fresh produce. both irradiation with ionizing radiation and appropriate use of hpp effectively inactivate both surface and internalized viruses. both ionizing and nonionizing radiation have been tested as disinfection strategies for vegetables contaminated with viruses. the most widespread used form of nonionizing radiation for decontamination is the uv light ( to nm). uv disinfection primarily occurs due to the germicidal action of uv-b ( to nm) and uv-c light ( to nm) on microorganisms (us epa ) . most studies use low-pressure (lp) mercury lamps with a major wavelength output ( %) at . nm (monochromatic uv radiation) (hijnen and others ; eischeid and others ) . inactivation by this ultraviolet range is based on the damage caused to the nucleic acids (dna/rna) of the cell or virus, for which the uv absorbance peaks near nm. among food-and waterborne pathogens, viruses are generally more resistant than protozoa, such as cryptosporidium and giardia, and the bacterial pathogens (hijnen and others ) . adenoviruses are the most uv-resistant class of viruses presently known and are, therefore, used as a standard for viral inactivation requirements in, for example, water disinfection (eischeid and others ). concerning fresh produce, uv light (dose: to mw s/cm²) was shown to be effective in the reduction of hav and fcv on lettuce and green onions, resulting in reduction of to log for hav and . to log for fcv. however, on strawberries significantly lower reductions were observed for both viruses (< log ). in a study by hirneisen and kniel ( b) , however, mnv- proved to be more resistant to uv light, as a dose of mw s/cm² resulted in a mere reduction of about . log on green onions. as such, the food matrix and surface typography play an obvious role (fino and kniel ) . also, a wide variation in viral sensitivity to uv has been recognized (eischeid and others ), making it impossible to estimate the possible influence on human nov. another disinfection strategy using nonionizing radiation is the use of pulsed light (pl) treatment. pl is a modified and possible improved version of delivering uv-c to bodies, using xenon lamps to deliver short-time pulses of an intense broad spectrum ( to nm) rich in uv-c light. pl treatment is a relatively new technology and only one study was identified applying pl treatment on produce. in this study the effectiveness of to pulses ( μs each, fluence of . j/cm /pulse) was tested on ms inoculated on black pepper, chopped mint, and garlic powder. however, only marginal reductions were obtained (generally < . log reductions, except for mint . log reduction) in comparison to the reductions obtained in viral suspension after merely pulses (> log reduction) (belliot and others ) . the downside of the use of nonionizing radiation compared to ionizing radiation is the superficial character of uv treatment. the light should be able to reach all surfaces of the product, but internalized microorganisms would be unaffected due to the light absorption by the surface. therefore, this treatment option is quite impractical for decontamination of lettuce on an industrial scale. ionizing radiation is radiation that carries enough energy to liberate electrons from atoms or molecules, thereby ionizing them. ionizing radiation used in food processing can be electromagnetic radiation (gamma rays and x-rays) or particulate radiation foodborne viruses in fresh produce . . . (electron beam). with the first type, γ -rays are produced from a radioactive source (co- or cs- ), the other (x-rays and e-beams) require specific equipment converting other energy sources, such as an electric current, without the involvement of any radioactive substance. as such, in the latter cases the producing equipment can be switched on or off depending on the need. the application of x-rays will not be further discussed as x-rays never found application in commercial food irradiation (rivm ) . electron beam irradiation is a relatively new technology. in contrast to γ -rays and x-rays, an electron beam's main disadvantage is poor penetration power. however, for irradiation of, for example, prepacked salads the penetration depth might be sufficient if the produce is irradiated from or more sites (niemira ) . studies using electron beam (sanglay and others ; espinosa and others ) and γ -rays (bidawid and others ; hsu and others ; feng and others ) for decontamination of viral contaminated fresh produce are available in the literature. viruses, having relatively little nuclear material and being small "targets," are relatively resistant to radiation compared to most vegetative bacteria (d values of . to . kgy) (efsa ). reported d values for enteric viruses/surrogates are, for example, . kgy for hav on strawberries (γ -rays) (bidawid and others ) and . kgy for fecv on lettuce (e-beam) (zhou and others ) . however, d values are affected by a number of factors including temperature, water activity, and chemical composition of the food (efsa ). for europe, the scientific committee on food (scf) has expressed several opinions on irradiated foods and acceptable doses for specific food classes/commodities (including , , and ) . as such, for vegetables and for fruits, overall average radiation doses (kgy) of up to and up to kgy, respectively, were evaluated as acceptable. however, as regulated in the eu by framework directive / /ec and implementing directive / /ec, so far only "dried aromatic herbs, spices and vegetable seasoning" at the maximum overall absorbed radiation dose of kgy are allowed (efsa ). currently, the u.s. fda approves doses up to kgy to control foodborne pathogens in fresh iceberg lettuce and spinach (fda ) as a response to multistate outbreaks of e. coli o :h traced to spinach and lettuce (cdc ) . however, this irradiation dose proved impractical for the inactivation of viruses on fresh produce as only < log virus reduction of mnv- ( kgy, γ -rays) was achieved on spinach, romaine lettuce, and strawberries in a study by feng and others ( ) , and a mere reduction of ࣘ . log of mnv- was achieved on cabbage and strawberries in a study of sanglay and others ( ) ( kgy, e-beam). hesitant consumer acceptance toward irradiated food, the doses required for a meaningful reduction of viruses typically exceed legally approved doses, and what most produce will tolerate in terms of changes in appearance, flavor, color, and texture (fan and others ) are still drawbacks that must be addressed. high-pressure processing (hpp) is a nonthermal operation that inactivates pathogenic and spoilage microorganisms as well as endogenous enzymes and has been used as a "cold pasteurization" method for fruit juices, fruit desserts, avocado-based products, sliced onions, and ready-to-eat vegetable dishes (kingsley ; rivm ) . pressures up to mpa are used that are instantaneously and uniformly transmitted throughout a sample, thus making this process independent of the shape or size of the food (kovac and others ; kingsley ) . in research the effectiveness of hpp for viral inactivation has been tested on fresh produce matrices such as green onion slices (kingsley and others ) , carrot juice, lettuce, blueberries (li and others b) , blueberry juice (horm and others a), orange juice (horm and others b) , and different purees such as strawberry puree, lemon puree, tomato puree, watermelon puree, and carrot puree (lou and others ) . although the resulting characteristics of the treated products are superior compared to heat-treated products, still hpp has been shown to affect sensory qualities such as color, texture, shape, and rheological properties. however, these variable effects on the sensor quality of fresh produce are depending on the pressure level and type of product (kovac and others ; lou and others ) . as such, hpp has been recommended for the processing of fruits intended for frozen storage, since freezing causes similar and more severe texture damage (lou and others ; li and others b) . fresh produce-related products such as purees, sauces, and juices are also fit for usage of hpp, as compared to intact fresh produce as they lack the presence of intercellular air spaces that can be severely compressed during pressure treatment, inducing physical damage to the tissue (li and others b). next to the treatment parameters such as pressure levels and treatment time, the matrix also can have a significant influence on the effectiveness of hpp (kingsley and others ; lou and others ; kovac and others ) . some parameters, such as temperature and ph (kingsley and chen ; lou and others ; li and others b) , were shown to influence the hpp inactivation of different types of viruses, in a contradictory way. for example, colder initial temperatures of the product enhanced the inactivation of human nov (gi. ) (leon and others ) and surrogates mnv- , tv, and fcv (chen and others ; li and others b). in contrast, hav, a picornavirus, is more resistant to hpp at a lower temperature than at room temperature (kingsley and chen ). the same for the parameter ph, where human nov (surrogates) tend to be more sensitive to hpp at neutral ph than at acidic ph (lou and others ; li and others a). whereas for hav the opposite is true (kingsley and chen ). as such, direct validation of hpp conditions within the food or food matrix will be required, given the complexity of food matrices and the variable response of different viruses (kingsley ) . among enteric viruses a high variability in pressure resistance has been noted, even different virus strains can behave differently under pressure (shimasaki and others ). as such, it is conceivable that different human nov genogroups, and perhaps different clusters within a human nov genogroup, would exhibit varied sensitivities to hpp (leon and others ) . during testing, human nov surrogates fcv and tv proved to be more susceptible to hpp compared to mnv- (horm and others a; li and others b). in the study by lou and others ( ) on the application of hpp in the fresh produce industry, the optimal condition for mnv- inactivation by hpp in diverse fresh produce matrices was determined to be refrigeration temperature with a treatment pressure of mpa and a holding time of min. using these conditions viral reductions between . and . log were obtained without significantly altering the physical quality of the food samples (lou and others ) . however, when the inactivation kinetics of mnv- (cell-culture) are compared to human nov gi. (obtained during a human feeding study using infected high-pressure processed oysters), human nov might be more resistant to hpp than mnv- . as in the human feeding study by leon and others ( ) treatment of oyster (seeded by injection) by hpp at mpa, for min at °c was insufficient to prevent nov infection in human volunteers, suggesting that log genome equivalent reduction was not achieved. while a min, mpa treatment at °c was sufficient to inactivate . log pfu mnv- in oyster tissue (kingsley and others ) . in the human volunteer study a mpa treatment for min at °c was successful to inactivate human nov gi. within raw oysters (leon and others ) . this higher resistance of human nov to hpp was also observed when binding assays, using porcine gastric mucin-conjugated magnetic beads followed by rt-qpcr assays, were used for discriminating potentially infectious human novs gi. (dancho and others ) and gii. (li and others a) following hpp. in food processing thermal processing is a classic inactivation strategy which involves heating of a food product at a temperature that ranges from to °c, primary to inactivate foodborne pathogens and to inactivate endogenous enzymes. in light of the main identified food commodities of concern, namely soft red fruits and leafy greens, this section will be restricted to the effect of classic heat treatment (pasteurization) and blanching, since heating of frozen berries has been regularly communicated as a mitigation strategy for foodborne outbreaks due to viral-contaminated berries (guzman-herrador and others ). the possible effectiveness of this measure was illustrated during the german outbreak in due to contaminated frozen strawberries. during the outbreak investigation it was noted that not all kitchens which used the implicated batch of frozen strawberries were linked to disease cases. this was a result of the different ways of preparing the strawberry compote among kitchens. as such, it was observed that those places receiving meals from kitchens where the strawberry compote was stewed (thoroughly cooked) were not affected by outbreaks. the schools and childcare facilities that received the compote from kitchens that did not sufficiently heat the compote were indeed obviously associated with disease cases (task force gastroenteritis ). in the literature, an overall lower virus sensitivity to temperature change has been noted in complex matrices (such as dairy and other food products) compared to simple matrices (for example, drinking water and synthetic media) at the high temperature range (> °c) (bertrand and others ) . hence, validation of a specific heat treatment in the relevant food matrix is well-considered. however, in the literature only a limited number of heat inactivation studies are available for produce matrices. relevant matrices used for traditional heat inactivation experiments of enteric viruses/surrogates are restricted to purees of soft red fruits (raspberry, strawberry, bilberry) others , ; baert and others a) and spinach (bozkurt and others a) . the risk of nov infection remains associated with mildly pasteurized ( s at °c and s at °c) raspberry puree, since reductions of less than log were obtained for mnv- (baert and others a) . the inadequacy of mild heat treatment steps at low temperatures can also be confirmed by a human challenge study in which human nov was found to remain infectious for volunteers after min at °c (dolin and others ) . next to the virus type, matrix factors such as ph and sugar content have been confirmed to have a significant effect on heat inactivation of enteric viruses and surrogates. as such, studies are available that observed a rise in inactivation time of hav (in strawberry mashes) and mnv- (in pbs), with increasing sucrose concentration and observed a moderate rise in inactivation time of hav (in strawberry mashes) with increasing ph. attempts have been made to model the heat inactivation of hav in berry mashes as a function of temperature and product characteristics, such as ph and sugar concentration (deboosere and others ; deboosere and others ) . however, validation of the model by deboosere and others ( ) in fruit-based products failed. weaknesses of the latter model of deboosere and others ( ) are the limited temperature range ( to °c) and the inclusion of the come-up time (about min) in the treatment time. this practice assumes that the temperature during this come-up time was constant and at the target temperature, and possibly explains the occurrence of a shoulder in the inactivation curves and the very low log reduction estimates when the model was used to calculate the effect of short heat treatments ( . and . log reduction at s and min at °c and ph . , respectively). in contrast, in-house data on mnv- heat inactivation in raspberry puree ( °c, s) suggest a reduction of ࣙ . log (unpublished data). as such, there is a need for additional studies that take into account heat-inactivation kinetics during the phase of temperature increase to reach the target temperature (deboosere and others ) or models that do not include the preheating step at all. as in validation of time/temperature treatments in food processing, generally preheating and longer exposure to these temperatures during cooling down are not included to assume a worst case scenario in which the reduction solely originates from the actual heat treatment (baert and others a) . another relevant thermal treatment process is blanching. blanching is a heat pretreatment (between and °c) that is generally conducted prior to freezing and canning to inactivate microorganisms and enzymes and to remove entrapped air. both the hot water bath blanching process and steam blanching have been proven to be effective. as such, a reduction of ࣙ . log mnv- (detection limit of assay was reached) was observed when fresh spinach was treated for min in a hot water bath of either °c or °c (baert and others b) . confirmation of the effectiveness of (steam) blanching was provided in a study on fresh herbs such as parsley, basil, mint, and chives. generally > log reductions were observed for hav and fcv on fresh herbs when blanched at °c for . min. when blanching was performed at °c for . min, more variation in heat resistance of enteric viruses was observed, varying depending on the herb (e.g., hav reduction on mint and chives was . and > . log , respectively) (butot and others ). in general, heat inactivation studies indicate that mild thermal inactivation methods (such as pasteurization) may not be stringent enough to eliminate human nov (baert and others a; escudero-abarca and others ). however, cooking procedures in which an internal temperature of the food reaches at least °c for s are considered adequate treatments to destroy viral infectivity in most foods (fao/who ). following the recommendation for heat treatment of shellfish ( °c for s), hav was successfully inactivated in shellfish (hewitt and greening ) . several other thermal studies suggest that high-temperature, short-time treatments ( °c, s) should suffice for inactivation (> log reduction) of human nov (surrogates) (bozkurt and others b; in-house data on mnv- reduction in raspberry puree: ࣙ log for °c, s). nevertheless, data concerning heat treatments of produce at temperatures > °c are scarce and only available for a limited number of surrogates (deboosere and others for hav). hence additional relevant heat inactivation foodborne viruses in fresh produce . . . studies for this high-temperature range in relevant produce matrices and for several (surrogate) viruses should be conducted to obtain more insight. overall, human novs are introduced in the fresh produce chain by human fecal pollution, and food handlers are believed to play a significant role. the high persistence of nov in the environment combined with high resistance of nov to 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attachment to and internalization by romaine lettuce pre-harvest viral contamination of crops originating from fecal matter short-and long-term variations of norovirus concentrations in the meuse river during a -year study period inactivation of ms f(+) coliphage on lettuce by a combination of uv light and hydrogen peroxide survival of respiratory viruses on fresh produce epidemiology of foodborne norovirus outbreak in incheon inactivation of feline calicivirus as a surrogate for norovirus on lettuce by electron beam irradiation a foodborne norovirus outbreak at a manufacturing company the research leading to this article has received funding from the iwt (agency for innovation by science and technology), from the research foundation-flanders (fonds voor wetenschappelijk onderzoek [fwo] vlaanderen) and the european community's th framework programme (fp ) under grant agreement no. (project veg-i-trade). this review is based on the literature used for the phd thesis of ann de keuckelaere ("detection and control of noroviruses in fresh produce," defended on february , ; promotor: prof. mieke uyttendaele; tutor: dr. dan li). it was afterwards updated and rewritten as a review paper by dan li. mieke uyttendaele worked on an elaboration of the structure and organization of the review. key: cord- -xzfo jjq authors: todd, ewen c. d. title: foodborne disease in the middle east date: - - journal: water, energy & food sustainability in the middle east doi: . / - - - - _ sha: doc_id: cord_uid: xzfo jjq food safety is a concern worldwide and according to the world health organization, developing countries are probably more at risk of foodborne illness because many of these, including those in the middle east, have limited disease surveillance and prevention and control strategies. specifically, the middle east and north africa (mena) region has the third highest estimated burden of foodborne diseases per population, after the african and south-east asia regions. however, it is difficult to determine what the burden is since little is published in peer-reviewed journals or government reports for public access. this chapter reviews autonomous nations, namely, afghanistan, bahrain, egypt, iran, iraq, israel, palestine, kuwait, lebanon, oman, pakistan, qatar, saudi arabia (ksa), syrian arab republic (syria), united arab emirates (uae) and yemen. countries range in size from bahrain with . million inhabitants to pakistan with a population of million. agriculture and local food production is much influenced by water availability for irrigation. water shortages are most severe in the gulf countries which rely on aquifers, desalination, and recycled waste water for most of their water supplies. this means that most food is imported which is expensive if not subsidized through petrodollars. this impacts food security which is a particular concern in countries under conflict, particularly, syria, yemen and iraq. gastrointestinal infections are frequent in this region from salmonella typhi and other salmonella spp., shigella spp., campylobacter jejuni and c. coli, rotavirus, hepatitis a virus, parasites, and more rarely from aeromonas, yersinia enterocolitica, brucella spp., and middle east respiratory syndrome coronavirus (mers-cov). reports indicate that children are the most susceptible and that many isolates are multidrug resistant. chemical contamination of water supplies and crops are probably more of a concern than published reports indicate, because of widespread indiscriminate use of fertilizers, antibiotics, and pesticides, coupled with increased industrial pollution affecting the water supplies. like many other parts of the developing world, foodborne disease surveillance is limited and outbreaks are most often reported through the press but with insufficient detail to determine the etiological agents and the factors contributing to the outbreaks, leading to speculation to the cause by those interested or responsible for food prevention and control. however, there are some well investigated outbreaks in the region that have those details, and reveal where the shortcomings of both the establishments and the inspection systems have been. where the causative agents are known, the kinds of pathogens are generally similar to those found in the west, e.g., salmonella, but many outbreaks seem to have short incubation periods that point to a toxin of some kind of chemical or biological origin, but these are almost never identified. because of sectarian warfare, residents and refugees have been given food that has made them sick and solders? have been deliberately poisoned. research has been focused on microbial contamination of locally-sold foodstuffs and manager and employee knowledge of food safety and hygienic conditions in food preparation establishments. an innovative pilot project in qatar is to use seawater and sunlight for raising crops through the sahara forest project. all countries have some kind of food establishment inspection system, but they tend to be punitive if faults are found in management or employees on the premises rather than being used for their education for improving food safety. restaurants may be closed down and owners and employees fined for often unspecified infringements. however, some food control agents are moving towards employee training through seminars and courses before problems occur, which is a good disease prevention strategy. unfortunately, many of the food handlers are from asian countries with languages other than arabic and english, which makes effective food safety communication and training difficult. tourists visiting popular resorts in turkey and egypt have suffered from foodborne illnesses, usually of unknown origin but poor hygienic conditions are blamed with law suits following, and the adverse publicity affects the long-term viability of some of these resorts. food exports, important for local economies, have occasionally been contaminated resulting in recalls and sometimes illnesses and deaths, notably fenugreek seeds from egypt (e. coli o :h ), pomegranate arils from turkey (hepatitis a virus), and tahini from lebanon (salmonella). overall, in recent decades, the middle east has made strides towards improving food safety for both residents and foreign visitors or ex-pat workers. however, within the countries there are large discrepancies in the extent of effective public health oversight including food safety and food security. currently, almost all of the countries are involved to a greater or lesser extent in the civil wars in syria and yemen, or are affected through political tensions and strife in egypt, iraq, iran, israel, palestine, lebanon and turkey. in addition, the current overproduction of oil on a world-wide scale has led to a rapid decrease in revenues to most gulf states. all this points to a severe setback, and an uncertain foreseeable future for improvements in obtaining both sufficient and safe food for residents in this region. the world health organization (who) eastern mediterranean region, comprising countries in the middle east and north africa (mena), has the third highest estimated burden of foodborne diseases per population, after the african and south-east asia regions. according to the who ( a), more than million people living in this region are estimated to become ill with a foodborne disease every year and million of those affected are children under years. diarrheal diseases caused by e. coli, norovirus, campylobacter and nontyphoidal salmonella account for % of the burden of foodborne disease. an estimated people die each year from unsafe food, caused primarily by diarrheal diseases, typhoid fever, hepatitis a, and brucellosis. both typhoid fever and hepatitis a are contracted from food contaminated by the feces of an infected person and the source of brucellosis is typically unpasteurized milk or cheese from infected goats or sheep. half of the global cases of brucellosis are in people living in this region, with more than , people infected every year, causing fever, muscle pain or more severe arthritis, chronic fatigue, neurologic symptoms and depression. cholera, which after a short incubation period of - days causing severe diarrhea and dehydration, is returning to those countries with limited public health infrastructure caused by conflict, such as iraq (agence france-presse ). the list of countries covered by this chapter is similar to that of who but leaving out north african countries except egypt (which has territory in eastern asia) and adding turkey which is not always considered in the region because it is not arabic, but has interesting food safety data. therefore, the countries under review are afghanistan, bahrain, egypt, iran, iraq, israel and palestine, kuwait, lebanon, oman, pakistan, qatar, saudi arabia (ksa), syrian arab republic (syria), united arab emirates (uae) and yemen. gulf countries bahrain, kuwait, oman, qatar, ksa and the uae have similar social, political, economic, culture, religion, language and ancestry with several similarities in their food control systems and food safety programs (al-kandari and jukes ). a food and agriculture organization (fao) report covering international investments in agriculture in the near east (not identical to the countries chosen for this chapter, but many of the findings apply) states that this region is characterized by a mix of very different countries' resources and incomes (tanyeri-abur and elamin ). the wealth in the richer countries of the region is primarily dependent on oil revenues and the past economic growth has been closely linked to the oil market; about % of regional gross domestic product (gdp) is concentrated in the high income countries (qatar, kuwait, uae, saudi arabia, and bahrain) which are home to only . % of the population in the region, and many of these are expatriates working in these countries. the report indicates that food insecurity varies sharply in the region but overall the percent of the undernourished population does not exceed % in most countries of the region, except for sudan, mauritania, djibouti and yemen where the proportion of undernourished exceeds %; however, in these percentages will be totally out of date for countries like syria and iraq and in neighboring countries where refugees have reached because civil war and jihadi terrorist groups have put considerable stress on public health facilities and food availability. the countries in the region however, are largely similar when it comes to the challenges in achieving sustainable agriculture and food security. for most of these countries, the overwhelming concern is to secure adequate and stable supplies of food at the national level, making food security a concern for both rich and poor countries of the region (tanyeri-abur and elamin ). the three major problems affecting most of the countries are (i) limited water availability; (ii) population growth; and (iii) heavy dependence on food imports. water scarcity in particular, is the most critical development problem in the region and the single most important factor in limiting agricultural growth, and water availability has been declining steadily since the late s. the region as a whole has % less availability of renewable water per person in - than in - . lack of water for irrigating crops but also for potable water supplies affects many of the countries, particularly in the gulf region. it is important to note that the wealthiest countries are also those with the highest water depletion record, namely, the uae and qatar. the unprecedented growth in investment in agriculture is in large part a result of the food crisis of , which brought about a rethinking of agricultural support policies, mostly in countries of the gulf and particularly saudi arabia, which has invested heavily in the last years in large-scale agricultural production using up valuable water resources. saudi arabia announced in january that it would phase out wheat and agricultural production in the course of the next years. in july , qatar and uae took similar policy decisions (tanyeri-abur and elamin ). crops grown in the region may serve as fresh food sources for the population, but much of the food is imported with limited locally processed products, and if the policies of ksa, qatar and uae expand to other countries, more will be imported in the future (tanyeri-abur and elamin ). thus, the main foodborne disease issues are with homemade, restaurant and street food, where isolated claims of illness are followed up by inspections and possible punitive action by public health agencies responsible for food safety. those countries that rely on tourism for their main source of gdp have sometimes been damaged by adverse publicity, e.g., egypt, and to a lesser extent, turkey and lebanon. according to the food and agriculture organization, less than % of the world agricultural trade is conducted in the region. even though by tradition many of these countries relied on growing their own food, today some of these countries import almost % of their food; . % of the food in the world alone was imported to saudi arabia and united arab emirates in , and the food trade balance in food in middle east is negative, estimated at over us $ billion dollars (tajkarimi et al. ). there are specific restrictions prevalent in the arab-speaking countries related to islam and judaism with the prohibition of eating pork and blood, the drinking of alcohol, and mixing dairy foods and meat under halal and kosher food laws. therefore, parasites related to pigs, e.g., trichinella and taenia spp., are unlikely to be prevalent in these populations. however, there are many muslim and jewish feast occasions with large gatherings such as eid linked to ramadan and particularly the muslim hajj, which put a strain on food preparation, distribution and storage. good health conditions for travelers to saudi arabia for the pilgrimage to mecca (hajj) are critical and any incident that occurs has to be quickly contained to prevent extensive infectious disease outbreaks (memish and al rabeeah ) . traditional middle eastern foods are mainly related to legumes, leafy greens, fruit, dairy products and meat on special occasions; details can be found in brittin ( ) . in urban areas today, grocery stores and supermarkets can supply most of the food requirements of a family but imported foods tend to be expensive. also, some fruit and vegetable items are seasonal and are only available once or twice a year such as local plums, almonds and bananas, which tend to be cheaper than imported varieties. quality of raw produce in stores varies but they often have short shelf lives and can spoil quickly because of harvesting ripe products, bruising, and high storage temperatures. traditional rural foods include aromatic stews, stuffed vegetables, wild leaves, pulses and cracked wheat, and occasional goat or lamb meat. a typical middle eastern meal starts with a variety of cold and hot mezze (appetizers), salads and pastries, especially in greece, turkey and lebanon. many contain herbs, cheese, pickles, nuts, seeds, and parsley and lettuce are widely eaten in salads or traditional mezzes. most mezzes are vegetarian and fresh fruits and vegetables are an integral and important part of the cuisine when they are in season. tabbouleh, a salad where parsley is a major ingredient with small pieces of tomato, and some bulgur (ground wheat) in it, is often served in leaves of romaine lettuce or raw cabbage. almost as popular is fattoush, a mixed bowl of lettuce, tomatoes, cucumbers, and fried or toasted pita chips, typically seasoned with a dusting of sumac and pomegranate molasses. since leafy greens do not have a final decontamination step, they are at risk from environmental fecal contamination as reported in lebanon by faour-klingbeil et al. ( ) . hummus, a smooth chickpea paste made with tahini/tehineh, lemon juice or citric acid, garlic and salt, and often served with olive oil, is the most ubiquitous mezze. since tahini and hummus are major exported products from the region, particularly lebanon, they are prone to salmonella contamination, and are sometimes recalled from other countries, which is damaging to the local economies. dairy products are also served regularly at meals and these are locally made or imported. labneh, strained yogurt, very similar to greek yogurts, is widely used as a base for mezze which might have olive oil, pine nuts or za'atar (a mixture of thyme, sumac, and sesame seeds) added. cheeses including the popular haloumi are frequently served in restaurants. shawarma/ shwarma is frozen or refrigerated raw or marinated meat (lamb, beef or chicken) cooked on a vertical rotisserie popular throughout mena countries and now frequently seen in western nations. higher fish consumption tends to be close to where these are locally caught, either sea or river netted. one example from iraq is masquf (split large fish cooked on stakes over a fire, and eaten outdoors by a river, served with slices of tomato and onion and arab bread. crustaceans are less frequently eaten but can be obtained from imports. cosmopolitan foods are widely available in the larger cities, as are multinational fast-food chains. foodborne illnesses have been sporadically reported throughout the region over the past decades and global assessments of the kinds of problems encountered reviewed, e.g., todd ( ) and al-mazrou ( ) and more recently by tajkarimi et al. ( ) . these last authors indicate that reporting foodborne disease is functioning well in jordan, kuwait, oman, saudi arabia and uae, compared to other countries in the region. however, the foodborne outbreak surveillance systems in middle eastern developing countries are still limited with reporting of less than % of the actual outbreaks; one reason is that many foodborne illnesses occur in homes and those ill may not visit medical care facilities. in addition, available laboratory analytical support for public health agencies is often minimal or lacking, even though some research institutions may have up-to-date equipment and technical expertize. change is gradually coming and a food and drug authority has been established in both saudi arabia and jordan (al-kandari and jukes ). also, new food legislation has been initiated by egypt, lebanon and syria (tajkarimi et al. ) , but is currently stalled in last two countries. improvements in inspection service, hand held computers, customized software and improved surveillance systems are some examples of developments in food safety systems in the region. jordan, saudi arabia and bahrain have been developing unified food safety activities from farm to fork (al-kandari and jukes ). however, there is a need for substantive food safety education for all foodservice staff. increasing quality and quantity of the food safety training and human resources in governmental agencies in the region will improve the public health infrastructure. for example, the municipality of dubai has established an international annual food safety conference to improve the food safety education system of those in the region, now in its th year ( ). the following sections of the chapter focus on five aspects: gastrointestinal infections; foodborne disease outbreaks in specific countries; food safety related research and surveys; issues relating to tourism and exported food; and government oversight of the food industry, with specific examples from countries in the region. gastrointestinal diseases are frequently encountered in the middle east and many etiological agents have been identified where specific studies have been carried out to look for bacterial, viral and parasitic pathogens. the average annual incidence of culture-proven shigellosis in israel was / , from to , but each reported case was considered to represent cases indicating the high burden of the disease in the country (cohen et al. ) . orthodox jewish communities, living in highly crowded conditions and with a high number of children aged < years were the epicenter of country-wide biennial propagated epidemics of s. sonnei shigellosis. s. flexneri was the leading shigella serogroup in israeli arabs. isolates showed high rates of resistance to ampicillin and trimethoprim/sulfamethoxazole, but very low rates to quinolones and third-generation cephalosporins. there is no indication if foods or water were vehicles of these shigellosis cases. also, in israel a study of pregnancy-related listeriosis cases from to , identified cases, resulting in a yearly incidence of - cases per , births (elinav et al. ). there were fetal deaths, two neonate deaths and one maternal mortality. the incidence of israeli pregnancy-associated listeriosis has a high yearly variability and is one of the highest worldwide. the geographical distribution varied greatly between years and had a different epidemiological pattern compared with nonpregnancy-related listeriosis. the sources of the infections were not studied but all listeriosis cases have a foodborne link. this has to be further researched as to diet, and the unawareness of the israeli public of the risk for certain food products contributing to the extremely high incidence in israel, in both general and pregnancy-associated listeriosis, as occurs in other countries. a total of stool samples were collected from palestinian patients with acute diarrhea from which ( . %) yielded enteropathogenic bacteria. salmonella, campylobacter coli/ jejuni, and aeromonas hydrophilia were isolated in equal numbers from samples / ( % each), shigella boydii / ( . %), yersinia enterocolytica / ( . %) (abdelateef ) . many strains were antibiotic-resistant. children younger than years old were more susceptible to infectious diarrhea; in addition, diarrhea was more frequent in those living in crowded houses, and in houses rearing poultry, including pigeons. salmonella enterica serovar typhi continues to be an important public health problem in kuwait. analysis of the isolates from patients, collected between and , showed that the majority were from patients from the indian sub-continent, and many strains were drug resistant (dashti et al. ) . typhoid fever in kuwait is predominantly associated with those who have traveled from endemic areas to work in kuwait. the circulation of enteric viruses among the population of cairo, egypt, between march and february was studied by kamel et al. ( ) . at least one type of virus was detected in % of fecal samples, . % of which were positive for rotavirus, % for norovirus, . % for adenovirus, and . % for astrovirus. over % of infections were mixed infections. among the noroviruses, half belonged to the predominant ggii. cluster which were similar to those circulating elsewhere, but there were also new ggii. variants that were not associated with any previously known ggii. isolate. although norovirus is rarely implicated in foodborne outbreaks compared with the us and other western countries, it is clearly present in egypt. further studies are required to assess the disease burden of enteric viruses in egypt and the impact of atypical strains. the disease burden of hepatitis a and e in egypt is one of the heaviest worldwide, based on serological analysis, with hav infections occurring very early in life, with almost % seropositivity after the first years of life (kamel et al. ) . to determine the actual contamination levels in the environment, these authors conducted a survey of hav and hepatitis e virus (hev) in sewage in cairo. hav was detected by rt-pcr in of ( %) sewage samples. in addition, all the hav-positive samples were also positive for enteroviruses. that only one stool sample was hev-positive might be explained by the lower level of excretion of the virus in stools, the fragility of the virion in the environment, and technical difficulties in concentrating and amplifying the virus with standard methods. bacterial etiology was found in . % of cases of childhood diarrhea in dhahira, oman, mostly shigella sonnei and to a lesser extent salmonella (patel et al. ) . antibiotics were prescribed in . % of cases and the resistance to the common antibiotics tested was low. one reason for the low pathogen isolation rate could be that many cases had viral etiology. rotavirus was detected in stool specimens from ( %) of children, who were admitted to regional public hospitals in oman for a median of days with severe diarrhea (al awaidy et al. ) . a diverse rotavirus strain pattern in oman was identified with g ( %), g ( %), and g ( %) accounting for most of typeable strains. the authors estimated the burden for the omani government at us$ , and us $ . million annually to treat rotavirus-associated diarrhea in the outpatient and hospital settings, respectively. they recommended a rotavirus vaccination program that would substantially reduce the burden of severe diarrhea among children in the country. unlike the above countries where the health care system functions for most residents, though not always to western standards, the same cannot be said for pakistan, particularly in rural areas. poor nutrition combined with diarrheal and other foodborne diseases puts the population at risk for serious illness and death, especially among infant and children in pakistan (akhtar ) . cholera, campylobacteriosis, e. coli gastroenteritis, salmonellosis, shigellosis, typhoid, and brucellosis have been demonstrated to be the major foodborne illnesses in the country as well as infectious diseases caused by viral and parasitic agents. many fatalities have been associated with food poisoning but the actual agent has rarely been determined. many health experts believe that rapid spread of gastrointestinal diseases cannot be controlled if the public has no awareness of prevention and control measures against cholera and other forms of gastroenteritis, and that in most parts of the country, sewage is continuously contaminating streams, lakes, springs, wells, and other drinking water sources (qasim ). in may , an epidemic of diarrhea and gastroenteritis occurred in kamalia, toba tek singh, with over children and others being admitted to hospitals which had few medical supplies. apart from lack of potable drinking water, the main reason given for the rise in cases was the heat of summer when there were frequent power cuts so that food "rots" or becomes "stale" (islam ) . in remote areas of pakistan, cholera has been responsible for many outbreaks. two examples in july and august of , both in areas of conflict near afghanistan, give an idea of local but severe outbreaks. in one case authorities seemed not to want to be involved and in the other vaccinations are carried out. although water is the primary vehicle of the vibrio cholerae pathogen, it can easily contaminate prepared foods through poor hygienic practices. in july , five deaths from cholera occurred in pashtoon kot area, balochistan region of pakistan (federally administered tribal areas) along the afghan border (staff ), some km from quetta, in the absence of any emergency medical aid. the condition of an additional people suffering from the disease was said to be critical. a local tribal elder expressed the fear that outbreak of cholera might cause loss of life at large scale. he complained that the doctor and paramedics deployed at the basic health center in panjpai live in quetta and are rarely seen at the center. officials of the provincial health department appeared to be unaware about the cholera outbreak and loss of lives (or ignored these), as they sent no medical teams to the affected area. in fact, pakistani government rebuffed international media's claims, and did not respond to requests to dispatch healthcare professionals to the balochistan area. it was assumed the outbreak would continue without medical aid. in , cholera outbreaks killed hundreds of people, mostly children, in flood-hit districts of nasirabad, jaffarabad and jhal magsi where waterborne diseases were reported at a large scale because of consumption of contaminated water by local people. in august , two people died and others had fallen ill, following a cholera outbreak in kurram tribal agency near afghanistan (hussain ) . dhand and kudiad khel were the worsthit areas but vaccinations were carried out amid tight security, and tribesmen were instructed not to drink water directly from the well and boil it first instead since the wells had been contaminated from the rain water. around people were shifted to parachinar headquarters hospital, while others were discharged after medical aid. sometimes diseases kept at bay by functioning public health systems come back when these break down as is occurring in a few of the countries embroiled in internal strife and outside attacks. for instance, in iraq in october, , > cases and deaths of cholera occurred which started along the euphrates valley in september with the governorates of baghdad and babil, south of the capital, being the worst affected with more than cases each. the epidemic then spread to the northern autonomous kurdish region, which hosts hundreds of thousands of people displaced by conflict from other parts of iraq (agence france-presse ). a previous outbreak killed four people in the kurdistan region in . the united nations says the number of people displaced by conflict in iraq since the start of has topped . million which would exacerbate the spread of the disease. authorities blamed the cholera outbreak mostly on the poor quality of water caused by the low level of the euphrates. limited vaccination programs are in place in areas of conflict. in october, , two persons arriving in kuwait from iraq tested positive for cholera and both were provided proper treatment and recovered. the ministry of health recognized that further cases could be discovered among people arriving from iraq, but because kuwait has a well-structured health infrastructure with water and sewers grids, and a supply of healthy and safe food, the disease should not spread into the kuwaiti population (anonymous a) . probably there are some cases in yemen and syria, countries also with limited public health infrastructures, but have yet to be identified. in saudi arabia, a country with a well-maintained health system, the main infectious disease concern today are the infections and deaths arising from exposure to the middle east respiratory syndrome corona virus (mers-cov), which has reservoirs in camels and bats (todd and greig ) . a potential food source for this virus and other pathogens is from unpasteurized camel milk, as camel farmers drink the milk as well as being exposed through other aspects of camel contact. this brief review indicates that diarrheal diseases, caused by cholera, dysentery, hepatitis a, salmonellosis, shigellosis, typhoid fever, and other enteric diseases through water and food are major contributors to ill health in the region in agreement with the who ( b) report on global estimates of foodborne diseases. in the region, not very many outbreaks of foodborne disease tend to be investigated, or at least reported publically, and those that are tend to have fatalities or are very large. for instance, in june, , two children and one adult were brought to a hospital in dubai, uae, with suspected food poisoning (vomiting) after they ate take-away food (the father was out of town). although the mother eventually recovered, the two young children ( and years old) died, one on arrival and the other the next day. the cause was not determined (saberi and scott ) . it is not known if the family or restaurant was primarily responsible for the deadly gastrointestinal attack as bacteria can multiply quickly in the hot summer months, and the public had been recently warned to minimize eating out at this time of year, especially at smaller eateries where hygiene levels are often of lower standard. a toxin was likely involved to cause fatalities so rapidly, but it could have been an accidental contamination of the food with a chemical such as a pesticide, as much as it could have been with an enterotoxin produced by staphylococcus aureus or bacillus cereus through careless ambient temperature storage. unfortunately, this was one episode in a string of incidents, most of them with fatalities, in the county. in april, , a -year-old died of suspected food poisoning in sharjah, and in august, a -year-old girl died of food poisoning in abu dhabi. in march, , six people fell ill after eating buffet food at a restaurant in the large ibn battuta mall, dubai; in november of the same year, employees at a cement factory were hospitalized after consuming what was considered rotten food prepared at the factory kitchen in another emirate, ras al khaimah. in may, , a -year-old girl died of suspected food poisoning in sharjah. the indian family of four rushed to the hospital after series of vomiting but were too late to save the girl. dubai has been reporting foodborne outbreaks and cases through its foodborne disease investigation and surveillance system since ; in that year there were cases reported in the first nine months (saseendran ) . in , suspected cases of foodborne illnesses were reported but only cases were confirmed. no deaths were reported since the surveillance system was in place. egypt has had a particular problem with foodborne illnesses in universities and schools, mostly without a confirmed etiology, which seem to be related to poor food quality. food poisoning is not uncommon in egyptian university dormitories, where basic hygiene standards are often not observed, but the following outbreak was one of the largest. on april , hundreds of egyptian students angered by a mass outbreak of food poisoning at a cairo university stormed the offices of the country's top muslim cleric and university president, ahmed el-tayeb, because of the students who were hospitalized after a meal served at the university dormitories in the nasr city district of cairo (associated press ). the university is affiliated with al-azhar mosque, the world's foremost seat of sunni muslim learning, and awards degrees in sciences and humanities, as well as in religious studies. in the protest, thousands of al-azhar students blocked roads, broke into el-tayeb's offices by the main campus, and chanted slogans against the university's management. the causative agent was unknown, and only with the incubation period, types of symptoms and their duration would it be possible to consider the potential etiologies of this illness. because of their poor quality, campus meals were not very popular before they were being blamed for the current food poisoning outbreak. although investigators were not able to find a specific cause, the university suspended its food services director and some other staff members. within a few weeks food poisoning affected students on april , at the same university, al-azhar (masriya ) . investigations were initiated within the university and by the ministry of health, and apparently "bad tuna" had been served at the campus cafeteria; no further details were given. if tuna was the vehicle of the outbreak, scombroid poisoning was the likely cause of the illnesses. the allergic-like symptoms generally begin - minutes after ingestion and usually resolve in a few hours. scombroid fish poisoning occurs after fish, most frequently tuna, with high levels of accumulated histamine or other biogenic amines, is eaten. but "bad tuna' could equally be contaminated with bacterial or viral enteric pathogens with a longer incubation period. a month later there was another outbreak. because at least three outbreaks of food poisoning occurred at al-azhar university between april and may with over cases of food poisoning detected in the university's male dorms, the dorm's director, the university's kitchen manager and eight chefs were sentenced in november, , to years in prison with a financial bail. in a similar situation, egypt's top prosecutor ordered a swift investigation into the cases of food poisoning reported in two primary schools in october, , in suez (masriya ). an official of the ministry of education indicated that the poisoning was caused by the consumption of milk provided by the schools. the distribution of milk to all schools in the governorate was halted until the milk's validity was ensured. if milk was responsible, the etiological agent could be bacillus cereus enterotoxin if the onset time was short, or less likely an infectious disease pathogen such as salmonella or e. coli o :h . on january , , female students were diagnosed with food poisoning at al-azhar university in upper egypt's assiut/ asyut governorate, by the banks of the nile, and were briefly hospitalized in an assiut city (anonymous b) . this follows a similar incident which occurred in april when students, also in the girls' dormitories, contracted food poisoning on the university campus in luxor. this report also flags two major poisoning incidents involving at least students ill consecutively at its campuses in cairo in (probably the ones already discussed). the reason given for these repeated mass foodborne illnesses among university students is the quality of the food served them. apparently cheap, subsidized food is poorly stored, cooked and distributed to the poorer university students. in most cases the attorney general would open a criminal investigation that would be closed without knowing the microbiological cause of these outbreaks. the promed-mena editor speculated that enterotoxins of staphylococcus aureus were the most probable cause of such communal food poisoning, as a toxic dose of less than . microgram in contaminated food is sufficient to produce symptoms of staphylococcal intoxication. this toxin level is reached when s. aureus populations exceed , /g, a condition likely to be present in these university kitchens because of intense pressure on them to feed a huge number of students in a short time, taking into consideration that most of these kitchens lack basic hygienic measures with regard to safe food handling. the editor also considered shigella, with its low infective dose ( - depending on the species) as another possible agent. however, the incubation period and symptoms of s. aureus intoxication and shigellosis or dysentery are quite different. pakistan is similar to egypt in that much of the country is rural but with very large cities with high populations (total population is million in egypt and million in pakistan, the most populous of all middle eastern countries). in september, , more than of the flood victims at a relief camp in bengali boys sindhi section school in ibrahim hyderi vomited after eating cooked food and then fell unconscious; of them had to be taken to a nearby hospital (aligi ) . a local philanthropist had been providing cooked food to the flood victims but by the time the food arrived at the relief camp, the cooked rice had turned "stale". since the rice did not show any sign of spoilage, it was served to the flood victims. a similar incident had taken place days earlier at another town where more than flood affectees had fallen unconscious after consuming "stale" food and were hospitalized. none was seriously affected. during the investigation, it was noticed that the sanitary situation in and around the relief camps was very poor. even though the reason for the illness was not determined, the police took action against the donor and two caterers. in fact, based on the information of the vehicle and the symptoms, bacillus cereus enterotoxin which is known to be produced in boiled rice, was the most likely agent. in the following two outbreaks yoghurt is blamed for the serious illness and deaths though details of the symptoms are not given. rapid onset of symptoms indicates the presence of a toxin of some kind, although yoghurt is not a food known to be frequently contaminated with pathogens because of its high acidity. either the yoghurt was made under very unhygienic condition with the source of the milk perhaps being spoiled (possibly containing bacillus cereus enterotoxin), or a chemical had been added accidently such as a pesticide, or deliberately and illegally to enhance the flavor. however, it is possible other foods were involved and yoghurt was not the contaminated vehicle. in january , in lahore, a hospital employee died and two other employees became critically ill after eating contaminated yoghurt. the three employees ate rice with yoghurt at a local restaurant (ians ) . action was taken against the restaurant owner and manager. no further details are known. in early april, , a rawalpindi family of ten became seriously ill after eating a home-prepared evening meal where yoghurt was suspected to have been the contaminated food, and they were taken to a hospital, where a teenage boy and -year-old girl died (asghar ) . the surviving family members remained in critical condition for some time but eventually recovered; the cause of the illnesses was not discovered, although it was postulated by a relative who had eaten the yogurt with the meal that it was possibly poisonous or, strangely he thought a lizard might have fallen into it. in february , at least four people died and another seven were hospitalized in a critical state after eating home-cooked biryani (a dish made with spices, rice and meat or vegetables) in a suburb of karachi (mahmood ) . the owner of a grocery shop, who provided the ingredients, was arrested, and a sample taken for analysis. it is not known if any toxin was found. a month later in march, in faisalabad, more than children and women were ill after eating contaminated aalo-chanay (potatoes, chick peas, onions, tomatoes and spices) purchased from an unidentified vender (anonymous c) . as soon as the children ate the aalochaney, they felt ill and started vomiting. although they were immediately rushed to a rural health center, one boy died. a medical opinion was given that the eaters suffered from "diarrhea and cholera". however, the onset was too rapid for anything but a toxin of some kind, most likely heat-resistant since the aalo-chanay was cooked. also, in march , as many as student nurses and eight staff nurses were hospitalized with acute food poisoning at a hospital in rawalpindi after eating food at the nursing hostel, but none was critically ill (anonymous d). the nurses residing in the hostel started reporting complaints of vomiting and diarrhea along with high-grade fever at an undisclosed time after a meal. the hospital administration was criticized for failing to provide safe food and drinking water to its employees and demanded immediate inquiry into the case, but none was reported on. the illnesses are consistent with an enteric infection such as salmonella or norovirus. in april , at least constables suffered from diarrhea and were admitted to hospitals when they ate food during the sehat ka insaf program, which is a blanket method of administering the polio vaccine along with eight other vaccines, hygiene kits and vitamin a drops in order to circumvent polio-specific terrorist attacks in pakistan. local administration purchased packed food, including piece of chicken and juices from a local supporter (mayar ) . no further details are given but the chicken could have been undercooked or cross-contaminated with enteric pathogens such as salmonella and campylobacter; if the packs had been left at ambient temperatures for some time, these pathogens could have multiplied on the chicken to large numbers. over thirty children in faisalabad were hospitalized over days because of diarrhea and gastroenteritis, three seriously, and other children were expected to be ill. undetermined contaminated food was postulated as the cause, more than usual because of the extreme seasonal heat combined with frequent power outages to allow rapid bacterial growth in contaminated food. the unavailability of clean drinking water was mentioned as a contributing factor to the increasing number of gastrointestinal disease cases. hospital administrators complained that vaccines and medications were required but were not forthcoming from the health department. probably many family meals were contaminated because of the lack of potable water and any unspecified enteric bacterial pathogens present could grow rapidly in the heat. children are more vulnerable than healthy adults to infections which might explain the high proportion of sick children seeking medical help. botulism outbreaks occur periodically in iran. in a study of stool and serum specimens of patients with clinical symptoms of botulism, who were at inpatient and outpatient medical centers in tehran and other areas of iran, between april to august , specimens of patients showed the toxin and spores of c. botulinum (modarres ) . type e was the most common causative agent found in this study, being responsible for . % in all specimens; other etiologic types, in order of frequency were types a ( . %) and b ( . %). type e strains are typically associated with fish and freshwater and marine sediments. the results of this study indicate that the cases had consumed salted fish, smoked fish and canned fish, along with cans of green beans and cucumbers. a similar result over a decade later confirms that c. botulinum type e is a major pathogen in iran. in gilan province, of fish samples collected in , % of processed fish and . % of non-processed fish contained clostridium botulinum, mainly type e (tavakoli and imani fooladi ) . the processing is insufficient to kill the spores or reduce much of toxin produced because the fish tend to be partly cooked with the intestines kept intact. a total of traditional food product samples ( cheese, kashk [a type of dried yoghurt or thick cream], and salted fish) were examined using a bioassay method for detection of clostridium botulinum toxin (hosseini et al. ) . standard monovalent antitoxins were used to determine the toxin types. c. botulinum toxins were detected in . % of examined samples ( . % of cheese samples and . % of salted fish samples). none was found in kashk samples. c. botulinum types a and e were dominant in cheese and salted fish samples, respectively. consumption of these traditional foods either raw or processed may contribute to foodborne toxicity in iranian populations. in may , a quickthinking mother immediately brought her -month old boy to an israeli hospital when she saw he was suffering from vomiting, difficulty in breathing, listlessness, glassy-eyed, apathetic, and an inability to nurse or eat (bender ) . a doctor at the hospital diagnosed the child as suffering from infant botulism. he decided to treat the baby with the antitoxin stored in the emergency stocks, even before they got back the lab test results. the hospital like all israeli medical facilities keep ample supplies of biological and chemical warfare antidotes on hand in case of war or terrorist attacks, and staffers are regularly drilled in dealing with the symptoms of various chemical, neural and blister agents. the infant started recovering soon after the administration of the antidote. in the rare disease of infant botulism, spores of clostridium botulinum are ingested and the infant's flora is not mature enough to prevent germination and slow growth of the toxigenic pathogen. it is entirely possible that infant botulism occurs more frequently in the region but is not diagnosed. foodborne disease surveillance depends on an infrastructure of reporting and diagnosis in hospitals, epidemiologists, and food testing laboratories. lebanon is an example of a country where modernization in public health seems to occur at a glacial pace. however, diseases including those of foodborne and waterborne origin, are documented and published. the law of december , regarding communicable diseases in lebanon mandates all physicians, from private or public sectors, in hospitals or ambulatory services, to declare to the epidemiologic surveillance unit of the moph all diseases considered a risk to public health. the data available at the ministry of public health (moph) are compiled from different sources, and the declaration of cases remains irregular and insufficient (moph ) . in , foodborne and waterborne diseases were the most frequently reported in lebanon at a rate of . ‰ (total of cases), with the highest rate in the bekaa ( . ‰) and the lowest in the south ( . ‰). the most common infection was viral hepatitis a, which represented . % of the total food and waterborne diseases with cases. there were also cases of typhoid ( . %), cases of food poisoning (unspecified, . %), cases of dysentery ( . %), cases of brucellosis ( . %, cases of parasitic worms ( . %) and cases of hydiatic cyst ( . %). no cases of cholera and trichinosis were declared. hydiatic cyst (cystic echinococcosisis) caused by echinococcosis (typically e. granulosis) is acquired by contact with animal feces contaminated with tapeworm eggs. sources include contaminated food (meat), water, and animal fur. cysts containing tapeworm larvae may grow in the body for years before symptoms appear. when cysts become large, they may cause nausea, weakness, coughing, and belly or chest pain. occasionally, well-investigated outbreaks are published; the following two examples are from lebanon and neighboring jordan. in may , employees suffered from diarrhea, fever, and abdominal pains . - . h (mean, . h) after eating chicken noodles au gratin at a catered lunch served at a bank cafeteria (hanna et al. ). a few cases had systemic infections. salmonella enteritidis (se) was confirmed in stool and blood cultures within - h after hospital admission of the first cases, and also in leftovers of the suspect food. the same dish had been served at the bank in the past with no apparent health problems. preparation normally started in the evening prior to the day the dish is served. however, in this instance, some of the constituents had been prepared days ahead, because the dish was to be served on a monday, immediately after the week-end closure. no salmonella was found in rectal and nasal mucosal swabs taken from all kitchen workers, or in the tanker water supply (although it had high fecal coliform counts), but se was found in a frozen batch of the same raw chicken breast consignment that had been used for the chicken noodles. the batch of chicken came from a large producer of poultry and eggs in lebanon, who was advised of its potential involvement in a major foodborne outbreak. however, the investigators were refused access to the poultry-producing facility. it is highly likely that contaminated chicken carcasses had been, and would continue to be, shipped to many parts of lebanon. that the same se strain occurred in the patients, the raw chicken, and the leftover food was confirmed through random amplified polymorphic dna polymerase chain reaction (rapd-pcr). it would appear the -day delay in the chicken noodle preparation was significant in allowing the salmonella present in the ingredients not only to survive but probably to grow; undercooking, cross-contamination, inadequate storage and reheating all may have played a role in the outbreak, but no more information was available to determine which of these were the key factors in the outbreak. the bank management decided to sue the caterer and because they were aware of apparently inefficient way that public authorities were conducting the procedure, they took the initiative to call upon an independent investigative team to obtain solid evidence to win any court action. the caterers, concerned that they would be the only party blamed for the salmonella outbreak, had succeeded in concealing some raw and cooked items from destruction by the public health authorities, which was their normal practice after a complaint. these items were central to establishing contamination upstream from the caterer's kitchen. no action seems to have been taken against the poultry producer who was the source of the se, a pathogen that is invasive of flocks and difficult to eradicate. the authors complained about the obsolete lebanese laws dating back to the s that still governed what should be done following a report of "food poisoning". public health officers are mandated to stop the spread by destroying allegedly contaminated food items and closing down incriminated facilities. hanna et al. ( ) stated that this kind of action is generally lauded by the public but does not help determine the cause to develop appropriate prevention and control strategies. they also complained that because no investigation is typically done, many non-implicated foods and ingredients are wastefully discarded. the jordanian example is over two decades old, but is worth noting in detail. in september , a -case outbreak of salmonellosis occurred in a university hospital in amman after employees, patients and visitors ate in the cafeteria. the incubation period ranged from to h. symptoms included diarrhea ( %), fever ( %), abdominal pain ( %), dehydration ( %), and bloody stool ( %); were hospitalized (khuri-bulos et al. ) . cultures of eight food items were negative, but stool culture on of patients and of kitchen employees yielded salmonella enteritidis (se) group d . a cohort study revealed a foodspecific attack rate of % for the steak and potato meal and % for the rice and meat meal. stratified analysis of the steak and potato meal revealed that the potatoes were implicated most strongly. cultures were obtained from all kitchen employees, who showed no symptoms of illness, but of grew se group d . one asymptomatic, culture-positive employee had prepared the mashed potatoes on september , h before the first case presented at the hospital emergency with severe gastroenteritis symptoms. all of the food workers had negative stool cultures months earlier. the potatoes were mashed by machine, but peeled after boiling and mixed with milk by hand, using a ladle but no gloves. two different batches, the first of which was served exclusively to hospitalized patients and the second to a few remaining patients and employees, were prepared and served within to minutes of preparation. from the epidemiological data it can be assumed that the infected handler fecally contaminated only the second batch of potatoes, thus sparing most of the highly susceptible inpatients from exposure. furthermore, while potatoes clearly were implicated, individuals who ate steak only had an elevated risk of being attacked. this probably was due to surface contamination of foods being served on the same plate. kitchen employees harboring salmonella were excluded from work until they had three negative stool cultures taken week apart; it took weeks for them to return to work. stool surveillance that was routinely carried out in the hospital was ineffective in detecting infected employees to prevent this outbreak and the investigators recommended that employees adhere to proper hygienic practices including thorough washing of hands, especially when preparing food. today, salmonella is only one of many of the pathogens that can be encountered in foodborne illness. one of the newer pathogens, well established in the west is norovirus (nov), which causes more cases of foodborne disease in the u.s. than any other agent (scallan et al. ). in may , a significant increase in acute gastroenteritis (age) cases was noted in the american health clinic at incirlik air base (iab) in adana, turkey. this increased rate of age led to discussions with local turkish military public health authorities, which confirmed that the turkish military community and the residents of adana were also experiencing an anecdotal increase in age illnesses (ahmed et al. ). an epidemiologic investigation was launched to attempt to identify the cause and possible source of this age outbreak at iab from may to june with the peak incidence of cases during the week of may -june , with a total of patients seeking medical care at the clinic. of the total infected persons, patients completed the case survey, % reported diarrhea, % reported vomiting, and % reported fever. the median number of days between symptom onset and clinic visit was days. during the days prior to symptoms, % of respondents reported travelling off base, % reported eating off base, and % reported using an outdoor pool. this outbreak had a significant negative operational impact, degrading mission readiness with nearly % of the american population in a -month period affected. initiation of a clinic case-based investigation yielded stool specimens in which nov was detected in %, with % of the positive nov specimens identified without a copathogen. dna sequencing data demonstrated that several relatively rare genotypes of nov contributed to this outbreak; four different genotypes were isolated from positive specimens. two of the nov strains were previously reported in iraq and only from deployed troops, while the other two genotypes were reported in south africa and in the us. in turkey, little systematic data on circulating nov genotypes exist. however, giib/gii. strains have been frequently identified in turkish children with gastroenteritis; strains belonging to this genotype have been found in europe and mainly in children. previous reports from british troops deployed to iraq indicated that two nov strains isolated were responsible for cases of gastroenteritis there. similar mixed nov outbreaks have been previously observed and are often attributed to systematic failure of cooking/cleaning/drinking water supplies (ahmed et al. ) . one limitation of this investigation was that the survey was not used to capture data from a control group, those without recent age, preventing carrying out a risk factor analysis. another limitation was the lack of environmental samples that could be tested for nov in order to track the source of outbreak. from anecdotal information, it is likely many in the local population and the turkish military base were ill, but a formal outbreak investigation in the turkish population was never performed. from the multiple genetic types involved, one specific contaminated food or water source seems unlikely. the largest turkish nov outbreak was in keçiborlu province of isparta county between april and , , with patients seeking medical help from the healthcare centers, after suffering from nausea, vomiting and abdominal pain (more frequent than diarrhea) (s€ ozen et al. ) . because of underreporting, the number of affected people was estimated to be higher. municipal water was the suspected source but no samples tested positive. as a cautionary note, the authors suggest that nov may not be the only causative agent of gastroenteritis outbreaks, especially from an undetermined fecal source, and bacterial, viral and parasitic agents should be examined together with the nov. in saudi arabia, a national policy for reporting, notifying, and recording incidents of bacterial food poisoning was established in (al-joudy et al. ). since then salmonella food poisoning outbreaks have been reported from different regions of ksa, exhibiting seasonal and regional variations, with chicken, meat, and rice being commonly incriminated food items, and frequently reported in the saudi epidemiological bulletin. al-mazrou ( ) reviewed the history of foodborne outbreaks in ksa and saw an increase over the last few decades, especially those caused by salmonella, with the main food vehicles being chicken, meat and eggs, and s. enteritidis being the most frequent salmonella serovar responsible. according to promed editorials, restaurants and communal feasts and institutional feeding (such as in school cafeterias, hospitals, nursing homes, prisons, etc.) where large quantities of food are prepared several hours before serving are the most common settings in which foodborne illness incidents occur (http://www.promedmail.org). for instance, in , a hospital in the jizan region received suspected food poisoning cases that were ill after taking meals from a restaurant, including a woman who suffered from severe diarrhea, abdominal pain, vomiting and dizziness (fagbo ) . the restaurant was closed down and three of its workers were detained pending the results of laboratory tests. the report of an investigative committee could not find a specific cause, but noted that the restaurant had earlier been responsible for some hygienic violations. in , cases suspected of foodborne illness after eating a meal at a restaurant were admitted to various hospitals in the najran region (alhayat ) . most of the cases were not seriously ill. no report was given on the samples that were taken from the suspected restaurant, which was closed temporarily. there is an interesting observation related to variant creutzfeldt-jakob disease (vcjd); four cases have occurred in the us since the disease was first diagnosed in the united kingdom in linked to consumption of cow meat suffering from bovine spongiform encephalopathy (bse); two of these were associated with the united kingdom (where bse was first reported), but one came from saudi arabia and the most recent case in had extensive travel to the middle east and europe (cdc ) . this may indicate some source of vcjd in the middle east including saudi arabia. one of the big concerns for ksa is the annual hajj with millions of muslims from around the world converging on mecca, in saudi arabia, each year. no other mass gathering can compare with the hajj, either in scale or in regularity, and various communicable disease outbreaks of various infectious diseases have been reported repeatedly, during and following the hajj (memish ) . in , an outbreak during the hajj occurred where all the cases came from one tent occupied by soldiers located in a government camp in mina, makkah province, near mecca (al-joudi ). the camp was served by a catering company that prepared and distributed three meals daily (breakfast, lunch, and dinner). a case was defined as any individual who developed diarrhea with or without abdominal pain after eating at the camp in mina in january, . of the soldiers who were interviewed, ( %) had developed gastroenteritis, most commonly manifested by diarrhea ( %), and abdominal pains ( . %). the mean incubation period was . ae . h and the epidemic curve suggested a common point source outbreak. out of three served meals, lunch with a rice dish was found to have a statistically significant association with illness. unfortunately, no food remnants were found for sampling, and the results of stool cultures of all diarrhea patients, and rectal swabs from all food handlers were inconclusive. temperature abuse was cited as a contributory factor in this outbreak. based on the incubation period and symptomatology, bacillus cereus would be the most likely etiological agent. another example of a foodborne illnesses associated with the hajj occurred in when bangladeshi pilgrims were taken to hospitals in madina (medina) after eating a meal prepared by an unlicensed caterer (promed-mena ). they suffered from abdominal pains associated with diarrhea and vomiting. the pilgrims were all treated and discharged, except for one who remained hospitalized. samples of the food they had eaten were sent for analysis but the results are not known. considering the mass of people converging on this small part of the middle east, it is surprising there are not more foodborne disease outbreaks. this may mean excellent food control by the authorities or some illnesses are simply not recognized and reported. at least bahrainis suffered from food poisoning after eating catered sandwiches served during a wedding celebration, the biggest mass poisoning outbreak in the country's history (promed-mena ) . the wedding took place in the safala village, near the eastern island of sitra. all eventually recovered after treatment but one man who had sickle cell disease, died. teams were formed to investigate the outbreak, and blood specimens from all workers at the bakery who prepared the egg, cheese, and mayonnaise sandwiches along with leftover sandwiches and their ingredients on the caterer's premises were sent for bacteriological analysis. the bakery which supplied the sandwiches was closed by the public health directorate at the ministry pending the investigation's results. unfortunately, no final report was released to the public. the promed editor considered the etiological agent could be salmonella or staphylococcus aureus enterotoxin, depending on the length of the unstated incubation period. the region experiences some unusual type of illnesses relating to on-going hostilities. for instance, the united nations has been sending aid to reach besieged towns in syria, close to the lebanese border, but in october, , it sent hundreds of boxes of "moldy" high-energy biscuits past their 'sell-by' date in september ( of the boxes transported) to zabadani and madaya, apparently causing food poisoning (afanasieva et al. ; muhkalalati and kieke ) . officials stated these could be the only cause of an outbreak of food poisoning among almost residents who came to makeshift hospitals, mainly children who had vomiting, diarrhea and abdominal swelling almost immediately after eating the biscuits. the biscuits were described as "moldy and rotten and had been poorly stored". apparently, when the last aid order that was sent was filled, there was a shortage of food. the red crescent, who was filling the order, took some of the expired goods to complete it. however, these biscuits had only just expired and normally would not have posed any health risks to those eating them. nevertheless, the words poorly stored suggest that moisture may have encouraged microbial growth (visible mold more likely than bacteria because fungi can grow aerobically in the presence of the presumably elevated sugar content in the high energy biscuits). also, contributing to the symptoms, the residents of zabadani and madaya had been blockaded for consecutive days, and their immune systems were extremely weak. refugees are also at risk of gastrointestinal diseases from contaminated water or food. up to two million syrian migrants fleeing syria due to the civil war were living in turkey, and supplying them with safe and secure food supplies is a challenge for any host country. one incident, no doubt, one among many indicates the risk of contaminated food. in april, , five security forces were injured after syrian migrants in a tent city in turkey's southeastern province of mardin reportedly attacked guards over allegedly being poisoned from the lunch at the camp (anadolu agency ). some syrian migrants were detained after the incident; syrian migrants out of the currently residing in the temporary sheltering center in mardin's derik district applied to the center's hospital with symptoms of food poisoning, dizziness, and vomiting. after treatment they were discharged, none of them in a critical condition. although an investigation was conducted and samples from the lunch sent to the lab for analysis, no further information was available on the outbreak. promed speculated that if the lunch food was the vehicle, it would be a short incubation illness likely caused by staphylococcus aureus, bacillus cereus, clostridium perfringens, or possibly a non-biological toxin. these illnesses may cause vomiting, diarrhea, or both, and are usually short in duration (less than h), and are not associated with prominent fever. in iraq, no recent foodborne disease outbreaks have been published, but no doubt many have occurred in the last decades with so much public health infrastructure dismantled. only the most newsworthy of outbreaks are being covered by the press today. iraq and other middle eastern countries are in sectarian turmoil and on two occasions islamic state (isis/is/isil) fighters (jihadis) were likely poisoned by cooks who infiltrated their camps. in november, , a group of defected syrian soldiers (free syrian army men) who posed as cooks reportedly poisoned isis militants after they ate a contaminated lunch at the fath el-sahel camp, where of them were based (gee ). apparently about a dozen of the jihadis were killed and taken to nearby field hospitals. the 'cooks' immediately fled, along with their families, with the help of fellow revolutionaries. seven months later, in july , jihadis died after ingesting an iftar meal eaten by isis militants (akbar ; variyar ) . it remains unclear whether the jihadis, who were breaking their ramadan fast in mosul, iraq, died of accidental food poisoning or intentional poisoning, but it is likely a repeat attack of the earlier incident described above. the nature of the poison or details of the illnesses in either episode are not known. however, in both episodes, onset and severity of the attack were rapid, probably caused by a relatively tasteless chemical in lethal doses added to one or more foods. targeting the military by any means including poisoning food has always been a strategy of opposing forces. in february , a deliberate attack was foiled when afghan border police detected a significant amount of bleach in fruit and coffee stored at their main border checkpoint between afghanistan and pakistan, a likely attempt to poison the afghan security forces (tucker ) . the police decided that although none of this food had been consumed, the level of contamination was high enough to cause serious injury, and it must have been done intentionally. there had been previous incidents of intentional food poisoning aimed at afghanistan's civil defense forces, including an episode in kabul in when several people were sickened. in , in southern helmand province militants killed four afghan policemen and two civilians inside a police checkpoint by poisoning their yoghurt coordinated with an attack (anonymous a). there had been several recent poisoning incidents involving members of the afghan national police, as part of attempts by the taliban to infiltrate the security forces; three police officers were reported missing, along with their weapons and a police vehicle, following that attack in helmand province. taliban militants had first poisoned the police officers' yoghurt before launching a full scale attack on the checkpoint. similar tactics had been used by insurgents in helmand before. the same thing happened again in january when a rogue policeman collaborating with insurgents in southern province of uruzgan shot dead colleagues after first poisoning their food, but no further details are given (reuters ). turkey does have food laws that are supposed to limit food contamination and resultant foodborne illnesses. the turkish food code stipulates that all turkish food businesses have to provide food hygiene training commensurate with the work activities of their staff. to see what progress had been made in this area baş et al. ( ) evaluated knowledge, attitudes, and practices concerning food safety issues among food handlers in ankara, conducting face to face interviews and administrating questionnaires. the majority of the food handlers who responded ( . %) had not taken a basic food safety training (and probably most of non-respondents had not either). the mean food safety knowledge score was . ae . of possible points. the self-reported hygienic practices showed that only . % of those who were involved in touching or distributing unwrapped foods always used protective gloves during their working activity. of those food handlers who used gloves, only . % and . % always washed their hands before putting them on and after removing them, respectively. in addition, there was a difference handlers' scores depending on where they worked. scores were higher for food handlers in catering establishments ( . ae . ), school food services ( . ae . ) and hospital food services ( . ae . ) than restaurants ( . ae . ), hotels ( . ae . ), takeaways ( . ae . ) and kebab houses ( . ae . ). these scores may also be biased upwards since they were self-reported and not observed practices. the study demonstrated that food handlers in turkish food businesses often have lack of knowledge regarding the basic food hygiene, e.g., critical temperatures of hot or cold ready-to-eat foods, acceptable refrigerator temperature ranges, and cross-contamination. those who were trained scored better, and the authors stated there was an immediate need for education and increasing awareness among food handlers regarding safe food handling practices. in istanbul from / , thermophilic campylobacter was isolated from . %, . %, and . % of beef, mutton, and chicken samples tested, respectively (bostan et al. ). there was no significant seasonal variation in the prevalence of the pathogen. c. jejuni was the species most commonly isolated from chicken meat, while c. coli was the most common in beef ( . %) and mutton ( . %) carcasses. campylobacter isolates were most often resistant to tetracycline ( . %), followed by trimethoprim-sulfamethoxazole ( . %), nalidixic acid ( . %), erythromycin ( . %), enrofloxacin ( . %), ciprofloxacin ( . %), chloramphenicol ( . %), and gentamicin ( . %). the results of this study suggest that a high proportion of meat samples, particularly chicken carcasses, are contaminated by campylobacters, most of which are antimicrobial-resistant strains. in yemen, the prevalence of salmonella in food was determined in sana'a city from april to april by ahmed ( ) . of the different food samples collected from local markets, salmonella spp. were isolated from ( . %). the highest prevalences were in red meat ( . %), chicken ( . %), eggs ( . %), cooked foods ( . %), raw milk and milk products ( %), juices ( . %), vegetables ( . %), sandwiches ( %), and pastries ( . %). serogroups identified were b, c , c -c , d , e , and e , and some foods contained more than one isolate with different serogroups, especially red meat. because handlers in foodservice facilities play a major role in transmission of foodborne diseases (greig et al. ) , studies have been carried out to demonstrate their knowledge of practices related to food safety. in jordan, osaili et al. ( ) measured food safety knowledge of food handlers working in fast food restaurants in the cities of amman and irbid. a total of food handlers in fast food restaurants participated in this question survey study. the overall knowledge of food handlers on food safety concepts was considered to be fair ( . %). the food safety aspect with the highest percentage of correct answers was "knowledge of symptoms of foodborne illnesses" ( . %) and "personal hygiene" ( . %), while the lowest percentage of correct answers was for "safe storage, thawing, cooking and reheating of the foods" ( . %), critical practices to prevent the survival and growth of pathogens. the mean knowledge score of "personal hygiene" reported in the study was much higher than . % and . % reported by martins et al. ( ) and baş et al. ( ) , for the food handlers in portugal and turkey, respectively. also, only . % of respondents considered the duration of hand washing to be ! s. when they were asked how they check that the poultry is sufficiently cooked, only % knew "when the meat has the correct thermometer reading", although % of the respondents had thermometers in their restaurants. about % of them answered that poultry is cooked "when it has been cooked for the stated time" ( %) and "when it looks cooked" ( %). about % of them would store leftovers on the steam table ( %) and in the refrigerator ( %) while about % of the correspondents would store leftovers at room temperature in kitchen or in the oven. a low percentage of the respondents ( %) reheated leftovers to the appropriate temperature ( c). about % and % of the respondents had heard about salmonella and hepatitis a virus, respectively, but % of the respondents knew about listeria monocytogenes, staphylococcus aureus, bacillus cereus, escherichia coli o :h , clostridium perfringens, campylobacter jejuni, or shigella. food workers who had enrolled in a food safety training course had significantly higher total food safety knowledge score than those who did not take any training. there was no association between the experience or any other characteristic of food workers and total food safety knowledge score. this study suggests adopting proper food safety education training courses to food handlers, periodic evaluation of food handlers' knowledge and food safety training course materials. also, the authors considered that better pay for food handlers would improve the food safety status in foodservice institutions. similar concerns over practices that could lead to food contamination and foodborne illnesses were demonstrated in lebanon. a survey was conducted in beirut to evaluate the knowledge, attitudes and practices related to food safety issues of food handlers (n ¼ ) in foodservice establishments (n ¼ ), and to assess the influence of management type on enactment of safe practices on food premises (faour-klingbeil et al. ) . the data suggest that while respondents do have some knowledge of food safety aspects, substantial gaps in their knowledge and self-reported practices associated with critical temperature of foods and cross contamination remain, therefore posing health risks to consumer health. food handlers in corporate managed food outlets showed a significantly higher awareness on food safety practices. it is concluded that the management type is an integral element of the theory of planned behavior that influence food handlers' practices and substantiate the need for more research work on safe food handling in the context of food safety culture framework in food businesses. as in many other mena countries, there is a critical need for food safety education interventions and technical guidance fostered by synergistic participation of the private and public sector to support food handlers in smes (small and medium sized enterprises). parasites are not often looked for in middle eastern countries but they are frequent, and one of the ones of most concern for pregnant women is toxoplasma gondii which is transmitted through undercooked meat and cat feces. since stray cats are common in some localities, of fecal samples of stray cats examined in kuwait, ( . %) were found to be infected with oocysts of coccidian protozoa (abdou et al. ) . toxoplasma gondii was found in . %, and cats < months old had higher infection rate with oocyst of enteric protozoa than older cats. a serosurvey of the stray cats revealed that . % were positive to t. gondii igg. toxoplasma sero-positivity was observed in a higher number of adult cats compared to younger ones suggesting that with age the risk of exposure to t. gondii increases. thus, pregnant women handling cats and particularly kittens or cleaning out sand boxes have a chance of infecting their fetuses and eating raw meat. in pakistan, enteric pathogens are present not only in water but also foods contaminated from the environment or through human actions. mishandling of foods allows these pathogens to contaminate and multiply in them. for example, street-vended fruit salads, locally called fruit chats, offered for sale at high ambient temperatures without coverings, and khoya and burfi, two indigenous sweet dairy products, and locally produced ice cream are often heavily contaminated with enterobacter, e. coli, klebsiella, salmonella and s. aureus (akhtar ) . these contamination scenarios have led to outbreaks with cases severe enough to be hospitalized. bus and train stations where pulses (edible seeds of various crops as peas, beans, or lentils), ground meat dishes, and chickpeas are sold to passengers, and are also heavily contaminated with bacteria including clostridium perfringens. sweet dishes and home-prepared foods in small communities are commonly contaminated with s. aureus, c. perfringens, and bacillus cereus leading to rapid intoxications. one study confirmed campylobacters to be present in % of tested samples of milk and meats and . % of vegetables in three major cities of pakistan (akhtar ) . a wide array of vegetables is routinely consumed in this country and serve as a rich source of vitamins, minerals, bioactive compounds, and fiber but these can be sources of enteric infections if they are consumed contaminated. shigella spp. has been shown to develop resistance and is generally thought to be a major cause of foodborne illnesses, especially among the poor where health care facilities are minimal; shigellosis is associated with poor sanitary conditions and unsafe water for drinking and preparing foods. possible etiologies can be postulated in the following outbreaks. unfortunately, it is not only pathogens that give rise to food-associated disease. soomro et al. ( ) highlighted the indiscreet use of pesticides in agriculture and its impact on environmental pollution. despite the increased production cost associated with extensive use of pesticides, their use is common in developing countries. numerous studies have demonstrated substantial levels of pesticide residues in various foodstuffs in pakistan, and the groundwater has been observed to be considerably polluted in many parts of punjab and sindh provinces of pakistan (akhtar ) . commonly used open rural wells in the punjab were polluted with six pesticides: bifenthrin, λ-cyhalothrin, carbofuran, endosulfan, methyl parathion, and monocrotophos. in the hyderabad region % of the tested samples of eight vegetables (cauliflower, green chili, eggplant, tomato, peas, bitter gourd, spinach, and apple gourd) were found to be contaminated with pesticide residues exceeding maximum recommended limits (mrls) (tariq et al. ; anwar et al. ) . heavy metals such as cadmium (cd), copper (cu), lead (pb), and zinc (zn) arising from increased industrialization can contaminate agricultural soils and these can be found in fruits (including widely-consumed mangoes), fruit juices, vegetables directly from soil uptake or from the processing and packaging (akhtar ) . for instance, spinach, coriander, and peppermint, grown in sindh province contained . - . mg/kg of arsenic resulting in a total ingestion of arsenic . - . μg/kg body weight/day in diet (arain et al. ; khan et al. ) . aluminum concentration in branded and nonbranded biscuit samples from hyderabad were found to range . - . and . - . mg/kg, respectively (jalbani et al. ) . similarly, javed et al. ( ) detected higher concentrations of cd, cr, ni, and pb residues (mg/l) in bovine and goat milk. pakistani foods are more prone to aflatoxin contamination because of the warm and humid climate, and the situation is exacerbated by malpractices during handling and storage of edible commodities (mobeen et al. ) . samples of broken rice, wheat, maize, barley, and sorghum ranged - % with the highest aflatoxin concentration ( . μg/kg), in wheat samples (akhtar ) . chilies are widely eaten and exported, but aflatoxin levels can be eightfold higher than the eu permissible limits to pose a potential health risk to pakistani consumers; concentrations can be reduced by more appropriate care and handling of the chilies at pre-and postharvest stages. nuts and dried fruits in pakistan are cultivated and processed in the northern areas and have been shown to have aflatoxin levels above the eu limit of μg/kg in up to % of samples (ahmad et al. ; luttfullah and hussain ) . aflatoxin m in milk and milk products requires regular monitoring in pakistan since % of the total tested samples of milk were found to exceed the us tolerance limit of . μg/l (hussain and anwar ; hussain et al. ) , and buffalo milk had higher levels of aflatoxin compared with cow's milk. intentional deception of consumers by blending low cost and inferior quality ingredients to make more profit of food intended for sale is prevalent in pakistan, where families are exposed toxic dyes, sawdust, soapstone, and harmful chemicals in beverages, oil or ghee, bakery products, spices, tea, sweets, bottled water, and especially milk and milk products where more than % of samples tested have had adulterants added (akhtar ) . one of the more innovative research projects to provide more home-grown food is in qatar. the sahara forest pilot (sfp) pilot study demonstrated that there are significant comparative advantages using saltwater for the integration of food production, revegetation and renewable processes: ( ) seawater cooling system for greenhouses supports production of high-quality vegetables throughout the qatari summer, and reduces freshwater usage to less than half that of comparable greenhouses in the region; ( ) solar and desalination technologies were successfully integrated as designed into the sfp system, such as the greenhouse and evaporative hedges providing wet-cooling efficiencies without cooling towers; ( ) the external evaporative hedges provide cooling of up to c for agricultural crops and desert revegetation with vegetable and grain crops growing outdoors throughout the year; ( ) commercially interesting algae showed good tolerance to heat and high evaporation rates in the leftover salty water (miss ; clery ). the concentrated solar power plant uses mirrors in the shape of a parabolic trough to heat a fluid flowing through a pipe at its focus. the heated fluid then boils water, and the steam drives a turbine to generate power. hence, the plant has electricity to run its control systems and pumps, and can use any excess to desalinate water for irrigating the plants. in summary, sfp allows food production in all months of the year ( crops) with half the fresh water usage than in comparable greenhouses. on the basis of the pilot success, sfp is now engaged in studies aimed at building a -hectare test facility near aqaba in jordan, large enough from the -hectare operation in qatar to demonstrate a commercial enterprise. tourism is popular in several middle eastern countries, particularly beach and coastal resorts in egypt and turkey. tourism has been the major economy in egypt for many years but can be threatened not only by civil unrest and terrorism but also by foodborne illness (costa ). tourists might not stop coming to egypt due to a few reports of diarrhea; however, widespread reporting of severe cases, and lawsuits, will make tour operators much more selective, and bring pressure on the egyptian hospitality industry to improve its hygienic standards. the greater challenge is for egypt to ensure that it has the capacity to sustain a safe food supply for its own people. in doing so, it provides safe food for those who want to explore its rich history and seaside resort areas. multiple reports of illness have been reported from nile river cruises and a resort town on the coast. from september to november, , cases of hepatitis a imported from egypt were reported to the german public health authorities (bernard and frank ) . investigations pointed to a continuing common source of infection, most likely linked to nile river cruises. in addition, eight cases from france had been travelling on a nile cruise and one on a red sea diving safari (couturier et al. ). one specific cruise ship was mentioned by six of ten belgian cases (robesyn et al. ). those who took a nile cruise had typically done this in combination with a hotel stay. at least three different ships and three different hotel accommodations were mentioned in the travel histories of the french cases. the patients affected had not been vaccinated, which emphasized the need for more effective travel advice before trips to hepatitis a endemic countries (sane et al. ) . possible sources of infection might have been contaminated food obtained from a common food catering company consumed onboard, contaminated tap water supplies for the ships' bunkers, or a common exposure on shore (e.g., a restaurant where tourist groups from various ships were taken during day trips). as all of these ships continuously traveled up and down a short stretch of the river (aswan to luxor and back) with standard mustsee stops along the way, the cases possibly shared an exposure on land. both the long incubation period of hepatitis a ( - days) and long delays in collecting information on the individual cases precluded any rapid intervention on location. no specific food source was identified but it could have been juices as recognized in an earlier major outbreak. in , tourists returning from egypt included hepatitis a case-patients from european countries who were infected with a single hav strain (genotype b) (frank et al. ). the case-control study identified orange juice most likely contaminated during the manufacturing process, e.g., by an infected worker with inadequate hand hygiene or by contact of fruit or machinery with sewage-contaminated water. citrus fruit and citrus juices have occasionally been implicated as vehicles of hav and salmonella infections, with contamination typically occurring during production, or preparation just before consumption. as hav is resistant to acid, it likely can survive for prolonged periods in orange juice. it is also possible that leafy greens could contribute to foodborne illness in egypt. an international study of contamination of leafy green lettuce and spinach samples taken between and from open-field farms in belgium, brazil, egypt, norway, and spain showed that the egyptian samples were the most contaminated at . % (liu et al. ) . these authors claimed that temperature had a stronger influence than did management practices on e. coli presence and concentration. region was a variable that masked many management variables, including rainwater, surface water, manure, inorganic fertilizer, and spray irrigation. temperature, irrigation water type, fertilizer type, and irrigation method should be systematically considered in future studies of fresh produce safety. also in the spring of , a young couple was ill with vomiting and abdominal cramps after their first meal at a sharm el sheikh -star hotel in the egyptian coastal resort area, and they remained there in their bedrooms for the rest of their week (this is staffordshire ). both continued to have ongoing issues months later, with one of them suffering from reactive arthritis. other guests also complained about diarrhea. they stated that the food was disgusting; the meat was undercooked, the buffet was left out for long periods of time, with new food being piled on top of the old food, and there were flies landing on food items. in august , a family stayed at a resort hotel, also in sharm el sheikh, and all suffered severe symptoms including diarrhea, stomach cramps, and vomiting. they were put into the hotel clinic given antibiotics and intravenous drips but had not completely recovered after they returned home (galley ) . at the time other guests were also ill. they noticed that the food including chicken and beef, appeared to be undercooked a couple of times, and that one of the chefs touched raw meat and then touched cooked meat without changing gloves. the booking company confirmed that "a very small number" of guests staying at the resort in reported that they had been unwell, "with symptoms similar to a virus". the company said that guests were offered the appropriate support and advice by their overseas holiday advisors. it claimed that all of its hotels were subject to stringent monitoring and audits and this hotel achieved an extremely high score in its audit carried out in the summer of . however, high audit scores do not necessarily correlate with day-to-day safe hygienic practices (powell et al. ) . the popular beach resort of sarigerme, turkey, on the aegean sea also has had a reputation for gastroenteritis, with repeat problems of foodborne illness with british tourists on vacations organized by tour companies, although the actual hotels were different. in , an outbreak of gastric illness at this resort led to £ . m paid out in compensation, with people suffering from infections including salmonella, cryptosporidium, campylobacter and e. coli (hutchison ) . in september, , hundreds of british holidaymakers suffered from salmonellosis after returning from a hotel complex in sarigerme (disley ) . final figures may have been close to , and several were hospitalized. in october , the swannell family had booked a week's stay at the first choice holiday village resort in sarigerme, when mark swannell, , fell seriously ill a few days into the break with diarrhea, abdominal pain, nausea and lethargy (hutchison ) . he said that some of the food he was served at the hotel had been undercooked, with some chicken bloody in the middle, food was not served at the correct temperature, food was left uncovered for prolonged periods of time, and the same food had been served more than once. the family stated that cutlery, crockery and table linen used in the restaurant was not up to standard, and they saw cats in the public areas of the hotel and in the restaurant. legal action was taken. in addition to ill tourists in middle eastern countries, contaminated exported food can affect those abroad, as illustrated in the following u.s. outbreak. from march to august , of patients identified with hepatitis a in ten states, ( %) were admitted to hospital, two developed fulminant hepatitis, and one needed a liver transplant, but none died (collier et al. ) . almost all cases reported consuming pomegranate arils (seeds) from one retail chain. hepatitis a virus genotype ib, uncommon in the americas, was recovered from specimens from people with hepatitis a virus illness. pomegranate frozen arils imported from turkey were identified as the vehicle early in the investigation by combining epidemiology, genetic analysis of patient samples, and product tracing. the product was then removed from store shelves, the public warned not to eat the seeds, recalls took place, and post-exposure prophylaxis with both hepatitis a virus vaccine and immunoglobulin was provided. this investigation showed that modern public health actions can help rapidly detect and control hepatitis a virus illness caused by imported food. egyptian trade has also been adversely affected by exports. in , there were three outbreaks of hepatitis a sickening persons in -european countries. in the first report in april, persons in four scandinavian countries were infected with hepatitis a (andrews ) . epidemiological investigations traced those cases to frozen strawberries grown in egypt and morocco, though no strawberries were found to be positive for hav. the second outbreak in april was larger in extent with ill in countries, all having recently visited egypt, and the outbreak strain of the virus had the same subgenotype as the first outbreak associated with strawberries. an epidemiological investigation into the second outbreak suggested the likely source was strawberries or another fruit distributed to hotels in egypt. the third outbreak was reported in germany in may, after nine germans were infected with hepatitis a after traveling to italy. this third outbreak infected about italian residents, as well as nine germans, one dutch traveler and five polish travelers; irish residents with no travel history to italy were infected by the same strain of the virus. separate investigations in italy and ireland both implicated imported frozen mixed berries as the source, with most of those berries coming from eastern europe. it is not known if these berries came from other regions, such as egypt, or were local to eastern europe. contributing factors to the larger number ill was lack of vaccination. because hav infections were declining in europe over the last few decades, fewer people had developed antibodies to repel the virus. couple that with the fact that hepatitis a was not on the vaccination schedule for citizens of many of the countries affected, and the result was a highly susceptible population. also, most of the european travelers to egypt were not advised to get hepatitis a vaccinations when staying in all-inclusive resorts, which were attracting an increasing number of europeans traveling to egypt. further, the investigators believe contamination of the berries occurred early in the food production chain. investigators suspect that irrigation water contaminated with sewage water likely contaminated the strawberries in the two outbreaks connected to egypt. but the contamination might have also been caused by infected workers in the field or the processing facility, or by contaminated water sprayed on the berries sometime before distribution. the outbreaks indicate that fresh and frozen berries are efficient vehicles of hav infection, as previously demonstrated in the us and elsewhere (palumbo et al. ) . european authorities agreed that "the experience demonstrated the absolute necessity for extensive collaboration between countries and between the public health and food sectors to identify as quickly as possible the vehicle of infection and, ideally, to control the outbreak in a timely fashion." a more serious outbreak damaged egypt's food export trade. in july , the european union (eu) banned the import of certain egyptian seeds and beans till at least october following an official report that a single batch of egyptian fenugreek seeds probably caused two european outbreaks of e. coli infections responsible for ill persons and at least deaths. a task force of health officials set up by the european food safety authority (efsa) reported that one lot of fenugreek seeds imported from egypt was the most likely common link between the two outbreaks in northern germany and in bordeaux, france (anderson ) . both were traced back a year and a half to a shipment of , pounds ( , kg) of fenugreek seeds, that was loaded onto a ship at the egyptian port of damietta on november , . on the ship's arrival at antwerp, belgium, the seeds were barged to rotterdam to clear customs. the sealed container was trucked into germany to an unidentified importer, who resold most of the lot. an unidentified german company then resold about pounds of the seeds to the german sprouter, which is believed to be the source of the sprouts that caused the extensive german outbreak. the german importer also sold about pounds of sprout seed to the english company thompson & morgan, which repackaged the seeds into . -ounce ( grams) packages. those packages were shipped to a french distributor, who resold the seeds to about garden centers around france. investigators believe that one of those packets was the source of the second european outbreak with cases in the bordeaux area. because the seeds were likely contaminated with e. coli o :h at some point before leaving the importer, and more contaminated seeds could be in circulation, it was deemed appropriate to consider all lots of fenugreek from the egyptian exporter as suspect. soil contact or animal or human fecal contamination of the seeds likely occurred during their production or distribution in egypt. even a negative laboratory test of those seeds could not be interpreted as proof that a batch was not contaminated. trace-forward findings indicate the german importer sold seeds from the suspected lot to companies, and the shelf life of the seed can be up to years. by mid-october, , the european commission (ec) lifted import restrictions on fresh and chilled podded peas and green beans and other fresh produce from egypt, but the ban on egyptian seeds and sprouts, scheduled to expire on october , was to be extended until the end of march, , following an "unsatisfactory audit" of seed producers in egypt (news desk ). the extended ban involved arugula sprouts, leguminous vegetable sprouts (fresh or chilled), soy bean sprouts, dried (shelled) leguminous vegetables, fenugreek seeds, soy beans and mustard seeds. the ec audit showed that measures taken by the egyptian authorities to address shortcomings in the production of seeds that may be sprouted for human consumption were not sufficient "to tackle the identified risks." those shortcomings were not seen in the growing and processing sites for fresh peas and beans, and therefore those vegetables were no longer considered a food safety risk. there is no need for actual illnesses to occur to affect trade. recalls, seizures, and bans can be employed by importing countries if standards are not met, and force exporting countries like egypt to take action. for instance, in the ec suspended the import of peanuts from egypt due to the presence of aflatoxin in concentrations in excess of maximum levels specified in eu regulations (technical cooperation department ) . egypt is a major peanut exporting country and the european markets then accounted for % of its peanut exports. this decision was repealed on december and was replaced by another decision, which imposed a requirement for certification to accompany every consignment and required systematic analysis of consignments and documentation by the importing member state. under this system only egyptian exporters were allowed to ship to the eu. in august , the decision was replaced by another decision that required the competent authorities in eu member states to undertake random sampling and analysis of % only of peanut consignments from egypt for aflatoxin b and total aflatoxins. this improvement came as a result of the efforts that the egyptian government put in complying with the requirements of the eu. to this end, the egyptian ministries of agriculture and land reclamation (malr) and ministry of foreign trade (moft) issued ministerial decree no. / , which covered all stages of production, processing, sampling and exporting of peanuts. the main provisions of the decree were: exported peanuts must be produced, inspected and prepared according to set scientific procedures; and exporters who violate the rules would be suspended for year; the decree also established the legal limit for aflatoxin in peanuts in both the domestic and eu export markets. in the egyptian domestic market, the legal limit was mg/kg aflatoxin b and mg/kg total aflatoxin content. for the eu market, the legal limits were mg/kg aflatoxin b and mg/kg total aflatoxin content. in addition, the decree specified the sampling procedures that must be followed for export certification. in september of the food and veterinary office sent a mission to egypt to assess egypt's compliance with its certification system requirements. a number of recommendations on steps egypt should take to improve the control system of foodstuffs intended for export to the eu were made. in response, the egyptian authorities declared that they were taking actions to address the mission's recommendation. but to achieve that there was a need to coordinate among a number of egyptian agencies involved in the production and export of peanuts and aflatoxin control: malr, the central administration for plant quarantine (capq), the agricultural research center (arc), the ministry of foreign trade (moft), and the customs service. also a laboratory capable of testing for mycotoxins was necessary. alongside this; egypt had technical assistance from international organizations in order to build human and physical capacities necessary for achieving compliance. the action by the eu forces egypt to improve the safety of its peanut production which would be beneficial both to europeans and to all who eat products made from egyptian peanuts, including the domestic consumers. lebanon used to be a tourist haven but is less today because of a seemingly dysfunctional government following a civil war. the country produces food for both the domestic and overseas markets. unfortunately, some exported food has caused illnesses and recalls. twenty-three cases of salmonella bovismorbificans in eight states and in the district of columbia (washington, d. c.) from august to november, were linked epidemiologically to hummus eaten at three mediterranean-style restaurants in the d. c. area, all owned by the same individual (goetz ) . although samples collected from all ingredients used to make the hummus tested negative for any salmonella, the hummus was recalled and the outbreak ceased. during its investigation of the restaurants, the d.c. department of health discovered multiple food safety violations at the establishments, including inadequate food temperature control, insufficient hand washing, and the presence of pests and insects, which had to be corrected. it is not clear if any abusive temperature conditions could have allowed growth of the salmonella in the hummus. the public was not notified because by the time the hummus had been withdrawn from the market, there were no further cases. however, the contaminated ingredient in the hummus was not discovered until may, , when a traceback by the u.s. food and drug administration (fda) revealed that the tahini used to make the hummus in one of the restaurants had recently been associated with recalls in canada for contamination with s. cubana (september ) and s. senftenberg (february ). all tahini linked to these outbreaks had been imported from the same company in lebanon. the fda then mandated that all tahini products coming from this lebanese company be tested for salmonella before entering the u.s. and has recommended that u.s. and canadian officials partner to inspect the tahini manufacturing plant. this was the first time s. bovismorbificans had been implicated in a tahini outbreak in the u.s. as a result of this outbreak, the author stated it is important for public health officials and consumers to be informed that products made with imported sesame paste have been shown to be associated with salmonella outbreaks and that they should be considered as possible sources for foodborne illness in the future. in fact, contaminated sesame seed paste was in the news a few days before a cdc report on the outbreak was made public, after a supply of contaminated tahini was stolen from a california importer's warehouse, where it was being stored because a sample had tested positive for salmonella. the tahini, which had also been imported from lebanon but from a different manufacturer, was awaiting destruction, and the fda warned the public that the stolen, potentially contaminated tahini may be on the market. lebanese tahini has been implicated in several outbreaks in the past and subject to recalls (harris et al. ) . government oversight of the food industry is variable across the region with many regulations stemming back to colonial days, but modernization changes are gradually being considered or implemented. unfortunately, where some middle eastern countries are slowly moving forward to improve food safety, others are slipping back in their oversight because of conflict and lower public health priorities. there are relatively few large food processing operations except those managed by multinational companies, and most of the government oversight is on smes particularly small foodservice outlets. the states in the gulf cooperation council (gcc), each have an aggressive food safety policy but do not always follow identical approaches, some of which are well-established and some of which are innovative. the ksa has had a food inspection system in place for many years with reports of outbreaks published regularly, though no doubt it could be improved with more cooperation between the ministry of health, the municipalities and the saudi food and drug authority (sfda). the sfda was established under the council of ministers resolution no ( ) dated january , , as an independent body that directly reports to the prime minister (el sheikha ). the sfda is responsible to regulate, oversee, and control food, drug, medical devices, as well as set mandatory standard specifications thereof, whether they are imported or locally manufactured. the control and/or testing activities can be conducted at the sfda or any other agency's laboratories. moreover, the sfda is in charge of consumers' awareness on all matters related to food, drug and medical devices and associated other products and supplies. the sfda has to negotiate with the moh their mutual responsibilities following specific foodborne disease instances or consumer complaints. bahrain claims to have one of the more advanced food control systems in the region. in july , as ambient temperatures heated up, the ministry of heath urged people to make sure the food they consume is properly stored during the summer months to avoid microbial growth and risk of food poisoning, e.g., keeping meat and fish at c and to cook food thoroughly (haider ) . the ministry was aware that both visitors and locals want to eat safe food, especially as bahrain is moving towards more tourism with people are eating out more often. the ministry ordered shops to provide appropriate storage facilities, e.g., coolers and refrigerators, for food as part of its efforts to protect the public's health. inspectors were checking food stalls, ice-cream parlors and vegetable shops to ensure that customers were not being sold contaminated or rotten products. the ministry claimed to thoroughly investigate any complaints it receives, and to facilitate this a new hotline number was launched by the ministry for general public to report food contamination complaints against supermarkets, restaurants, coffee shops and hotels. specific advice for consumers included: being careful when buying salads; fruits and vegetables should be washed thoroughly before they are consumed; and dairy products such as milk, cheese and eggs, should always be refrigerated, since microorganisms grow faster in these products. the ministry claimed that bahrain has one of the best food control methods and food safety records in the region, and could even act in the future as a consultant in this field for other countries, including other gcc states. by , government oversight had stepped up. in april, the ministry of health warned people against buying food advertised on social media or sold on the street by unlicensed retailers in bahrain, either made in people's homes or by street hawkers (anonymous c) . the ministry stated that control of these home operations is difficult if someone suffers from food poisoning since inspectors are not allowed to go into homes. many homes sell food without a license and some would-be entrepreneurs even have barns where they slaughter livestock and market the meat illegally. there were , inspection visits conducted in by inspectors from the food safety and licenses group, which closed of around registered outlets. inspections cover imported food from ports right up to where it reaches restaurants and food outlets; , visits revealed around , tonnes of imported food were permitted for consumption, but tonnes were considered as non-consumable (rejected), during the same period. one of the more recent important programs is the smart inspection project launched in april . inspectors, many with masters and phd degrees, visit restaurants and coffee shops to take food samples, as well as explain to staff how to store food and ensure its safety (anonymous c) . it includes awarding food outlets that achieve a % food safety standard a blue sticker, while those meeting % of standards get a green sticker. outlets that fail to achieve basic standards are warned with a red sticker. the total number of outlets assessed between august and february was ; were presented with blue stickers, with green stickers and with red stickers. this project features daily inspections and is focused on small food outlets, some of which have caused food poisoning in the past. inspection visits depend on the hygiene of each outlet and the complaints received about them; some require two or more visits annually. high-level restaurants already have certified inspectors for evaluation and most of them require only one visit per year. the ministry's ultimate goal through this project is to decrease cases of foodborne disease, particularly important as bahrain is increasing its tourism efforts and, thus, ensuring food safety is essential. to support the ministry's initiatives, live demonstrations on food safety practices were promoted in kitchens in hypermarkets. however, if red sticker facilities fail to take advantage of educational material, they may be punished for neglecting food safety standards and guidelines though public prosecution. in a bid to improve standards of hygiene in restaurants, qatar's supreme council of health (sch) increased the number of spot checks on food outlets and has launched a hotline for residents to report food poisoning (walker ). the council is responsible for monitoring food establishments and implementing qatar's food laws along with the ministry of municipality and urban planning (mmup/baladiya). the sch embarked on an intensive inspection campaign, collecting food samples from all restaurants and food outlets in the country including suppliers. the inspection teams, which include specialized doctors from the sch's communicable diseases department and the environmental health inspection department, also medically check workers responsible for preparing food to ensure they are not carrying infections. those found to be handling food in an unhygienic way would be immediately dismissed. following a hotline complaint call, a report is filed, a team from the sch visits the affected people, then inspects the related food outlet and collects samples for laboratory examination. the latest crackdown was in response to the illness of a family of four which suffered food poisoning after eating chicken, rice and salad at a popular turkish restaurant which was closed down because a medical report prepared by the sch's environmental health section confirmed that the outlet served contaminated food and violated health regulations. tests conducted in the central food laboratory at sch found three types of bacteria causing diseases in food served by the restaurant. medical tests on the victims also showed that they were infected by the same bacteria, as well as one of the restaurant workers. another popular turkish restaurant was closed for months after it was found that several customers were treated in the hospital for food poisoning symptoms including intense nausea, vomiting and diarrhea. as part of the sch's new campaign, experts would undertake community awareness drives, and organize seminars and training sessions about food contamination to improve understanding among owners and workers in food establishments. other closures occurred because of serving food with moldy ingredients, rotten vegetables in the kitchen, insects in pasta, and generally violating the provisions of the food law. the mmup increased the number of spot-checks and naming and shaming erring establishments on its website in arabic. the amendments to the food law gave greater powers to authorities to fine and close down venues that break the law including temporarily closing down establishments if it has violated food safety and hygiene regulations, and also has the power to recommend severe penalties. a follow up to one of these closed doha turkish restaurants was after a trial when five staff were each been handed fines, jail sentences and deportation orders after they were found guilty of causing food poisoning to approximately customers ill with vomiting, nausea and diarrhea (santacruz ) . the restaurant was accused of serving spoiled and unsafe food on october, . an affected pregnant woman gave birth to her baby months prematurely. the manager of the restaurant was fined approximately $ and sentenced to spend months in jail while three other staff members were each fined approximately $ and sentenced to month in jail. during an inspection it was found that another staff member did not hold the necessary health certificate and was subsequently fined approximately $ and also sentenced to month in jail. as well as the staff members being sentenced to jail and fined, the court of environmental misdemeanours also found that the restaurant itself was guilty of causing the food poisoning outbreak, and issued the restaurant with approximately $ in fines and ordered it closed for a further months. in other parts of the world these penalties would seem unduly harsh, as it would be difficult for this restaurant ever to recover financially. coupled with education, there has been recent enforcement blitzes on food establishments such as hotels, restaurants and bakeries by oman municipalities, and a leading bakery in muscat was closed down because of rats in the premises in late december, (staff . this led food safety experts and the public to call for stricter rules and heftier fines to be imposed after surprise checks conducted by the muscat municipality, especially when it was disclosed that nearly half the restaurants in the bausher area were not following food safety standards. surprise inspections by the muscat municipality at restaurants in bausher found that around restaurants did not meet food safety standards and were violating rules formulated by the municipality. also, in the same time frame, ibri municipality officials were forced to shut down commercial shops and they destroyed more than km of outdated food in . according to the municipality's officials, health violation letters were issued throughout the year, as well as warnings were issued to different institutions operating in the wilayat of ibri. there are no easily-accessible reports on government oversight in pakistan and inspection actions are more likely to be released to the public through the press. in , the islamabad capital territory (ict), administration conducted a drive against adulterated food items with unannounced inspections of food outlets in different markets and imposed fines amounting to rs , (about us$ ) on owners for unhygienic conditions at their premises including restaurants, cafes, bakers, candy (sweet) stores, and a hotel was sealed (app ) . cleanliness conditions at the outlets' kitchens were found unsatisfactory and unhygienic while workers had not been vaccinated against viral diseases. some business owners were also paying less to their workers in contravention of the minimum wages act. business owners were directed to improve cleanliness conditions and ensure food safety standards failing which strict action would be taken against them. a cattle market was also ordered to "beef up" its security. punjab, pakistan's most populous province, has a population that is more than double that of california, and lahore, the provincial capital, has a vast array of food outlets. from the available press reports, the punjab food authority (pfa) has a mixed record of oversight of food operations. a pfa team visited the polo ground restaurant at the race ground park and found expired food, blocked sinks and unhygienic conditions in the kitchen and food storage area in contrast to the claimed high quality standards by the management of the supposedly high-class restaurant (raza ) . the team faced resistance from the management but it managed to enter the kitchen for inspection. pfa officials said the kitchen condition was similar to that of an ordinary road-side eatery, dispelling general perception that restaurants serving the elite follow higher standards of hygiene and food safety. however, the pfa in lahore had received a complaint that an assistant food safety officer had received rs , (about us$ ) bribe from the restaurant owner so he could keep his restaurant open (anonymous d) . another restaurant on peco road sealed by the pfa for poor hygiene and unsanitary conditions of its workers in the second week of march, was opened for business the very next day. typically, according to the pfa's standard operating procedure (sop), a restaurant sealed for the first time may resume business after a week. at the end of the week, the proprietor has to submit an affidavit assuring the authority that all problems pointed out by the food safety officer had been taken care of prior to reopening it for business. the pfa director general (dg) had constituted a three-member committee to probe the complaint of bribery but it was later shelved. similar situations occurred when restaurants that had reopened before the stipulated period for closure had expired. in the first week of , a restaurant was fined rs , (about us$ ) for unhygienic conditions and lack of soaps in the workers' washrooms, instead of following the pfa sops of sealing the premises. the sops regarding duration of closure and required permission from the pfa dg were stated to be flouted openly. however, a pfa spokesperson denied any wrongdoing, and the sop was being observed to the letter. she said a written permission from the dg used to be mandatory in order to de-seal restaurants, but now an operations deputy director can also issue permission for it. she also stated that the restaurant on peco road had not reopened on orders of the pfa; its owner had de-sealed it illegally. these reports indicate that there may be some illegal activities including bribery by inspectors but miscommunication on how much leeway inspection staff have on prevention and control practices may be more of the issue. in mid- ayesha mumtaz became the new operations director of the pfa, tasked with ensuring food in punjab is unadulterated and safe (reeves ) . her self-declared war on unhygienic food generated so much publicity in the last months that she became a household name in pakistan. mumtaz says many food producers know nothing about hygiene but are willing to learn. there's also a hardened mafia who are only interested in profit, she says. everyone in the street seems to know about mumtaz. storekeepers begin shooing away customers, hauling down the shutters, and heading into the shadows in the hope that mumtaz's scrutinizing eye will not fall on them. these traders would sooner lose business than risk a visit from a woman whose campaign to clean up the kitchens and food factories of pakistan has made her a national celebrity. she declared that the pfa cannot allow them to get away with their "perverse" activities and to "play havoc" with the lives of the people. consumers are unaware that the cakes and sweets that they buy over the counter are produced amid unhygienic conditions. she has found spoons encrusted with filth, fly-blown cans of gooey liquid lying around haphazardly, dirty containers, grimy rags and rusty tin cans, moldy scraps of cake, all involved in making cakes and sweets to be sold to the public. civil servants in pakistan are often accused of being lazy and corrupt. mumtaz is being feted as a rare example of a government official who actually champions the public's rights. she and her inspectors have so far raided more than , businesses, and pakistanis seem to approve. her fans call mumtaz the fearless one. hundreds of thousands have clicked like on the pfa's facebook page in appreciation of her work. there was a very famous hotel in the heart of lahore that she inspected and found the chiller where they keep all the foods together (vegetables with chicken, meat), but also a big rat; this became big news for the public. however, there are complaints that she does her raids with police and cameras to be broadcast nationally even before the owners are convicted, according to the lahore restaurant association. in , the abu dhabi food control authority (adfca) planned to check all food handlers by . the authority's emirate food safety training (efst) program, started in , provides basic training in food hygiene and safety to those who work in food outlets (olarte ) . according to the adfca, small catering businesses in most countries have the lowest standards of food safety, and most workers in abu dhabi's small restaurants are illiterate and do not speak fluent arabic or english, making it a challenge for them to understand and follow safety guidelines and regulations; % of managers and % food handlers in the capital speak south asian languages such as urdu, hindi and malayalam (pennington ) . the training is now offered in four languages -english, arabic, urdu and malayalam -which the majority of food service personnel speak, and covers basic food hygiene issues including staff hygiene, food temperature, cross-contamination, cleaning and sterilization. to help them understand and follow food-safety rules, the adfca is using photographs to teach employees how to handle food safely according to international standards. the scheme is an extension of a pilot involving small restaurants carried out in - . as part of the efforts to ensure retention of their learning, the adfca conducted spot checks at food outlets in marina and khalidiya malls, and gave guidance and advice to staff for those with violations, rather than just penalizing them, the normal practice in most middle eastern countries. the field operations manager at the adfca noted that the differing cultures, education and languages are the barriers that sometimes hinder food handlers from carrying out what they are trained to do. he recommends that supervisors should quiz them on hygienic and safety issues so that they know how to properly prepare and serve food. those who have learning difficulty or are illiterate are given assistance through illustrations, in order to make it through the lessons and pass the examination. one of the critical elements of food safety that the adfca has to monitor and ensure, is that food handlers are aware of cold ready-to-eat food being kept at c, while hot food should be kept and served very hot > c. the adfca categorizes the food premises and carries out inspections based on their risk factors -high, medium and low. restaurants and hypermarkets belong to the high-risk group; warehouses to the medium risk; while groceries, honey shops and vegetable and fruit outlets are considered low risk. recently, the establishment of the egyptian food safety authority was initiated by the minister of trade and industry, with the support of the ministry of health and the ministry of agriculture. it would be responsible for food safety and consumer protection through the provision of sound data and guidance to deal with processed or genetically modified food in accordance with food safety standards (anonymous b) . the strategic plan for the new draft law includes a revision of all egyptian laws and legislation that deal with food safety since , including around other legislations. the authority would need to apply food safety standards on imported food the same way it does for locally produced foodstuffs. adopting the draft law would in effect cancel all existing laws and create one food safety law for the country. the food safety authority plans to monitor the foods consumed by egyptians of different age groups as a basis for where to put resources. another issue to be faced is that studies in egypt based on us statistics have revealed that the cost of food spoilage costs the country million egyptian pounds annually. the chamber of food industries indicated that a unified body for food safety to apply international quality specifications and unite regulators was lacking. this reduced the competitiveness of local products, especially since most foreign countries do not recognize egyptian regulations. it was hoped that investors in food industries would bring in new investments to the sector in the upcoming period if a food safety authority were to be established, as per a ministerial decision issued in . the food safety authority has received several approvals from governments that ruled during the -year period following the revolution, but apparently nothing has been yet finalized until recently (mefreh and saeed ) . in a similar way to egypt, the lebanese government has been debating a new law on food safety for many years but unlike egypt, it has yet to make much progress. lack of agreement at the parliamentary level has resulted in different ministries (health, agriculture, industry, environment, tourism) taking action as they see fit. the latest was in november , when the minister of health conducted an extensive campaign of inspections in lebanese establishments and naming of facilities that did not meet the ministry's expectations (naylor ) . the minister personally revealed that numerous supermarkets, bakeries, butchers and restaurants had been violating food safety and sanitation standards. they shut down slaughterhouses, restaurants, supermarkets and other retailers selling contaminated food. for instance, changes needed to be made for the slaughterhouse to conform to health standards; the report said livestock must be hanged during slaughter and not laid on the ground and that the abattoir should also be equipped with refrigerators and storage units for separate types of meat and their cuts. however, discord among ministries is apparent with the tourism minister trying play down the publicity of the health minister's food safety blitzes by saying "we are in favor of full transparency, but we feel like we were 'deceived' because the food safety situation in lebanon is good and better than other countries. we apologize to tourists, but more importantly, any of the ministry of health staff is ready to apologize to the lebanese citizens for the public sector's failures throughout the years?" (yaliban ) . foodborne disease surveillance is limited in lebanon and cannot be used to indicate the actual level of foodborne illnesses in the country. lebanese food exports are also being required to conform to international standards. tahini made from sesame seed paste is a major food export to the west, but recalls of tahini manufactured in lebanon because of salmonella contamination are more frequent than they should be; one recent example was a health hazard alert for certain clic, al nakhil and al koura brand tahina products that may have contained salmonella, recall/advisory dated august , posted from canadian food inspection agency [also see tahini/hummus linked illnesses under foodborne disease in specific countries]. under the new us food and drug administration food safety modernization act, foreign companies importing foods to the us must demonstrate that they have the operational plans and facilities sufficient to produce safe food before they can ship any product to the us (fda ), which is causing some concern among lebanese tahini manufacturers and government agencies. thus, although there is knowledge about foodborne disease and other food safety issues within government, industry and academia, the political inertia means that many foodborne illnesses will continue to occur but not be properly reported or know what factors were present to cause the outbreaks. industry currently is taking the lead; apart from companies promoting food safety like boecker and gwr food safety, mena food safety associates (mefosa) (http://www.mefosa.com/), based in beirut, assists mena companies hone their competitive edge by establishing and verifying procedures and practices that ensure quality, wholesome and safe products through consulting, auditing and training services in haccp, gmps, and hygienic practices. however, lebanon's lack of a coordinated system of government oversight of the food industry pales into insignificance compared to that in syria. prior to the war, syria's healthcare system had hospital and doctor levels equivalent to other middle-income countries such as brazil, turkey and china, with life expectancy of years, and most of the disease burden being similar to that in the west with non-communicable diseases, but four years of violence have changed all of that. child vaccination levels dropped from % pre-conflict to % in march (templeton ) . as a result, outbreaks of diseases that had long been under control have spread across the land and into neighboring countries: hepatitis, measles, leishmaniasis, multi-drug-resistant tuberculosis, typhoid and even polio, which had not been seen in the middle east for years. life expectancy has dropped by two decades. medical personnel are clearly targeted because they are seen as potential enemies helping the opposite side. the majority of syria's doctors have been killed or fled the country (> medical workers have been killed since ). the situation has been called the worst humanitarian catastrophe this century, and the worst concerted attack on healthcare in living memory. at least , syrians have been killed and more than million others have been forced from their homes since the conflict began on march , , with over four million people in areas that are hard to reach for humanitarian aid, and Á million have fled mostly to neighboring turkey, lebanon, jordan, and northern iraq, while others have sought safety in europe, provoking a political crisis in the -member bloc (devi ) . another middle eastern country under stress but with less publicity is yemen. currently there is little government oversight into food as there is little to be had. the situation in yemen is characterized by large-scale displacement, civil conflict, food insecurity, high food prices, endemic poverty, diminishing resources, and movement of refugees and migrants (wfp ). the un world food programme (wfp) has been in yemen since . in , wfp conducted a comprehensive food security survey which found that % of the people ( . million) were food insecure, of which some five million were severely food insecure, meaning they were unable to buy or produce the food they need to survive. the organization's protracted relief and recovery operation (prro), aims to reach six million people between mid- and mid- with , metric tons of food and us$ . million in cash and vouchers at an overall cost of us$ million. if the conflict continues, this goal is unlikely to be met in time since both the airport and shipping port are areas being fought over. the wfp has been attempting to bring in relief supplies but cannot do so under fire, which means that only small amounts are occasionally delivered to the country (mukhashaf and miles ) . one example of this occurred in aden on july , when a ship docked after waiting a month to unload enough u.n. food aid to feed , people for a month. previous repeated attempts to send ships to aden were been blocked due to severe fighting in the port area. the prro is aligning wfp's activities with moves to increase the government's capacity to respond to the crisis and will promote recovery and resilience to enable food insecure households and communities to better withstand and recover from the effects of conflict and shocks. there are many similarities as well as substantial differences in the descriptions of issues concerning food safety and foodborne disease of each country in the region. gastrointestinal diseases are frequent throughout the middle east with some countries identifying their etiologies, such as egypt, kuwait, israel, pakistan, turkey, yemen. these include bacteria and parasites, e.g., salmonella, shigella, campylobacter, enterotoxigenic e. coli (etec), giardia, entamoeba, and occasionally enteric viruses such as hav and norovirus. however, none of the countries has a well-functioning foodborne disease surveillance system, but a few report on a regular basis like ksa, and starting recently, lebanon with pulsenet. mostly it seems that only large outbreaks or ones with fatalities that are reported on, and mainly through the press. these outbreaks are often related to point sources which are in most cases communal foods prepared for a large number of individuals as in feasts, student hostels, schools, campuses, or military camps. however, the actual etiological agents and the factors contributing to outbreaks are only rarely determined. one example is a very large outbreak in bahrain in with at least people suffering from foodborne illness after eating contaminated egg-andmayonnaise sandwiches served at a wedding party, but the etiology was not determined, even though clinical specimens and food samples were analyzed, at least in a publically-released report (promed-mena ) . based on the type of preparation including the length of time taken for preparation of the implicated food and the time from consumption to the appearance of symptoms of foodborne illness, the types of symptoms, and what has already occurred historically in foodborne disease outbreaks, possible agents can be surmised, such as bacillus cereus and staphylococcal enterotoxins, and salmonella, shigella, or norovirus infections, but promed is continually asking for more information once an outbreak is announced, and hardly ever receiving it (promed-mena ). all this indicates that even if clinical specimens or food samples are taken and analyzed, laboratories are only rarely able to determine an etiologic agent, or at least report on their results. most agents described with the little information available seem similar in all the mena countries and to those encountered in the west. however, a few pathogens are more likely to be restricted to a few nations, such polio in pakistan, cholera in iraq, mers-cov in ksa, and botulism in egypt and iran where river fish are often eaten (one case of infant botulism was diagnosed in israel but it is a rare disease anywhere); the first two are more likely transmitted though water or poor hygienic conditions, the third by camels, and only botulism exclusively through food. brucellosis is widespread in the middle east but only a few country studies indicate its link to meat or dairy products. much of the middle east is in the throes of conflict which results in unique situations in specific countries to exacerbate foodborne disease or food poisonings; these include relief agencies supplying "stale" food to those trapped and starving by the syrian civil war, almost lack of food at all in yemen, deliberate poisonings of enemies in afghanistan, syria and iraq, accidental pesticide poisonings in iran, preventing unsafe food being sold to those on the hajj in ksa, improperly prepared catered food for foreign troops in bases in afghanistan, iraq, kuwait, ksa, and turkey. countries where tourism is a major source of income can be adversely affected by bad publicity over complaints over food served in resorts, such as in egypt and turkey. also, gulf countries tend to employ workers from india and other surrounding territories, and these are typically housed in camps or separate communities from citizens and visitors, and are transported to work sites and back; conditions are not always conducive to safe food, and outbreaks are occasionally reported either from their work sites or their overnight residences where meals are prepared or catered. most food to many of these countries is imported, especially those with limited agricultural land and adequate water supplies; fruits and fresh vegetables, tend to be grown in rural or peri-urban settings for local consumption and these can be contaminated at source through polluted river or well water, such as in the bekaa valley of lebanon and mountain communities in pakistan, and the nile, tigris and euphrates fluvial plains. on one occasion, iranian watermelons were recalled and future sales banned in ksa, qatar, and uae because they were suspected of being poisoned or were injected with pesticides (nobody claimed to be ill after eating the melons), because holes were found in a few of them. however, the rationale of iranian farmers deliberately losing money seems to counter this argument, and it is more likely a sectarian economic barrier (abdullah ) . in fact, with the temporary ban the price of watermelons went up in the countries that had banned them. random tests carried out on the fruit confirmed they were free from any chemical substances, insecticides or other pollutants. the holes were most likely caused by emerging insect pupae. countries outside the gulf region reported no problems with the imported iranian melons. where some processed foods are exported, there is a risk of the importing countries recalling these if they cause foodborne illnesses or contaminants are found in them. this has happened in egypt with hepatitis a virus in strawberries and e. coli o :h in fenugreek seeds causing serious illnesses in europe and restricting further trade for an extended period. the same issue affected turkish pomegranate arils and lebanese tahini (made from imported ground sesame seeds), both containing salmonella, exported to the us. large to medium operations for broiler chickens and egg layers in ksa, kuwait, lebanon and other countries try and meet national standards or international guidelines for salmonella but are not always achieved, resulting in recalls and fines. governments are also aware of increasing concern over campylobacter in chickens, as widely-eaten poultry is a major source of this pathogen, but campylobacteriosis is not often cited as causing foodborne disease. raw milk (cow, sheep and camel) and raw milk cheese are still widely consumed in the middle east at the local level, though not usually obtained through supermarkets, and the risk of infections is high, as it is in other parts of the world, but with the added concern of brucella spp. and mers cov (the latter in the gulf countries where camels are bred and milked), both serious pathogens. yoghurt, surprisingly since it is acidic and is a source of gut beneficial lactobacilli, apparently was the foodborne vehicle to cause illnesses and deaths in afghanistan, israel, and pakistan. no agent was found in any of the samples. in the afghani example, the yoghurt was claimed to be deliberately poisoned; in the israeli one, it was apparently "stale" given to palestinian prisoners; there were two episodes in pakistan, one was from a home-prepared meal and the other from a restaurant which served rice and yoghurt. for prevention and controls strategies, most countries seem to rely on local authorities (municipalities) to do inspection of food facilities, more typically restaurants than processing plants as there are far more of them. illegal sales for unapproved products by local entrepreneurs are sometimes an issue, e.g., homeslaughtered meat in bahrain, and palestinians shipping food to israel. these illegal operations probably occur more often in porous borders within the region, and are only recognized when authorities decide to become vigilant in this area. some countries have conducted research and surveys much more than others based on the publication record, e.g., egypt, israel, palestine, ksa, turkey, and to a lesser extent, iran, lebanon, pakistan, uae, and yemen, but some research may occur without formal publication in recognized journals, making it difficult to have a true picture of how food safety problems are recognized and controlled. a few surveys have shown that home makers and food employees have limited knowledge of food safety, as in other regions. thus, some agencies or industry associations, sometimes in collaboration with outside organizations like fao or who, have attempted to train food employees in basic haccp principles, including best hand hygiene practices, and speakers give the latest food safety issues at the annual dubai international food safety conference, now in its th year. a few governments have established food safety agencies that have broad powers to inspect and control without overlapping responsibilities; these include jordan and ksa with food and drug administrations, uae with abu dhabi and dubai food control authorities, oman with its national food quality and safety centre, and pakistan with a punjab food authority. egypt and lebanon are initiating food safety authorities. israel, palestine and jordan have a cross-border agreement to collaborate on food safety issues. typical of many food control agencies in developing countries, periodic campaigns are launched to "crack down" on foodservice operations and sometimes processing plants. these are usually stimulated by complaints of the public, or the need for the responsible ministry to be seen doing something to justify its existence in compliance with regulations (if they exist). this has occurred recently in lebanon, qatar and pakistan. one issue is that poorly constructed or out-of-date regulations may be interpreted in different ways by the owners and the agencies (kullab ) . if a violation is found, the facility may be fined and/or temporarily closed down until it has satisfied the inspectors at the next visit. in one extreme instance in qatar, the owners and employees, were fined, imprisoned and deported. unfortunately, although the names of those at fault are often publicized by the media, their specific violations and how they relate to the regulations are not usually documented or at least publically released. another issue is that whether illnesses are suspected or not following a complaint, inspectors often insist that all food be discarded as soon as a sufficient violation, which may be unrelated to the complaint, has been determined; this prevents any samples being taken for outbreak investigations (hanna et al. ), as well as using the outbreak for a teaching tool for the owner and other similar operations. in conclusion, some progress has been made in the surveillance of foodborne disease in the middle east, but the disease's health and economic burden is barely being considered in many countries for future decision-making policies, an issue that is being tackled at the global level (who b). food control agencies seem to be trying to stop apparent abuses but have limited resources to do much more. this region, in particular, is severely strained because of sectarian distrust, on-going civil wars, and terrorist attacks, with refugees from iraq seeking shelter toward europe but stalled in turkey and lebanon for long periods of time. the crisis in syria is considered the greatest humanitarian disaster of the twenty first century, or even since world war ii, and it looks like the on-going fighting including outside armed forces will make food insecurity in the affected countries even worse in the foreseeable future. less public attention has been directed to yemen where food insecurity is a major concern. this coupled with gulf countries losing their wealth over low oil prices and a resultant stagnant global economy means a focus on food safety will likely become lower in priority for many of these countries. since secure food has to be safe, as illustrated by "stale" food being issued to besieged syrian residents and prisoners, it is important that relief agencies and countries themselves be aware of the risk of foodborne diseases associated with immunocompromised persons, particularly children. however, even in countries where the food supply is acceptable, inadequate hygienic practices put the local and tourist population at risk of illness and exported foods jeopardize industry profits and a poor reputation for future trade. as demonstrated by ksa, jordan and uae, single agencies or multiple agencies with clear-cut roles responsible for food safety, should be pursued by governments in consultation with industry and academia. duplication creates ambiguities for enforcement and education strategies as well as being unnecessarily costly. water supplies are also critical and some governments are weaning away farmers from depleted groundwater aquifers, and making irrigation more efficient where there are sustainable supplies. water for irrigation and processing has to be both free of pathogens and unacceptable levels of chemicals, and effectively treated waste water can substitute for groundwater. the sahara forest project in qatar is one example of a very dry country using seawater resources effectively; an even larger project is being considered from the -hectare in qatar to a -hectare test facility in jordan (clery ) . all these issues are being compounded by climate change and expected higher temperatures in already arid lands, which will make the region all the more dependent on more expensive imported foods. gulf counties have enough petro-dollars to afford these, but other countries are struggling to be self-sufficient for the near future even if the fighting ceases. the repair to destroyed infrastructure will be immense, coupled with the lack of trained personnel to create a restored food system at all levels from primary production through food processing, foodservice, and retail to the home. antimicrobial resistance for enteric pathogens isolated from acute gastroenteritis patients in gaza strip enteric protozoan parasites in stray cats in kuwait with special references to toxoplasmosis and risk factors affecting its occurrence sale of watermelons with holes stopped in uae. khaleej times u.n. causes food-poisoning with deliveries of old, 'moldy' biscuits to syria, says rights body iraq cholera cases grow, spread to kurdish region. relief web presence of aflatoxin b in the shelled peanuts in karachi incidence and distribution of salmonella serogroups in some local food in sana'a -yemen viral gastroenteritis associated with genogroup ii norovirus among u.s. military personnel in turkey isis fighters killed by poisoned ramadan meal. daily mail online food safety challenges-a pakistan's perspective considerations for introduction of a rotavirus vaccine in oman: rotavirus disease and economic burden foodborne illness -saudi arabia: (najran) restaurant. archive number: . . promed-mena flood victims suffer food poisoning. the daily times an outbreak of foodborne diarrheal illness among soldiers in mina during hajj: the role of consumer food handling behaviors outbreak of food borne salmonella among guests of a wedding ceremony: the role of cultural factors a situation analysis of the food control systems in arab gulf cooperation council (gcc) countries food poisoning in saudi arabia. potential for prevention? syrian migrants attack gendarmerie in southeastern turkish tent city, five injured one egyptian seed shipment: two outbreaks. food safety news what can we learn? food safety news afghanistan: militants 'kill police by poisoning food'. bbc news pakistan-minor dies of food poisoning. the news international accessed pakistan -over nurses hospitalized after food poisoning. the news moh on cholera alert; two patients detected 'food poisoning' cases at al-azhar dorms in egypt's assiut new guidelines: punjab food authority giving 'unsanitary' restaurants an easy time of it determination of pesticide residues in fruits of nawabshah district surprise inspections: pakistan officials fine food outlets, seal hotel. express tribune determination of arsenic levels in lake water, sediment, and foodstuff from selected area of sindh, pakistan: estimation of daily dietary intake teenage boy, sister die of food poisoning egypt students storm office of top al-azhar cleric. the record the evaluation of food hygiene knowledge, attitudes, and practices of food handlers in food businesses in turkey israeli doctor's bio-warfare serum saves infant from botulism death cluster of hepatitis a cases among travellers returning from egypt prevalence and antibiotic susceptibility of thermophilic campylobacter species on beef, mutton, and chicken carcasses in istanbul the food and agriculture around the world handbook confirmed variant creutzfeldt-jakob disease (variant cjd) case in texas desert farming experiment yields first results recent trends in the epidemiology of shigellosis in israel a middle east subregional laboratory-based surveillance network on foodborne diseases established by jordan, israel, and the palestinian authority outbreak of hepatitis a in the usa associated with frozen pomegranate arils imported from turkey: an epidemiological case study food-borne illness and its effect on tourism in egypt. food safety and environmental health blog cluster of cases of hepatitis a with a travel history to egypt salmonella enterica serotype typhi in kuwait and its reduced susceptibility to ciprofloxacin syria's health crisis: years on british holidaymakers in turkey hit by salmonella food safety issues in saudi arabia pregnancy-associated listeriosis: clinical characteristics and geospatial analysis of a -year period in israel food poisoning -saudi arabia (jizan): request for information investigating a link of two different types of food business management to the food safety knowledge, attitudes and practices of food handlers in beirut understanding the routes of contamination of ready-to-eat vegetables in the middle east making certain imported foods meet u.s. standards under fda food safety modernization act. u.s. food and drug administration major outbreak of hepatitis a associated with orange juice among tourists dream five-star holiday 'ruined' after family struck down by vomiting bug a dozen isis fighters killed after chefs infiltrate camp and poison terrorists' lunch. daily mirror cdc: salmonella from tahini sickened last year. food safety news outbreaks where food workers have been implicated in the spread of foodborne disease. part . description of the problem, methods and agents involved poisoning alert over improper food storage food-borne salmonella outbreak at a bank cafeteria: an investigation in an arab country in transition. la revue de santé de la mé diterranée orientale outbreaks of foodborne illness associated with the consumption of tree nuts, peanuts, and sesame seeds. in outbreaks from tree nuts, peanuts, and sesame seeds survey of clostridium botulinum toxins in iranian traditional food products deadly disease: two dead, over affected in kurram's cholera outbreak. express tribune a study on contamination of aflatoxin m in raw milk in the punjab province of pakistan aflatoxin m contamination in milk from five dairy species in pakistan blood in the chicken and cats around food': father-of-three hospitalised with severe gastric illness at same turkish holiday resort where fell ill in man dies after eating contaminated yoghurt. gaea times gastro epidemic: rising temperatures turn stomachs. express tribune evaluation of aluminum contents in different bakery foods by electrothermal atomic absorption spectrometer heavy metal residues in the milk of cattle and goats during winter season predominance and circulation of enteric viruses in the region of greater cairo presence of enteric hepatitis viruses in the sewage and population of greater cairo soil and vegetables enrichment with heavy metals from geological sources in gilgit foodhandler-associated salmonella outbreak in a university hospital despite routine surveillance cultures of kitchen employees experts emphasize need for food safety measures after scandals. daily star impacts of climate and management variables on the contamination of preharvest leafy greens with escherichia coli studies on contamination level of aflatoxins in some dried fruits and nuts of pakistan pakistan-food poisoning claims four lives. pakistan observer food handlers' knowledge on food hygiene: the case of a catering company in portugal egypt: azhar's food poisoning cases rise to -moh egypt: cases of food poisoning in two suez primary schools cops suffered from diarrhea during sehat ka insaaf drive. the nation establishment of food safety authority will allow investments in food industries the hajj: communicable and non-communicable health hazards and current guidance for pilgrims. eurosurveillance ( ) global perspectives for prevention of infectious diseases associated with mass gatherings qatar pursues water and food security aflatoxins b and b contamination of peanut and peanut products and subsequent microwave detoxification a survey of clostridium botulinum in food poisoning in iran outlook/srq m / _moph_national_health_statistics_report_in_lebanon.pdf. accessed december ) hepatitis a spreading because of lack of awareness aid delivers food poisoning as residents' immunity 'extremely weak u.n. ship brings food aid to yemen's aden as fighting rages in food-crazed lebanon, a war over tainted chicken and messedup meze eu ban on egyptian fenugreek seeds extended. food safety news % of food handlers complete hygiene and safety training food safety knowledge among food workers in restaurants in jordan survival of foodborne pathogens on berries. fshn - , food science and human nutrition department, uf/ifas extension, gainesville factors associated with acute diarrhoea in children in dhahira, oman: a hospital-based study abu dhabi food authority provides clearer picture of safety rules in restaurants. the national uae audits and inspections are never enough: a critique to enhance food safety mass poisoning in bahrain foodborne illness -saudi arabia foodborne illness -egypt: (suez) school children, milk susp nih confirms cholera case in capital polo ground eatery fined for expired food, lack of hygiene. the news international pakistan's food safety czar declares 'war' on unhygienic food after poisoning, rogue cop shoots dead policemen in afghanistan. hindustani times cluster of hepatitis a cases among travellers returning from egypt dubai siblings die of suspected food poisoning. gulf news multistate foodborne hepatitis a outbreak among european tourists returning from egypt-need for reinforced vaccination recommendations jail sentences and deportation for qatar food poisoning cases of food borne diseases recorded in dubai foodborne illness acquired in the united states-major pathogens insecticides in the blood samples of spray-workers at agriculture environment: the toxicological evaluation an outbreak of norovirus gastroenteritis in a county in turkey cholera claims five lives muscat municipality shuts down leading bakery in ruwi food safety challenges associated with traditional foods in arabic speaking countries in the middle east an overview of international investments in agriculture in the near east pesticides in shallow groundwater of bahawalnagar, muzafargarh determination of contamination with clostridium botulinum in two species of processed and non-processed fish regional programmes for food security in the near east: towards sustainable food security and poverty alleviation couple may take action on holiday nightmare sickness. the sentinel foodborne and waterborne disease in developing countries -africa and the middle east. dairy food and environmental sanitation viruses of foodborne origin: a review. virus adaptation and treatment afghan cops; food poisoning at border post isis fighters die in 'iftar poisoning'; more ill after eating ramadan meals in mosul. international business times, india edition amid growing complaints, sch launches food poisoning hotline in qatar yemen: current issues and what the world food programme is doing who's first ever global estimates of foodborne diseases find children under account for almost one third of deaths. world health organization who estimates of the global burden of foodborne diseases. foodborne diseases burden epidemiology reference group - . world health organization food scandal: food poisoning rate in lebanon lowest, says tourism minister key: cord- - uey ou authors: mulvad, gert; petersen, henning sloth; olsen, jørn title: arctic health problems and environmental challenges in greenland date: journal: arctic alpine ecosystems and people in a changing environment doi: . / - - - - _ sha: doc_id: cord_uid: uey ou nan the traditional diet in greenland is to a large extend based upon marine animals and fish (deutch ) . today the greenlandic diet is a mixture of traditional food and imported food, this is the way it has been for some generations. due to weather conditions most of fresh food come from wild animals or fish. greenland has a production of lamb and a limited supply of vegetables but most produced foods are imported from outside. a large part of the diet still stem from seafood, fish or sea animals, but imported fabricated foods are expected to continue to take over an increasing part of their energy consumption (deutch , mulvad . in any community it is important how food is produced, how it is prepared and how it is consumed. these things are important to the individual and for the way people come together. that is why food is more than just getting the necessary nutrition, it is also essential for social life and the ways families function. since food is increasingly imported and come in full or almost full fabricated forms the quality of nutrition changes. along with this public health may be affected as well as the social aspect of eating and preparing the meals. still the traditional diet is very important to the population culturally and financially. it is also of importance in order to get sufficient nutrients, because in many places imported food is available mostly in poor quality (deutch , pars . high levels of long range transported contaminants to the arctic have been documented by (amap ) . in greenland high contents of organic contaminants are found in people , deutch and the pollution has reached a level of concern. however, the replacement of traditional food by substandard, imported food is of significant concern. pollutants that accumulate in this part of the food chain can best be studied in the inuit population. other dietary studies focusing upon a diet rich in fat, like n- fatty acids, have been subject to study (dyerberg ) . however, much more could be done. the partly isolated inuit population with its ethnic background provides new opportunities for genetic studies, as well as studies on the health impact of unique social circumstances, light and extreme cold weather. greenland is now in a transition between a disease pattern characterized by acute diseases, mainly infections, and chronic diseases, diabetes and cardiovascular diseases. this transition took place in europe many decades ago but now we have a chance to study the process with modern technology. organization and logistic of the health care system in sparsely populated arctic regions is of great interest. further more greenland has public health problems which more than anything require a long term strategy for prevention. a common problem for some environmental contaminants is that they have natural half lives of many years. they are also long range transported and can cause problems for generations. contaminants examined by the arctic monitoring and assessment program, (amap), are pcbs, pesticides such as ddt, hcb, hch, chlordane, dieldrin and toxaphene, and heavy metals. the persistent organic pollutants (pops), are accumulated in the food chain in fatty tissue, creating the highest levels in orsoq/blubber from seals and tooth whales. barleene whales, however, have a lower place in the food chain and are therefore less contaminated. the highest levels are also found in the oldest individuals. humans and polar bears are at the top of the food chain, and are thus highly exposed to these chemicals (neri ) . generally the levels are low in fish from greenland and it is not a problem to eat greenlandic fish. in the baltic there has been found levels in seals up to times higher than along the coasts of greenland, but in the countries around the baltic, seals are not eaten. currents in the sea and in the air spread the contaminants unevenly so that seals and people along the east coast of greenland are more exposed to most pops (deutch . in greenland, research on mercury is extensive. mercury is a heavy metal that has always been in the environment, it also constitutes a pollution without borders. mercury levels in blood from greenlandic people are some of the highest measured in human samples (hansen et al. ). mercury level are some of the highest measured in human samples. (mulvad, pedersen, hansen et al. ) lead is a well known contaminant that may stem from hunting bullets (neri ) or from petrol and gasoline. cadmium comes mostly from smoking cigarettes. the high smoking frequency in greenland creates rather high blood levels in greenlandic people in general. heavy metals are accumulated on their way through the food chain and are also accumulated in human tissues. it is not dangerous for adults to eat the traditional food and the change from traditional diets to westernized macdonalization may be a poor option concerning health. it is in relation to pregnant women and especially unborn babies that contaminants cause concern. clinical studies have shown an effect on the ability to learn and on memory, as a function of exposure to e.g. mercury early in life (weihe et al. ) . some surveys indicate that the hormone balance and the immune system may be affected, i.e. the ability to fight infections (amap ) . some of these effects may perhaps be counteracted by the fatty acids in sea mammals. as the woman accumulates contaminants throughout her life, contaminants will be present in the body even if the diet is changed during pregnancy (deutch ) . some surveys also suspect pops for affecting the quality of sperm (abell et al. ) . the traditional greenlandic diet, where sea mammals are dominant, provides heat, energy and a healthy diet, at least for physical active people (pars , dyerberg et al. ; the well known fat from sea mammals protects against coronary heart diseases and possibly also immune and inflammatory diseases. a great amount of evidence from epidemiological studies and clinical trials support a theory of protective effect against coronary heart disease for fish consumption and intake of marine omega- fatty acids (jul et al. , pedersen . biological pathways for this risk reduction include membrane stabilization in the cardiac myocite, inhibition of platelet aggregation, favorable modifications of the lipid profile, decrease in blood pressure and reduction of the inflammatory response of the endothelium. results from epidemiological studies suggest a threshold effect for the consumption of fish and omega- fatty acids. relative concentrations are expressed as the percentage of total acids in plasma phospholipids. this number represents all women who were within the same group of age risk reduction is especially important for cardiac sudden death. nevertheless, protection against non-fatal coronary heart disease has also been observed . menstrual discomfort in danish women reduced by dietary supplements of seal oil capsules. shown in a trial done in aarhus university . omega fatty acid may also help prevent pre-term births (olsen et al. ) . selenium is an important vitamin which limits the effect of mercury. a number of other vitamins and trace elements are well represented in the traditional diet and at the same time it is a diet which is high in protein and low in sugar. it is a diet well suited for physical active hunters living in the cold arctic environment. vitamin d is obtained from dietary sources and from endogenous synthesis in the skin. dietary sources rich in vitamin d are fat fish and sea mammals. ordinary meat, milk and eggs contain less vitamin d and vegetables are void of vitamin d. the endogenous synthesis occurs in the skin under ultraviolet light b (uvb) stimulation. the endogenous production depends on sun exposure, age, clothing, skin pigmentation, and use of sun protection. the exposure to uvb depends again on latitude, solar height, absorption in ozone layer and atmosphere, and reflection from clouds. in greenland, protective clothing is customary, and summer is short with a low solar zenith altitude thus, yearly exposure to uvb-sunlight is limited. however, the traditional inuit diet is rich in sea mammals that contains large quantities of vitamin d. during the last decades, significant cultural changes have occurred in greenland. today, many greenlanders are living on a westernized danish diet that is low in natural dietary sources containing vitamin d furthermore, danish food is not fortified with vitamin d. changes from a traditional-to a westernized-fare are associated with a reduced vitamin d status in greenlanders, especially in winter time. (rejnmark et al. ). the influence of age, gender, latitude, season, diet and ethnicity on plasma -hydroxy-vitamin d ohd was studied showing that in addition to ethnicity (danes versus greenlanders), ohd levels were influenced by age, season (summer > winter), and diet (a traditional inuit diet > westernised diet). a longitudinal study on osteoporosis was conducted in nuuk, in september . the objective was to evaluate risk factors of osteoporosis and changes in parameters of ultrasound densitometry, after two years, among perimenopausal inuit women who previously participated in a cross section study. after two years, the prevalence of osteoporosis has doubled. moreover, the study suggests an association between smoking and change in stiffness, and mono-ortho pcb congeners concentration was strongly and negatively associated with bone stiffness (cote et al. ) . the first known immigration was by eskimos who came from the west more than . years ago, and since then there has been immigrations by eskimos and their descendants -inuit -the latest only about years ago. from the east came the vikings . years ago, but they disappeared after a few hundred years, perhaps without leaving any genetic trace. until the s, only - % of the greenlandic population were non-greenlanders, so a major genetic influence on the inuit tribe has only taken place during the last decades, where especially in the s and s a stream of laborers, employers and academics invaded the country and with an overweight of younger virile men that made significant marks not only on the color of the kids today, but also resulted in relative depletion of greenlandic females. in spite of common beliefs these bureaucrats and craftsmen were more successful in spreading their genes than the vikings. more than % of the population were foreigners at that time. since the late 's, the ratio has slowly decreased. looking at the diversity in samples of greenlandic inuit shows % of the y chromosomes have been assigned to european origin in contrasts with a complete absence of european mitochondrial dna, it indicates a male-biased european admixture. (bosch et al. ). greenland is now in a transition between a disease pattern characterized by acute diseases, mainly infections and chronic diseases, diabetes and cardiovascular diseases. after world war measles epidemic, tuberculosis, sexual transmitted diseases and hepatitis has been described. the lifestyle of the inuit is in the same period undergoing a rapid transformation, like in most other countries that are not isolated from the rest of the world. these transitions also influence health parameters in greenland. infections are still frequent, especially acute respiratory infection, hiv, chlamydia, (koch , homoe . we also se an increase in the food born infections due to the increase of imported food. the effect of the western lifestyle, obesity and central fat pattern are associated with several cardiovascular risk factors including diabetes, hypertension and dyslipidemia. central fat patterns and obesity are more prevalent among the inuit compared to the danish population . for obvious reasons, experience in how to establish an efficient and competent public health system in sparsely populated arctic regions is of great interest in the northern part of north america as well as in northern europe and russia. it is also a well known fact that technology from one area cannot necessary be transferred from one area to the next. since most of health technology is developed by means of research in technically advanced settings we face a shortage a knowledge for how best to modify and transfer this technology to quite different settings. greenland is the largest island in the world covering . million sq. kilometers of which % is covered by ice, and % is a narrow strip of land along the coastline. the climate is arctic. about . inhabitants are settled in towns and settlements along a coastline of . km. the towns have - . inhabitants with the exemption of the capital, nuuk, that has . inhabitants. about % of the total population live in settlements with to inhabitants. health care takes place in district medical centers, one for each town including its settlements. nuuk has a central hospital for specialized treatment, and one of the university hospitals in copenhagen (rigshospitalet) is used for more intensive care or specialized treatment. the district medical centers are basically autonomous units. depending on the population, there are - physicians, nurses, midwifes, health care assistants, labtechnicians, translators, secretaries and others. typically, the doctors and nurses are danish and the rest greenlanders. in the smallest district, a doctor and a nurse are the only medically trained personnel. a district has from to surrounding settlements to look after, and the distance can be kilometers. boats and dog sledges can be used for transport, but in many emergency cases only helicopter is an option, and a helicopter is often placed far away. the cost for an emergency transportation can be very high. the advantage of the health care system is the very close contact between the health care staff and the patients. the staff members are themselves part of the local communities and usually know their patients well. this contact is key to optimize immunization programs pr treatment modalities for venereal diseases, diabetes and mental diseases. also the close relation to the social care system, police and institutions has advantages. the staff should be in a good position to implement prevention and more comprehensive public health programmers when such programmers are formulated by the health care authorities. to strengthen the connections between remote units to the main hospital and to specialists outside greenland, the implementation of telemedicine is now of growing importance. telemedicine is the use of information technology for electronic transmission of information, pictures, sound and other health-related data that is needed to make appropriate diagnosis and treatment plans. based on the experience already obtained with telemedicine in greenland, , there are good reasons to implement telemedicine on a fig. . . telemedicine is important between remote units. larger scale (stensgaard ) . it is important that the results are registered and analyzed currently throughout the period in order to ensure that the experience gained will support the continued use of telemedicine in greenland and also be published to the benefit of others. video-consultations can be established and x-ray photos and electro-cardiograms can also be transmitted. sonography of heart, dermatology and psychiatry are other areas. a common record system will also help provide updated information about each patient. the major characteristic of recent health and social problems in greenland are (compared to denmark): low mean lifetime expectancy, high infant mortality, increasing rates of diabetes, cardiovascular diseases and cancer, high rate of infectious diseases (tuberculosis, hiv, hepatitis b virus infection, helicobacter pylori infection, meningitis), high rate of suicide, high rate of lethal accidents, high rate of legal abortions, domestic violence, tobacco, alcohol and drug abuse, mental health are stressed by unstable family relationships, contamination of the traditional diet (chief medical officer ) . the health of the population does not match the amount of money spend on health care. health expenditure/gdp (per cent) greenland: , , denmark: , norway: , . (health statistic in the nordic countries ). social studies and public health science have to take into consideration the conditions under which people live, e.g. health standards and housing, schools and education as well as social relations should be studied further. we need research in greenland for the people not only on the people, and with the people. lifestyle diseases, the incidence of dental diseases, mental health, various forms of cancer, as well as infectious diseases are important in relation to the well-being and health of the population (lynge . social studies and studies on public health are to a great extent designed to accommodate the specific need for research in greenland (bjerregaard et al. , commission for scientific research in greenland , covered by this strategy within the framework of the effort. to promote health, well-being and economy of the greenlandic population, it is suggest that, within this broad framework, social studies and public health science together encourage research which includes health hazards as an integral part of cultural aspects as well as research on social behavior in general. since many of the problems related to problems that global pollution has reached a level where the environment is affected and there is concern for people and animals that seat on the top of the food chain. replacement of traditional food by substandard, imported food is also of significant concern. any food recommendation must be structured to the community and take into consideration the available sources of food. for this reason it is important to keep monitoring the pollution that accumulates in the food chains and to take this information into consideration together with other available information concerning nutrition. these recommendations have to be well balanced and to incorporate all health aspects of diet and the social and economic consequences of our diet and how we get the food we need to eat. the pattern of disease will be increasingly influenced by chronic diseases being developed over long periods of time. the causes for this may be found early in life; during pregnancy, when all organs are formed, and during early childhood, where habits and the conditions for children form the basis for the future of greenland both economically, socially and for health. the position of the family and the definition of its responsibilities are central matters in this process. time has come to concentrate the effort where it will have the greatest and longest lasting effect. a research program like this one should focus on families who are just starting to have children. research should include genetic, social and cultural aspects on one hand and disease, behavior and cognitive development on the other. research should have a longitudinal angle and should provide possibilities of trying out theory through interventional projects. time has come for the policy makers to think ahead and to make decisions that span more than time periods of election. cultural change and mental health in greenland: the association of childhood conditions, language and urbanization with mental health and suicidal thoughts among the inuit of greenland decreasing overweight and central fat patterning with westernization among the inuit in greenland and inuit migrants studying health in greenland high level of male-biased scandinavian admixture in greenlandic inuit shown by ychromosomal analysis strategi for danskgrønlandsk polarforskning a longitudinal study of bone mass among perimenopausal inuit women of greenland biostatistik og epidemiologisk vurdering af levevis og miljømedicinske data fra grønland. mph thesis high human plasma levels of organochlorine compounds in greenland. regional differences and lifestyle effects menstrual discomfort in danish women reduced by dietary supplements of omega- pufa and b (fish oil and seal oil capsules) dietary composition in greenland , plasma fatty acids and persistent organic pollutants fatty acids composition of the plasma lipids in greenland eskimos arctic monitoring and assessment programme (amap), strategy and results with focus on the human health assessment under the second phase of amap prenatal exposure to methyl mercury among greenlandic polar inuits otitis media in greenland diabetes and impaired glucose tolerance among the inuit population og greenland the relationship between a low rate of ischaemic heart disease and the traditional greenlandic diet with high amounts of monounsaturated and n- polyunsaturated fatty acids a longitudinal community based study of respiratory tract infections in greenlandic children: disease burden and risk factors mental disorders in greenland. past and present the inuit diet. fatty acids and antioxidants, their role in ischemic heart disease, and exposure to organochlorines and heavy metals. an international study contaminants in the traditional greenland diet. ministry of the environment low consumption of seafood in early pregnancy as a risk factor for preterm delivery: prospective cohort study forbruget af traditionelle grønlandske fødevarer i vestgrønland atherosclerose og intracerebral haemorrhagi i relation til fedtsyrasammensaetningen i fedtvaev og validering af dødsårsagsmønsteret atherosclerosis in coronary arteries and aorta among greenlanders: an autopsy study vitamin d insufficiency in greenlanders on a westernized fare: ethnic differences in calcitropic hormones between greenlanders and danes udbygning og styrkelse af det telemedicinske samarbejde i de nordiske og tilgraensende områder neurobehavioral performance of inuit children with increased prenatal exposure to methylmercury the present papers has been supported by the commission for scientific research in greenland, sygekassens helsefond, denmark, greenland home rule. key: cord- -ktet wl authors: lim, jong-min; do, eunju; park, dong-chan; jung, go-woon; cho, hyung-rae; lee, seo-young; shin, jae wook; baek, kyung min; choi, jae-suk title: ingestion of exopolymers from aureobasidium pullulans reduces the duration of cold and flu symptoms: a randomized, placebo-controlled intervention study date: - - journal: evid based complement alternat med doi: . / / sha: doc_id: cord_uid: ktet wl aim: the objective of the study was to assess the efficacy of exopolymers from aureobasidium pullulans (eap) on the incidence of colds and flu in healthy adults. methods: we conducted a randomized, double-blind, placebo-controlled study at the onset of the influenza season. a total of subjects ( – years of age) were recruited from the general population. the subjects were instructed to take one capsule per day of either eap or a placebo for a period of weeks. the duration of cold and flu symptoms, a primary variable in assessing effectiveness, and serum cytokine levels as well as wbc counts as secondary variables were also evaluated. results: eap was associated with a statistically significant decrease in the duration of cold and flu symptoms, a primary variable in assessing effectiveness. although cold and flu symptom levels were not significantly different at a significance level of %, the cold and flu symptom levels of the eap group were less severe compared to the placebo group. no statistically significant changes of serum cytokine levels as well as wbc counts were observed. conclusion: the results showed that eap is a useful pharmaceutical and functional food material for preventing and treating colds and flu. the immune system has evolved to protect multicellular organisms, including humans, from pathogens. immunostimulatory effects are regulatory actions that counteract reduced immune responses caused by immunodeficiency diseases, viral infections, malnutrition, tumors, and aging. two strategies have been developed to stimulate the immune system. one method is to increase antigen-specific or nonspecific immune responses, and the other method involves the use of appropriate immunosupplements for antigen administration [ ] . respiratory viruses are among the most infectious pathogens in humans, and many differences occur in the kinds of pathogens, their antigenicities, and their worldwide infection patterns. recently, respiratory diseases such as middle east respiratory syndrome, severe acute respiratory syndrome, and the flu caused by novel swine-origin influenza a strains have emerged and begun to spread rapidly [ ] [ ] [ ] . as the associated respiratory viruses show very strong tendencies to spread, there is a growing interest in foods that promote immune functions as well as a global monitoring system for influenza [ ] . the results of several researches have revealed a positive correlation between food nutrition and the control of human immune functions, and various foods have been recognized as functional foods that can improve immune functions. these food materials may be derived from vegetables [ ] , evidence-based complementary and alternative medicine seafood [ ] , mushrooms [ ] , microbes such as lactic acid bacteria [ ] , chitosan [ ] , and peptides [ ] . - , / , -glucan is derived from yeast cell walls and modulates many in vivo and in vitro activities [ , ] . its main immunopharmacological activities [ ] [ ] [ ] are associated with antitumor effects [ ] , increased host resistance to viral, bacterial, and parasitic infections [ ] , and adjuvant effects [ ] . proximate composition of extracellular polysaccharides of aureobasidium pullulans is carbohydrate . %, sugar . %, crude protein . %, and moisture . %. namely, above % of the proximate composition is polysaccharides and there is a small amount of protein and fat (personal comm. dr. dong-chan park). it has been reported that the extracellular polysaccharides isolated from aureobasidium pullulans are pullulan (poly-- , -maltotriose-based exopolysaccharide, eps) [ ] , aubasidan ( - , -d-glucan with - , -branches to - , side chains) [ ] , and -glucan ( - , / , -d-glucan) [ ] . however, the physiological activity of polysaccharides produced by aureobasidium pullulans has been mainly studied for - , / , -d-glucan [ ] . exopolymers purified from aureobasidium pullulans sm- (eap; its solubility is about % in water), the test food material used in this study, containing % - , / , -glucan [ ] , are used in foods and have shown potent immunomodulatory activities in a mouse model [ ] . in addition, eap showed no adverse events in clinical studies designed to evaluate its effectiveness on bone metabolism improvement [ , ] and on atopic dermatitis [ ] . therefore, -glucan is considered safe for human ingestion. many reports have described the immunomodulatory activities of -glucan against immune-related diseases [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , but only a few reports have described its effects against colds and flu. for this reason, a clinical study is now being performed to evaluate the efficacy and safety of -glucan from aureobasidium pullulans against colds and flu in patients. in this study, we selected adult subjects who provided written, informed consent to participate, who satisfied our selection criteria, and who did not meet exclusion criteria. we randomly administered eap or a placebo, where subjects took a daily dosage of mg for weeks. we evaluated immunological improvements of the test food by observing functional changes in the immune system before and after administering the test food materials in the eap and placebo groups. we also observed the duration and total levels of cold and flu symptoms during the test period. the eap and placebo products used in this clinical research study were packaged inside boxes provided by glucan co., ltd. (busan, korea) and were supplied and distributed by aribio co., ltd. (seongnam-si, gyeonggi-do, korea). some eap samples were deposited in the herbarium of silla university (busan, korea; encoded as eap choi ). sixty-five capsules were provided to each subject, taking into consideration an -week dosage ( days, capsules), a visitation window of days ( capsules), and storage products ( capsules). the test food was manufactured as maroon-colored hard capsules, and each capsule of test food contained mg of eap and . mg of microcrystalline cellulose, whereas the placebo food contained . mg of microcrystalline cellulose. the test food was supplied to a testing agency in sealed white plastic bottles, each containing capsules intended for person. the test foods used in this study were identical in appearance and description and would be difficult to distinguish with the naked eye. the experiment was conducted in doubleblind format for the subjects and researchers by attaching identical labels to the test foods. the main ingredients, generic names, and lot number were not recorded on the test food labels to avoid exposing the differences between the test groups. subjects took eap hard capsule once daily for weeks on an empty stomach, with a sufficient amount of water. the subjects were healthy adults who did not have any disease that required proactive treatment. the number of subjects assigned to each group was ( overall). in consideration of a potential % dropout rate, the number of subjects in each group would decrease to , the minimum number of subjects for an effectiveness analysis ( figure ). subjects included in this study had to meet the following criteria: adults between and years of age; individuals with a white blood cell (wbc) count of - × / l; individuals who could be monitored throughout the test period; individuals who listened to a thorough explanation of the study's purpose and contents and voluntarily signed an informed consent form to participate in the experiment. subjects for whom the following criteria were applicable were excluded from the experiment: individuals with a body mass index (bmi) under or over ; individuals who exceeded the normal maximum alanine transaminase and aspartate transaminase levels by -fold; females who were pregnant or were breast-feeding; females of childbearing age who did not agree to use contraceptives via medically proven methods (e.g., condoms, lubricant, and femidom) during the test period; individuals with a fasting plasma dextrose concentration over mg/dl; individuals with high blood pressure (systolic blood pressure of mm hg or diastolic blood pressure of mm hg); individuals continuously using medicine that could affect the effectiveness assessment (hyperlipidemia medicine, steroid medicines, hormone medicines, immunosuppressants, and antibiotics); individuals who require continuous treatment for psychiatric disorders such as anorexia, depression, and manic depression; individuals with systemic diseases such as immunity-related diseases, serious hepatic and renal insufficiencies, malignant tumors, pulmonary disease, collagenosis, multiple sclerosis, allergic skin conditions, and other autoimmune diseases; individuals with a medical history of drugs and clinically significant allergic reactions; individuals with a history of gastrointestinal disorders that could affect the absorption of the test foods or a history of gastrointestinal surgery (excluding a simple appendectomy or hernia operation); individuals who consumed medicine or herbal medicines within a month of participation in the experiment which could affect immunity; individuals who participated in a different human study or clinical test and took experimental products within months of participation in this experiment (excluding human studies with cosmetics); and individuals whom the researchers otherwise determined might have difficulty completing the experiment. dosages of the experimental products were temporarily suspended at instances where it was appropriate to stop the experiment for the welfare of the subjects. events that may have occurred. in the following cases, administration of the test foods was temporarily suspended: (a) a temporary interruption on the occurrence of an adverse reaction or for the treatment of an adverse reaction; (b) when showing adverse events related to the safety of the test foods; and (c) in case of showing acute reactions (allergies and hypersensitivity) to the test foods. however, in the case of a temporary interruption for the occurrence of an adverse reaction or for the treatment of an adverse reaction, if there was no problem in its compliance, the study was continued. cases that were processed as dropouts included those in which test foods were allocated and the subject or a legal representative withdrew consent from participation in the experiment, cases where results for a final inspection could not be obtained, cases where subjects did not adhere to the test protocol resulting in a significant effect on the test results, cases where there was an interruption in contact with the subject (i.e., when the subject could not be traced), cases where the subject failed to make visits, subjects for whom a disease was discovered which went unnoticed during the screening inspection, cases where compliance with usage of the test food fell below %, as assessed with the usage log, cases in which, without the direction of the researcher, the subject used a medicine or product while they were taking the test food which could affect the research results or interpretation of data, cases in which the subject had an average weekly drinking quantity as ethanol of g/week throughout the test period, or cases where the lead researcher determined that the research proceedings were inappropriate or that there could be a significant effect on the safety of the subjects or the experiment results. subjects stopped taking test foods and were processed as dropouts for the following reasons, in which it was not possible to continue the human study: cases in which a serious adverse event occurred with the subject, cases in which an adverse event made participation in the experiment impossible, cases in which the researcher determined that the usage and observation of the test foods would be impertinent, or cases in which clinical tests were not possible due to the death of a subject or emergence of a disease. subjects who took the test foods and later dropped out of the study, where a portion or the entire estimate value of the final assessment (visit ) was omitted, were included in the itt group's analysis data. missing values were processed after a dropout occurred using missing value processing method for effective assessments. the results of all subjects who dropped out were excluded from assessment of the per protocol (pp) group ( figure and table ). . . . drinking, diet, and exercise among the subjects. during the experiment, subjects maintained regular levels of drinking, diet, and exercise which were similar to levels prior to participation in the experiment. to verify this, on the day of base evaluations, we examined the dietary contents evidence-based complementary and alternative medicine for contiguous days prior to the visitation day and the weekly exercise types and times prior to the visitation day. the number of alcoholic drinks and the amount of ethanol consumed during the week prior to the visitation day were also examined. subjects kept a daily record of whether they consumed the test foods and recorded contiguous days of their diets, including saturday or sunday. exercise, alcoholic drinks, and test food consumption were recorded in a chart provided by the testing agency, a comparison was made against these quantities prior to participation in the experiment, and observations were made as to whether there were any changes that could have significantyl affected the experiment results. subjects were assigned to the eap group (the group taking eap) and the placebo group (the group taking the placebo) based on a randomized list produced with a random sampling table generated using microsoft excel on microsoft windows ( figure ). the exclusion criteria used to select subjects during the screening visit (visit ) were verified, and individuals who met selection criteria and had met no exclusion criteria were selected as subjects for this study. food materials were allocated to the subjects during visit . the subjects selected for the experiment were issued a subject number in the order of visits made during visit and were provided with the test foods, which were randomly allocated. the foods used in the human test were provided only to the participating subjects, based on the process described in the human test protocol ( table ) the visitation dates allowed for the set base visitation days + additional days. those who were selected as test subjects received the test foods within days from the base evaluation date (selection inspection date) and began taking the test foods by the next morning. demographic data including the initials, age, gender, birthdate, weight, and height of the subjects and basic information such as medical history, medicinal intake history, combined treatment, concomitant drugs, smoking, drinking, and exercise habits were recorded in detail. the contents during the last years were recorded in the medical histories, and contents during the last weeks were recorded in the medicinal intake history. the types of exercise and the exercise times were examined for week prior to the time of the visitation day. diet and exercise were compared during the base evaluation period and experimental period and observed to determine whether any important changes occurred which could affect the test results. the number and quantity of alcoholic drinks consumed during the week preceding the visitation day were examined, and that information was converted into the number of grams of ethanol consumed and recorded. levels. blood pressure, body temperature, and pulse were measured and recorded as vital signs. obesity levels were measured using a body fat analyzer (inbody . , biospace, korea), and the bmi (kg/m ), percent evidence-based complementary and alternative medicine my daily life was very uncomfortable due to symptoms, and proactive treatment was needed. in the case of severe discomfort, i may stop working or studying or be admitted to the hospital body fat (%), waist-hip ratio, and visceral fat area (cm ) were recorded. hematological examination of wbcs, red blood cells, hemoglobin levels, hematocrits, and platelets was performed using an automated analyzer (sysmex xp- ; sysmex, kobe, japan). the levels of blood urea nitrogen, creatinine, uric acid, total bilirubin, albumin, total protein, alkaline phosphatase, glucose, alanine transaminase, aspartate transaminase, gamma-glutamyl transferase, triglyceride, total cholesterol, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol were measured using a clinical chemistry analyzer (dimension xpand plus; siemens, munich, germany). all urine samples were stored in the dark at ∘ c and were analyzed within two hours of collection. the ph, specific gravity, and protein and glucose levels were measured using a semiautomated analyzer (uriscan pro ii; yd diagnostics, seoul, korea). pregnancy testing was performed using a kit detecting human chorionic gonadotropin. serum concentration of cytokines was analyzed by using hmaglxsa ( plex) multiplex elisa kit (r&d systems, minneapolis, mn). cytokine levels were determined using luminex (luminex, austin, tx, usa) and the data were reported as median fluorescent intensities. comparisons. if immune functions improve, the disease duration and symptom levels should decrease due to increased resistance to viral diseases such as colds and flu. accordingly, we examined the duration and levels of cold and flu symptoms after consuming the test food products as a functional index of immunological improvements. for the survey following the administration of test foods, a form was provided in which subjects made a daily record of their health conditions, with a daily record of their test food dosages. nine symptoms were monitored to inspect the health conditions of the subjects in the survey: fever, chills, runny nose, nasal congestion, coughing, sneezing, sore throat, headache, and gastrointestinal symptoms (nausea, vomiting, diarrhea, and abdominal pain). subjects marked i for "symptoms exist" and × for "no symptoms." to record the symptom levels, subjects used a -step scoring point system, where they marked ( ) for no symptoms, ( ) for minor symptoms, ( ) for moderate symptoms, and ( ) for serious symptoms [ ] and marked whether they took early leave or were absent from work or school due to symptoms. table shows a detailed explanation of the criteria used for reporting symptom levels. to assess the effectiveness of the experimental food products, subjects kept daily records in their dosage logs of cold and flu symptom durations and symptom levels during the testing period. compliance with ingesting test foods was evaluated based on the food-usage logs. during the final visit, the number of remaining foods collected was compared with the usage log records. in cases where there were differences between the recorded and actual amounts of food taken, compliance was verified when the differences were small. primary effectiveness assessment variables included the duration and total score of symptom levels for cold and influenza. secondary effectiveness assessment variables included serum il- , il- , il- , il- , tnf-, and inf-levels, as well as wbc counts and differential blood counts. evidence-based complementary and alternative medicine on significance comparisons between the eap and placebo groups. the methodologies described below were followed for detailed analysis. analysis sets obtained from the test subjects were composed largely of an itt analysis group and a pp analysis group. the itt group comprised the primary data set used for effectiveness assessments, and the pp group was additionally analyzed to assess the effectiveness. subjects in the itt group included those who had taken the test food materials and whose assessment variables were measured at least once during visit . subjects in the pp group included those in the itt group who completed the test according to the study protocol. it has been predicted that fewer subjects will contract viral diseases such as cold and flu if their immune functions are enhanced and that the duration and levels of symptoms will decrease if one of the diseases is contracted. the activation state of principal cells related to immunity can be determined by measuring changes in the serum contents of cytokine il- , il- , il- , il- , tnf-, and inf-. to assess the effectiveness of the test food materials, the significance of the mean difference (visits - ) was tested for each variable included in the effectiveness test. in other words, a statistical comparison was made between the average variation before and after food ingestions in the eap and placebo groups. to this end, normality was tested for the evaluation data. the parametric method of a twosample t-test was chosen if normality was satisfied, whereas the nonparametric method of a wilcoxon's rank-sum test was chosen if normality was not satisfied. in addition, the above significance tests were performed on mean differences between the eap and placebo groups between each visit after test food ingestions. to analyze the prevalence of cold symptoms, subjects recorded the duration and levels of symptoms when they contracted a cold or the flu prior to ingesting the test food. during visit , subjects recorded the duration and total symptom scores of cold and influenza symptoms during the test period. accordingly, it was not meaningful to compare the mean difference between visits, considering that the rating scales used in visits and were different. in other words, we confirmed homogeneity between the test groups in visit and evaluated the effectiveness by comparing the results between test groups in visit . forward (locf) method (a single-imputation method) for data missing in the final effectiveness assessment. typically, the locf method is easy to use in clinical trials, despite the restricting assumption where missing data are treated as a constant. the locf method is commonly used because it provides conservative results. however, there are no commonly recommended methodologies for processing missing values [ ] . in this study, the statistical analytic data collected was comprised of only the baseline assessment prior to the ingestion of test food materials and the final assessment after ingestion of test food materials. the missing values during the final assessment were not replaced by the base assessment values but were substituted by the average of each group and assessed. in this study, we screened individuals who voluntarily agreed to participate in this human study, and subjects who met the selection criteria and did not meet any exclusionary criteria were enrolled. among the subjects, were assigned to the eap group and were assigned to the placebo group ( figure ). four instances were verified in which subjects violated the study protocol while consuming the test foods. these subjects were processed as dropouts. among the subjects who were selected, individuals from the eap group dropped out due to violations in the visitation schedule and shortfalls in compliance, and individuals from the placebo group dropped out due to withdrawal of informed consent and shortfalls in compliance. the remaining subjects adhered to the test protocol and completed the test. the current states of dropouts are separated according to the test group ( figure ) . compliance with ingesting test food materials was assessed in visit . the contents recorded in the daily record filled out by the subjects as well as the quantity of remaining products returned during the final visit were confirmed and assessed. compliance was calculated using the following formula: compliance (%) = (number of food materials ingested/number of food materials that should have been ingested) × , where the number of food materials ingested = number of food materials provided − number of food materials returned. subjects whose compliance was below % were set as dropouts, and there were dropouts in this study due to compliance shortfalls. the compliance of test food material ingestion was . ± . % in the eap group and . ± . % in the placebo group. a significant difference in compliance between the test groups was not observed (table ) . a homogeneity test was conducted between test groups for the following: measurement values prior to food material ingestion regarding demographic information of the subjects including age, gender, medical history, treatment history, medication history, and concomitant medication and measurement values before and after ingestion of food materials regarding items that could affect the test results based on changes in lifestyle habits during the test period including regular exercise, smoking, and drinking. the results of a preliminary investigation on the age, gender, medical history, treatment history, medication history, concomitant medication, exercise, smoking, and drinking among the subjects are summarized in tables and . no significant differences were found between the test groups regarding any of the items examined. missing values were replaced with averages and used in the itt group data analysis. (a) (b) figure : foundational statistics and comparisons of cold symptom durations (days; (a)) and levels (b) between test groups: eap group (black columns) and placebo group (gray columns). variables in the itt group. the results of a -test performed to evaluate significant differences between groups before and after ingesting the test food materials verified that the duration of cold symptoms ( value = . ) and cold symptom levels ( value = . ) at visit were not significant at a significance level of %. statistical analysis also showed that no difference occurred between test groups prior to the ingestion of food materials. during visit , the duration of cold symptoms in the experiment group ( . ± . days) was lower than that of the placebo group ( . ± . days). the difference between the test groups was statistically significant ( value = . ). the eap group also had a lower score for cold symptom levels than the placebo group ( . ± . versus . ± . , resp.). this difference was significant at a level of % ( value = . ) but not % (figure ). were verified with respect to the mean difference of each measured item between the visitation times to assess the effectiveness of the test food materials on the blood test results. the results were not significantly different between the eap and placebo groups (table ) at a significance level of %. for wbc, basophil, and lymphocyte counts that wilcoxon's rank-sum test was used to analyze variables that did not follow normality. missing values were replaced with averages and used in the itt group data analysis. did not follow normality, a nonparametric wilcoxon's ranksum test was conducted. the results were not significantly different between the eap and placebo groups (table ) at a significance level of %. to assess the effectiveness of the test food materials, a -test was conducted to evaluate significance differences in the mean cytokine concentrations between visits - . the results were not significantly different between the eap and placebo groups (table ) at a significance level of %. il- , il- , il- , and tnf-values did not satisfy normality; a nonparametric statistics wilcoxon's ranksum test was conducted, revealing no significant differences in any of the items at a significance level of % (table ) . adverse events were observed in individuals from the placebo group and in individual from the eap group. in the placebo group, nausea and pruritus were confirmed in subject e , asthenopia and rash in subject e , and a sore throat in subject e . no other adverse events were observed aside from these. in the eap group, headache was confirmed in subject e , but no other adverse events were confirmed aside from this. all these adverse events subsided within a few days. in the case of subject e , who ingested the test food materials, the headache was completely alleviated after days, and the subject was judged as having no cause-and-effect relationship with ingesting the test food materials (data not shown). while the sgot or sgpt exceeds normal upper limit by fold, the finding is not considered to represent an abnormal phenomenon. however, the -gtp value was found to be abnormally high during visit for subject e , but examination of the results showed that the abnormal values were not related to the ingestion of test food materials. instead, the results were due to excessive drinking, where the subject consumed alcoholic drinks frequently ( days/week) and a high quantity of ethanol (average = g/week) (data not shown). with the occurrence of adverse events and abnormal changes in clinical test results, no items were found to correlate with the use of test food materials or were suspected to have a correlation. thus, the test foods were found to be safe in the context of this study. the various biological activities of -glucan were verified through in vitro testing, animal testing, and clinical trials [ ] . recently, the effectiveness of -glucan on respiratory diseases has been studied in rodent [ ] and human [ ] [ ] [ ] because their prevalence has increased rapidly. eap, exopolymers purified from aureobasidium pullulans sm- , containing % - , / , -glucan [ ] , are used in test foods and have shown potent immunomodulatory activities in a mouse model [ ] . however, this study is the first to evaluate the use of eap against respiratory diseases. to assess the ability of eap to improve human immunological responses and to alleviate cold or flu symptoms, adults aged - years with a white blood cell count of - x / l were screened. individuals were enrolled as subjects who satisfied the selection criteria and did not fall under any exclusion criteria (data not shown). in an aspect of subject's respiratory morbidity, none of the subjects had a respiratory disease at the time of enrollment. within weeks prior to the screening date of the subjects, there were subjects with light respiratory disease. after confirming no symptoms at the enrolment, the subjects were proceeded to obtain informed consent. the subjects (administrated with the test foods for a period of weeks) were randomly assigned to either eap or a placebo group. blood tests and surveys of cold or flu symptoms were conducted before and after ingesting test food materials, and the duration and symptom level of colds or flu, as well as the results of the blood test and cytokine analysis, were compared. the eap and placebo groups were composed of individuals that exhibited homogeneity and showed no statistically significant differences in their compliance of ingesting test foods or in gender, age, compliance, regular exercise, smoking, drinking, medical history, medicinal history, or concomitant drug administration. clinical data have shown that immunity-promoting functions can prevent acute respiratory infections from cold or influenza viruses and reduce the frequency of contracting colds or flu, symptom levels, and symptom durations based on effectiveness criteria [ ] . in this study, statistical analysis of the duration and level of cold symptoms, a primary variable for assessing effectiveness, showed that there were no differences in assessment values between the eap and placebo groups before ingesting test food materials. however, the duration of cold and flu symptoms after ingesting test food materials was significantly lower in the eap group than in the placebo group at a % significance level. the eap group also showed lower levels of cold and flu symptoms, which were statistically different at the % (but not %) significance level than placebo group. it is predicted that individuals whose immune functions are enhanced will contract fewer viral diseases such as colds and flu, with reduced durations and levels of symptoms. the activation state of primary cells related to immunity can be determined by measuring the serum levels of the cytokines il- , il- , il- , il- , tnf-, and inf- [ ] . according to the "guideline for safety and efficacy assessments of functional food on immune function improvement" from the ministry of food and drug safety of korea, changes in cytokine levels, wbc counts, t cell counts, and nk cell activity in the peripheral blood should be measured when determining the functionality of immunity reinforcement in humans [ ] . in this study, secondary variables including serum cytokines (il- , il- , il- , il- , tnf-, and inf-) and wbcs (neutrophil, eosinophil, basophil, lymphocyte, and monocyte) for assessing effectiveness did not exhibit statistically significant differences before and after ingestion of test food materials at a significance level of %. these results are consistent with those of choi et al. ( ) [ ] , where the daily intake level of eap (polycan tm ) or placebo food materials was set at mg, and changes in serum cytokines were studied (with the intention of observing effectiveness in immunity improvements of eap), but no statistically significant changes were found. although eap has shown potent immunomodulatory activities in a mouse model [ ] , no immunity improvement of eap on the human was observed in this study. the cytokine is a factor that needs to change suddenly according to the individual health condition and then return to the normal range [ ] . on the normal range of blood cytokine concentration, its individual variation is very large. thus, a large number of subjects are required to measure the normal range of cytokine concentrations [ ] . indeed, in a study of normal korean cytokine levels, subjects were studied [ ] , and in a study of normal american cytokine levels, subjects were examined [ ] to estimate the normal range of blood cytokine concentration. serval studies have shown that no changes in blood cytokine levels have been observed following ingestion of multivitamin and mineral supplement [ ] , probiotic supplement [ ] , fish oil [ ] , and cordyceps militaris [ ] , which are known to help improve immunity. this may be because the cytokine level increased during the test period and then returned to normal, or the number of subjects was small, indicating that the individual deviation range was not statistically significant. in this study, the total number of subjects was : in the test group and in the control group, respectively. therefore, the results of this study may not statistically overcome the individual variation range of the subject's cytokine level due to the small number of subjects. further research is needed on extensive clinical studies with clear statistical numberings to confirm the effects of eap on plasma cytokines. no significant adverse events occurred during the period of test food material intake, and adverse events (excluding colds) were observed in individuals from the placebo group (nausea, pruritus, asthenopia, rash, and sore throat) and in individual from the experiment group (headache). all these adverse events subsided within just a few days and were determined to have no cause-and-effect relationship with the ingestion of test food materials. changes in blood test values were also observed in the eap group with an increase in sgpt, tg, and -gtp values, but this was difficult to determine as being clinically abnormal. in addition, in an aspect of the respiratory morbidity, the subjects who suffered from cold during the test period appeared and then fully cured after the treatment, and no respiratory morbidity was shown in all subjects. therefore, eap was verified to be harmless to the human body. collectively, our data revealed that eap was associated with a statistically significant decrease in the duration of cold and flu symptoms, a primary variable in assessing effectiveness. although cold symptom levels were not different at a significance level of %, the cold and flu symptom levels of the eap group were less severe compared to the placebo group. no statistically significant changes were observed in the serum cytokine concentrations, wbc, and differential blood counts (secondary variables for assessing effectiveness). therefore, our data showed that eap is a useful medicine and functional food material for preventing and treating colds and flu. the data used to support the findings of this study are available from the corresponding author upon request. the authors declare that there are no conflicts of interest. human infection with mers coronavirus after exposure to infected camels from sars to avian influenza preparedness in hong kong whole-genome characterization of a novel human influenza a(h n ) virus variant, brazil epidemiological characterization of respiratory viruses detected from acute respiratory patients in seoul a review on immunostimulatory plants bioactive compounds from marine processing byproducts-a review mushroom immunomodulators: unique molecules with unlimited applications probiotic immunomodulation in health and disease application of chitin and chitosan derivatives in the pharmaceutical field bioactive peptides: production and functionality clinical and physiological perspectives of -glucans: the past, present and future functional food for immune regulation-beta-glucan a week randomized, double-blind human trial to compare the efficacy and safety of aureobasidium pullulans cultured solution and placebo on improvement of immune in subjects immunomodulatory activities of oat -glucan in vitro and in vivo immunomodulatory effects of aureobasidium pullulans sm- exopolymers on the cyclophosphamide-treated mice effect of glucan on natural killer (nk) cells: further comparison between nk cell and bone marrow effector cell activities purification of solubleglucan with immune-enhancing activity from the cell wall of yeast glucan as an adjuvant for a murine babesia microti immunization trial characterization and enzymatic hydrolysis of hydrothermally treated - , - , -glucan from aureobasidium pullulans an aubasidan-like -glucan produced by aureobasidium pullulans in thailand the structure of the carbohydrate moiety of an acidic polysaccharide produced by aureobasidium sp. k- production of ß , / , glucan by aureobasidium pullulanssm safety and efficacy of polycalcium for improving biomarkers of bone metabolism: a -week open-label clinical study randomized, doubleblind, placebo-controlled trial of the effects of polycan, ß-glucan originating from aureobasidium pullulans, on bone biomarkers in healthy women a clinical study for the efficacy and safety of ß-glucan from aureobasidium pullulans in mild to moderate atopic dermatitis patients a placebo-controlled trial of korean red ginseng extract for preventing influenza-like illness in healthy adults korea food and drug administration (kfda, guidelines for clinical trial statistics sample size calculations with dropouts in clinical trials Β-glucan derived from aureobasidium pullulans is effective for the prevention of influenza in mice immunomodulatory effect of pleuran ( -glucan from pleurotus ostreatus) in children with recurrent respiratory tract infections preventive effect of pleuran ( -glucan from pleurotus ostreatus) in children with recurrent respiratory tract infections -open-label prospective study placebo-driven clinical trials of yeast-derived ß-( , ) glucan in children with chronic respiratory problems efficacy of cold-fx in the prevention of respiratory symptoms in community-dwelling adults: a randomized, doubleblinded, placebo controlled trial guidelines for functional evaluation of health functional foods, 'can help improve immune function conceptual and methodological issues relevant to cytokine and inflammatory marker measurements in clinical research serum cytokine profiles in healthy young and elderly population assessed using multiplexed bead-based immunoassays baseline levels and temporal stability of multiplexed serum cytokine concentrations in healthy subjects the effects of a multivitamin/mineral supplement on micronutrient status, antioxidant capacity and cytokine production in healthy older adults consuming a fortified diet probiotic supplement consumption alters cytokine production from peripheral blood mononuclear cells: a preliminary study using healthy individuals proand anti-inflammatory cytokines in healthy volunteers fed various doses of fish oil for year regulation of human cytokines by cordyceps militaris this research was performed with the support of the industry core technology development project (no. ), ministry of trade, industry, and energy, republic of korea. jong-min lim and eunju do contributed equally to this work. key: cord- - wlciz authors: fairbairn, madeleine; guthman, julie title: agri-food tech discovers silver linings in the pandemic date: - - journal: agric human values doi: . /s - - - sha: doc_id: cord_uid: wlciz nan perhaps in the recent past you've questioned the need for food delivery bots. we had too, that is, until covid- relegated us to our homes, and shopping became the equivalent of entering the chernobyl exclusion zone. our curiosity on this point stems from our participation in a collaborative study with agri-food researchers across three university of california campuses (https ://after proje ct.sites .ucsc.edu/) that is investigating silicon valley's recent foray into food and agriculture as sites of innovation and investment. one of our research questions revolves around how the tech sector defines and represents the problems it undertakes to solve. these problems, we've observed, are frequently vast in scope, while the solutions proffered are notably narrower, driven less by public need than by technological availability and investor interest. how has the advent of covid- -a problem of seismic proportions if ever there was onechanged this industry dynamic? as the virus has carved its exponential path through our economic and social lives, the agri-food tech sector has undertaken an almost instantaneous repositioning. industry think pieces rapidly emerged weighing the impact and discovering "silver linings from the dark cloud of covid- " (albrecht ). an open letter from the founder of indie-bio, a biotech incubator that has fostered such food-tech darlings as clara foods and memphis meats, exhorted its companies to "find opportunity in this crisis," stating that "this pandemic will amplify the need for your existence" (gupta ). an article on agfundernews, meanwhile, was quick to point out that venture capitalist investing in agri-food tech are better positioned than almost all of their peers-as essential services, food and agriculture constitute a relatively safe bet given that "the only thing people are buying right now is food" (pothering and burwood-taylor ) . (apparently, venture capital is less interested in toilet paper.) so what specific virus-induced shifts are we seeing, or expecting to see, in the sector? one is a pivot in overarching tropes. since it began to cohere as a self-identified sector about years ago, agri-food tech has laid claim to a range of world-saving ambitions. at pitch nights and innovation summits, we have seen technological fixes promised for everything from climate change to plastic pollution to inhumane treatment of animals. the specter of food insecurity caused by population growth-the oft-referenced ten billion by -has, of course, been a near constant refrain. food safety has always featured prominently in this litany of challenges, but it now seems poised to emerge, at least temporarily, as the reigning problematic of ag-tech solutionism. this reorientation makes a certain amount of sense. neo-malthusian productivism was always a dubious underpinning given the prevalence of over-production in agriculture (a vast problem about which the tech industry seems curiously unaware), and food safety could actually prove to be a more apposite frame for agri-food tech solutionism. as covid- gives a new lease on life to a pasteurian politics of purity, we're also getting a preview of the kinds of technology most likely to benefit. a heightened awareness of animal-borne disease is providing new rationales for cellular meat and other alternative protein products that replace the need for livestock production. companies involved in indoor vertical agriculture are amplifying claims about the superiority of their highly controlled environments. and concern about hand-to-face transmission of covid- is giving new justifications for the touchless harvest and food delivery promised by robotics. little mention is made of the predominantly minority farm and food service workers who are bearing the brunt of virus exposure now, but whose livelihoods may eventually be lost in the pursuit of sterility that follows. whether such sterility is even possible to achieve remains a dubious proposition. it is arguable that highly controlled agricultural environments are actually more prone to disease outbreaks and therefore less resilient. they certainly stand in stark contrast to the probiotic sensibility that has long "this article is part of the topical collection: agriculture, food & covid- ". * madeleine fairbairn mfairbai@ucsc.edu university of california, santa cruz, usa undergirded agroecology and these days supports regenerative agriculture. in the long run, that cure may be just as scary as the disease. silver linings form the dark cloud of covid- . the spoon a letter to our founders agrifoodtech vcs assess covid- 's impact on the sector and portfolios. agfunder news. https ://agfun derne ws.com/ agri-foodt ech-vcs-asses s-covid - s-impac t-on-the-secto r-andportf olios .html?utm_sourc e= k+from+cm+that+didnt +come+acros s&utm_campa ign= ea be -email _campa ign_ _ _ _copy_ &utm_mediu m=email &utm_term= _ df dcb - ea be - acknowledgements research discussed herein has been supported by the national science foundation (grant # ). publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.madeleine fairbairn, phd, is a sociologist and assistant professor in the environmental studies department at the university of california, santa cruz. she studies the political economy of agriculture, including the financial sector's growing interest in acquiring farmland and, more recently, the silicon valley agri-food tech sector. her first book, fields of gold: financing the global land rush is forthcoming in july, from cornell university press.julie guthman, phd, is a geographer and professor of social sciences at the university of california, santa cruz, where she teaches several courses on food and agriculture. her publications include three multiaward winning monographs, the latest of which, wilted: pathogens, chemicals, and the fragile future of the strawberry industry, was the recipient of the aag meridian award for outstanding scholarly work in geography. she is also the recipient of the excellence in research award from the agriculture, food and human values society. key: cord- -r xkpwte authors: keeble, matthew; adams, jean; sacks, gary; vanderlee, lana; white, christine m.; hammond, david; burgoine, thomas title: use of online food delivery services to order food prepared away-from-home and associated sociodemographic characteristics: a cross-sectional, multi-country analysis date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: r xkpwte online food delivery services like just eat and grubhub facilitate online ordering and home delivery of food prepared away-from-home. it is poorly understood how these services are used and by whom. this study investigated the prevalence of online food delivery service use and sociodemographic characteristics of customers, in and across australia, canada, mexico, the uk, and the usa. we analyzed online survey data (n = , ) from the international food policy study, conducted in . we identified respondents who reported any online food delivery service use in the past days and calculated the frequency of use and number of meals ordered. we investigated whether odds of any online food delivery service use in the past days differed by sociodemographic characteristics using adjusted logistic regression. overall, % of respondents (n = ) reported online food delivery service use, with the greatest prevalence amongst respondents in mexico (n = ( %)). online food delivery services had most frequently been used once and the median number of meals purchased through this mode of order was two. odds of any online food delivery service use were lower per additional year of age (or: . ; % ci: . , . ) and greater for respondents who were male (or: . ; % ci: . , . ), that identified with an ethnic minority (or: . ; % ci: . , . ), were highly educated (or: . ; % ci: . , . ), or living with children (or: . ; % ci: . , . ). further research is required to explore how online food delivery services may influence diet and health. according to global estimates from , % of men and % of women were living with obesity, which has been associated with multiple co-morbidities [ , ] . whilst the drivers of obesity are complex, the role of excess calorie intake through consumption of food prepared away-from-home has been recognized in previous research [ ] [ ] [ ] . food prepared away-from-home is often energy dense, high in fat and salt, and less healthy than food prepared at home, and more frequent consumption has been associated with elevated bodyweight [ ] [ ] [ ] [ ] [ ] . food prepared away-from-home is typically served ready to consume and has become a major contributor to overall dietary intake [ , ] . in the usa, for example, food prepared away-from-home accounted for over % of total food expenditure in [ ] . traditionally, this food may have been purchased through 'conventional' modes of order whereby customers would visit food outlets in-person or contact food outlets directly to place orders before collection or delivery. third-party platforms that facilitate online ordering and delivery, referred to throughout as 'online food delivery services', provide an alternative mode of order that appears to have grown in popularity [ ] . whilst business models vary, online food delivery services typically operate as intermediaries between customers and food outlets [ ] . customers place orders through online platforms, their orders are forwarded to food outlets where meals are cooked, and once ready, meals are delivered to customers by couriers working for the food outlet or the online food delivery service [ , ] . in , prominent online food delivery services just eat (including subsidiaries) and uber eats, were available in countries, deliveroo was available in countries, and grubhub was established in many cities across the usa [ ] [ ] [ ] [ ] . online food delivery service availability has been forecast to increase, which could lead to greater use. in turn, this could increase the purchase and consumption of food prepared away-from-home [ ] . to our knowledge, there is currently a limited understanding about the nutritional quality of food items sold through online food delivery services. nonetheless, given that food sold through online food delivery services is primarily prepared in existing food outlet facilities [ ] , it may have a similar nutrient profile to food prepared away-from-home ordered in conventional ways. as such, online food delivery services could contribute to excess calorie intake and adverse health outcomes [ , , ] . accordingly, interventions to reduce online food delivery service use or to improve the nutritional quality of food that is available, may be called for in the future. previous research into online food delivery services is limited. a narrative review identified business reports stating that convenience and choice of food outlet were potential drivers of online food delivery service use, supporting findings from malaysia and indonesia [ , ] . a further study investigated the availability of food outlets through an online food delivery service in one city in each of australia, the netherlands, and the usa [ ] . in each city, a diverse range of food types were available and the number of food outlets that were available differed by area level deprivation. to date, the prevalence and frequency of online food delivery service use and the sociodemographic characteristics of online food delivery service customers have not been investigated, and thus remain poorly understood. understanding how often online food delivery services are used and the sociodemographic characteristics of current online food delivery service customers will establish a baseline against which future use can be compared, allow any future interventions to be targeted towards frequent users, serve as an indicator of potential public health harm and of the need for further research. in this study, we aimed to describe the prevalence and frequency of online food delivery service use, investigate associations between online food delivery service use and sociodemographic characteristics, and describe how online food delivery service customers used other modes of order to purchase food prepared away-from-home, in and across five upper-middle or high-income countries. we used cross-sectional data from the international food policy study (ifps), conducted in australia, canada, mexico, the uk, and the usa in november . data collection methods have been described elsewhere [ ] . briefly, data were collected via self-completed online surveys from adults aged years or over, recruited through nielsen consumer insights global panel and their partners' panels. panelists were screened for eligibility and quota requirements based on device screen size, age, and sex. email invitations containing links to an online survey in national languages were sent to a random sample of eligible panelists in each country. respondents provided consent prior to survey completion. the ifps was reviewed by and received ethics clearance through a university of waterloo research ethics committee (ore# ). all respondents were asked: "during the past days, how many meals did you get that were prepared away-from-home in places such as restaurants, fast food or takeaway places, food stands, or from vending machines?". a similar question has been asked in previous research [ , ] . respondents who had purchased at least one meal prepared away-from-home reported the number of meals ordered: "using a food delivery service (e.g. country specific examples) and delivered", "directly from a restaurant and delivered", "at a restaurant/food outlet within minutes of your home", and "at a restaurant/food outlet more than minutes away from your home". country-specific examples of online food delivery services available in each country included uber eats (all countries), just eat (canada, mexico, uk), deliveroo (australia, uk), foodora (australia), skipthedishes (canada), and grubhub (usa). in our analyses, we collapsed "at a restaurant/food outlet within minutes of your home" and "at a restaurant/food outlet more than minutes away from your home" into a single category: 'directly from food outlets in-person'. we included sex, age, ethnicity, education, body mass index (bmi), and living with children aged under years as independent variables. age was reported in years (continuous). ethnicity was reported as the group that best described racial or ethnic backgrounds. we dichotomized responses into 'majority' (white, predominantly english speaking or not indigenous) and 'minority' (all other responses). education was reported as the highest level completed. we categorized respondents as having: 'low' (high school completion or lower), 'medium' (some post-high school qualifications), or 'high' (university degree or higher) levels of education, and used this variable as a marker of socioeconomic status [ ] . height and weight were reported in either metric or imperial units. we calculated bmi (kg/m ) and grouped respondents by world health organization categories: 'underweight' (bmi < . ), 'normal weight' (bmi . - . ), 'overweight' (bmi . - . ), or 'obesity' (bmi ≥ ) [ ] . we collapsed the 'underweight' and 'normal weight' categories into a 'not overweight' category (bmi < . ), and as individuals with greater bmi may not always report their height and weight, we included respondents with missing data for this variable and categorized them as 'missing' [ , ] . living with children aged under years was reported as a binary variable. in total, , respondents completed the online survey. we excluded respondents with missing data for variables of interest (except for bmi), when the total number of meals purchased away-from-home and the number of meals purchased through each mode of order summed did not match, or when the total number of meals purchased away-from-home in the past days exceeded (n = ). we considered to be the maximum number of meals that could be purchased away-from-home based on daily consumption of three meals in the past days. the final analytical sample included , respondents. to reduce non-response and selection bias, we applied post-stratification sample weights. weights were constructed using population estimates from the census in each country based on age, sex, region, ethnicity (except in canada) and education (except in mexico) [ , ] . in each country, we determined the prevalence of online food delivery service use by identifying respondents who reported that they had used an online food delivery service at least once in the past days. for these 'online food delivery service customers' we identified the frequency of online food delivery service use and calculated the number and proportion of all meals purchased away-from-home for each mode of order ('online food delivery services', 'directly from food outlets for delivery' and 'directly from food outlets in-person'). for respondents who had purchased at least one meal prepared away-from-home directly from food outlets for delivery or in-person but had not used an online food delivery service ('non-online food delivery service customers'), we calculated the number and proportion of all meals purchased away-from-home 'directly from food outlets for delivery' and 'directly from food outlets in-person'. in analyses, we used online food delivery service use as our dependent variable. as data were not normally distributed, we dichotomized respondents into any online food delivery service use in the past days or not. we used pearson's χ to compare differences in sociodemographic characteristics of online food delivery service customers in each country. to investigate associations between our dependent variable and sex, age, ethnicity, education, bmi, and living with children aged under years, across all countries combined, we used logistic regression following a sequential modelling strategy. model was unadjusted, model was adjusted for all independent variables except education, to investigate variation by individual-level socioeconomic status, and model was maximally adjusted [ , ] . to investigate differences in online food delivery service use between countries, we used separate, maximally adjusted, logistic regression models with each country as the reference category. we investigated differences in prevalence of online food delivery service use and independent variables between countries by adding a two-way interaction term (country x independent variable) to separate maximally adjusted logistic regression models and used post-estimation wald tests to determine interaction term significance. when interaction terms were significant, we stratified analyses by country. we used stata version . (statacorp llc., college station, tx, usa) to complete analyses in , with a significance threshold of p < . used throughout. amongst our sample, % (n = , ) had purchased at least one meal prepared away-from-home in the past days; % (n = ) had used an online food delivery service at least once, and % (n = , ) had purchased food prepared away-from-home directly from food outlets for delivery or in-person, but had not used an online food delivery service. overall, more than half of our sample were female or identified with an ethnic majority, most had low education, over % were living with obesity, the median age was years, and less than % lived with children aged under years (supplementary material: table s ). overall, more than half of the online food delivery service customers were male, identified with an ethnic majority, were highly educated, or were living with children aged under years, while around % were living with overweight or obesity, and the median age was years (table ) . sociodemographic characteristics of respondents that had purchased at least one meal prepared away-from-home directly from food outlets for delivery or in-person, but had not used an online food delivery service (n = , ), are shown in supplementary material (table s ) . around half of respondents that reported any online food delivery service use in the past days, had used this mode of order once (supplementary material: figure s ). table reports the modes of order used to purchase meals prepared away-from-home. overall, online food delivery service customers ordered a median of two meals prepared away-from-home through an online food delivery service, which represented % of all meals purchased away-from-home. online food delivery service customers also ordered a median of one meal directly from food outlets for delivery and two meals directly from food outlets in-person. overall, the median number of meals that non-online food delivery service customers ordered directly from food outlets for delivery was two, which was the same as the median number of meals ordered directly from food outlets in-person. note: a -unless specified, data reported as n (%). b -p values from pearson's χ test. c -online food delivery service customers had purchased at least one meal prepared away-from-home through an online food delivery service in the past days. table . modes of order used in the past days to purchase meals prepared away-from-home. note: a -p value from pearson's χ test. b -online food delivery service customers had purchased at least one meal prepared away-from-home through an online food delivery service in the past days. c -data reported as median (interquartile range (iqr)) number of meals, and median (iqr) proportion of all meals purchased away-from-home, per person. d -non-online food delivery service customers had purchased at least one meal prepared away-from-home directly from food outlets but not through an online food delivery service, in the past days. sociodemographic correlates of any online food delivery service use in the past days from unadjusted and partially adjusted models are reported in supplementary material (table s ). figure reports findings from the maximally adjusted model. overall, there were greater odds of online food delivery service use amongst respondents who were male (or: . ; % ci: . figure . associations between prevalence of any online food delivery service use in the past days and sociodemographic characteristics (n = , ). data are from , collected through the international food policy study, analyzed using adjusted logistic regression a . note: a -reference groups: ethnicity-majority, education level-low, body mass index (bmi) category-not overweight. the greatest prevalence of any online food delivery service use in the past days was amongst respondents in mexico (n = ( %)). respondents in canada had lower odds of online food delivery service use compared to respondents in all other countries, whilst respondents in the uk and mexico had greater odds compared to respondents in all other countries (table ) . amongst online food delivery service customers in australia, mexico, and the usa, the median number of meals ordered through online food delivery services per person, was two, whereas in canada and the uk, the median number, per person, was one ( table ) . there were significant between-country interactions. the association between online food delivery service use in the past days and each of age (p < . ), living with children aged under years (p = . ), sex (p < . ), and education (p < . ) varied between countries (supplementary material: table s ). the greatest prevalence of any online food delivery service use in the past days was amongst respondents in mexico (n = ( %)). respondents in canada had lower odds of online food delivery service use compared to respondents in all other countries, whilst respondents in the uk and mexico had greater odds compared to respondents in all other countries (table ) . amongst online food delivery service customers in australia, mexico, and the usa, the median number of meals ordered through online food delivery services per person, was two, whereas in canada and the uk, the median number, per person, was one ( table ) . there were significant between-country interactions. the association between online food delivery service use in the past days and each of age (p < . ), living with children aged under years (p = . ), sex (p < . ), and education (p < . ) varied between countries (supplementary material: table s ). figures - report country-stratified findings. odds of online food delivery service use in the past days were lower per additional year of age amongst respondents in all countries. respondents who lived with children aged under years had greater odds of online food delivery service use in all countries, with the strongest association observed amongst respondents in the usa (or: . ; % ci: . , . ) . there was no difference in odds of online food delivery service use by sex amongst respondents in mexico (or: . ; % ci: . , . ), whereas males in all other countries had greater odds of online food delivery service use. respondents with high (versus low) levels of education had greater odds of online food delivery service use in all countries except the uk (or: . ; % ci: . , . ). to our knowledge, this is the first study in the published international literature that has examined the prevalence and frequency of online food delivery service use and identified sociodemographic characteristics of online food delivery service customers. our findings from multiple countries provide knowledge about the individual and wider contextual factors that may relate to online food delivery service use. overall, % of respondents across australia, canada, mexico, the uk, and the usa reported online food delivery service use in the past days, however, almost two thirds of respondents had purchased food prepared away-from-home directly from food outlets but had not used an online food delivery service. online food delivery services were most frequently used once in the past days. overall, online food delivery service customers ordered a median of two meals through an online food delivery service, and the median proportion of all meals purchased away-from-home ordered through an online food delivery service was more than %. respondents who were male, younger, with higher education, lived with children aged under years, or that identified with an ethnic minority had greater odds of online food delivery service use. respondents in mexico and the uk had greater odds of online food delivery service use compared to respondents in other countries, and whilst correlates of online food delivery service use were similar in each country, the strength of associations varied. as the first study to investigate the prevalence and frequency of online food delivery service use in and across multiple countries, we are unable to conclude that the levels we identified are relatively high or low. nonetheless, our findings regarding the modes of order used to purchase food prepared away-from-home provide novel insight into how multiple ways of purchasing food prepared away-from-home may coexist. when having food delivered, those who reported any online food delivery service use in the past days appeared to favor this mode of order compared to ordering directly from food outlets. our observation could support the suggestion that online food delivery services have the capacity to disrupt conventional and established purchasing formats within food retail, which in turn, could influence how individuals interact with the built food environment [ ] . however, a high proportion of online food delivery service customers reported that they also visited food outlets in-person, indicating that the traditional practice of visiting neighborhood food outlets persisted regardless of online food delivery service use. therefore, promotion of healthier neighborhood food environments, for example through the use of urban planning or 'zoning' continues to be a potentially effective public health intervention [ ] . importantly, using multiple modes of order to purchase food prepared away-from-home may lead to greater total consumption, increased risk of excess weight and adverse health outcomes [ , ] . the full extent to which using multiple modes of order, and in-particular online food delivery service use, increases consumption of food prepared away-from-home, is unclear without longitudinal data. consistent with our finding that men had greater odds of online food delivery service use, men reportedly purchase food prepared away-from-home more frequently and cook at home less than women [ , ] . it is unclear how reasons for purchasing food prepared away-from-home might differ based on mode of order used, and how these reasons may vary by sex. respondents that identified with an ethnic minority had greater odds of online food delivery service use. analyses of data from the national health and nutrition examination survey completed in the usa indicated that black respondents cooked at home less frequently than other groups [ ] . however, further research from the usa [ ] and uk [ ] concluded that individuals that identified with an ethnic minority allocated more time to home food preparation and consumed more home cooked food than individuals that identified with an ethnic majority. online food delivery service use could reduce home cooking, which might have implications for the overall diet quality of customers. whilst it is possible to meet dietary guidelines through consumption of food prepared away-from-home, it may be more difficult and more expensive than through food prepared at home [ , ] , and bound by the types of food outlet available [ ] . in our study, online food delivery service customers were likely to be younger, have higher education, or live with children aged under years. similarly, marketing companies and online food delivery services suggest that individuals with these sociodemographic characteristics often report online food delivery service use [ ] . older individuals may be disinclined to order food online due to lacking familiarity with technology and a loyalty towards conventional modes of order, whilst individuals who are younger, highly educated, or parents, often report having limited time and may purchase food prepared away-from-home to offset pressure stemming from having limited time resources [ ] [ ] [ ] [ ] . as previously described, reasons for using one mode of order over another are currently unclear [ ] . future research should engage with online food delivery service customers to better understand their reasons for online food delivery service use. analysis of the uk's national diet and nutrition survey identified that living with obesity was associated with greater consumption of food from fast-food outlets but not restaurants or cafés [ ] . in our study, online food delivery service use was not associated with weight status. to some extent, this may be due to our cross-sectional study design and the simultaneous measurement of our exposure (online food delivery use) and outcome (weight status). however, it is also possible that this reflects the potential for online food delivery services to offer food from different types of food outlets, including restaurants, which may offer healthier food than is traditionally served away-from-home [ ] . in our analysis it was not possible to disaggregate online delivery service use by the type of food outlet that meals were ordered from. future research investigating which food outlets are ordered from when using online food delivery services, and the nutritional composition of foods sold, would provide greater insight into associations between food delivery service use and weight status. this understanding would serve to inform the need for development of public health interventions. the prevalence of online food delivery service use, the proportion of all meals prepared away-from-home purchased through online food delivery services, and the number of meals purchased directly from food outlets in-person by non-online food delivery service customers, were each greatest for respondents in mexico. together, these findings may reflect cultural norms aligned with frequent purchase of food prepared away-from-home in this country [ ] . individuals with greater access to food outlets through online food delivery services could be inclined to use them more frequently. this may explain plans from just eat, branded as skipthedishes, to increase the number of food outlets in canada who are signed up to accept orders through their platform [ ] . indeed, our finding that respondents from canada had lower odds of online food delivery service use compared to respondents in all other countries could indicate that there is currently limited access to food outlets through this mode of order. future research could investigate the extent to which access to food outlets signed up to accept orders through online food delivery services is associated with online food delivery service use. sociodemographic characteristics of online food delivery service customers were similar between countries, however, the strength of associations varied. notably, higher education was associated with greater odds of online food delivery service use in all countries except the uk. food outlets signed up to accept orders through online food delivery services in the uk may not sell food that accommodates the needs of individuals with higher education, possibly limiting use. the type of food available through online food delivery services in the uk is currently unclear. whilst the uk may be different, amongst food outlets signed up to accept orders through an online food delivery service in australia, the netherlands, and the usa, common food labels used to describe the type of food sold included 'burgers', 'pizza', and 'italian', with 'healthy' food labels less common [ ] . however, labels selected by food outlets may not always reflect the food they sell and the nutritional quality of food available through online food delivery services remains unclear. given the apparent lack of 'healthy' food choices, further work to develop an understanding about how well self-selected labels reflect the types of food that outlets sell, and the nutritional quality of this food, is warranted. this study represents the most comprehensive description of online food delivery service use to date. nonetheless, the findings are subject to limitations, including those common to survey-based research. respondents were recruited using nonprobability-based sampling. thus, findings are not necessarily nationally representative. we applied post-stratification sample weights to improve representativeness, yet respondents in mexico had higher levels of education than census estimates and average bmi scores were lower than national averages for respondents in all countries [ ] . recruitment may have been biased towards individuals with internet access. in , however, internet penetration rates ranged between % (mexico) and % (australia), with rates of % or higher in canada, the uk, and the usa [ ] . analyses were based on cross-sectional data, limiting the ability to draw causal inference. additionally, data were self-reported and collected through online surveys. social desirability bias may have led to the number of meals purchased away-from-home, online food delivery service use, and body weight being under-reported. this risk may have been reduced by use of online surveys that offer respondents a sense of anonymity when reporting sensitive information [ , ] . finally, we used education as our marker of socioeconomic status which may not be internationally comparable [ , ] . it is possible that the global covid- pandemic has accelerated changes in consumer behavior with regards to use of online modes of order [ ] . at least in terms of the research contexts studied here, individuals that may have previously visited food outlets in-person to purchase food prepared away-from-home are likely to have found that this option has been restricted, and may therefore have adopted online modes of order. whilst there is much uncertainty, it is possible that short-term changes in consumer behavior persist long term. research is required to fully understand short-and long-term changes in online food delivery service and in-person food outlet use. we found that % of adults across australia, canada, mexico, the uk, and the usa had purchased food prepared away-from-home through online food delivery services in the past days. online food delivery service use was associated with being male, from an ethnic minority, younger, highly educated, or living with children aged under years. sociodemographic characteristics of online food delivery service customers were consistent across countries, yet there was variation in the strength of associations. norms surrounding the purchase of food prepared away-from-home, stressors on time that limit the opportunity for home meal preparation, and the number and type of food outlets that can be accessed through online food delivery services may vary internationally and could help explain observed differences between countries. whilst we identified sociodemographic characteristics of online food delivery service customers, which is important information for future intervention development, further research is needed to understand the extent to which use of an online food delivery service contributes to overall purchasing and consumption of food prepared away-from-home, whether online food delivery services are used in place of, or in addition to, traditional modes of order, and associated implications for public health. supplementary materials: the following are available online at http://www.mdpi.com/ - / / / /s , table s : sociodemographic characteristics of analytic sample, table s : sociodemographic characteristics of non-online food delivery service customers, figure s : frequency of online food delivery service use in the past days amongst online food delivery service customers, table s : associations between prevalence of any online food delivery service use in the past days and sociodemographic characteristics, table s : odds ratio (or) and % confidence intervals (cis) from two-way interaction term added to separate, maximally adjusted, logistic regression models. fast-food restaurant, unhealthy eating, and childhood obesity: a systematic review and meta-analysis world health organization. global health observatory (gho) data dietary quality among men and women in countries in and : a systematic assessment implications of the foresight obesity system map for solutions to childhood obesity the single most important intervention to tackle obesity 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surveys: a literature review analysis of the over uk national diet and nutrition survey indicators of socioeconomic position (part ) covid- : impact on the urban food retail system, diet and health inequalities in the uk the authors thank the participants from wave two of the international food policy study. the authors declare no conflict of interest. key: cord- -j w u authors: gaupp, franziska title: extreme events in a globalized food system date: - - journal: one earth doi: . /j.oneear. . . sha: doc_id: cord_uid: j w u our food systems are complex and globally interdependent and are presently struggling to feed the world’s population. as population grows and the world becomes increasingly unstable and subject to shocks, it is imperative that we acknowledge the systemic nature of our food system and enhance its resilience. after the prevalence of undernourishment had declined over the last decades, since , the number of people who suffer from hunger is increasing again. today, more than million people in the world are hungry, and around billion people do not have regular access to nutritious and sufficient food. a growing and more affluent population will further increase the global demand for food and create stresses on land, for example, through deforestation. additionally, food production and agricultural productivity are further affected by an increasingly changing and variable climate, including extreme events, which further undermine the resilience of our systems. we are facing increased frequency, intensity, and duration of climate and extreme weather events, such as heat waves, droughts, and floods. increased temperatures have contributed to land degradation and desertification in many parts of the world. erratic precipitation patterns and unpredictable rainy seasons increase uncertainty about planting times and can lead to crop failure. changing land conditions through human actions on the regional scale, such as deforestation and urban development, can further accentuate these negative impacts at a local level. given that extreme events are expected to further increase through the st century, we need to increase the stability of the global food system. increases in global temperatures will affect processes involved in land degradation (such as vegetation loss or soil erosion) and food security (through crop losses and instabilities in the food supply). a . c global warming is projected to lead to high risks of food-supply instabilities, including periodic food shocks across regions and spikes in food pricing, and our current trajectory has us on course to significantly exceed this threshold. although climate and climate extremes affect our ability to produce food, food and nutrition security is more than just agricultural productivity. today's food system is globalized and consists of highly interdependent social, technical, financial, economic, and environmental subsystems. it is characterized by increasingly complex trade networks, an increasingly efficient supply chain with market power located in fewer and fewer hands, and increased coordination across interdependent sectors via information technology. between and , trade connections for wheat and rice doubled and trade flows increased by % and % respectively. furthermore, market power along the global food supply chains is consolidating. the three largest seed suppliers increased their combined market share from % in the s to % in . in the uk, the three largest supermarkets hold a market share of %. although these emergent network structures of commodity supply chains increase gains in economic efficiency, they lead to systemic instability susceptible to shocks. trade networks are more interconnected and interdependent than ever, and research has shown that they can be intrinsically more fragile than if each network worked independently because they create pathways along which damaging events can spread globally and rapidly. it is true that these trade networks could, for instance, help connect local producers to global markets and increase their incomes, but there is a risk that increasing network densities and complexities might lead to food insecurity in one part of the system as a result of the food system's inherent response to a shock rather than as a result of the initial shock itself. furthermore, local events might trigger consequential failures in other parts of the system through path dependencies and strong correlations and thus lead to amplification of the initial shock through cascading effects. a shock in the integrated global food supply chains can lead to ripple effects in political and social systems. the droughts in wheat-producing countries such as china, russia, and ukraine, for instance, led to major crop failures, pushing up food prices in the global markets. this in turn contributed to deep civil unrest in egypt, the world's largest wheat importer, as people were facing food shortages and helped the revolution to spread across the country. although it has been shown that global economic integration continues to strengthen our resilience to smaller shocks through trade adjustments, the current network structure and functional relations create higher vulnerabilities to so-called systemic risks. given how interconnected the food system is globally, taking a systems approach is vital to help us ensure food security. doing so requires an understanding of the systemic characteristics and vulnerabilities of the global interconnected food system. although one extreme event and the consequent crop losses in a single production region can be buffered by highyielding harvests in other places, grain storage, and trade, multiple-breadbasket failure is a growing reason for concern. correlated or compound climate and ll weather events (a combination of correlated climate drivers that surpass the coping capacity of the underlying systems) on both local and global scales could trigger systemic risks in the global food system. locally, non-linear dependencies between heat and drought conditions have been shown to have severe consequences for crop production in specific breadbasket regions, such as the mediterranean. on a global scale, largescale atmospheric circulation patterns, such as el niñ o-southern oscillation or rossby waves, can cause simultaneous extreme heat and rainfall events in different parts of the world. in summer , simultaneous heat extremes in the northern hemisphere were associated with amplified rossby waves, resulting in reduced crop production in central north america, eastern europe, and eastern asia. because those regions include important areas of crop production, such teleconnections have the potential to cause multiple, simultaneous breadbasket failures, posing a risk to global food security. if climate extremes are additionally co-occurring with other hazards, the systemic vulnerability of our global food system becomes apparent. this can currently be observed in east africa and yemen, where the population is fighting against a desert locust upsurge while experiencing conflicts, climate extremes, and coronavirus disease (covid- ), all of which further constrain surveillance and control operations in the locust crisis. the combination of those multiple hazards has led to warnings that in the second half of , million people will experience acute food insecurity. the climate-agri-food system is characterized by dynamic interactions across spatial and temporal scales, ranging from global to local and from shocks such as heat waves to long-term stressors such as biodiversity loss. nonlinear dynamics in the climate system can lead to rapid and irreversible changes if the system surpasses a certain threshold. one of those so-called climate ''tipping points'' that might have major consequences for europe's climate and lead to significant losses of crop yields is the weakening and potential collapse of the atlantic meridional overturning circulation (amoc). greenland melting and arctic warming are driving an influx of fresh water with lower salinity and density into the north atlantic, which is weakening the overturning circulation, an important part of global heat and salt transport by the ocean. if amoc weakened and even collapsed in the coming decade as a consequence of further warming, europe's seasonality would strongly increase and lead to harsher winters and hotter and drier summers. this is projected to reduce global agricultural productivity and to increase food prices. not all shocks to the globalized food system are directly linked to agricultural productivity or climate. the complexity and inter-connectedness and vulnerability of our globalized food system have become painfully evident in recent weeks after the emergence of a different type of shock to the system: a global pandemic. having started as a health crisis, covid- quickly trickled through the political, social, economic, technological, and financial systems. in the food system, lockdown measures and trade and business interruptions all over the world led to cascading effects that are projected to trigger food crises in many parts of the world. although harvests have been successful and food reserves are available, interruptions to global food supply chains have led to food shortages in many places. products cannot be moved from farms to markets, processing plants, or ports. food is rotting in fields because transport disruptions have made it impossible to move food from the farm to the consumer. at the same time, many people have lost their income, and food has become unaffordable to them. the world food programme has warned that by the end of the year, million additional people could face famine. in the fight against covid- , borders have been closed, and a lack of local production has led to price spikes in some places. in south sudan, for example, wheat and cassava prices have increased by % and %, respectively, since february. in the coming months, planting, harvesting, and transporting food are likely to further face logistical barriers, which will again exacerbate food shortages and drive up prices. a lack of food access and the related grievance could then lead to further cascading effects, such as food riots and collective violence. besides compound shocks, non-linear dynamics, and cascading events, the complexity of the global food system entails feedback loops that further amplify initial shocks. as a consequence of covid- , the fear of food shortages and price spikes due to global trade interruptions has led to export restrictions on food in several countries. at the time of writing, countries have active, binding export restrictions on food, as shown by the international food policy research institute's food policy tracker. russia, the world's biggest wheat exporter, announced in april that it will halt exports until july, when farmers will start to bring in grain from the new harvest. other wheat suppliers, such as kazakhstan and ukraine, have also capped sales. importers such as egypt, on the other hand, are hoarding crops in fear of shortages, creating feedback loops that will further drive up prices. especially in lowincome countries, this might make food unaffordable for large parts of the population and increase the threats of food insecurity. the visible and measurable systemic characteristics of the global food system are complemented by hidden links and consequences that become visible only after a shock has hit the system. the current pandemic has revealed structural weaknesses in our food system. little storage and just-in-time supply chains have increased economic efficiency but led to systemic instability. just how vulnerable and easy to disrupt the supply chains in some parts of the world are has become evident in the last several weeks. further food-system interdependences that were previously ignored but are becoming apparent now include the role of schools in providing nutritious food to children. the world food programme estimates that globally, million school children miss out on meals that they would normally receive in schools because classes are shut down. if we want to make the global food system resilient to future shocks, we need to pay attention to both quantifiable and uncertain systemic risks and foodsystem interdependencies. to address the challenges of a globally interconnected, complex food system that is projected to be hit by more frequent and severe extreme events, we need to take a systems approach and one earth , june , ll acknowledge the systemic characteristics of the global food system (figure ) . we need better food-system models that can account for systemic risk characteristics and increase our understanding of non-linear dynamics, tipping points, feedbacks, dependence structures, and adaptive behaviors. we need transdisciplinary approaches that bring together different disciplines as well as other forms of expertise, such as knowledge of local practitioners. quantitative and qualitative methods need to be combined, and different model types need to be integrated to link climate hazards with technological and civilizational risks. artificial intelligence and new machine-learning tools can improve our understanding of the food system's complexity but must be complemented by qualitative assessment, such as perceptions, social concerns, or socio-economic impacts. robust data and statistics that are accurate, timely, disaggregated, and accessible are needed for monitoring and early warning systems. systemic risk and systemic opportunities need to be incorporated into the design of food-related policies. effective governance needs to consider the interconnectedness among different parts of the global food system. a network perspective that pays attention to the ll interdependent actors and nodes is required. one solution could be a systemic-risk transaction tax as suggested for the financial markets. individual actors (such as large trading companies or retailers) that increase systemic risks in the network will be taxed proportionally to their marginal contribution to the overall systemic risks. the tax can be seen as insurance for the public against costs arising from cascading failure. additionally, we need global collaboration to work toward better management of trade barriers to ensure that food value chains function even in moments of crises to prevent price spikes and provide ''all people, at all times, [with] physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for a healthy and active life.'' more shocks are likely to hit our global food system in the future, unleashing the potential for systemic risks to cascade through the system and to lead to major impacts and system breakdowns. these include projected increases in simultaneous climate extremes in breadbasket regions, crop pests, and other, unexpected shocks. if we want to avoid major threats to food security, we need to take a systems perspective in analyzing, managing, and governing the global food system. the state of food security and nutrition in the world: safeguarding against economic slowdowns and downturns special report on climate change and land (intergovernmental panel on climate change globally networked risks and how to respond amplified rossby waves enhance risk of concurrent heatwaves in major breadbasket regions fao makes gains in the fight against desert locusts in east africa and yemen but threat of a food security crisis remains, fao news article running amoc in the farming economy soaring prices, rotting crops: coronavirus triggers global food crisis covid- food trade policy tracker coronavirus: rationing based on health, equity and decency now neededfood system expert, the conversation global monitoring of school meals during covid- school closures modelling food security: bridging the gap between the micro and the macro scale governance of systemic risks for disaster prevention and mitigation united nations office for disaster risk reduction elimination of systemic risk in financial networks by means of a systemic risk transaction tax global strategic framework for food security and nutrition the author would like to thank the editor and michael obersteiner for valuable suggestions and comments in the development and improvement of the manuscript. the author's work is supported by the receipt project (grant agreement ) and by eit climate-kic's ''forging resilient regions deep demonstration.'' key: cord- -h hxroos authors: wielinga, peter r.; schlundt, jørgen title: one health and food safety date: - - journal: confronting emerging zoonoses doi: . / - - - - _ sha: doc_id: cord_uid: h hxroos many, if not most, of all important zoonoses relate in some way to animals in the food production chain. therefore food becomes an important vehicle for many zoonotic pathogens. one of the major issues in food safety over the latest decades has been the lack of cross-sectoral collaboration across the food production chain. major food safety events have been significantly affected by the lack of collaboration between the animal health, the food control, and the human health sector. one health formulates clearly both the need for, and the benefit of cross-sectoral collaboration. here we will focus on the human health risk related to zoonotic microorganisms present both in food animals and food derived from these animals, and typically transmitted to humans through food. some diseases have global epidemic—or pandemic—potential, resulting in dramatic action from international organizations and national agricultural- and health authorities in most countries, for instance as was the case with avian influenza. other diseases relate to the industrialized food production chain and have been—in some settings—dealt with efficiently through farm-to-fork preventive action in the animal sector, e.g. salmonella. finally, an important group of zoonotic diseases are ‘neglected diseases’ in poor settings, while they have been basically eradicated in affluent economies through vaccination and culling policies in the animal sector, e.g. brucella. here we will discuss these three different foodborne disease categories, paying extra attention to the important problem of antimicrobial resistance (amr). in addition, we present some of the one health inspired solutions that may help reduce the threat of several of the foodborne diseases discussed. people in ancient times already understood they could get sick from consumption of infected meat. by keeping their animals healthy, and by using dedicated methods of food preparation and conservation, ancient farmers learned how to improve health and prevent disease. probably the oldest written document about it is 'on airs, waters, and places', written by hippocrates, which describes how human health is influenced by its interaction with the environment. since then, our health situation has improved by applying these simple rules of thumb, and even more through improved technologies such as good animal management, hygiene and biosecurity, vaccination programs and prudent animal drug treatment. nowadays, some of the most feared zoonotic diseases such as anthrax or brucellosis are absent in many countries. however, there are still many important diseases that threaten human health and which have animals as their reservoir. these animal reservoirs range from wildlife to domestic animals, both in companionship and agricultural settings. by the obvious close contact and the sheer number of animals needed for consumption, the animals produced for food form the largest reservoir and production grounds for emerging zoonotic pathogens. actions of authorities to protect society from zoonotic diseases differ significantly according to socio-economic status and the zoonotic pathogen in question. basically, zoonotic diseases related to food animals can be separated into three groups. in the first group are diseases with a potential for global spread and with a dramatic public relations potential, often these diseases have a significant human reservoir showing human-human transmission, e.g. sars, avian influenza and certain types of amr bacteria. the second group is constituted by persistent zoonotic diseases related to the industrialized food production chain, such as salmonella and campylobacter, which are broadly distributed in the farm-to-fork chain. these human pathogens are often non-pathogenic in animals and seem to be distributed in all countries, both rich and poor. in the third group are the 'neglected zoonotic diseases'. they are zoonotic diseases which have been eradicated (or drastically reduced) in affluent economies through vaccination and culling policies, and through introduction of hygienic and animal biosafety management practices. however, in many poor settings these diseases are 'neglected diseases' and receive very little attention from national authorities or even international organizations. this group includes brucella, bovine tb (tuberculosis), i.e. mycobacterium bovis, and many parasitic diseases, e.g. leishmaniasis and cysticercosis. in addition to these traditional infectious diseases there is a new threat of antimicrobial resistant (amr) bacteria. caused by the use of antimicrobials both in human and veterinary medicine this problem has emerged and is now to be recognized as one of the most important threats to human health. although in the detail the control of these groups of diseases differ, they are all most efficiently prevented by a one health approach which considers the full farm-to-fork chain. such preventive and holistic approaches may reduce both the disease burden to human health and the economic burden to developing economies, and therefore represent a significant potential for improvement related to food safety as seen in a one health perspective. through food and feed, direct contact, and via the environment, the human-and the animal microbial flora are in contact with each other. figure . outlines the most important routes of transmission for infectious diseases between humans and animals. via these routes infectious diseases from (food-)animals may enter the human reservoir and vice versa. the foodborne transmission route is probably the most important gateway for this contact, and the vast majority of human infections with enteric zoonotic bacterial pathogens, such as salmonella enterica, campylobacter coli/jejuni, and yersinia enterocolitica, occur through this route. for other diseases there is evidence that transmission also occurs via direct contact between (food) animal and humans, e.g. live-stock associated methicillin resistant staphlylococcus aureus (mrsa) (graveland et al. ) . next, there is transmission via the environment (e.g. surface water or water used to irrigate plants) mainly as a result of spreading of manure into the environment (spencer and guan ; hutchison et al. ) . and though much less frequently reported, there may be transmission of pathogens from humans to animals, which most probably was the meat/milk/eggs etc. direct contact and products (eg.skin) veterinary medicine food & consumer authorities food environment indirect contact via water/air (faeces / urine / corpses) fig. . schematic presentation of important microbial transmission routes via which the human and (food) animals are in contact with each other. in blue control mechanisms are shown, and in red some of the transmission routes that are more difficult to control. via the environment transmission may take place of microorganisms present in excretion products, and in diseased animals and people. in addition, wildlife constitutes a risk, as it holds a broad spectrum of diseases, including many highly pathogenic diseases case for the staphylococcus aureus cc (price et al. ) . in many developing countries, wildlife forms an additional important reservoir for foodborne pathogens, not only through consumption of wildlife. because of often lower bio-safety levels in these countries, direct contact between humans and food animals is generally more frequent, and diseases from the wildlife community may cross over more easily to domestic animals. for instance, the general understanding now is that the sars epidemic in originated in direct human contact with and/or consumption of wildlife, or indirectly through contact between wildlife and domestic animals (guan et al. ; shi and hu ) . wildlife holds a broad spectrum of diseases including some of the most feared, such as ebola, rabies and anthrax and, and in contrast to other food sources, much of the consumption of wildlife goes undetected by food controlling agencies. for these reasons, and because of the global trade in wildlife derived food and other items (pavlin et al. ), consumption of wildlife animals, and the spillover of infectious diseases from wildlife to food/production animals, should not be overlooked. the spread of foodborne zoonoses through the food production chain is often referred to as the 'farm-to-fork ' (or 'farm-to-table' or 'boat-to-throat') chain. it should be noted that risk mitigation solutions under this framework typically have focused on a consideration of the full food production continuum, involving all relevant stakeholders, i.e. a typical one health framework invented before the one health paradigm was defined. figure . tries to capture a generalized picture of a farm-to-fork chain, starting with animal feed and ending in human consumption of animal food products. although a number of very important zoonoses are related to wildlife-and in some cases directly transmitted from wildlife animals-the vast majority of zoonotic disease cases in the world relate to animals that are bred for food purposes. such zoonotic pathogens include bacteria such as brucella, salmonella, campylobacter, verotoxigenic escherichia coli and leptospira; parasites, such as taenia, echinococcus and trichinella; and viruses, such as influenza a h n (avian influenza) and rift valley fever virus. next to these infectious diseases, derived agents such as (microbial) toxins and prions (prusiner ) form another important zoonotic subgroup. diseases originating on the farm can in many cases most efficiently be dealt with on the farm itself, thereby eliminating more complex measures or crosscontamination down the farm-to-fork chain. for example, brucellosis in animals (mainly cattle, sheep and goats) has been eliminated in many countries, thereby virtually eliminating the human disease burden (godfroid and käsbohrer ) . also, some of the main parasites can be effectively controlled at the farm level, and this could work for both taenia solium in pigs (defined by who/fao/oie as a 'potentially eradicable parasite'), as well as, trichinella spiralis which is found in many wild animals and importantly in pigs for human consumption. both parasites have essentially been eliminated from farmed pigs in most northern european countries (who/fao/oie ; gottstein et al. ). however, both diseases still form a serious 'neglected diseases' threat in settings where there is potential for contact between wild and domestic animals. it was primarily the outbreaks of sars and zoonotic influenza, amr (dealt with separately) and bse (bovine spongiform encephalopathy) which alerted the world to the need for a one health approach. outbreaks of viral diseases in humans, originating in or spreading through farm animals (avian flu-h n and swine flu-h n ) have caused major global alerts in the last decade. these influenza outbreaks spread very quickly, either in the animal population (h n ) or directly in the human population (h n ), and formed a global threat for human health. h n was therefore characterized by the world health organization (who) as a pandemic. although in total the human disease burden related to the endemic bacterial zoonoses is probably many fold higher than these influenza outbreaks, it is basically these relatively few but fast spreading outbreaks that have put one health on the global agenda. in addition, the failure to predict, monitor and control the spread of these diseases in animals presented regulators and politicians with a wake-up call, and made them demand (better) cross-sectoral collaboration between the animal and human health sectors. prions, non-living infectious agents, have been a significant burden of disease in animal and man. the most well-known zoonotic prion disease is probably the one causing bovine spongiform encephalopathy (bse) in cows, and new variant creutzfeldt-jakob disease in humans, as represented by the massive outbreak of 'mad cow disease' in the uk in the s and s. this agent, a mutant protein, which mainly sits in the brain, got into the (beef) food chain by the feeding of ruminant derived meat and bone meal to ruminants. prions (prusiner ) , scrapie (the disease in goats), spongiform encephalopathy of rocky mountain elk, transmissible mink encephalopathy, kuru and creutzfeldt-jakob disease were known before the large outbreak of bovine spongiform encephalopathy in the uk. it, however, took some time and great efforts, and an early one health approach, to establish the links between the different animal diseases and the human disease (hill et al. ; prusiner ; ghani et al. ). this insight created a background to efficiently stop the spread of this prion disease, by banning the use of animals in animal feed, and seeing a subsequent decrease of the disease in humans (hoinville ) . in the western world prion diseases have attracted much attention, and their control has resulted in a large economic burden to society. in developing countries, often with less strict rules about the re-use of dead animals, and more direct contact with wildlife, prion diseases may still be endemic though unrecognized. in contrast to the dramatic outbreaks discussed above, many food-related zoonoses are endemic in farm animals and some of the most important of these do actually cause disease in the animals. it should be realized that most countries-including most developing countries-produce large amounts of food animals, and most of the production takes place in some sort of industrialized setting. such settings are invariably linked to a number of important zoonotic pathogens. table . shows three lists of the most important food pathogens, as reported in studies published by the cdc in the usa and by rivm (havelaar et al. ) in the netherlands, as well as a list of pathogens recognized by ecdc as focus organisms for the eu. although widespread, these pathogens are often not recognized as important human pathogens because of their often mild disease syndromes in healthy persons (e.g. limited to diarrhea and vomiting) and because of the complexity of source attribution. however, they do form a serious threat to the vulnerable segments of our societies (i.e. the young, the elderly, the immune-compromised and recovering patients), and some patients may develop long-lasting chronic disorders (e.g. arthritis and neurological disorders) (mckenna ). these facts, together with the sheer number of infections they cause, results in a substantial total burden of disease for these pathogens as expressed in disability-adjusted life years (dalys) (see murray ) . for instance, the study of havelaar et al. ( ) showed that the total burden of the diseases he studied was , dalys, for a total of . million cases and deaths caused by these diseases (in million people). source attribution estimates showed that one-third could be attributed to foodborne transmission. similarly large numbers were reported for the usa (cdc ), where surveillance studies of known pathogens gave an estimated total of . million illnesses, , hospitalization and , deaths attributed to foodborne diseases (in million people). importantly, the latter report also showed that the pathogens studied make up only % of the foodborne diseases, and the majority of % is caused by unknown agents. this situation is probably not unique for the usa, and thus indicates that there is still much health to be gained from improved food safety. table . shows that an almost identical list of disability-adjusted life years (dalys), are a combined estimate of the burden of disease due to both death and morbidity. one daly can be thought of as year of healthy life lost and is often expressed in years of life lost on the population level, and can be thought of as a measure of the gap between current health status and an ideal situation where each individual in the population lives to old age, free from disease and disability (murray ) for the list of the cdc and the netherlands the ranking in terms of incidence, hospitalizations, deaths or daly is given. the list from ecdc was generated by expert consultation and for use as an eu focus list in future disease burden studies important foodborne pathogens are found in europe, and that toxoplasma gondii, listeria monocytogenes, campylobacter, rotaviruses, noroviruses and salmonella, should probably form the key targets for interventions. except for norovirus, these pathogens have been shown to be zoonotic, and find their way to humans via food and the environment ( fig. . ). a one health approach ensuring efficient crosssectoral collaboration and data-sharing, could lay the foundation for a realistic description of the situation, and could help implement sensible cross-sector solutions. building on the idea of one health to control these diseases, there are several countries (especially in northern europe and north america) that have instituted cross-sectoral data collection and collaboration. this is typically done through the construction of zoonosis centers or their equivalents. these centers aim to stimulate and facilitate the collaboration between human, veterinary and food institutes. some examples of such specialized centers are the us national center for emerging and zoonotic infectious diseases (http://www.cdc.gov/ncezid), the british national centre for zoonosis research (http://www.zoonosis.ac.uk/ zoonosis) and danish zoonosis centre which is part of the danish national food institute (http://www.food.dtu.dk/english/research/research_groups/zoonosis_ centre.aspx). two clear examples of what such centers can accomplish are: the reduction of salmonella in food animals in denmark, and the danish integrated approach to combat amr (described below in a separate section). in the danish salmonella reduction program, data sharing across animal, food and human health sectors has enabled science-based solutions, and has most noticeably resulted in significant reductions in human salmonellosis through lowering salmonella prevalence in animals (wegener et al. ) . in relation to laying hens the program started with a simple and inexpensive serological surveillance of egg producers. flocks found positive were either culled and repopulated, or used to produce heat-processed eggs, danish eggs are now considered free of salmonella. next to this arm, a program of surveillance and eradication of infected broiler flocks was setup. the effect of the whole program was measured in term of cases of human salmonellosis, which were found to be significantly reduced as the project progressed in time. the construction and solutions of this program clearly followed one health principles. food, veterinary and human health sciences worked together, using similar detection and (geno)typing techniques, which enabled comparison and sharing of data. this top-down selection of salmonella-free poultry could work in other countries with industrialized food animal production as well. in other countries-including most likely most developing countries, salmonella-positive animals have been imported from big producers in industrialized countries. one such documented example was the import into zimbabwe of salmonella enteritidis via live animals. salmonella entered the country through import of infected poultry in the commercial national production system around , and thereafter spread quickly to the communal sector (small-scale farming), as well as to the human population (matope et al. ). the most likely reason for the spread within zimbabwe was that old animals from the commercial sector were sold to small-scale communal production systems. as the trade of live animals is done on a global level and does not take into account whether the traded animals carry any of the diseases from table . , reducing the prevalence in the commercial sector in producing countries, may also lower the global spread and human disease burden in the rest of the world. the spectrum of neglected diseases is broad and includes diseases caused by bacteria, viruses and parasites. many are found world-wide but their prevalence in the human and animal populations varies according to the local agricultural, demographic and geographic conditions and tradition. for many of the neglected diseases solutions to dramatically decrease the disease burden are well-known, but action is lagging, this is the case for example for many of the parasitic zoonoses. this is the reason why the who refers to these diseases as 'neglected diseases' (who ; molyneux et al. ) . neglected diseases may be categorized into two (strongly overlapping) categories. in the first category are the neglected tropical diseases which include chagas disease, trypanosomiasis, leprosy, rabies, schistosomiasis and others, many of which are zoonotic and parasitic diseases. the second category are the neglected zoonotic diseases, covering many of the diseases above and also some bacterial diseases such as anthrax, bovine tuberculosis (tb), brucellosis, and also cysticercosis and echinococcosis. many of the neglected diseases are carried by wildlife and in poor and rural settings by livestock (e.g. brucellosis, anthrax, leptospirosis, q-fever and bovine tb). in addition, many are food-and waterborne (e.g. brucellosis, cysticercosis/ taeniasis and echinococcosis). in particular, the prevalence of bovine tb appears to be increasing in many poor settings and has been linked to hiv infections as an important factor for progression of a tb infection to an active tb disease (lobue et al. ) . brucellosis and bovine tb in cattle cause lowered productivity in the animal population, but seldom death, and both have largely been eradicated from the bovine population in the developed world by test-and-slaughter programs, which in effect has eliminated the human health problem (godfroid and käsbohrer ) . some of the parasitic diseases (e.g. schistosomiasis, cysticercosis, trematodiasis and echinococcosis) have high mortality rates and long-term sequelae including cancer and neurological disorders. cysticercosis is emerging as a serious public health and agricultural problem in poor settings (garcía et al. ) . humans acquire taenia solium tapeworms when eating raw or undercooked pork contaminated with cysticerci. the route of transmission is, pigs infected through taenia eggs shed in human faeces, and the disease is thus strongly associated with pigs raised under poor hygienic conditions. this means that the cycle of infection can be relatively easily broken by introducing efficient animal management, as has been done in most developed countries. given that % of the rural population in poor countries is dependent on livestock as working animals to survive (fao ) , the effect of these animals carrying a zoonotic disease can be dramatic, both relative to human health directly, but also as it affects the potential to earn an income. this also affects the potential mitigation action; for instance the large-scale culling of animals, which can be a viable solution in rich countries, might be problematic in the poorest countries. such solutions would not only mean loss of food, but also a serious socio-economic disruption, in some cases leading to national instability. some of the recent serious outbreaks of antibiotic resistant (amr) foodborne disease, such as ehec in germany (mellmann et al. ) , have shown us a new problem. there seems to be a global trend with the prevalence of amr rising (who ; danmap ; ecdc ; aarestrup ) . especially dangerous is the emergence of resistance against antimicrobials that are considered critically important in human medicine, and in multidrug resistant (mdr) infections (potron et al. ; kumarasamy et al. ). in the early s antibiotics were first introduced to control bacterial infections in humans. the success in humans led to their introduction in veterinary medicine in the s, where they were used in both production and companion animals. nowadays, antibiotics are also used with intensive fish farming and to control some infectious diseases in plants. their use is thus widespread. antibiotics in animals are mainly used in three ways: ( ) for therapy of individual cases, ( ) for disease prevention (prophylaxis) treating groups of animals, and ( ) as antibiotic growth promoters (agp) treating groups of healthy animals with sub-therapeutic concentrations to promote animal growth. when first introduced, the use of antibiotics led to improved animal health, and subsequently higher levels of both food safety and food security. all use, but in particular the use as agp, resulted in a dramatic rise in the use of antibiotics, and for instance, between and the use in the united states alone went from to , t (who ). however, the use of antibiotics in animals has over the years also resulted in a selective pressure for amr microorganisms, contributing significantly to the human health problem of amr bacteria. notably a number of bacterial strains that were previously susceptible to antibiotics are now in very high frequencies becoming resistant to various antibiotics, some of which are very important as last resort treatment potential for humans (bonten et al. ) . in particular the use as agp is questionable, as the concentrations used are sub-therapeutic which result in the selection for resistance but do not efficiently kill microorganisms. nowadays there are serious efforts by national authorities and some international organizations to reduce the antibiotic overuse in animals (food agricultural organization of the united nations (fao)/world organization for animal health (oie)/who ; who ; u.s. food and drug administration (fda) ( )), especially-but not only-through abolishing their use as agp. however, there seem to be major problems in ensuring cross-sectoral understanding, since the veterinary and medical professions are still in debate about how the amr problem has emerged (phillips et al. ; karp and engberg ; smith et al. ; price et al. ) . to achieve a science-based understanding of the problem, data on amr from both the animal and the human side should be compared, and both risk assessments and source attributions performed in an integrated way. in other words, a one health approach in which human and animal health sectors, including food and environmental sectors, work together, may help to deliver answers needed and suggest ways to reduce problems in both human and animal reservoirs (figs. . and . ). in addition to the factors described above, food production and food trade are now more and more global, and thus some of the food related problems are also global food problems. on the positive side, globalization has helped with some of the important global food issues: it raised food security, made our food more varied and tastier, and even including transport costs in the equation, still has global financial advantages. however, together with the food also the foodborne diseases now travel the globe. and if we do not stay on top of the problem, disease outbreaks might affect large parts of the global food sector negatively, in the end leading to negative health-but will also have financial and socio-economical consequences. a more holistic and pro-active approach to food safety may help prevent future food disasters and build healthy economies. one health approaches to combat zoonotic foodborne diseases need to consider at least three levels, the international level, national level and the farm level where the actual production takes place. to facilitate the work at all these levels, many countries have established specialized zoonosis centers. these centers focus their work on zoonotic diseases and promote collaboration between different sectors, and between different countries. they examine the prevalence of zoonotic diseases in humans and (food-)animals, their routes of transmission, the risk associated with their presence in our food chain, and the relation between human disease and zoonotic transmission. in addition, as our food production system has become increasingly dependent on global trade, the approaches taken by these zoonoses centers (should) also include a global angle. national zoonosis centers may also help tackle the global problems associated with zoonotic diseases. however, at the moment most of this work is done by international and global organization, such as the who, oie, and fao. these three international organizations have recognized that combating zoonoses is best achieved via a one health approach, as stated in their seminal paper 'a tripartite concept note' (fao/oie/who ), in which they express the need to collaborate for a common vision. given the impact zoonotic diseases have in socio-economical terms and on the vulnerable sectors in our societies, a one health vision is also endorsed by the world bank and the united nations children's fund (unicef) (world bank/who/unicef/oie/fao/unsic ). in their common vision, they say that a one health approach may lead to novel and improved solutions, including solutions that have not been considered before because of the high costs involved. for instance, while in some cases vaccination is the ultimate tool to prevent disease, it is not always considered because the costs of mass vaccination are higher than the public health benefit savings, or because of global trade regulations. under a one health approach sharing of costs, as well as other mitigation strategies could likely enable novel ways of reaching sensible solutions (narrod et al. ) . for global infectious disease safety national authorities report to who important outbreaks of human disease which have the potential of cross-border spread, under the auspices of the international health regulations (ihr) (who ) . these regulations also cover foodborne diseases associated with globally traded food. however, given the major impact that such announcements may have on global food trade, such as was the case with bse in the uk or the more recent trade barriers put up after the ehec outbreak in germany, national authorities may have become more careful and restricted in what they report. a global one health approach which both considers human health aspects and socio-economic consequences would therefore be a welcome improvement to the ihr of . next to who, other organizations are active in reporting global infectious disease outbreaks, most notably promed-mail (http://www.promedmail. org), which is an internet based program for monitoring emerging diseases worldwide, set up by the international society for infectious diseases. the program is dedicated to rapid global dissemination of information on outbreaks of infectious diseases and acute exposures to toxins that affect human health, including those in animals and in plants grown for food or animal feed, and thereby supports the one health principles. many of the (international) organizations and governing bodies named above have generated guidelines to control -and disseminate information about-food related zoonoses, such as for instance who's global foodborne infections network (gfn) (www.who.int/gfn), the european food safety authority (efsa) (www.efsa.europa.eu/en/topics/topic/zoonoticdiseases), foodnet from the us centers for disease control and prevention (www.cdc.gov/foodnet) and others. the goal of these networks is essentially the same: to help capacity-building and promote integrated, laboratory based surveillance and intersectional collaboration among human health, veterinary and food-related disciplines to reduce the risk of foodborne infections. the emergence of amr in food animals is a serious threat for modern human medicine. the risks exist that both (i) the overuse by mass prophylaxis and agp in animals, and (ii) the misuse of human critically important antibiotics in animals, will lead to the emergence of new amr organisms which may spread to the human reservoir, and via global food trade spread around the world. in the most critical scenario this will make our arsenal of antibiotics unfit to treat previously treatable infectious disease, and it might take us back to a situation as before world war ii, when antibiotics were not yet used in human medicine. one health principles may help mitigate this risk and deal with the amr problem in an efficient way. collaboration between the fao/who codex alimentarius commission and the oie have generated important guidance on how an integrated approach and the prudent use of antimicrobials may reduce the emergence of amr in (food-)animals and subsequently in humans. previous to this, in the who published the 'global principles for the containment of antimicrobial resistance in animals intended for food' (who ) which all countries should follow to reduce the risk of amr. the three major principles are: • use of antimicrobials for prevention of disease can only be justified where it can be shown that a particular disease is present on the premises or is likely to occur. the routine prophylactic use of antimicrobials should never be a substitute for good animal health management. • prophylactic use of antimicrobials in control programs should be regularly assessed for effectiveness and whether use can be reduced or stopped. efforts to prevent disease should continuously be in place aiming at reducing the need for the prophylactic use of antimicrobials. • use of antimicrobial growth promoters that belong to classes of antimicrobial agents used (or submitted for approval) in humans and animals should be terminated or rapidly phased-out in the absence of risk-based evaluations. these global principles have been supplemented with, ( ) guidance on the prudent use of antibiotics from the codex alimentarius commission together with oie, and ( ) six priority recommendations from who to reduce the overuse of antibiotics in food animals for the protection of human health (who ), being: ( ) require obligatory prescriptions for all antibiotics used for disease control in (food) animals; ( ) in the absence of a public health safety evaluation, terminate or rapidly phase out the use of antibiotics for growth promotion if they are also used for treatment of humans; ( ) create national systems to monitor antibiotic use in food-animals; ( ) introduce pre-licensing safety evaluation of antibiotics [intended for use in food animals] with consideration of potential resistance to human drugs; ( ) monitor resistance to identify emerging health problems and take timely corrective actions to protect human health; ( ) develop guidelines for veterinarians to reduce overuse and misuse of antibiotics in food animals. a recent publication (who ) covers the broader scope of amr in relation to both animals and humans. thus, a 'one health' approach has explicitly been proposed by these international organizations to mitigate the risk of amr. since the occurrence of amr in the food production sector, different programs to contain zoonoses and amr zoonoses have been developed following these principles and guidelines. the danish program to contain amr zoonoses, danmap, has in particular gained international attention and has been analyzed in different publications (who ; hammerum et al. ; aarestrup et al. ) . the reason for this was the early one health approach that the danish government and stakeholders proposed to combat amr. in , after publication of the finding that % of enterococci in all industrial produced chickens in denmark were highly resistant to vancomycin (a last resort drug for human therapy) the government decided that actions had to be taken (wegener et al. ) and set up the danish integrated antimicrobial resistance monitoring and research program (danmap). figure . shows the organization of danmap and how the animal health, food safety and public health sectors work together. the objectives of danmap are: ( ) to quantitatively monitor the consumption of antimicrobials used in (food) animals and humans, ( ) to quantitatively monitor the occurrence of amr in (zoonotic) bacteria in animals, food and humans, ( ) to study and describe the associations between antimicrobial consumption and antimicrobial resistance, and ( ) to identify routes of transmission and areas for further research. next to this an automated/ict program, called vetstat, was introduced to collect quantitative data on all prescribed medicine for animals from veterinarians, pharmacies and feed mills (stege et al. ) . vetstat data on drug usage proved important for understanding the different aspects of the antibiotic usage problem, and to provide tools to control the use. for instance, with the information from vetstat it has been possible for the danish veterinary and food authority (dvfa) to introduce "the yellow card initiative" (dvfa ) . this initiative works similarly to that in football, and farmers and veterinarians get a yellow card when their antimicrobial use is excessive as compared to similar farms. only by reducing the antibiotic use, which may be done for instance by adopting management practices from low users, the card can be retracted. this has not only worked as a stick, it also gives the farmers a sense of how they are doing compared to their colleagues. in the european union several countries have now also started to collect antibiotic usage data and to compare antibiotic use at country level (ema ). surveillance of foodborne infections, and infectious diseases in general, is important to understand the transmission of infectious diseases and identify risks. to do this efficiently data collection should be done in a harmonized way, so data can be compared and integrated. until now, this has been difficult because different human medical, veterinary medical, food and environmental laboratories have been using different techniques for surveillance, making it often almost impossible to compare data. with the introduction of whole genome sequencing (wgs) this problem may be solved. its unbiased way of detecting dna and its single platform (the dna code) for comparing genomic information gives wgs the potential to take disease diagnostics to a new level. some early uses showing the value of wgs for diagnostic and epidemiological purposes were the tracking of the massive cholera outbreak in haiti in (hendriksen et al. ) and by the ehec outbreak that was first detected in germany and later also found in other countries and which could be traced back to egyptian imported fenugreek seed using wgs (mellman et al. ). following up on these successes, an international group of scientists with representatives from oie, who, ec, usfda, us cdc, ecdc, universities and public health institutes, came together in brussels, september , to further discuss the possibilities of using wgs on a larger scale. their simple conclusion was that the technology to use wgs for diagnostic purposes is available, and its potential high, however, to make efficient use of the data, a global genomic database is needed (kupferschmidt ; aarestrup et al. ). such a database should be open to, and supported by, scientists from all fields: human health, animal health, environmental health and food safety, and should include genomic data for all types of microorganisms as well as meta-data to trace back the source of the microorganism. building such a database depends on a global one health approach, and in a one health manner both human health as well as other sectors will benefit from it. an important aspect of pursuing this initiative is that it will not only be beneficial for the developed world, but it may especially be beneficial for developing countries. for them genomic identification will mean a giant leap forward as they do not need to implement the wide variety of specialized methods that are nowadays used in the developed world. if set up in a sensible, inclusive, open-source framework wgs analysis will provide the world with a strong weapon in the fight to combat infectious diseases in all sectors. one health approaches may be synergistic in controlling foodborne zoonotic diseases to support both sufficient food safety, and sustainable food security. clearly, because of the unique situation of transmissibility between humans and animals, zoonoses control relies on the control of the microorganisms in ( ) animals, ( ) the food chain and in ( ) humans. in addition, as zoonoses originate in animals before being transmitted to humans, the most effective interventions may be achieved at the source, i.e. at the farm. to be most effective, approaches to reduce the risk of foodborne zoonoses should include all stakeholders from the human as well as the animal health side. at the transmission level, it will be of major importance to involve food and consumers authorities and related stakeholders (e.g. environmental specialist), to make sure the spillover from the animal reservoir is kept as low as possible. the exact solution will differ per country and type of disease (e.g. in many developing countries neglected diseases may still be of importance). given that % of the rural population in poor countries is still dependent on livestock as working animals to survive, the effect of these animals carrying a zoonosis will work out differently than in the industrialized settings. a number of the most important zoonoses relate directly to food production systems in poor settings which could be reduced dramatically through well-known interventions, such as has been the case for brucella, bovine tb and cysticercosis. furthermore, it is important to realize that much of the one health efforts until now have focused on zoonotic pathogens with a potential for dramatic global spread (such as avian influenza and bse). however, major health gains can be obtained with the endemic zoonotic pathogens. for instance salmonella causes a dramatic global disease burden because of the sheer number of cases and the global spread via food and live animal trade. for salmonella there are efficient methods to reduce the prevalence in food animals. one health approaches in the food sector are complex and involve both public and commercial stakeholders, which may put limitations on what can be done. on the one hand food should be nutritious and adding to one's health. on the other hand most food is commercially produced and traded. as food is a commercial product, one of the ways to make food producers (the supply-side) produce more healthy food, is if the public demands this (the supply-demand balance). therefore, educating the public to buy healthier food may be a way to make food manufacturers produce healthier food. next, there are other stakeholders and fields of science (e.g. industrial sciences or logistics) and policy (e.g. economics) that contribute to the food chain, but which may focus on other aspects than healthy food alone, and their conclusions may conflict with the food safety principles (e.g. the use of agp to improve animal growth). clearly food safety is a complex issue, and integration of all its problems and data is difficult and should best be limited to its essential components. for this reason, countries should learn from experiences abroad that have documented success. there are many examples of one health approaches that have helped lower the risk of zoonotic foodborne disease. key to all approaches has been surveillance of the farm-to-fork chain. surveillance should be done at relevant levels of the chain, at the farm level by the veterinary system, and at the food production stage by food-scientist. findings should be shared and compared with the findings in human medicine, to be able to make decisions about potential risks for human health. thus the animal, food and human sectors need working together, to collect and to share data in such a way that they may be compared. as there are still many different techniques used in all three fields, it is still difficult to compare data. an important development in infectious disease diagnostics will be the introduction of wgs techniques, and the construction of a global, open-access genomic database for microorganisms. in a one health manner, the latter would take diagnostics to a new level, and will greatly improve human, animal and food safety. sustainable farming: get pigs off antibiotics changes in the use of antimicrobials and the effects on productivity of swine farms in denmark integrating genomebased informatics to modernize global disease monitoring, information sharing, and response vancomycin-resistant enterococci: why are they here, and where do they come from? cdc estimates of foodborne illness in the us the danish integrated antimicrobial resistance monitoring and research programme the yellow card initiative annual report of the european antimicrobial resistance surveillance network (ears-net) methodology protocol for estimating burden of communicable diseases trends in the sales of veterinary antimicrobial agents in nine european countries improved animal health for poverty reduction and sustainable livelihoods. fao animal production and health paper the fao-oie-who collaboration -a tripartite concept note food agricultural organization of the united nations (fao)/world organization for animal health (oie)/who ( ) joint fao/oie/who expert workshop on non-human antimicrobial usage and antimicrobial resistance: scientific assessment cysticercosis working group in peru. taenia solium cysticercosis epidemiological determinants of the pattern and magnitude of the vcjd epidemic in great britain brucellosis in the european union and norway at the turn of the twenty-first century epidemiology, diagnosis, treatment, and control of trichinellosis persistence of livestock associated mrsa cc in humans is dependent on intensity of animal contact isolation and characterization of viruses related to the sars coronavirus from animals in southern china danish integrated antimicrobial resistance monitoring and research program disease burden of foodborne pathogens in the netherlands population genetics of vibrio cholerae from nepal in : evidence on the origin of the haitian outbreak the same prion strain causes vcjd and bse decline in the incidence of bse in cattle born after the introduction of the 'feed ban' analyses of livestock production, waste storage, and pathogen levels and prevalences in farm manures comment on: does the use of antibiotics in food animals pose a risk to human health? a critical review of published data emergence of a new antibiotic resistance mechanism in india, pakistan, and the uk: a molecular, biological, and epidemiological study outbreak detectives embrace the genome era tuberculosis in humans and animals: an overview salmonella enteritidis in poultry: an emerging zoonosis in zimbabwe food poisoning's hidden legacy prospective genomic characterization of the german enterohemorrhagic escherichia coli o :h outbreak by rapid next generation sequencing technology zoonoses and marginalised infectious diseases of poverty: where do we stand? quantifying the burden of disease: the technical basis for disability adjusted life years a one health framework for estimating the economic costs of zoonotic diseases on society risk of importing zoonotic diseases through wildlife trade, united states does the use of antibiotics in food animals pose a risk to human health? a critical review of published data european dissemination of a single oxa- -producing klebsiella pneumoniae clone staphylococcus aureus cc : host adaptation and emergence of methicillin resistance in livestock prion diseases and the bse crisis a review of studies on animal reservoirs of the sars coronavirus agricultural antibiotics and human health public health implications related to spread of pathogens in manure from livestock and poultry operations vetstat-the danish system for surveillance of the veterinary use of drugs for production animals food and drug administration (fda) ( ) years of resistance who global principles for the containment of antimicrobial resistance in animals intended for food: report of a who consultation with the participation of the food and agriculture organization of the united nations and the office international des epizooties who global strategy for containment of antimicrobial resistance impacts of antimicrobial growth promoter termination in denmark. the who international review panel's evaluation of the termination of the use of antimicrobial growth promoters in denmark international health regulations neglected tropical diseases: hidden successes, emerging opportunities tackling antibiotic resistance from a food safety perspective in europe guidelines for the surveillance contributing to one world, one health: a strategic framework for reducing risks of infectious diseases at the animal-human-ecosystems interface key: cord- - pjajl authors: moriconi, eleonora; feraco, alessandra; marzolla, vincenzo; infante, marco; lombardo, mauro; fabbri, andrea; caprio, massimiliano title: neuroendocrine and metabolic effects of low-calorie and non-calorie sweeteners date: - - journal: front endocrinol (lausanne) doi: . /fendo. . sha: doc_id: cord_uid: pjajl since excessive sugar consumption has been related to the development of chronic metabolic diseases prevalent in the western world, the use of sweeteners has gradually increased worldwide over the last few years. although low- and non-calorie sweeteners may represent a valuable tool to reduce calorie intake and prevent weight gain, studies investigating the safety and efficacy of these compounds in the short- and long-term period are scarce and controversial. therefore, future studies will need to elucidate the potential beneficial and/or detrimental effects of different types of sweeteners on metabolic health (energy balance, appetite, body weight, cardiometabolic risk factors) in healthy subjects and patients with diabetes, obesity and metabolic syndrome. in this regard, the impact of different sweeteners on central nervous system, gut hormones and gut microbiota is important, given the strong implications that changes in such systems may have for human health. the aim of this narrative review is to summarize the current evidence for the neuroendocrine and metabolic effects of sweeteners, as well as their impact on gut microbiota. finally, we briefly discuss the advantages of the use of sweeteners in the context of very-low calorie ketogenic diets. on the basis of their energy content, sweeteners can be classified into calorie, low-calorie and non-calorie compounds. calorie-sweeteners include natural sugars ( ), such as sucrose, glucose, fructose, maltose, lactose, and trehalose. they are mainly present in fruits, honey, milk, dairy products, and mushrooms ( ) and their caloric values is on average kcal/g. their sweetening power is measured in relation to sucrose, which is considered as a reference sugar ( ) . low calorie and non-calorie sweeteners provide no or few calories and are characterized by a high sweetness taste. low-calorie sweeteners include polyols or sugar alcohols, which are low-digestible compounds obtained from the replacement of an aldehyde group with a hydroxyl one ( ) . the most common polyols are sorbitol, xylitol, maltitol, mannitol, erythritol, isomalt, and lactitol; they are naturally found in fruits, vegetables, and mushrooms ( ) . non-calorie sweeteners are mostly obtained by chemical synthesis (except stevia rebaudiana), and are characterized by minimal or absent nutritional content ( ) . they include saccharin, aspartame, acesulfame-k, and sucralose ( ) . in the last few decades, intake of sugar (free and added sugars) is dramatically increased, especially in western world ( ) . high intake of sugars has been related to the development of several diseases, including obesity, type diabetes, cardiovascular disease, non-alcoholic fatty liver disease ( ) ( ) ( ) , as well as tooth decay ( ) , neurocognitive diseases ( ) , and chronic inflammatory disorders ( ) . in , the world health organization (who) recommended the consumption of free sugars below % of total daily energy intake. however, a further reduction in free sugars intake below % of total energy intake has been strongly suggested ( ) . for a healthy adult, % of total energy intake is equivalent to ∼ g of sugar per day. free sugars include all sugars added to foods by the manufacturer, as well as sugars naturally present in non-intact fruit and vegetables (i.e., juiced or pureed). free sugars do not include sugars naturally present in intact fruit, vegetables, and dairy products ( ) . with regard to children and adolescents, a scientific statement published by the american heart association (aha) in recommends < g of added sugars per day, although added sugar should not be included in the diet for children < years of age ( ) . according to a recent study, in uk added or free sugar intake has been estimated between % and % of total energy intake, respectively, and it is higher in children than in adults ( ) . the prevalence of obesity and its comorbidities (such as type diabetes, cardiovascular diseases and cancer) has dramatically increased ( ) and several governments started to promote policies aimed to encourage a healthy diet and lifestyle ( ) . in denmark introduced a tax on saturated fat, which was repealed in , since it demonstrated a positive but not consistent effect on health ( ) . in the same year, hungary added levy on foods with high fat, sugar, salt and caffeine content; soft drinks and alcohols were also taxed. in , france introduced a tax on sweetened beverages ( , ) . in united states, where sweetened beverages consumption is still high, taxes on sugarsweetened beverages have been approved since ( , ) . in california, the first state which approved the tax, a % reduction of sweetened beverage consumption was reported ( ) and a positive impact on health care cost savings was observed ( ) . since , uk approved several policies in order to reduce childhood obesity, including the "sugar tax" on sweetened beverages, called the soft drinks industry levy, which became effective in april ( ) . in hungary, sugar tax resulted in a qualitative improvement and reformulation of food products ( , ) . in addition, nutrition labeling has been encouraged in order to help consumers to choose healthy foods. in , the food standards agency in the uk promoted a color coding in labeling system. in this color coding system, red, yellow, and green labels correspond to high, medium, and low percentages of fat, salt, sugar, and total energy present in the product, respectively ( ) . in this regard, some studies found that front-of-package nutrition labels can readily convey to consumers key information on the nutritional profile of different food products, showing that green labels are associated with the highest healthfulness perception of these products ( ) . however, vasiljevic et al. found that nutritional labels of snack foods had limited impact on perceptions of healthiness and no effects on the snack choice, whereas emoticon labels had stronger effects on perceptions of taste and healthfulness of snacks compared to color labels ( ) . a recent cochrane review evaluated the effects exerted in the general population by the taxation of unprocessed sugar or sugar added foods in terms of consumption of these foods and changes in prevalence and incidence of overweight, obesity, and other diet-related diseases ( ) . the authors concluded that there is still limited (and low-quality) evidence to support that taxing unprocessed sugar or sugar added foods has a significant impact on reducing their consumption and preventing overweight, obesity or other adverse health outcomes ( ) . therefore, future studies are needed to draw concrete conclusions in this direction. notably, an article by fernandez and raine ( ) recently reviewed the impact of sugar-sweetened beverage taxation on obesity, concluding that current evidence is still limited. importantly, authors suggest that sugar-sweetened beverage taxation will likely fail to have a significant impact on the prevalence of obesity and associated non-communicable diseases until this policy will not be associated with interventions aimed to increase access to non-sweetened beverages, educate consumers about healthy beverage alternatives and explore taxation of other beverages and non-nutritive foods ( ) . to address the growing health issue of obesity, sweetener consumption has gradually increased over the last years ( ) ( ) ( ) ( ) . indeed, when used judiciously, non-calorie sweeteners may facilitate reductions in the intake of added sugars, leading to decreased total energy, weight loss, prevention of weight gain and/or subsequent beneficial effects on related metabolic parameters ( ) . nonetheless, these potential benefits may not be fully achieved without reductions in total food intake and/or in presence of a compensatory increase in energy intake from other sources ( ) . in addition, animal and human studies have reported controversial results on the safety of non-calorie sweeteners ( ) . besides their potential to reduce daily calorie content, non-calorie sweeteners were reported to potentially display detrimental metabolic (weight gain) ( ) and neuroendocrine (addiction) effects ( ) . conversely, some intervention studies reported that consumption of non-calorie sweeteners is associated with weight loss and improved metabolic parameters ( , ) . despite a growing use of non-calorie sweeteners, which is gradually increasing in both healthy and obese/overweight individuals, there is indeed a knowledge gap regarding their safety and efficacy in the long term-period. therefore, there is an urgent need to update the current positions from international agencies on the use of these compounds. we will review here the metabolic and neuroendocrine properties of the most commonly used low-calorie (polyols) and non-calorie sweeteners, along with their safety profile and main use in food industry. sugar alcohols (also referred to as polyols) are characterized by a lower calorie content ( to kcal/g) ( ) than sucrose ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , or high gi (≥ ) ( ) . c source ( , ) . d source ( ) . e source ( ) . ( table ) ( ) . low amounts of polyols are naturally present in vegetables, mushrooms and fruits (melon, peach, apple, pear, apricot), but also in oat ( , ) . they include hydrogenated mono-, di-, oligo-, and polysaccharides ( ) and are mainly used in "sugar-free" products, sweets, and chewing gums ( ) . polyols are stable compounds at high temperatures and do not interfere in the maillard reaction ( ) . the late stages of maillard reaction lead to the generation of the so-called ages (also referred to as "advanced glycation end-products") in foods and biological systems ( , ) . of note, ages contribute to the development of micro-and macrovascular complications of diabetes ( ) ( ) ( ) , by inducing oxidative stress and activating inflammatory pathways ( , ) polyols do not affect glucose homeostasis ( , ) . also, polyols have long been suggested as valid sugar substitutes able to exert a beneficial role on insulin resistance and glucose control in patients with type diabetes and/or metabolic syndrome. nonetheless, robust evidence on the longterm effects of polyols in terms of glucose control and chronic complications in diabetic patients is still scarce and inconclusive ( ) . interestingly, most of these compounds do not undergo fermentation by oral bacteria flora ( ); therefore, polyols can reduce the risk of tooth decay because they represent a poor source of energy to resident bacteria of the oral cavity and do not create an acidic environment ( , ) . polyols increase saccharolytic anaerobic and aciduric bacteria in the colon and give rise to the production of short-chain fatty acids which play a key role in the maintenance of the intestinal epithelial barrier ( ) . although acceptable daily intake (adi) dose has not been established for polyol increased polyol consumption may cause gastrointestinal discomfort and laxative effects in healthy individuals ( , ) . the european union legislation approved the use of seven different polyols, including erythritol, isomalt, lactitol, maltitol, mannitol, sorbitol, and xylitol ( ) . herein, we summarize the main properties of the polyols that are most commonly used in food and beverage industry, also discussing their potential impact on human health. sorbitol provides . kcal/g. sorbitol is naturally present in grapes, prunes, cherries, peaches, apples, pears, and fruit juices ( ) . sorbitol is poorly absorbed in the small intestine, while in the colon it is converted by gut microbiota into gases and shortchain fatty acids, providing energy ( ) . sorbitol has osmotic effects and it acts as a laxative when ingested in high doses ( - g) ( ). in addition, chronic ingestion of sorbitol through chewing gums can cause increased intestinal motility regardless of its osmotic effect ( ) . therefore, sorbitol use should be avoided by individuals with irritable bowel syndrome ( ) . in fda approved sorbitol use as generally recognized as safe (gras) ( ) . mannitol is naturally present in mushrooms, marine algae, strawberries, onions, and pumpkins ( ) . only % of ingested mannitol is absorbed in the gut, whereas the remaining part is excreted in the urine. in the gut, mannitol is slowly fermented ( ) . mannitol is virtually inert and does not interfere with pharmacological compounds. due to this reason, it is used also in hygiene products, drug filler and intravenous fluid solutions ( ) . moreover, the osmotic diuretic properties of mannitol account for its use as intravenous solution in the management of elevated intracranial pressure and cerebral edema ( ) . xylitol is a natural sweetener found in fruits, vegetables and oats, and it is extracted from birch trees ( ) . due to its low caloric content ( . kcal/g) and low glycemic index, xylitol has long been suggested as a valid alternative to glucose and sucrose in patients with diabetes ( ) . in a pre-clinical study, week administration of xylitol at high doses has been shown to improve glucose tolerance in rats ( ) . conversely, a randomized, placebo-controlled, crossover trial conducted in lean and obese volunteers showed that acute xylitol and erythritol ingestion did not significantly affect circulating levels of glucose and insulin, despite being able to stimulate the secretion of the gut hormones cholecystokinin (cck) and glucagon-like peptide- (glp- ). of note, the marked increase in cck and glp- levels was accompanied by a significant slowing in gastric emptying ( ) . these findings are interesting and do not exclude that chronic ingestion of these sweeteners may play a role in the regulation of glucose homeostasis. also, the increase in glp- levels may have relevant clinical implications beyond the insulinotropic action of glp- , considering the well-known role exerted by glp- receptor agonists in the reduction of cardiovascular risk among diabetic patients, along with the anorexigenic properties of glp- and its analogs ( ) ( ) ( ) . remarkably, cck has also been shown to induce short-term satiety and to play a role in the regulation of insulin secretion and overall β-cell function and survival, displaying complementary biological actions with those exerted by glp- ( ). erythritol is a polyol contained in fruits (e.g., melon, peach), wine and beer ( ) . it is chemically derived from the fermentation of natural sugars (e.g., glucose and sucrose) by trichosporonoides megachiliensis ( ) . its sweetening power corresponds to - % of that of sucrose ( ) . erythritol is poorly absorbed in the jejunum and is excreted unmodified in the urine ( ) . only a small fraction of erythritol undergoes gut fermentation. therefore, an excessive consumption of erythritol can be associated with laxative effects ( ) . gastrointestinal discomfort is generally observed when erythritol intake is > , mg/kg of body weight ( ) . erythritol intake does not appear to have detrimental effects on glucose control and its use is generally deemed as safe in patients with diabetes ( ) . similarly to other polyols, erythritol does not participate in maillard-type reactions and, therefore, does not cause the production of ages. in addition, by acting as a scavenger for hydroxyl radicals, erythritol exerts anti-oxidant and endothelium-protective properties ( ) . erythritol provides a negligible amount of energy ( . kcal/g) ( ) . thus, it is commonly used as part of the dietary patterns recommended for people with obesity ( ) . due to its sweet taste and high digestive tolerance, and the fact that it is virtually calorie-free and non-cariogenic, erythritol is widely used in the food and beverage industry. non-calorie sweeteners (also known as artificial sweeteners or non-nutritive sweeteners) are defined as compounds with high sweetening power. although most of them do not provide calories upon ingestion, some of these compounds (such as aspartame and stevia rebaudiana) have a measurable caloric value that is considered negligible at the doses commonly used by humans. non-calorie sweeteners can be of synthetic or natural origin ( table ) . stevia rebaudiana has a natural origin. it is commonly called stevia and derives from a plant that grows in south america ( ) . stevia contains steviol glycosides, stevioside, and rebaudioside a, that account for its sweet taste, and other minor glycosides, such as rebaudioside b, rebaudioside c, rebaudioside d, rebaudioside e, rebaudioside f, dulcoside a, rubusoside, and steviolbioside. stevia also contains a complex of terpenes, tannins, sterols, vitamins, carotenes, flavonoids, and other microelements ( ) . after ingestion, the steviol glycosides contained in stevia are ( , ) . b source ( , ) . c source ( , ) . d source ( ) . not digested in the upper gastrointestinal tract ( ), but they are metabolized by bacteria of the bacteroidaceae family in the colon, resulting in the production of steviol ( ) , which is subsequently processed in the liver and converted into steviol glucuronide ( ) . energy from fermentation of steviol glycosides (usually assessed as kcal/g) is low ( ) . stevia has a strong sweetening power, -to -fold higher than that of sucrose ( ) . its maximal recommended daily intake is mg/kg, and it is considered unsafe at higher doses (eu regulation / ) ( ) . this quantity corresponds to approximately nine tablets per day. considering that stevia is to times sweeter than sugar, it is extremely unlikely for an individual to ingest the maximum dose of mg/kg over a h period. stevia offers several advantages over other non-calorie sucrose substitutes. in vitro, stevia displayed antiviral effects ( ) , immunomodulatory activity ( ) and antiinflammatory properties, through inhibition of nf-κb and pro-inflammatory cytokines expression ( ) . in rats, stevioside showed antihyperglycemic effects through the enhancement of the first-phase of insulin secretion with a concomitant suppression of glucagon levels; stevia also caused a pronounced reduction of both systolic and diastolic blood pressure in rats ( ) . intriguingly, pre-clinical evidence suggests that steviol glycoside derivatives can exert antiproliferative properties in several cancer cell lines, including pancreatic ( ), breast ( ) , and gastric cancer ( ) cell lines. aspartame was discovered in ( ) . it provides kcal/g, but it is included in the group of non-calorie sweeteners, due to its strong sweetening power ( ) . it is composed by phenylalanine, aspartic acid and methanol ( ) . given the high content in phenylalanine, aspartame use is contraindicated in individuals with phenylketonuria, a rare autosomal recessive inborn error of metabolism characterized by a decreased metabolism of the amino acid phenylalanine ( ) . although the use of aspartame has been approved in united states since ( ) and in europe since ( ), its safety is still debated. after several studies performed during the s and the s ( - ), a long term study was carried out in rats to assess its carcinogenic potential ( ) . rodents treated with different dosages of aspartame until their natural death showed an increase in the frequencies of lymphomas and leukemias, carcinomas of the renal pelvis and ureter, and schwannomas ( ) . these results were confirmed even at doses of mg/kg body weight, which are lower than the recommended maximum daily intake in europe and in united states ( ) . the potential carcinogenicity of aspartame was first attributed to methanol, that is converted into formaldehyde and then into formic acid both in rats and humans ( ) . based on data obtained from different studies, the european food safety authority (efsa) was called in to re-evaluate the safety of aspartame on human health. efsa concluded that aspartame is safe at a dose of mg/kg body weight/day ( ) . however, aspartame safety on human health is still under debate; in fact, a recent study highlighted several important shortcomings in the efsa document ( ) . acesulfame-k is a potassium salt of -methyl- -axanthiazine- ( h)-one , -dioxide. its sweetening power is -fold higher than sucrose ( ). acesulfame-k does not provide calories. since it is not catabolized in humans, acesulfame-k does not affect serum potassium levels despite its potassium content ( ) . the acceptable daily intake (adi) of acesulfame-k is mg/kg body weight. it is used in various sweet foods and beverages ( ) . hydrolysis of acesulfame-k gives rise to acetoacetamide, a degradation product that can be toxic if produced in large amounts ( ) . acesulfame-k carcinogenicity has been investigated in rats, where no carcinogenic effects were observed ( ) . the majority of studies noted that it displays neutral effects on body weight or glucose tolerance ( , ) . sucralose is derived from sucrose after replacement of three chloride atoms with three hydroxyl groups ( ) . it was discovered in and has a sweetening power -to fold higher than sucrose. the adi of sucralose is mg/kg body weight in united states ( ) and mg/kg body weight in europe ( ) . only up to - % of sucralose is absorbed in the gastrointestinal tract, while the remaining undergoes intestinal excretion unmodified ( ) . sucralose is stable during baking and it is considered safe in beverages and foods that require cooking ( ) . sucralose consumption does not affect glycemic control or insulin sensitivity in healthy individuals when administered alone, whereas its use in combination with carbohydrates showed a negative impact on glucose metabolism ( ) . several studies in vitro ( , ) and in vivo ( , ) demonstrated that sucralose is not a carcinogenic compound. only two studies noted a positive relationship between sucralose and mutagenic activity. in one, two human colon cancer cell lines (caco- and ht- ) and one human embryonic kidney cell line (hek- ) were exposed to very high doses of sweetener solutions for up to , , and h, leading to cell alterations and dna fragmentation ( ) . in the other, mouse lymphoma cells showed doubtful results when exposed to mg/ml sucralose concentrations ( ) . however, in both studies very high sucralose concentrations were used. recently, soffritti et al. raised questions regarding sucralose safety ( ) , although efsa revaluation judged that these results were not supported by the available data ( ) . saccharin is a non-calorie sweetener derived from , benzoisothiazol -( h). its sweetening potency is almost -fold higher than that of sucrose. saccharin has an unpleasant bitter or metallic taste ( ) . experiments conducted in the s have showed a link between saccharin and an increased incidence of bladder cancer in a rat strain genetically susceptible to bladder tumors, when exposed to % saccharin in the diet for weeks ( ) . nonetheless, saccharin generates a urinary precipitate mainly composed of calcium phosphate, which can exert cytotoxic effects on urothelial cells of rats and induce mild hyperplasia ( ) . however, very high saccharin concentrations were tested in animal models, if compared to the doses commonly ingested by humans ( ) . with regard to metabolic parameters, a recent study evaluated the administration of saccharin (at different doses, namely: . , , and mg/kg) in male wistar rats ( ) . an increased body weight was noted in rats after and days of mg/kg saccharin treatment. authors also observed an increase in glucose, uric acid and creatinine levels, as well as in oxidative status in the liver of saccharin-treated rats, suggesting that saccharin may impair glucose homeostasis, induce obesity and lead to impairments in kidney and liver function ( ) . the world health organization and the eu scientific committee for food declared saccharine as safe up to the approved daily intake doses ( mg/kg body weight) ( ) . nowdays, saccharine is commonly used in soft drinks, baked foods, jams, canned fruit, candy, dessert toppings, and chewing gum ( ) . the consequences of low-calorie and non-calorie sweeteners on daily food consumption and eating behavior are still controversial. eating causes an amplification of dopamine release in the nucleus accumbens, similar to what occurs upon substance abuse ( ) . however, the ingestion of palatable foods causes an increase in dopamine production greater than standard food ( ) . given that palatable foods stimulate the same neural pathways involved in drug addiction, it has been suggested that an excessive sugar intake can lead to addiction. moreover, after long-term consumption of sugar, withdrawal symptoms have been described in rats, similarly to what has been observed in morphine and nicotine dependence ( ) . food addiction leads to changes in the expression of dopamine receptors ( ) . neuroimaging studies revealed that obese individuals exhibit lower dopamine sensitivity in nucleus accumbens accompanied by a decrease in dopamine d receptor expression, similar to what has been observed in drug-addicted subjects ( ) ( ) ( ) ( ) . interestingly, dopamine d receptor expression is inversely related to body mass index in obese patients ( ) . these findings suggest that chronic exposure to sugar decreases dopamine-d receptor expression. furthermore, it has been hypothesized that obese subjects respond to dopamine deficiency by overeating palatable foods ( ) . several brain regions are involved in food-reward, namely: lateral hypothalamic area (lha), ventral tegmental area (vta), nucleus accumbens (nac) and prefrontal cortex (pfc). several neurotransmitters (gaba, glutamate and opioids) are involved in different aspects of reward in the above-mentioned brain regions ( , ) . in particular, the dopaminergic circuitry from lha to vta and from vta to the nac is involved in hedonic processes ("liking"), reinforcement ("learning"), and motivation ("wanting") ( ), while acetylcholine is involved in the aversive aspects of withdrawal ( ) . during withdrawal state, extracellular dopamine decreases in the accumbens, while acetylcholine is released from accumbens neurons. intermittent or excessive sugar consumption induces neurochemical modifications, mimicking the effects of opioids ( ) . food choice and food intake are physiologically regulated by metabolic and neural signals. in particular, metabolic signals act as nutritional status sensors and mediate the ingestion of a sufficient amount of energy. on the other hand, sensory signals regulate food choice and are linked to subsequent metabolic adaptation, resulting in conditioned responses to these foods ( ). the combination of learned responses with metabolic and sensory signals results in a specific pattern of food intake. the responses to sensory inputs, such as taste, texture, and sight of food, include consecutive preabsorptive physiological responses, which are collectively referred to as cephalic phase responses. such digestive preparation confers to the body the ability to anticipate the particular challenge a food poses for maintaining energy homeostasis ( ) . among these responses, the cephalic-phase insulin response, elicited by sugars, enhances glucose tolerance in humans ( ) ( ) ( ) . although replacing calorie with non-calorie sweeteners definitely reduces the energy density of foods and beverages, this does not necessarily translate into metabolic advantages and improved health status. it has been hypothesized that daily intake of non-calorie sweeteners can "trick" the brain by encouraging sugar craving and addiction ( ) . indeed, lack of calories generally abolishes the post-ingestive food reward mediated by the hypothalamus ( ) . in keeping with this, it has been suggested that uncoupling sweet taste from energy causes progressive weakening of conditioned responses to sweet taste ( ) . as previously mentioned, sweet taste is able to evoke physiological adaptations which play an important role in the finely-tuned regulation of energy homeostasis, by sensing the presence of caloric nutrients in the gut and facilitating the absorption and subsequent utilization of energy. when sweeteners are not associated with caloric intake, their ability to sense energy is altered, with a subsequent reduced ability to use energy and a mitigated activation of the peripheral and central pathways that promote the feeling of satiety ( ) . it is also known that non-calorie sweeteners evoke different brain responses compared to calorie sugars. in particular, sucralose is known to display reduced ability to activate midbrain areas related to reward, including lha, vta, and nac ( ) . indeed, given the critical role of melanin-concentrating hormone (mch) neurons in the lha in establishing nutrient preference, a preclinical study showed that sucrose activated mch neurons, resulting in dopamine release (da). by contrast, sucralose was able to induce da release in mice only in the presence of light stimulation, which led to the activation of mch neurons. these findings suggest that non-calorie sweeteners require additional stimuli to obtain the same rewarding effect of sucrose (figure ) ( ) . significant controversy exists over the effects of low-calorie sweeteners on metabolic health. studies conducted on rodents ( ) and humans reported a positive association of low-calorie sweetener consumption with weight gain and/or diabetes ( ) ( ) ( ) , other studies a positive association with lower bmi and weight loss ( , ) , in other cases their use was not related to metabolic parameters ( , ) . such heterogeneity is probably due to methodological limitations of some of these studies ( ) . a recently published study shed some light on the controversy regarding the effects of low-and non-calorie sweeteners on metabolic health ( ) . authors reported that consumption of sucralose was able to rapidly impair glucose metabolism and brain response to sweet taste in healthy subjects only when administered in the presence of carbohydrates. in fact, insulin sensitivity as well as neural responses to sugar were not altered by sucralose or carbohydrate alone. notably, the combined effect of sucralose and carbohydrates was even more pronounced in adolescents, who showed a dramatic increase in insulin resistance measured by the homeostatic model assessment for insulin resistance index (homa-ir). these findings refute the "sweet uncoupling hypothesis, " which is based on the concept that uncoupling sweet taste from caloric content could determine metabolic dysfunctions and reduce the potency of sweet taste ( ) . these data may help explaining the obesogenic potential of low-calorie sweeteners in the context of western diets, especially considering the frequent use of "diet drinks, " often containing non-calorie sweeteners, associated with carbohydrates-rich meals. the sweet taste perception begins with the activation of taste receptors of the tongue, which are located within the taste buds of lingual papillae ( ) . taste receptors include g protein-coupled figure | brain reward circuitry involved in central effects of sweeteners. the dopaminergic pathway is strictly involved in hedonic processes ("liking"), reinforcement ("learning"), and motivation ("wanting"). midbrain dopaminergic circuits include lateral hypothalamus (lha), ventral tegmental area (vta), and nucleus accumbens (nac). dopamine release is driven by orexin (orx) peptides and melanin-concentrating hormone (mch) secreted by lha. in particular, orx and mch neurons from lha project to vta, where orx peptides and mch mediate the activation of dopamine (da) neurons and increase the release of da in projection areas such as the nac. it has been established that dopamine reward pathway response induced by caloric sweeteners consumption, such as sucrose, is greater compared to non-calorie sweetener sucralose. interestingly, a preclinical study provided evidence that mch neurons account for the natural preference for sucrose over sucralose and that such effect can be reversed by stimulating mch neurons with light. this suggests that non calorie-sweeteners require additional stimuli to obtain the same rewarding effect of sucrose. receptors and ion channels. type taste receptors (t rs; sweettaste and umami receptors) and type taste receptors (t rs; bitter-taste receptors) are both g protein-coupled receptors ( , ) . the activation of these receptors generates second messengers, such as inositol trisphosphate and diacylglycerol, leading to the activation of taste-transduction channels ( ) . these metabolic pathways project to brain circuits, allowing the appreciation of taste. sweet-taste receptors are also expressed outside of the oral cavity. they have been found throughout the gastrointestinal tract, particularly in the enteroendocrine l and k cells ( , ) . besides the gastrointestinal tract, sweet-taste receptors have also been found in pancreatic β-cells ( ) , bile ducts ( ) , and lungs ( ) . in the gut, glucose is absorbed through sodium-dependent glucose cotransporter- (sglt- ) localized on the luminal membrane and the passive glucose transporter (glut ) on the basolateral membrane of the enterocyte ( ) . glucose binding to sweet-taste receptors present on enteroendocrine cells leads to glp- and peptide yy (pyy) secretion from l-cells, promoting satiety ( ) . since both non-calorie and low-calorie sweeteners bind to sweet-taste receptors present in the oral cavity and subsequently lead to the sweet taste perception, it has been hypothesized that noncalorie sweeteners and low-calorie sweeteners may activate the same sweet-taste receptors expressed on enteroendocrine cells, promoting gut hormone secretion. in vitro, sucralose has been shown to stimulate glp- secretion from a human l-cell line (nci-h cells) ( ) and to increase glp- and glucosedependent insulinotropic peptide (gip) release in a murine enteroendocrine cell line ( ) (figure ) . however, these results were not confirmed in vivo. several studies showed no effect of oral sucralose ( ) , aspartame, and acesulfame-k on glp- , pyy, ghrelin, or gip secretion ( ) . these results have been confirmed also for sucralose administration before a solid meal, which did not elicit any effects on gip or glp- release ( ) . nevertheless, other studies showed controversial results. in fact, non-calorie sweeteners ingested through diet soda have been shown to synergize with glucose to enhance glp- release in healthy subjects, even if it is unclear whether this effect was due to the activation of sweet-taste receptors present on taste buds of lingual papillae and/or enteroendocrine cells, or if it was due to other mechanisms ( ). moreover, non-calorie sweeteners (such as sucralose, acesulfame-k and saccharin) have been shown to increase glucose absorption in the small intestine by up-regulating sglt expression in mice through the activity of enteric neurons ( ) . indeed, glp- stimulates the release of neuropeptides, which in turn bind to g protein-coupled receptors (expressed on the basolateral membrane of enterocytes) and induce sglt expression ( ) . in vivo, these sweeteners displayed the same effects by increasing glut expression at the level of the apical membrane ( ) . giving the ability of non-calorie sweeteners to increase sugar absorption during a meal, it is worth considering their potential implications in terms of metabolic effects. the recent report that simultaneous consumption of sucralose and maltodextrin-derived glucose acutely disrupts glucose tolerance and insulin sensitivity ( ) may be a likely consequence of the increased intestinal glucose absorption following the upregulated expression of sglt and/or glut . in vitro studies demonstrated that sucralose, saccharin, and acesulfame-k stimulate pancreatic β-cell insulin secretion in the frontiers in endocrinology | www.frontiersin.org presence of glucose ( ) . the natural non-calorie sweetener stevia is also able to enhance glucose-induced insulin release, through inhibition of atp-sensitive k-channels ( ) and stevioside has been shown to reduce plasma glucose levels in mice ( ) , postprandial glucose and glucagon levels in subjects with type diabetes ( ) . finally, mechanistics studies are needed to better elucidate the effects of different sweeteners on gut hormone-mediated glucose homeostasis in humans. figure depicts some of the effects of non-calorie sweeteners on enteroendocrine cells and gut hormones secretion, which have mainly been inferred from in vitro and animal studies. it has been hypothesized that the relationship between sugar, metabolic syndrome and its related disorders may be mediated, at least in part, by changes in the gut microbiota ( , ) . in particular, increased added sugar and novel sweeteners consumption may alter the carbohydrate pools in the gut, thus creating distinct environments that can favor adaptation and enhance colonization and virulence of some endogenous and/or exogenous pathogenic microbes ( ) . since most sugars and sweeteners are absorbed at the level of the small intestine by sugar transporters, only up to % of these compounds reach the large intestine ( ) . therefore, the small intestine environment is more enriched in sweeteners compared to large intestine. moreover, microbes in the small intestine have a greater number of carbohydrate uptake and utilization genes and transcripts compared to those in the large intestine ( ) . gut microbiota composition displays a remarkable spatial heterogeneity across the gastrointestinal tract, with different microbial communities creating distinct microenvironments at different gut locations (a phenomenon also known as "gut biogeography") ( ) . di rienzi and britton recently proposed that the variation in microbial communities found along the gastrointestinal tract can also depend on the variation in sugars and sweeteners present at different gut locations ( ) . furthermore, changes in sugar and sweetener pool can lead to adaptation of the gut microbiota involving transcriptional, metabolic and compositional changes in gut microbes. these changes allow for increase in abundance of microbes whose niche and microenvironment are best filled. in addition, genetic changes can also allow existing microbes to alter their niche in order to better utilize the new nutrient pool ( ) . suez et al. demonstrated that saccharin-fed mice developed glucose intolerance as a consequence of compositional and functional alterations to the gut microbiota ( ) . similarly, germ-free mice receiving fecal transplantation from saccharin-fed animals displayed glucose intolerance, suggesting that derangements in glucose metabolism are mediated by saccharin-induced alterations to the gut microbiota ( ) . similar findings were reproduced in healthy human subjects consuming saccharin for week ( ) . importantly, saccharin-fed mice showed a reduction in akkermansia muciniphila, a mucin-degrading bacteria with probiotic properties associated with favorable metabolic effects ( ) . saccharin consumption has also been shown to affect microbiota composition in rats; the growth of six bacterial strains (three lactobacillus species and three escherichia coli strains) was inhibited and the fermentation of glucose was decreased ( , ) . mice treated with saccharin ( . mg/ml) for months showed gut dysbiosis, which is broadly defined as any change in the composition of resident commensal microbial communities relative to the community found in healthy subjects ( ) , along with an increased expression of pro-inflammatory inducible no synthase (inos) and tnf-α in liver ( ) . sousa et al. clearly demonstrated that a specific diet can alter gut microbiota by changing the abundance of specific strains. of note, authors inoculated mice with an escherichia coli strain carrying a mutation disrupting the ability to consume galactitol (a galactose-derived sugar alcohol) ( ) . surprisingly, part of the e. coli population regained galactitol metabolism, resulting in the coexistence of two distinct strains within the gut microbiota that could or not consume galactitol (galactitol-positive and galactitol-negative strains, respectively) ( ) . apart from the role of sweeteners as nutrients for gut microbiota, it is worth considering that some of these compounds may exert direct toxict effects on specific microbes. for instance, xylitol cannot be metabolized by oral bacteria ( ) and is therefore added to oral products or chewing-gums. also, stevia glycosides (stevioside and rebaudioside a) have been shown to inhibit the growth of strains of lactobacillus reuteri, a symbiotic lactobacillus species which inhabits the gastrointestinal tract of mammals and is often administered as a probiotic additive in healthy foods ( ) . however, inulin and fructans-contained in the roots of stevia-favored the proliferation of bifidobacteria and lactobacilli in a pre-clinical study ( ) . stevia also showed a bactericidal effect on enterohemorrhagic escherichia coli ( ) . also, some sugar alcohols have been shown to promote an increase in the number of beneficial gut microbes both in rats and in healthy human volunteers ( , ) . mice fed a high-fat diet plus xylitol showed a reduced fecal content of bacteroidetes and barnesiella, along with an increased abundance of firmicutes and prevotella ( ) . moreover, xylitol promoted a substantial change in rodent fecal microbiota, decreasing gram-negative and increasing gram-positive bacteria ( ) . of note, the ability of sweeteners to affect gut microbiota composition may also have important immunological implications. in this regard, a recent study conducted on streptozotocin-induced diabetic mice and non-obese diabetic (nod) mice-which are both widely used as animal models of human type diabetes-has shown that trehalose, a natural caloric disaccharide derived from a rodent intestinal nematode and characterized by antioxidant properties ( ) , is able to affect gut microbiota by increasing the abundance of ruminococcus spp. ( ) . such change in intestinal microbiota composition appears to account for the induction of cd + regulatory t cells, which play a role in inhibiting the onset of diabetes and reducing blood glucose levels in diabetic animals ( ) . in addition, authors found that patients with type diabetes, when compared to healthy volunteers, had fewer cd + regulatory t cells, as well as lower serum trehalose concentrations and fecal content of ruminococcus ( ) . these results suggest that trehalose may have a potential prophylactic and/or therapeutic role in humans (e.g., use of trehalose and ruminococcus strains as a prebiotic and probiotic, respectively), as a tool to induce cd + regulatory t cells in order to prevent the development of type diabetes and/or counteract the immune-mediated β-cell destruction shortly after the onset of the disease. since sweeteners cross the placenta ( ) and are found in the maternal milk ( ) , there is the potential for a relationship between prenatal exposure to different sweeteners and gut microbiota composition later in life. animal studies indicate that acesulfame-k crosses the placenta during pregnancy and can potentially lead to an increased sweet preference during adulthood ( ) . on the other hand, prenatal sucralose exposure does not affect fetal organogenesis ( ) , but increases the risk for hematopoietic neoplasia in male mice ( ) and favors adipocyte differentation in cultured pre-adipocytes ( ) . these results suggested that non-calorie sweeteners consumption during pregnancy could impact on offspring adipose tissue differentiation, promoting childhood obesity ( ) . moreover, exposure of pregnant mice to a mixture of acesulfame-k and sucralose at different concentrations demonstrated that non-calorie sweeteners were able to affect gut microbiota composition in the offspring in a dose-dependent manner, increasing firmicutes content and reducing the amount of beneficial species, including akkermansia muciniphila ( ) . in conclusion, early prenatal exposure to specific non-calorie sweeteners could favor the occurrence of metabolic diseases later in life, by inducing detrimental changes in the gut microbiota composition. the aforementioned findings support the notion that sweetener consumption modifies the nutrient environment in the gut and induces a series of functional changes in the gut microbiota, which potentially result in transcriptional, metabolic, compositional, and/or genetic adaptation by gut microbes. in turn, microbial adaptation to sweeteners may affect host-microbe interaction and influence the subsequent immune responses (e.g., pro-inflammatory, anti-inflammatory, immune responses that promote microbe survival or clearance) ( ) . however, the mechanisms underlying the microbial adaptation to a given sweetener are not fully understood yet. in particular, it is still not clear if dietary sugars and sweeteners can also induce changes in the host environment. the exact impact on the host exerted by microbial metabolites derived from added sugar and sweetener metabolism also needs to be clarified and addressed in future studies. to date, the european union (eu) and efsa approved the use of non-calorie sweeteners, namely: acesulfame-k (e- ), advantame (e- ), aspartame (e- ), aspartame-acesulfame salt (e- ), cyclamic acid and its sodium and calcium salts (e- ), neohesperidin dihydrochalcone (e- ), neotame (e- ), saccharin (e- ), stevia (e- ), sucralose (e- ), and thaumatin (e- ). eu and efsa confirmed that non-nutritive and low-calorie sweeteners are safe for human health if used within the adi ( ). amongst low-calorie sweeteners, eu approved the following compounds: sorbitol and sorbitol syrup (e ), mannitol (e- ), isomaltose (e- ), polyglycitol syrup (e- ), maltitol and maltitol syrup (e- ), lactitol (e- ), xylitol (e- ), and erythritol (e- ). unlike non-caloric sweeteners, polyols and low-calorie sweeteners are classified as gras and adi is not reported for them ( ) . an international consensus statement on the use of low-and non-calorie sweeteners has been signed in lisbon in july ( ) . the consensus concluded that low-and noncalorie sweeteners consumption is safe, as also supported by who, fda ( ) and efsa ( ) , and the dietary consumption of low-and non-calorie sweeteners promotes dental health when these compounds replace free sugars ( , ) . therefore, the consensus encourages the education of consumers on the use of products containing low-and non-calorie sweeteners, in order to increase awareness of general population on their correct use ( ) . finally, consumption of low-and non-calorie sweeteners during pregnancy showed neutral effects on offspring health and data obtained from animal studies were not confirmed in humans ( ) . although more research is needed to fully assess the effects of in utero exposure to sweeteners, current evidence does not suggest adverse effects in pregnancy. nevertheless, it is recommended that sweeteners are consumed in moderate amounts, adhering to the acceptable daily intake standards established by regulatory agencies ( ) . fda has approved several types of sugar substitutes, considering them as safe. nonetheless, the american heart association and the american diabetes association suggest to limit the use of sweeteners due to the lack of strong evidence for their effects on body weight and cardiometabolic risk factors in the long-term period ( ) . with regard to effects on gut microbiota, most of the sweeteners affect bacterial gut composition, potentially inducing dysbiosis. among sweeteners, polyols seem to show a good safety profile. moreover, they are non-cariogenic, do not negatively affect gut microbiota and are characterized by a very low-energy value ( ) . moreover, the potential favorable effects of polyols on glucose homeostasis may suggest their use as a valid option in subjects with type diabetes and metabolic syndrome, although further research is needed in this area. in this context, a careful nutritional advice is essential for a conscious use and for a correct transition, through the use of sweeteners, from sweetened foods to sugar-free foods. the role of nutrition specialists appears therefore crucial to recommend a diet with a proper use of sweeteners, avoiding the risk of an excessive use of these compounds. given the scarcity of data on sweetener safety in the longterm period, it is important to carefully evaluate the use of these compounds particularly in selected patients, such as those affected by metabolic derangements. indeed, different studies and meta-analyses found an association between the consumption of sweeteners and artificially sweetened beverages with increased risk of overweight, obesity, metabolic syndrome and type diabetes ( , , ( ) ( ) ( ) , thus highlighting the need for future prospective studies aimed at evaluating the exact impact of different types of sweeteners on human health from a metabolic perspective. however, when consumed in moderate amounts, sweeteners may be used as part of a nutritional rehabilitation program aimed to limit daily consumption of refined sugars ( , , ( ) ( ) ( ) . over the last decades several healthy dietary patterns have been proposed to tackle the growing obesity epidemic. dietary approaches based on marked reduction of carbohydrate and refined sugar consumption are emerging in clinical practice and are highly debated. during the last few years, interest in very low-calorie ketogenic diets (vlckd) has gradually grown due to their safety and their marked potential in inducing weight loss ( ) . in this context, non-calorie sweeteners represent a valuable tool for improvement of patient adherence to a strict nutritional regimen and rehabilitation program. the addition of non-calorie sweeteners to food replacements allowed for a marked reduction in carbohydrate and sugar content (< g/day, ≃ % of total energy intake), with preservation of food palatability and diet satisfaction ( ), thereby avoiding craving and increase in appetite, which may reduce the efficacy of a vlckd. on the basis of the recent findings on the effects of sucralose ( ) , the association of non-calorie sweeteners to a very low-carbohydrate nutritional regimen represents a valid approach to prevent the detrimental metabolic effects on insulin sensitivity and the altered neural response to sugars induced by an excessive carbohydrate consumption (figure ). dietary consumption of sweeteners has progressively increased over the last decades in order to reduce the burden of cardiovascular and metabolic diseases caused by modern western diets, which are characterized by a high content in refined and added sugars. also, the introduction of sugar taxes in several countries is likely to cause an even greater use of these compounds. nonetheless, at present there is still scarce evidence to establish conclusively whether the consumption of different types of sweeteners (e.g., low-calorie sweeteners vs. non-calorie sweeteners) can result in significant beneficial or detrimental effects on energy balance, appetite, body weight, and/or cardiometabolic risk factors in healthy subjects and patients with metabolic diseases (particularly obesity and type diabetes). indeed, the health impact of sweetener consumption, as well as the potential health consequences resulting from switching from one sweetener to another, still remain poorly understood. therefore, future prospective studies aimed to address short-and long-term safety and efficacy of different types of sweeteners in various clinical settings (e.g., obesity, type diabetes, metabolic syndrome) and in different age groups are needed. another area that warrants further investigation is the impact of different types of sweeteners on gut microbiota. emerging evidence supports how different food components (including sweeteners) can drive changes in the gut microbiota, resulting in relevant implications for human health and disease ( , , , , ) . mechanistic studies using gut organoids or animal models will certainly help to better elucidate: (i) how different types of sweeteners can reshape the gut microbiota, (ii) the interactions between sweeteners/sweetener metabolites, gut microbiota and host, and (iii) the consequences of these interactions on host physiology and biological processes in the short-and long-term period. future studies will also be helpful to evaluate which sweeteners are able to promote the growth of beneficial or detrimental gut microbes, resulting in potential human health benefits or harms. additionally, clinical studies evaluating the impact of different sweeteners on gut microbiota composition will further help to fully address all these unanswered questions regarding the sweetener-gut microbiotahost triad. finally, the extent to which all the aforementioned sweetenerinduced changes at different levels (central nervous system circuits, gut hormone secretion and gut microbiota) are clinically relevant in terms of human health is still not clear. genetic, anthropometric and dietary differences may, at least in part, account for the high interindividual variability in the response to different types of sweeteners ( ) . future studies based on epidemiological approaches combined with tools used in precision medicine may help to better establish the subset of individuals who are more likely to receive benefit or harm from sweetener consumption ( ) . all authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication. mc and em conceived, wrote, and revised the manuscript. afe and vm prepared the figures and wrote part of the manuscript. mi wrote part of the manuscript and carefully revised it. ml and afa revised the manuscript. we wish to thank dr. elisa fabbrini for critical reading of the manuscript. figures generation has been performed by using biorender software. this work is dedicated to the shining memory of dr. italo nosari, and to all other healthcare workers who died of covid- . natural sweeteners in a human diet the health implications of sucrose, high-fructose corn 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population impact of sweet beverage intake and type diabetes, and effects of substitutions with alternative beverages the association between artificial sweeteners and obesity very-low-calorie ketogenic diet (vlckd) in the management of metabolic diseases: systematic review and consensus statement from the italian society of endocrinology (sie) interplay between food and gut microbiota in health and disease how non-nutritive sweeteners influence hormones and health key: cord- -aq cfh authors: cattaneo, andrea; sánchez, marco v.; torero, máximo; vos, rob title: reducing food loss and waste: five challenges for policy and research date: - - journal: food policy doi: . /j.foodpol. . sha: doc_id: cord_uid: aq cfh despite broad agreement in policy circles on the need to reduce food loss and waste (flw), considerable gaps in information still exist. this paper identifies policy-relevant information gaps, summarizes recent research that tries to fill these gaps and identifies five challenges for researchers, policymakers and practitioners in reducing flw. the five challenges identified are: (i) measuring and monitoring flw, (ii) assessing benefits and costs of flw reduction and the tradeoffs involved, (iii) designing flw-related policies and interventions under limited information, (iv) understanding how interactions between stages along food value chain and across countries affect outcomes of flw reduction efforts, (v) preparing for income transitions and the shifting relative importance of losses and waste as economies develop. the last decade has seen an exponential increase in interest on the issue of food loss and waste (flw), in policy circles, academia, and even the private sector. the increase in publications has led to a number of different definitions of flw, depending on the focus of the publication. for the purpose of this article, food loss and waste is defined as the decrease in quantity or quality of food along the food supply chain (fao, ) . quantitative flw refers to food that exits the food supply chain, while qualitative flw refers to the decrease in food attributes that reduces its value in terms of intended use. following fao, in practice food losses are considered as occurring along the food supply chain from harvest (or slaughter/catch) up to, but not including, the retail level. food waste, on the other hand, occurs at the retail and consumption level. this definition aligns with the distinction implicit in sdg target . , which focuses on halving per capita global food waste at the retail and consumer levels and reduce food losses along production and supply chains. the increase in awareness on flw started with a few publications that raised the profile of flw. the review of fragmentary evidence coupled with interviews with international food supply experts in parfitt et al. ( ) was very influential in highlighting the scale of the problem, as was the fao estimate that one third of food produced was either lost or wasted (fao ) . concerning post-harvest losses (phl), the world bank (zorya et al., ) highlighted the importance of phl in cereals in sub-saharan africa. on consumer waste, the waste and resources action programme (wrap) initiative in the united kingdom led the way to demonstrate the magnitude of food waste in developed countries (wrap, (wrap, , ). these publications raised awareness of flw and its implications. the extent of reported flw raised concerns about food availability, farm and food supplier incomes, natural resource sustainability, food safety, and the global ramifications of their impacts. even though those studies emphasized the need for more data, the idea that "one third of food produced is wasted" has stuck with many observers and policymakers as a "stylized fact." with the increase in awareness came a call to action, such as the one by lipinski et al. ( ) , leading to adoption of a specific target for flw reduction (sdg . ) as part of the sustainable development goals (sdgs). this recognition was based in good part on the premise that reducing flw would contribute substantially towards ending hunger and making consumption and production systems more sustainable. such notions have subsequently been reconfirmed in influential studies on the sustainability of food systems (see e.g., the eat lancet report by willett et al., ) . the spread of the novel coronavirus disease in has drawn further attention to the risks of substantial food loss, particularly those of dairy, meats, fruits and vegetables, as social distancing measures have caused supply chain disruptions and demand to drop in many countries with a potential to increase losses specially in high value and nutrient-rich food commodities (torero, ; laborde et al., ) . both the pandemic and inadequate food access can increase morbidity (fao et al., ) . at the time of writing, it was unclear whether these immediate impacts would have lasting effects on supply chains and consumption behavior, but no doubt they raise the importance of addressing flw as part of the food policy agenda. since , there has been a proliferation of empirical studies on flw. according to xue et al. ( ) , two-thirds of the studies on the topic were published after . before , the bulk of the literature on flw was mostly technical in nature and confined to specialized publications and very few contributed to the economic literature. despite the recent surge in policy-oriented studies, evidence to inform policymakers on the magnitude, causes and remedies of flw remains extraordinarily sparse and highly diverse in methods, coverage of the stages of the value chain, and definitions. however, a number of recent studies signal the beginning of a new literature that can provide the basis for improved measurement of flw and insights into the design of effective interventions. some are conceptual (bellemare et al., ; koester, ; ellison et al., ) . others are based on meta studies or literature surveys (affognon et al., ; sheahan and barrett, ; xue et al., ; aragie et al., ; reynolds et al., ) . a few recent studies have emerged that have proposed and applied improved measurement methodologies (garrone et al., ; delgado et al., ; fao, ) and have influenced the development of new protocols for accounting and reporting standards for flw to be deployed by companies, governments, and other actors (flw protocol, ) . the editors of this special issue (si) on flw believe there is a need to bring together the issues of measurement, methodologies, determinants of flw, and trade-offs linked to policies or actions for reducing flw. effective policies and actions will require flw to be adequately measured and their drivers understood. this paper, which serves as an introduction to this special issue, summarizes what policy-relevant advances are needed. it outlines the contributions of the papers included in the special issue in these priority areas. a common denominator of these papers is the notion that flw is largely driven by economic decision-making and behaviors of actors along food supply chains, from farmers to consumers. policymakers aiming to reduce flw will likely see their efforts fail if they do not properly account for these factors. to address flw, policymakers need to consider complex pieces of evidence. we group those information needs into five categories: (i) detailed measurement of the extent of flw along food supply chains; (ii) evidence about the context-specific drivers of flw; (iii) private and social cost-benefit assessments to identify potential effectiveness of interventions for reducing flw and how to target those interventions; (iv) value chain or food system-wide assessments that help inform whether to specifically target flw or make it a subsidiary goal of broader policies aiming at improving the efficiency and sustainability of food systems at large; and (v) identification of possible unintended and undesired implications of reducing flw. table summarizes these needs for evidence-based policy decisionmaking and identifies the main knowledge gaps in these five areas of interest to policymakers. below, we provide an overview of the contributions made in this volume to each of the five categories of information needs. at the same time, the related challenges may serve as an organizing framework for a policy research agenda on flw reduction. since the first global assessment attempted by fao ( ), progress has been made on both conceptual and measurement frameworks for flw. as a result, the boundaries of flw have been more clearly defined, the evidence base has increased, and global estimates of the magnitude of flw have been refined. for example, xue et al. ( ) were able to provide quantitative flw estimates at the global level by major commodity groups. using different sectoral boundaries and a mix of officially reported and model-generated data, fao ( ) estimated food losses to amount to about percent of food production at global level, considering losses occurring at the farm level as well as during storage, transport, processing and distribution of food. the new estimate does not include the amounts of waste occurring during the stages of retail and final consumption. fabi et al. (in this si) start with an overview of the main conceptual frameworks proposed for measurement of flw, followed by a metaanalysis of existing quantitative evidence on food losses and how it varies by product and region. for example, they find that median share of lost output of fruits and vegetables is more than percent in africa and latin america, while in europe and north america this share ranges between percent and percent. losses in cereal production are lower across all regions -between . percent and . percent -and the difference between regions is less pronounced than it is for fruits and vegetables. in particular, the paper focuses on ways to improve monitoring progress towards sdg target . . it makes clear that sdg target . can catalyze action, but also that the data challenges to overcome are considerable. delgado et al. (in this si) take an innovative approach to the measurement of food losses along the value chain of five staple crops in six developing countries allowing for the identification of critical loss points along the value chain. they test and compare four methodologies to account for both quantitative and quality losses from pre-harvest to post-harvest handling, processing, and distribution. they find that losses are highest at the farm level and most product deterioration occurs before harvest. aggregated self-reported measures, which are most frequently used in the literature, consistently underestimate actual food losses. another dimension of imperfect measurement is linked to qualitative losses and how they are related to issues of food safety. hoffmann et al. (in this si) highlight how degraded quality may reflect a problem of food safety, but as in the case of aflatoxin in maize, food safety losses are not always readily observable by market actors. when this is the case, farmers, traders, and processors will lack incentives to address food safety losses specifically. if food quality is correlated with valued and observable food attributes, as delgado et al. (in this si) observe for maize, beans, teff, potatoes, and wheat, then quality losses are reflected in lower prices, thereby partially correcting this information failure. despite this progress, reliable and systematic evidence on the total amount of losses and waste is still missing for a wide range of commodities and along the whole food supply chain. various papers in this si contribute new evidence on the magnitudes of flw in a variety of contexts (see first column in table ). wider application of the measurement approaches proposed in this si, especially for high-value food commodities, will be essential. doing so, on a systematic basis for all countries and the wide range of food items, will also require finding more cost-effective measurement approaches than current methods based on surveys and model-based estimations. blockchain technology and other tools for tracking produce along the supply chain could provide a basis for improved measurement. causes of flw differ widely along the food supply chain and may be revised global estimates of food waste for downstream stages of food supply chains are in the process of being developed by the un environmental programme (unep) to create a global food waste index. as an example of the challenges faced, taking the median estimates reported in fabi et al. provides a different picture from the most recent fao estimates of food losses, which uses a mix of officially reported and model generated data. the global average of food losses reported by fao, estimated at approximately percent, is higher than the highest median in fabi et al. a. cattaneo, et al. food policy xxx (xxxx) xxxx directly or indirectly linked to a specific loss point. causes are contextspecific. for example, we know that important causes of on-farm losses include inadequate harvesting time, climatic conditions, practices applied at harvest and handling, challenges in marketing produce, and lack of economic incentives to prevent losses (delgado et al. -in this si and fao, ) . inadequate storage conditions and decisions made at earlier stages of the supply chain can predispose products to a shorter shelf life, causing significant losses (fao, ; liu, ) . adequate cold or dry storage, in particular, tend to be crucial to prevent quantitative and qualitative food losses (delgado et al., ) . during transportation, good physical infrastructure and efficient trade logistics are vital to prevent food losses (rolle, ) . confirming this, minten et al. (in this si) find that well-integrated rural-urban value chains have lower losses than typically found in the literature. analyzing self-reported post-harvest loss from different value chain agents, they find aggregate post-harvest losses (phl) over all segments of the value chain (from farmer to retailer) for teff and milk in ethiopia, which amount to between . percent and . percent of total quantities produced. processing and packaging can play a role in preserving foods, but losses in these stages of the supply chain can be caused by inadequate facilities, technical malfunctioning of equipment, or human error. brander et al. (in this si) apply a randomized control trial to examine the effect of use of hermetic storage bags for maize on seasonal food security in two districts in tanzania. they find that the adoption of this low-cost technology resulted in a percent decrease in the proportion of severely food insecure people during the lean season. delgado et al. (in this si) find the presence of pests, lack of rainfall, and lack of appropriate post-harvest technologies to be major factors behind the losses in the food value chains covered in their study. concerning indirect determinants of flw, sheahan and barrett ( ) rightly emphasize the importance of economic incentives and understanding the microeconomic rationale for why post-harvest losses occur, and that this is often missing in the debate on flw. using farmlevel data, anríquez et al. (in this si) compare marginal benefits and costs of loss reduction in wheat farming in tunisia and in the tomato supply chain in egypt. they find that market incentives to reduce losses are absent in the case of tunisia and rather weak in egypt. this result highlights that actors along the food value chain will weigh private benefits and costs of reducing losses to determine whether to intervene, and to what extent. as pointed out by sheahan and barrett ( ) , given the likely increasing marginal cost of reducing losses the 'optimal' level of food loss will most likely be greater than zero. at the retail level, direct causes of food waste are mostly associated with limited shelf life, the need for food products to meet aesthetic standards in terms of color, shape, and size, and variability in demand. consumer waste is often caused by poor planning during food purchasing and meal preparation, excess buying (influenced by overly large portion sizes and packaging), confusion over labels ("best-before" and "use-by" dates) and improper food storage at home. new insights in this regard are provided by yu & jaenicke (in this si), who conduct a natural experiment and observe that extending a food product's sell-by date has clear benefits for consumers who purchase less milk, spending less, but end up consuming more of it. another fundamental challenge stems from shoppers becoming less price sensitive as incomes increase. this is likely to lead to an increase in food waste in currently low-and middle-income countries (lopez barrera & hertel, in this si). furthermore, because avoiding flw typically requires additional labor and increases production costs, the table five policy-makers needs on food loss and waste: what can be answered and what needs to be further developed. do we know how much food is lost or wasted? • in the aggregate, a sizeable amount of food is being lost or wasted. • methodologies are being improved (fao, ; flw protocol, ) . however, it is difficult to harmonize approaches (chaboud and daviron, ; ellison et al., ) • identifying critical loss points. • measurement approaches. • opportunities using blockchain. what are the causes of flw? • food prices relative to production costs are critical explanatory variables in determining flw rates. • economic incentives for adoption of flw reducing technologies are weak deficiencies in public infrastructure. • better understanding of private benefits and costs as key determinants of flw. • identifying indirect causes that need to be addressed as part of broader agri-food value chain development policies. q what interventions are best suited to address flw and how to target them? should policymakers focus on loss, waste, or both? • depends on the underlying motivation of reduction (fao, ) . even the appropriate measure (losses in tons, nutritional or economic value) depends on the objective (flw protocol, ). • strategies for reducing food losses and food waste will have to be different: for waste reduction consumer awareness is key; for loss reduction understanding private costs and benefits and what drives them is key. • flw reduction should be treated as an intermediate goal and interventions designed and targeted in function of the policy's ultimate goal (e.g. food security, reducing ghg emissions, etc.) • based on answers to q and q , identify stakeholders for whom interventions can be most effective. what is the rationale for public intervention? how ambitious should we be in setting reduction targets? • overall economic welfare improves when lower flw implies improved efficiency of food systems. • producing food that is lost or wasted has an environmental impact (kummu et al., ). • food security and nutrition improves by reducing losses, as -in principle -more food becomes available at lower prices, benefiting households that are net buyers of food. food banks that avoid food waste provide support to the food insecure. • achieving zero flw may not be realistic, given increasing marginal cost of investing in flw reduction (ellison et al., ) . • need to focus more on quantifying the actual environmental improvement obtained by specific interventions to reduce flw once economic feedbacks of an intervention are taken into account. • more research is needed on the distributional effects of flw interventions: reducing losses could harm producers because of lower prices. • improving the assessment of efficiency, environmental and food security benefits of interventions, since there is very limited knowledge about societal benefits of reduction in flw. are there trade-offs and unintended consequences of reducing flw? • impacts will be felt both upstream and downstream of an intervention. for example, reductions at one stage can trigger losses and waste elsewhere. • flw reduction leading to lower prices may affect incomes of food producers and weaken economic incentives to invest in flw reduction. • efforts at improving food safety (reducing contaminants and spoilage) may cause higher reported flw. • better understanding of how flw reduction at one stage of the food value chain impacts market conditions upstream and downstream the supply chain. • identify trade-offs between different objectives associated with flw reduction. a. cattaneo, et al. food policy xxx (xxxx) xxxx opportunity cost of investing in flw reduction will increase with income levels. as a result, first-order policy objectives aiming to improve productivity and incomes will naturally work against second-order policy objectives, such as flw reduction. this suggests that pure market-based policy instruments may not suffice to simultaneously achieve both types of objectives. other instruments may be needed, such as those that influence socio-cultural norms and awareness about food waste. min et al. (in this si) find income levels matter when it comes to consumer waste and how consumers respond to better information about diets. the authors find that where the level of community development is low, dietary knowledge may increase food waste by households. however, where it is high, better dietary knowledge will decrease food waste. consequently, policies promoting nutrition knowledge on food waste and loss should take note of differences in levels of community development. in a similar vein, hoffmann et al. (in this si) find that greater awareness about food safety with regard to contaminants, spoilage, and other food quality aspects may lead to an increase in reported flw. the authors highlight the challenges consumers face in correctly identifying proxies for food safety concerns as opposed to qualitative losses. this reiterates a point made earlier, which is that problems of flw cannot be addressed in isolation. rather, they should be treated in conjunction with other policy objectives related to health, food security and nutrition, and the environment. policymakers typically face resource constraints, requiring them to prioritize among multiple policy needs and, in the context of food policy, among sub-sectors within food systems. specifically targeting flw will require having detailed measurements of losses and waste by food product in the supply chain where they occur. this is needed to identify critical loss points by type of foods to be targeted and to quantify the costs and benefits of flw reduction to justify targeted resource allocations. for instance, the levels of food loss are generally much higher for fruits and vegetables than for cereals and pulses (fao, ; fabi et al. in this si) . studies on waste at the consumer stage, mostly confined to high-income countries, also indicate that waste levels are particularly high for foods that are highly perishable, such as animal products and fruits and vegetables (lipinski et al., ; fao, ) . another challenge is deciding which actors to target when trying to reduce flw, which can be fairly context specific. for example, minten et al. (in this si) find that, based on primary data from urban food retailers, the emerging modern retail sector in ethiopia on average has only half the level of phl incurred by the traditional retail sector. this could justify targeting interventions towards actors in the traditional retail sector. however, the finding may not be generalizable. chaboud & moustier (in this si), for instance, do not find that losses are lower in modern marketing channels as compared with traditional ones in the case of colombia's tomato value chains. how best to focus flw interventions will depend further on the policy objective. in the case of environmental objectives, cattaneo et al (in this si) distinguish between pressure on natural resources (land and water use) and ghg emissions as the objective, and how this determines whether interventions should focus more on losses or on waste. de gorter et al. (in this si) show empirically that losses occurring in one stage of the supply chain can have cascading effects throughout the food chain. policies should account for such effects when targeting interventions at any particular stage (primary production, distribution, processing, retail, or final consumption). as mentioned, delgado et al. (in this si) account for losses along the supply chain for a range of staple crops in developing countries to find that losses are highest at the farm level and that most product deterioration occurs before harvest. this suggests that interventions at the table how the articles in this si contribute to answering our five policy-relevant questions. economic efficiency distributional issues & food security farm level would be an important entry point, but the authors further point out that the reasons why farmers leave produce on the field or do not invest in better handling practices also depend on factors beyond the farmgate, such as lack of adequate storage capacity and market volatility (e.g., when output prices drop below the cost of hiring labor during harvest and other input costs). taking a global economy-wide perspective, kuiper & cui (in this si) examine the role of loss reduction in different regions and for different commodities, while lopez barrera & hertel (in this si) look at the role of waste reduction in the coming decades. kuiper & cui make the case for targeting interventions by value chain in accordance with the primary objective of flw reduction. they argue that for improving food security, reducing flw in value chains for fruits and vegetables has highest potential, while for reducing ghg emissions larger impacts may be achieved through reducing flw of animal products. lopez barrera & hertel's projections to point to the need to prioritize policy interventions and behavior changes for waste reduction in middle-income countries, where uneaten calories per capita at the household level are expected to grow most rapidly. policymakers will have to decide whether flw reduction is a first-or second-order policy objective. put differently, should interventions specifically target the prevention and reduction of flw or rather achieve this as part of broader interventions making food supply chains sustainable while improving food safety and food security and nutrition? the reduction of flw potentially may simultaneously improve food system efficiency and serve societal goals of food security and environmental sustainability. if flw is caused by a lack of infrastructure (e.g., poor-quality roads) or public services (e.g., an erratic electricity supply), flw can be viewed simply as a sector-or economy-wide efficiency loss. this would provide additional justification for the provision of public goods in the form of better infrastructure and basic services as part of a broader development strategy with flw reduction as a secondorder objective. such interventions would improve the enabling environment, and market actors would be encouraged to invest in flw reduction. minten et al. (in this si) and chaboud & moustier (in this si) provide examples in ethiopia and colombia, respectively, of how wellintegrated rural-urban agri-food value chains are the key to low losses. other market failures resulting in flw also warrant complementary public intervention. for example, poorly functioning credit markets could deprive many farmers of access to finance to pay for the initial cost of adopting loss-reducing production systems. public policies addressing such market failures can be essential for food supply actors to see an economic payoff of investing in flw reduction. this is especially important when the business case for making such investments seems weak to individual stakeholders or when they do not have full information about the options available to them (see, for example, anríquez et al. in this si) . even where the business case for food loss or waste reduction is clear, stakeholders may be unable to implement the necessary actions because of financial constraints. pursuing flw reduction as part of a social objective function requires looking beyond the individual business case. as mentioned, flw reduction may be viewed as instrumental in improving food availability and access for the food insecure (fao, ; brander et al. and kuiper & cui, both in this si). at the same time, reductions of flw may be viewed as a way to lessen pressure on land and water resources, and reduce ghg emissions from agricultural production (cattaneo et al.; kuiper & cui; lopez barrera & hertel in this si). the potential for such societal benefits would guide policymakers in the allocation of public resources for investments in flw reduction. however, few of such social benefit-cost assessments related to flw reduction are available and also difficult to undertake in practice. finally, nutritional and food safety considerations related to flw may form additional reasons for public intervention. regulation for food safety, such as requiring "conservative" labelling of sell-by dates that are very risk-averse, could increase the probability of food waste (see yu & jaenicke in this si for the case of milk). hoffmann et al. (in this si) discuss the challenges informing measures to guarantee food safety based on evidence on qualitative food losses. the authors study the issue by linking proxy indicators for food safety problems in the case of aflatoxin contamination to consumer perceptions about qualitative losses. similarly, min et al. (in this si) provide evidence suggesting that improving dietary knowledge can be critical to behavioral change leading to food waste reduction and lower calorie loss at the household level. lastly, a further critical issue relates to policy coherence. coordination across policy domains will be required to address tradeoffs between objectives, which in turn requires that all policy options are weighed together for their impact to arrive at solutions that promote one objective without unintentionally harming another one. de gorter et al. (in this si) stress thepotential trade-offs between reducing natural resource stress, increasing farm welfare, and improving food security. similarly, cattaneo et al. (in this si) point out that reducing losses may help improve supply-chain efficiency and food security but could induce greater ghg emissions from the food system (e.g., through greater energy use in cold chains as more food reaches the retail stage). kuiper & cui (in this si) note, for example, that reducing food losses leads to an "expansion effect," which could stimulate other economic activities and this rebound effect could induce more, not less, economywide ghg emissions on balance. other tradeoffs can arise if food policies to improve food security and nutrition have the unintended effect of increasing flw. for instance, this could occur when these policies promote dietary diversity through greater production of nutrition-rich but also highly perishable foods, such as fresh dairy products, fruits and vegetables (see the cited example earlier of milk in yu & jaenicke in this si). flw may occur as an unintended consequence of an inefficient and distorted food system. for instance, agricultural subsidies could lower food prices thereby weakening incentives for consumers and producers to avoid loss and waste of food. this may thus limit the effectiveness of more targeted interventions for flw reduction, thus underlining the importance of policy coherence across food policy domains. economic development, independently of market distortions, can have an impact on levels of flw. lopez barrera & hertel (in this si) indicate that the share of food waste tends to increase with higher per capita income, which could be seen as an unintended outcome of a successful development strategy. unintended by-effects can also be positive. another example of such impacts is provided by qi et al. (in this si) who find that with the liberalization of livestock markets and central policies promoting livestock intensification in china, the pressure for greater efficiency also induced lower waste of livestock products at the household level. the choice of measurement concepts can also have unintended consequences. for example, as delgado et al. (in this si) point out, preharvest and harvest losses can be important, but tend to be left out as many measures focus only on post-harvest losses. not considering the losses occurring before and during harvest may thus miss out on an important part of the problem. failing to account for all losses along the supply chain could thus lead to overestimation of the impact of interventions. despite the proliferation of studies on flw over the past decade, policymakers continue to face a dearth of information to guide policymaking, as identified in the five gaps illustrated earlier. the evidence provided in this special issue suggest five major policy challenges to achieving sdg target . of halving food waste and reducing food loss. a. cattaneo, et al. food policy xxx (xxxx) the measurement challenges posed by flw are epitomized by the debate on the definition of what should be considered flw. there is no single best definition. definitions will be guided in part by what motivates the interest in flw. for example, if stakeholders strive for a "circular economy," they will probably only consider the food that is incinerated or ends up in landfills as lost or wasted. if food security is the main focus, all food that is not used for human consumption will be considered as waste, thus also including that used as animal feed. therefore, the policy purpose will influence choices of concepts and units of measurement (flw protocol, , appendix d) . the recently developed food loss index (fli) measures the economic value of food losses, using farmgate prices of commodities (fao, ) . the index provides a common definition and is useful for costbenefit assessments of interventions for flw reduction. alternative measures express flw in terms of calories lost, which would be relevant for interventions focused on improving nutritional outcomes. if the policy focus is on environmental sustainability (e.g., reducing greenhouse gas emissions), it will be important to also measure flw in physical quantities and relate these to the natural resource use and emission intensity of the related production processes. the flw protocol ( ) recognizes this challenge and provides a framework that allows stating the scope of an inventory by choosing the material type being considered (food and/or inedible parts), what destination is considered flw (animal feed, composting, bio-based materials, etc.), and the boundaries of the inventory (food category, lifecycle stage, geography, and organization). this approach brings clarity on the underlying assumptions of an inventory done using the flw protocol. a major challenge for policymakers is that the information provided under this system tends to be fragmented and rarely comparable across inventories. policymakers wanting to monitor progress towards the achievement of sdg . will need a consistent way of making inventories at the national level. while not in conflict with the flw protocol, it does require a transparent set of assumptions and methods to make sure the inventory properly reflects the flw situation nationwide. the food loss index developed by fao ( ) and the food waste index under development by unep are the agreed indicators to monitor sdg target . . progress is being made in this area. however, considerable data challenges in developing these indices remain. for now, much of the new evidence generation will continue having to rely on the ingenuity of researchers as highlighted by the effort of lopez barrera & hertel (in this si) , who develop a new panel database on household food waste at the national level based on the energy balance equation, including adjustments for changes in body weight over time. even so, these efforts cannot replace more detailed commodity-specific food waste estimates needed for more detailed commodity market modelling of global food systems. the growing interest in using blockchain for traceability along food supply chains -intended to manage supply chain risks, prevent or respond to food contamination, disease, or pesticide residues -may become an important tool to address the challenge of measuring food losses in a commodity-specific manner and in real time (see tripoli and schmidhuber, ; antonucci et al., ) . for example, the united nations economic commission for europe is already piloting an online blockchain-supported marketplace for food that would otherwise be lost along the supply chain. weighing the costs and benefits of flw reduction should provide essential policy guidance. decisions of policymakers may be driven predominantly by social benefit-cost ratios, i.e., the current and future societal benefits as compared with a program's expenditure or the cost of implementing a new regulation. private actors (farmers, intermediaries, agro processors, wholesale markets, retailers and consumers) will more likely assess whether their own economic gains of reducing flw exceed the direct and opportunity cost of the related actions. both need to be taken into account. actions to reduce food loss or waste may require the involvement of different actors, according to the type of food loss or waste targeted. a challenge can be that those needing to bear the costs of food loss or waste reduction are not necessarily the ones who enjoy its benefits. indeed, the impact of flw reduction efforts on farmers, processors, distributors, retailers, and consumers depends on how the effect on prices is transmitted throughout the food supply chain (de gorter et al.; cattaneo et al., in this si) . some may benefit, while others may lose out. this is the case of extending sell-by dates whereby less milk is purchased, potentially causing a loss to producers, but more milk is consumed benefiting consumers (yu & jaenicke, in this si) . the environmental dimension of benefits is also difficult to assess. for example, kuiper & cui (in this si) find ghg emissions increase when food losses in animal products are reduced in primary production within a single region, but this increase could be nullified if reductions in primary animal production losses happen concurrently across all regions. the net effect depends on the relative emission intensities of food production in different regions, on trade, and general equilibrium effects outside the food sector. this type of environmental outcome is thus in part beyond the control of national policymakers. the domestic dimension of potential increases in ghg emission when food losses are reduced is confirmed by cattaneo et al. (in this si) . they provide an assessment of the benefit of flw reduction in three environmental dimensions (ghg emission, land use, and water use). they find that reducing food waste always reduces environmental pressures, and that reducing food losses can lead to an increase in ghg emissions from domestic production, negating the environmental grounds for interventions. the authors make the point that the environmental impact is always mediated through prices, making it difficult to measure the actual environmental benefit after economic adjustments to the intervention have taken place. also, for other objectives, such as improvements in food security, it may be difficult to assign a monetary value to the benefits. for example, brander et al. ( in this si) find food security benefits but fall short of doing a cost-benefit analysis, and these nonmonetary assessments may well be the best information that can be made available to policymakers to inform their decisions. using a global partial equilibrium model projecting scenarios through , lopez barrera & hertel (in this si) confirm that reducing food waste can contribute substantially to reducing pressure on land resources as well as improving food security and nutrition in sub-saharan africa. they note, however, that associated benefits depend crucially on whether international markets are integrated or segmented. de gorter et al. (in this si) highlight the potential conflicts between different policy goals, such as a reduction in resource stress, increases in farm welfare, and enhanced food security. the authors show that whether these outcome measures move together depends in large part on the domestic demand elasticity in combination with the prevailing trade regime. in addition, the authors emphasize that it is not clear that cuts in waste at the consumer level are always more beneficial than equivalent cuts at the producer level. the relative effectiveness of cuts, taking into account costs and benefits, will depend on the presence and magnitude of cascading effects, the relative costs of cutting waste rates at the two stages, and the distribution of waste rates along the supply chain. as long as data remain scarce, scattered, of unknown quality or limited representation for specific policy needs, policymakers should a. cattaneo, et al. food policy xxx (xxxx) xxxx spearhead context-specific studies of individual supply chains to inform targeted interventions to reduce flw. however, conducting many such studies will take time and will be costly. this means that in the immediate future, policies to change producer and consumer behavior will need to be identified with limited information. this limits decisionmaking as to how and where to target interventions to reduce flw. part of the solution would be to better integrate value chains for reducing food loss (rather than targeting food loss reduction directly) and putting incentives to induce food waste reduction at retail, food service and consumer ends. fabi et al. (in this si) highlight the large variability in loss estimates and provide a roadmap for measuring food loss and monitoring it over time. however, this is but work in progress and will have to be supplemented by survey data at the country level, which are yet to be collected on a systematic basis. in general, considerable heterogeneity exists in food losses along value chains, suggesting that policies aiming to curb phl in developing countries need to be informed by contextspecific evidence and that solutions should not be generalized. another dimension that policymakers may find challenging is balancing issues of food safety and flw, as exemplified by the results of yu & jaenicke (in this si) on sell-by dates for milk, and hoffmann et al. (in this si) examining the interplay between observability of qualitative losses and food safety concerns for maize. the two papers highlight the difficulty of identifying an optimal level of loss or waste. in the case of milk, the sell-by-date is interpreted by consumers as a spoilage date leading to more waste than would be optimal, and the authors find that extending sell-by-dates results in waste reduction. in the case of maize, the limited observability of aflatoxin contamination can lead to unsafe food being consumed, thereby improving observability of contamination would lead to the removal from the supply chain of the unsafe food and as a result greater food losses will be reported. these two examples show how limited information can lead to flw being above or below what would be optimal level if the missing information were available. finally, the impact of interventions will be often difficult to quantify. one example is provided by cattaneo et al. (in this si) . the authors highlight that environmental impact of reducing flw on water scarcity or land pressure will be difficult to evaluate because of heterogeneity of environmental impacts spatially (horizontal heterogeneity) and supply chains with diversified sourcing (vertical heterogeneity). as min et al. (in this si) show, heterogeneity among stakeholders also plays a role in terms of how dietary knowledge affects waste among consumers. on a positive note, minten et al. (in this si) find that well-integrated rural-urban value chains have lower losses than typically found in the literature, indicating that it may not be necessary to invest in phl reductions in well-integrated rural-urban value chains, allowing policymakers to focus phl reduction efforts elsewhere, thereby easing the information requirements for policy design. when some food suppliers manage to reduce losses, this does not imply that there will be a net flw reduction overall. second-order market interactions (e.g., reduction in food prices) could cause rebound effects pushing flw back up elsewhere in the system. the net effect will depend, among other things, on the degree of price adjustment determined by the price elasticity of supply and demand, and on how price effects are transmitted vertically from one stage of the food supply chain to the next, and horizontally across countries. flw reduction could thus make food cheaper, which in turn could weaken incentives for consumers to avoid food waste, as much as it may increase the demand for food. the interactions between stages along the food value chain are well captured by several papers in this si. as mentioned, de gorter et al. (in this si) disentangle the cascading effects up and down the supply chain and find that interventions to reduce food waste are reinforced at subsequent stages in some cases, while the effects are offset in other cases. this underlines the importance of assessing flw along the entire supply chain. cattaneo et al. (in this si) come to similar conclusions when looking at environmental impacts. the authors find that price transmission along the supply chain plays a key role in determining environmental outcomes of flw reduction strategies, highlighting that market structure will affect how flw reduction strategies perform. using a global partial equilibrium model lopez barrera & hertel (in this si) find that segmented markets limit the impact of food waste reduction on both food security and environmental outcomes. looking at losses along the supply chain, kuiper & cui (in this si) , based on a global computable general equilibrium model, find a modest global response in terms of aggregate primary production. this results from the net effect of an output-augmenting effect of reductions in on-farm losses dominating the contracting effects due to input-saving productivity improvements in processing. furthermore, they find that while reductions in food losses may help reduce global ghg emissions emitted from agriculture, it may be offset by consequent increase in ghg emissions because of increased activity in non-food sectors. this indicates that food loss reductions may have limited impact on ghg emissions if not accompanied by emission reductions in other sectors. although knowledge of waste levels in low-income countries is limited, it is generally considered that losses are proportionately larger in these countries, and that they decrease as per capita income increases. this is in line with the finding of minten et al. ( in this si) that well-integrated rural-urban value chains tend to have lower losses, and as countries develop, rural-urban value chains will become more integrated and the share of losses will decrease. however, it is expected that the levels of waste will tend to increase with income as food expenditures become a smaller share of income. furthermore, as the opportunity cost of time grows with incomes, the effort in waste reduction may decrease as time is put to more "productive" uses. these issues are well captured by lopez barrera & hertel (in this si) showing projections for increase in consumer waste. in , in rich countries the share of food waste is anticipated to level off, so that middle-income countries, particularly china, and lower-income countries in south asia, south east asia, and sub-saharan africa are expected to be largely responsible for global food waste. another aspect linked to rising incomes emerges from the contribution of chaboud & moustier (in this si) . they show that modern marketing channels do not necessarily generate fewer losses than traditional channels. this is because the demand for food by low-income groups, purchased through traditional channels, may reflect greater acceptance of lower quality produce than what more affluent buyers would purchase in modern markets. as incomes increase, this direct demand for low quality produce may disappear and would need to be replaced by a system whereby these products are redirected towards processing. min et al. (in this si) highlight how food waste will continue to increase, with further economic development and urbanization in china in the future. however, improving the nutrition knowledge of food decision makers in china can help reduce food waste overall. they find that beyond a certain level of development, improved dietary knowledge will help reduce both food waste and calorie loss. as such, promoting dietary knowledge of food decision makers is expected to play an important role in reducing food waste and calorie loss. cattaneo et al. (in this si) analyze the extent to which reductions in flw can improve resource use efficiency in light of the increase in demand that will occur in the coming decades. in a forward-looking perspective, they suggest that land and water use efficiency improvements of reducing either food loss or food waste can lessen the impact of an increase in demand. specifically, reducing waste can effectively counterbalance the a. cattaneo, et al. food policy xxx (xxxx) xxxx shift in demand if the food waste avoided is equal to the increase in demand, thereby limiting ghg emissions. counterbalancing demand growth through a corresponding waste reduction can serve as a rule of thumb in countries where food demand is expected to increase. in countries with rising incomes the waste rate is expected to increase, and it will be difficult to reverse the trend. the papers in this si are grounded on two premises: (i) rational actors will undertake efforts towards flw reduction insofar as the benefits of those efforts outweigh the costs for them; and (ii) this notion should be taken into account when designing policies for flw reduction. the implication is that flw policies demand vast knowledge of synergies, trade-offs, and potential unintended consequences. in general, a certain level of food loss or waste is unavoidable, and determining the optimal level of flw may require a considerable amount of information that is not readily available. lack of information can lead to excessive rates of flw, but it can also lead to rates of flw that are too low. an example of the former is when actors underestimate how much food is lost thereby limiting their perception of benefits from reducing it. conversely, the latter can happen if unsafe food is being unknowingly consumed, and society may be better off discarding it, thereby increasing reported losses. limited information also makes it more challenging for policymakers to target interventions where they will be most effective and justified. the case for public intervention can be made on the grounds of improving food security and nutrition, overall efficiency, and reducing the environmental impacts of food systems. the extent of these benefits may guide policymakers in determining how much public money to devote to this objective; however, the quantification and comparison of these effects may prove difficult in practice. in this overview paper, we presented critical policy questions and assessments of available evidence and knowledge gaps to identify five major challenges to policies aiming to reduce flw. these questions and challenges span issues of measurement of flw, of quantifying the benefits and costs, and examining the linkages between different parts of the value chain and trade-offs between food policy objectives. inevitably, policy design will have to grapple with the heterogeneity in the degree of flw along and across value chain and different contexts, as well as differences in interests of actors in the food system. despite the challenges, the papers in this si provide additional guidance on how to improve measurement of losses to better target interventions and the type of interventions that can help reduce flw. on the loss side, this means investing in policies that provide an enabling business environment, such as market access, improving storage options, and integrating rural-urban value chains. governments can also work towards flw reduction by raising suppliers' and consumers' awareness of the benefits (making the business case) of any reduction. they can play an important role by modifying incentives to reduce flw (changing the business case). for example, by issuing regulations that affect the decisions of individual actors regarding flw or providing financial incentives for reduction through taxes, subsidies, or exemptions. in some cases, fine-tuning these policies will require contextspecific information on the value chain to focus on and identifying the point of intervention along the supply chain. however, such detail should not distract from the broader societal objectives of improving food-system efficiency, food security and nutrition, and environmental sustainability. disclaimer: the views expressed in this publication are those of the authors and do not necessarily reflect the views or policies of the food and agriculture organization of the united nations (fao), the consultative group on international agricultural research (cgiar) or the international food policy research institute (ifpri). unpacking postharvest losses in sub-saharan africa: a meta-analysis in search of economically significant food losses: evidence from tunisia and egypt. food policy. available online a review on blockchain applications in the agri-food sector does reducing food losses and wastes in sub-saharan africa make economic sense? waste manage on the measurement of food waste improved on-farm storage reduces seasonal food insecurity of smallholder farmer households 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food and agriculture organization the food loss and waste accounting and reporting standard opening the black box of food waste reduction observability of food safety losses in maize: evidence from kenya. food policy. available online food loss and waste as an economic and policy problem using food loss reduction to reach food security and environmental objectives -a search for promising leverage points bringing it all together: linking measures to secure nations' food supply covid- risks to global food security food policy xxx (xxxx) xxxx reducing food loss and waste food losses and food waste in china: a first estimate. oecd food, agriculture and fisheries papers global food waste across the income spectrum: implications for food prices, production and resource use (this issue). dietary knowledge affect household food waste in the developing economy of china? food policy post-harvest losses in rural-urban value chains: evidence from ethiopia food waste within food supply chains: quantification and potential for change to food waste declined more in rural chinese households with livestock. food policy consumption-stage food waste reduction interventions-what works and how to design better interventions improving postharvest management and marketing in the asia-pacific region: issues and challenges review: food loss and waste in sub-saharan africa without food there can be no exit from the pandemic emerging opportunities for the application of blockchain in the agri-food industry. fao and ictsd: rome and geneva food in the anthropocene: the eat-lancet commission on healthy diets from sustainable food systems the food we waste. banbury, uk. isbn: - - - household food and drink waste in the uk. banbury, uk. isbn: - - - missing food, missing data? a critical review of global food losses and food waste data the effect of sell-by dates on purchase volume and food waste. food policy missing food: the case of post-harvest grain losses in sub-saharan africa food policy xxx (xxxx) xxxx the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. key: cord- -owce xg authors: fitzpatrick, kevin m.; willis, don e. title: homeless and hungry: food insecurity in the land of plenty date: - - journal: food secur doi: . /s - - -x sha: doc_id: cord_uid: owce xg homelessness continues to challenge service providers in the united states where , + individuals are without their own place to stay on any given night. with significant barriers preventing access to food, homeless persons remain at risk for experiencing long-term food insecurity. as such, the primary intent of this paper was to examine specific hypotheses that explored the impact of both risks/stressors and resources on the reported food insecurity among homeless adults. using a stratified quota sample, data were collected from homeless adults residing in two counties in northwest arkansas. one hundred and sixty-eight face-to-face interviews were conducted with homeless persons living in sheltered and unsheltered environments. we found a strong positive association with persons who had been arrested and reported food insecurity; anxiety symptoms and physical health symptoms were both positively related to food insecurity. additionally, there were significant resources (access to medical services, and community connectedness) that were negatively related to food insecurity among homeless adults. findings are discussed in the context of how important it is for service providers to have a clear picture of the health and well-being of their clientele, particularly as they work towards minimizing service disruption and maximizing client access to sustainable food sources. homelessness continues to challenge service providers in the united states (usa) where nearly , individuals are without their own place to stay on any given night (naeh ) . millions more experience homelessness when factoring in the number of families with children that are doublingup with friends and relatives. homelessness presents enormous challenges for both service providers and policymakers working to address basic needs and their overlap with health outcomes. these challenges are exacerbated when considering the difficulty that homeless persons have in acquiring food. with significant barriers preventing access to healthy, socially acceptable food, homeless persons remain at risk for experiencing long-term food insecurity. food insecurity is defined as "access by all people at all time to enough food for an active, healthy life" . we build on previous work which highlighted the differentiated experience of food insecurity among the homeless (lee et al. ) by assessing the role of multiple risks, stressors, and resources. we offer a unique contribution to this limited body of research on food insecurity among the homeless by highlighting the role that interaction with the criminal justice system and medical institutions playing in shaping an outcome critical to public health in the usa. while the primary research on homelessness and food insecurity is limited, there are several studies that offer evidence of the expected relationship between homelessness and food insecurity, and the secondary risks (circumstances, mental and physical health) that often are the consequence of this limited access to food (dachner and tarasuk ; goldrick-rab et al. ; smith and richards ) . homeless persons have a higher risk of food insecurity than the general population (baggett et al. ; gundersen et al. ; lee and greif ) . even among college students, housing insecurity, instability, and homelessness are some of the key predictors of food insecurity (goldrick-rab et al. ) . similar to research that provides evidence that the homeless experience is vastly different across subgroups, locations, and circumstances (fitzpatrick and lagory ; fitzpatrick and lagory ; lee et al. ) , there is a limited body of work that has demonstrated homeless persons do not experience hunger and food insecurity uniformly. food insecurity among the homeless is often differentiated by psychosocial coping resources such as mental health or social ties (lee and greif ; parpouchi et al. ) . similar to the general population, food insecurity varies across social circumstances as well as sociodemographic subgroup membership. building on previous research demonstrating practices which criminalize poverty, homelessness, and providing food to homeless persons (dum et al. ; gonzalez ; herring ; herring et al. ) , we expected experiences of arrest to be a salient predictor in determining food insecurity among the homeless. that finding would complement brayne's ( ) research on "surveillance and systems avoidance" which demonstrated that individuals who have been arrested are less likely to interact with medical, financial, labor market, and educational institutions, which can be critical sources for alleviating food insecurity. questions remain with understanding the link between health and food insecurity among homeless persons. thus, the present study sought to better understand the mechanisms that link health indicators such as mental and physical health symptomatology to levels of food insecurity among members of a homeless population. we examined these mechanisms among a homeless population found in two counties within the northwest region of arkansas state, guided by a stress-process framework. the stress process literature explains health disparities by highlighting unequal exposure to stressors, as well as the varying role that coping resources play to deal with that stress (aneshensel ; pearlin et al. ; thoits ) . lee and grief ( ) used an adaptation framework informed by the stress-process model to make sense of their findings on homelessness and hunger using data from the national survey of homeless assistance providers and clients (nshapc) project. in doing so, they confirmed that exposure to the stressor of homelessness was further differentiated by both the exposure to additional stressors (e.g., alcohol, drugs, and mental health issues), as well as social and economic resources (e.g., social ties and employment). these findings complement thoits' ( ) theoretical position that resources related to whether or not someone was able to exercise agency were both unequally distributed according to social status and highly consequential when it comes to one's ability to buffer negative stressors such as homelessness. our intent was to extend both the empirical and theoretical elements of this literature. we examined the role of circumstances/stressors that may inhibit one's ability to exercise the agency needed to acquire basic needs (e.g. food), as well as access personal and community resources such as mastery of fate, community connectedness, and medical services, that can enable individuals exercise of agency. the stress-process model helps explicate health disparities first by directing our attention to the unequal exposure of stressors across various experiences. building on this theory, thoits ( ) argues that attention must also be paid to the role of personal coping resources related to one's physical and mental health. these may be stressors in and of themselves, and may offer some indication of how much agency one can exercise in the face of other external stressors. because food is a source of the energy and nutrition necessary to reproduce and replenish the body, food insecurity has a clear and direct impact on health; however, chronic physical and mental health are also strong predictors of who will experience food insecurity (bhargava et al. ; choi et al. ; hanson and olson ) . symptoms of poor physical health or impairment can constrain one's ability to exercise agency, particularly in built environments where there is little consideration for physical impairment or other symptoms of poor physical health. furthermore, chronic health conditions often bring with them significant medical costs and debt that place an additional strain on household food budgets. while food insecurity is itself a source of stress that can lead to negative mental health outcomes, mental health (e.g. anxiety) may also shape one's entry into, duration, or severity of food insecurity. as seligman and schillinger ( ) have demonstrated, the relationship between food insecurity and health is a reciprocal one. the stressor model consistently alludes to the important role that life events can play in determining a host of negative health-related outcomes (lin and ensel ; thoits ) . work in the general and homeless population literatures finds that these external, negative experiences can be significant correlates of poor health outcomes (fitzpatrick and lagory ; thoits ) . somewhat related to the negative life experience of being arrested and having to interact with criminal justice is the circumstantial experience of living on the street unsheltered, and just how different than can be compared to persons living in some type of emergency, transitional, or permanent supportive housing. the ongoing crisis of being without shelter is consuming and can impact a person's ability to acquire food. when individuals are consumed with locating a safe and secure place to sleep every night, food or healthy food may take a backseat to the immediate importance of securing shelter. given this literature regarding the role that stressors play in determining levels of food insecurity, we propose the following: h : stressors will be associated with higher odds of food insecurity. in addition to stressors, the stress-process model emphasizes the possibility of individuals utilizing both personal and community level resources to buffer against hardships such as homelessness. the ability to leverage personal and community resources is likely to be a key factor when it comes to differentiating the experiences/severity of food insecurity among homeless persons. several of these resources are outlined below. access to medical services also plays a critical role in the cyclical relationship between food insecurity and health, as illustrated by seligman and schillinger ( ) . not only does access to medical care potentially prevent further health complications that often lead to or exacerbate food insecurity (bhargava et al. ; choi et al. ; hanson and olson ) , the costs of care-and the strain on one's budget-may also increase the longer one goes without medical access and/ or treatment. community connectedness has been defined as a "feeling that members have of belonging, a feeling that members matter to one another and to the group, and a shared faith that members' needs will be met through their commitment to be together" (mcmillan and chavis , p. ) . in other words, it is both a psychological and material resource-a link between belonging and a sense that one's needs can and will be met. another important psychosocial resource is mastery of fate. mastery of fate refers to "the extent to which people see themselves as being in control of the forces that importantly affect their lives" (pearlin et al. , p. ) . it is an important "element of self" which can be a coping resource (thoits ) , but can also be diminished in the face of stressful life events (pearlin et al. ) . past research has linked mastery of fate to quality of life among the homeless (o'connor and fitzpatrick ). given this literature regarding the role that personal and community resources play in determining levels of food insecurity, we propose the following: h : personal and community resources will be associated with lower odds of food insecurity. the data for this study came from a survey of homeless persons (n = ) in a mid-sized suburban/rural area in northwest arkansas. a january point-in-time (pit) census of sheltered and unsheltered homeless persons living in both washington and benton counties, arkansas, represented the population base from which the primary sample parameters for the current study were derived (fitzpatrick et al. ) . the pit has a number of limitations and was only used to identify population estimates from which the final sample was constructed. the pit and subsequent survey interviews collected data across service provider locations including unsheltered sites. some of the service locations were food pantries and places where homeless persons typically access food on a daily basis, including day centers, community meals, and shelters. five hundred and twelve homeless adults were interviewed in the pit, which represented the visible homeless population count on a single night in january for the two-county area. using this population as our framework to construct the sample, we stratified the sample by county, by city, where respondents spent their last night, gender, and race. individual sample quotas were derived based on the population estimates from the pit and all sampling quotas were met within ± % range. finally, respondents were randomly selected at all interview locations, either through a random number selection that used client lists, or random selection of respondents using a four-square method of selection from open spaces at interview locations like day centers, soup kitchens, food pantries, and other non-sheltered environments. respondents were selected to participate in the survey based on meeting the above criteria for inclusion in the study. once selected, respondents were offered a us$ incentive for completing the survey. each respondent was reminded of the confidential nature of the data collection and asked to sign a consent form agreeing to participate; the primary investigator's university irb approved the protocol. a -min interview was completed by adults living in washington and benton counties in northwest arkansas; fewer than persons refused to participate in the survey and the response rate exceeded %. we measured food insecurity using the standard, -item, usda (united states department of agriculture) adult food security module (usda ). the -item measure was selected due to time constraints and the desire to use those questions that most appropriately captured the circumstances for homeless respondents. we began our module with the following prompt: "thinking about your experience with food over the past year." they were then provided statements to which they could respond with "often true," "sometimes true," "never true," or "don't know or refused." they responded to the following statements: ) i worried whether my food would run out before i got money to buy more; ) the food that i bought just didn't last and i didn't have money to get more; ) i couldn't afford to eat balanced meals. the remaining questions could be responded to with "yes," "no," or "don't know"-questions about how often the experience occurred were answered with "almost every month," "some months but not every month," or "only or months." these questions included the following: ) in the last months, did you ever cut the size of your meals because there wasn't enough money for food?; ) how often did this happen?; ) in the last months, did you ever eat less than you felt you should because there wasn't enough money for food?; ) in the last months, were you ever hungry but didn't eat because there wasn't enough money for food?; ) in the last months, did you lose weight because there wasn't enough money for food?: ) in the last months, did you ever skip meals because there wasn't enough money for food?; ) how often did this happen? all affirmative responses, including "some months" or "almost every month" were coded as . respondents who answered in the affirmative to or more items were considered food insecure, while those who answered in the affirmative to or fewer items were considered food secure (coleman-jensen et al. ). circumstantial risk because the homeless population is generally a diverse one, and that diversity is reflected in the current sample, we elected to control for several risk variables. we were unable to find any comprehensive treatment of these variables in the food insecurity and homelessness literature. nevertheless, we anticipated differences among certain subgroups given the extant literature on sociodemographic variation among homeless persons (fitzpatrick ; irwin et al. ; o'connor and fitzpatrick ) . as such, we included both housing ( = unsheltered); arrest ( = yes) in the current analysis. there are several stressors that we anticipated as being related to food insecurity among an adult homeless population. we outline, in detail, three specific factors that we believe are important and would be positively related to food insecurity. physical health symptoms physical symptoms are measured using a standard collection of physical ailments typically reported by persons experiencing both acute and chronic illness. respondents were asked if they experienced any of the health symptoms in the last month prior to the interview. health symptoms included frequent headaches, sore throat/repeated cough, dizziness, shortness of breath/difficulty breathing, coughing up blood, frequent backaches, stomach problems, broken bones, and skin problems. respondents answered yes = or no = and the items were summed into a symptoms scale that was reliable with a cronbach's α = . . fewer than % of those respondents who were asked these questions said they were currently experiencing no physical health symptoms. anxiety symptoms anxiety is measured using symptoms from the brief symptoms inventory (bsi) subscale for anxiety (derogatis and spencer ) . there were considerable time limits placed on us during the interview and thus we only measured the presence of symptoms (not intensity). the symptom index was comprised of the following symptoms associated with high levels of manifest anxiety, including panic attacks, terror, tension, and apprehension. each question had dichotomous responses and the scale was the summation of these responses. scores range from to and typically scores less than are considered mild; scores of and above are moderate and noteworthy. of the different anxiety symptoms that were assessed, % reported four or more symptoms in the past month. the scale was reliable with a cronbach's α = . . weight status weight status was determined using the centers for disease control (cdc) charts that provide estimates based on gender and age (centers for disease control ). respondents were classified based on these national standards: ) underweight (bmi < th percentile); ) normal (bmi th to th percentile); ) overweight (bmi th to th percentile); and ) obese (bmi > th percentile). respondents who were underweight were removed from this particular analysis and we combined overweight and obese ( %) into a single category (value = ) and normal bmi ( %) in a second category (value = ). the number of persons in our sample who were actually underweight was small (< ). their impact on this analysis was examined and determined to not influence any of the results. thus it was much easier to simply remove them from the analysis and maintain the integrity of the dichotomous dependent variable. there are a number of resources (social and psychological) that we hypothesized as being related to food insecurity among an adult homeless population. we outline, in detail three specific resources that we expected to be negatively related to food insecurity. community connectedness we measured connectedness using the inclusion of community in self (ics) scale, which is a single-item picture measure that consists of six pairs of overlapping circles. this measure, as an extension and variation of the inclusion of others in self scale (ios) (aron et al. ) , and a psychological sense of community (psoc) (mcmillan and chavis ), seemed particularly apropos in the present context for studying homeless persons and their degree of connectedness to community. figure provides the graphic that respondents were asked to characterize where they saw themselves in terms of personal connection to their community. in fig. , the circles are of equal size and begin with two circles that are not touching one another and move left to right in varying degrees of closeness between the circles. the final set of circles are fully integrated with one circle essentially being inside of the other circle. one circle represents the "self" and the other circle "community." participants were asked to look at the venn diagrams and respond with a number associated with a particular circle set that best described their relationship to the community at large. with little or no additional explanation provided by interviewers, the majority of respondents had little difficulty responding to the purposely vague construct of "community at large." if additional explanation was needed, interviewers offered guidance by telling them that they were to think about the community as "all those persons, places, and things that made up the larger community¨. no specific group or subgroup was used as a referent and interviewers reported very few problems with obtaining what they believed to be reliable responses. mastery of fate another resource variable (psychological), was assessed using a -item likert scale that asked respondents about their ability to control their environment. we used a scale developed by pearlin and schooler ( ) where higher scores indicate greater mastery and locus of control. scores are from to with responses ranging from (strongly disagree) to (strongly agree). for the current sample, the scale is reliable with a cronbach's α = . . access to medical services respondents were asked a number of questions related directly to their access or lack thereof to medical services. for this particular indicator we selected three specific dichotomies and each of the variables had responses that were coded as yes = and no = . respondents were asked: ) if in the last year were they able to see a medical professional?; ) specifically, did they see a dentist in the last year?; and ) were they able to receive treatment for some medical condition?. descriptives are presented to help the reader orient to the sample characteristics that we report. the primary focus of the analysis was to examine the relationships of circumstantial risk, stressors, and resources with food insecurity using hierarchical logistic regression. we entered each of these sets of variables into the regression models as blocks to demonstrate both main effects and their collective influence on food insecurity. while a typical study of food insecurity might also include a set of sociodemographic controls, our early analyses found that factors like race, ethnicity, and sex, were not differentiating the odds of being food insecure among the homeless; thus, our analytic strategy focused on circumstantial risks, stressors, and resources. the logistic analysis presented in table , shows individual odds ratios (or) when larger than one, suggests an increased odds in food insecurity and when odds ratios are less than one, a decreased odds in food insecurity. additionally, % confidence intervals (ci) are presented to assess the statistical significance of individual variables, and also the "strength" of that significance given the range of confidence interval reported. finally, a descriptive summary measure that assesses the strength of each model (nagelkerke r ) is also presented. three successive models were assessed with each one reflecting the addition of a set of variables that we were able to assess. the cumulative explained variation that is reached in model reflects the strength of the model when all the variables were included in the equation. in table we present descriptive data on the variables used in the analysis of homeless adults in northwest arkansas. the sample of homeless adults was predominantly male, over , and white, with a high school education. on average, homeless adults answered in the affirmative to nearly six ( . ) out of the ten food insecurity questions. not a single person in this sample scored a zero on the food insecurity scale-the score necessary to be considered completely food secure-and % scored three or higher-the threshold fig. inclusion of community in the self scale typically used to identify someone as categorically food insecure. this is a much higher prevalence of food insecurity than the % who are considered to be food insecure in the overall us population (coleman-jensen et al. ). the average anxiety symptom score was high relative to the general population. homeless respondents on average reported at least six physical health symptoms, and had relatively low mastery of fate scores. two-thirds of the sample of respondents was either overweight or obese, which is very close to the % who are estimated to be overweight or obese in the general us population (cdc ). community connection scores were slightly lower than average. table provides the results for the models with the food insecurity dichotomy regressed on circumstantial risks, stressors, and resources in four separate models with each group added in a hierarchical fashion. the consistent circumstance variable of being arrested was significant (p < . ) in all three models. homeless respondents that had experienced arrest were . to nearly times more likely to report food insecurity compared to those homeless respondents that had not experienced arrest. while the experience of being unsheltered was not significant, we interpret that result with some caution. the number of unsheltered respondents in the sample was low, which may be related to the lack of statistical significance. additionally, all of the stressor variables were positively related to food insecurity as originally hypothesized. higher levels of anxiety symptomatology and physical health symptoms were the two stressor variables that were statistically significant (p < . ). anxiety symptoms increased the odds of food insecurity by nearly %, while physical health symptoms increased the odds by %. the model that included the circumstantial risk and the stressors variables was significant with nagelkerke = . . these stressors compound already desperate circumstances for many homeless adults and clearly impact their access to food, and/or their consistent access to healthy foods. in addition to these negative stressors, we added a set of important resources that we expected to be negatively related to food insecurity among this homeless population. medical access and community connectedness were statistically significant and in the expected (negative) direction. community connectedness lowered the odds of food insecurity among the homeless by almost %, and medical access lowered the odds by approximately %. the psychological resource, mastery, was not significant and the final model as a whole was significant with a nagelkerke = . . extant research has demonstrated that homelessness is not experienced uniformly across all population subgroups and circumstances (o'connor and fitzpatrick ) , and that food insecurity among the homeless is differentiated further by the resources available to them and the additional risks they face (lee and greif ; parpouchi et al. ) . the present study sought to examine the differentiated experience of homelessness and further explore some of the mechanisms which might help explain why some homeless persons' experience food insecurity while others do not, and why some homeless persons experience food insecurity with more severity than others. our findings highlight how the interactions of homeless persons with two key institutions-the criminal justice system and medical institutions-play a significant role in shaping their likelihood to experience food insecurity in arkansas. specifically, arrests nearly tripled the odds of food insecurity for the homeless in this study, while medical access reduced the likelihood of food insecurity by more than %. these findings also raise additional questions for new lines of research regarding exactly how those institutions heighten or reduce the chances of food insecurity among the homeless. we suggest that future studies explore further the possibility of what brayne ( ) has termed "surveillance and systems avoidance," in which individuals who have been arrested tend to avoid a whole host of institutions (e.g., financial, medical) which might be critical to reducing their odds of food insecurity. our findings underscore the importance of the health-food relationship impacting america's most vulnerable. this population is often receiving temporary food relief from pantries that typically are not providing access to healthy foods, but snacks, desert items, and other items that are highly processed, high in sugar content, and provide little nutritional substance. again, food insecurity and the risk for negative health outcomes related to this insecurity is typically not as much about a lack of food, as it is about the limited access to healthy foods and socially acceptable ways of accessing food. the findings reported here are consistent with earlier work that reports high risk for food insecurity among the homeless population generally, and the chronic, unsheltered homeless population more specifically (baggett et al. ; kushel et al. ) . in addition, the link between health risks and food insecurity that is reported elsewhere is, in part, confirmed here; yet, this subject still requires a more comprehensive examination of the intersection of food access, nutrition, and negative health outcomes among high-risk homeless adults. despite the present study's findings that highlight the importance of health-related stressors, social and psychological resources for both the food insecurity literature generally, and the homeless literature specifically, we note some important limitations. first, the research was limited by the exclusive use of self-report measures, which could be confounded by a common method variance, and self-report bias that could be improved with multiple methods of reporting, thus improving the validity of findings. furthermore, some measures such as medical access may represent more than barriers to medical care, but could also indicate personal prioritization given that the questions asked only whether they saw certain medical professionals or received care for something. additionally, this was a -min and sometimes even longer interview. we acknowledge the potential for interviewee/interviewer fatigue, which may have implications for some of the responses that were coded and used in the current analysis. second, the data used here are cross-sectional and while we can establish the nature of the relationships between sets of independent and dependent variables, these findings do not lend themselves to causal conclusions. longitudinal data would vastly improve our ability to make these causal connections, but nevertheless this particular subgroup of underserved are extremely transient and would represent a major challenge to follow over an extended period of time. we also recognize the bi-directionality of some of these relationships as well as the counter/alternative arguments that are made for why a particular variable may or may not be important to our analysis. third, the use of single measures for many of the variables used in the analysis is a further limitation. future research could include both a wider range of variables and a series of more complex models to further explicate the interrelationships between health stressors, resources and food insecurity among homeless persons. finally, we recognize that these findings are placed in the context of a single sample of homeless adults living in a particular region of the south-central part of the united states. nevertheless, this sample was not a convenience sample: the sampling design followed strict protocols that guaranteed randomness and representativeness. as highlighted earlier in the paper, all the quotas important to sampling design were met, ensuring generalizability to the larger homeless population of this region. while these are significant limitations, they are balanced out by several strengths of this research design and the substantive contribution of the findings. this study adds to a limited body of research regarding food insecurity among . * . ** . *** p < . *; p < . **; or = odds ratios; ci = confidence intervals the homeless, and provides new insight into why some homeless struggle even more severely than others in terms of access to basic needs. while our data collection took place five years ago, much of our work, these findings, and its relevance to food insecurity being unevenly distributed across socially vulnerable subgroups remain relevant. additionally, the recent novel coronavirus (covid- ) pandemic has alerted us to the fragility of our food distribution system both in the united states and world-wide, with stark reminders that those persons who were experiencing food insecurity prior to the pandemic, are potentially at greater risk not only for greater food insecurity but negative physical and mental health consequences too (béné ; fitzpatrick et al. a and b; tsai and wilson ) . this pandemic has amplified the problem of food access, food safety, food distribution, and the importance in identifying weaknesses in our local food systems. clearly, new and innovative strategies will be required to address these weaknesses as we face future shocks to our food systems as a result of both natural disasters and public health crises (barker and russell ; devereux et al. ; fitzpatrick et al. a, b) . this study utilized a stress-process framework to investigate factors that distinguish the experience of food insecurity among homeless adults. our findings support three primary conclusions. first, health stressors are associated with higher levels of food insecurity. both physical and mental health symptoms were significantly associated with higher levels of food insecurity. these findings are consistent with the model developed by seligman and schillinger ( ) which posits a reciprocal relationship with health and food insecurity, wherein they both influence each other, as well as several empirical studies which demonstrate similar findings (choi et al. ) . the implication here is that, just as addressing food insecurity impacts health care systems by alleviating the long list of negative health outcomes it is associated with, health care policy must play a significant role in addressing issues of food insecurity. second, resources are associated with lower levels of food insecurity. community connectedness and access to medical services were associated with lower levels of food insecurity. this is consistent with previous work showing both social and economic resources to be significant predictors of food insecurity (bhargava et al. ; fitzpatrick et al. b; heflin et al. ; willis ; willis and fitzpatrick ). thus, we find support for both the h and h series of hypotheses. lastly, these findings highlight the role of two major social and institutional forces in shaping the experience of homelessness. the two variables that influenced the odds of food insecurity the most were arrests and medical access-arrests increasing odds nearly threefold, and medical access lowering them by almost %. based on these results, we conclude that the criminal justice and health care systems in the usa play important roles in shaping everyday access to healthy food among homeless persons. moreover, these two systems highlight drastically diverging methods of addressing homelessness-one being a punitive or criminalizing approach, the other an approach with care-and this divergence is indicated in part by their opposite impacts on food insecurity among this population. while this study is not the first to link the experiences of homelessness to these two diverging systems, the degree to which an arrest or access to medical care can shape the odds of homeless persons meeting their basic human need for food is a unique and striking contribution. these findings demonstrate what the criminalization of homelessness can mean for food insecurity, as well as the potential for reducing the risk of food insecurity among homeless persons through targeted policies that can expand their access to medical care. tsai, j., & wilson, m. ( ) . covid- : a potential public health problem for homeless populations. the lancet public health, ( ), e -e . usda. ( ). usda ers -survey tools. https://www.ers.usda.gov/ topics/food-nutrition-assistance/food-security-in-the-us/surveytools/#adult. accessed october . willis, d. e. ( ). feeding the student body: unequal food insecurity among college students. american journal of health education, ( ), - . willis, d. e., & fitzpatrick, k. m. ( ) . food insecurity and social capital among middle school students. youth and society, ( ), - . kevin m. fitzpatrick , phd, is a community sociologist with years of experience as a researcher, consultant, and advocate. kevin is a university professor in the department of sociology and criminology at the university of arkansas. his work primarily focuses on health and the intersection of place as it impacts disadvantaged populations, homeless persons, persons facing the aftermath of a natural disaster, and low-income minority adolescents. food insecurity has been an ongoing part of his work that is looking at the outcomes of disadvantage, limited access, and a continued lack of affordability to healthy foods in low-income settings. professor of sociology and poverty studies coordinator at the university of arkansas at little rock. his research examines the intersections of poverty, inequality, health, and food. consistent throughout his work is a critical eye towards the social patterning of life chances. social stress: theory and research inclusion of other in the self scale and the structure of interpersonal closeness food insufficiency and health services utilization in a national sample of homeless adults feeding the food insecure in britain: learning from the covid- crisis resilience of local food systems and links to food security -a review of some important concepts in the context of covid- and other shocks socio-economic, behavioural and environmental factors predicted body weights and household food insecurity scores in the early childhood longitudinal study-kindergarten surveillance and system avoidance: criminal justice contact and institutional attachment about adult bmi | healthy weight | cdc very low food security in us households is predicted by complex patterns of health, economics, and service participation household food security in the united states in (no. err- ). u.s. department of agriculture household food security in the homeless "squeegee kids": food insecurity and daily survival administration, scoring and procedures: bsi-manual-i. department of psychiatry and behavioral sciences conceptualising covid- 's impacts on household food security punishing benevolence: the criminalization of homeless feeding as an act of state harm understanding community connectedness among homeless adults placing" health in an urban sociology: cities as mosaics of risk and protection unhealthy cities: poverty, race, and place in america a comprehensive examination of homelessness in washington and benton counties assessing u.s. food insecurity in the united states during covid- pandemic food insecurity in a time of fear and panic: assessing risks and protections among a national sample of adults during the covid- pandemic hungry to learn: addressing food & housing insecurity among undergraduates still hungry and homeless in college hunger, poverty, and the criminalization of food sharing in the new gilded age homelessness and food insecurity chronic health conditions and depressive symptoms strongly predict persistent food insecurity among rural low-income families food insufficiency and women's mental health: findings from a -year panel of welfare recipients complaint-oriented policing: regulating homelessness in public space pervasive penality: how the criminalization of poverty perpetuates homelessness social assets and mental distress among the homeless: exploring the roles of social support and other forms of social capital on depression revolving doors: imprisonment among the homeless and marginally housed population homelessness and hunger the new homelessness revisited life stress and health: stressors and resources sense of community: a definition and theory state of homelessness. national association to end homelessness do place and time make a difference? examining quality of life among homeless persons in northwest arkansas and birmingham food insecurity among homeless adults with mental illness the structure of coping the stress process hunger and socioeconomic disparities in chronic disease dietary intake, overweight status, and perceptions of food insecurity among homeless minnesotan youth on merging identity theory and stress research personal agency in the stress process acknowledgements the wal-mart foundation funded this research. kf collected the data, conceptualized the study and current manuscript, outlined the analysis, and wrote extensive sections of the paper and its revisions. dw helped with the conceptualization and food insecurity focus, helped with the analysis and the writing up of results and construction of tables, as well as wrote significant sections of the paper and its revisions. we would like to thank the anonymous reviewers and editorial team for their suggested improvements of the manuscript. finally, our heartfelt thanks to all of the interviewees that took the time to respond to us despite their precarious and uncertain circumstances that they were facing on a daily basis.availability of data upon request. conflict of interest the authors declared that they have no conflict of interest.code availability upon request. key: cord- -dhkz co authors: chamorro, melina fernanda; ladio, ana title: native and exotic plants with edible fleshy fruits utilized in patagonia and their role as sources of local functional foods date: - - journal: bmc complement med ther doi: . /s - - - sha: doc_id: cord_uid: dhkz co background: traditionally part of the human diet, plants with edible fleshy fruits (peff) contain bioactive components that may exert physiological effects beyond nutrition, promoting human health and well-being. focusing on their food-medicine functionality, different ways of using peff were studied in a cross-sectional way using two approaches: a bibliographical survey and an ethnobotanical case study in a rural community of patagonia, argentina. methods: a total of studies were selected for the bibliographical review. the case study was carried out with % of the families inhabiting the rural community of cuyín manzano, using free listing, interviews, and participant observation. in both cases we analyzed species richness and use patterns through the edible consensus and functional consensus indices. local foods, ailments, medicines and drug plants were also registered. results: the review identified peff, the majority of which ( %) were native species, some with the highest use consensus. peff were used in different local foods, but mainly as fresh fruit. of the total, % were used in a functional way, in different medicines. the principal functional native species identified in the review were aristotelia chilensis and berberis microphylla. in the case study peff were in current use ( % were native), and consensus values were similar for native and exotic species. these were used in different local foods, mainly as fresh fruit. only % were recognized for their functional value by inhabitants (mainly as gastrointestinal and respiratory treatments). the species with the highest functional consensus were the exotic sambucus nigra and rosa rubiginosa, followed by the native a. chilensis, ribes magellanicum and b. microphylla. infusions also constituted important local functional foods. conclusions: this survey highlights the importance of studying the different local functional foods to depict the biocultural diversity of a human society. the preparation of different beverages and herbal medicines was relevant, and would be a promising subject to investigate in the future. the living heritage of peff appears to have undergone hybridization processes, such that exotic species play an increasingly significant role. a poor diet, with little consumption of fruit and vegetables, among other characteristics, is known to be strongly associated with mortality through noncommunicable diseases (such as cardiovascular diseases and cancer) [ ] . extra-nutritional substances present in plants have the capacity to reduce cellular oxidative stress, thus lessening the probability of developing these illnesses [ ] [ ] [ ] . the current challenge is to generate policies centered not just on nutrients, but on healthy foods [ ] . species with edible fruits deserve special attention not only for their value per se, but also as local foods. the importance in this study of the variety of ways of ingesting plant-based foods is highlighted by heinrich et al. [ ] . they developed the concept of "local foods" through the study of the mediterranean diet, distinguishing those recipes that are shared in a territory or culture, and which form a fundamental part of local food knowledge [ ] . this represents an interesting field of study in the subject of functional foods, a concept that originated in japan in the s as foods for specified health use (foshu). at the present time, "functional food science in europe" (fufose) proposes that functional food is that which is "satisfactorily demonstrated to affect beneficially one or more target functions in the body, beyond adequate nutritional effects, in a way that is relevant to either an improved state of health and wellbeing and/or reduction of risk of disease" [ ] . from an ethnobotanical perspective, other concepts arise such as "folk functional foods" [ ] , or what we will call here "local functional foods", based on the multifunctional character of food use by local inhabitants [ ] . the study of plant-based local functional foods currently offers an opportunity for ethnopharmacological research, as a wide range of biocompounds is revealed, which is made available to humans in the different recipes used, capable of transforming human gastronomic habits. the study of native and exotic edible plant use in rural and indigenous communities offers an opportunity to appreciate how humans have experimented with the diversity of their plant surroundings in search of wellbeing. as established by etkin and ross [ ] , plant studies in these communities should be approached with understanding of the integral nature of food and health concepts. in their search for this functionality, humans have intentionally selected dual-purpose resources (ediblemedicinal) and have also tended towards diversification of food types and new forms of consumption. consequently, we are interested in showing the multidimensionality and multifunctionality of the peff, considering all their plant parts in an integral way. the study of the potential of patagonian native fruit species is relatively recent. progress has been made from the perspectives of agronomy [ , ] , phytochemistry [ ] [ ] [ ] and nutrition [ , ] . several studies have demonstrated the antioxidant properties of some patagonian fruits and their usefulness in regulating glucose metabolism, thus indicating their nutraceutical value [ ] [ ] [ ] . nevertheless, the diversity of existing species and their local foods has been little described up to now [ ] . one aspect highlighted in the ethnobotanical studies carried out in patagonia is the high proportion of exotic edible plant use in some local communities [ ] [ ] [ ] . for example, in rural areas, the gathering of edible plants seems to be linked to environmental changes, with the incorporation of more exotic fruit-bearing species that grow wild, including invasive plants like sweet briar, elmleaf blackberry and apple (rosa rubiginosa l., rubus ulmifolius schott, malus domestica borkh) [ ] . due to processes of colonization and imposition, since the arrival of europeans the region has tended towards the cultivation of exotic fruits [ ] . in market gardens and fruit farms % of the fruit grown is exotic in origin, such as plums and apples [ ] . this pattern, called the hybridization process [ ] , is prevalent and of great interest when considering local foods. in this study we focus on native and exotic plants with edible fleshy fruits (peff) that grow in patagonia; that is, species that may be wild, cultivated or in an intermediate state of domestication, which bear fruit that is distinguished by its flavor, preferably sweet, and its use principally as a food resource. in general, they have a high proportion of water and sugars that are easily digested and absorbed, and they have long contributed fiber, minerals and vitamins to the diet of local populations [ ] . very little information is available concerning the total number of species involved in this group and how people have used them. in addition, far fewer studies exist that deal with the safety aspect of consumption of peff and their different preparations. understanding the use patterns of peff as part of the local biocultural heritage of patagonia is crucial [ ] . in recent times, as in the rest of the world, rural and urban societies of this region have experienced sociocultural and environmental changes. these changes have led to a reduction in traditional plant use [ ] , and some elements of the flora seem to be in danger [ ] . these alterations will have serious long-term repercussions for peff use, as motivation for the generational transmission processes (oral traditions) is weakened, and consequently, the patrimony for future generations is reduced. in this study we propose a cross-sectional approach which enables exotic and native species richness, local foods, medicines and their use patterns to be evaluated, and which will also help us understand in greater depth, from an ethnobotanical perspective, that diet and health are linked concepts. we will carry out a bibliographical review and a case study of a current rural community in order to synthesize existing information on the functionality of native and exotic peff, and analyze their use patterns and potential. our main questions were: which native and exotic plants from patagonia constitute peff? which species are currently in use? what proportion is used as functional food? how many local foods are involved? this analysis of mixed information also enables us to show the continuity or change in use of functional and nonfunctional peff, shedding light on the existing biological and cultural diversity, and its potential. the bibliographical review involved quali-quantitative analysis of ethnohistorical and ethnobotanical texts published since which mention the use of native and exotic fruits in the patagonian region [ ] . the review was conducted using scopus, science direct and scielo, and google scholar search engine, as well as the library and database of the grupo de etnobiología. the key words and phrases used in the search were: native and exotic edible fruits and patagonia; edible plants and patagonia; medicinal plants and patagonia; patagonian flora and uses; ethnobotany of patagonia; medicinal and alimentary uses and patagonia, and native fruits of patagonia. the search was carried out in spanish and english, and a total of documents were examined. the works selected were mainly primary field studies, but compilations were also included given that each review used independent protocols for species evaluation, according to the author of the work. location of database publications: the articles selected were from studies carried out in argentine rural and urban communities with non-indigenous people, creoles, and people of mapuche-tehuelche-selk'nam ancestry, distributed over an area extending approximately between o and o lat. s. of the articles studied, % dealt with organized indigenous communities, while the remainder were rural and/or urban communities which were pluricultural in character. the phytogeographical heterogeneity of the bibliographical approach led to the inclusion of a high diversity of plants, life forms and botanical families that were used by the majority of the indigenous populations in the region [ , ] . fieldwork location: the fieldwork was carried out in the rural community of cuyín manzano, which is located in nahuel huapi national park, ( ° s and ° w), km from bariloche city. this location lies within the andino norpatagonica biosphere reserve (unesco). the climate in the region is temperate-cold and humid, with a mediterranean precipitation regime, such that rain and snow fall principally in winter (mat . °c). the rural community is located in an ecotonal environment between steppe and forests of austrocedrus chilensis and nothofagus spp. the population is of mestizo origin; some individuals are direct descendants of the mapuche people, while others have mixed ancestry, known locally as criollos (creoles). at present only families live here, due to strong processes of emigration. the economic activity of inhabitants has become more varied with time; they work with livestock, tourism, handicrafts and also as employees in the state school hostel and a private ranch. this community has a longstanding history of settlement in the area, according to archeological records [ ] . our previous studies in this location [ ] [ ] [ ] have shown that this population is very representative of a typical patagonian rural community. considering its low population density at present, the native and mixed ancestry of the people, its immigration and migration process, its contact with the city and the maintenance of its traditions, cuyin manzano reflects shared sociocultural patterns with other rural settlements. in addition, the fieldwork was greatly facilitated due to the close ties of trust we have built up with the people over several years. the information obtained from each source was systematized in a database according to the following criteria: ) the species should be identified taxonomically in the original study; ) it should grow in argentine patagonia; ) native and exotic species were included. native species were defined here as plants whose origin is central or southern argentina, below °southern latitude, and exotic species were those which did not fulfill this condition [ ] ; ) wild, semi-domesticated and cultivated species were included; ) the species were categorized as exclusively edible, and , functional, when the plant had at least one functional citation (edible, with also one or more medicinal uses) in the bibliography. following these criteria, studies and citations were included. each citation corresponds to a species referred to in a publication, with its corresponding ethnobotanical information. the following information was selected: species, common and indigenous names, richness of local foods, medicinal uses, herbal medicines made with peff and parts of the plant used (named plant drugs). the local foods were classified as: fresh fruit (f), jams and sweets (s), non-alcoholic drinks (d), fermented drink called "chicha" (ch), other (ot). the classification of ailments was adapted from molares and ladio [ ] : respiratory (rs), gastrointestinal (gi), urinary (u), pain and inflammation (pi), dermatologic (de), fever (f), obstetric (obs), gynecological (gyn), blood (bl), circulatory and heart (ch), nervous system (ns), cultural syndromes (cs), osteo-articular and muscular (oa), allergies (al), dentistry (den), ophthalmological (op), refreshment (re), others (ot). the different herbal medicines were classified according to method of administration: fruit ingestion (f), infusion (in), decoction (de), bathing, washing and rubbing (ba), gargling (ga), poultices and compresses (ca), creams and ointments (oi), other (ot). the plant drugs were categorized according to the part of the plant used: fruit (f), flowers (fl), leaves (l), branches (b), bark or stalk (s), root (r), the whole plant (pl). fieldwork was carried out according to the code of ethics of the international society of ethnobiology (ise) and the consensus statement on ethnopharmacological field studies [ ] . free listing, semi-structured interviews, in-depth interviews and participant observation were performed with participants [ , ] , prior oral informal consent. if the participant consented to being recorded during the interview, oral consent was also taperecorded. this procedure is supported by national research regulatory agencies and international agreements (argentinian national law n.° , ). a total of % of the population ( households) took part in the study, including several members of each family. the ages of the adult participants ranged from to years. inhabitants were consulted on their knowledge of the peff that grew in the area, and their alimentary and functional uses. the information gathered was reorganized following the categories used for the bibliographical review. the database included citations with information on peff. each citation corresponds to a species referred by each interviewee. the same quali-quantitative analysis [ ] was performed for both approaches. due to the categorical nature of the data, the analyses were principally non-parametric, using the spss package for windows. species richness (s) was calculated in total, according to biogeographical origin, and by botanical family. native and exotic species richness were compared using the binomial test (p < . ) [ ] . whether a native or exotic species was used as edible or functional was evaluated by consensus indices, mainly utilized for use pattern analysis of ethnobotanical data [ ] [ ] [ ] [ ] . these indices enable us to consider the agreement in a community or between diverse authors (and their publications) on the use of a certain species or plant family. the cultural importance index of edible plants (cie) was calculated for the species and for the families: cie = fc/n × , where fc = the frequency of citation of the species or family and n = the number of total publications/informants. we also calculated the cif index for functional species and families, as cif = fc/n × , where fc = the frequency of citation of the functional species or family. the mann whitney test was performed to compare these indexes for native and exotic species (p < . ). the percentage of each category was calculated in relation to the total reported methods of use of all the peff, that is, the total foods. %sc a = s sca / s sca..i × . where %sc a = the percentage of the subcategory a (for instance, drinks); s sca = the richness of species of the subcategory a; and s sca..i = the total of local foods. the use value is an index that indicates the versatility of a species, that is, the diversity of ailments that can be treated by a given species [ , , ] . it was obtained as follows: uvs = uvis/n [ ] , where uvis = the number of different medicinal uses registered by publication/informant for species s. similarly to local foods, the percentage of each category was calculated in relation to the sum of the plant richness for each subcategory. that is, in relation to the total medicines or plant drugs (medicinal parts of the plants). in the field study all native and exotic plant species were mentioned by their common names, and were later identified taxonomically by the authors. the collection of wild and cultivated species with fleshy fruits was performed with the assistance of local dwellers. in addition, field herbaria and photographs were utilized in the interviews to confirm the taxonomic identity of plants. plant identification followed correa [ ] [ ] [ ] plant specimens were placed in the ecotono-ethnobiology group-inibioma-university of comahue herbarium, and will be deposited in the herbarium of the centro regional universitario bariloche (bcru). voucher specimens of all reported species are shown in table . it should be noted that the berberidaceae family was treated according to landrum [ ] . all scientific names were updated using world flora online (www.worldfloraonline.org). a total richness (s) of species was found through the bibliographical review (table , fig. a ). the average richness per study was . species (min: , max: ). richness of native species ( %, species) was notably greater than that of exotic plants ( %, species) (p < . , binomial test). coincidentally, the cie of native peff was higher than for exotic plants (p < . , mann whitney test) (fig. b) . the native species with highest cie were berberis microphylla, ribes magellanicum, fragaria chiloensis, ephedra ochreata, aristotelia chilensis, gaultheria mucronata, berberis darwinii and berberis empetrifolia (fig. a) . the exotic species with highest cie were sambucus nigra, rubus idaeus, prunus cerasus, rosa rubiginosa, ribes aureum and ribes uva-crispa. the peff belonged to botanical families, the main ones being rosaceae ( species), grossulariaceae ( species), anarcardiaceae and berberidaceae ( species each). the families with the highest cie values were berberidaceae, rosaceae and grossulariaceae. in the bibliography, local foods were identified. most publications reported the use of fresh fruits ( % of the total local foods). a wide variety of preparations were found that generally included the addition of sugar, such as jams and jellies ( %). the most significant species used to make jams were b. microphylla, b. darwinii, r. magellanicum, r. cucullatum and f. chiloensis. another important way of taking advantage of peff was the preparation of drinks, mainly as soft drinks. these included non-alcoholic beverages ( %) made from the fruit of different species, such as ephedra triandra, aristotelia chilensis and berberis microphylla. the next most common drink was the fermented "chicha" ( %), which used different peff, amongst which stood out schinus polygama, geoffroea decorticans, r. magellanicum and amomyrtus luma. the production of "chicha" from a. luma mixed with fruits of other species is also mentioned. fifteen percent of local foods includes preparations with cooked, boiled or roasted fruits, as in the case of maihueniopsis darwinii. wines are also prepared, such as those made from a. chiloensis fruit, or liqueurs from b. microphylla or gaultheria poeppigi fruits. similarly, this category includes flours such as those made with condalia microphylla and geoffroea decorticans fruits. of the total number of species registered, the proportion of functional peff was % ( species, table ), similar to the non-functional species ( %, species) (p > . , binomial test). the richness of functional species was composed mainly of native species ( %, p < . , binomial test). it was also found that the cif of native species was significantly higher than that of exotic plants (p < . , mann whitney test). the principal functional species according to the cif values were the native aristotelia chilensis, ribes magellanicum, ephedra ochreata, berberis microphylla, fragaria chiloensis, luma apiculata and amomyrtus luma, and the exotic sambucus nigra, rosa rubiginosa and prunus cerasus ( table ) . the functional peff found belonged to botanical families. among these were anacardiaceae ( species); berberidaceae, ephedraceae and rosaceae with species each, and myrtaceae with species. at botanical family level, elaeocarpaceae, ephedraceae, grossulariaceae, myrtaceae, anacardiaceae, rosaceae, adoxaceae and berberidaceae were families with high cif values. the functional peff registered in the bibliography were used for a wide range of ailments (table ) , mainly gastrointestinal, respiratory, dermatological, gynecological, obstetric, related to the nervous system, heart and circulatory system, fever, pain and inflammation. the most versatile species according to their uv value were aristotelia chilensis, used to treat more than ten ailments, followed by berberis microphylla, luma apiculata, sambucus nigra, fragaria chiloensis and fuchsia magellanica ( table ) . the peff used as herbal medicines totaled (table ) , which mainly included forms that can be ingested, but also some of external use. the most important were two forms of drink: decoctions ( %) and infusions ( %). for example, infusions made of leaves or bark of r. magellanicum were used to "componer la sangre" (depurative) and for digestive ailments. a decoction of b. microphylla bark is also used to bring down a fever, or its fruit is used to combat diarrhea. the direct ingestion of a. chilensis fruit was also used to treat fever and diarrhea. among the methods of external use that stand out were: bathing ( %), for example, using luma apiculata leaves to bathe infected wounds; gargling ( %), with the same species but in this case to treat lesions of the gums. the application of exudates and poultices ( % each) has also been documented, for which the aerial parts of the plant were generally used, such as the exudate of schinus johnstonii leaves used to treat toothache. the exudate of l. apiculata as an anti-inflammatory is also frequently cited in the literature [ , , ] . poultices such as those prepared from dried a. chilensis leaves were used to clean wounds. creams and fresh fruit made up the remaining %. the parts of the plant most frequently used medicinally were the leaves ( %), fruits ( %), bark or stalk ( %) and roots ( %). a total richness of peff was found (table , fig. a) , an average of species being cited per informant (min: , max: ). this richness was divided equally between native ( species) and exotic ( species) plants (p > . , binomial test). in contrast to the findings from the review, in cuyín manzano the cie was the same for native and exotic species (p > . , mann whitney test) (fig. b) . the native species with highest cie were berberis microphylla, fragaria chiloensis and aristotelia chilensis (fig. a) . these were followed by other berberidaceae species, such as the "michay de la costa" (b. empetrifolia) and "michay de cordillera" (b. serratodentata). according to the cie values, some of the most important exotic species were rosa rubiginosa, prunus cerasus, sambucus nigra, prunus avium, prunus domestica, and finally rubus idaeus, which is known throughout the world (fig. a) . the peff in cuyín manzano belonged to eight botanical families. rosaceae contributed most to the list ( the asterisks show the species listed in the iucn red list of threatened species * = least concern, ** = near threatened, *** = vulnerable, **** = endangered, na native, ex exotic, f fruit, s sweets, d drinks, ch chicha, o others, nm not mentioned chamorro and ladio bmc complementary medicine and therapies ( ) : page of species), followed by grosulariaceae ( species) and berberidaceae ( species). however, the families with the highest cie were berberidaceae, rosaceae and elaeocarpaceae. in cuyín manzano local foods with peff were registered. of these, % were consumed as fresh fruits. in general, this method of use implied consumption at the time of gathering, with no storage involved. locals reported consuming these fruits when they were out in the countryside and felt hungry, the main reasons being that they like them a lot (such as the berberis fruits), and they are "good for them". to a lesser extent, the peff were lightly processed, through the addition of sugar or cream. also frequently consumed were sweets ( %), including jams, jellies and syrups made from mature fruit. among other preparations ( %), were the alcoholic beverages, which in this case played a role as social drinks. the most frequently cited of these was the "guindado" made with the fruit of the exotic prunus cerasus, which was served to visitors in the home. non-alcoholic drinks represented % of this category, mainly in the form of infusions, such as those prepared with the fruit of rosa rubiginosa and sambucus nigra, but also in the form of juices. other forms of consumption were also mentioned, such as the addition of fruit to baking products in the home. furthermore, the fruit tended to be used in the form of desserts, as in the case of stewed fruit, where fresh fruit such as plums were boiled in water and sugar. consumption of dried fruit called "orejones" was also registered. it is worthy of note that the preparation of "chicha" from peff was not mentioned here as it was in the review. a total of species ( %) were known to locals for their functional value (table ) ; however, the proportion of edible and/or functional species did not differ statistically (p > . , binomial test). the functional species included native and exotic species. in contrast to the review, in cuyín manzano the cif values were similar for native and exotic species (p > . , mann whitney test). as shown in table , the functional peff with highest cif were the exotic rosa rubiginosa and sambucus nigra, followed by the native aristotelia chilensis, ribes magellanicum, berberis microphylla and ribes cucullatum. the peff in cuyín manzano belonged to botanical families: grossularaciaceae ( species), and rosaceae, berberidaceae, elaeocarpaceae and adoxaceae ( species each). in terms of cif, the families that stood out were: adoxaceae ( %), rosaceae ( %), and to a lesser extent, elaeocarpaceae ( %). the peff in cuyín manzano were used principally to treat respiratory, gastrointestinal and dermatological ailments (table ) . sambucus nigra was one of the most versatile species, followed by rosa rubiginosa, aristotelia chilensis and ribes magellanicum, and finally, berberis microphylla. the inhabitants of cuyín manzano used medicines prepared from peff to treat specific local ailments (table ). these species were mainly used in the form of infusions ( %), utilized generally to treat or prevent respiratory disease. one of the most frequently used infusions was sauco (elderberry) tea, which was drunk at night to "warm up the body", and probably played a preventative role. this infusion was prepared by putting a spoonful of sambucus nigra syrup in a cup, then adding boiling water. the syrup was also consumed alone, without dilution, mainly by children but also by adults suffering cold symptoms ( %). mosqueta (rosehip) tea was used similarly as a recreational drink, to warm up the body and treat illness. fresh fruits were always consumed ( %) in the context of relieving gastrointestinal problems, and decoctions were also prepared ( %). the only external method of application was using creams ( %) made from rosa rubiginosa fruits by women from a nearby community. the medicinal parts of functional peff are mainly the fruits ( %) ( table ) , and to a lesser extent, leaves ( %), the whole plant ( %), followed by flowers, seeds, bark and roots ( % each). finally, five of the medicines were also considered as food by locals: elderberry and/or rosehip infusions, the fresh fruits of maqui and michay, and elderberry syrup, which in total represent % of local foods. the bibliographical analysis revealed a high number of native and exotic peff ( species), providing an overall picture (spanning years and an ample geographical range) that shows the study potential of all these patagonian species. the nutritional role of this plant diversity and the safety of their use is still unknown, but they presumably represent food security for locals. food security is founded on three elements: the availability, access, and utilization of food, elements that were elucidated indirectly in both the bibliographical texts and the testimonies of cuyin manzano inhabitants. it is also important to consider that the conservation status of some of the native species ( species, table ) is challenging, and must be solved by cultivation and/or sustainable management, given that their availability and access are threatened. the need for an integrated study of these aspects must be taken into account in future investigations. moreover, the field study showed that peff on this list continue to be used. although this rural community is probably experiencing a process of dietary transition from smallholder farming-based to industrialized food systems, as well as integration into the global food trade, peff continue to be part of their local heritage. lifestyle changes probably affect food production, plant gathering and consumption, with consequences for the healthfulness of diets, but these species still have an appreciated role in home-produced foods. further field research should be carried out in other patagonian communities, using this tool to survey food security in order to investigate whether local people keep peff use alive in their food traditions. this aspect is of great importance given the processes of abandonment and loss of knowledge associated with plant use observed in cuyín [ ] and numerous other rural communities throughout the world [ ] . our cross-sectional approach coincides in the cultural importance of the three native species with highest consensus: berberis microphylla, fragaria chiloensis and aristotelia chilensis. the michay plant has attractive blue-violet berries with a flavor which is sweet, but sour, and is widely distributed in forest and the patagonian steppe, therefore present also in the most arid zones. the native strawberry has strongly scented fruits, and has been used to obtain fragaria x annanasa, the strawberry which is commercially cultivated throughout the world [ ] . the berries of the maqui plant are acid to the taste, and have been designated a superfood due to their high content of anthocyanins [ , ] . at present these species are being intensively studied as target species [ ] and are attracting much attention for future innovation and development projects [ , ] . the remainder of the list of peff may also be considered by policy makers and researchers in the planning of agricultural and phytochemical research action that will support sustainable diets and local food systems. all this biodiversity is introduced into local gastronomy through a large variety of local foods. remarkably, in both studies the use of fresh fruit is high ( % in the review and % in cuyín manzano). traditional culinary habits could promote better use of nutrients, since a lower level of processing generally leads to greater availability of nutrients such as vitamin c [ ] . in second place, the preparation of preserves and beverages from the fruit indicates strategies that favor preservation over time, storage, and the use of excess fruit, as found in other parts of the world [ , ] . preserves include some forms, such as syrups, which are of great interest due to the compounds that contribute phenolic acids, fiber, and soluble solids [ ] [ ] [ ] . these plant preparations could be also highlighted, as local people could be skillfully managing the plant chemicals during food processing. patagonian communities have experimented extensively with the diversity of peff fruits in the preparation of fermented beverages, mainly in the form of "chicha". this drink is made with fruit and seeds, which in many cases were chewed by the people before being stored for fermentation. this preparation holds great cultural and spiritual value, as it is drunk in traditional mapuche festivities [ ] . nevertheless, in cuyín manzano preparation of these beverages with the peff berries was not identified. although the medicinal use of these preparations was not documented, some studies associate moderate consumption of fermented beverages with prevention of cardiovascular diseases and cancer, due to their polyphenol and alcohol content [ ] . this opens up a wide range of possibilities for the exploration of fermented beverages, taking into account ancient food traditions. these customs are considered key elements for development projects related to food sovereignty [ ] . the peff heritage possesses a great richness of species whose functional value has been well taken advantage of, and which can therefore constitute alternative healthy or phytotherapeutic food. the species taken from the bibliography and listed here are mainly native to patagonia, and represent opportunities for study, for which the consensus values can be a useful guide. in this sense, our findings are in accordance with jennings et al. [ ] as to functional species use. to understand the meaning of their functionality, contextualization of the food-plant spectrum based on both local beliefs and wider structural factors is needed. in our field study we found that dwellers consider that the fruit did them good. from the mapuche worldview, their consumption of wild fruits implies nourishing the earth's energy (called in native mapuzungum "afutum"), energy that cannot be transferred in any other way [ ] . in other words, the classification of a species as functional is inseparably supported by both the local worldview and its chemical and biological attributes. a whole universe of chemical compounds may be related to the health effects of the peff. the medicinal value of the species used as food has been explained in detail by authors such as johns [ , ] , based on the presence of a wide range of phytoconstituents. today we know that food plants have diverse constituents such as polyphenols, in addition to nutritional compounds. these molecules are recognized for their antioxidant properties; they are important radical scavengers through inhibition of prooxidant enzymes and restoration of antioxidant enzymes. however, new mechanisms of action have been proposed to explain their bioactivity, such as interaction at the level of the plasmatic membrane with proteins and phospholipids, and the regulation of signal transduction pathways [ , ] . of the peff, those which have berry-type fruits stand out as functional species, and are known worldwide as healthy foods. berries contain vitamins, minerals and phenolic compounds, and are credited with antioxidant, antiaging, chemoprotective and chemotherapeutic, anti-inflammatory and neuroprotective properties [ , ] . with a strong consensus between our two studies, the key species are: a. chilensis, ribes magellanicum, ephedra ochreata and berberis microphylla. a. chilensis is the species with the highest number of described pharmacological properties, including the ability to attenuate pain and inflammation [ ] . this activity matches the local ailment treatments described in our work. little is known about ribes magellanicum, but the antioxidant potential in vitro of the fruits found in argentine-chilean patagonia has been demonstrated [ ] . unfortunately, ephedra ochreata is one of the leaststudied species in the region. concerns about it eventual toxicity, should be carefully considered, since other ephedra spp. have been demonstrated to exhibit toxicity (https://www.health.harvard.edu/staying-healthy/thedangers-of-the-herb-ephedra). it must be used with great care, given that toxic effects have been reported for other species of ephedra, such as cardiac and psychiatric disorder [ ] [ ] [ ] . future research should focus on e. ochreata in order to test its food safety. the study of other species, such as b. microphylla, have begun only recently, revealing promising antioxidant content and antidiabetogenic activity according to chamorro in vitro and in vivo studies [ ] [ ] [ ] . again, more studies and further analysis is required to relate these chemical and biological findings to the health claims presented here. similar to the peff heritage, the use of functional species seems to be undergoing hybridization processes. this was evident in the rural community we worked in, where the cif values were similar in native and exotic plants. these results show how locals have been using a combination of native and foreign species in edible and functional terms. although this has been happening for a long time in the region, it seems to be more prevalent at the present time [ ] , probably due to changes in food procurement. the use of exotic functional peff in our region may be interpreted as a reflection of the long, strong historical influence of european immigration on the use patterns of this area. various studies carried out in south america have shown that the introduction of eurasian plants led to diversification in the use of medicinal plants [ ] , and many edible fruits form part of the pharmacopeias brought from europe [ ] . shikov et al. [ ] and totelin [ ] suggest that the use of edible fruits as medicine is due to the great influence of the food-medicine conceptions of ancient greece. however, the food-medicine interface had also been described previously, without the use of exotic plants, in patagonian indigenous communities [ ] . we suggest, therefore, that this food-medicine continuum may have been generated independently, and that the knowledge of indigenous and european communities converged at a later date. some of the exotic berries registered in this work have been extensively studied with regard to the biological activity that supports their local functional use. in the case of sambucus nigra, there is in vitro evidence to support the effectiveness of its antibacterial and antiviral properties [ , ] . hawkins et al. [ ] recently found that elderberry fruit can improve respiratory complaints associated with influenza, and so mccarty and dinicolantonio [ ] propose its use (in a dose of - mg) for the treatment of covid- infection. rosa canina, a species closely related to rosa rubiginosa, has been studied with regard to its use in treating skin ailments [ ] . the dermatological use of r. rubiginosa and use of the other functional exotic species were also registered in our field work. this pattern shows how the berry repertoire grows with input from highly reputed exotic plants. with respect to ailments, the review shows that more than ailments have been treated with peff. in cuyín manzano this number is much lower (only five ailments) and is focused on primary health care issues. the broad scope of the review shows the potential of these species, even though the main ailments treated with peff are those most frequently treated by traditional medicine, such as digestive and respiratory complaints. several studies have proposed that this redundancy gives flexibility to the regional herbal medicine, the use of a. chilensis and s. nigra fruits standing out as being the most versatile elements the population has within its reach [ ] . the peff are also important sources of herbal medicines ( in the review and in cuyín manzano) since, as previously shown, different plant parts of the peff are used in an integral way. infusions (and decoctions according to the bibliography) constitute the main method of medicinal use in the region, and this is also, within local foods, the main form of beverage in cuyín manzano. recent research has revealed how infusions of exotic rosa rubiginosa fruit can contribute compounds with antioxidant activity [ ] . the same occurs with the infusion of exotic sambucus nigra fruit, which was shown to contain considerable amounts of polyphenols and anthocyanins, comparable to an ethanolic extract [ ] . infusions are therefore, in general, good vehicles for phenolic compounds, and this is possibly the basis for their functional value in patagonian cultures. according to our analysis of the information gathered from the review, complemented by the fieldwork, we can reinterpret the comprehensiveness of the food-medicine interface in patagonia, outlined in fig. . in the review work we found a notable superposition of use (edible and medicinal) for single native or exotic species (given by the sum of citations of different authors and different study sites). however, in the analysis of each one of the studies included in the review and the fieldwork, we observed that the patagonian communities have not only experimented with native and exotic plants and discovered their medicinal properties, but they have also developed diverse forms of preparation. these make up a wide range of methods of use, but also form part of local food tradition, which considers plants from the perspective of functional, complementary logic, for their general health in their daily lives, local foods and medicines. within this group there are forms of preparation that prove effective as food and medicine (superposition of use forms depending on context), known in the literature as food medicines or healthy foods [ ] . within this group we find the subgroup of the local functional foods. as shown in our field study, this is the case of rosa rubiginosa and sambucus nigra, two exotic berries that are used in the form of infusions and indistinguishable as food or medicine. they are used as a preventative food, which in nutrition is known as a functional food [ ] . these infusions seem to be important local functional foods, given that these water solutions are good vehicles for active compounds found in plants, such as polyphenols [ , ] . finally, the functionality attributed by a culture to its native and exotic species includes superposition at different levels, and may be described in theoretical terms as different categories. however, most important is that they are principally based on the use of the entire plant. in the case of patagonian native and exotic plants with edible fruit, the people seek food, healing, and also prevention ("it warms up the body", "it does you good") through the use of infusions and the ingestion of fresh fruit. previous studies have shown the potential of some native peff, due to their polyphenol content, but little has been studied on the teas prepared with them. more integrative research is required into this use pattern of native and exotic species, their local foods and their potential as local functional foods. argentine patagonia holds great richness of native and exotic peff and the cultures who have lived on these lands have experimented with them as a source of local foods and medicines, generating a food-medicine continuum. the living heritage of patagonian peff appears to have undergone hybridization processes, such that exotic cosmopolitan species play an increasingly significant 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grateful to the families from cuyín manzano for their willingness to participate, and for sharing their knowledge. special thanks to mr. antonio bergant, who was not only a great person, but also the best field assistant. the authors acknowledge with appreciation the constructive comments made by the referees andrea pieroni and timothy johns on the earlier version of this paper. we would also like to thank the cultiva (cyted) network. authors' contributions m.f.c.: conducted the review process, the fieldwork, analyzed the data and contributed to the manuscript. a.l.: conceived and designed the research, conducted the review process, analyzed the data and contributed to the manuscript. the author(s) read and approved the final manuscript. this investigation was supported by the consejo nacional de investigaciones científicas y técnicas (conicet) of argentina (pip ), and by centro de investigación y extensión forestal andino patagónico (ciefap). the datasets used and/or analyzed during the current study are available from the corresponding author on request. this study was conducted according to the ethics guidelines of ise code of ethics (http://ethnobiology.net/code-of-ethics/) and nagoya protocol (argentinian national law n.° ). all informants orally confirmed free and informed consent prior to data collection. no other specific additional procedure is mandatory for this kind of study in our country. not applicable. the authors declare that they have no competing interests.received: august accepted: may key: cord- -c urbl l authors: hicks, t.m.; verbeek, c.j.r. title: protein-rich by-products: production statistics, legislative restrictions, and management options date: - - journal: protein byproducts doi: . /b - - - - . -x sha: doc_id: cord_uid: c urbl l congruent to a rapidly growing population is the generation of horticultural and agricultural by-products and waste. the modern-day food cycle includes agricultural production, postharvest handling and storage, food processing and packaging, and distribution and retail, ending with consumption and waste disposal. of these, agricultural production and postharvest handling and storage result in unintended losses and by-products whereas the other steps generally result in food waste. approximately one-third of the worldwide food production is wasted each year. although it is most desirable to prevent waste and by-product formation, followed by reuse or recycling, the formation of by-products and waste is inevitable, and management options must be innovative and also meet legislative requirements. however, management options are mostly a compromise between what is viewed acceptable based on legal requirements and local perceptions, and what is deemed technologically and financially feasible. most of the world's food is derived from agricultural, horticultural, and fishery processes. with a growing population, urbanization, and increased income, the food industry has become increasingly market driven. as a result of globalization and reduced trade barriers, it has grown to account for approximately % of the world's gross domestic product (murray ) . fortunately, environmental protection and sustainability are currently better aligned with the worlds' consumption of natural resources. over the past few decades, it has tried to adopt technologies to improve waste minimization and environmental performance. although the most valuable elements are extracted from foods during harvest and processing, what remains in both the product-specific and product-nonspecific wastes may also contain other potentially valuable components. predicting future food production and associated by-products is complicated and has to take into account not only changes in population size, dietary composition, land requirements, and primary resources, but also climate and environmental aspects (godfray et al., a) . overall, increased global demand for animal-based products requires a substantially greater increase in plant and other feed resources, which will subsequently generate a much larger volume of protein-rich materials than currently produced. the quantity of food materials wasted each year is exorbitant, and urbanization and the increasing per capita income will see this quantity rise further through increased consumption of staple foods and through diversification into animal products, such as meat, fish, and dairy. this will be most challenging for transitional countries, which are expected to undergo a much more rapid increase in per capita meat consumption compared to high-income countries (ie, china will increase by ∼ %, from kg in to kg per capita per year in compared to an increase of ∼ %, from kg to kg per capita per year, in higher income countries) (msangi and rosegrant, ) . such nutritional transitions result in a rapid increase in animal products, putting a significant amount of pressure on food supply chains within transitional countries than those in the developed world. a major facet of the problem we face, is being able to source adequate quantities of high-quality protein from which to feed both humans and animals, without intensifying the overall environmental impact (van huis, ) . obviously, increasing production of animal-based products will result in a much higher consumption of grain and protein feeds to feed livestock, which are estimated to require ∼ kg of plant protein for every kilogram of protein they produce (pimentel and pimentel, ) . however, this could be better perceived by the ∼ kg of grain required to produce kg of edible boneless meat from grainfed cattle (foley, ) . conversely, while chicken and pork are more efficient converters of plant proteins, pasture-fed cattle are able to convert nonfood material into usable protein. the technology for recovering nutrients and usable materials from industry is often feasible, but the regulations regarding what can be done with by-products of industry may not always allow for the technology to be adopted. despite a concerted effort to better use by-products of the agricultural and food industry to improve the management of resources, sensible legislative incentives also need to be implemented. this chapter identifies areas of food production and related industries generating waste and byproducts with high levels of recoverable protein, in particular, those derived from agricultural production itself. current and future management options for the transformation and/or disposal of these wastes and by-products are then considered in light of current legislation and technological restrictions. the modern food cycle is comprised of several stages, including agricultural production, postharvest handling and storage, food processing and packaging, distribution and retail, and finally, end-of-life and consumption ( fig. . ) (kummu et al., ) . agricultural production, postharvest handling, and storage of food give rise to unintended food losses and ancillary byproducts, while processing and packaging and distribution and retail result in "food waste." food loss, by-products, and food waste are formed at every stage of the food production process. while the generation of by-products, such as crop residues and animal by-products (abps) during agricultural production is considered unavoidable, food losses, owing to a lack of market or degradation during handling or transportation could be avoided with care, but when considering statistics, it is often difficult to distinguish between the two. for various reasons, approximately one-third of the food produced worldwide is wasted (godfray figure . general food production stages, starting from agricultural production and postharvest handling and storage to processing and packaging, distribution, retail, and consumption. et al., a; food and agriculture organization of the united nations, ). these wastes (and possible by-products) are created during the manufacturing processes and are often removed in order to give the product the desired sensory and nutritional qualities. although the magnitude of food losses, by-products, and food waste varies depending on the product type (table . ) and the stage of production considered (table . ), it is strongly influenced by the technology and infrastructure available to the region. it has been estimated that around million metric tons (mmt) of abps are produced worldwide every year (leoci, ), along with significantly higher quantities of crop residues (santana-méridas et al., ) . obviously, industrial processing of any food, whether it is intended for human or animal consumption (or other industrial processes, such as biofuels) leads to a vast quantity of waste and by-products, typically ranging between and % by weight (table . ). in the case of crops, only % of global production is used for human consumption, mostly in the form of grains, pulses, oil plants, fruits, and vegetables, leaving % as by-products (used for animal fodder) and the remaining % for conversion to biofuel and other industrial products (foley, ) . in high-income regions, most food waste occurs during distribution and consumption, with high losses also occurring during agricultural production of plant products and fish (table . ). harvesting of crops also results in an inedible portion of the biomass (including edible product lost during harvest) contributing to what is known as crop residues. for most common edible crops, the residue-to-crop-production ratio is between . and to (scarlat et al., ) . this mass is not accounted for in table . , however, typical quantities of some common food crops are given in table . . in lower-income regions, losses occur at every stage, particularly postharvest, to a much higher degree, but occur significantly less at the consumption stage. higher losses throughout production in low-income regions are an artefact of inadequate knowledge, skills, technologies, and infrastructure to support the food supply chain compared to the industrialized world (godfray et al., b) . globally, billions of tons of agro-industrial residues and by-products are generated annually (table . ). these include solid, liquid, and gaseous residues and can be seen as one of the most abundant, cheap, and renewable resources available (santana-méridas et al., ) . given that food waste has a typical composition of ∼ - wt.% starch, - wt.% lipids, and - wt.% protein (pleissner and lin, ) , millions of tons of protein, from plant and animal sources, could be better used. agricultural production also has other unavoidable wastes associated with it, including manure and effluent, which also contain high levels of recoverable protein. these by-products and wastes find new life, often as animal feed ingredients. waste materials generated during agricultural production, including inedible plant and animal parts, are removed during harvesting and postharvest processing. other unavoidable nutrient-rich wastes, such as manure and deadstock, are also produced. due to their high levels of recoverable protein, carbohydrate and fiber, many of the by-products and wastes of the agricultural industry currently find reuse as animal feeds or animal feed ingredients. animal feed ingredients are blended in such a way as to create a more nutritious food for livestock. plant-derived ingredients include grains, such as maize, barley, sorghum, oats, and wheat (which can also be used for bioethanol production), from which the by-products are often diverted back to feed. these grain by-products include corn gluten meal, brewers and distiller's grains, malt sprouts, brewer's yeast, and wheat mill feed (lefferts et al., ; naik et al., ) . more importantly, it has been assumed that by , up to % of transportation fuels will be derived from biofuels, generating up to mmt of additional protein . higher value applications for inedible and nonessential amino acids derived from these by-products may eventually be commercialized, providing a feedstock for protein-based plastics, milk and dairy . - - . - - . - regions were grouped (gustavsson et al. ) into medium-to high-income regions (europe, united states, canada, oceania, and industrialized asia) and low-income regions (sub-saharan africa, north africa, west and central asia, south and southeast asia, and latin america). production process biopesticides or commodity organic compounds (naik et al., ; scott et al., ) . oil production by-products (oil meals and press cakes) from processing oilseeds, such as soybean, canola, sunflower seed, linseed, palm kernel and others, are also important feed ingredients. oil meals are obtained by solvent extraction of the oil cakes, which are obtained by pressing the seed. in , mmt of various oil meals were produced globally, of which mmt was soymeal (united states department of agriculture, a). in the united states alone, mmt of soymeal is produced annually (united states department of agriculture, a), representing more than two-thirds of the proteinaceous animal feed in the country (lefferts et al., ) . other oilseed meals are lower in protein and higher in fiber and are often used for feeding ruminants. cottonseed meal is also high in protein and is mainly used as cattle feed in the united states or as aquaculture feed. unlike other seeds, the press cake obtained from castor seeds during castor oil production is inedible because of its high level of phytotoxins (ricin, a toxic protein), hydrocyanides, and other allergens, however, this too has a high level of protein, ∼ - % (table . ). other plant ingredients may include alfalfa by-products, such as alfalfa meal, pellets, and concentrated alfalfa solubles, which are typically fed to ruminants. further, various nuts, seeds, and their by-products, such as hulls and seed screenings; legume by-products, such as bean straw meal and hulls; and even dried roots and tubers, such as sweet potatoes and chipped or pelletized cassava, find use in animal feed. agricultural production-specifically the production of animal-derived goods-also results in by-products. in fact, around wt.% of an animal produced for food is not used directly for human consumption, and downed or dead animals are another waste artefact of production. these waste materials are processed by the rendering industry, producing protein-rich products (table . ). global production of abp meals from rendering is in excess of mmt per year ( fig. . ) . these products include meat meal, meat and bone meal, poultry by-product meal, poultry meal, blood meal, feather meal, hydrolyzed leather and leather meal, eggshell meal, hydrolyzed hair, unborn calf carcasses, ensiled paunch, bone marrow, and dried plasma (lefferts et al., ) . other than the preceding, about wt.% of the fish caught globally each year is not used directly for human consumption; instead it is used to produce protein-rich marine by-products, in excess of mmt per annum (table . ). typical animal feed ingredients derived from marine origin include fishmeal, dried fish solubles, crab meal, shrimp meal, fish protein concentrate, and other fish by-products (lefferts et al., ) . finally, animal waste has also been used as a feed ingredient, including dried ruminant waste (manure), dried poultry waste, dried poultry litter, dried swine waste, undried processed animal waste products, and processed animal waste derivatives (lefferts et al., ) . according to the association of american feed control officials, in the united states, these processed animal waste products must be treated appropriately to ensure that the product is free of harmful pathogens, pesticide residues, parasites, heavy metals, or drug residues (association of american feed control officials, ). although recycled animal wastes have been knowingly incorporated into animal feed for almost years, the food and drug administration does not endorse the use of recycled animal waste (lefferts et al., ) . regardless, protein content in dried manure ranges from to wt.% for cattle, to wt.% for poultry, and to wt.% for pigs (chen et al., ) , making it another source of valuable protein and nutrients. just as the sources of waste are diverse, so too are the wastes generated, each with a different chemical and physical makeup, directly affecting how they are best used (table . ). many studies focused on the valorization of these and ( ); fuller et al. ( ) castor seed meal . annongu and joseph ( ) corn gluten meal . - . national research council ( ) continued ) other waste streams in a profitable way. obviously, for protein meals that can be fed to livestock or fish, the price for which they are sold will generally cover the cost of producing them, and in the case of abps, the revenue generates a reasonable profit. however, for inedible protein meals (including meals which either have no market or limited market access), adding value through conversion into novel products is of greater necessity. the problems with imparting additional value to these products is not necessarily related to the scientific or technological feasibility or even cost, but are most commonly associated with the perceived risks and often restrictive supporting legislation. every nation strives to maintain its biosecurity to protect its ecological and economic resources from disease and invasive pests. the most effective means of governing the risks posed by the importation of dangerous or questionable materials, and the harm they may cause to animals or humans, is to impose legal restrictions. the importance of maintaining biosecurity is most apparent when considering the risks of international trading. the introduction of invasive pests and disease through international trade could lead to adverse effects, not only on plant a based on production statistics for - in animal feeds compendium ( (ash, total global production ∼ million metric tons. and animal health, but biodiversity and food production as a whole, and should be appropriately managed (maye et al., ) . these measures must consider not only the scientific evidence supporting such a restriction, but must also consider any reasonable precautions that can act to offset any deficiencies in a solely scientific approach. hence, during the development of a new policy, a risk analysis is first performed, followed by evaluation of that risk through the lens of current legal, institutional, social, and economic circumstances, all of which is undertaken by the stakeholders who represent them (mills et al., ) . as such, risk governance deals with the management of both perceived and scientifically founded risks. although risk management implemented through public policy is focused at the national level, many food and natural resource policies operate at levels both below and beyond the national level (mills et al., ) . however, as a result of the discrepancies between each state's local policy making and a lack of cohesive global regulations, the intersection between risk and commerce continues to be a major challenge facing the international trading system. a significant amount of trade conflict experienced at the world trade organization has involved the united states, canada, and/or the european union (hornsby, ) . some topics that became the focus of either formal or informal disputes have included hormone-fed beef, bovine spongiform encephalopathy (bse), raw milk cheese, genetically modified organisms, chlorine-washed chicken, and wood packing materials. such disputes imply the presence of a transatlantic divide over what constitutes a legitimate risk regulation, however, this is an oversimplification. although the risk regulations set forth by the european union take a precautionary approach, acting in light of scientific uncertainty and taking into account public concerns, the us system is based on a "sound science" approach, free from political influence, however, this has not always been the case. it has been argued that the united states used to be more precautionary than the european union (hornsby, ) , but was pressured to limit the calculation of risk in public policy. the eu's regulatory failures during food safety crises served to undermine public trust in the eu institutions, resulting in the use of a precautionary approach (hornsby, ) . overall, it has also been proposed that both regions partake in "occasional and selective application of precaution to different risks in different places and time" (wiener, ) . nevertheless, there are some consistencies around the world regarding the safe handling, distribution, and disposal of food, animal wastes, and by-products. products from byproducts dairy milk, butter, cream, yogurt, cheese, ice cream whey, wastewater whey protein adapted from de las fuentes et al. ( ) and ramachandran et al. ( ) . the degree to which protein by-products, particularly abps, can be used is limited by the customs, religions, and regulatory requirements of the region. all feedstuffs imported into a country must comply with rules regarding hygiene, traceability, contaminants, labeling requirements, and health issues given its expected use. the use of the product is then subject to more specific rules, largely limiting the use of those feedstuffs containing animal-derived products. the first diagnosis of bse in the united kingdom in and the subsequent publication in that new variant creutzfeldt-jakob disease in humans had most probably arisen from exposure to bse-infected meat, sparked a global crisis with respect to food safety and risk management. up until the outbreak of bse during the s, almost all protein by-products were used as feed supplements for livestock. in , the practice of feeding ruminant animal protein meals to other ruminants was banned, along with the use of specified bovine offal (brain, spinal cord, other organs potentially infected with bse) (ockerman and hansen, ) . more recent infectious disease outbreaks, such as avian influenza and severe acute respiratory syndrome, have further jeopardized diplomatic relations, frightened the public, and caused massive economic losses by disrupting global commerce (karesh and cook, ) . since then, concern over the risks posed by abps, including infectious diseases (such as swine fever, foot and mouth) and other contaminants (such as dioxins), to human and animal health, has resulted in strict regulations regarding their safe handling and disposal (cunningham, ; department for environment food and rural affairs, ). as such, most countries now have local regulations put in place that are typically broad in scope and directly affect any person or business that generates, uses, disposes, stores, handles, or transports food waste containing animal products and abps derived from the food processing industry. currently, most countries no longer allow animal by-product meals containing any amount of ruminant tissue to be fed to other ruminant animals, although meat and bone meals containing ruminant tissue are still able to be fed to nonruminant animals, such as poultry, swine, pets, and aquaculture species in most countries, including new zealand (garcia and phillips, ). to the contrary, throughout the european union, meat and bone meals are banned from the feed of any animal that may become human food, and as a result, in the european union, meat meal and meat and bone meal are primarily incinerated or used as an ingredient in pet food (kirchmayr et al., ) . in most countries, legislation for waste disposal and disposal of dead animals and of slaughterhouse materials (animal rendering) is already in place. in germany, the animal disease act, the meat hygiene act, the poultry meat act, and the meat hygiene ordinance also regulate the disposal of slaughterhouse offal. to protect animal and human health, the canadian food inspection agency (cfia) enforces federal regulations governing the production and use of rendered materials that may be used in animal feed. however, a policy established by the national renderers association, which prevented ovine material (sheep) from being used in meat and bone meals in the united states and canada, and has been withdrawn (malone, ) . compared to canadian and us policy, the framework of the eu regulations regarding abps and derived products is complex, resulting from ongoing reviews by the eu commission. each updated regulation is a result of the successive amendment to the initial regulation (ec) / , most recently amended with (eu) no. / . the regulation covers the safe disposal options available for all animal products, including meat, fish, milk, and eggs not intended for human consumption, and other products of animal origin, including hides, feathers, wool, bones, horns, and hooves. it also prohibits catering waste being used as livestock feed and covers disposal of fallen stock, companion animals, and wild animals if they are suspected of being diseased. the regulations also control the use of abps as feed, fertilizer, and technical products with rules for their transformation via composting and biogas operations and their disposal via rendering and incineration (department for environment food and rural affairs, ). when looking at the existing options available for management of these by-products (and/ or wastes), both legal regulations and the best ecological and economical solutions need to be considered. whether a material is deemed to be a valuable by-product (or a waste that needs to be disposed of) depends on the social, legal, and technological framework surrounding its origin. from there, the most sensible form of management becomes a compromise between what is viewed as acceptable, based on legal requirements and local perceptions, and what is technologically and financially feasible ( fig. . ) . although it is most desirable to prevent waste and by-product formation, followed by reuse or recycling into other product lines, the formation of by-products and waste is inevitable, and management options must be innovative and also meet local regulatory requirements. waste management is then possible through several media: to use it in its current form, dispose of it through incineration or landfill, or add value to it through bioprocessing or valorization technologies ( fig. . ) . the choice of media used will largely depend on the cost, customs, and regulatory environment. for example, converting the by-product to animal fodder (bioreduction) may not be feasible in all countries. excess and waste food has been used as animal fodder for centuries, and in many parts of the world, farmers still use waste food to feed their animals-primarily pigs and poultry. the practice of feeding waste material containing meat products to pigs was banned in the united kingdom in (statutory instrument , no. the animal by-products amendment) to prevent further spread of bse, and soon after, a new regulation was implemented throughout the european union (the animal by-products regulation, ec no: / ) prohibiting catering waste from being fed to farmed animals. this includes all waste food and used cooking oils, as well as waste from vegetarian restaurants and kitchens. based on these laws, only certain types of waste food can be given to livestock and must first be treated appropriately. if the by-product cannot be immediately used as it is or treated appropriately for use as an animal feed, it must be safely disposed of. because of the time and expense of treating these food wastes, most end up in landfill. currently, landfilling and incineration account for the treatment of greater than % of food waste in most european countries (melikoglu et al., ) . in general, using the biomass waste in the form it is in, either as an animal feed or fertilizer or as a fuel to generate electricity, is the most simplistic approach and generates a value of ∼us$ - per metric ton of biomass (tuck et al., ) . incineration is the simplest means of waste disposal, with its major advantage being the significant reduction in volume of the waste stream, which is up to % for waste streams with high amounts of paper, cardboard, plastics, and horticultural waste (hoornweg and bhada-tata, ) . however, most food wastes are not appropriate for incineration, owing to their high moisture content. when properly equipped, an incinerator can be used as a means of energy recovery to generate electricity. heat released from the combustion of waste can be used to produce steam, which can turn a steam turbine, generating electricity. however, because of the increased concentration of toxins in the ash, incinerators must be operated alongside landfill systems in order to dispose of them. combustion destroys chemical compounds and diseasecausing bacteria, leaving it pathogen free, but causes serious environmental problems through the production of carbon dioxide, nitrogen oxides, sulfur dioxide, and trace quantities of toxic pollutants, such as heavy metals and dioxins. the remaining residues are often landfilled, owing to their high heavy metal content. thermochemical conversion of food and industry wastes are an effective means of converting energy-rich biomass into a more easily used liquid or gaseous intermediate. high temperatures can be used with minimal (gasification) or no oxygen present (pyrolysis) to break down hydrocarbon containing wastes, resulting in combustible syngas mixtures, containing carbon monoxide and hydrogen ( %), with small amounts of carbon dioxide and methane. this syngas intermediate can be further processed to produce bio-based gasoline, diesel, or jet fuel, or be used in a fuel cell to generate electricity or steam. landfills-burying the material-are a common final disposal site for waste and the residues remaining from other treatment options. at atmospheric pressure, metric ton of organic material generates approximately - m of landfill gas over a - year timeframe (jardine et al., ) , comprised of - % methane and - % carbon dioxide, which represents around % of the anthropogenic methane (ch ) emitted worldwide (melikoglu et al., ) . methane has times the global warming potential of carbon dioxide and can be recovered and burned (with or without energy recovery) to reduce greenhouse gas emissions (hoornweg and bhada-tata, ) . other serious environmental implications of landfilling include the risk of leachate (potential toxic liquid that drains from landfills) entering surrounding soils and groundwater. although the use of landfills is common, their use has been discouraged through the implementation of landfill taxes and directives, such as the uk "landfill tax" in and eu landfill directive established in (jardine et al., ) . obviously, other disposal options are preferred to landfilling, which costs ∼us$ per metric ton. around % of the municipal waste sent to landfill is biodegradable and mostly comprised of food waste (hoornweg and bhada-tata, ) . this makes bioprocessing, such as composting and anaerobic digestion, sensible options for disposing of these organic waste streams. a common means of obtaining a safe end product is achieved through composting. this involves a combination of chemical and microbiological processes occurring throughout three stages that convert organic materials to a stable, soil-like product called compost (som et al., ; verbeek et al., ) . provided composting is carried out well, the volume and mass of the waste can be reduced by up to %. for composting to occur efficiently, the conditions of the composting process must be maintained at an optimal level to encourage microbial growth. because of changes in the composition of waste material with location and over time, the compost mixture needs optimization through regular adjustments. for example, if the system becomes anaerobic, offensive odors can be produced, and if it becomes too wet or too dry, the process will halt altogether. some of these organic waste materials require specific pretreatment before composting can occur. in the united kingdom, eu standards must be implemented over and above uk standards if the site treats category abps, which have first been pressure rendered, or category abps if they exclude catering waste. exceptions apply for some types of abps in the united kingdom, which can be composted in closed reactors at °c for more than h or in housed rows of piled green-waste (windrows) at °c for more than days under strict operating parameters with a maximum particle size of mm. although compost is of limited value, it is still a more economic option compared to landfilling. other bioprocesses can be employed that produce more valuable products. biofuels can be produced using fermentation, valued at us$ - per metric ton more than the initial biomass waste (tuck et al., ) . anaerobic digestion is another means of disposing of organic waste materials and is carried out in an enclosed vessel. the methane generated can either be flared or collected for combustion to generate heat and/or electricity, which also adds value to the waste biomass. the maximum value can be recovered from these waste materials by converting them into more purified streams and using them in the manufacture of lubricants, surfactants, plastics, fibers, and industrial solvents. theoretically, all abps in the european union could be combusted as fuel for energy, provided the eu commission formulates the appropriate rules and regulations, which as of yet has not been done. although there are many technologies currently available (or in developmental stages) that aim to valorize by-products of industry, legislation has yet to be passed that explicitly deals with higher technology outcomes. most current law deals with the safe handling and disposal of animals, their products, and by-products and animal feeding. although it is necessary to contain health and environmental risks through appropriate legislation, it is becoming apparent that the use of abps and food wastes (excluding crop residues and some agro-industrial byproducts) for animal fodder and composting is not only obsolete, but in many nations, illegal. many technologies exist that aim to valorize by-products of the agricultural industry. although the edible portion of these protein-rich by-products could be used for recovery of essential amino acids for human consumption, or as is for use in animal feeds, higher value applications for inedible and nonessential amino acids may include providing a feedstock for proteinbased materials, such as plastics, and for the production of biopesticides and commodity organic compounds (naik et al., ; scott et al., ) . along with more obvious uses of protein hydrolysates-animal feeds and biomass for energy recovery-protein-based meals from crop residues and agro-industrial by-products also find value addition through use in biological processes. an example is the use of various oilseed cakes, which have been shown to be ideal mediums for many types of bacteria and fungi responsible for producing a variety of enzymes, antibiotic and antimicrobial compounds, and bioactive metabolites (ramachandran et al., ) . protein-based raw materials can be used for the production of , -ethanediamine and , -butanediamine from the amino acids serine and arginine, respectively . furthermore, protein-based surfactants are valuable mild surfactants, because the structure and properties of the amino acids in the surfactants are similar to the amino acids that make up the tissue of skin. if valorization technologies are to be implemented on a commercial scale, they must work within current legal constructs. however, this does not deal directly with the science involved and may inhibit progress if new legislation is not developed that more closely examines the evidence and whether risk regarding human and animal health is still an issue. in light of current legislation and potential markets for value-added commodities, it is becoming apparent that the use of protein-rich agricultural by-products for lower value applications, such as animal fodder, is no longer a sensible use of such a valuable resource. energy values of feed ingredients for white pekin ducks comparative nutritive value of cassava feaf meal, soya beans, fish meal and casein in diets for growing pigs proximate analysis of castor seeds and cake official publication: association of american feed control officials marine and freshwater products handbook value-added chemicals from animal manure. pacific northwest national laboratory, united states department of energy total food: exploiting co-products-minimizing wastes: proceedings. institute of food research, norwich, england. department for environment, food and rural affairs, . controls on animal by-products: guidance on regulation (ec) / and accompanying implementing regulation (ec) / , enforced in england by the animal by-products (enforcement) (england) regulations . department for environment, food and rural affairs evaluation of cow pea seed meal, vigna sinensis, as a dietary protein replacer for nile tilapia shrimp byproduct feeding and growth performance of growing pigs kept on small holdings in central vietnam protein quality of shrimp-waste meal. bioresour protein utilisation, lysine bioavailability and nutrient digestibility of shrimp meal in growing pigs can we feed the world and sustain the planet? a five-step global plan could double food production by while greatly reducing environmental damage potential for detoxified castor meal physical distribution and characteristics of meat and bone meal protein food security: the challenge of feeding billion people the future of the global food system global food losses and food waste: extent, causes and prevention. food and agriculture organization of the united nations fish meal: historical uses, production trends and future outlook for sustainable supplies market potential and processing of blood products: some overseas observations what a waste: a global review of solid waste management risk regulation, science, and interests in transatlantic trade conflicts. international political economy series variation in ruminal degradation and intestinal digestion of animal by-product proteins methane uk, research report . environmental change institute, university of oxford world renderers organization: rendered products worldwide. global feed & food congress in situ ruminal dry matter and crude protein degradability of plant-and animal-derived protein sources in southern turkey the human-animal link. foreign affairs proximate composition of selected potential feedstuffs for smallscale aquaculture in ethiopia nutritional evaluation of various feedstuffs for livestock production using in vitro gas method. pak utilization of by-products and treatment of waste in the food industry feed for food-producing animals: a resource on ingredients, the industry, and regulationvol. bloomberg school of public health animal by-products (abps): origins, uses and european regulations. universitas studiorum, mantova nra rescinds sheep material policy. american sheep industry association, asi weekly blood and haemoglobin meal as protein sources in diets for gilthead sea bream (sparus aurata): effects on growth governing biosecurity in a neoliberal world: comparative perspectives from australia and the united kingdom. environ analysing global food waste problem: pinpointing the facts and estimating the energy content. cent. eur integrating natural and social science perspectives on plant disease risk, management and policy formulation feeding the future's changing diets: implications for agriculture markets, nutrition, and policy. paper presented at the international food policy research institute conference: leveraging agriculture for improving nutrition and health the world's biggest industry investigation to determine digestibility coefficients of various raw materials in diets for gilthead sea bream animal by-product processing and utilization evaluation of shrimp waste meal as a probable animal protein source for broiler chickens sustainability of meatbased and plant-based diets and the environment valorisation of food waste in biotechnological processes evaluation of traditional sorghum (sorghum bicolor) beer residue, shea-nut (vitellaria paradoxa) cake and cottonseed (gossypium spp) cake for poultry in burkina faso: availability and amino acid digestibility feed composition table use of the mobile nylon bag technique to determine the digestible energy content of traditional and non-traditional feeds for swine oil cakes and their biotechnological applications-a review biorefinery as the bio-inspired process to bulk chemicals agricultural residues as a source of bioactive natural products assessment of the availability of agricultural crop residues in the european union: potential and limitations for bioenergy use biomass in the manufacture of industrial products-the use of proteins and amino acids stability and maturity of a green waste and biowaste compost assessed on the basis of a molecular study using spectroscopy, thermal analysis, thermodesorption and thermochemolysis market report: us rendering: a $ billion industry comparative value of fish meal alternatives as protein sources in feeds for hybrid striped bass valorization of biomass: deriving more value from waste oil crops outlook. united states department of agriculture, washington, dc. united states department of commerce, . current industrial reports: manufacturing profiles . economics and statistics administration, bureau of the census editors, united states department of commerce biodegradation of bloodmeal-based thermoplastics in green-waste composting livestock meat processing: inventory data and methods for handling co-production for major livestock species and meat products. paper presented at the ninth international life cycle assessment of foods conference the reality of precaution: comparing risk regulation in the us and europe key: cord- -j gbj vi authors: prüβ, birgit m. title: microbes in our food, an ongoing problem with new solutions date: - - journal: antibiotics (basel) doi: . /antibiotics sha: doc_id: cord_uid: j gbj vi despite an increasing number of techniques that are designed to mitigate microbial contamination of food and the resulting food borne disease outbreaks, the united states and many other countries across the world continue to experience impressive numbers of such outbreaks. microbial contamination can occur during activities that take place in the pre-harvest environment or in the processing facility post-harvest. current treatments of food that are aimed at reducing bacterial numbers may be only partially effective because of the development of bacterial resistance, the formation of bacterial biofilms, and inactivation of the treatment compound by the food products themselves. this special issue will include basic research approaches that are aimed at enhancing our understanding of how contamination occurs throughout the food processing chain, as well as more immediate and applied approaches to the development and use of novel anti-microbials to combat microbes in food. novel techniques that aim to evaluate the efficacy of novel anti-microbials are included. overall, we present a broad spectrum of novel approaches to reduce microbial contamination on food at all stages of production. while the world may be focused on sars cov- and covid- this year, infectious diseases by other organisms, including bacteria, fungi, or parasites continue to happen. in particular, a number of foodborne disease outbreaks occurred just this year in the united states and other countries. the special issue entitled "development of novel anti-microbials to reduce bacterial contamination of food" is dedicated to finding new solutions to an ongoing problem. with this commentary, the special issue editor outlines the ongoing problem and presents examples of current techniques to mitigate the problem, together with limitations of these interventions. brief research summaries will be included for those special issue authors who have been in communication with the special issue editor prior to submission of their article or who have submitted their article early. the centers for disease control and prevention in the united states (cdc; www.cdc.gov) list seven outbreaks of escherichia coli (serotypes o , o :h , o , o ), outbreaks of salmonella enterica (serovars enteriditis, newport, javiana, dublin, uganda, concord, carrau, schwarzengrund, infantis), four outbreaks of listeria monocytogenes, and two outbreaks of cyclospora between january of and august of (table ). note that many of these outbreaks were not limited to or originated in the us. as one example, the e. coli outbreak associated with sunflower kits involved five us states and canada; it included reported cases, as well as hospitalizations. as a second example, the papayas that caused the salmonella outbreak had been imported from mexico; the outbreak included reported cases in states and hospitalizations. there have been multiple outbreaks in many countries across the world. among these, a multi-country outbreak of e. coli gained significant attention in germany in [ ] . not only did this new e. coli o :h cause , cases of diarrhea, accompanied by cases of hemolytic uremic syndrome and deaths, but it also spread across european countries over the summer. using newly developed tracing tools and network graphs, the origin of the strain could be traced back to fenugreek seeds that had been imported from egypt in [ ] . the virulence mechanism of the new o :h serotype is still not fully understood and it is questioned whether the danger might still be "out there" [ ] . canada experienced a total of outbreaks of salmonella between and [ ] . the incidence of listeriosis increased in south africa, starting in june of to become the world's largest outbreak of listeriosis by july of [ ] . the who estimates that the global burden of foodborne diseases between and was considerable; especially in africa and south-east asia and for children under five years of age and persons of low income [ ] . a general schematic detailing the food processing chain is provided in figure . a typical food processing chain consists of the raw animal or plant, slaughter (of the animal) or harvest (of the plant), processing in a facility, often packaging, and then distribution to the consumer. figure includes examples of environmental conditions that impact the presence of food borne pathogens, as well as common sources of microbial contamination. the raw food stage includes the pre-harvest environment, in which growing animals and plants are exposed to many environmental conditions and stressors, including but not limited to uv exposure, temperature, and humidity [ ] . on plants, contamination by e. coli, s. enterica, and l. monocytogenes depends on irrigation water, manure, and wildlife feces [ ] . to complicate matters, pre-harvest environmental conditions can increase resistance to post-harvest stresses, including those that bacteria will experience during processing and that are aimed at reducing their numbers (e.g., peroxyacetic acid [ ] ). at the harvest stage, transmission of pathogens can depend on the temperature within the facility, as well as humidity and aeration. when harvesting (slaughtering) animals, the hides and the intestines of cattle can be sources of contamination at harvest (slaughter) stage [ , ] . the next step, food processing within the facility involves many surfaces [ ] , including counter tops and conveyor belts. for plants, processing can involve consecutive rounds of wash water [ ] . antibiotics , , x for peer review of wildlife feces [ ] . to complicate matters, pre-harvest environmental conditions can increase resistance to post-harvest stresses, including those that bacteria will experience during processing and that are aimed at reducing their numbers (e.g., peroxyacetic acid [ ] ). at the harvest stage, transmission of pathogens can depend on the temperature within the facility, as well as humidity and aeration. when harvesting (slaughtering) animals, the hides and the intestines of cattle can be sources of contamination at harvest (slaughter) stage [ , ] . the next step, food processing within the facility involves many surfaces [ ] , including counter tops and conveyor belts. for plants, processing can involve consecutive rounds of wash water [ ] . interventions to inactivate microbes on food are diverse. at the food processing stage, they include chemical, physical, and biological treatments. for meat such as beef or chicken and certain vegetables including leafy greens, chemical treatment with organic acids is a common practice, often used in combination with other treatments. as one example, carpenter and coworkers were able to reduce e. coli o :h and salmonella by . to log/cm on beef and chicken meat surfaces by a combination of % levulinic acid with lactic acid or acetic acid [ ] . on leafy greens, chlorine as well as range of other chemicals are used in the wash water to reduce cross-contamination [ ] . intriguingly, the efficacy of such treatments can be limited because of the inactivation of the free chlorine by fresh cut plant exudates, which facilitates cross-contamination during the wash cycles [ ] . in addition, bacteria can form biofilms on many surfaces, including stainless steel, when treated with sub-lethal concentrations of the anti-microbial [ ] . among the biological treatments, bacteriophages have gained importance. as one example, a cocktail of six lytic bacteriophages was used to control salmonella in pet food, so it can no longer be transmitted to humans [ ] . as an example of biological treatment at raw food stage, bacteriophages have been administered to cattle orally and rectally to reduce shedding of e. coli o :h [ ] . in this case, the bacteria were unable to develop resistance to the phages. at the consumer end, the cdc recommends to wash hands and surfaces often, keeping raw food products separate from ready to eat foods, cook to the correct temperature (e.g., f for beef and pork, f for poultry), and keeping food in the refrigerator at f or below. while all these preventative techniques are undoubtedly helpful, outbreaks of food borne infectious disease continue to happen, and a need for novel and innovative approaches is evident. interventions to inactivate microbes on food are diverse. at the food processing stage, they include chemical, physical, and biological treatments. for meat such as beef or chicken and certain vegetables including leafy greens, chemical treatment with organic acids is a common practice, often used in combination with other treatments. as one example, carpenter and coworkers were able to reduce e. coli o :h and salmonella by . to log/cm on beef and chicken meat surfaces by a combination of % levulinic acid with lactic acid or acetic acid [ ] . on leafy greens, chlorine as well as range of other chemicals are used in the wash water to reduce cross-contamination [ ] . intriguingly, the efficacy of such treatments can be limited because of the inactivation of the free chlorine by fresh cut plant exudates, which facilitates cross-contamination during the wash cycles [ ] . in addition, bacteria can form biofilms on many surfaces, including stainless steel, when treated with sub-lethal concentrations of the anti-microbial [ ] . among the biological treatments, bacteriophages have gained importance. as one example, a cocktail of six lytic bacteriophages was used to control salmonella in pet food, so it can no longer be transmitted to humans [ ] . as an example of biological treatment at raw food stage, bacteriophages have been administered to cattle orally and rectally to reduce shedding of e. coli o :h [ ] . in this case, the bacteria were unable to develop resistance to the phages. at the consumer end, the cdc recommends to wash hands and surfaces often, keeping raw food products separate from ready to eat foods, cook to the correct temperature (e.g., f for beef and pork, f for poultry), and keeping food in the refrigerator at f or below. while all these preventative techniques are undoubtedly helpful, outbreaks of food borne infectious disease continue to happen, and a need for novel and innovative approaches is evident. the authors of this special issue address the above outlined need for the development of novel intervention techniques. dr. valentina trinetta from kansas state university in the us studies a variety of foodborne pathogen bacteria, including salmonella typhimurium monophasic, listeria monocytogenes, and stec e. coli. her research focus on understanding pathogens' ecology and identifying microbial entry routes into the food supply chain. one study described different serotypes of s. enterica in feed mills, including s. agona, s. mbandaka, s. senfenberg, and s. scharzengrund, all of which are of a public health concern [ ] . dr. trinetta's work extends to the development and implementation of antimicrobial interventions to reduce and control foodborne pathogens on different foods. her group's contribution to this special issue will be a study on the effect of combinations of several antimicrobial strategies for the processing of strawberries. dr. siyun wang from the university of british columbia in canada pursues an interesting range of food safety related research. one of her studies described an oxidizing mixture of hypochlorite and hydrogen peroxide to reduce e. coli o :h , l. monocytogenes, and s. enterica from alfalfa and radish seed. the combination treatment reduced bacteria by log, but was less effective when seeds had been stored for weeks or longer [ ] . most recently, her group is conducting a series of research projects exploring the use of bacteriophages (i.e., viruses that infect bacteria) on inactivating foodborne pathogens on fresh produce and poultry products [ ] . this group works on improving food processing and safe food handling for long term food security. dr. christina andrea müller, together with dr. gabriele berg and their research group from graz university of technology in austria, specialize on the study of the plant microbiome. recognizing the relevance of the plant microbiome and the metabolic pathways of the plant associated bacteria for the discovery of bioactive compounds, she described the potential of the moss microbiome in the discovery of such compounds (sphagnum spp.) [ ] . another research article described the microbiome of edible plants of the genus brassica and the isolation of bacterial strains of public health significance, in particular the prevention of cancer [ ] . the new emphasis of her plant microbiome studies is the discovery of anti-microbials for applications in food production technologies. dr. kalidas shetty from the department of plant sciences at north dakota state university in the united states has over years of teaching and research experiences. the goal of his research is the development of climate change-resilient food system innovations to combat global food and nutritional insecurity-linked public health challenges. he does this by studying the critical role of cellular and metabolic basis of redox-linked biology and dual functional roles of plant phenolics. recent articles have highlighted the phenolic bioactive-linked anti-hyperglycemic and anti-bacterial properties in the herbs from the lamiaceae family [ ] , as well as the antioxidant and anti-diabetic functionalities in peruvian corn [ ] and bioprocessed cashew apple juice [ ] . the contribution to this special issue is from another research focus; metabolic-linked system innovation to enhance inducible phenolics with antimicrobial properties in food and medicinal plants for food safety and human health relevant applications. this manuscript is co-authored by dr. dipayan sarkar and ashish christopher. a research group including bruno kolb, lorina riesterer, anna maria widenhorn, and leona bier from the student research centre in Überlingen, germany contributed an article to this special issue where monitoring the emission of hydrogen using a specific hydrogen sensor led to a recognition of contamination by borrelia of cockerel and blood in the case of lyme disease. this group of researchers has a background of similar research, utilizing headspace gas chromatography to monitor hydrogen and carbon dioxide for the purpose of determining efficacy of anti-microbials [ ] . the same technique of headspace gas chromatography was used to metabolically profile borrelia in blood [ ] . overall, the techniques by this research group aim at testing efficacy of anti-microbials. this special issue covers an impressive array of novel techniques to reduce microbial contamination of food and food products. from anti-microbial treatments to phages, as well as genomics approaches to reducing bacterial contamination, we present a range of biologically derived interventions and include chemical techniques to determine the effectiveness of anti-microbials. these novel techniques are all fundamentally different from what is currently in use and once in application, should aid in the mitigation of food borne bacterial infections diseases. funding: bmp was supported by the usda national institute of food and agriculture, hatch project number nd . prospective genomic characterization of the german enterohemorrhagic escherichia coli o :h outbreak by rapid next generation sequencing technology trace-back and trace-forward tools developed ad hoc and used during the stec o :h outbreak in germany and generic concepts for future outbreak situations german enterohemorrhagic escherichia coli o :h outbreak-the danger is still out there hexemer, a. outbreaks of salmonella illness associated with frozen raw breaded chicken products in canada outbreak of listeria monocytogenes in south africa, - : laboratory activities and experiences associated with whole-genome sequencing analysis of isolates estimates of the global burden of foodborne diseases; world health organization effect of relative humidity on preharvest survival of bacterial and viral pathogens on the surface of cantaloupe, lettuce, and bell peppers fitness of human enteric pathogens on plants and implications for food safety assembly and characterization of a pathogen strain collection for produce safety applications: pre-growth conditions have a larger effect on peroxyacetic acid tolerance than strain diversity survival of escherichia coli o :h on cattle hides detection and quantification of seven major serogroups of shiga toxin-producing escherichia coli on hides of cull dairy, cull beef, and fed beef cattle at slaughter(dagger) properties of the stainless steel substrate, influencing the adhesion of thermo-resistant streptococci insight into the prevalence and distribution of microbial contamination to evaluate water management in the fresh produce processing industry efficacy of washing meat surfaces with % levulinic, acetic, or lactic acid for pathogen decontamination and residual growth inhibition effect of acidified sodium chlorite, chlorine, and acidic electrolyzed water on escherichia coli o :h , salmonella, and listeria monocytogenes inoculated onto leafy greens modeling of free chlorine consumption and escherichia coli o :h cross-contamination during fresh-cut produce wash cycles effect of chlorine-induced sublethal oxidative stress on the biofilm-forming ability of salmonella at different temperatures, nutrient conditions, and substrates bacteriophage cocktail for biocontrol of salmonella in dried pet food oral and rectal administration of bacteriophages for control of escherichia coli o :h in feedlot cattle characterization of salmonella enterica isolates from selected u.s. swine feed mills by whole-genome sequencing disinfection of afalfa and radish sprouting seed using oxidizing agents and treatments compliant with organic food production principles inactivation of salmonella enterica on post-harvest cantaloupe and lettuce by a lytic bacteriophage cocktail bioprospecting plant-associated microbiomes two phages of the genera felixunavirus subjected to hour challenge on salmonella infantis showed distinct genotypic and phenotypic changes evaluation of phenolic bioactive linked anti-hyperglycemic and helicobacter pylori inhibitory activities of asian basil (ocimum spp.) varieties. j. herb evaluation of phenolic antioxidant-linked in vitro bioactivity of peruvian corn (zea mays l.) diversity targeting for potential management of hyperglycemia and obesity beneficial lactic acid bacteria based bioprocessing of cashwe apple juice for targeting antioxidant nutraceutical inhibitors as relevant antidotes to type diabetes monitoring of hydrogen emission from bacteria in food, animals and in the blood of humans suffering from lyme disease by a specific hydrogen sensor metabolic profiling of borrelia in ticks and in whole blood samples by headspace gas chromatography-a case report the author thanks v. trinetta, s. wang, c. müller, k. shetty, and b. kolb for editing and approving the paragraph on their own research. the author declares no conflict of interest. antibiotics , , key: cord- -rsgdqk x authors: nikolova, milena s. title: chapter best practices and approaches using behavior-smart thinking in tourism industry scenarios date: - - journal: behavioral economics for tourism doi: . /b - - - - . -x sha: doc_id: cord_uid: rsgdqk x this chapter provides ten practical case studies illustrating application of behavioural thinking in different contexts across the travel industry. the practical examples come from a wide variety of entities – from young innovative startup companies to clever destinations experimenting with new management models. the stories were selected to demonstrate that behavior-smart thinking works with different scale, at different levels and can be effectively applied to commercial challenges such as optimising experience design or to complicated sustainability issues such as food waste and climate footprint. throughout the previous chapters, this book advances the idea that behavioral economics can enhance the thinking and practices in the growing travel economy. many of the discussions in the text propose that behavior-smart thinking helps explain some of the failures in the contemporary tourism system and can be at the core of the solutions to address them. chapter , tourism of the (near) future: growing, faster, on-the-go, reviewed some of the big picture trends in our societies and contemporary living that will deepen issues such as our relationship with technology, human impact on pristine areas, and the sustainability crisis. chapter , behavior-smart thinking for destinations, zoomed into the contemporary realities of destination management and offered a behavioral read of why some of the challenges exist and how they can be fixed. chapter , behavior-smart thinking for tourism companies, applied a behavioral lens to the practices in the private sector and proposed that behavior-smart thinking can optimize commercial success and the footprint of businesses along the tourism value chain. to build on that, this chapter offers a set of different cases that demonstrate how behavior-smart thinking can work in reality. to enhance the conceptual propositions and discussions presented throughout the book, this collection of cases reveals already existing practices that can serve as a proof that there is a significant benefit in drawing on behavioral economics knowledge. many of the projects and solutions that are presented in the cases are new and still under development, but they are producing results and lessons learned that can be of benefit to others willing to experiment. the scale of the different examples collected here also differs. the first case explores a bold experiment conducted by virgin atlantic and offers an ambitious demonstration of how simple and low-cost behavioral interventions can produce significant reduction in the carbon footprint and profitability of the airline sector. with the growing attention on the climate crisis and the economic challenges that covid- caused to the airline industry, this story is worth wider attention. the second case presents a recently developed technology-enabled tool for the restaurant industry that translates the complicated science of estimating the carbon footprint of different foods into a simple-to-understand system categorizing meals from low-to high-impact. the story talks about how this system influences customer choices and empowers chefs to optimize the carbon footprint of their entire menus. the third case presents the tourism strategy of one of the innovationoriented destinations, the netherlands, and shows the benefits of using behavioral segmentation. another destination-level case reveals the experience of finland's capital, helsinki, with the roll-out of a sustainability platform that uses behaviorsmart thinking to simplify responsible choice-making for both residents and visitors. the fifth case focuses on an unusual resort located in the bulgarian rhodope mountains that use behavior-smart design to engage its guests in experiences and activities that are good for them and good for nature. case takes the reader to beautiful iceland and discusses its experience with the iceland academy, an online platform using behavior-smart design to ensure that travelers arrive at the destination prepared for the unusual weather conditions, rugged terrains, and specific cultural norms. another northern example comes from fogo island, which is the focus of the seventh case presenting the economic nutrition mark developed there and discussing why it is a brilliant solution to the behavioral barriers for responsible traveler behavior. case presents adventure junky, a young but fast-growing tourism company from australia that gamifies sustainable tourism experiences and rewards responsible choice making. the ninth case talks about the efforts of the food service industry in norway to cut food waste and optimize failures along the food value chain. the discussion highlights tools and tactics that are at the core of the waste-cutting strategy and explains why they are effective in producing the desired behavioral change. the final case in the collection takes the reader to the västmanland regionÀa small but ambitious regional destination in sweden. it tells the story of the bold experiment of the local tourism authority in applying behavior-smart thinking to support the achievement of its strategic goals and to enable local tourism businesses to apply behaviorally informed solutions to optimize profitability and sustainability efforts. the diversity of the stories is a demonstration of the different scale and scope with which behavioral practices can be applied in the travel industry. they can be a good encouragement for individual entrepreneurs and business leaders, who are offered proof that companies can optimize their commercial practices and strengthen sustainability performance by adopting behavior-smart thinking. the real-world stories from destinations can hopefully inspire more tourism authorities and politicians to apply insights from behavioral economics and improve policy and management practices. case behavior-smart lowering of airline carbon emissions. . .today one of the biggest sins of the travel industry is the carbon footprint of air travel. the fast growth of the tourism sector is accompanied by a fast increase in the number of flights that are taken internationally ( . % increase in ) or domestically ( . % increase in ) (icao, ) . the aviation industry produces about million tons of co annually, which constitutes % of the global emission generated by human activities (atag, ) . even though the industry is making progress in fuel efficiency technology and utilization of biofuels, this takes time and requires sizable investments. the behavioral approach an experiment conducted a few years ago by virgin atlantic and researchers from the university of chicago, and the london school of economics revealed that there might be great potential in applying behavior-smart tactics for the lowering of co emissions of planes with the existing technology and existing fuels. as one of the airlines that lead in efforts to do business in a responsible manner, virgin atlantic has a special fuel efficiency team, tasked with exploring ways in which co emissions can be lowered through optimization of the fuel efficiency of flights. the three most effective tactics established by the team require proactive efforts of the pilots and include (gosnell, list, & metcalfe, ) : . efficient fuel load, which means calculating and loading the precise amount of fuel needed for the respective flight to avoid unnecessary overload. . efficient flight, which means benefitting from several in-flight behaviors that can impact fuel efficiency, including ensuring optimal speed and altitude based on information from air traffic control, monitoring and adjusting to enroute weather updates, and ensuring efficient aerodynamic arrangements with respect to flap settings, takeoff, and landing gear. . efficient taxi-in, which means turning off at least one engine during taxiing to the gate upon landing. despite the simplicity of the three approaches and their inclusion in the standard operating procedures in pilot manuals (virgin atlantic, ) , most pilots did not automatically adopt them. to encourage the proactive use of these fuel efficiency tactics, the team leading the experiment applied a series of behavioral interventions that aimed to influence the motivation of pilot teams. about captains were randomly assigned to four groups: three experimental and one control group (metcalfe, gosnell, & list, ) : À the feedback group: pilots in this group started receiving a monthly report of their fuel efficiency flight performance, which included comparing the percentage of flights in which they applied the three fuel-saving tactics to the percentage from the prior month. À the targets group: captains in this experimental group also received a monthly report of their fuel efficiency flight performance, but it was complemented by a personalized monthly performance target that was % above their preexperiment baseline performance. for example, if the preexperiment performance was %, the target for the following month was set at %. À the prosocial incentives group: pilots in this experimental group received the monthly performance report, as well as targets and were also informed that if they achieve their personalized targets, a d donation will be made on their behalf to the charity of choice. À the control group: pilots in this group continued operating as usual but were aware of the ongoing experiment. the experiment was executed over an -month period covering over , flights. the results of this unique trial reveal that soft behavioral interventions produce significant optimization of fuel efficiency leading to lowering of co emissions and significant cost savings. the researcher team estimated that over the course of the study, the modified behavior of pilots produced . million kilograms of fuel saved for the airline translating to cost savings of $ . million and co reduction of million kilograms. these savings translate to the impressive cost of emission reduction of negative $ per ton of co given that at the time of the experiment, efficient residential lighting is the lowest cost technology for reducing carbon emissions performing at about $ per metric ton of co abatement (gosnell et al., ; metcalfe et al., ) . this experiment is probably the most significant effort to apply behavioral knowledge toward more sustainable operations in the travel industry. the effective behavioral change among captains is triggered mainly by the so-called hawthorne effect or the awareness of being monitored. the mere fact that fuel efficiency behavior is monitored and tracked makes captains much more likely to apply the three fuel-saving tactics. this is observed across all groups, including the control group in the experiment. the personalized performance reports and especially personalized targets are very powerful in fueling pilots' motivation to engage in fuel-efficient flying. the prosocial incentive did not strengthen the likelihood that captains will apply the tactics beyond the levels achieved by the personalized targets but increased their job satisfaction. an important finding was that the experiment triggered long-term changes in pilot behavior sustained long after the end of the project. the results of this experiment hold several important lessons for the airline industry and the travel sector at large. first, while investment in new clean technologies, energy efficiency, and cleaner fuel mixes should not slow down, there seem to be opportunities for behavioral optimization of company operations that can produce significant savings and lowering of footprint. a widespread adoption of the same soft behavioral measures by all airlines can immediately produce significant reduction of co emissions and generate substantial fuel and cost savings for the companies. if virgin atlantic achieved co reduction of million kilograms and saved . million kilograms of fuel over , flights, imagine the magnitude of co reduction and fuel optimization that can be achieved by the . million scheduled flights that were executed globally in (atag, ) . second, companies in the sector, especially large ones such as airlines, transport operators, large hospitality groups, big tour operators, attraction operators, and others, hold tremendous power for triggering responsible behavior among their employees and producing significant improvement in sustainability performance across the sector. if more companies made their staff aware that, for example, energy efficiency, fuel efficiency, or social impact behavior are priorities, and therefore relevant employee behavior is monitored and reported on regular basis, they can produce major effects. the fact that the behavioral measures are relatively simple and inexpensive further reinforces the importance of exploring this potential on a sector-wide level. best practices and approaches using behavior-smart thinking chapter | the challenge the food system on global level is responsible for the production of a quarter of greenhouse gas emissions. the livestock sector alone generates the equivalent of . gigatonnes of co e emissions per year, which represents % of the emissions produced by the food system and more than % of all human-induced greenhouse gas emissions (fao, ) . the majority of the harmful emissions come from beef and cattle milk production, which respectively contribute % and % of what the entire sector generates. pork accounts for about % followed by poultry and egg production, which contribute % to the emissions of the sector (gerber et al., ) . while many other harmful activities that contribute to climate change and degradation of the natural environment can be limited or prevented, food is a basic human need. the food products provided by the livestock sector are fundamental to diets in many cultures around the world. that means that there is a need to explore ways in which food habits can be adapted to sustain healthy nutrition while at the same time lowering negative impacts on global warming. one of the beliefs that shape contemporary thinking about food and climate change is that moving to a menu with more plant-based foods and meats from animals with little enteric fermentation can lead to lower emissions from the food system (bryngelsson, wirsenius, hedenus, & sonesson, ; carlsson-kanyama & gonzalez, ) . emphasis on local produce can also have an impact as long-haul transportation can increase the emission footprint of foods that are imported from distant source markets even if they are climate-friendly when produced locally (carlsson-kanyama & gonzalez, ) . in that sense beans or rice that are generally characterized with lower footprint than fresh chicken, might end up being less climate-friendly than chicken if imported from a producer from another continent. the main challenge with prompting a change in eating behavior that accounts for climate footprint of different foods is complexity. first, climate change is a complicated issue that people effectively ignore in everyday life (marshall, ) . second, the science that underlies the footprint of different foods is not easily accessible to everyone. third, making an effort to track food and adjust eating behavior based on climate footprint is nearly impossible for the average contemporary person who is not equipped with scientific tools that make it possible to calculate the co emissions of every food on their daily menu and whose attention is drowning into many other tasks with much more immediate consequences. a brilliant solution to the complexity of tracking the climate footprint of foods is carbonate-a carbon footprint calculator that enables restaurants to add climate labels to menus. powered by extensive scientific knowledge, the web-based system provides an easy to use menu-planning tool for restaurants and generates easy to understand carbon footprint labels for their guests. on the back end, the system enables restaurant owners and chefs to plan and ensure smooth management of purchasing processes. to power the climate footprint calculator the platform prompts chefs to enter detailed information about the ingredients that go into each meal. based on that carbonate produces a climate footprint value for every item on the restaurant menu. depending on the estimated value meals are marked as green if their climate footprint value is low, yellow if the value is average, and red if the footprint value is comparatively high. the color code system simplifies the processing of the value and makes it easy for customers to understand whether a meal is more or less climate-friendly. food choice is one of the contexts in which present bias or the inclination to put more focus on immediate gains rather than likely gains in the future is most powerful. usually when restaurant guests decide what meals to choose they are motivated by the need to satisfy the hunger they feel at the respective moment and less so by the importance of tackling climate change. in general, it has been established that food choice is usually more heuristic-driven rather than fueled by rational weighting of options (scheibehenne, miesler, & todd, ) . the carbonate food label makes it possible to include climate footprint as a factor, albeit secondary, in the decision-making process. after guests see the menu, they usually bring their choices down to two to three options that align most with their taste and try to make a decision between them. at this stage the carbon footprint value can be a factor considered by the guest and can become the reason for choosing one meal versus another from the narrowed choice set. initial experiments with carbonate's labeling system confirmed its effectiveness in influencing consumer behavior by increasing the likelihood of choosing a green-labeled meal and lowering the likelihood of going with a red-labeled option (brunner, kurz, bryngelsson, & hedenus, ) . further applications across different contexts confirmed that labeled menus produce emission reductions from existing users of up to %À % (bryngelsson, ) . an interesting side effect of the introduction of the carbonate solution is modification in the behavior of head chefs in restaurants using the system. empowered by the climate labels, the chefs in many of the participating restaurants felt motivation to make adjustments to meal recipes in effort to lower their carbon footprint and strengthen the overall climate profile of the menu (bryngelsson, ) . changing diets and nudging people to make food choices that are more climate-friendly can lead to significant optimization of the footprint of the food system but also improve the well-being of consumers. it is important to realize that climate footprint might not be the factor that leads to the decision-making of most guests or consumers (peattie & collins, ) but the salience of the footprint information makes it possible to include climate-friendliness as a factor in general. a visible and easy to understand classification enables guests to easily process and compare climate-related information, and include it as factor in the decision-making. consumers will not make the effort to figure out climate footprint of foods and meals in a restaurant or at home but once it is available and easy to understand, they readily take that into account. the challenge an essential component of marketing strategies is segmentation. this is the step of breaking down the total market into groups of consumers that are united by similar characteristics. once segments are defined, companies or destinations can select the ones that they would like to target as part of their strategy. even though marketing textbooks have long ago rejected the effectiveness of using basic demographic characteristics as basis for formulating segments, many tourism destinations continue to do so. the main identifier that is used by destination authorities to characterize segments is nationality or source destination. this means that numerous national and regional tourism strategies are grounded on the goal of targeting visitors from germany, france, or the united states rather than visitors who travel in a certain way. while this approach is simple and easy to manage, it is not optimal in terms of defining who is really the desired customer and what will be the impact their travel behavior will have on the destination. nationality alone cannot be an effective differentiator because two families living on the same street in a city in say, germany might have radically different travel styles and holiday expectations. one family might be the classical sun-and-sand resort goers interested in all-inclusive holidays with everything taken care of and little possibility for surprise. their next-door neighbor family might love adventure and have interest in places where they can experience interesting cultures and have fun out in nature while hiking or biking. the different holiday preferences of these two families require different tourism offerings, different services, and different physical infrastructure. on the other side, their travel styles produce different impacts on the destination and the local service providers. in that sense their nationality does not reveal much except the starting point of their trip. as discussed in earlier chapters of this book, there is much more meaning in using travel behavior as basis for segmentation and identification of desired traveler profiles for targeting. for years many leading destinations have been using personas or traveler profiles to identify desired consumer audiences based on their value systems, travel curiosity, and holiday habits. a great example among them is the netherlands with its perspective strategy, which identifies a careful selection of targeted traveler profiles as a key step toward its goal of making tourism beneficial for all dutch citizens (nbtc, e). it states: "in order to amalgamate tourism with the everyday society as optimally as possible, to optimise the benefits for dutch people and the economy and to minimise overload trouble, we aim to attract visitors who will contribute to the netherlands as a future-proof destination. these visitors will add value and will not cause trouble." in order to identify the desired visitors who could be attracted to the netherlands and will make positive impact on its economy, the dutch tourism board (nbtc) produced five excellent personas with details about their specific lifestyles and holiday preferences. they include: achiever michaelÀa young professional in his mid- s with strong orientation toward status, materialism, and career. still unmarried and with higher than average income, michael is eager to spend on experiences that involve thrill, physical activity, and entertainment (nbtc, a) . upper-class paulÀan established and successful professional in his s who cares about tradition, family, and etiquette. with grown-up kids and a successful career, paul is health-and environment-conscious making him interested in experiences that offer opportunity to share interesting experiences with family, be active, and feel rejuvenation away from crowds and close to nature (nbtc, d) . traditional maryÀa family-oriented part-time professional with strong preference in predictable and well-planed life. with grown-up kids and grandchildren, mary lives away from the city and is comfortable with traditional norms, order, and discipline. she is interested in holiday experiences that are outside of the main season and include quiet, somewhat active and relaxing activities (nbtc, c) . postmodern noraÀa young freelancer in her mid- s with one child and an open-minded, immaterial, and tolerant outlook to the world. nora is an urban creature and fan of yoga, photography, and travel adventures with friends. an enjoyable holiday for her means an open itinerary, which includes some socializing and bar hopping, shopping, and enjoyment of local lifestyle (nbtc, b) . mainstream peterÀa traditionalist in his early s with a wife and two children, peter seeks to balance between his older-school thinking and the recognition that the contemporary realities bring new norms and values. he likes spending time with the family but loves socializing too. an ideal holiday for him includes some classics such as taking a beach vacation, staying at an allinclusive resort, and visiting amusement parks. the nbtc personas are a fantastic illustration of the value of a behavioral deep dive in desired market segments. to offer a realistic sense of who is the traveler that is to be invited to the netherlands the profiles offer a glimpse at the persona's daily calendar and work life, as well as personal lifestyle specifics such as favorite magazines and music, hobbies, and typical leisure activities. a fun and exciting element of these personas is the look in their hand luggage revealing further details about them. for example, in his small black bag achiever michael carries an ipad and noise-isolating headphone, a sports magazine, mints, sunglasses, a high-quality sports watch, and a male cosmetic set. on the other hand, postmodern nora carries a casual beige personal bag with a couple of magazines such as psychology today, a lonely planet guide, purple sunglasses, a bag of dried basil, a classical photo camera, a black moleskine notebook, and a pencil. based on all lifestyle details the personas include specifics about the attitude toward the netherlands and the characteristics of a potential holiday in the destination. for example, we find out that upper-class paul associates the netherlands with cycling, amsterdam, beautiful landscapes, cheese, and friendly locals. he finds it an attractive destination for a short holiday. he would visit with his family during shoulder season, stay at a nice hotel in amsterdam, and mix cultural experiences with culinary adventures and shopping. the likely holiday of traditional peter is also short and not his main family vacation for the year. his visit style, however, is very different from paul's. he is likely to stay at a holiday home rather than a hotel and be in duirell rather than amsterdam where the family can go to the local amusement park, spend some time at the nearby beach, and enjoy some dutch pancakes. the use of behavioral segmentation that groups travelers on the basis of how they travel and consume the visited destination, is the most effective way of understanding potential audiences and targeting the ones that are a good fit. it ensures a great level of focus that matters for two reasons. first, a deep behavioral dive helps ensure the best match between the offerings of the destination and the visit style of the guests. if a small region is predominantly rural and has well-preserved traditional villages with little infrastructure, it makes sense to target travelers who are curious about local traditions, comfortable in rural setting, and do not mind hiking or biking. targeting a wider audience risks inviting guests who are uncomfortable with the travel style that the destination requires and whose unmet expectations will lead to great dissatisfaction. the second reason is that in the era of overtourism casting a wide net of targeting entire nations is not sensible because it stimulates overdemand that is damaging. to balance between the opportunity to extract socioeconomic benefits from tourism and the threat of being overwhelmed with too many visitors requires careful selection of targeted audiences. behavior-smart targeting is also the best way to ensure optimal balance between visible and invisible tourism impacts. there is one more significant benefit in the use of behavioral segmentation and personas. the development of personas that are realistic and easy to imagine is powerful for local businesses. they can easily relate to them and build natural familiarity with the potential guests, which makes them more successful in meeting their needs. contemporary destinations should no longer use source destination as a generalizing characteristic that is basis for segmenting the market. in order to identify the travelers whose behavior will best fit with the local social norms and align with economic goals, tourism boards should place traveler behavior at the heart of their segmentation and targeting strategy. case using behaviorally-friendly design to encourage loan payoff the challenge according to data from the federal reserve bank of new york as of december , , total household indebtedness of us households was $ . trillion, marking a . % increase from the third quarter of and . % from the second quarter of . as of december , , . % of us household outstanding debt ($ billion) was in some stage of delinquency and . % ($ billion) was seriously delinquent (at least days late or "severely derogatory") (federal reserve bank of new york, ). a large share of household debt is associated with mortgages. in the total number of households using more than % of their income for housing increased to million, with almost % of households using more than % of their income to pay for housing costs (common cents lab, ) . long payoff periods generate additional debt burden due to interest, higher risk of default, and lack of savings. to respond to this need, fintech startup apasave developed a smart softwarebased service that intelligently syncs household income and expenses to enable faster mortgage payoff and thus an increased savings rate. even though the opportunity offered by the young company is easy to use and translates to obvious benefits such as decrease in loan term by over years and faster building of net worth through saving money, consumers are very hesitant to enroll and benefit from this opportunity. assumptions that fuel the problem according to traditional thinking, debt repayment decisions are a tradeoff between the desire to minimize current and future total costs over the life of the loan. if this reflects typical consumer behavior, most debtors would base their repayments on a calculated amount that offers optimal balance between minimizing current costs and total costs depending on the household's income. however, behavioral scientists have established that due to a strong anchoring effect, minimum required payments strongly determine the decision for what amount the consumer will pay (navarro-martinez et al., ) . making information about future cost of the debt salient has also proved to influence debt repayment behavior, suggesting that under regular circumstances, consumers do not consider future cost and do not seek to optimize against their current ability to pay. another traditional assumption, which seems to be violated here, is that consumers optimize when choosing between different options available to them. if that was the case, making debtors aware of the apasave service should be sufficient to motivate them to choose the service, as it provides a favorable optimization between current costs and long-term wealth accumulation. the behavioral explanation for why the problem exists previous research in the area of behavioral finance has revealed that average consumers seek to simplify financial decisions and often use heuristics. biases, such as anchoring, have powerful influence on the decisions that consumers make, including when deciding on what payment amounts to make on their debts (navarro-martinez et al., ). one common heuristic used by consumers to simplify debt payment decisions is rounding. according to wang and keys ( ), two-thirds of the consumers who stick to minimum rate payments when repaying their credit cards round up within $ of the required amount. analysis of mortgage repayment data conducted by the common cents lab and apasave also revealed that many people are paying more than required due to rounding of payment amounts to the nearest $ or $ . this suggests that the voluntary inclination of debtors to make higher payments is part of a decision simplification tactic rather than rational effort to optimize current and future costs. resistance to switching to the more favorable apasave service could be explained by two effects. one is inertia or status quo bias, which has been shown to have strong influence on consumers' financial decisions, preventing them from benefiting from apparently superior options (madrian & shea, ) . the second effect is associated with the perception of savings as loss (seeing earned money as money that cannot be spent). to respond to the challenge, common cents lab and apasave took a behaviorally-informed approach. first, to suppress the association between savings and loss, communication messages promoting the company's services were reframed around earning money back rather than saving. the value proposition of the service was changed from "save money on a mortgage" to "earn money back from a mortgage." as part of that intervention, the name of the company was also changed from apasave to earnup (common cents lab, ). the second intervention revolved around battling the anchoring effect of minimum payment rates. to overcome the inertia of choosing to make a monthly payment that equals the required minimum, earnup proactively prompted consumers to overpay by explaining the advantage of increasing monthly payments by even a small amount. given that the average mortgage amount for a new loan in the united states is $ , at a -year-fixed interest rate of . %, adding just an extra $ a month to the repayment amount will translate to savings of over $ , and early full repayment by a whole year (common cents lab, ) . using knowledge about rounding up as heuristic, the team tested two prompt designs: ( ) prompt to overpay by rounding up and ( ) prompt to overpay without a suggestion for rounding up. the emphasis on earning versus saving in the value proposition and in the name of the company translated to a sharp increase of the interest among consumers exposed to advertisement. the new framing of the marketing messages led to an increase of click-through rates on online advertisements by %. direct prompts for overpaying provided rationale and also led to change in repayment behavior. both conditions (prompt to overpay and prompt to overpay by rounding up) increased individual monthly payments, but the rate observed for the roundup group was higher ( % compared to % for the general overpay prompted group). in both conditions, the average amount by which consumers decided to overpay was $ , which translated to about $ , of savings over the life of a loan and a total of $ , , in interest saved for earnup users who agreed to pay more than their minimum payment. a full % of the people who agreed to overpay declared that they had never before done that with any other loan (common cents lab, ) . based on insights on financial behavior, earnup continues to successfully grow its business of integrating loans and optimizing their repayment. using heuristics-based design in messaging and service, the startup simplifies financial decision-making and optimizes repayment and saving in a way that is favorable for debtors and profitable for the company. the principles of healthy and happy living are well knownÀeating high-quality, fresh and carefully prepared food; spending more time outside in nature; being physically active and exercising; and spending time with close ones (helliwell, layard, & sachs, ) . because contemporary daily life has evolved in a way that makes all of these principles difficult to adhere to, they often remain plans for the future when there is more time and energy, maybe during the next holiday. in reality, however, holiday is rarely a time when travelers get the chance to eat healthier or be more physically active than their day-to-day life. the design of most holiday resorts also does not help and creates favorable environment for people to do what they "normally" do in day-to-day life both in terms of food or activity. in most recent years technology has exacerbated that. whether it is television or mobile devices, they absorb the attention of family members and take away from social interaction and relationships (ayeh, ) . devices also alienate guests from the space around them and the place of their holiday (tribe & mkono, ) . in that sense, even if they are at a resort in a destination with fantastic nature, guests can easily miss the opportunity to engage with it. for children who do not experience nature in day-to-day life being outdoors during a holiday can be an opportunity to establish an important link to nature and learn about it (bruni, winter, schultz, omoto, & tabanico, ) . what if the holiday is designed in a way that includes all the "right" elements making guests do what is best for them but in a way that is effortless and enjoyable? there are already examples of resorts that nudge travelers to stay away from technology (by limiting access to wi-fi), to eat healthy (by offering only healthy items on the menu), or to stay active (by offering different sports activities as part of the holiday package). in most cases, however, these are specialized places that guests book because they intentionally want to get away from unhealthy dynamics in daily realities. and what about the rest who might know "what is right" but who do not have the time or means to go on such a holiday. an example of how the traveler experience can be designed to gently nudge the guest to do what is good for them comes from factory food-n-dance, a small outdoors resort for families located in a mountainous village in the rhodope mountains in bulgaria. the resort was found by a young couple who early in life realized that the stressful lifestyle of the busy professionals in the big city cannot be a healthy setting for a family. they decided to find a life model that allows them to live outdoors and raise their children in a way that keeps them connected to nature and ensures healthy living. this led the couple to the idea to open a resort that was designed to offer a back-to-nature experience for families. the design of the complex is such that it keeps guests mostly outside engaging them in a variety of family adventures. the accommodation space is simple and relatively small, which makes it less likely for people to stay in, except when they are sleeping. there are no tv sets anywhere in the resort and no internet connection beyond the mobile g, which is spotty. the outdoors area is large and green with plenty of attractive facilities and exciting things to do. in addition to a natural water pool with boats, there is a dry pool (a large pool with small balls offering children an alternative when weather makes swimming less attractive), hot tubs, sauna, steam room, a himalayan salt room, an extra-long tube slide, trampoline, giant lego corner, large jumping airbag, bike track, electric bikes, foam making machines, as well as snow-sliding donuts for the winter. all of these amenities make up a family paradise, which attracts parents and children for a holiday of fun. what makes the factory food-n-dance extraordinary, however, goes beyond its physical features. the all-inclusive format of the resort actually engages guests in a mindfully designed sequence of nature-based and healthy recreational activities. from the delicious all-natural meals with mostly local ingredients to the craft workshops for children and parents, guests are invited into a behavioral routine that is good for their bodies, their minds, and their relationships. the daily program starts with a healthy breakfast, during which children can make their own pancakes or waffles. in the afternoon children take part in bread-making or home pizza making workshops, which teach them how to prepare their own food and how to be creative with it. every morning and every afternoon there are hikes in the surrounding mountains, offering a wide variety of routes with nature observations spots, small rivers, waterfalls, diverse landscapes and a rich biodiversity. hikes are usually led by the factory's founder who enriches the experience with different stories and local legends. every day there are some craft workshops engaging children and parents in learning how to work with leather and wood or how to knit and paint. in the evenings, children also learn how to make home-made chocolate candy or other healthy desserts. the end of the day for young guests is in the himalayan salt room where the factory's owner tells them interesting stories or plays music for some dancing fun. at the same time parents can enjoy some social fun with a cup of local herbal tea or a glass of wine around the fire in a large outdoors tent. the -degree experience offered at the factory is a great example of how behavior-smart thinking can lead to the design of holidays that are both exciting and good for the traveler. families do not really come to this resort for a wellness holiday. their primary motivation is the attractive design of the space and the richness of things to do for the kids. it is the mindfully crafted routine combined with the attractive space that leads to the powerful combination of offering an enjoyable and healthy vacation. both the physical space and the intangible routine influence the behavior of resort guests. the physical space is designed in a way that nudges everyone to be outdoors. the many exciting attractions for children naturally keep them physically active and outside, away from devices and screens. the workshops and food preparation sessions give them a break from physical movement, and engage their hands and minds thus developing their creativity, sense of independence, and facility. the excitement of preparing their own meals also makes them more likely to eat them. the availability of fruits and only freshly squeezed seasonal fruit juices means that children do not have an alternative to healthy food and drink. the fun activities planned for the evening in the himalayan salt room are also inspired by behavior-smart thinking. it is healthy and calming for children to spend time in a salt room but making that a requirement would not work well. therefore by organizing fun things to do in the salt room, the focus is placed on the fun and not on the salt therapy itself. the resort routine hides wellness nudges for parents too. the plenty of nice ways to spend time outside by the pool, the hot tubs, sauna, steam bath, and the fun workshops engage them in activities that do not involve technology and that offer opportunity for interacting with family, friends, and other guests. the regular daily hikes trigger a social conformity effect gently attracting guests who would not typically be interested in walking in nature. the interesting stories and interpretation make the hike enjoyable and educational as guests learn about plants, animals, and often enjoy picking some seasonal wild fruits. available yoga and crossfit classes also present an opportunity for many who have not done that before, to try and experience. the social space around the fire encourages guests to spend evening time together and interact while being outside even in the dark. a key factor in the success of the factory model is the all-inclusive format. the only way that guests can come to this attractive family resort is by paying for everything in a package. namely because the price includes everything, including workshops, activities, and classes, they actually engage in them. if the factory gave guests the opportunity to pay only for accommodation and food, and then asked them to pay extra for everything else, many would not take part in the workshops, the hikes or the classes. the all-inclusive model eliminates a barrier for trying something new so the mix of social conformity and curiosity actually nudges guests to do so. for many nature walks or yoga classes become something pleasant that potentially finds place in their live after the holiday. factory food-n-dance is a great example that illustrates how behaviorsmart thinking can influence the design of both physical space and the leisure experience in ways that can facilitate exciting and restorative holidays. with reverse responsibility in mind, this is an illustration that more suppliers in the industry can find ways to combine good and fun in the design of offerings that do not trade off wellness for excitement. the challenge as this book argues in earlier chapters, overtourism does not have to be caused by overwhelming volumes of visitors; it can be caused by an overwhelming mismatch between local behavioral customs and traveler behavior. this mismatch can relate to two areas. first, it can concern local social dynamics and cultural norms, in which case it produces irritation among host residents who perceive guests as disrespectful or disruptive. second, it can concern interaction with local surroundings and the local environment, in which case it demonstrates lack of preparedness for local lifestyle, nature, or weather conditions. with the fast rise of tourism and the increasing accessibility of even remote spots around the world, many destinations are facing the undesired effects of the mismatch between local behavioral norms and traveler behavior. and while lack of awareness about local customs or lifestyle can merely lead to unpleasant situations or awkward experiences for guests and hosts (sharpley, ) , lack of preparedness for local weather conditions and interaction with the specific local surroundings can produce life-threatening situations (kaltenborn, haaland, & sandell, ) . with the constantly increasing number of trips taken internationally and domestically (before the covid- crisis imposed a global pause of the tourism sector) professional and academic discussions often emphasize local perceptions of well-being and quality of life as the indicators that truly measure the balance between desired growth and undesired impacts. they suggest that negative attitudes toward tourism and visitors are fueled by the sense that public resources, natural attractions, cultural heritage, and urban public spaces do not feel the same way because they are used by tourists in ways that modify them (jó hannesson & lund, ). iceland, which has been referred to as a posterchild of the fast growth of contemporary tourism (sheivachman, ) , has been focus of especially interesting analyses about whether it is facing a problem with the pure volume of visitors or a challenge with the way they behave in local cultural and environmental realities (anna & hall, ) , and the extent to which public spaces need to cater to visitors rather than residents (jó hannesson & lund, ). the nordics are one of the regions enjoying growing appeal among tourists from different regions around the world. it is also an area where the behavioral aspects of the mismatch between resident lifestyle and the acts of the growing numbers of tourists has been very visible. a growing number of publications in general media and academia have been discussing the effects of the growing tourism economy across norway, sweden, and iceland emphasizing as a problem both dimensions of the resident-visitor behavior mismatchÀdisrespect to local social dynamics and cultural norms, and lack of preparedness for the local environment and weather conditions (becker, ; jó hannesson & lund, ; sheivachman, ) . it has translated in multiple issues such as sudden increase of waste in natural areas, which until recently did not need to be cleaned because being out in nature with no trace is part of everyday culture in the nordics. the growing number of foreign guests who engage in outdoor activities, however, come with different habits, including leaving waste behind. another challenge has been safety and preparedness for being out in nature and understanding the dynamics of nordic weather. along with increase in international arrivals countries in the region have experienced a sharp rise in rescue operations assisting tourists who were caught outdoors by severe weather or who suffered injuries due to lack of proper gear and physical fitness. understanding weather patterns and recognizing signs of approaching weather changes is part of the advanced outdoors culture of residents in the nordics who know when it is wise to turn around or not go to the mountains at all. for the lessexperienced tourists, a sunny start of the day can easily trick them into starting a long hike without the needed gear and without even suspecting that the weather might drastically change. another frequent problem is undermining the risks of going off trails, walking on rocks, approaching powerful waters, walking on moss or plants, etc. knowing how to stay safe and respect nature is part of common sense in the nordics so locals like outdoor spaces natural without significant visitor infrastructure except perhaps markings. they do not need safety railings or signs to take care when they are close to steep rocks or near turbulent sea shores and rivers; they know not to walk outside of trails and avoid stepping on moss or plants. for visitors, however, the lack of paved trails, manmade steps in steep areas, safety or support infrastructure, warning and information signs is unexpected and produces challenges, and occasionally even high-risk situations. while different countries and regions in the nordics have launched a variety of interesting initiatives seeking to close the preparedness gap for visitors in the region, this case will put the spotlight on one particular program called iceland academy initiated in by the national tourism promotion body inspired by iceland. iceland academy is an initiative that seeks to close the cultural gap between residents and visitors by shedding light on local customs related to everyday behaviors, culturally-specific activities and safe interaction with the local natural environment. best practices and approaches using behavior-smart thinking chapter | the program includes six short brief video courses that cover the following safety and etiquette topics: what does it teach? iceland is one of the most awe-inspiring places on earth. this course shows how visitors can respect and be in harmony with nature while enjoying their travels. topics include stepping or walking on moss, proper camping etiquette, and rules for setting a tent. driving in iceland involves passing through rugged terrains so this course warns guests that they should be prepared for both paved and unpaved roads, narrow paths and one-lane bridges. specific guidance is given for stopping to take pictures of nature while being on the road and for understanding specific road signs. taking a hot tub is one of the most treasured customs for icelanders and naturally a desired activity for visitors. this course prepares guests for the proper hygiene steps that they need to take to avoid unpleasant situations and awkwardness. a guide to safe selfies as we know selfies are now part of the routine of visiting interesting spots. in a rugged terrain, severe weather and proximity to powerful natural forces, that can be dangerous. this course reminds travelers of the risks they may mistakenly take while looking to make the perfect selfie. it points to specific dangers such as slippery areas, powerful waters and high water temperature around hot springs. icelandic nature is beautiful but also harsh. this course invites visitors to take safety seriously and to prepare for safe exploration of iceland's natural treasures. it offers guidance on proper equipment, reminds guests to charge their phones and using location beeper when venturing out in nature. it also offers tips for using extra gear for specific activities such as going on glaciers. pack warm iceland is home to stunning nature but parts of it has been shaped by hard weather, which presents risks, especially for guests who have not visited the nordics before. this course advises travelers to expect dynamic weather conditions and dress in layers allowing them to adjust to changes that can sometimes happen within minutes. the style in which the academy content presented is well thought out. it uses humor but without undermining important messaging. the topics focus on very specific issues that are observed to be at the heart of unpleasant encounters, damaging behavior or high-risk situations involving international visitors. because it has been established that in many cases these problematic situations are caused by lack of preparedness rather than anything else, the courses target this gap with information that is understandable and fun to consume. for example, in most instances guests walk on the beautiful moss because they are unaware that while it looks sturdy it is in fact fragile and takes decades to recover; or visitors embark on exploring iceland by car without expecting that they will have to drive on unpaved roads and follow wellestablished protocol for driving through narrow bridges and icy paths. the course leaders delivering the content are with interesting and relevant profiles too. they are experts in the respective fields they cover and are perceived as reliable sources of the presented guidelines. for example, safety topics are delivered by jó nas guðmundsson who is a project manager for accident prevention in tourism in iceland. stinga bang who is a tour guide by professional is another instructor covering topics such as responsible travel in iceland and safe taking of selfies. a neat detail is that guests are invited to complete the full set of courses and to receive a certificate of completion from the iceland academy. researchers in the area of cultural differences have long known that cultural gaps between hosts and guests impact psychological needs and the experiences, and require preliminary awareness and education (reisinger & turner, ) . this is especially valid when the gap between the sociocultural background of the guests and the sociocultural make of the destination differ greatly. in the example of iceland, which attracts with its unusual nature and rugged terrains, the potential for safety issues is higher so the gap between local norms and tourism behavior can produce dangerous situations that go beyond cultural misunderstandings (kaltenborn et al., ) . residents of iceland grow up with strong connection to nature and with advanced outdoors culture that nurtures appropriate skills for enjoying and surviving in the natural environment. this translates into advanced ability to mitigate the risks of extreme weather and rugged landscapes, as well as to preparedness to enjoy nature without leaving a footprint. for foreign visitors coming from destinations where outdoors culture is significantly different, proper behavior out in nature is not automatic. with the rising numbers of guests visiting iceland from regions with various attitudes, weather and relationship with nature, it is not hard to understand that most of the acts of undesired tourist behavior are due to lack of awareness rather than malicious intentions. therefore with its focus and style, the iceland academy is a behavior-smart solution that precisely addresses gaps in traveler understanding of local etiquette and the specifics of interacting with nordic natural environment. the typical icelandic style of presenting the content and the employment of humor increase the appeal of the program and the likelihood that the content will be consumed in ways that will have a real impact. researchers have proven that safety guidelines presented with humor are more likely to be processed and remembered than similar information presented in serious manner (seneviratne & molesworth, ) . iceland's awareness raising program for international guests is a good example for destinations that seek to be more proactive in declaring and encouraging desired norms of behavior. as it was argued earlier in this book, as part of their strategic management efforts, destinations should be much more proactive in identifying targeted segments based on their behavioral profiles and in setting norms about what behavior is in line with local culture and expectations. an effective way of doing this is by being proactive in making the traveler aware before or upon arrival about what are the fundamental rules and principles of behavior they are expected to abide by. in that aspect, iceland academy is a best practice that could serve as example for others. the big challenge with such programs is how to design them in order to increase their reach and ideally ensure that every future visitor has been exposed to them. in this specific the initiative is executed by the promotional body of iceland and is available on the main website that most potential visitors are likely to explore when planning their trip. this increases the likelihood for exposure and impact. the incorporation of a reward mechanism, a certificate of completion, gamifies the experience and increases the likelihood that visitors will really benefit. its voluntary nature, however, still leaves the opportunity for many to miss or skip the program and come for their iceland adventure unprepared. it remains to be seen whether in the future destinations will find it useful to move to formats that require visitors to complete such programs as part of the entry procedures or as part of a pledge they sign upon arrival. the challenge while tracking economic impact of tourism activity in its full has been recognized to be challenging, it is known that its main driver is the monetary contribution to the local economy, respectively the well-being of the residents of the visited area (frechtling, ) . there is also sufficient understanding that different activities and different modes of travel leave different shares of the tourism revenue in the local economy (lens, ; nikolova, fernandes, & shahidsaless, ) but there is also understanding that the default principles for many large players in the industry is optimization of profit rather than local contribution (ambrosie, ) . among the biggest challenges in encouraging travelers to be sustainable in their choices are the complexity and invisibility of the impacts of tourism activity and their choices (epler wood, milstein, & ahamed-broadhurst, ) . tracking the social impacts of a tourism operation, let alone an entire destination industry network, is complicated. this reflects on the behavior of both suppliers and buyers. while many suppliers of tourism and hospitality services are motivated to operate as responsible enterprises (garay & font, ) they often cannot observe or quantify the impact breakdown and therefore do not have basis for improvement. for the customer lack of understanding and information make the idea for responsible consumption vague. every visitor has the freedom to apply their own understanding, values and motivation in choosing how to travel and whether to consider impact as a factor in their consumer choices. even if they proactively seek to make responsible choices and achieve higher positive impact with their spend, they have no way of knowing whether they have been successful. fogo island is recognized as one of the pioneering and inspiring illustrations of sustainable development in the contemporary tourism industry. even if on small scale, it illustrates how a tourism industry ecosystem can be shaped around the principles of place enhancement and community betterment. in many ways, it is a real-life example of how the shared value principle introduced by porter and kramer (porter & kramer, ) looks in the context of the contemporary travel economy. the fogo island story is inspiring in all its aspects: from how old traditions can be given new life through contemporary art and storytelling, how local architecture can coexist with futuristic design, to how tourism can inspire a whole array of new local businesses that reinvent the island's economy (lewis, ) . a particularly interesting element of the story, which is the focus of the current case, is the pioneering of a tool for recognizing and stimulating positive local impact of the tourism economyÀthe economic nutrition mark. developed by the local charity organization shorefast, the economic nutrition certification mark is intended to serve as "a means to help increase buyer awareness of the economic impact of their purchasing decisions while also spotlighting seller accountability" (shorefast, n.d.) . so what is the economic nutrition label? it mimics nutrition labels, which reveal the type and quantity of the different ingredients that have been used to prepare a food product. in a similar format it breaks down the price tag that customers are asked to pay and identifies the different items that form the price along with their respective shares. for example, the economic nutrition label for a one-night stay in fogo island inn reveals the following breakdown (fogo island inn, n.d.): share (%) labor % food, room supplies % commission, fees % operations, admin % sales, marketing % surplus (reinvested in the community of fogo island) % even more importantly that that, the economic nutrition label offers an easy look at where the generated revenue goes specifying the share that stays in the island's economy, the share that goes in the broader economies of newfoundland and canada. for example, the fogo island inn guests learn from their receipts that the money they have paid for their stay leaves % of their spend in the local economy of fogo island, %Àin newfoundland, % in the economy of canada, and %Àelsewhere in the world. the mark is designed to be used by tourism businesses to track and demonstrate the makeup of their prices, and to make customers aware of their impact at the point of the purchase. it is also hope that it can serve as an example for others in the industry "looking to build a new economic system that offers a better balance between the return on economic capital and the health of diminishing sacred capital (natural, cultural, social, human, and physical capital)" (the woodshop on fogo island, n.d.). the reason fogo island's economic nutrition mark is a behavioral best practice is that in a brilliantly simple way it overcomes two psychological barriers that currently complicate responsible traveler behavior. first, it overcomes the complexity behind tourism and hospitality services, which makes it impossible for the traveler to understand what it takes to deliver accommodation service or a tour for example, and how that impacts the local economy. because it is complex and because they are on holiday guests cannot be expected to make an effort to understand the details of how their experience is organized and delivered. the economic nutrition label makes it very easy to understand the exact makeup of the accommodation experience or the elements that go into the production of a piece of local craft. the second behavioral barrier that the economic nutrition label overcomes is invisibility or the fact that a traveler often does not think about where the money they spend during a holiday goes and who it might benefit. by presenting in simple terms the share of the spend that stays in the local economy and goes for local salaries or local purchasing the label makes the local economic impact of traveler choices visible and easy to understand. while it cannot reflect the full complexity of the socioeconomic impacts associated with tourism activity, it focuses on the main factorÀshare of the spending that stays in the local economy, which is easy to understand and relate to. as discussed in a previous case study in this book, saliency tools such as the economic nutrition label (similar to carbonate and carbon footprint) influence not only the behavior of customer but that of suppliers too. this reverse effect is a fact because the label can nudge operators to constantly improve their "balance" of impacts and increase the desired local impact. in the case of fogo island enterprises are set up to maximize local sourcing from the start (the woodshop on fogo island, n.d.) but for tourism businesses that might decide to adopt the tool in other destinations, the ability to track and improve local impact could be an expected side effect. it is worth noting that from a behavioral point of view the economic nutrition mark complements an overall behavior-smart approach that is at the heart of the fogo island tourism modelÀthe fact that the sustainability decisions are premade by the host and are not left to the visitor. as this book argues, it makes much more sense for destinations and host businesses to take control of sustainability by choosing and setting the norms and principles that define tourism on their territory. for example, by default all fogo island businesses are social businesses and the local tourism ecosystem is set up to revitalize the local economy and make it resilient in the new socioeconomic realities (cbc news, ) . this means that the decision about maximizing the impact of the traveler spending is premade for the traveler and not left up to them. in this sense the economic nutrition mark is a tool for transparency and awareness rather than a nudge to choose a responsible option. it is also a trigger for consumer pride and satisfaction because even when customers do not make the proactive decision to spend responsibly, they enjoy the recognition that they have done good. in any case, just like many other aspects of the fogo island experience can serve as inspiration for bettering of the contemporary tourism model, the economic nutrition mark is a brilliant best practice that can be shared by businesses and destinations around the world. it is a tool that holds the behavioral power to nudge operators to pursue better and better makeup of their price tag with stronger economic impact. it is also a brilliant way to demonstrate to travelers how their exciting holiday experiences can be personally enriching but can also deliver well-being for host places and their residents. know that even when people have the information they make poor decisions regarding their own health (loewenstein, asch, & volpp, ) , let alone the health of a place that they are vising for a short period of time or the planet, which is a vague and difficult-to-imagine concept anyway. growing media coverage of overtourism and tourism's impact on the climate have triggered growing awareness among travelers on the need to be mindful of their impact during holidays. despite that, there are two significant behavioral barriers that people face in changing the way they travel. the first is lack of understanding of what it means to be sustainable and lack of idea where to start. even if more and more people have genuine desire to make the right choices, they do not know how to translate sustainability principles into specific decisions that they make during travels. the second behavioral barrier is associated with the natural inclination of people to release of control during holidays. when they are away from home and daily routines, travelers seek to free themselves of worries, including about daunting issues such as sustainability or the climate. therefore they are not only not likely to behave more responsibly than at home but are quite likely to deviate from sustainability routines or habits that are part of their everyday behavior (miller, rathouse, scarles, holmes, & tribe, ) . for example, even if one is religiously strict with separate waste collection and efforts to recycle as much as possible at home, they might spare themselves the effort to keep waste separate during holidays, especially if there are no easily accessible bins for separate collection. given that awareness raising and education is not likely to produce fast and impactful change of traveler behavior, there is need for other more effective solutions. while people are on holiday, they should enjoy themselves. and what better way to do that than to have fun and do good at the same time. an exciting contemporary solution that activates responsible traveler behavior in a guilt-free way is adventure junky, a platform gamifying sustainable travel (sims & malone, ). how does it work? adventure junky connects subscribed travelers to its constantly growing collection of carefully curated exciting adventures from around the world. as they engage in different travel experiences subscribers collect points and badges that are automatically added to their profile. every adventure comes with a points score and badges that are added to the profile of anyone who has experienced it. points and badges are the basis for a global ranking of adventure junky travelers called the leaderboard, which fuels serious competition for who will collect more and climb to a higher spot. the essential key here is that the score is generated by an algorithm designed around solid sustainability principles. for example, a high-score adventure would be one that is delivered by a b corp certified travel operator, that is carbon neutral, includes no single use plastics, offers only locally-sourced food options, includes multiple-nature-friendly low-impact activities and engages a local guide. the list of sustainability criteria that are the core of adventure junky's scoring algorithm includes: biodiversity, biosphere reserve, buying local, carbon offsetting, community development, conservation, eco-lodge, energy efficiency, homestay, indigenous, leave no trace, research, rewilding, and world heritage site. for illustration about % of all adventures on the platform include a conservation element, more than % incorporate buying locally, over % have positive impact on community development, over % are designed around leave-no-trace-behind principles, and over % include carbon offset. despite growing concerns about the impact of travel, people's desire to explore and visit new places around the world will not vanish. nor it should, because travel is associated with great benefits for the traveler, as well as the host. at the same time the sustainability crisis in tourism requires a drastic change in tourist behavior and new social norms that guide it. as explained earlier, the classical approach of educating tourists and hoping that they will automatically improve their impact, is not optimal. the adventure junky way is actually to flip the process and first shape behavior along the desired norms while weaving education for the phase when responsible consumption is already a fact. traveler motivation is shifted away from the daunting "save the earth," which is more likely to suppress desire to act (thaler & sunstein, ) and which is in conflict with the natural inclination of travelers to release control. the motivation with adventure junky is the fun and the competition. travelers join the game to engage in exciting experiences and to compete against other players. a major draw is also the fact that the platform promises predesigned adventures that are curated and that cover a wide range of preferences. that eliminates the need to think about where to go next and to have to design every trip on one's own. it also eliminates the need to consider sustainability as all trips on the platform are designed responsibly. in other words, while subscribers join for the fun and the exciting competition with peers, they automatically become sustainable travelers because sustainability is a non-negotiable element in the adventure junky model. an important aspect of the platform is the mentioned earlier flipped approach to educating travelers. the points system and the badges are tied to established sustainability principles so as users seek to increase their performance in the leaderboard, they begin identifying the trip characteristics that give them points and continue to seek to pursue them. along the way the platform offers brief and easy to understand explanations for why staying with locals or visiting a national park are acts of responsibility, not only points generators. this bitesize gradual education along with the learning that users do by seeking out high-score adventures, produce much more effective and sustainable behavioral change than classical approaches. in the words of one of the adventure junky travelers: "what started off as a game, which is what grabbed my attention, has turned into something completely different. . . .now i'm looking for experiences like meeting the locals, supporting the community, learning about the cultures and places i visit." case cut food waste : an integrated effort to cut food waste the challenge according to the united nations environment program (unep), one-third of food around the world is not consumed and is wasted due to inefficiencies in the global food system (unep, ) . the gaps in the food chain that lead to such dramatic losses are numerousÀfrom failures in production, processing, and packaging protocols through inadequate storage and transportation facilities (fao, ) . and while physical infrastructure and amenities play a major role, processes and practices at restaurants, catering operators and hotels (as well as private households) are a major contributor to the loss of food too. the throwing away of usable food is a two-fold problem. first, it means that the global food system wastes products that are fit for consumption while large shares of the global population ( % of the population in developing regions) do not have access to sufficient food (unep, ) . second, food waste contributes to climate change as when it ends up in landfills it emits methane, which is a potent greenhouse gas (world wildlife fund & american hotels & lodging association, ). the processes and protocols at food service operators are complex and influenced by numerous considerations such as health, safety, and profitability. a lot of the inefficiencies leading to the loss of eatable products are due to the behavior of the suppliers (owners and workers) at the food establishments on one side and the behavior of clients on the other side. restaurant, catering and hotel staff contribute to food loss by failing to use products or ingredients that are good enough for use, by not making an effort to donate remaining good food and divert it from reaching landfills (world wildlife fund & american hotels & lodging association, ). on the customer end the behaviors that contribute to food loss include ordering or taking from the buffet more food than can realistically be consumed, trying out foods or meals as experiment or as experiencing something different (especially when visiting a different country with different culinary traditions) (juvan, grü n, & dolnicar, ) . both, for suppliers and customers, these damaging behaviors are due to the fact that motivation is shaped by other considerations and food waste is not a forefront concern that impacts decisions. as result of proactive awareness raising by major international organizations and charities, there is increased sensitivity toward the need to minimize food waste at different points of the global food system. and while there are many fruitful practices that come from different players around the world, there are few instances of integrated industry efforts on country level. this case tells the story of norway's national-level program designed to unify and integrate industrywide efforts to cut waste using behavior-smart techniques. norway's concentrated effort to cut food waste especially by changing food management practices at hotels, restaurants, supermarkets and other food establishments was launched in . the cut food waste program was initiated and has been led by matvett ("food sense")Àan entity set up by the food and service industry especially to coordinate efforts to reduce and prevent food waste. the common goal was to cut food waste by % by and to engage at least % of the industry in this effort (ministry of climate & environment, ) . the initial analysis of the food waste problem identified the factors that fueled it and that needed to be addressed to achieve the ambitious goal. it revealed that a lot had to do with operational practices in the kitchen, kitchen workers perceptions about food waste and lack of prioritization of avoiding waste (schrøder, ) . on the consumer side the main contributing factors seemed to be mainly lack of awareness about the scale of the problem and the tactics that could help avoid food waste. armed with clarity on the awareness and behavioral factors that fueled food waste in the food and service industry the cut food waste program developed solutions to address them. the first challenge that needed to be solved was salience. both kitchen workers and consumers needed to be made aware of the scale of the food waste problem in a way that is easy to understand so the program developed an impactful awareness raising campaign. it was based on visual posters and display cards that illustrated in simple terms the scale of the challenge. for example, they would include an image of a fresh fish or a deliciously looking plated meal with a line cutting through one-third of it to visually show how much of the product or meal is likely to end in the waste bin. the awareness raising visuals were placed in kitchen areas to target workers in the sector as well as in consumer halls, buffet and shopping areas to increase the sensitivity of clients. awareness alone was not going to be sufficient so the approach of the cut food waste program naturally included a second levelÀdesigning tools for action that would facilitate behavioral change. on the consumer side participating food service providers used a set of tactics that seek to influence the decision at the moment of ordering food (at a-la-carte facilities) or picking up food (at buffets). first, wherever possible, they transitioned to using smaller plate sizes, which is a proven technique for cutting food consumption and respectively waste, especially at entities with a buffet format (kallbekken & saelen, ) . in addition to this nudge customers were openly encouraged to make conscious efforts to minimize food waste through postcards and stand cards that sought the influence the social norm and the sense of acceptability of returning to the buffet and picking up food multiple times rather than seeking to pile large amounts at once. this addressed the established concern among consumers that returning to the buffet tables multiple times is not perceived favorably (schrøder, ) . the matvett toolset targeting professionals in the industry was two-step. the first step was to perform proper measurement of food waste and incorporate that in the kitchen processes. this is important for two reasons. first, it quantifies the wasted volume and offers a clear picture of what products and ingredients are lost at what point of the preparation journey. second, it allows staff and entities to monitor the effect of applied tactics and to track their progress toward the end goal. the rolling out of regular measurement as a permanent step in kitchen processes is challenging so the role of the toolset was to offer the specific steps facilitating behavioral change and to ensure the measurement practices are consistent across the industry. the second step of the matvett approach was focused on equipping the industry professionals with specific tactics for cutting food waste. this included the development and distribution of specific solutions for canteen and buffet design, as well as for the safe reuse of left-over ingredients or product parts. the know-how was delivered and disseminated through hands-on manuals and different forms of training that were available for workers at participating operations. the cut food waste program continues to grow in its influence every year and has already triggered significant change in the practices and behavior of employees and hotel guests throughout the food service industry in norway. recent data published by the program reveals that in many of the participating entities have achieved the goal of reducing food waste by %, including % of the hotels, % of the canteens, and % of the restaurants. the main success factor has been identified to be the transition to smaller servings and plate sizes (matvett, ) . the cut food waste program is a great illustration of how behaviorsmart thinking can enhance large-scale initiatives that seek to correct fundamental sustainability challenges in hospitality, tourism, and other sectors. its approach is based on mapping the behavioral factors that contribute to the food waste problem and targeting them directly. the two-phase solution involves awareness raisingÀmaking the problem visible and impossible to ignore for both sides of the market (the service supplier and the consumer). as simple as this sounds, this is extremely important because until a problem is clearly visible and quantified, it is psychologically easy to ignore. in addition, decisions on the side of the consumer and the supplier are driven by more immediate factors than battling food loss. for service providers these are profitability, competition with other players on the market and hygiene requirements. as these are more forefront concerns, they take lead in shaping processes and behaviors of businesses in the sector. similarly, for consumers food waste is a vague and distant issue, and their decision-making at the point of purchase/ food selection is shaped by factors such as food taste, interest in experimentation and sometimes the fear of missing out prompting people to put more food on the plate. in that sense the simple but impactful communication campaign using posters and cards visualizing the problem at the point of preparation and selection is an effective way of making food waste salient at the right moment when it can impact choice. the second phase of the program approach is equipping both consumers and professionals with tactics enabling them to act. experience shows that even when people are alert and generally concerned about a problem such as the environment or poverty, they often do not act on it because they feel they are not empowered or do not know what to do (datta et al., ) . consumers are empowered to contribute to cutting food waste through very simple tactics, including optimization of available foods, smaller servings, and smaller plates. this is supplemented with gentle nudges such as reminders that buffet customers are invited to come back and serve themselves a second time rather than take everything at once or as the possibility to top up dips and side dishes. increased awareness in combination with these tactics influence social norms and change the desirability of acts that minimize food loss. suppliers are empowered to act through practical solutions that target the moments when food waste is most likely to occur: during the preparation of meals, and after meals (or parts of them) are prepared but not consumed. the first major focus that is addressed is measurement. by providing the steps and tools to execute careful measurement the program enables service providers to quantify and monitor food waste, and to map the moments when food waste is most likely to occur. feedback from food and beverage professionals reveals that the ability to measure alone has powerful awareness effect on staff members who suddenly really understand the scale of the problem and begin to proactively contribute with ideas. measurement leads to salience of food waste as success indicator on the job as well and this makes it impossible to ignore (metcalfe, gosnell, & list, ) . the ability to track which kind of ingredients or products were left unused or unconsumed empowers decision makers to optimize by reengineering menus and redesigning buffets. through the program they were equipped with safe tactics for efficient use of products. for example, slight adjustments of menus could ensure that parts of a tomato are used for a fresh salad and the left overs are cooked into a sauce for a main course rather than thrown away. measurement offers a systematic look into the problem allowing participating businesses to optimize food processes beyond the tactics provided by the program. for example, the ability to track the food that is least consumed at a buffet leads to the easy decision to eliminate it from the menu. in fact, service providers relying on a buffet format report cutting food waste by more than % by merely cutting the quantities and the number of items they serve, and by focusing on foods that are favored and rarely left. optimizing the size of servings without really limiting the amount of food available to the customer emerges as an effective solution for a-la-carte restaurants. the volume of wasted side dishes or dips prompts service providers to move to smaller portions but to offer customers free top-ups if they desire them (matvett, ) . this measure alone leads to tremendous cuts in lost food. the entire process of buying, storing and preparing meals can be optimized once there is specific measurement revealing which foods are most likely to remain unconsumed, on which week day and at what time of the day. tracking the food journey also gives companies the opportunity to organize food donation or programs such as "too good to go," which are adopted by many entities participating in cut food waste . in conclusion, it is important to mention that the integrated effort to equip the food service industry with tools that facilitate behavior change incorporates new norms in the design of the sector. the integration of measurement and food waste elimination tactics in daily protocols ensures sustainable transition to new behavioral models for the entire professional community. this is of great importance because the industry often relies on young, untrained and temporary workers who cannot be expected to learn everything about food waste as part of their standard training but who will adhere to the already existing norms that make the loss of food undesirable and easy to avoid. case piloting behavior-smart thinking on destination level (västmanland region, sweden) as the texts throughout this book argue, the advancing knowledge about human behavior offers a wealth of insights that can help destinations improve current approaches to planning and management. tourism is complex and involves the operationalization of orchestrated coordination among multiple small and large, public-and private-sector players. behavioral insights can add value at multiple levelsÀfrom optimizing the design and operations of the individual business to the strategic models and processes that shape destination management. at the individual company level behavior-smart thinking can inform decisions that guide the training and management of staff, sustainability efforts, marketing tactics, pricing strategies and the design of offerings in ways that guarantees that the hearts and minds of travelers will be captured. at the destination level behaviorally-informed solutions can address strategic marketing, including segmentation and the setting of norms for the behavior of visitors. it can also influence the collaboration between the different players in the local industry network and the coordinated efforts to optimize the balance between desired and undesired impacts of tourism. to the best of the knowledge of the author of this book, at the time of writing, no destination, except the one featured in this case, has made an effort to experiment with behavior-smart thinking as a way of accelerating the achieving of its strategic market and sustainability goals. as the rest of the cases included in this book reveal, there are already examples of behaviorally-informed solutions at individual company level or at the level of a specific solution. västmanland, a small regional destination in sweden, is the first to experiment with behavior-smart thinking as vehicle for optimizing commercial and sustainability practices among local tourism businesses. the project "applying behavioral economics thinking to tourism in västmanland region" is executed in À by the local tourism board västmanland tourism. it is initiated with the aim to benefit from the advances in behavioral sciences and use them to support local service providers in improving their marketing tactics such as messaging, pricing, online presence, etc., as well as their sustainability efforts (stanaway & wernersson, b) . the hope is that by helping companies throughout the destination adopt behavior-smart tactics, the region will benefit from the cumulative effects of stronger commercial success and optimized footprint of the tourism sector. because of the innovative nature of the project and the lack of previous experience with behaviorally-informed solutions, the program design included a strong experimentation component to help arrive at the specific measures that would be developed and shared with the entire business community in the region. it involved working with a small set of innovation-prone pilot companies interested in experimenting with behavior-smart tactics to confirm their validity for the local context. the following table summarizes the key steps and milestones in the project. key project activities and milestones. purpose why? project ideation phase create the design and plan the activities that guarantee meeting of objectives this is a specific project, which in itself represents an experiment with a lot of unknowns. it was important to design a unique process that accounted for the uncertainties but guaranteed maximum likelihood for success. introduce the project and behavior-smart thinking to the local industry to raise awareness and invite pilot participants behavior-smart thinking is relatively new for the travel industry and not many businesses have structured knowledge about it. this kick-off activity was designed to provide the framework and explain the benefits of using insights from behavioral sciences to optimize business and destination success. it also served as the basis to identify companies, which were interested and motivated to serve as pilot host of the experimentation activities. select a set of meaningful tactics that would be tested and applied to the industry throughout the region it was important to arrive at a set of solutions to be tested that are both relevant to the larger business community but attractive enough for the participating pilot companies because they are the ones investing time and resources at this phase of the project. execution of the testing action plans for the selected tactics; analysis of the results and synthesis of the findings the results of the solution tests was essential in ensuring that they work in the specific context and that they can be easily executed by a large number of operators throughout the region. the testing also offered very convincing and directly relevant data that motivated the interest of more businesses to roll these solutions out. hands-on manual synthesis of the practical steps to apply behaviorsmart solutions in a manual for businesses in order to reach the entire business community throughout the region, the knowledge about the tested behavior-smart solutions needed to be distributed in a format that is easily digestible and available in a flexible format. västmanland tourism decided that the best approach was to develop a hands-on manual with specific step-by-step guidance on how to plan, test and execute behavioral solutions. destination-wide roll-out workshops and consultations in order to activate interest and engage companies in exploring and applying the available and tested behavior-smart solutions västmanland tourism initiated a series of workshops with private sector companies throughout the destination. their purpose was to introduce the manual, engage entrepreneurs in using the tactics it presents and offer advisory assistance to ensure that they receive all necessary support to succeed. västmanland tourism identified three pilot companies to test the behaviorsmart tactics and offer insights as to how they can be applied to the rest of the business community. they three offered a good mix representing different segments of the industry. the first participant representing attractions was kokpunkten actionbadÀan indoors water park with a wide variety of slides and water-based attractions for adults, young adults and children. the water park is one of the main attractions in the region geared toward residents of the area and visitors coming for a short holiday or on a day trip. the second participant in the project representing food service providers was saluhallen slakterietÀan indoors food market featuring different restaurants, small shops, and small event venues emphasizing local and sustainable food. while the outfits in the food complex offer food from around the world, there is strong emphasis on local sourcing and the promotion of nearby farms, herbs and locally produced ingredients. the final participant, schenströ mska herrgården, represented the accommodation and event sector in the region. schenströ mska herrgå rden is a stylish mansion away from the city and surrounded by nature. it attracts leisure guests who stay for short holidays or long weekends, and hosts private and business events (from weddings to corporate celebrations and retreats). once the pilots were confirmed each of them was engaged in a process of identification of relevant tactics that will be tested by them. the factors that influenced the selection were (stanaway & wernersson, a) : . ensuring that the tactics relate to existing and relevant issues that will produce direct benefits for the participating business . ensuring that the solutions can realistically be tested within the timeline of the project . ensuring that the testing of the tactics is not resource-intensive . ensuring that each of the pilots tests at least one commercial and one sustainability practice . ensuring that the tested solutions are relevant to a wide share of the local industry community the table below summarizes the tactics that were tested with the participating pilot companies. summary of selected behavior-smart solutions. the results from the pilot projects were the basis for the synthesis of a set of behavior-smart tactics to be used by all tourism businesses operating in västmanland region. they were presented in a special hands-on manual that offered brief overview of the principles of behavior-smart thinking followed by a step-by-step guide on how to execute each presented solution. the guiding document offers all tools, such as a short evaluation, or a measurement plan, that an entrepreneur needs to apply the solution. the document was tested with business audiences to ensure that the language and content are indeed practical and relevant (nikolova, ) . the final step in the project was the roll out of the manual with a series of workshops and advisory services for companies (stanaway & wernersson, ) . the events involved presenting the manual in details and engaging companies in selecting and starting to work with tactics that seem relevant to their businesses. the available advisory support ensured that any professionals will receive support at any stage of the execution. västmanland tourism is one of the smallest regional destination in sweden but despite that, it was the first to experiment with behavior-smart thinking on destination level. from a behavioral perspective the project "applying behavioral economics thinking to tourism in västmanland region" is a best practice for three reasons. first, it extracts relevant insights from behavioral sciences in order to optimize the commercial and sustainability practices of businesses operating on the territory of the region. there is unlimited potential in using insights about human behavior and decision-making in the optimization of marketing content, pricing strategies, or experience design for travel companies. the second aspect is the very design of the project, which aimed to operationalize the solutions and ensure that they are adopted by a maximum number of companies in the destination. the experimental nature of the program made it natural to include a pilot test element, which not only allowed the testing of specific tactics in the local context but provided local evidence. this secures an important psychological effect as the rest of the business community is much likelier to engage with new solutions if they have been tested locally with peers. the third important success factor was the writing of the manual and the roll out with hands-on workshops. preparing a document that will reach all companies in the region made a lot of sense because it becomes a resource that can reach the local industry network and that offers entrepreneurs the flexibility to use it when they have the time and resources. to make sure the tone of voice and context are completely aligned with the needs of the business, a small group of companies were asked to review and provide feedback on the tactics and the offered guidelines. the downside of a passive document is that it can be read and remain as a resource on the shelf. the decision of västmanland tourism to roll out the manual with a series of activation workshops and available advisory services minimized this risk. by educating companies how to best benefit from the resource and by helping them launch some of the solutions the workshops increase the likelihood that more companies will adopt behavior-smart thinking and that the destination will enjoy cumulative effects with behaviorally-optimized commercial and sustainability practices. carbon label at a university res-taurantÀlabel implementation and evaluation distracted gaze: problematic use of mobile technologies in vacation contexts getting to know nature: evaluating the effects of the get to know program on children's connectedness with nature not such smart tourism? the concept of e-lienation from boiling to frozen? the rise and fall of international tourism to iceland in the era of overtourism arctic crush: the friendly residents of one of the most remote parts of norway have begun to organize to combat overtourism. travel weekly beyond overtourism: studying the entanglements of society and tourism in iceland the public right of access À some challenges to sustainable tourism development in scandinavia cultural differences between asian tourist. differences employing humour and celebrities to manipulate passengers' attention to pre-flight safety briefing videos in commercial aviation host perceptions of tourism: a review of the research. tourism management, , À iceland and the trials of the st century tourism sun & sea tourism: fantasy and finance of the all-inclusive industry entrepreneur zita cobb 's social conscience lands her in the business hall of fame everything starts with believing destinations at risk: the invisible burden of tourism fogo island inn: economic nutrition certification mark. fogo island inn website assessing the economic impacts of travel and tourismÀintroduction to travel economic impact estimation. travel, tourism and hospitality research doing good to do well? corporate social responsibility reasons, practices and impacts in small and medium accommodation enterprises assessment of the mountaineering sector in the possibility of an island. the new york times style magazine, À strengthening tourism competitiveness in the oecs countries: market analysis creating shared value how to reinvent capitalism-and unleash a wave of innovation and growth economic nutrition certification mark. shorefast foundation website the woodshop on fogo island: economic nutrition mark. the woodshop on fogo island website analysis & commentary behavioral economics holds potential to deliver better results for patients, insurers, and employers public understanding of sustainable tourism a behavioral approach to water conservation: evidence from costa rica (no. food loss & waste biting off more than they can chew: food waste at hotel breakfast buffets nudging" hotel guests to reduce food waste as a win-win environmental measure cut food waste virgin atlantic tested ways to change employee behavior personal communication with anne marie schrøder on why do we need to change our food system? united nations environment program world wildlife fund, & american hotels and lodging association smart ways: a manual with behavior-smart solutions for increased profitability and sustainability in the tourism industry personal communication with a˚sa stanaway and angelika wernersson on personal communication with a˚sa stanaway and angelika wernersson on personal communication with a˚sa stanaway and angelika wernersson on the challenge the classical approach to influencing traveler behavior toward more responsible choices during holiday relies on awareness and education. there are two major problems with it. the first is associated with the mere volume of travelers, international and domestic, that trot across the globe. educating all of them would take monumental efforts and resources. the second major problem is that we key: cord- -jgpdohq authors: van asselt, e. d.; meuwissen, m.p.m.; van asseldonk, m.a.p.m.; teeuw, j.; van der fels-klerx, h. j. title: selection of critical factors for identifying emerging food safety risks in dynamic food production chains date: - - journal: food control doi: . /j.foodcont. . . sha: doc_id: cord_uid: jgpdohq abstract a pro-active emerging risk identification system starts with the selection of critical factors related to the occurrence of emerging hazards. this paper describes a method to derive the most important factors in dynamic production chains starting from a gross list of critical factors. the method comprised the semi-quantitative evaluation of the critical factors for a relatively novel product on the dutch market and a related traditional product. this method was tested in an expert study with three case studies. the use of group discussion followed by individual ranking in an expert study proved to be a powerful tool in identifying the most important factors for each case. human behaviour (either producers’ behaviour or human knowledge) was the most important factor for all three cases. the expert study showed that further generalization of critical factors based on product characteristics may be possible. food safety has ameliorated over the years due to the application of hazard analysis critical control points (haccp) systems and the development of risk assessments (ra). haccp is a systematic approach to the identification, evaluation and control of those steps in food manufacturing that are critical to product safety. the basic objective of the haccp concept is assuring the production of safe food products by prevention instead of quality inspection (luning, marcelis, & jongen, ) . haccp is a system applied to identify known food safety hazards, and is currently applied per stage in the production supply chain instead of the total production chain. food safety ra comprises the scientific evaluation of known or potential adverse health effects resulting from human exposure to specific food borne hazards (codex, ) . it typically uses data on the particular hazard and production chain under consideration, and modelling to estimate the final likelihood of harm due to human exposure. both haccp and ra focus on known hazards and make use of historical data related to the particular hazard(s) as well as to the particular chain of interest. risk managers and assessors need to get access to all available data on food safety hazards as soon as possible. for this purpose, there are various warning systems for notification on the likelihood of a hazard. examples are the eu rapid alert system on food and feed (rasff, http://ec.europa.eu/food/food/rapidalert/index_en.htm), the who-global outbreak alert and response network (http:// www.who.int/csr/outbreaknetwork/en/) and the global public health intelligence network (gphin) in canada (http://www. phac-aspc.gc.ca/media/nr-rp/ / _gphin-rmispbk_e.html) ). such warning systems address known, wellcharacterized food and feed safety hazards vwa, ) . in order to identify and prevent emerging hazards leading to food safety risks, it is necessary to move towards a more pro-active system for identification of emerging food and feed related risks ). an emerging risk (er) is defined as a risk resulting from a newly identified hazard to which a significant exposure may occur, or from an unexpected new or increased significant exposure and/or susceptibility to a known hazard (efsa, ) . er may be directly linked to the food production chain or indirectly connected to it . therefore, in order to identify emerging risks in an early stage, an holistic approach is proposed (vwa, ) . this approach implies that emergence of a risk can be the result from factors inside the production chain (endogenous) or outside the chain (exogenous). in addition, emergence of hazards related to risks is usually a result of a particular change inside or outside the production chain. a pro-active system for the identification of emerging food safety risks should, therefore, preferable be based on (endogenous and exogenous) factors characterizing the dynamics of a food production system. endogenous factors (associated with changes within the production chain) may be related to technological innovations, their implementation driven from production perspectives. exogenous factors (associated with changes outside the production chain) may include for example economic changes, climate change, international trade and changes in human behaviour. these exogenous factors are related to influential sectors as described in the emrisk and peri-apt project (vwa, (vwa, , . once critical factors are identified, signals can be established that indicate (directly or indirectly) the occurrence of an emerging hazard; the so-called indicators. an example of a critical factor is climate change with temperature and rainfall as indicators (van der fels-klerx, kandhai, & booij, ; vwa, ) . these indicators form the key elements of an er identification system. for these key indicators, information sources (data and expertise) and critical limits should be determined. when the limit of one or more indicators is exceeded, required actions can be taken in an early stage to prevent food safety problems occurring as a result of substantial changes in novel and/or dynamic production chains (vwa, ) . several studies have been performed on the identification of critical factors to be used in an er identification system. in these studies, a retrospective approach has been applied in which cases from the past were analysed in order to select the most important critical factors. examples of cases studied are avian influenza (ai), severe acute respiratory syndrome (sars), acrylamide, trans fatty acids, dioxins and bovine spongiform encephalopathy (bse) (hagenaars et al., ; vwa, vwa, , . although these studies elaborated on critical factors, they are restricted since they are event and/or hazard driven and, consequently, the results may be case-sensitive. as such, it is unclear whether these findings are also applicable to identify emerging food safety risks in dynamic production chains. the aim of this research is to explore the feasibility of a systematic approach to identify the most important critical factors related to changes in production chains that may lead to food safety problems. the method developed, to identify critical factors for emerging risks related to dynamics in production chains, was based on a two-stage approach: . identification of the most important critical factors indicating changes in production chains. . linking the selected factors to the occurrence of emerging food safety risks. for this purpose, a comprehensive list of potential critical factors was established based on a literature review (section . ) and their importance evaluated for three cases. the cases consisted of a traditional product versus a relatively novel product on the ( ), more (+ ) much more (+ ). b substantially declined food safety risk (À ), declined risk (À ), no impact ( ), increased risk (+ ) substantially increased risk (+ ). c excluding animal feed. dutch market for the same food chain (section . ). by means of expert elicitation, the critical factors indicating change in a production chain and their subsequent potential food safety implications were evaluated in each of the three cases (section . ). first a gross list of critical factors was compiled that characterize both dynamics in food supply chains and potential food safety risks. factors were divided into endogenous, exogenous and consumer related factors. the latter are also exogenous factors; however, they have a more short-term effect in comparison with exogenous factors such as climate change. for example, increased individualization in society (a lifestyle change) gives a higher demand for smaller consumption portions and ready-to-eat foods. this has a short-term effect on the production of novel products that can fulfil this demand. therefore, consumer related factors are treated separately in this paper. the gross list of critical factors related to the influential sectors identified in the emrisk (vwa, ) and peri-apt (vwa, ) project. this list was downsized based on results of (retrospective) cases (hagenaars et al., ; kleter, groot, poelman, kok, & mar-vin, ; kleter, poelman, groot, & marvin, ; vanderroest et al., ) resulting in a list of critical factors that were generally seen as important in the sense that they both indicate dynamics in the food chain and can be linked to food safety risks (see tables - ). the first six factors (number of chain participants, number of processing steps, number of raw materials, number of suppliers of raw materials, logistics and destination of produce) relate to the food chain complexity. the more complex the system is, the higher the possibility of errors resulting in food safety risks. factors - (firm size, information exchange, contractual agreements and integration and cooperation) are linked to the producers' attitude towards food safety (deneux, van der fels-klerx, tromp, & de vlieger, ) . it is assumed that larger firms (factor ) are more up-todate with food safety requirements, which thus reduces food safety risks (holt & henson, ) . furthermore, network embeddedness (characterized by factors - ) influence the food safety status of a company . the effect of companies on food safety risk is further characterized in producers' compliance to food safety regulations (factors - ). this compliance can be quantified using the ' ( ), more (+ ) much more (+ ). b substantially declined food safety risk (À ), declined risk (À ), no impact ( ), increased risk (+ ) substantially increased risk (+ ). c the ''a" relates to legal requirements in the country of origin and the issue of frequently changing legal requirements in the netherlands; ''b" relates to the fact that, at a certain point of time, legal requirements for produce on the dutch market are in principle identical for imported and dutch produce. which together decide the extent to which legislation is complied with. for food safety issues and ease of elicitation these dimensions were aggregated into three factors that were judged to be critical: food safety awareness, probability of detection and severity of sanctions (factors - ). more technical factors related to innovation in the food chain are indicated in factors - and are linked to the influential sector 'science and technology'. other influential sectors are represented in the exogenous and consumer factors - . origin of raw materials is a factor that links to the influential sector 'industry and trade'. it implies the effect of trade on the food chain and possible import of food safety hazards. legal requirements (factor ) is a factor belonging to the influential sector 'government and politics'. a change in legislation will influence the food safety status of the food chain. climate change (factor ) belongs to the influential sector 'environment and energy'. an increase in temperature and humidity may influence the growth of fungi and thus the production of mycotoxins. economic status is a factor related to the influential sector 'economy and finance'. a change in economic status may influence the finances available for the security of food safety in the chain. consumer related factors added to the list are related to the influential sectors 'information and communication' and 'health' and capture factual items, such as size of demand (factor ), factors reflecting recent food trends such as the demand for conve-nience foods (factor ) (bondt et al., ) , and factors covering consumer concerns such as animal welfare (factor ), see for instance meuwissen and van der lans ( ) . these factors can be seen as drivers that influence food chain dynamics with possible consequences for food safety. the usefulness of the thus obtained gross list of critical factors (presented in tables - ) to identify dynamic production chains related to food safety risks was evaluated in an expert study using three case studies. in each case study, the factors were scored for their relevance for a traditional product as well as for a relatively novel product on the dutch market produced for the same food chain. for the traditional product, developments over time were scored by comparing the list of factors for the year with . subsequently, the novel product in was compared to the traditional product in . by comparing the scores of the two assignments, those factors can be filtered that indicate both dynamics in chains and food safety consequences. case studies were selected based on the stimulus for innovation, which can arise from inside the chain (endogenous), outside the chain (exogenous) or through consumer demands. the three cases are outlined below: table critical factors for table potato and frozen stew (x = expert; g = group consensus workshop). ( ), more (+ ) much more (+ ). b substantially declined food safety risk (À ), declined risk (À ), no impact ( ), increased risk (+ ) substantially increased risk (+ ). case : the dairy case. this case focused on a dairy production chain in which packed pasteurized milk was compared with ''valess" (a vegetarian product prepared from algae and curdled milk) to represent an endogenous stimulus (technological innovation). case : the fruit case. this case focused on a fruit production chain in which a traditional domestically produced apple was compared with imported mango to represent an exogenous long-term stimulus. due to increased international trade and global sourcing, the import of exotic products increases resulting in a changed product supply. for this case, all chain related factors for the novel product (mango) were compared to dutch apple in , but consumer related factors were compared to mango in , since the two products were too different for comparison related to these factors. case : the potato case. this case focused on a potato production chain, in which traditional table potato (used for preparing mashed potatoes) was compared with frozen stew (which contained besides mashed potatoes, vegetables, meat or cheese, and herbs) to represent a consumer stimulus (increased demand for convenience foods). expert studies were used to select the most important factors from each of the three cases, and to relatively weigh the various factors. the procedure followed included. the aim of the interviews was to determine whether the formulated gross list of critical factors (see section . ) contained all relevant critical factors that characterize both dynamics in production chains and related food safety risks. for the 'dairy' case, the quality assurance manager of the producer of both pasteurized milk and valess was interviewed. for the 'fruit' case, two experts from an agri-food research organization were consulted. for the potato case, an agricultural production expert (farmer as well as consultant) and the manager of research and development from a stew producing factory were consulted. the aim of the workshop was to digest the most important critical factors for each case and to evaluate possible generalization per stimulus of innovation. in total experts were invited to participate in the workshop including risk managers, experts from the food industry, three experts from socio-professional organizations and nine experts from research institutes in food safety. the experts were selected in such a way that knowledge and expertise from each case was represented as well as general food safety expertise. half of the invited experts attended the workshop; including seven risk managers, five experts from the food industry, one from a socio-professional organization and five from research institutes. the workshop consisted of two rounds. in the first round, participants were divided into three subgroups and each subgroup was asked to evaluate one case. experts were divided over the subgroups such that their expertise matched the case. the dairy case consisted of representatives of research institutes, dairy (regulatory) industrial organizations, food safety authorities and the dutch ministry of health, welfare and sports. the fruit case consisted of representatives of research institutes, food safety authorities, the horticulture product board, a socio-professional organization and the ministry of agriculture, nature and food quality (department of trade and industry). the potato case consisted of representatives of research institutes, food safety authorities and the agricultural product board. the experts were asked to score a change (over the period of [ ] [ ] [ ] [ ] [ ] [ ] [ ] in the listed critical factors from À (much less change) to + (much more change). for each change in critical factors, its subsequent consequences on food safety risks were scored from À (much less risk) to + (much more risk). the findings of the in-depth interviews were depicted on a scoring-card. the scores were orally clarified using the arguments of the interviewees. this offered a basis for discussion and the experts proceeded by taking up the scoring tasks themselves. by no means was a consensus strived for, the approach merely facilitated the clarification of definitions used and relevant arguments. after the most important factors were extracted from the three cases, the subgroups gathered for a plenary session. the aim of this second round of the workshop was to determine whether the obtained critical factors per case could be used in general for stimuli originating either from inside the production chain (dairy case), outside the production chain (fruit case) or driven by the consumer (potato case). this was done by comparing the various cases with other products or processes originating from an endogenous, exogenous or consumer stimulus. for the dairy case, which had an endogenous stimulus, examples used for the discussion were products produced under modified atmosphere packaging (map) or pulsed electric field (pef). another example comparable to the fruit case, which had an exogenous stimulus, is the increased import of exotic products like couscous or kumquat. an increasing amount of convenience products and functional foods were additional examples that were compared with the potato case that originated from a consumer stimulus. the aim of this part of the expert study was to further specify the critical factors that were characterized in the workshop as most important for each case. in a mailing round, participating experts were asked individually to score the most important critical factors identified for their case. participants were asked to give a score to each of these factors (from to ) with the restriction that the sum of the scores should be . subsequently, the average scores (total score per factor divided by the number of respondents) and standard deviations were calculated and represented as the relative importance of each critical factor. according to the views of the experts of the in-depth interview (described in section . ), the list of critical factors seemed to be complete for identifying critical factors indicating dynamics in production chains related to food safety risks. the approach was, therefore, further explored in a workshop with a group of food safety experts (see section . ) examining three case studies. the results of the group discussions are depicted in tables - and are described below. factors that are marked with two scores (two 'g's in adjacent columns) in the tables were scored by the group as between two columns or group consensus was lacking. for example, in the dairy case the number of chain partners for ''valess" was seen as between + and + meaning that there were between 'more' and 'much more' chain partners for valess production compared to pasteurized milk. the most important factors for the dairy case, as deducted by the subgroup, were (between brackets: factor number and corresponding scores indicating change and food safety risk, respectively): number of chain participants (factor : + . and + ); number of processing steps (factor : + . and + ); number of raw materials (factor : + and + ); logistics (factor : + and + . ); and origin of raw materials (factor : + . and + ). the participants of the workshop rephrased the latter factor to 'quality of raw materials' and remarked that this quality is related to the producers' food safety awareness. the higher this awareness, the better the quality of the raw materials and thus the lower the expected food safety risk. since the exact origin of raw materials for valess was unknown to the experts, the participants found it difficult to rate its food safety risk (bandwidth was collectively set at up to + ). the other factors all relate to an increased product and chain complexity of valess compared to pasteurized milk, since it contains more raw materials and has more process steps than pasteurized milk, which may result in increased food safety risks. the group scores coincided well with the results of the in-depth interview, although some factors were rated differently. one of these was the number of suppliers of raw materials (factor ). for the company of the interviewed expert (see section . ), this number increased over time, whereas the group of experts judged that, overall for the netherlands, this number decreased due to increased farm size over the years. other factors that were rated differently included the consumer factors 'animal welfare' (factor ) and 'convenience' (factor ). although these factors can indicate a change in the production process, they were judged as not important for food safety in this case and thus will not be elaborated upon. an increase in convenience can lead to more ready-to-eat refrigerated products, but in this case both products (milk and valess) are refrigerated, so there is no difference in food safety risk. within the group there was also variability in answers. one factor with large variation was 'legal requirements' (factor ). in january , the general food law has been implemented (ec, ) . some experts thought this implementation comprised a large change in the production chain compared to the previous system, whereas others thought the new regulations were comparable. the same accounts for the effect of these new eu regulations on food safety. some experts judged that the general food law can be interpreted more freely offering possibilities for less high food safety standards. these considerations applied to both milk and valess, since they belong to the same dairy sector. the most important factors for the fruit case, as deducted in the workshop, were (between brackets: factor number and corresponding scores indicating change and food safety risk, respectively): logistics (factor : + and + ); information exchange (factor : À and + ); contractual agreements on quality and safety (factor : À . and + ); origin of raw materials (factor : + and + ); and legal requirements (factor : À and + ). the workshop scores for 'origin of raw materials' (factor ) illustrate well the situation for mangoes: compared to the dutch apple there is a considerable shift in country of origin (+ ) which, for mango, varies according to the season from e.g. australia to india. as a result, workshop scores for the related food safety risk range from to + , since food safety risks are perceived rather differently for these countries. for example, small-scale producers in india have a higher perceived food safety risk than industrial plantations in australia. for the same reason, almost identical ranges in food safety scores can be found for firm size (factor ), integration and cooperation (factor ), producers' food safety awareness (factor ), and probability of detection (factor ). the rather extreme scores (À and + ) for 'legal requirements' (factor ) when comparing mango to apple are due to two reasons. firstly, in general, there are much less strict safety requirements in (some) countries of origin (À ), thereby potentially leading to an increased food safety risk for the dutch market (+ ). secondly, for most exotic fruits legal agreements on authorised plant protection products are much less sta-ble (À ), thereby inducing the regular introduction of unauthorised plant protection products (+ ). the - scores for legal requirements relate to the dutch market as they are in the end identical for all products sold in the netherlands. when comparing workshop scores with the in-depth expert interviews, it is evident that workshop scores, in general, are somewhat less extreme. this is caused by the fact that the individual expert mainly considered the local situation in a small-business country, i.e. india, while the workshop participants covered the whole range of mango producing countries, including long-distance transportation, information exchange and sanctions set by western european retailers. the most important factors for the potato case, as deducted in the workshop, were (between brackets: factor number and corresponding scores indicating change and food safety risk, respectively): number of chain participants (factor : + and + . ); number of processing steps (factor : + and + ); number of raw materials (factor : + and + ); logistics (factor : + and + ); transport (factor : + and + ); process (factor : + and + . ) and human factor (factor : À and + ). since the stew contains more ingredients than traditional potatoes, more chain partners are involved indicating an increased chain complexity, which (as in the dairy case) may result in increased food safety risks. apart from increased chain complexity, the production process is also more complex in comparison with table potato, since it comprises more process steps. as stew should be kept frozen, which has its implications for transport and logistics, this may have its impact on food safety according to the expert group. it is essential to keep the ingredients frozen during transport, therefore, truck drivers should understand this importance and act accordingly. for this purpose, the ''human factor" (factor ) was added by the subgroup, comprising knowledge of the importance of cooling the product, especially during transport. factors that the group of experts rated higher than the consulted expert of the in-depth interview related to the impact that a frozen, composed product will have on food safety in comparison to a fresh, non-composed product (factors , and ). group expert opinions were more profound (i.e., rated as a substantially increased risk), while the individual expert rated these factors merely as an increased risk. the latter compared those factors with other frozen products within the same company concluding that risks increased slightly (+ ). group experts compared the innovative stew product, in line with the task at hand, with a traditional table potato and thus came to a different conclusion regarding food safety risks related to the factors , and (+ . or + ). on the other hand, workshop participants expected considerable improvements in factors related to producers' behaviour (factors - ). this can be explained by the fact that a recall will harm a large-scale processor much more than a product which is marketed by relatively small-scale producers. the stew expert compared those factors with other frozen products within the same company concluding no change. according to the workshop participants, the most important factors identified in the three cases could not be generalized to other novel products with an identical stimulus. on the other hand, resemblances between the factors selected in the potato and dairy case were recognized (like number of chain participants and number of process steps). in these cases, a simple product (either pasteurized milk or table potato) was compared to a more complex product (valess and stew) resulting in comparable critical factors. therefore, according to the workshop experts, generalization of the critical factors identified may be possible based on product characteristics rather than on the originating stimulus. another outcome of the plenary session was that some of the factors identified as most important were strongly related and could be clustered. for example, the number of processing steps and the number of raw materials (factors and ) could be clustered into product complexity. these identified clusters are depicted in table . after the workshop, the same experts were asked to score the most important factors individually in order to facilitate a ranking of factors. in this ranking procedure, the clusters as analysed in the plenary session of the workshop were used instead of the separate critical factors. since a generalization per stimulus was not possible, items were rated for the three cases separately. the results of this mailing round are given in table , which shows the relative importance of the various factors. for the fruit case, the highest relative importance, both for indicating change in the production chain and related food safety risk, was attributed to ''origin" with scores of . and . respectively. also, ''compliance and information" and ''producers' food safety awareness" were perceived to be important factors. from the three clustered factors presented for the potato and dairy case, ''product complexity" was perceived to be the far most important factor for indicating change (with scores of . and . respectively). however, this factor was not (solely) perceived as being most important for food safety. in the dairy case, food safety risks related both to changes in product complexity ( . ) as well as to quality of raw materials and food safety awareness ( . ). the large standard deviations of these clustered critical factors do not allow any prior-itisation. in the potato case, food safety risks were perceived to be mainly related to the so-called ''human factor" ( . ). the three cases showed that for traditional products relatively few changes in the production chain have occurred during the past years, whereas the selected novel products coincided with many changes in the production chain. this shows that the current method helps to identify the most important changes in a production chain indicating innovation. not all changes were judged to be equally important with respect to food safety. in general, for both the dairy and the potato case endogenous factors clustered in 'product complexity' were evaluated as important. in these cases, the novel products originated from the same production chain as the traditional product, the stimulus being either consumer or producer driven. this may explain why exogenous factors were judged to be less important. in the fruit case, the selected novel product originated from outside the dutch production chain and, consequently, exogenous factors like the origin of the raw materials were judged to be important for food safety. in general, the consumer factors (factor - ) can be seen as drivers for product innovation, but in the cases examined, they did not have a direct impact on food safety. for all three cases, factors related to human behaviour played an important role: in the fruit case this included compliance with contractual agreements; in the dairy case, producers' food safety awareness was judged important; and in the potato case, knowledge of the importance of cooling (human factor) was the most important factor influencing food safety. the importance of factors related to human behaviour was also recognized in the peri-apt and emrisk project. in those projects, it was concluded that introducing human factors into the risk analysis paradigm would make the process more pro-active (vwa, (vwa, , . previous studies on emerging risks identified critical factors based on (retrospective) cases (hagenaars et al., ; kleter et al., kleter et al., , van der roest et al., ; vwa, ) resulting in factors that are specific for the case chosen. in our approach, we aimed to extract a list of critical factors from these and other literature studies that are of general importance to food safety thereby using endogenous and exogenous factors. the expert study revealed that the compiled gross list of critical factors was complete for indicating dynamics in production chains related to food safety risks. the only factor added was the human factor in the potato case (see table ). based on this gross list of critical factors, the most important factors were filtered in the workshop by the three subgroups. in the second round of the workshop, the group discussion revealed that some factors were related and could be clustered for ease of quantifying the relative importance of the various factors. furthermore, this round showed that selection of factors from the gross list was case-sensitive. in this regard, the stimulus for innovation (either endogenous, exogenous or consumer driven) played a less important role in the selection of critical factors than the product characteristics. therefore, generalization of critical factors should preferably be based on product features, which should be further explored. for example, by comparing a 'simple' product with few ingredients with a more complex product, domestically produced products with imported products, or cooled products with fresh products. the established gross list contains many critical factors for which it is not realistic to determine indicators and monitor signals in a pro-active er system. therefore, it is necessary to filter the most important ones from this list . in this paper, expert studies were used for ranking the critical factors. experts used were divided over the cases according to their expertise. many studies have been performed on the quality of expert judgements and what makes a person an expert (bolger & wright, ; rowe & wright, ) . the choice of experts used in our case and the relative proportion in the group will have influenced the outcome of the study. a repetition of this study with another set of experts may thus give different ranking results. however, it is expected that, overall, the most important factors derived for each of the three cases will be identical, since experts used had considerable knowledge and experience in food safety and/or production processes. a different set of experts with comparable background is thus believed to result in the same factors as depicted in table (although the percentages may differ). there are different ways in setting up an expert study varying from the use of individuals (isolated or coacting), statistical aggregates (such as pooled responses) or group processes. in general, group performance is qualitatively and quantitatively superior to the performance of the average individual (hill, ) . in our study, in-depth interviews with individual experts in the field were used as a starting point for the group discussion in the workshop. this may have influenced the group discussion; however, the advantage of this approach was that it facilitated clarification of the critical factors used. a consensus was not strived for, as can be seen in the different ratings between the group and the individual experts (tables - ) . selection of most important factors was based on discussion within a group of experts and subsequent ranking by the individual experts following a hybrid interacting/ nominal procedure. one of the disadvantages of interacting groups is the dominance of higher status, more expressive or stronger personalities ( van de ven & delbecq, ) . another approach to filter most important items from a broad list of factors is the use of a group decision room. in this approach, factors are ranked individually and anonymously using a delphi procedure on the computer (rowe & wright, ) . such an approach will give better insights in individual scores of various items, but has the disadvantage that factors may be interpreted differently among participants ( van de ven & delbecq, ) . in our case, a uniform interpretation of the critical factors used was essential, therefore, interaction in a group was needed. once this is established, evaluation of factors can be based on the same underlying definitions and the effect of misinterpretation can thus be minimized. the group discussions were followed by nominal voting allowing individual ranking with the group decision as the pooled outcome of the individual votes (van de ven & delbecq, ) . combining individual forecasts to an average rate has in many fields shown to be the best or almost best method (clemen, ) . in our case the average score was used to identify the most important factors related to food safety risks. this hybrid interacting/nominal procedure in which group discussions were followed by nominal voting enabled us to optimally combine the advantages of using both group work and individual scoring of experts. this study described a method to filter the most important critical factors indicating dynamics in production chains related to food safety risks based on a gross list of critical factors. the method comprised a comparison between a traditional and a new product from the same food chain using expert judgement. the use of group discussion followed by individual ranking proved to be a powerful tool in deriving these factors. the identified critical factors were case-sensitive with human behaviour as common feature in all three cases. a further generalization of most important factors may be possible, and should be further investigated, based on product characteristics rather than the stimulus for innovation. assessing the quality of expert judgment: issues and analysis nederlandse levensmiddelenketens combining forecasts: a review and annotated bibliography principles and guidelines for the conduct of microbiological risk assessment factoren van invloed op voedselveiligheid the 'table of eleven' -a versatile tool. the hague, the netherlands: expertise centre for the administration of justice and law enforcement laying down the general principles of food law, establishing the european food safety authority and laying down procedures in matters of food safety definition and description of ''emerging risks" within the efsa's mandate pro-active approaches to the identification of emerging risks in the food chain: retrospective case studies group versus individual performance: are n + heads better than one? information for good hygiene practice in small businesses inventory of possible emerging hazards to food safety and analysis of critical factors timely awareness and prevention of emerging chemical and biochemical risks in foods: proposal for a strategy based on experience with recent cases food quality management -a techno-managerial approach a working procedure for identifying emerging food safety issues at an early stage: implications for european and international risk management practices trade-offs between consumer concerns: an application for pork supply chains the delphi technique as a forecasting tool: issues and analysis differences in expert and lay judgments of risk: myth or reality? risk analysis nominal versus interacting group processes for committee decision-making effectiveness the effectiveness of nominal, delphi, and interacting group decision making processes a conceptual model for identification of emerging risks, applied to mycotoxins in wheat-based supply chains options for pro-actively identifying emerging risk in the fish production chain emerging risks identification in food and feed for human health -an approach. the hague, the netherlan s. <www forming a global system for identifying foodrelated emerging risks -emrisk. the hague, the netherlands all experts who contributed to this study are kindly thanked for their valuable contribution. the food and consumer product safety authority (vwa) is thanked for financial support of the study. marcel mengelers (vwa) and jacques trienekens (wageningen cns) are kindly thanked for critically reviewing this paper. key: cord- -t dn bc authors: spring, Úrsula oswald title: food as a new human and livelihood security challenge date: journal: facing global environmental change doi: . / - - - - _ sha: doc_id: cord_uid: t dn bc as a result of a process of “regressive globalization” (kaldor/anheier/glasius ; oswald b) and of an increasing concentration of wealth in few hands, the economic gap has widened between north and south and within the countries between rich and poor, which has often affected the survival of social groups. as a result of a process of "regressive globalization" (kaldor/anheier/glasius ; oswald b) and of an increasing concentration of wealth in few hands, the economic gap has widened between north and south and within the countries between rich and poor, which has often affected the survival of social groups. this inequality is one of the core elements of failure in the eradication of hunger and poverty. therefore, many multilateral organizations, such as the world bank (wb), the international monetary fund (imf), and regional associations like the economic commission for latin america and the caribbean (cepal), the inter-american development bank (idb), the asian development bank (adb), and the african development bank (afdb) and the east african development bank (eadb), have recommended to the governments to reduce the internal gap and to dedicate more resources for human development. they should address basic food production systems with job creation, increase low salaries and subsidies for the marginalized and promote cheap prices of basic food for the urban poor. these recommendations have directly linked 'food security' to the wider concept of 'human security' (brauch ; oswald b, d; brauch/oswald/ mesjasz/grin/dunay/behera/chourou/kameri-mbote/ liotta ). 'freedom from want' requires sufficient food ('food security') and water ('water security'), and both are key demands of any human security concept as a necessity for survival, and thus it has become a basic human right. human security requires not only a quality of life and a decent livelihood, but also health and stable productive conditions for almost half of the world population living in marginal rural and urban areas (see part ix and chap. to ). in the early st century, more than billion persons depend on food self-sufficiency and another billion peasants suffer from eroded and polluted land, are unable to satisfy basic human needs, and are often forced to migrate to shanty towns or to cross illegally the borders to industrialized countries in search of jobs and quality of life (schteingart ; oswald a). thus, in this author's understanding 'food sovereignty' goes beyond the physical conditions of production and market, and involves social (campos ; strahm/oswald ), cultural (arizpe ), economic (calva /a; martínez ; cadena this article has been substantially improved as a result of an international cooperation. i want to thank two anonymous reviewers for helpful comments and hans günter brauch for his critical input to the first draft. he also compiled box . and systematized important parts of box . . i am immensely grateful for his careful editing and style correction and to ronnie lappin for his language editing. regressive globalization is understood in this context as a doctrine, rooted in the confidence of the efficacy, institutional building and moral authority of us power, allied with transnational capital in the sphere of communication, military, commerce, finance, and productive system. using the term democracy and progress it is promoting a liberal global world order, favouring international capital and transnational productive systems. in the poor countries this process creates greater poverty, technological dependency, debts, massive rural migration and often loss of food sovereignty, while a small elite benefits from this alliance. for the definition of and the scientific debate on the term 'security' in english and spanish see albrecht/ brauch ( , a ; brauch ( a brauch ( , brauch ( , brauch ( , a brauch ( , b brauch ( , c ; and oswald/ brauch ( , c) . the author will not use the term 'food security' developed during the past four decades (see part . , where the debate in the fao and world bank has been briefly documented and criticized as a too technological and top-down approach), but will developed a wider concept of 'food sovereignty'. the author has developed in chap. her proposal for a new and wider policy-relevant security concept that combines human, gender and environmental security (huge) dangers and concerns. on this dual political and conceptual background, this chapter addresses the following research problem: food represents not only a security issue of intake of nutrients, but it forms part of a holistic understanding of life and a constituting element of any civilization. thus it includes networks of connectedness (vertical: patron-client, and horizontal: social groups), belonging, relationship of trust, reciprocity, cooperation and exchange. it creates social benefits and risk reduction, but also innovative activities through a wider access to information and learning. it is a process of anchoring of personal and group identity (see chap. by oswald on huge), where social relations reaffirm the integration of a person inside a community with clear rights and obligations, such as access to land, credit, technology, training, market, life quality and rituals. besides guaranteeing the physical and cultural survival, food also creates new opportunities for people-centred poverty alleviation and new understanding of 'rurality'. it represents a critical response to the past development and modernization paradigms and opens ways for diverse rural life processes, where agricultural activities and environmental services coexist with services, technology, and industries. in addressing this research question, this chapter links the concept of food security with food sovereignty, a term developed by peasant movements, especially via campesina that was later also taken up by fao. it first reviews basic concepts such as food security, food sovereignty, survival strategies, self-sufficiency, and livelihood ( . ). then it scrutinizes the contradiction that in a world with increasing production and a diverse offer of food, hunger is still one of the most important causes of illness and death, because an important part of food is used for livestock and for industrial purposes. recently, biofuels have aggravated the scarcity of food worldwide and regionally, affecting above all vulnerable groups such as poor peasants and marginalized urban people in the south and north. this part reviews the internal food intake not only globally, but also for latin america and in a case study of mexico that focuses on the remote indigenous regions of chiapas, oaxaca, and guerrero where undernourishment is still high and one of the causes of child mortality ( . ) . part explores three global models of food production: a) the productive paradigm, represented by the 'green revolution' that emerged in mexico; b) the new paradigm of the 'life sciences', where transnational enterprises (tne) have converted food not only into a commodity, but also into health and medical items; c) the third paradigm refers to 'organic agriculture' that cannot be globalized. it uses traditional agricultural methods developed in each region; recycles organic waste, produces soil enrichment with compost and uses biopesticides and natural seeds. the transformation of food uses long-established techniques and avoids the use of chemicals for conservation. this production system not only conserves the natural nutritional values of food and soils, but it is also an alternative for the self-sufficiency of poor peasants worldwide ( . ). in the concluding part these three models are compared and related to its repercussion on environmental, gender, and human security (oswald , a and chap. below on huge). it links 'food security' with some traditional models of self-sufficiency that were proposed by julius nyerere in his 'ujamaa' philosophy and by ecofeminists (mies ; shiva/mies ; d'eaubonne ). it was taken up by via campesina, the most important world peasant movement and developed into a 'food sovereignty' paradigm. this approach is able to link up small producers from south and north, east and west, and to produce enough food for a livelihood with dignity. this approach integrates democratic land reforms, local market structures, green agriculture, and natural seeds as the patrimony of peasants and communities, with a culturally diverse livelihood (shiva , see preface essay in this vol.). why is food important for humans? food, water, and air are the crucial elements of survival for humans. food creates energy required for growth, sustenance, and biological and physical activities; it acts within the cells and it purveys the structural and catalytic components to build anabolism. whenever one of these vía campesina is a world organization of peasants and small producers and fishermen from the south and north with sub regional association such as latin american peasant organizations (cloc in spanish), in latin america, north america, europe, asia and africa. their goal is to defend an integral process of rural livelihood including agriculture, livestock, orchards, fishing, hunting and recollection, including direct producers, rural workers, women, elders and the young. their executive committee is democratically elected and regionally representative, caring about gender and youth equity. functions fails, organisms substitute it with another process (oswald : - ). food is the generic term used for vegetal and animal nourishment as a whole, in parts or its different versions (flowers, fruits, leaves, roots, milk, eggs, muscles, kidney, blood, etc.). it can be distinguished from nutrition, which is the process through which food is absorbed and transformed. food intake is a biological necessity, determining the quality of life and health of a human being, and its nutritional requirements vary according to age, sex, physical activities, climatic factors, and health conditions. nutrition refers to the process of absorption of food by living organisms'. it starts with ingestion, continues with digestion, where the proteins are transformed into amino acids and keeps on with the absorption of nutrients in the intestine. once integrated into the blood, they are assimilated by the body and transformed metabolically in each cell. the last phase is the excreta of faecal material and urine, where also toxins are eliminated from the body. nevertheless, food cannot be reduced only to this physiological process. it is a holistic experience where different senses intervene (smell, flavour, touch, view). each civilization has developed a culture of tra-ditional, ritual and food specialties linked to religious and civil events. different diets and food preparation, but also taboos, ceremonies and rituals, are able to reinforce the cultural and territorial identity of people. maxwell and smith ( ) had counted more than definitions of 'food security' (fao a (fao , c . within the food and agricultural organization (fao) the food security concept has gradually been developed as a guiding concept for fao's evolving food policy (box . ). the general definition of 'food security' that was inspired by fao is related to the personal right to sufficient food for a person and a nation, discounting nofood uses. the us department of agriculture (usda) evaluates national food security by measuring the gaps between actual food consumption, domestic production, plus commercial imports, minus unused food and consumption targets. sometimes, nutrition gaps are also measured by the minimal daily nutritional requirements in relation to age, sex, and activities. thus, food security is assuring the physical availability and the economic accessibility to enough food in an environmentally and socially sustainable manner, where adequate quantity and quality, but also culturally acceptable food for everybody at any time is able to guarantee a healthy and active life. quantity refers to amount, distribution, calories and proteins, and quality to safe, innocuous, nutritious balanced, good and culturally accepted food. among the many anabolism is the process which builds up complex molecules from smaller units, able to give the body the required energy that is coming from glucose and fatty acids. therefore, it refers to chemical reactions that produce a combination of different molecules. the result of anabolism is the creation of new cellular material (enzymes, proteins, cells and its membrane, organs and tissues). thus, anabolism is crucial for growth, maintainance, and reparation of tissue. an optimal functioning of an organism or of its cells requires about a hundred different substances located in the environment. their function is to maintain the structure and to control the metabolism. metabolism means the sum of chemical changes taking place inside an organism by which food is transformed and utilized by the organisms, and water products are eliminated. according to fao ( a) the food security concept gradually emerged in the mid- 's when the initial focus was on: food supply problems -of assuring the availability and to some degree the price stability of basic foodstuffs at the international and national level. that supply-side, international and institutional set of concerns reflected the changing organization of the global food economy that had precipitated the crisis. a process of international negotiation followed, leading to the world food conference of , and a new set of institutional arrangements covering information, resources for promoting food security and forums for dialogue on policy issues (odi ). focus was put on productivity, within a frame of green revolution, independent of social, environmental, and political costs. the problems of famine, hunger, and food crises were analysed in detail, resulting in a "redefinition of food security, which recognized that the behaviour of potentially vulnerable and affected people was a critical aspect" (fao a). the insight that the green revolution "did not automatically and rapidly lead to dramatic reductions in poverty and levels of malnutrition ... were recognized as the result of lack of effective demand" (fao a). food security was defined in as: 'availability at all times of adequate world food supplies of basic foodstuffs to sustain a steady expansion of food consumption and to offset fluctuations in production and prices' (un ) . in , fao expanded its concept to include securing access by vulnerable people to available supplies, implying that attention should be balanced between the demand and supply side of the food security equation: 'ensuring that all people at all times have both physical and economic access to the basic food that they need' (fao a) . the commoditization of inputs and food markets widened the existing social gap, giving support to large-scale industrial agriculture and expelling millions of peasants from their land. an influential world bank ( ) report on poverty and hunger addressed the temporal dynamics of food insecurity and introduced the "distinction between chronic food insecurity, associated with problems of continuing or structural poverty and low incomes, and transitory food insecurity, which involved periods of intensified pressure caused by natural disasters, economic collapse or conflict" (fao a). the food security concept evolved to: "access of all people at all times to enough food for an active, healthy life" (world bank : chap. ). in the mid- 's, this definition was widened: to incorporate food safety and also nutritional balance, reflecting concerns about food composition and minor nutrient requirements for an active and healthy life. food preferences, socially or culturally determined, now became a consideration. the poten-tially high degree of context specificity implies that the concept had both lost its simplicity and was not itself a goal, but an intermediating set of actions that contribute to an active and healthy life. in undp's ( ) human security concept, food security was one of its seven aspects. in , the world food summit adopted an even more complex definition: food security, at the individual, household, national, regional and global levels [is achieved] when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life (fao b food security … as a phenomenon relating to individuals. it is the nutritional status of the individual household member that is the ultimate focus, and the risk of that adequate status not being achieved or becoming undermined. the latter risk describes the vulnerability of individuals in this context. … useful working definitions are described below. food security exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food which meets their dietary needs and food preferences for an active and healthy life. household food security is the application of this concept to the family level, with individuals within households as the focus of concern. confronted with new models of fast food, people began to suffer more from obesity, cardio-vascular accidents, diabetes and cancer. thus the concept of food security shifted again, now to healthy and innocuous food, able to maintain a person vigorous and active by reducing the intake of animal fat, sweet beverages, and junk food. but when confronted still with million hungry people, food insecurity was addressed, together with the fact that per cent of the poor live in rural areas and agriculture employs almost per cent of them: rural development is critical for improving food security. the traditional agriculture sector has low productivity due to the lack of investment, inadequate water supply and scarce arable land. rapid depletion of groundwater resources may be the most serious problem facing the countries (fao : ) . definitions of 'food security' used in the scientific and policy oriented food discourse those selected here indicate its scope: • "when people do not need to live with hunger or fear starvation" ; • "physical and economic access, at all times, to sufficient, safe and nutritious food to meet dietary needs and food preferences for an active and healthy life" ; • "the ability of individuals to obtain sufficient food on a day-to-day basis" ; • "the notion that all people, especially the most vulnerable, have dignified and unthreatened access to the quality and quantity of culturally appropriate food" that will fully support their physical, emotional, and spiritual health (wolfe/frongillo/valois ); • "state in which all persons obtain a nutritionally adequate, culturally acceptable diet at all times through local non-emergency sources" (riely/ mock/cogill/bailey/kenefick ); • "condition of having enough food to provide adequate nutrition for a healthy and productive life" (usaid, bureau for africa a). usaid defined 'food security' as: all people at all times have both physical and economic access to sufficient food to meet their dietary needs for a productive and healthy life. achieving food security requires that the aggregate availability of physical supplies of food is sufficient, that households have adequate access to those food supplies through their own production, through the market or through other sources, and that the utilization of those food supplies is appropriate to meet the specific dietary needs of individuals. achieving food security requires that the aggregate availability of physical supplies of food is sufficient, that household have adequate access to those food supplies through their own production, through the market or through other sources, and that the utilization of those food supplies is appropriate to meet the specific dietary needs of individuals (riely/mock/cogill/bailey/kenefick : - ). the us food and drug administration (fda ) defined 'food security' as the daily balanced intake of proteins, carbohydrates, vitamins and minerals re-quired for a healthy life. the disequilibrium in quantity and polluted food, or with toxins, could generate illnesses and limit the physical and mental development of children. finally, food security is also related to food safety such as hygiene and prevention of illnesses caused by food in bad conditions or foodborne sicknesses. according to who, bacteria are the main threat for innocuous food that are present in the domestic and professional food chain. food security, as defined by fao, does not include social and cultural factors of food and nutrition, nor land rights, seeds, credits, family ties, social relations of productive and consumption pattern together with communitarian cohesion. therefore, via campesina understood 'food sovereignty' as "the right of peoples, communities, and countries to define their own agricultural, labour, fishing, food and land policies, which are ecologically, socially, economically and culturally appropriate to their unique circumstances. it includes the true right to food and to produce food, which means that all people have the right to safe, nutritious and culturally appropriate food and to food producing resources and the ability to sustain themselves and their societies" (food sovereignty: a right for all, political statement of the ngo/cso forum for food sovereignty, rome, june ). thus important elements of food as a cultural and not only as a technical process are lacking in the fao definitions. the concept of "food sovereignty represents both a social and a personal right of individuals and communities to healthy, culturally appropriate and permanent food" (oswald : ), but includes also the process of production, land tenure, local native seeds, access to water and to other natural resources, storage processes, transformation of food, eating, fiestas and rituals in which women play a key role. social movements such as via campesina have used in their daily struggle the concept of food sovereignty, including geopolitical, socio-economic, identity and cultural aspects (box . ). this new concept of 'food sovereignty' that differs significantly from the concept of 'food security' (box . ) that is being used by fao and the food aid community has been taken up by the un forum for indigenous peoples during its sixth session, - may that defined food sovereignty as: the right of peoples to define their own policies and strategies for the sustainable production, distribution, and consumption of food, with respect for their own cultures and their own systems of managing natural resources and rural areas, and is considered to be a precondition for food security. this concept has also been discussed by several ngos, such as the africa europe faith and justice network (aefjn) that adopted a food sovereignty document in september that points to many shortcomings of the food security concept (box . ). these definitions on food sovereignty by social movements representing the interest of farmers in the south (via campesina, box . ) and of an african-european catholic group (box . ) are just two exemplary snapshots that point to major shortcomings of the debate on food security during the past three decades. they are also responsible for the lack of progress against hunger since until today , people, above all small children, die daily of hunger. the next two concepts of 'survival strategies' and 'livelihood' that have been developed in the south address different means for the marginalized poor to achieve 'food security' with 'food sovereignty'. vía campesina, social movements, ecofeminists and indigenous organizations define food sovereignty as an integral process of production, commercialization, transformation and intake related to the family and community culture of food, proper of any region, social class and nations. their understanding of food sovereignty includes: a.) local production and trade of agricultural products with access to land, water, native seeds, credits, technical support and financial facilities for all participants; b.) women are the main food producers worldwide ) and they are often in charge of transformation and local trade; c.) therefore, access to land, credit and basic production means for women and girls at home and in the community is a guarantee of food security, but it is also able to overcome the violent and unjust patriarchal structures within families, communities, social organizations, countries, and global economic systems; d.) inclusion of the indigenous, women, and peasants in regional and national rural policy and decision-making processes related to agriculture and food sovereignty; e.) the basic right to consume safe, sufficient, and culturally accepted non-toxic food, locally produced, transformed and sold, since food is more than intake of proteins and calories: it is a cultural act of life; f.) the rights of regions and nations to establish compensations and subsidies to get protection from dumping and artificial low prices as a result of subsidies in industrialized countries; g.) the obligation of national and local governments to improve the food disposal of its citizens through stimulus of production and transformation of food, subsidies, and economic programmes to achieve food sovereignty in basic crops; discounts in urban poor regions, able to guarantee the basic food basket; popular kitchens; breakfast in schools, and special food for undernourished babies and pregnant mothers; h.) governments should guarantee an adequate nutrition above all for babies, infants, and pregnant women, offering food supply for poor people; i.) during bad harvests the importation of basic crops from the world market, and when countries are threatened by famine, with the advice and support from the world food programme; j.) clean water and sewage facilities to eliminate parasites, viruses, helminth and protozoa ) ; k.) links among environmental services, agriculture, territorial planning and democratic participation in the decision-making process to guarantee the livelihood and dignity of the most vulnerable in rural areas. they create opportunities for rural population to stay on their field without pressure for migration. the sum of these processes reinforce for each citizen the basic rights of life, but also the right of non-migration, thanks to sustainable life with dignity in its own communities and countries. on july some representatives of aefjn met … to discuss the principles of food sovereignty as a possible framework for the work of aefjn. the discussion stimulated interesting reflections about the definition of the term, the difference with other mainstream concepts such as the right to food and food security, weaknesses and strengths of this paradigm, and the specific aspects that can relate food sovereignty to catholic social teaching, human rights and policymaking. we would like to summarize here some of our findings. life is the most precious gift. the right to life is therefore the most fundamental right for any human being. an essential condition to sustain life is food. access to food is recognized as a basic human right. the right to food was recognized in the universal declaration of human rights in . it is also included in the international covenant on economic, social and cultural rights of : "everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food…" (universal declaration of human rights, art. . ) therefore the right to food is an integral component of human rights, based on existing international law and protected by a legally binding framework in international law. also important are the fao "voluntary guidelines " (november ) formally accepted by fao members states as a useful tool to challenge unwilling governments to take their internal and external responsibilities serious. the concept of food security has long dominated the discussion about the question how to diminish and eliminate poverty and hunger. coined in the context of the un specialized agencies, such as fao, the term has been used since the 's. although there is a definition agreed by all, the world food summit defined food security as 'the situation in which all people, at all times, have physical and economic access to safe and nutritious food that meets their dietary needs and food preferences for a healthy life'. though it refers to having enough food to eat, it doesn't talk about where the food comes from, who produces it, how and under which conditions it has been grown. food sovereignty is a global or national vision oriented towards production, rather than access to food by deprived persons and groups. the way to have access to food can be different: to grow food, to have paid work to buy food, or to receive welfare in case of inability. this allows the big food producers both in the north and south to argue that the best way for poor countries to achieve food security for their people is to import cheap food from abroad rather than trying to produce it themselves. it does not question the existing relations of inequality and processes that increase these social gaps, within a country by landlords and outside by tne. in spite of the green revolution, improved productivity and tremendous efforts to provide food security, the number of hungry people in the world has been growing. surprisingly, the very people who grow food, the small peasant farmers, particularly women, are afflicted by hunger and can no longer make a living on their land. to speak only of food security is no longer enough. we have to look at the question of what kind of food is produced, how it is produced, for whom it is produced. food security is a definition of a goal rather than a programme with specific policies that aim at the eradication of the causes of hunger and malnutrition. therefore a more comprehensive notion is under discussion today to ensure the daily food for all through food sovereignty. there are several definitions of 'food sovereignty': food sovereignty is the right of people, communities, and countries to define their own agricultural, pastoral, labour, fishing, food and land policies which are ecologically, socially, economically, and culturally appropriate to their unique circumstances. it includes the right to food and to produce food, which means that all people have the right to safe, nutritious, and culturally appropriate food, and to food-producing resources and the ability to sustain themselves and their societies. food sovereignty also refers to the right of states to protect their population by restricting the dumping of products in their markets and through the control of the domestic market. the notion of food sovereignty has not been invented by intellectuals. it comes from the grassroots, from peasant farmers and indigenous people in latin america who started to reflect on the root causes of their misery and to look for a way to live a dignified life. farmers associations in asia took up the concept. today farmers in europe are threatened as well in their existence by the effects of globalization. they, too, begin to accept food sovereignty as a revolutionary alternative to the dominant neo-liberal model, which tends to look at reality exclusively from an economic and a commercial angle. more important, the concept of 'food sovereignty' wants to integrate the welfare of people/human beings as well as/and to integrate the notions of the common good of society and ecological sustainability into concepts of the market economy. the concept of food sovereignty is not necessarily opposed to that of food security, but it goes beyond it. food sovereignty actually expands the focus by looking at the causes of hunger rather than concentrating only on the effects. food sovereignty can be an alternative to the current mainstream thinking on food production. it is people-centred as it looks at people not only as consumers of food, but at active agents in the production of food. there are various definitions of food sovereignty. we want to look at the definition accepted by the forum for food sovereignty in rome in . food sovereignty is the right of people, communities, and countries to define their own agricultural, pastoral, labour, fishing, food and land policies which are ecologically, socially, economically, and culturally appropriate to their unique circumstances. it includes the right to food and to produce food, which means that all people have the right to safe, nutritious and culturally appropriate food and to food-producing resources and the ability to sustain themselves and their societies." let us analyse the most important elements: the democratic principle (who decides what we grow and eat?): at present the decision concerning what is grown on farms and sold in supermarkets is taken by a few powerful transnational companies, which control much of the food production and distribution. their principle aim is to produce and sell as cheaply and as profitably as possible. the concept of food sovereignty wants to give back to states or groups of states and agricultural communities and farmers the possibility to decide what kinds of food they want to grow and how to grow it. states are to remain "sovereign" and need to have a political space in order to implement their own agricultural policies. the question of ownership (who controls the means of production?): with the advance of industrialized farming the means of production (land, water, and seed) are taken over by companies, turning farmers into underpaid slave labour or slum dwellers. in an economy of food sovereignty the state will provide small farmers with the resources needed to grow their own food. agrarian reform and redistribution of land is the most appropriate means to achieve that. in contrast to the social-ist model (state ownership of the means of production) and the capitalist model (the capital is owner) food sovereignty demands that it is the producers who remain in control of their resources. food is a social and personal right. the right to protection: today the political choices made by the multilateral institutions, like imf and wto tend to protect the agribusiness industry both in the north and the south, and to destroy the livelihood of millions of subsistence and family farmers by controlling the food cycle all the way from agricultural inputs and the growing of the crops to the distribution, processing, and selling of food. the dumping of heavily subsidized agricultural products onto the world market thus drives local farmers into bankruptcy. this is the very vision of agriculture that the concept of food sovereignty challenges. not only does this practice constitute a grave injustice, it contributes to the decline in food production and to the increase of hunger, and at the same time creates mass unemployment for millions of people. food sovereignty stipulates the right of peoples to protect themselves against dumping through protective tariffs, to retain the capacity of receiving remunerative prices for their products and so remain masters of their own way of life. the principle of ecological sustainability (who can best produce healthy food without destroying the environment?): the present system of industrial monocultures is economically efficient and profitable. yet, for the environment it is a disaster. biodiversity and the nutritional value of the food are reduced. the destruction of the environment for the sake of profits destroys the irreplaceable richness of animal and plant life for future generations, and is thus a crime against them. food sovereignty favours food production through family units who produce healthy food in respect of natural processes. economic models are based on ideas and a vision of human nature, of the role of society, and of the purpose of creation. the present economic philosophy sees human beings mainly as producers and consumers. the social dimension which used to be part of the 'social market-economy' is gradually eliminated. the long-term ecological cost of our way of producing, transporting, and selling our goods is completely neglected. food sovereignty wants to come back to a holistic view of the world and integrate the different dimensions that make up our reality. economic activities have consequences for social relations and the environment that have to be considered. the scientific modernization theories , the economic recipes of the neoliberal 'chicago school' , and the 'washington consensus' offered by northern theoreticians that have been implemented by many development agencies and international financial institutions (ifis), especially by the bretton woods organizations (wb, imf, ifc), have failed to achieve thier goals in many parts of africa, asia, and latin america. the implementation of these theories by governments in latin america is reflected in three lost decades of development, while the policies have failed to eradicate poverty and to overcome hunger. in many cases these neoliberal concepts have worsened the situation of the rural and urban poor who still experience undernourishment with all the negative human, social, economic, and cultural effects. due to the low income of the marginalized poor as a result of underdevelopment, economic crises, the increase of productive costs and chemical inputs, the rise of prices for basic products when crop prices collapsed, erosion of soils and scarcity as well as pollution of water, the peasants started in latin america in the 's to migrate massively to big towns. in marginal slums, they have lived with survival strategies (box . ) that are defined by diego palma as "a sum of initiatives able to complement the salary in terms of the reproduction of their labour force" (palma : ). nevertheless, the origin of the concept started with duque and pastrana ( ) when they described the situation of rural migrants invading urban marginal land in chile, and started to create their new livelihood. susana torado included in the concept "the procreation of family life cycle and labour migrations" and named them "strategies of family life" (nd: ), a term that was amplified by the group of quito as "strategies of existence" (pispal ). thus, 'survival strategies' were consolidated in the socio-economic crises of latin america, when in the 's the models of capital accumulation and of import substitution as post-war strategies were exhausted and the neoliberal globalization process was reinforced. on september , chile experienced first with the military coup the neoliberal imposition of the chicago school. argentina followed with a military coup in , and many other countries in south and central america experienced this regressive globalization combined with repression and empoverishment of large social groups. mexico (like venezuela and ecuador) seemed to be exempted from these repressive coups due to its richness in hydrocarbons, however, with the fall in oil prices, and a corrupt financial management of the governments (oil rent), elites were unable to consolidate and distribute profits, and thus crashed the 'mexican wonder'. confronted with the incapacity to pay the debt service, the imf imposed its structural adjustment policies (sap, see figure . ). from mexico the crisis spread all over la, africa, and to several asian countries. the affected nations were obliged though draconic policies to pay back at any cost their debts, and as a consequence public support and subsidies were drastically reduced. the adjustment costs of this failed policy were transferred to the workers and peasants, and later to the middle classes, which resulted in massive unemployment, loss of purchase power, increasing prices of the basic food basket, the elimination of controlled prices in basic products, a growing monopoly in the trade system, and a reduced purchase power parity (ppp) ( members, neighbours, and from the corner shop. soon, these possibilities disappeared due to the persistence of economic crisis, and food became scarce. then, e.g. in mexico city (oswald ), women organized themselves, picking up half-perished products from the garbage of the central market and transformed these products into food in collective popular kitchens collective community work (kitchen, child rearing, pressure on public functionaries) was organized through a system of rotation. united, they fought for basic services (electricity, water, roads, security, health and community centres; rosiques ) and the legalization of land and services. due to lacking cash and jobs, they struggled also for public subsidies and poverty alleviation programmes (ramírez ). besides all these activities, women still found time for some temporary paid work as domestics, washing or ironing; others generated services, handicrafts, food selling, etc. to be able to maintain their families. children, grandparents, and sometimes husbands supported these complex strategies, where poverty of time was the highest cost paid by women (damian ) . furthermore, these popular colonies have not only been hazard-prone but also exposed to organized crime and gangs. thus, only a strong social organization permitted them to fight against public insecurity, where often the police was involved in illegal activities. the sum of these complex actions empowered women, and therefore they were also able to fight against interfamilial violence. as a result these women were often abandoned by their partner, and as heads of household they had to struggle for the future of their children (inegi ) . after a decade of intensive mobilization and organization, most of these quarters achieved some social and economic consolidation (oswald (oswald , b , and their living conditions and livelihood improved. when they have been confronted with chronic unemployment, they integrated their microbusinesses vertically and horizontally (cadena ) with popular savings banks, collective childhood, pre- these are some of the alternatives to avoid perverse poverty and to improve their quality of life. . in india, bangladesh and africa similar processes of survival strategies took place, all of them replete with criticism of the imposed liberal modernization and globalization process. "over the past two decades every issue … what the industrial economy calls 'growth' is really a form of theft from nature and people" (shiva : ) . after the slogan in seattle "no new round, turnaround", she added that the real challenge is to "turn the rules of globalization and free trade around, and make trade subservient to higher values of the protection of the earth and people's livelihood" (shiva : ) . the future of the three billion impoverished people in the world lies on small farms, peasant and marginal urban livelihood, able to produce safe and culturally accepted food. this productive process is neither marginalized nor criminalized, and food sovereignty is a secure basis for regional sovereignty. the there exists a vicious circle linking hunger and undernourishment with poverty and ignorance ( figure . ) . these authors analysed the food transition in the mexican diet from traditional corn and bean intake to a modern food pattern that is rich in carbohydrates, fat and sugar, thus inducing illnesses, excess of weight, and hypertension which starts in the womb of mothers, creating chronic malnutrition and later obesity and associated epidemics. this phenomenon exists worldwide and has contributed to a deterioration of food, livelihood, and health security. thus, hunger is a complex interrelation where poverty is reinforced by ignorance and propaganda in the mass media, inducing people to buy junk food with their scarce money. unhealthy food creates further health problems above all for children, limiting their brain and bone development and adversely creating modern illnesses and degenerative processes from childhood on. the world the fao ( a) estimated that there are still million people suffering from hunger in poor countries, implying a loss of gdp of billion dollars/ year. chronic infant undernourishment linked to a lack of iron and iodine reduces the intellectual capacity of infants by to per cent. combining proteincalorie insufficiency with missing micro elements, the economic loss in poor countries affects to per cent of their gdp, equivalent to bd/year. regions threatened by war and internal conflicts are responsible for per cent of deaths limited by famine. nevertheless, malnutrition is basically concentrated in rural areas of poor countries and increasingly chronic undernourishment is present in urban slums, affecting also industrialized countries . the global demand of food is estimated to increase between to per cent between and , and simultaneously an increase of irrigation water of to per cent is estimated, due to an unsustainable management of aquifers. water withdrawal is regionally limited and it will affect regions that have already today overexploited its reserves. this refers also to areas with high population growth and countries such as india, the south of the usa, and northern mexico, peru, to the south-east of australia, to north africa, spain, the sahel region, the nile basin, east africa, south africa, central asia, the south of china, pakistan and mongolia (millennium ecosystem assessment ). thus, the future of food production increase is limited due to the availability of water, desertification processes, and loss of soil fertility, but also due to growing food prices since because of the promotion of biofuels. the trend towards an increasing undernourishment may grow when natural, population, and economic factors together become more urgent ( figure . ) .. in , in countries with a high human development index (hdi) the intake was , calories ( . per cent more than in ) and . g of proteins (a per cent increase); in countries with a medium hdi the intake was , calories ( . per cent increase) and . g of proteins ( . per cent increase) and in countries with low hdi the intake was , calories ( per cent less) and . g of proteins ( . per cent less). another indicator of life quality is the birth weight. in industrialized countries in seven per cent of babies had low weight, per cent in countries with medium development and per cent with low hdi (undp : - ) . according to undp . this process reduced the workers' capacity to negotiate labour conditions and salaries, and the survival problems pulverized the labour struggles of a whole favor of capital. in , when on june the rally against hunger started in the us, million us citizens ( million children) were exposed to food insecurity, meaning, they suffered from hunger or did not know how to get their next food. hunger increased in african countries affected by war, but also in east and south asia, and an increase of million in latin america. furthermore, regional and social differences exist ( figure . ) . food production has augmented, but at the same time poverty, hunger, and preventive illnesses (hiv/aids) increased in several countries, above all in sub-saharan africa (ssa). this region has at its disposal today per cent less food than years ago, despite the population increase (undp (undp , (undp , (undp , . the ssa countries produced between and about . million tons of cereals; a small increase compared with the . mt of the previous year. this production is insufficient to feed the population and . million people are threatened by famine or require international food support (figure . ). causes are complex: in the former grain reserve of the region in zimbabwe a corrupt government rules; in congo a civil war is ongoing; and namibia is confronted with a severe desertification process. in general, severe droughts and disasters have affected food production in many countries, but also the international trade rules are unequal for africa (turner ). in ssa the fifth poorest segment of the population obtained only per cent of nutritional requirements, in latin america per cent, and in the recent independent countries of the former ussr, per cent. the gap among and within countries in africa and asia is increasing, and only the fifth wealthiest will get their nutritional requirements in the near future. these negative results are reinforced by the present policy of cash crops, the food production, and the policy of biofuel controlled by multinational enterprises (mne). tajikistan and probably azerbaijan will lose their food security without armed conflicts, but the food situation can get worse in the event of political destabilization (chap. by salih). in sum, with the estimated population growth in poor countries and the present policy of food as a commodity, poor countries will be highly affected by the change of food patterns, and therefore more exposed to hunger and famine. these processes are reinforced by propaganda, where occidental introduced values of food patterns are taking away the few resources able to offer healthy food to poor people. with a global population of more than . billion inhabitants, more than one sixth in countries are suffering from hunger (usda ). natural factors such as loss of fertile soils, salinization of coastal areas and deltas, intrusion of salty water into coastal aquifers, and greater droughts will increase food vulnerability in countries that are today food insecure. these processes will be aggravated by climate change and more frequent hazards. the export of primary commodities from the poor countries to the world market equals that of , representing per cent of the global trade. nevertheless, the imports grew from per cent in to per cent in . the net food imports in the poorest countries have increased by about per cent between and (a rise from us$ . to us$ billion). the increase in medium income countries was per cent (from us$ . to us$ ; see: kwa : ). food distribution is another unequal issue (sen ). globally, one fifth of the world population has access to per cent of world consumption, compared with the poorest per cent that obtain . per cent, and consumption in rich countries is still rising. these data show the concentration of food in industrialized countries and a situation of increasing hunger in the poorest nations as a result of missing money, unemployment, low prices for prime material, unjust terms of trade and trade system, low salaries, population growth and corrupt governments, but also missing land and production means for the poorest. especially women and girls belong to the group of highly vulnerable persons, and are affected by this perverse poverty. the sum of these factors prevents rural people from getting sufficient food to overcome hunger, and thus many are forced to migrate to slums in cities where environmental, social, and economic deterioration affects again the most vulnerable (villareal ; schteingart ). during / , low income countries required . million tons (mt) of grain from food aid, and in it increased to mt. the usda estimated that this aid covered per cent of the projected needs, and the minimal nutritional requirements are . mt. the fao ( b) calculated that the food deficit will grow in , and with the same minimal ingestions, per capita insufficiency will increase by per cent to . mt, while nutritional deficiency will rise by per cent to . mt. as a result, poor countries will experience food shortage and countries more must reduce food intake. this implies new subsidies for food surpluses and a greater food power for exporting countries (usa, canada, eu, australia). this power is based on highly subsidized prices affecting poor countries and their rural people. tne obtain a wide with global horizons sufficient, regional horizons limited or missing local horizons gas, gasoline, kerosene gasoline, gas wood, excrement, organic waste high considerable low extreme poverty is better characterized as 'perverse poverty' (oswald ). the perversity lies in the fact that a child before being born, is condemned already to becoming a second class citizen due to brain damage, caused by chronic undernourishment and having an anaemic mother. later, the child enters into the 'valley of death' between and ½ years of age, because of its fragile immune system. if they survive despite chronic hunger, often the growth, intellectual improvement, and motricity of the child is seriously damaged. during the first year of life a child requires per cent of the nutrients for brain development and growth. malnutrition causes irreversible intellectual and physical damage. besides the small size, there are problems for logical learning, altercated micro-motricity, and slow reactions. major part of these subsidies, and gorelick ( ) estimated that profits obtained by big companies in the usa in form of subsidies and external support amount to us$ . billon dollars, without including environmental costs or health damages. vandana shiva ( ) calculated that each kilogramme of food consumed in the usa travels , miles, generating kg of co , thus contributing to global warming. these structural inequalities create worldwide prototypes of food consumption, depending on economic possibilities (see table . ). it represents a kind of schizophrenic behaviour of upper classes that are damaging to the global environment (see chap. by dalby/brauch/oswald) and their personal health, with their inadequate food intake (murray/lópez ). middle classes are becoming aware of their health and consume more locally produced organic food, but they also buy fruit and vegetables from outside. the lower classes struggle not only for their food survival, but also for drinking water and other basic services. these social groups create the lowest environmental impact. this global food pattern is the result of complex and multicausal processes, where local and global activities get negatively reinforced, and where free trade agreements (fta), indiscriminate openness of agricultural markets in the south, sap imposed by imf (strahm/oswald ; stiglitz ), failed policies by the world bank (mega-projects of dams and irrigations districts, and modernization of agriculture in hands of agribusiness) have created hunger. this critical situation worsened due to subsidies for agricultural products by industrialized countries, corrupt national governments, and local elites , financial monopolies, exports of prime materials at international prices below production costs, debt payments, bank rescues, patriarchal structure inside families and society, lack of peasant support also for organic agriculture, and low agricultural wages. with deteriorated and marginal land, polluted resources and high prices ( ) referred to one billion environmental refugees due to desertification, water scarcity, and soil depletion. the repercussions of the failed development policies in latin america are affecting vulnerable groups, especially indigenous and rural children, the elderly, and women. the causes of chronic hunger in the most biodiverse countries of the world are complex and are directly related to the unequal income distribution, (undp (undp - . most affected by these developments were peasants and indigenous people during these crises years, which were often pushed from their land and natural resources by tne that imposed a model of capital intensive production when the country had enough human power. as a model of this unsustainable agribusiness a modern chicken farm must produce yearly about , birds. after paying credit and inputs to the tne "this prodigious (and inhuman) production left the farmer only us$ , , or five cents/ bird" (gorelick : ) . mexico is one of the most unequal countries, with the richest man in the world (forbes, august ). during the 's its model of import substitution and stable development was replaced by a neoliberal globalization process (klein/fontan/tremblay ). after joining nafta in , the effects in rural areas and for the peasant economy were disastrous. the wealth has been even more concentrated (table . ). the effects of free trade, promoted by business monopolies, and the rapid openness by government without compensatory processes permitted an evaluation a decade later. the results are complex: economic growth was below one per cent; the employment policy was unable to offer to more than one million young people a job and the new employments are precarious, without social protection, and with 'white' trade union leaderships that are favouring enterprises. about half of the labour force is (self-) employed in the informal, often illegal sector, salaries declined by ures . and . ) . the severe undernourishment hardly declined since due to inflation and economic crises, while the concentration of wealth owned by a tiny elite has increased dramatically. women have developed survival strategies for their children and elders, and often they have to pay the debt for the illegal crossing of their husbands. also feminization of agriculture rose to per cent (inegi ) . food imports affect both countries: the usa due to pollution of agrochemicals to raise yield productivity, and mexico due to payment of us$ billion for food imporation and job creation in a foreign country (inegi ) . only a small elite representing . per cent of the population benefits from this type of modern rape capitalism, owning . per cent of national wealth and per cent of financial savings (table . ) . nevertheless, these global data do not reflect the existing regional disparities. the food perspectives for the future are uncertain, and will most likely get worse due to the massive use of corn and oil seeds for biofuel. furthermore, confronted with climate change, disasters and greater drought, mexico must take its food security problem seriously, especially if the usa and canada that presently provide more than million tons of basic grain should become food insecure. therefore, the term of 'food power', created in by henry kissinger, may generate structural instability, migration, and social riots (figure . ). (innsz (innsz , (innsz , (innsz , based on global and regional scenarios on temperature rise, precipitation, decline in groundwater, and hydro-meteorological disasters, together with biofuel from cereals, the worldwide supply of basic grain will be reduced drastically. in , still half of the people live in regions with a low level of underground water, including the three large grain producers: china, india, and the usa. countries such as mexico, iran, israel, pakistan, saudi arabia, jordan, and yemen are overexploiting their aquifers and limiting alternatives for the future. due to projected water scarcity in the next years, cheap grain will disappear from the world market and only very few countries will be able to improve their agricultural production due to climate change. in , the world market price of rice, highly vulnerable to water, increased by per cent reaching us$ /t (usda ). the corn price in mexico rose between september and december from , to , pesos/ton, as a result of the demand for biofuel for corn in the usa, but also due to speculative practices. therefore, the future of the world food system is complex and uncertain, and a new policy of food sovereignty will play an important role in the political stability of many countries. related to the conceptualization of food security and food sovereignty (see . ), three models of food production and commercialization have evolved: a) the productivity model based on the green revolution; b) the life science model that relies on modern biotechnology and genetics; and c) the traditional organic or green model. throughout the th century the productivity model tried to homogenize food crops similar to industry, and during the last two centuries the supply of food and agricultural inputs was in the centre. the green revolution promoted monocultures, intensive use of chemicals, veterinarian drugs, improved seeds, machines, fossil energy, and irrigation systems. politically, this system relied on high government subsidies (usa, eu, ocde, japan), offering the consumers cheap products. the production was controlled by agronomists, veterinarians, and the chemical industry. health and environment concerns were marginal. the ministry of agriculture managed natural resources such as soils, water, forests, flora, fauna, and fish. internationally, this model should have eradicated hunger and given the whole world food security. until today it remains the basic tool against hunger (fao a, a, , b, c) . high crop yields and 'free markets' were at the centre of the concern and therefore hunger could not be eradicated, owing to the maximization of profit of agribusiness and governmental subsidies in developed countries. hunger and poverty were considered undesirable side effects for southern countries and for people with a low capacity to modernize. social, environmental, and cultural factors of diverse food production are only marginally considered. food is not treated as a cultural good or as a patrimony of thousands of years of human effort. the limits of this model are imposed by negative effects on health (gallaher ) and on the environment (scarcity in water and oil resources). in the st century a new model is emerging that establishes links among health, food production, and dietetic habits. it represents the new health safety and food security concerns where individuals with purchasing power are at the centre of attention. concrete genes were linked to specific illnesses (nestlé ), creating a scientific basis for life or a 'life science' paradigm (lang/heaseman ). this model is demand-oriented and takes into account the consumers and their needs. productivity is still important. it refers to the balanced daily intake of proteins, carbohydrates, vitamins and minerals, all of them necesary for a healthy life. this life science model integrates the food chain in the form of clusters and relates it to production, transformation, and trade of food. it combines genetic research with field experiments, including biology, engineering, nutrition, pharmacology, health, and mobile field labs. the industries are controlled by multinational food chains. they offer clean, safe, and homogenous products that can stay for weeks on the shelves of supermarkets, thanks to genetically modified genes and organisms (gmo). food is not only modified but also enriched artificially with nutrients to prevent illness, such as enzymes, proteins, minerals, etc. at the centre of concerns is the individual health, improved by technological proceedings in bio-labs, where specialists are in charge of human lives (nestle ). these processes of 'healthy' food can only be controlled through sophisticated scientific procedures in well-equipped laboratories in universities or research institutes of mne. the experts are paid by the food mne, which are simultaneously producers, sellers, and supervisors. when nonconformities arise, due to the complexity of the process, governments rely on these institutions, where those who are interested and involved are both judge and arbiter (beck ; ) . independently of an intensive propaganda in mass media, some undesired effects can not be denied, and ngos are trying worldwide to carefully educate people on these negative effects. most evident are genetic modified crops (gmo), which started commercially in . in more than million hectares were produced in the usa ( per cent), per cent in argentina, per cent in canada, and per cent in china. south africa, chile, india, and brazil are joining this production process. on gmo seeds there exists an oligopoly of four main multinational enterprises. one sole holding (monsanto) controls per cent of all seeds with two genetic modified proprieties: a herbicide (roundup) and an insecticide (bt). conclusive results are still lacking whether these seeds are innocuous, but there are risks that the recombinant process could produce unknown effects in human and animal health and environment. unwanted pollution occurred in canada where wind, water, insects, and other animals have polluted natural crops of canola with gmo ties, destroying the great biodiversity and the natural production of this crop (schmeiser ). another threat is related to new toxics, new plagues, and insects resistant to gmo and other insecticides. paediatricians have found a high level of food allergy in babies and therefore baby food is produced without gmo seeds. in socio-economic terms, eight mne merged in into four, able to produce per cent of biotechnological research in the world. this is a threat for the freedom of science and technology in favour of humankind. there is another danger that small farmers may be forced to stop farming due to the expensive productive processes of gmo seeds ( per cent of cotton production in ), what is reinforced through subsidies that are highly concentrated in big enterprises. finally, these gmo seeds are controlled by patents and the wto is the arbiter through trips (heineke ; schmid ; oswald ; ) . the study of fao ( a) in different countries has shown that the income of producers in mexico in-creased by per cent using cotton gm-seeds from monsanto, but the benefits were more than three times as high in china where a national research institute produced their own gm-seeds. the 'life science' paradigm continues with the same model of productivity, but it oriented at the consumers and their health needs. the integration into the food chain is through clusters. this model of production has generated new illnesses (bse ) and could promote new epidemics such as avian flu, since genetically modified organisms work with virus and bacteria that could have their own dynamism when they are modified and inserted into different plants or animals. therefore, the cornucopian vision to resolve by mne environmental, social, and health problems through science and technology shows its limits, but above all poor people have to pay for the mistakes, and biodiversity can get lost for ever. it is horrific that thousands of peasants have committed suicide when gmo harvests failed and credits could not be paid back (shiva , , ). with regard to food sovereignty there is no doubt. this model of production has enormously increased the costs of production (gm-seeds), and created a monopoly of agrochemicals and the transformation of basic food in the hands of tnes. these processes are able to concentrate wealth within few hands, increasing poverty not only due to more expensive food, but also due to associated health problems. the green model generates symbiotic relations and mutual dependence between nature and food production, and therefore uses soft methods of agriculture. they are regionally diverse and utilize policultivation, association of crops, rotation, mixed agriculture, fixation of nitrogen from air to soil, biopesticides, traditional methods of soil conservation and food, integral management of water, plagues, and environmental services. the combination of traditional and modern knowledge is consolidating food sovereignty in any region. a biodiverse and regionally adapted use of seeds is conserving diversity of species, and therefore is agro-ecological. this mode of production cannot be globalized. the surplus of production is sold in the local markets and thus reduces environmental pollution and global warming linked to transnational agribusiness and global markets. local agricultural production and trade, with access for peasants to water, seeds, credits, as well as technical and financial support could promote this model of agriculture. this green model takes women and peasants as key elements for food issues and agricultural consolidation. it encourages the participation of indigenous, women, and peasants in the national and regional definition of rural policies. it can guarantee women access to land for production and livelihood, and through empowerment they can overcome the violent and patriarchal structures inside families, regions, countries, and the global economic system. it includes the right that peasant organizations have developed their own model of food sovereignty and are now struggling for their right to produce and consume healthy, permanent, and culturally accepted food which is locally produced, sold, cooked, and consumed. governments have the obligation of protecting their economy from subsidized food imports. they have to establish agricultural prices which are able to cover the production costs and to protect the environment. by linking environmental services with farming, land planning, and participative democracy, this paradigm supports a stable rural development and therefore respects the human right for non-migration. when livelihood in villages and countries is guaranteed with public resources for poverty and hunger alleviation, bottom-up efforts can be reinforced. in the medium term, safe ecosystems and stable social relations create synergies and cooperation where safe food and the environment improve public health and cultural diversity at the local level. this third model reflects the food sovereignty debate. it understands food in a holistic way, where livelihood, sustainability, and culture are the driving elements to maintain the genetic diversity for future generations, offering healthy nutrition and establish- bse is a result of feeding cows with waste from animals instead of grass. after years research of more than drugs, it was proven that bovine somatropina, an amino acid able to stimulate growth in cows, is responsible for an increase of per cent of breast cancer in pre-menopausal women and the same number of prostate cancer in men (world cancer research fund ). confronted with avian flu threats, the same mnes are producing expensive medicaments with dubious results to combat a potential epidemic. foreign food aid from outside has to be targeted to avoid a distortion of non-market items such as equity, corruption, electoral use, etc., but above all it can destroy the local productive systems. thus, it must always be an emergency support, limited in time and for specific events. ing a direct relation among productive, commercialization, and consumption cycles. it represents also an alternative for more than . billion peasants and small farmers who still depend on their ancient technology. they carefully selected the seeds from the former year that were and are able to guarantee the next harvest. it consolidates the basic right to consume safe, sufficient, and culturally accepted toxicfree food that is locally produced, transformed, and sold. thus, in the green agricultural paradigm food is a cultural act of life and more than the intake of proteins and calories. it is until today the only real possibility to overcome existing famine and hunger and offer humankind an opportunity to create justice and well-being all over the world by fulfilling the universal declaration of human rights in its art. . . food sovereignty within the green paradigm represents the rights of people, communities, and countries to define their own ecological, social, economical, and cultural project of the future. besides maintaining food as a pleasure of life, and not a threat to health and survival, it consolidates the world food culture and consumption for the future. food perspectives: models of production, population growth, climate change, and environmental deterioration 'food security' in the context of the model of agribusiness production or life science has failed to improve the world food situation. it is not a problem of the amount of food and of the knowledge how to produce more, but it is basically a problem of poverty (fao ) . therefore the evidence is that in most poor countries the total number of hungry people has not been reduced, except for china and india and the former countries of ussr. rather, new threats of food insecurity are rising. this requires the reformulation of the basic assumption of how to reduce hunger and how to achieve the mdgs. the globalization process in its regressive phase has reversed some advances, but in countries with high population growth that are threatened by severe impacts of climate change and disasters, the eradication of hunger is further limited. both the 'productivity' and the 'life science' paradigms have also led to higher emissions. aquifers have collapsed in india and mexico. through genetic pollution both models have been destroying the biodiversity of southern countries. thus, with regard to food security, but also for the survival of humanity and nature, the present understanding of food security has failed to combat hunger. it has rather increased the threats and risks of more serious famine not only in africa, but worldwide. imposing food security instead of food sovereignty, and destroying the traditional green production, could become a boomerang also for northern and developed countries. from to organic food production has grown by to per cent. in germany organic food products grew annually by per cent. a major increase has also occurred in the us where the national organic programme (nop) supports small farmers and promotes the certification of green agriculture where organic products grew from us$ to billion from to . in about million hectares of land were certified and , farmers were affiliated. in most countries, due to the productive model of the political elites, the support for organic agriculture is still limited. nevertheless, the tnes have discovered this green option for supermarkets. they are now charging higher prices for naturally grown products. consumers, confronted with doubts about gmo, are demanding comprehensive labelling, but tnes have tried to influence national laws to avoid or restrict this. propaganda on different products is confusing the consumers even more by letting them believe that they determine their own model of life. via campesina has challenged this tne and has campaigned against gene modified seeds and promoted laws favouring its alternative agricultural model. they insisted that environmental, cultural, and social factors are as important as the economy. further, economic crises and increasing poverty in rural areas have created among peasants, the indigenous, and women a sense of security that they can manage their own food supply with regional resources and local seeds. at the international level, fao has argued that food needs could be linked with a protection of the natural heritage by: promoting market-based incentives that compensate farmers for their stewardship efforts, thus maintaining their economic viability; replacing polluting agricultural practices with approaches that can reverse the dramatic trends in biodiversity loss; thriving on community par- ticipation in land conservation. meeting food needs while protecting the natural heritage is a challenge shared by all countries of the planet. organic agriculture can meet this challenge head-on by: promoting marketbased incentives that compensate farmers for their stewardship efforts, thus maintaining their economic viability; replacing polluting agricultural practices with approaches that can reverse the dramatic trends in biodiversity loss; thriving on community participation in land conservation (el-hage scialabba : ). simultaneously, fao has also promoted gmo seeds in diverse poor countries, and continues to support the 'green revolution' model. many existing contradictions are inherent in the three productive models, and reflect the struggle for hegemony. they can be synthetized as follow: the 'productive' model is unsustainable due to the scarcity and pollution of natural resources (water, soil, seeds, and loss of biodiversity). ministers of agriculture have shifted slowly to the 'life science' model that is supported by ministers of trade who promote free trade and bilateral agreements. health ministers have supported nutria-genomic research, biosecurity protocols and vaccines that are often produced from genetically modified plants. productivity concerns dominate over inherent risks and threats for biodiversity and humankind, due to the uncertainty and insecurity of genetic manipulation and nanotechnology. both could affect the essence of human beings and the future of life (habermas ). these two models induce a scenario of a 'food war' (lang/heasman ), when multiple factors of aggravation of conflicts intervene: the quality and innocuous food demand, international commerce, governmental regulations, nutritional requirements, control of tnes, anti-monopoly laws in transportation, financial monopsony, security in food chains, supply of safe food products, coexistence of over-and undernourished people, environmental damages, science and technology (s&t). arbitration among these many contradictions are often handled by experts associated with tnes. but despite the unimaginable advances in s&t; hunger is still increasing and far from being eradicated. why is this so? there is a second related factor. the model of transnational agribusiness is oriented at the individual, considering his or her consumption and ppp. as with the modern health system, the individuals become victims and objects of persuasion for food recipes to strengthen their health that are often counterproductive. these two realities have opened for social movements, ngos, and critical scientists a space for struggle. confronted with the nutritional and health deterioration, they have denounced these tnes and often corrupt government allies which try through early alerts and catastrophic predictions about epidemics to push the errors and possible consequences of this erroneous productive system to various 'natural' causes. the global deterioration of life quality and limited progress in hunger alleviation in most developing countries, as well as high levels of obesity and cancer in industrialized countries, offer organic agriculture an option for the future. social movements understood these opportunities and are promoting food sovereignty with native seeds and organic input as a real alternative against hunger and malnutrition. table . summarizes, contrasts, and compares the many advantages and disadvantages of the 'life science' model with those of the 'sustainable organic agricultural' model. in synthesis, the paradigm of 'science of life' relies on governmental financial resources; however, the consolidation of this model depends on the acceptance by consumers who are induced through advertisements to buy these products. therefore, the competition among some tnes could leak information about damages in health through this model of food intake, and strict governmental control can avoid a manipulation of consumers. but often the same pharmaceutical holdings are also selling medicaments, control hospitals through the stock market, and often repel demands to pay compensation for damages caused by unhealthy food. their treatment (chemo- value of change, with maximization of profits and socialization of losses value of use with maximization of social relations and collective livelihood therapy and radiotherapy) creates further collateral effects compensated with other expensive drugs. their goal is only the maximization of profits by taking away the surplus created by society. these contradictions in the health, education, and food system were exposed by ivan illich ( ). on the other side, there is the small green production for poor people, peasants, women and minorities. organizing production and transformation, food diversity, and local markets increase local food security. more governmental support is still lacking, and also scientific and technological efforts to combine traditional and modern knowledge has to be developed, e.g. in new zealand. there are enough universities that could support green models of production able to facilitate the creation of local jobs and offer young people an opportunity for employment and a decent life. however, the political and economic elites that benefit from the other two productive models are preventing an enhanced 'food security' combined with 'food sovereignty' and a dignified livelihood (nord/andrews/carlson ). conclusions: food security with self-sufficiency, food on this dual political and conceptual background, this chapter addressed the following research question: food represents not only a security issue of intake of nutrients, but it forms part of a holistic understanding of life and a constituting element of any civilization. thus, food includes networks of connectedness, belonging, and relationship of trust, reciprocity, cooperation, solidarity, care, and exchange. it creates social benefits and risk reduction, but also innovative activities through the wider access to infor- artificial international prices due to subsidies, generating dumping in the world market local, interchange of products and services fixed by the economy of solidarity and support for the vulnerable monopolies, oligopolies and monopsonies local chains of integrated micro-business monopsonies integrated in fta, wto controls through gats, trips and international arbitration family unity and local market with incipient household transformation, local non-violent conflict resolution food disposal world supply-demand, depending on available capital and prices, speculation with crops, increase of hunger proper system of production for local food, family and regional storage the case of old people is often dramatic. they loose their savings for medical treatment and hospitalization. once without resources they are abandoned and in the best case they go back to the traditional medical sector. however, governmental controls can further limit this alternative. mation and learning. it is a process of anchoring of personal and group identities (see chap, by oswald on huge; oswald a), where social relations reaffirm the integration of a person inside a community establishing rights and obligations, such as access to land, credit, technology, training, market, life quality, and rituals. besides guaranteeing physical and cultural survival, 'food sovereignty' creates also new opportunities for people-centred poverty alleviation and new understanding of rurality as a complex social network. it represents a critical response to the accepted development and modernization paradigms, and opens ways for diverse rural life processes where agricultural activities and environmental services coexist with services and industries. thus, food is part of a holistic model of life and a constituting element of any civilization. networks of interrelationships, and processes of identity and social belonging, create relationships of trust, reciprocity, cooperation and exchange. they are at the basis for 'food security' which could evolve into an integral 'food sovereignty'. confronted with new threats of global environmental change, 'food sovereignty' represents social benefits and contributes to risk reduction through innovative creativity where instant world communication helps to establish new learning processes. during this process of achieving 'food sovereignty', personal and group identity is anchored and social relations may overcome stereotypes by reaffirming the integration of a person or a group within a community. such a wider understanding of rurality that includes non-agricultural activities facilitates critical responses to historical injustice, abuse and environmental changes, and opens ways for diverse ruralurban life processes, where agricultural activities and environmental services coexist with other services and non-contaminating industries and transportation systems. the future is getting complex and the world is confronted with unexpected climatic events, generating massive migrations, chaotic urbanization, pollution of natural resources, and loss of biodiversity. the ecological footprint and the size of the 'food footprint' is converted from food consumption by this equation: where crop yields are taken from the fao database (friends of the earth ). population growth creates new challenges when billions of young people ask for dignified employment. on the contrary, the lack of jobs could create complex emergencies. in this multifaceted panorama new agreements among governments at all levels with business and organized civil society should be negotiated where public well-being has to prevail over private interests. this implies to transform through creative activities related to food production, transformation and consumption, the existing monopolies into local chains of micro-enterprises that are able to offer cheap, healthy and, culturally accepted food in a framework of an economy of solidarity. but market forces are pushing in a contrary direction. the future food sector will experience a competition between the 'life science' and 'sustainable small production' model. new food-related illnesses (e.g. bse) have created a greater awareness among people, what they are eating. in europe, some per cent of the population is familiar with the associated risks of agribusiness by tnes and per cent reject gmo food. increasing degenerative illnesses and obesity have forced the tnes to focus on new products, and the culture of 'light' food has been their response. however, only a comprehensive approach with preventive health, vitamins, proteins, iodine, flour, and other microelements for the undernourished will be able to alleviate hunger and create livelihood for all with a distribution of profits. the future will show if the public relations activities by tnes will be able to counter a wider public awareness on the risks associated with the life science approach or whether small green food production will slowly replace big food monopolies. however, there are some global decision-making processes that may contribute to and speed up a strategic shift aiming at 'food sovereignty' (cloc ): tries women produce most of the local food (fao ; b) . . regional food sovereignty: via campesina, cloc ( ) , mst ( ) , and the peasant university of the south (unicam) are promoting an integral model of food with democratic landreform, credits and local savings, green agriculture, chains of integrated local micro-businesses, an economy of solidarity, and traditional medicine. . food policy to alleviate hunger: brazil proposed a model of food support for popular sectors linking the small production system with an offer of healthy food, increase of minimal salary of workers, and an urban offer of cheap food for the poor (figure . ). . a well developed system of periodic measurement of basic indicators of undernourishment is needed, above all for children below five years, including anthropometric measurements of weight and size related to their age. unicef, who, and innsz have proposed six steps with minimal costs to avoid premature deaths, slow development, and brain damage in infants: vitamin a complements; a complete scheme of vaccines; nutritional supplements to overcome severe undernourishment; periodic elimination of parasites, complements of iron, iodine, and other minerals (such as flour against caries) depending on the water composition, floors covered with cement, latrines, clean water access, and nutritional education and care (Álvarez/oswald ). furthermore, the metabolic syndrome of undernourished children with small size should be addressed. they of- . improvement of local food through a mixed agriculture of fruit trees, plants able to fix nitrogen from the air to the soil, rotation of crops, organic composting, and bio-pesticides; . community health centres able to treat the most common gastro-intestinal illnesses, malaria, dengue, reproductive health and campaign for vaccination, undesired pregnancy, and sexually transmitted illnesses; . basic education: training in simple technologies for production, and conservation of safe food at the community level, especially for women; . renewable energies: solar systems, biogas, oil and other energies able to give children light for studying, energy for water pumps, machines for grain mills, and refrigeration of medicaments and food; . clean water, building of latrines, water harvesting, protection of wells, and other simple techniques to conserve safe water and to avoid water-borne illnesses. ten rely on a diet that is rich in carbohydrates and fat, and are subsequently frequent victims of obesity, later on diabetes and coronary illnesses. . education, training, and the rescue of traditional elements of food culture are basic requirements to improve the nutritional situation in poor countries. education and training, especially of women, reduces not only the illnesses in families and premature death, but it opens the cooperation in reproductive health and creates stable livelihood conditions in villages, and colonies, and slums of the urban poor. ) enabling women, indigenous, and peasants to handle food and nutrition for their families in an integral way, improving their quality of life, and reducing premature death and preventing diseases. such a new comprehensive security process that combines 'food security' with 'food sovereignty', and also with 'water' and 'health security', may be better able to resolve the food problems of the other half of the world population for whom food security has been an issue of daily survival of their families that avoids the overconsump-tion and loss of life quality with which the food security problems of the oecd world and the elites in the global south are struggling (see chap. by salih). the discussion has shown that the evolution of the concept of 'food security' within multilateral organizations has failed due to a top-down approach that is neither questioning the demands of the people, nor the interests behind the driving forces of world business. the continuous adaptation of the 'food security' concept and model by fao reflects its basically technocratic approach that is far away from the real problems of hunger and of agribusiness. the fao has tried to resolve a complex health problem with aspirin (preker/feachem/de ferranti ). confronted with serious environmental deteriorations and adverse economic conditions resulting from the neoliberal approach, the directly affected people started first with a critical analysis of agricultural and food aid policies from industrialized countries. greater environmental destruction, new threats due to climate change, and deeper ecological footprints forced organization of civil society to create the new paradigm of 'food sovereignty' as a holistic life concept. that there "are no secrets how to eradicate hunger. there are no new technologies necessary. simple political will is required to change the existing policies which make the rich richer and the poor poorer or ) linked the multidimensional roots of hunger to poverty. in the kenyan village of sauri he tried 'the big five' with us$ per person and year women are not only more affected by modernization, they represent also an alternative for self-sufficiency and to the food supplies by tnes this understanding could overcome the limited productive approach, but also the behaviour of converting poor people into victims of their circumstances, when the real causes of their situation of marginalization are precisely the forces of the free market, the political domination and the exploitation of humans and nature for profit. the future is complex and the situation will probably get worse. then biodiverse and culturally determined approaches to food sovereignty could foster solidarity among human beings and protect their remaining common natural and cultural capital. key: cord- -m t hwco authors: denney, justin t.; brewer, mackenzie; kimbro, rachel tolbert title: food insecurity in households with young children: a test of contextual congruence date: - - journal: soc sci med doi: . /j.socscimed. . sha: doc_id: cord_uid: m t hwco household food insecurity, an inability to provide adequate nutrition for a healthy, active lifestyle, affects nearly in households with children in the united states. though rates of food insecurity declined to pre-recession levels just prior to the covid- pandemic, they are now once again increasing. as a result, in one of the wealthiest countries in the world, millions of young children continue to grow up in households that struggle daily with a problem that is often associated with the developing world. the result is both immediate and long-term health and development deficits for children. we propose that the degree of demographic and socioeconomic congruence between the households of young children and their neighborhood of residence lends unique insights to food insecurity. we examine this using the ecls-k - for children in families with incomes below percent of the federal poverty line (n = , ). results show that congruence between household and neighborhood education and race/ethnicity associates with the likelihood of experiencing food insecurity. for example, households with non-hispanic black children living in neighborhoods with high proportions of non-hispanic blacks have significantly lower probabilities of food insecurity than similar households living in neighborhoods with smaller black populations. similarly, more highly educated families experience lower probability of food insecurity in high education neighborhoods than when they reside in low education neighborhoods. focusing on neighborhood risk factors as absolute and independent contributors limits our understanding of how families experience food insecurity as well as any policy efforts to address it. food insecurity, a household's inability to consistently provide enough food for an active and healthy lifestyle, affects nearly in households with children in the united states (coleman-jensen, rabbitt, gregory, & singh, ) . though rates of food insecurity declined to prerecession ( ) levels (coleman-jensen et al., ) just prior to the covid- pandemic, the current crisis is resulting in never before seen levels of food insecurity (bauer, ) . the impacts of food insecurity for children, especially during important developmental periods, can have immediate and long term consequences (gundersen & ziliak, ; kirkpatrick, mcintyre, & potestio, ) . these include physical and mental health ailments, declines in academic performance, higher rates of absenteeism, repeated grades, behavioral and attention problems, and more mental health counseling (alaimo, olson, & frongillo, jyoti, frongillo, & jones, ; kleinman et al., ; murphy et al., ; whitaker, phillips, & orzol, ) . given these consequences, a growing literature aims to identify the risk and protective factors associated with food insecurity among young children (gundersen & ziliak ) . although research on food insecurity has focused on the characteristics of individual families and children (gundersen & ziliak, ) , an established literature shows the importance of residential location for shaping child health and development (leventhal and brooks-gunn ) . residential context can impact food insecurity through the physical and socioeconomic characteristics and resources available (or not) in communities (brisson, ; denney, kimbro, & sharp, ; jackson, johnson, vaughn, & hinton, ; king, ) . extant research, however, has paid insufficient attention to the neighborhood conditions that increase or decrease vulnerability to food insecurity. this oversight is important to address if household food j o u r n a l p r e -p r o o f insecurity is rooted in family and community-based factors (denney et al., ; jackson et al., ; king, ) . to fill this research gap, we use a nationally representative sample of households with young children linked with contextual data to investigate the importance of neighborhoods for household food insecurity, and suggest, as have others (sharkey & faber, ) , that an investigation of neighborhood effects is incomplete without considering characteristics of households and residential neighborhoods in tandem. rather than treat neighborhood conditions as having a uniform impact on every resident, a key contribution of our study is examining whether neighborhood conditions impact residents differently depending on their individual or family characteristics. are poor households, for example, more likely to be food insecure in lower-income or higher-income neighborhoods? and are households that are not below the poverty line more likely to be food insecure in lower-income or higher-income neighborhoods? in the current study, we investigate the role of congruence -the degree to which individual (or household) and neighborhood conditions align or diverge -across poverty, education and race/ethnicity in relation to household food insecurity. in doing so, our study allows policymakers to better identify where food insecurity occurs and for which households. numerous individual and household determinants of food insecurity have been identified. food insecurity is closely tied to a household's financial status (coleman-jensen et al., ) , such that the prevalence and severity of food insecurity is higher among lower-income and asset poor households compared to the national average (chang, chatterjee, & kim, ; gundersen & ziliak, ) . non-financial risk factors include but are not limited to single-parent households j o u r n a l p r e -p r o o f and those with grandchildren (ziliak & gundersen, ) , households with an adult smoker (cutler-triggs, fryer, miyoshi, & weitzman, ) , poor caregiver mental and physical health (balistreri, ; kaushal, waldfogel, & wight, ) , lack of nonresident father involvement (nepomnyaschy, miller, garasky, & nanda, ) , immigrant households (brewer, kimbro, & denney, ; cook, ) , and low maternal education (kimbro, denney, & panchang, ) . though informative, these factors do not fully account for the onset or severity of food insecurity among u.s. households. recent studies from the neighborhood effects literature suggest the importance of residential context for predicting household food insecurity. research concerned with whether residential context influences wellbeing emerged within a framework focused on absolute differences: put simply, are residential characteristics linked with life chances, regardless of individual and household characteristics (robert, ) ? from here, researchers have sought to understand how social, cultural, economic, and physical characteristics of individuals' neighborhoods influence wellbeing (frohlich, corin, & potvin, ; kawachi & berkman, ; singh, siahpush, & kogan, ) . to summarize, researchers document disparities in social and developmental wellbeing for children in disadvantaged communities because the resources, infrastructure and related services that promote wellbeing are inaccessible, ineffective, or unavailable in these communities (chetty, hendren, & katz, ; jencks & mayer, ). as such, there are many reasons to believe social and economic indicators of neighborhoods might reveal important insights into the risk of experiencing food insecurity. neighborhood scholars reason that the health benefits of socioeconomic status (ses) are not j o u r n a l p r e -p r o o f limited to individual status-high-income and highly educated places should benefit individuals through improved infrastructure and more highly resourced social networks, regardless of their individual or household ses (sampson, ) . neighborhoods with more wealth can attract more institutional resources, such as large chain grocery stores (walker, keane, & burke, ) . further, some more advantaged neighborhoods may be characterized by a greater density of other institutional resources like schools, libraries, and community organizations, the lack of which may contribute to the impact of neighborhood disadvantage on residents' wellbeing (wilson, ) , including food security status. community organizations, for example, are important both for enrolling families in formal governmental food assistance programs, but also for creating and maintaining the informal channels that connect families to each other and encourage strategies to overcome food shortages (king, ) . neighborhoods with higher levels of perceived social cohesion might experience greater levels of trust and resource sharing between residents, which promotes food security (denney, kimbro, heck, & cubbin, ; king, ) . still, evidence for neighborhood ses contributing independently to the risk of household food insecurity is sparse. a descriptive study showed significantly greater proportions of food insecure households in neighborhoods with higher poverty rates and higher less than high school educated populations (kimbro et al., ) . a more recent study, however, using neighborhood concentrated disadvantage as a marker of ses found no direct adjusted association (denney et al., ) . focusing on individual, household, and even neighborhood risk factors as absolute and independent contributors may limit our understanding of how families experience food insecurity. what if, for example, the infrastructural resources and sociodemographic j o u r n a l p r e -p r o o f characteristics of communities, which promote or hinder health, matter for food insecurity in different ways for different residents (sharkey & faber, ) ? in the current study, using a framework of contextual congruence, we investigate the importance of neighborhoods for household food insecurity, and suggest, as others have (sharkey & faber, ) , that an investigation of neighborhood effects is incomplete without considering the dynamic nature of households and residential neighborhood characteristics in tandem. that is, we move beyond the inquiry that if context matters for food insecurity it will matter equally for all households regardless of their demographic and socioeconomic differences. instead, we examine whether congruence across poverty, education, and race/ethnicity at the individual and neighborhood-level associates with household food insecurity risk. these indicators have specific relevance to food insecurity. at the household-level, poverty, for example, indicates material well-being, which is strongly linked to a family's ability to secure enough food (coleman-jensen et al., ) . parental education also indicates material well-being, as well as human capital and other skills, such as financial management, tied to a household's food security status (gundersen & ziliak ). at the neighborhood-level, rates of food insecurity, as well as health risks, are unequally distributed across place according to the socioeconomic and racialethnic composition of residents (gundersen, engelhard, & waxman, ; lichter & qian, ) . theoretically speaking, congruence between household and neighborhood conditions may reduce risk of household food insecurity. households that feel connected to those around them, perhaps by sharing a similar demographic or socioeconomic profile, are likely to pool j o u r n a l p r e -p r o o f resources and share information and strategies to acquire adequate food supplies (ahluwalia, dodds, & baligh, ; stack, ) . in contrast, neighborhoods where distrust pervades the community are places where social resources have difficulty taking hold, and neighbors may consequently keep to themselves (rankin & quane, ) . lending some support for this theory, jackson and colleagues' recent study ( ) finds that families experiencing low social capital in their neighborhood, especially in combination with violence and perceived danger, are significantly more likely to experience food insecurity after accounting for household ses. additionally, denney and colleagues ( ) find that neighborhood socioeconomic disadvantage is linked with greater risk of food insecurity among higher-ses families but lower risk among low-ses families. the authors speculate that lower ses families in disadvantaged communities engage in more information and resource sharing which mitigates food insecurity risk. in other words, social relationships and social support which improve health (berkman and glass ) and lower food insecurity risk (denney et al. ; king ) may be greater in places where congruency is higher regardless of absolute neighborhood characteristics. to date, although not focused on food insecurity, research exists that illustrates some health benefits of living in neighborhoods where residents share a similar demographic profile or socioeconomic status. looking at racial and ethnic status, pickett and wilkinson ( ) review evidence of a race/ethnic group density effect on health and wellbeing and find that several studies have linked better mental and physical health for racial/ethnic minorities who live in places with higher percentages of their same racial/ethnic identity. such examinations turn attention away from absolute differences to a discussion on how congruence between household and community characteristics can impact wellbeing. one study found, for example, that middleincome blacks in the new york metropolitan area chose to live in predominantly black, j o u r n a l p r e -p r o o f socioeconomically disadvantaged, communities so that they might have greater access to cultural resources and limited exposure to everyday acts of discrimination (mullings & wali, ) . similar bodies of work have documented wellbeing disadvantages for whites in predominantly non-white communities compared to whites in predominantly white communities (pickett & wilkinson, ) . these group density effects are not isolated to racial and ethnic identity. halpern ( ) and others (pickett & wilkinson, ) discuss the relevance of other community and individual characteristics, such as social class and religion, which, when aligned, provide benefits for psychological wellbeing. in all, there is theoretical and empirical evidence that supports the idea that individuals embedded into communities with congruent characteristics may have more ready access to health promoting resources than when individuals are in communities that are different from their circumstances. importantly, this all suggests, for example, that both poor families in more advantaged places and non-poor families in more disadvantaged places would experience deficits as both experience contextual incongruence. on the other hand, differences among residents may promote well-being, the sharing of information and strategies, and thus result in lower food insecurity. in a classic urban ethnography, jane jacobs ( ) suggested that economic heterogeneity leads to more informal contact between residents and enhanced social cohesion. more recent research on spatial stigma reveals that disadvantages associated with residential context can accumulate with household disadvantages (keene & padilla, ) . this would suggest that disadvantaged families might benefit most from locating in less disadvantaged places. spatial stigma, however, can be embodied and carried by these families from one location to the next, thereby limiting the possible benefits that disadvantaged families in more advantaged places may experience (keene j o u r n a l p r e -p r o o f & padilla, ). in contrast, other research shows that disadvantaged families from disadvantaged and stigmatized neighborhoods can generate strong social networks, durable social ties, and enhanced social cohesion in spite of and in response to their stigmatization (august, ; thomas, ) . we aim to understand if household characteristics within residential context is important for household food insecurity. thus, we address three primary hypotheses: h . the odds of household food insecurity will be lower with congruence between household and neighborhood poverty statuses. h . the odds of household food insecurity will be lower with congruence between household and neighborhood educational statuses. h . the odds of household food insecurity will be lower with congruence between household and neighborhood race/ethnic statuses. support for congruence would show that the closer aligned household characteristics are with neighborhood characteristics, the lower the odds of food insecurity. support as it relates to race and ethnicity, for example, would show that households have lower food insecurity when they reside in neighborhoods with more co-ethnic residents than when they reside in neighborhoods with fewer residents of a similar race or ethnic status. we test these hypotheses against their alternatives; namely, household food insecurity will be lower with incongruence between household and neighborhood poverty, education, and race/ethnicity. support for this alternative j o u r n a l p r e -p r o o f as it relates to poverty, for example, would show that households living in poverty have lower food insecurity when they reside in lower poverty neighborhoods than when they reside in higher poverty neighborhoods. finally, we lack appropriate data in the current study to properly test for issues related to how households select into or move within or between neighborhoods with more or less consistent demographic and socioeconomic characteristics to their own. however, we examine congruence across related but distinct indicators of demographic and socioeconomic characteristics and, importantly, do so for a sample of children in households with lower income levels (less than % of the federal poverty line [fpl] ). we use restricted, geo-coded data on children and their families from the early childhood the ecls-k sample includes , children (in accordance with our restricted data agreement we round all sample sizes to the nearest ) with valid geocodes at the spring kindergarten wave. about % of this sample is missing a parent interview at the spring wave, when food insecurity was collected, limiting our sample size to , children. we further restrict our sample to those with incomes below percent of the fpl in . this leaves a final sample of , children who live in , census tracts. roughly % of the sample represents the sole observation in their census tract and the average number of children per j o u r n a l p r e -p r o o f census tract is . ; as described below, we estimated single-and multi-level regression models and find no evidence this creates estimation problems (bell, ferron, & kromrey, ) . household food insecurity, a binary measure created from the usda's -item food insecurity scale (bickel, nord, price, hamilton, & cook, ) , serves as our outcome measure. ecls families are asked questions regarding food supplies and household resources to purchase food over the last month period. we follow convention (bickel et al., ) and code households where parents answered affirmatively to three or more of the items as food insecure. to isolate any associations between contextual congruence and household food insecurity, we control for relevant measures of children and their families. these include the gender of the child, age of child in months, age of mother in years, child's race/ethnicity, the family living arrangement, the number of siblings in the household, number of years lived at the current address, whether the child attends school in an urban area, parent's perception of whether their neighborhood is safe for their child to play outside, and an abbreviated version of the center for epidemiological studies of depression scale (ces-d) indicating whether the primary caretaker is likely depressed (radloff, ) . finally, we include household income in categories of less than % fpl (the referent), - % fpl, - % fpl, and - % fpl. at the neighborhood-level, we account for median monthly rent and residential stability, measured as the proportion of the neighborhood who lived in the same home one year ago. in sensitivity tests, we also accounted for the proportion of the neighborhood's residents which were children, as well as the density of food retail establishments and food pantries (using u.s. census bureau business pattern data), which did not substantively alter the findings. to capture the association between contextual congruence and food insecurity, we take two measurement and assessment approaches. first we generate congruence measures that represent the proportion of neighborhood children who share the household's poverty status (we replicated results with the proportion of adults in poverty and the results are nearly identical), the proportion of residents who share the level of parental education, and the proportion of residents who share the child's race/ethnicity. these measures are constructed specific to each household so that, for example, a value at or above for the relative poverty measure would indicate that the majority of children in the neighborhood share the household's status (below poverty or not). the relative measures are standardized in the regression results (in table ) so that associations can be interpreted in standard deviation units. for example, an odds ratio less than . for coeducation would mean that the odds of household food insecurity are lower for a one standard deviation increase in congruence between the child's parental education status and the neighborhood education level (measured as bachelor's degree or higher or less than a bachelor's degree). such an approach is useful in that it allows us to assess if household food insecurity is associated with congruence between household and residential contexts. it is limited in that it does not make clear for whom the association is important. thus, our second strategy uses neighborhood measures of poverty, educational attainment, and race/ethnic composition and interacts them with household level measures. for poverty, we construct a dichotomous measure indicating greater than or equal to % of children in the neighborhood are below the poverty line (bishaw, ) . for educational attainment, we created empirical terciles to represent neighborhoods with low, medium, and high proportions of residents with a bachelor's degree or more. for race/ethnic composition, we capture j o u r n a l p r e -p r o o f race/ethnicity-specific terciles of co-race/ethnic composition of the neighborhood, and dichotomize the results into low (the lowest tercile) and medium/high co-race/ethnicity. approximately % of children remaining in our analytic sample were missing data on one or more household or child level characteristics of interest, with the majority ( %) only missing on the number of years the child had lived at the current residence (because it was only collected in the fall kindergarten wave). we employ the latest techniques for multiple imputation of missing data and generate five sets of probable values for each missing value using a diverse set of predictors and stata software (royston, ) . regression models on the un-imputed sample provide substantively similar results and are available upon request. we estimated two sets of logistic regression models on the imputed data, adjusting the standard errors for clustering of children by neighborhood. we also estimated multilevel logistic models but results were substantively similar (available upon request) so we present the onelevel logistic models here. in table , we predict food insecurity with a robust set of control measures, and then test each contextual congruence measure (co-poverty, co-education, and corace/ethnicity). in table , we test interactions between our household and categorical neighborhood characteristics of interest to better understand associations between contextual congruence and household food insecurity. we present odds ratios (or) for all regression results in the tables. finally, we generate fully adjusted predicted probabilities with pairwise comparisons to illuminate the interaction results and present those in figures - . j o u r n a l p r e -p r o o f table provides weighted proportions and means for household food insecurity and for the individual/family and neighborhood characteristics for the full sample and separately for children in food secure and insecure households. table shows that food insecurity for households with young children varies considerably by child and family characteristics consistent with large bodies of work in these areas (gundersen & ziliak, ) . thus, we focus our discussion here on panel b. table provides information on the neighborhood characteristics for children in food secure and insecure households. turning first to the neighborhood congruence measures, which for ease of interpretation are presented here as the percentage of residents in the neighborhood who share the characteristic, we see that on average, children live in neighborhoods where % of residents share household and neighborhood poverty status, measured simply as poor or not poor. food insecure children, however, on average live in neighborhoods where % of residents share their poverty status, while food secure children on average live in neighborhoods with much higher congruence ( . %). the high poverty measure further shows that % of the food insecure sample resides in the poorest neighborhoods while % of the food secure households reside in high poverty neighborhoods. the relative education measure shows a different story. that is, food insecure children live in neighborhoods where, on average, . % of residents share their parents' highest educational attainment, while food secure children live in neighborhoods with greater educational heterogeneity ( . % congruence). but in terms of absolute differences, food insecurity by neighborhood education is distributed similarly to neighborhood poverty; a smaller proportion of children in food insecure households live in neighborhoods with a high proportion of residents with a bachelor's degree or more. for race/ethnicity, on average, the children live in neighborhoods where . % of j o u r n a l p r e -p r o o f residents share their own race/ethnicity. this proportion is lower for food insecure children ( . %) than for food secure children ( . %). when categorized as "low co-race/ethnicity," however, we do not see significant differences by food security. ( table about here) table provides odds ratios from logistic regressions with clustered standard errors predicting household food insecurity using the co-poverty, co-education, and co-race/ethnicity standardized measures. model includes the household and child-level characteristics. among this < % fpl sample, the adjusted odds of household food insecurity are lower the further away the household is from the fpl. ( table about here) the control measures in model of table associate with food security in wellestablished ways (see gundersen & ziliak ) . model shows that the association of living in a neighborhood that shares household and neighborhood poverty status is below . (p < . ). model suggests that, when household and neighborhood educational attainment align, the odds of household food insecurity are, again, lower (p < . ). finally, model shows the odds ratio for co-race/ethnicity is also below . , but the adjusted association is not statistically significant. these models begin to assess the adjusted association between contextual congruence and food insecurity, but they cannot reveal for whom congruence may matter most. table takes a different approach by considering whether the association between contextual congruence and food insecurity differs for higher and lower-ses families, and by race/ethnicity. for parsimony, we present just the main effects and interactions for our variables of interest, but the results are net of all control variables included in table . first, panel a j o u r n a l p r e -p r o o f displays results for household and high neighborhood poverty. model a shows that among this lower to moderate income sample, after adjusting for relevant household and child-level covariates, living in a high poverty neighborhood is not associated with the odds of household food insecurity. model b, however, investigates not if neighborhood poverty is related to food insecurity but for whom it is most relevant. the interaction results in model b suggest, relative to families living below poverty, the odds of food insecurity for children in households that are - % fpl are impacted to a greater degree (p < . ) by living in high poverty neighborhoods; neighborhoods that are largely incongruent with their household poverty status. in figure , we plot the predicted probabilities generated from the estimates in table , model b. in all, figure shows little support for an association between contextual congruence and food insecurity in terms of poverty. the likelihood of food insecurity is much higher for children in families living below and near poverty than for children in families further away from the poverty line. but looking within family types who live in low and high poverty neighborhoods, however, shows no significant differences. the predicted probability of food insecurity for children in families - % of the fpl and living in high poverty neighborhoods ( . ) is marginally higher than similar children living in low poverty neighborhoods ( . ) but that difference does not reach significance. similarly, the predicted probability for children living below poverty is higher when their household is located in a low poverty ( . ) versus a high poverty ( . ) neighborhood but the difference does not reach significance. table , model a of panel b shows that the adjusted association between neighborhood education and household food insecurity does not reach statistical significance. model b, once again, aims to examine for whom neighborhood educational attainment might matter most. the interaction terms, along with the direct effects, suggest that the associations of neighborhood education are dependent upon parental education in the household. the significant interaction shows that the protective association of living in a high education neighborhood is shaped by whether children live in families where at least one parent has a college education. figure shows that food insecurity is less likely for children in more highly educated households when they live in more highly educated neighborhoods compared to when they live in less highly educated neighborhoods. specifically, for children with at least one parent with a bachelor's degree, their lowest likelihood of food insecurity ( . ) is in high education neighborhoods and their highest likelihood of food insecurity ( . ) is in low education neighborhoods. further, in high education neighborhoods, the difference between children in families with ( . ) and without ( . ) a college educated parent is significant. ( figure about here) next we turn to panel c in table , which presents results testing whether the influence of living in a low co-race/ethnicity neighborhood on food insecurity varies by race/ethnicity. in model a, the low co-race/ethnicity variable is positive (or = . ) but does not reach statistical significance. in model b, however, we again see some evidence that contextual congruence matters for predicting food insecurity, specifically for non-hispanic blacks. the interaction for non-hispanic blacks suggests that living in a neighborhood with fewer residents identifying as black is associated with disproportionately higher odds of food insecurity (or = . , p < . ). there is no significant interaction for hispanics, meaning the odds of food insecurity for hispanics is not different whether there are small or large proportions of hispanics living in the neighborhood. these results are depicted in figure . the likelihood of food insecurity for whites and hispanics are not statistically significantly different when they live in low co-ethnic or mid to high co-ethnic neighborhoods. but the probability of food insecurity for blacks in low co-ethnic neighborhoods ( . ) is significantly higher than the probability of food insecurity when blacks live in mid to high co-ethnic neighborhoods ( . ). in the current study, we argue that empirical investigation into the congruence between individual and neighborhood-level characteristics provides a more holistic understanding of how neighborhood context impacts family and child well-being, specifically, the conditions that increase (or decrease) vulnerability to food insecurity. in doing so, our study establishes directions for future research on neighborhood health effects and identifies areas of prevention and intervention for addressing food insecurity among families. though an ample body of research documents the importance of neighborhood factors for children's healthy development, researchers often treat neighborhoods as monolithic, with a uniform impact on every resident, when in reality, the same neighborhood may impact residents differently depending on their individual or family characteristics (sharkey & faber, ) . household food insecurity, an outcome that has recently received attention in neighborhood studies (brisson, ; denney et al., ; jackson et al., ; king, ) , is theoretically linked to the physical and social resources available or not available in communities. however, a fuller understanding of how neighborhoods matter for food insecurity may lie in our j o u r n a l p r e -p r o o f understanding of how family characteristics align or diverge from the broader community in which they reside. to address this gap in the literature on neighborhood health effects, as well as food insecurity research, we use a framework of contextual congruence to investigate the degree to which individual and neighborhood-level alignment (or divergence) across poverty, education and race/ethnicity associates with household food insecurity risk. we found evidence that contextual congruence is related to the odds a household with young children experiences food insecurity. upon closer inspection, this was most evident in two ways. first, among this low to moderate income sample, more highly educated families experienced lowest risk of food insecurity in the most highly educated neighborhoods. at the same time, less educated families in those same neighborhoods experienced significantly higher risk of food insecurity compared to their more highly educated neighbors. the tangible benefits when the socioeconomic characteristics of families more closely align with their communityproviding possibly enhanced access to social capital, social support, and social ties that can be used to avoid food insecurity-may be limited to certain kinds of families in certain kinds of places. indeed, the probability of food insecurity between low and high educated families in other kinds of neighborhoods were not significantly different. more troubling, this reveals that lower educated families receive little to no benefit, in terms of food security, when they reside in more advantaged communities. in other words, this suggests those who are in strongest need of assistance may not receive it. second, we report on the association of contextual congruence with regard to race and ethnicity. specifically, we find that, for non-hispanic black children, the odds their household experiences food insecurity are significantly lower when the family resides in a neighborhood with high proportions of blacks compared to when the family resides in a neighborhood with j o u r n a l p r e -p r o o f lower proportions of blacks. this aligns with and adds to health research that has linked better mental and physical health for racial/ethnic minorities who live in places with higher percentages of their same racial/ethnic identity (pickett & wilkinson, ) , though it is unclear why a similar relationship is not present for households with hispanic children residing in neighborhoods with a higher proportion of hispanic residents. future research should expand on the underlying reasons why this ethnic density effect (pickett & wilkinson, ) for food security may be specific to non-hispanic blacks. on the one hand, the forms of contextual congruence we have identified may be a reflection of greater connectedness to others and integration into communities of others experiencing similar circumstances (bourdieu, ; durkheim, [ durkheim, [ ] . this results in social networks that, in the case of food security in households with young children, can be relied upon to acquire and share resources necessary to adequately feed a household. food insecurity is a fluid condition, with families transitioning in and out of states of food security (nord, coleman-jensen, andrews, & carlson, ) . if families impacted by food insecurity are surrounded by other families that can connect socially and culturally, they may have unique access to enhanced informal support and resources from the local community (denney et al., ) . on the other hand, these tangible benefits from shared status and identity may only reveal themselves for some families in some places. better understanding the conditions when contextual congruence relates to improved outcomes is important for another reason. in our study, we found that the likelihood of food insecurity for poor families is the same in high and low poverty communities. this suggests that poor families receive few benefits in terms of food security when they reside in low poverty neighborhoods. in some ways we might predict that the odds of food insecurity would be much j o u r n a l p r e -p r o o f higher for poor families in poor places. however, similar to research on spatial stigma (august, ; thomas, ) , poor residents in high poverty neighborhoods may develop strategies to deal with food insecurity similar to how they navigate other challenges. indeed, a recent qualitative study of low-income caregivers of young children identified several innovative strategies that are used to alleviate and prevent food shortages, including reliance on social networks and information sharing (jarrett, sensoy bahar, & odoms-young, ) . we might also reasonably assume that the probability of food insecurity would be lower for poor families in more advantaged neighborhoods. we find no evidence of that here and it provides limited support for a by-product of spatial stigma, whereby disadvantaged families carry associated negative effects with them when they move to more advantaged places (keene & padilla, ) , thereby limiting the benefits they might receive from improving neighborhood conditions. in other words, disadvantaged families may experience barriers to accessing helpful resources in higher-income neighborhoods. examining food insecurity in the way we have highlights the important times in which congruence might matter, but also the importance of families in need not receiving benefits by living in more socioeconomically advantaged places. this further suggests that community-based efforts to combat food insecurity should not be limited to disadvantaged communities but also consider at-risk families residing in more advantaged neighborhoods. we faced several limitations in the current study. first, we lack complete information on the residential history of families. we try to minimize the possible impact of this omission by including a measure of the duration that the child has lived at the current residence. this is a particularly important limitation with regard to understanding the best ways to address neighborhood disadvantage and the well-being of children. indeed, chetty and colleagues ( ) j o u r n a l p r e -p r o o f have reported important results from the moving to opportunity study that indicate positive effects for children when moving from disadvantaged to more advantaged places. these are pronounced when the move occurs when children are younger, such as the sample of children in the ecls-k used in the current study. for our study, this also suggests that any possible benefits of contextual incongruence for household food security status, especially for disadvantaged families, might require a longer period of time than the current study considers. second, though a major strength of our study is identifying where food insecurity occurs and for which families, assessing the mechanisms related to congruence and food insecurity is beyond the scope of the current analysis. we hypothesize that contextual congruence reflects stronger social networks and enhanced access to various forms of social capital, which in turn, reduce food insecurity risk (denney et al., ; garasky, morton, & greder, ; king, ; martin, rogers, cook, & joseph, ). yet, we have no measures of social cohesion, social ties, or social participation in the neighborhood of residence, with the exceptions of our measure of whether the parent believes it is safe for the child to play outside and our neighborhood residential stability measure. more research examining the potential mechanisms, such as social capital, linking congruence and food insecurity is needed to better understand why congruence impacts food insecurity risk for some families and not others. third, our focus and analyses are centered on the neighborhood of residence and this leaves out sources of support and integration that can come from friends and family outside one's residential space. fourth, although food insecurity is a fluid condition for many american families (nord et al. ) , the current study is cross-sectional and is unable to assess the relationship between contextual congruence and fluctuations in food insecurity. the united states is one of the wealthiest nations in the world, and a nation with large disparities in child health, development, and achievement. accurate identification of where families with young children facing food insecurity are located is, thus, imperative to generating effective solutions to combat a problem contributing to long-term deficits in health and wellbeing. our results suggest that we must consider not just the absolute characteristics of households or neighborhoods, but rather the degree to which those characteristics align or diverge. doing so will help us identify families in need and help us understand how residential context impacts the wellbeing of children. social support and coping behaviors of low-income families experiencing food insufficiency in north carolina family food insufficiency, but not low family income, is positively associated with dysthymia and suicide symptoms in adolescents food insufficiency and american school-aged children's cognitive, academic, and psychosocial development challenging the rhetoric of stigmatization: the benefits of concentrated poverty in toronto's regent park family structure, work patterns and 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healthy food in the united states: a review of food deserts literature food insecurity and the risks of depression and anxiety in mothers and behavior problems in their preschool-aged children when work disappears: the world of the urban poor multigenerational families and food insecurity key: cord- - y uj h authors: han, aixi; chai, li; liao, xiawei title: demographic scenarios of future environmental footprints of healthy diets in china date: - - journal: foods doi: . /foods sha: doc_id: cord_uid: y uj h dietary improvement not only benefits human health conditions, but also offers the potential to reduce the human food system’s environmental impact. with the world’s largest population and people’s bourgeoning lifestyle, china’s food system is set to impose increasing pressures on the environment. we evaluated the minimum environmental footprints, including carbon footprint (cf), water footprint (wf) and ecological footprint (ef), of china’s food systems into . the minimum footprints of healthy eating are informative to policymakers when setting the environmental constraints for food systems. the results demonstrate that the minimum cf, wf and ef all increase in the near future and peak around to , under different population scenarios. after the peak, population decline and aging result in decreasing trends of all environmental footprints until . considering age-gender specific nutritional needs, the food demands of teenagers in the – year group require the largest environmental footprints across the three indicators. moreover, men’s nutritional needs also lead to larger environmental footprints than women’s across all age groups. by , the minimum cf, wf and ef associated with china’s food systems range from to million tons, to km( ) and to billion gm( ) respectively under different population scenarios. this study builds a bridge between demography and the environmental footprints of diet and demonstrates that the minimum environmental footprints of diet could vary by up to % in under different demographic scenarios. the results suggest to policymakers that setting the environmental constraints of food systems should be integrated with the planning of a future demographic path. to ensuring food security is commonly recognized as a global challenge, the united nations has set "ending hunger, achieving food security and improved nutrition, and promoting sustainable agriculture" as the second of its seventeen sustainable development goals for the year [ ]. by , the world needs to feed nine billion people with food demand being % higher than it is today [ ] . with the largest population in the world, china's food security plays an important role in underpinning its social and economic development. to ensure food security, china set a goal of complete self-sufficiency for grains and basic self-sufficiency for meat, eggs, milk, and vegetables as early as [ ] . 's . million births [ ] . the comprehensive effect of the "universal two-child" policy was gradually released, and china's population structure will change further. therefore, the impact of future population changes in chinese society caused by population policies on the environmental impact of the food system deserves further study. furthermore, china's food systems are facing increasing environmental challenges. first, china has committed to cutting its carbon intensity by - % from levels by and reaching the peak levels before [ ] ; secondly, climate change is expected to aggravate water scarcity in some regions by changing water regimes, both in terms of availability and variability; last but not least, rapid urbanization is shifting an increasing amount of arable land to urban areas, which is set to constrain the available land resources for food production. the previous studies have proved that adopting a healthier diet is able to significantly reduce environmental footprints. it is informative for policymakers to determine how much environmental pressure would be posed at minimum by food consumption when aiming at human health goals. this minimum environmental pressure can be quantified according to the dietary guidelines; however, this is uncertain and strongly depends on demographic characteristics. in this study, we reveal how the minimum environmental footprint of diet varies with demographic characteristics by integrating the demographic study with the environmental footprint assessment. this study has enlightenments ( ) for further researches that demographic characteristics need to be considered when studying the environmental footprints of diet, and ( ) for policymakers that demographic characteristics needs to be considered when setting future environmental constraints and redlines for food systems. results in this study are of global significance because, while china has the world's largest population to feed, it has also overtaken the us in as the largest carbon emitter in the world. maximizing the carbon reduction potentials of china's food sector will be indispensable to reach global climate change mitigation targets. furthermore, china is one of the mega-biodiversity countries in the world and harbors nearly % of all plant species and % of animals on earth [ ] . land and water conservation in china are important for global biodiversity conservation efforts. we use padis-int software in this study to predict china's population size and structure from to . the padis-int software is developed based on the queue element method, which is a commonly used method to predict the population [ ] . we do not consider migration in this study as the overall net migration rate is low in china [ , ] . the padis-int software is developed based on the cohort-component method, which is a commonly used method to predict the population [ ] . the cohort-component method looks at the changes in the population of different death, fertility, and migration risks during the forecast period. simulating this change requires corresponding death, fertility and migration parameters. here, we do not consider migration in this study as the overall net migration rate is low in china [ , ] . for the age and gender structure of the starting population, which is the most important factor in predicting the overall situation, interpolation techniques are used to make reasonable predictions. padis-int provides a linear interpolation method for assignment in the main age group. that is, given any two points, an interpolation method can be used to calculate and specify the value of the middle year between the two points. the interpolation method follows the following formula: where i means single-year-old group; a represents the age group with a mantissa of or that is slightly less than the age of the single-year group (that is, the middle age group in the five-year group (i -a) foods , , of actually refers to the age difference between the two); j represents the five-year-old group where a is located; and p represents the corresponding population. when using padis-int to predict the population by age and sex, the key is to set the fertility level, life expectancy, death pattern and sex ratio at birth [ , ] . this article is based on the data of the sixth national census, combined with the analysis of previous census data and the analysis of social and population development trends, the basic parameters are set as follows: tfr: the total fertility rate refers to the average number of children born to each woman during childbearing age in a specific country or region. although scholars still find a lot of controversy about the actual fertility level, it is generally believed that the total fertility rate is about . - . [ ] . in , the "universal two-child" policy was launched, aiming to ease the pressure of aging. this policy has had a profound impact on the chinese population size and structure since it allows every family to have two children, which may influence the fertility rate of china. zhai et al. have pointed that the "universal two-child" policy will bring about a relatively significant rebound in china's tfr and the highest tfr may exceed . but will not exceed [ ] . after the cumulative effect is released, the tfr will be in . - . . it was also believed that raising the tfr closer to the intergenerational replacement level of . through policy adjustments, such as . to . , is the most optimistic assumption [ ] . the national population development strategy research report proposed that if the total population peak is controlled at about . billion people, the national total fertility rate should be maintained at about . over the next years, and a value higher or lower than this number is not conducive to the coordinated development of the population and society [ ] . therefore, we propose three scenarios for setting tfr parameters to predict all possibilities from the influence of the "universal two-child" policy. before that, we set the tfr of , the starting year, to . according to wpp (world population prospects) [ ] . in the first scenario we set the "universal two-child" policy as having not caused changes in fertility levels, so the tfr maintains its current level with slight fluctuations. it fell to . in , which is the current range of fertility levels, and remained unchanged from then. in the second scenario, we considered that the "universal two-child" policy had some impact on tfr but one that was not so influential. because the goal of china's family planning rate is to be stable at . by , it is reasonable to set the tfr as rising to . in and then slowly dropping to . in [ ] . in the third scenario, we consider that the "universal two-child" policy can significantly increase the chinese population, so it is assumed that china's tfr will reach . in , close to the intergenerational replacement level of . , and this assumption is regarded in the literature as the greatest possibility of china's total factor productivity [ ] . life expectancy: the population division of the national bureau of statistics points out that in the process of increasing the average life expectancy of china's population, women have increased faster than men, and the difference between the two has also further expanded. the law of change is consistent [ ] . according to the who population life expectancy ranking, the average life expectancy of females in china was . years in and . years for males. we set the life expectancy of men to increase by . every five years, reaching . by ; the life expectancy of women to increase by . every year, to reach . years by . death pattern: the core element of the population forecasting method based on the cohort element method is to calculate the survival ratio according to age, which needs to be supported by the life table. the basic calculation formula is: where n t (x) represents the population in age x at time t ; n t (x+n) represents thepopulation in age (x + n) at time t ; and l is the survival probability in the specific age. [ , ] . among them, the western model was built on the data of actual life tables, which mainly come from countries in africa and asia, such as israel, japan, the taiwan province of china, and south africa. there is no obvious systematic deviation in their death data. therefore, when applied to chinese population predictions, this group of models is more widely representative than the other groups and is regarded as the standard model life table. so we adopt the coale-demeny mortality table in this study to perform age shift and to use is a as death pattern. sex ratio at birth: the sex ratio at birth refers to the ratio of the total number of male babies born to a total number of female babies in a certain period, usually expressed as the number of male babies per female babies. the "universal two-child" policy is expected to alleviate the imbalance of sex ratio at birth in china. while the data of the sixth census ( ) shows that the sex ratio at birth in china is . , the normal range identified by the united nations is from to [ ] .zhang, a former director of the national population and family planning commission, pointed out that the implementation of the "universal two-child" policy could alleviate the imbalance in the sex ratio at birth in china, and it shows a downward trend within a certain range [ ] .wang pointed out that the "inflection point" of the sex ratio of the birth population in china has emerged and is continuing to strengthen comprehensive governance. under the conditions, the sex ratio at birth will enter a declining process [ ] . therefore, we assume that the sex ratio will reduce to in and will remain unchanged after that. table summarizes key parameters used in this study to predict china's future population size and structure until . the environmental footprint coefficients were obtained from a database for the double food-environmental pyramid (dfep) model [ ] . table shows these coefficients. the dfep database has been adopted and works reliably in recent studies assessing the environmental footprint of china's food system [ , ] . the lifecycle footprint assessment based on this database is in a boundary "from cradle to gate", i.e., the stages of transportation, storage, and retailing are not included. three types of footprints are considered in this study to examine environmental impacts, namely water footprint, carbon footprint, and ecological footprint. the water footprint is an indicator of water use based on consumption. it measures the total water demand for all products and services produced by the residents of that country or region. three water footprints are considered here, namely green water, blue water, and grey water. green water refers to the evaporation of water during food production [ ] . blue water refers to surface runoff and groundwater [ ] . grey water is the fresh water needed to dilute sewage [ ] . the carbon footprint measures the total amount of greenhouse gas (ghg) caused by an activity (or accumulated in the life cycle of a product) [ ] . the intergovernmental panel on climate change (ipcc) has proposed global warming in terms of co equivalents to assess greenhouse gas emissions [ ] . the ecological footprint assesses human impact on ecosystems by measuring how much humans today use nature to sustain themselves. it covers all land (including foods , , of arable land, forests, construction sites, etc.) and converts it into the same unit of measurement, that is, hectares of production land [ ] . the scope of this study is focusing on the environmental footprint embodied in the diet rather than the whole food system, so we did not consider the impact of international trade. importing food indeed can reduce the internal environmental footprint for a country, and therefore the global trade model is encouraged to be integrated into and extend this study in future research. for this study, ignoring the imports is acceptable as china currently has a very high self-sufficient rate of over % [ ] . this ratio is expected to elevate more in the future, especially after covid- . although the nutrient group item can more accurately assess the quality of the diet, it also lacks operability to a certain extent, so the use of the food group can make the index tool more acceptable and easier to operate. therefore, we use the food group data given in the dietary guidelines, that is, the recommended daily dietary intake measured by grams per day. we have selected different guide data for different age groups: the - at the same time, we divided the food group into categories and unified them with the previous data for environmental footprint: ( ) cereals and tubers,( ) vegetables,( ) fruits,( ) red meats and poultry,( ) eggs,( ) aquatic products,( ) dairy products,( ) soybeans and nuts,( ) oils, ( ) salt, and ( ) sugars. from dietary guidelines, we can get a detailed energy recommended intake (i.e., eer) for each age group and the caloric amount of different food items. the optimal dietary structures of different foods , , of age groups can be obtained based on such information. furthermore, based on the environmental footprint coefficients of the consumption of different food items, the environmental footprints of food consumption of people in different age groups can be calculated, which can be used as an indicator of the minimum environmental footprints of food consumption that meet the lowest nutritional requirements of different age groups. similar to the previous prospective study, we assume that environmental footprint intensities of food consumption will remain the same into the future [ ] . our analyses focus on the impacts of two prospective changes in china's future food system: (i) the dietary guidelines are used to understand the impacts of future age-and gender-specific dietary patterns; (ii) scenario analyses are conducted to show the impacts of demographic changes. the research route and framework is summarized in figure below. figure shows the changing trend of the total population with time in three scenarios. under all scenarios, china's population in the future generally demonstrates a trend of first rising and then declining, with peaks at different times. under the first scenario with the lowest tfr, china's population will first grow and reach . billion in and will then gradually decline to . billion and million by and respectively. similarly, the second scenario projects china's population to grows to . billion by and then decline to . billion and million by and respectively. assuming that the "universal two-child" policy has a significant effect on population growth, the chinese population is expected to peak at . billion in and then gradually decline to . billion and billion by and respectively. therefore, although the "universal two-child" policy offers the potential to stimulate population growth in the short term, china's population is expected to decrease eventually, and people's willingness to have children is expected not to meet expectations, and the cumulative effect of adjustment and release of fertility policy can only last for a short time period. figure shows the changing trend of the total population with time in three scenarios. under all scenarios, china's population in the future generally demonstrates a trend of first rising and then declining, with peaks at different times. under the first scenario with the lowest tfr, china's population will first grow and reach . billion in and will then gradually decline to . billion and million by and respectively. similarly, the second scenario projects china's population to grows to . billion by and then decline to . billion and million by and respectively. assuming that the "universal two-child" policy has a significant effect on population growth, the chinese population is expected to peak at . billion in and then gradually decline to . billion and billion by and respectively. therefore, although the "universal two-child" policy offers the potential to stimulate population growth in the short term, china's population is expected to decrease eventually, and people's willingness to have children is expected not to meet expectations, and the cumulative effect of adjustment and release of fertility policy can only last for a short time period. therefore, although the "universal two-child" policy offers the potential to stimulate population growth in the short term, china's population is expected to decrease eventually, and people's willingness to have children is expected not to meet expectations, and the cumulative effect of adjustment and release of fertility policy can only last for a short time period. under the first scenario, the existing fertility level being kept unchanged gradually results in an aging society, while the "universal two-child" policy that is considered in the second and third scenario is expected to alleviate such a trend to different extents. foods , , x for peer review of figure shows that china's population pyramid shows a slow bottom-shrinking phenomenon. under the first scenario, the existing fertility level being kept unchanged gradually results in an aging society, while the "universal two-child" policy that is considered in the second and third scenario is expected to alleviate such a trend to different extents. the optimal dietary patterns that meet the eer by chinese dietary guidelines of different age groups are demonstrated in figure . it can be seen that the population aged - . (six months) mainly depends on breast milk, so there is no specific food consumption. after the age of . , with the growth of age, the total food consumption gradually increases, reaching the peak at the age of - , and then slowly decreases. on the other hand, the difference between the food consumption of men and women begins to emerge after the age of , because under normal circumstances, gender the optimal dietary patterns that meet the eer by chinese dietary guidelines of different age groups are demonstrated in figure . it can be seen that the population aged - . (six months) mainly depends on breast milk, so there is no specific food consumption. after the age of . , with the growth of age, the total food consumption gradually increases, reaching the peak at the age of - , and then slowly decreases. on the other hand, the difference between the food consumption of men and women begins to emerge after the age of , because under normal circumstances, gender differences in food consumption among preschoolers are not considered. considering gender differences, after the age of , men consume a higher amount of food than women in general [ ] . in terms of dietary pattern, dairy products and vegetables account for the largest proportions. take the population of to years for example, dairy products account for about . %, and vegetable consumption accounts for about . %. environmental footprint coefficients of different food items used in this study are summarized in table below. water footprint coefficient (wfc), carbon footprint coefficient (cfc), and ecological footprint coefficient (efc) respectively represent water consumed, carbon emitted, and land resources used throughout the life cycle of certain food products. it can be seen from table that animal products have much higher environmental footprint coefficients than vegetable products; therefore, the increasing consumption of animal products is set to exert increasing pressures on natural resources and the environment. figure demonstrates the environmental footprints of age-gender specified dietary requirements according to the national nutritional dietary guidelines. it can be seen that people's food consumption's environmental footprints have gradually increased since . -year-olds in general, and people in the - age group, require the largest environmental footprint to meet their dietary needs. men require higher environmental footprints for their food requirements than women, with the gap peaking from to . dairy products, fruits and cereals and tubers require the largest water footprints throughout their life cycles, occupying %, %, and % respectively on average. dairy products, vegetables and cereals and tubers require the largest carbon footprints throughout their life cycle, occupying %, %, and % respectively on average. in terms of ef, on average, dairy products, aquatic products and meats require the largest ef, occupying %, %, and % respectively on average. it can be seen that dairy products account for the largest environmental footprints, and that the food requirements of the ~ age group has the largest environmental footprint. specifically, fruits, environmental footprint coefficients of different food items used in this study are summarized in table below. water footprint coefficient (wfc), carbon footprint coefficient (cfc), and ecological footprint coefficient (efc) respectively represent water consumed, carbon emitted, and land resources used throughout the life cycle of certain food products. it can be seen from table that animal products have much higher environmental footprint coefficients than vegetable products; therefore, the increasing consumption of animal products is set to exert increasing pressures on natural resources and the environment. figure demonstrates the environmental footprints of age-gender specified dietary requirements according to the national nutritional dietary guidelines. it can be seen that people's food consumption's environmental footprints have gradually increased since . -year-olds in general, and people in the - age group, require the largest environmental footprint to meet their dietary needs. men require higher environmental footprints for their food requirements than women, with the gap peaking from to . all three indicators of environmental footprints first increase, then peak around - and then decrease toward . under scenario where the population trend remains unchanged, wf, cf, and ef first increase and peak in at km , million tons co eq and , billion gm respectively. under scenario and where the "universal two-child" policy effect is to different extents, wf, cf, and ef all peak in a later year, in , at km , million tons co eq and , billion gm respectively under scenario where the "universal two-child" policy's effect is conservative and around at km , million tons co eq and , billion gm under scenario where the "universal two-child" policy's effects are substantial. after the peaks, dietary pattern change offsets the impacts brought by population increase and leads to environmental footprints decreasing until . by , the minimum cf, wf, and ef associated with china's food systems range from to million tons, to km and to billion gm respectively under different population scenarios. it can be seen from figure that the impacts of the different fertility rates applied in the three population scenarios are negligible until , but gradually become visible from and are substantial toward . two observations worth notice from figure , are that the differences resulted from different population scenarios are most visible in lower aged groups under and , this is because the "universal two-child" policy of today mainly has impacts on the population size of under by and under by . therefore, apparent discrepancies can be observed in environmental footprints of the population under in and of the population under in . furthermore, figure further demonstrates that male members of the society require larger environmental footprints to meet their food demands than their female counterparts since all the figures in figure have a fatter left part. dairy products, fruits and cereals and tubers require the largest water footprints throughout their life cycles, occupying %, %, and % respectively on average. dairy products, vegetables and cereals and tubers require the largest carbon footprints throughout their life cycle, occupying %, %, and % respectively on average. in terms of ef, on average, dairy products, aquatic products and meats require the largest ef, occupying %, %, and % respectively on average. it can be seen that dairy products account for the largest environmental footprints, and that the food requirements of the ~ age group has the largest environmental footprint. specifically, fruits, vegetables, and aquatic products, which share in wf, cf, and ef, respectively, all peak at the - age group, at %, %, and %. furthermore, food requirements environmental footprints of males have been consistently higher than those of females, with the difference increasing significantly after age . all three indicators of environmental footprints first increase, then peak around - and then decrease toward . under scenario where the population trend remains unchanged, wf, cf, and ef first increase and peak in at km , million tons co eq and , billion gm respectively. under scenario and where the "universal two-child" policy effect is to different extents, wf, cf, and ef all peak in a later year, in , at km , million tons co eq and , billion gm respectively under scenario where the "universal two-child" policy's effect is conservative and around at km , million tons co eq and , billion gm under scenario where the "universal two-child" policy's effects are substantial. after the peaks, dietary pattern change offsets the impacts brought by population increase and leads to environmental footprints decreasing until . by , the minimum cf, wf, and ef associated with china's food systems range from to million tons, to km and to billion gm respectively under different population scenarios. it can be seen from figure that the impacts of the different fertility rates applied in the three population scenarios are negligible until , but gradually become visible from and are substantial toward . foods , , x for peer review of two observations worth notice from figure , are that the differences resulted from different population scenarios are most visible in lower aged groups under and , this is because the "universal two-child" policy of today mainly has impacts on the population size of under by and under by . therefore, apparent discrepancies can be observed in environmental footprints of the population under in and of the population under in . furthermore, figure further demonstrates that male members of the society require larger environmental footprints to meet their food demands than their female counterparts since all the figures in figure have a fatter left part. being constrained by limited planetary boundaries, there is a growing consensus that all anthropogenic activities should take into account and strive to minimize their environmental impacts. with the largest population and unprecedented economic growth, china is facing emergent challenges to meet its demands in a sustainable way. among all the demands for different commodities, food demand poses the foremost challenge due to its fundamental importance. while food provision processes require large amounts of water consumption, carbon emission and land occupation, china's food system is posing increasing pressure on its environment and natural resources. in , china pledged to peak its carbon emissions by in copenhagen, which is further reiterated in china's intended national determined contribution. furthermore, china is also facing stringent finite water and land limitations. china is not abundant in water, with the country's national average water resources amounting to only one third of the global average at around being constrained by limited planetary boundaries, there is a growing consensus that all anthropogenic activities should take into account and strive to minimize their environmental impacts. with the largest population and unprecedented economic growth, china is facing emergent challenges to meet its demands in a sustainable way. among all the demands for different commodities, food demand poses the foremost challenge due to its fundamental importance. while food provision processes require large amounts of water consumption, carbon emission and land occupation, china's food system is posing increasing pressure on its environment and natural resources. in , china pledged to peak its carbon emissions by in copenhagen, which is further reiterated in china's intended national determined contribution. furthermore, china is also facing stringent finite water and land limitations. china is not abundant in water, with the country's national average water resources amounting to only one third of the global average at around m . moreover, the scarcity of arable land is a defining feature of chinese agriculture [ ] . in , china fed . percent of the world's population with only . percent of the world's arable land [ ] . such challenges are further aggravated by the spatially uneven distribution of china's natural resources. for example, with merely percent of china's renewable water resources, the yellow river basin contributes to percent of the national gdp and supports nearly percent of the national population, . percent of the arable land. it is therefore of paramount importance to examine the environmental impact of the future food system in exploring a sustainable path meeting both environmental and social objectives. according to china's dietary guidelines, we evaluate the environmental benefits of food pattern change of the chinese population and demonstrate that while population growth may play the primary role in driving the increasing environmental footprints associated with the food system in the near future, food pattern change offers potentials to offset such impacts and result in net decreases of food system's environmental impacts after the s.it should be noted that although the guidelines represent the minimal energy and nutrition intakes that are recommended for age and gender-specific groups, the average chinese person's current diet has not reached the recommended levels and therefore may have a smaller environmental footprint than our results. however, as recognized by the nd sdg (sustainable development goals), nutritious diet plays a fundamental role in sustaining human lives, fostering healthy human capital, and underpinning other aspects of social economic development, results in this study represent the minimal environmental footprints that are required to meet the sdg (sustainable development goals) under which scenario every person has access to nutritious food as recommended by the guidelines. as recognized by previous studies, optimizing food diets helps to contribute to the global climate change mitigation agenda [ ] [ ] [ ] . china pledged to peak its carbon emissions by , and while its food system makes up % of global carbon emissions, our results show that carbon emissions associated with the food system in china will likely peak between and , which is in line with china's national efforts to comply with the paris agreement [ ] . different age and gender groups have different dietary needs, therefore using dietary pattern of one single group, normally adults, as a proxy results in overestimation of the food systems' impacts on the environment. adopting age-gender specified dietary patterns, results in this study demonstrate that teenagers aged between and require the largest environmental footprint for their food requirements. dairy products require the largest wf, cf and ef across all age and gender groups. this raises alarms for people's increasing livestock-based food consumption with a bourgeoning lifestyle. the environmental footprint for food systems could be reduced from both producer and consumer's sustainable practices. from the producer's perspective, low environmental-impact farming practices should be encouraged. for example, dripping irrigation is useful in reducing agricultural water consumption. from the consumer's perspective, environmentally responsible food choices should be promoted. for instance, the increasing consumption of avocado by urbanites is imposing increasing water pressure along the life cycle supply chain. environmental information disclosure and raising awareness such as via environmental labeling could be a useful way to change people's consumption behaviors. furthermore, organic agricultural and husbandry has gained increasing appreciation worldwide, its application in china merits cautions as organic farming require larger amount of water and land inputs as well as greenhouse gas emissions per calorie of food products [ ] . while most of the existing studies have examined china's food systems' environmental footprints until , it is shown in this study that the population policy's effects only become significant after that because that's most new-born become adults whose food requirements reaching the maximum environmental impacts. it is therefore important to look beyond . our results offer three particular novel insights: ( ) by adopting different population scenarios, our results have shown that the food system's environmental footprints may reach the peak several foods , , of years later delaying from to due to population effects resulted from loosening policies. such effects may cause conflicts with other existing policies, for example, as the food system is a major contributor to the society's total carbon emissions, the delaying peak of carbon emissions associated with the food system can impede the achievement of china's carbon emission targets by . while the "universal two-child" policy is expected to generate positive impacts on the shrinking workforce and aging society, its environmental implications need further studying and corresponding policies should be formulated [ ] . enhanced technology advancement should be promoted to reduce the food system's environmental intensities to mitigate the effects of a growing population. for instance, nitrogen optimization and manure management may be effective in reducing the lifecycle greenhouse gas emission intensity of live-stock consumption [ ] . ( ) secondly, our results highlight the importance of adopting a longer-term view in both academic research and policy formation. while most existing studies have examined china's food systems' environmental impacts until , our results have shown that the population policy's effects only become significant after because that is when most new-born become adults whose food requirements reaching the maximum environmental impacts. while many non-structural environmental policies, such as raising environmental awareness and promoting healthy diet patterns, take decades to be effective, many structural policies, such as irrigation infrastructure, are at risk being locked-in [ ] .therefore, it is important for policymakers to look beyond the mid-term and adopt longer term perspectives. ( ) last but not least, by adopting the national age and gender-specific dietary guidelines, our results determine the minimal environmental impacts of the food system in china, which lays the foundation for future studies and for policymakers to evaluate the trade-offs with other sector policies as well as to explore potential synergies. there are certain limitations embodied in this study that merit future studies. first, we estimate the residents' dietary structures based on the chinese dietary guidelines. while the current dietary guidelines did not take environmental sustainability into consideration, we recommend future dietary guidelines to be further updated upon environmental considerations. therefore, future studies are recommended to consider optimized dietary structures. second, water consumption and land occupation have different impacts in different places due to different levels of water and land scarcity. for instance, water consumption in china's arid northern regions generated higher impacts on water consumption in china's water-abundant southern regions [ ] . therefore, upon place-specific trade data available, it is meaningful to take into account such considerations to evaluate the lifecycle scarce water and scarce land use by food systems. food products that are produced from water-abundant and land-abundant regions should be preferred over food produced from where water and land are scarce. thirdly, environmental-friendly diet modes not only depend on a reasonable diet structure but also on the need to reduce food waste and losses. garcía-herrero et al. pointed out that reducing food loss is considered to be an important means to improve food security and reduce the pressure on natural resources [ ] . according to research by chai et al., the dietary patterns of vegetarians, non-vegetarians, and omnivores have different effects on the environment [ ] . therefore, in the following discussion, combined with demographic scenario analysis and different diet patterns, it is more scientific to judge which diet has the least impact on the environment of our planet, so as to make reasonable adjustments to the improvement of the dietary structure. at the same time, china is increasingly playing a significant role in the global food market. willett et al. have reported that the global food system may have an important impact on human health and environmental sustainability. providing a healthy diet for the growing global population from a sustainable food system is an urgent challenge [ ] . it is therefore recommended to link china's food system with the global food system in future studies, while combining population scenario analysis with global food allocation, to explore an ideal dietary structure satisfying both health and environmental sustainability. we evaluated the minimum environmental footprints, including the carbon footprint (cf), water footprint (wf), and ecological footprint (ef), of china's food systems into under different demographic scenarios and using the national age-gender specified energy and nutrition intake requirements. our results show that food consumption's environmental impacts peak for the - age group, the environmental footprint of china's food system is expected to peak around to . under different population scenarios, the peaks of wf, cf, and ef are expected to range from km , million ton co eq and , billion gm respectively to km , million tons co eq and , billion gm . higher fertility rates under less strict population policies are also expected to delay those peaks by at most five years. after the peak, environmental footprints of the food system are expected to continuously decline until and reach to million tons (cf), to km (wf), and to billion gm (ef) under different population scenarios. the minimum environmental footprints that are required to meet the healthy dietary targets in china are important considerations for policymakers to better coordinate future efforts and 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-lcvbaguj authors: bolte, gabriele; knauss, margarete; metzdorf, irene; stern, martin title: postnatal maturation of rat small intestinal brush border membranes correlates with increase in food protein binding capacity date: journal: dig dis sci doi: . /a: sha: doc_id: cord_uid: lcvbaguj to investigate maturational changes of membranefood protein binding capacity, we studied bindingcharacteristics of brush border membranes isolated fromsmall intestines of newborn and adult rats. binding of biotinylated gliadin peptides, cow's milkproteins (α-casein, β-lactoglobulin,α-lactalbumin, bovine serum albumin) and lectinswas assessed by a sensitive chemiluminescence blotassay. we found specific food protein binding with regardto saturation and inhibition. maximal binding of mostfood proteins and several lectins to brush bordermembranes of newborn and adult rats was comparable, whereas binding of β-lactoglobulin wassubstantially less. common or adjoining binding sitesfor the different food proteins tested were indicated bycorresponding membrane protein binding patterns and by inhibition properties of unrelated proteins.compared to newborns, adult membrane vesicles as well asisolated membrane proteins showed higher bindingcapacities. thus postnatal maturation of smallintestinal brush border membranes correlated withincreased food protein binding capacity. in addition to their barrie r function and participation in dige stive , absorptive , and se cretory proce sse s, small inte stinal e nte rocyte s were propose d to contribute to mucosal immune re actions by pre senting antige ns coming from the gut lume n ( , ) . binding of fore ign prote ins to the apical brush borde r membrane (bbm) was reporte d to facilitate uptake and to in¯uence intrace llular proce ssing ( ± ). interactions of luminal molecules with the bbm also could re sult in signal transduction and cellular re sponse s ( , ) . rats are a suitable mode l for studying deve lopm ental change s in bbm archite cture and enterocytic functions, because profound change s occur during post-natal maturation. at the time of weaning, the shift from milk-base d to carbohydrate -rich fee ding is accompanie d by change s of bbm, in e nzyme activitie s, prote in and lipid composition, glycosylation, and membrane¯uidity ( , ± ) . furthe rmore, the ne wborn rat mucosal barrie r appe ars to be more leaky, as indicate d by highe r rate s of endocytosis ( , ) . enhance d inte raction of prote ins with bbm is suppose d to contribute to the increased uptake see n in ne wborn rats ( ) . con¯icting results were obtaine d e arlie r in our laboratory using diffe rent approache s to study intestinal food prote in binding in vitro. in e xpe rime nts using whole gut sacs, we found a maturational increase in binding and uptake of b -lactoglobulin and bovine se rum albumin whe n comparing immature -day-old rats with mature adult rats ( ) . in contrast, a maturational decrease in the binding capaci-ties of isolate d bbm ve sicles from ne wborn to adult age was de monstrate d for a -lactalbumin, b -lactoglobulin, bovine se rum albumin, and the gliadin pe ptide b ( ) . o ur aims, therefore , we re to clarify whether e nhance d bbm food prote in binding occurs before weaning and to characte rize membrane compone nts that inte ract with food prote ins. food prote ins of clinical importance (gliadin pe ptide s, cow's milk prote ins, ovalbumin) and le ctins (controls for spe ci® city of binding and for de te ction of de velopmental change s in membrane glycosylation) were use d. anim als. adult sprague-dawley rats, weighing ± g, and timed-pregnant rats were obtained from charles-river wiga (sulzfeld, ge rmany). they we re kept on a glute n-fre e and cow's milk protein-poor rat chow (diet no. c , altromin, lage, ge rmany). newborn rats were allowed to suckle fre ely and we re killed at the age of hr. adult rats were fasted one day prior to the study. brush border mem bran e vesicles. for isolation of brush border membrane vesicles, whole small intestines of newborn rats and proximal halves of adult small intestines we re removed and washed with cold physiological saline. starting with homogenates of neonatal intestines or scrapings of adult intestinal mucosa, bbm ve sicles were obtained by a modi® ed ca -precipitation technique as described before ( ) . for e ach preparation, small intestines of several newborn rats or mucosa scrapings of two adult rats we re pooled. activities of the bbm enzymes lactase , sucrase, alkaline phosphatase , and total maltase activity we re dete rmined according to dahlqvist ( ) and bowers and mccomb ( ) . one unit was de® ned as m mol substrate hydrolyzed per minute under the e xperimental conditions. speci® c e nzyme activities were expressed as units per milligram of protein. protein concentrations we re measured using bovine serum albumin as standard ( ) . electron microscop y. bbm ve sicles we re ® xed in % (v/v) glutaraldehyde , mm cacodylate buffe r, ph . , for hr at °c and collecte d by centrifugation ( min at , g). pe llets were washed three times with cacodylate buffe r, pellete d, and post® xe d in % (v/v) osmium te troxide in cacodylate buffe r for . hr at room tempe rature. afte r washing, the me mbranes we re dehydrate d ste pwise in e thanol and tre ate d with saturated uranyl acetate for contrast enhanceme nt. ultrathin sections were prepared from me mbrane vesicled e mbedded in araldite, stained with lead citrate, and analyze d with a z eiss em e lectron microscope. biotin ylation . food proteins were labeled with biotin, using biotinamidocaproate-n-hydroxysuccinimide ester for cow's milk proteins and biotinamidocaproate-n-hydroxysulfosuccinimide ester for gliadin peptides as described previously ( ) . gel electrop horesis. sodium dodecyl sulfate ± polyacrylamide ge l electrophoresis (sds-page ) was performed using the mini-protean ii e lectrophoresis system (bio-rad, munich, germany) according to laemmli ( ) under nonreducing conditions. western blot. electrophoretic transfe r of proteins from polyacrylamide ge ls to nitrocellulose shee ts was performed by tank blotting as described before ( ) , using the mini trans-blot electrophoresis transfe r cell from bio-rad. to enhance transfe r, sds was adde d in a ® nal concentration of . % (w/v) to the electrode buffer. ch em ilum in escence binding assay. intact bbm ve sicles or e lectrophoretically separate d membrane proteins were immobilized on nitrocellulose sheets by the dot blot ( ) or we ste rn blot technique. free binding sites of nitrocellulose we re blocked with % (v/v) twe e n in phosphatebuffe red saline (pbs), ph . . to diminish nonspeci® c adhe rence, . % (v/v) tween in pbs was used in each washing or incubation step. afte r incubation with biotinylated proteins overnight at °c, bound probes we re detecte d using peroxidase-conjugated streptavidin and ecl blotting dete ction reage nts. chemilumine scence signals we re qua ntitate d d e nsitom e trica lly with the vide odensitomete r syste m biopro® l (ltf labortechnik, wasserburg, ge rmany), using the program bio- d ve rsion . (v ilber lourmat biotechnology, marne la valle e, france). binding intensity was e xpressed as densitometric units per microgram bbm protein in relation to biotinylated standard proteins (bio-rad), which we re applied directly to nitrocellulose. saturation and inhibition of protein binding we re assessed as criteria for binding speci® city. inhibition of protein binding was measured by addition of nonlabeled proteins to solutions of biotinylated probes. change s in binding we re calculated in relation to binding of biotinylated proteins alone. maximal binding intensities were calculated from results of saturation e xperiments. statistical an alysis. all data are expressed as mean standard deviation (sd). student's t te st was used for statistical analysis of diffe rences of bbm binding capacities betwe en newborns and adults. ch aracterization of bbm vesicles. bbm vesicle s were isolate d from rat small inte stines, forming close d vesicle s of varying size s. cytoske leton prote ins of the brush borde r appe are d as e le ctron-de nse mate rial inside the vesicle s ( figure ). enrichm ent of bbm marke r enzyme s indicate d suf® cie nt purity of membrane preparations (table ) maa binding was not saturate d in the concentration range te ste d ( figure ). food prote in binding to adult bbm re ache d . to . de nsitom e tric units/m g bbm prote in e xce pt blg, which was signi® cantly less bound to bbm ( table ) . adult bbm bound signi® cantly more pt-gli, cas, blg, ala, bsa, and o v a than ne wborn membrane s. lectin binding re¯ected known change s in membrane glycosylation during postnatal maturation. according to the shift from sialylation to fucosylation, ne wborn bbm bound more pna, maa, and sna, but less uea i ( table ). in h ibition of bin din g. be sides saturation, spe ci® city of food prote in binding to bbm was studie d by inhibition e xpe riments. binding of pt-gli, cas, blg, and ala was inhibite d by a -fold e xcess of nonlabe le d prote in. howe ver, the obse rved aggre gation of bsa and o va, de ® ne d as the ability of the biotinylate d prote in to bind to the immobilize d unmarke d counte rpart, was not compatible with this kind of e xpe rime nt (figure ) . o nly in the case of weak binding due to low conce ntrations of biotinylate d prote ins was a -fold exce ss of nonlabe le d prote in suf® cient to achie ve % inhibition (data not shown) . with concentrations above . m g/ml, assay sensitivity did not allow % inhibition of speci® c le ctin binding, too, using e ithe r nonlabe le d lectins or monosacchari des (figure ). food protein bin din g to isolated mem bran e protein s. binding characte ristics of isolate d membrane prote ins were furthe r analyze d in weste rn blots to de ® ne maturational diffe rences. in accordance with results obtaine d with whole bbm in dot blots, isolate d membrane prote ins of adult rats showe d highe r binding capacitie s for pt-gli, ala, blg, and o v a and more binding sites than ne wborn rats ( figure ). this maturational diffe rence was also se e n with bsa and cas (de nsitom etric pro® les not shown) . common or at least adjoining binding sites for food prote ins were de te cted on newborn membrane prote ins of ± kda, ± kda, and kda. adult membrane prote ins of ± kda, ± kda, ± kda, ± kda, ± kda, ± kda, and ± kda share d food prote in binding abilitie s. to e xclude that the se maturational diffe rences were due to methodical errors, e g, failure to isolate ne wborn bbm prote ins, lectin binding was studie d in western blots, too. newborn membrane prote ins had more binding site s and e nhance d binding capacity for sna, pna, and maa than adults, whe re as uea i binding was lowe r in ne wborns compare d to adults (data not shown) . inhibition e xpe rime nts with unre late d prote ins indicate d common binding of food prote ins be cause cow' s milk prote ins, e spe cially cas, were able to re duce bbm binding of an unre late d prote in, whe reas o v a interfe red to a lower e xte nt with cow' s milk prote in and gliadin peptide binding (table ) . it was not possible to discriminate whe the r inte rfere nce was due to prote in interactions in solution, to nonspe ci® c membrane binding, or to the pre sence of common binding site s. on the othe r hand, cow' s milk prote ins and o v a did not inte rfe re with le ctin± bbm interactions and did not disturb the che milumine scence reaction. addition of a -fold e xce ss of nonlabe led food prote ins to solutions of biotinylate d lectins at a conce ntration of . m g/ml did not re sult in signi® cant change s of le ctin binding. due to its strong adhe rence to bbm, only cas was able to re duce le ctin binding by . ± . % . diffe rent approache s have be en re porte d to study bbm± prote in interactions and to characte rize deve lopme ntal change s in bbm structure . be side histochemical studie s ( , ) and utilization of isolate d enterocyte s ( ) and of gut sacs ( , , , ) , bbm vesicle s have bee n use d. as the smalle st unit for studying membrane structure and function ( ) , bbm vesicle s allow description of e nte rocytic binding structure s in detail, at the same time reducing the complexity of the inve stigate d syste m. binding characte ristics of rat bbm ve sicle s for food prote ins and le ctins have bee n asse ssed in centrifugation and ® ltration binding assays ( , , ± ) . a conside rable drawback of the se methods was the ir low sensitivity in de tecting weak food prote in binding. to improve se nsitivity, we use d a chemilumine scence binding assay in this study. food prote in binding to bbm of ne wborn and adult rats was found to be spe ci® c with re gard to saturation and inhibition. ove rall food prote in binding capacity of bbm was comparable to le ctins, except for blg. saturation of food prote in binding was only re ached at -to fold highe r molar conce ntrations compare d to le ctins and cas. this differe nce betwe en food prote ins and le ctins is in accordance with former studie s ( , ) . in contrast, the former centrifugation binding assay did not show any saturation and inhibition of food prote in binding to bbm vesicle s ( , , ) . in our opinion, results of nonspe ci® c food prote in binding to bbm were obscure d by methodological dif® cultie s in the centrifugation binding assay, which did not allow washing of ligand± bbm comple xe s without concurrent loss of binding signals. while colye r et al ( ) reporte d up to % inhibition of gliadin pe ptide binding to isolate d e nte rocyte s, farre castany et al ( ) demonstrate d nonspe ci® c binding of a pe ptic± tryptic dige st of gliadin to the colon carcinom a e pithe lial cell line ht- . the authors studie d bindin g prope rtie s of ovalbum inblocke d and glutaralde hyde -® xed ht- cells, which might be an e xplanation for the obse rve d concentration-de pe nde nt, but nonspe ci® c, gliadin binding. nevertheless, gliadin is able to associate with many prote ins, mainly by hydrophobic interactions ( ) . to exclude weak hydrophobic inte ractions be twee n food prote ins and bbm, we studie d binding phe nomena in pre sence of the de te rge nt twee n . experiments with bbm vesicle s in dot blots gave a marke d incre ase in food prote in binding capacitie s from ne wborn to adult rats. this ® nding contradicts pre vious re sults of a maturational de crease of food prote in binding to rat bbm ( , ) and might be due to the more sensitive and spe ci® c binding assay use d in this study. howe ver, our ® ndings are in accordance with data on increased binding and uptake of blg and bsa obtaine d in gut sacs of adult rats compare d to juve nile rats ( ) . for measure ment of strong and highly speci® c le ctin binding to bbm, the binding assay system was not found as critical. the same maturational change s in bbm glycosylation were obse rve d using e ithe r the chemilumine scence binding assay in this study or othe r methods as de scribe d e lse where ( , , ) . neve rthe le ss, minor differe nce s indicate d enhance d sensitivity of the chemilum inescence assay. binding of sna to adult bbm and of uea i to ne wborn membrane prote ins was measurable , in contrast to the earlie r re sults of taatje s and roth ( ) and le noir et al ( ) , which were base d on a diffe rent methodology. the maturational decrease in the lipid/prote in ratio of bbm ( , membrane prote in pro® les in figure ) is accompanie d by an increase in food prote in binding to isolate d bbm prote ins. in western blots, membrane prote ins of adult rats had more binding site s and highe r binding capacitie s than bbm prote ins of ne wborn rats. although membrane prote ins are denature d during sds-page , the ir binding prope rtie s are not necessarily de stroye d, as has be en shown for seve ral re ceptor± ligand inte ractions in weste rn blots ( , ) . o ur data of multiple binding site s do not support the hypothe sis of distinct re ceptors for food prote ins comparable to the e nzyme aminope ptidase n as a receptor for coronavirus ( ) . moreover, prote in± oligosaccharide inte ractions le ading to membrane attachme nt could be e xclude d be cause food prote in binding patte rns did not show any similarity to le ctin patte rns in western blots. lectin-like binding characte ristics of bsa and ala binding to rat bbm vesicle s and of gliadin to model glycoprote ins were rule d out earlie r by othe r inve stigators ( , ) . in our opinion, prote in± prote in inte ractions are responsible for food prote in attachme nt to bbm. this kind of interaction was obviously not in¯uence d by the diffe re nt composition and physicoche mical characte ristics of the investigate d cow's milk prote ins, gliadin pe ptide s, and ovalbumin. o n the contrary, common or at le ast adjoining binding site s e xist for the diffe re nt food prote ins, as indicate d by western blot ® ndings. inhibition by unre late d food prote ins supports this possibility. control e xpe riments could exclude artifacts cause d by biotinylation of food prote ins. v e sicle de struction leading to re le ase of brush borde r cytoske leton prote ins could possibly in¯uence binding characte ristics re corde d in we ste rn blots. for example , actin as a major compone nt of adult brush borde r might have caused the positive signals in the are a of kda. there fore furthe r e xpe rime nts have to be conducte d to ide ntify structure s in membrane binding and their orientation towards the intestinal lume n in vivo. in conclusion, contrary to e arlie r re ports, bbm food prote in binding was found increased during ente rocytic maturation of rat small intestine. it has to be ke pt in mind that any experimental de sign using isolate d bbm vesicle s in vitro lacks important parts of the mucosal barrie r ( ) . diffe rences in prote in re sistance to inte stinal hydrolysis (gliadin, blg in contrast to cas) ( ) in¯ue nce the ir acce ss to small intestinal e pithe lial cells in vivo. for e valuation of conseque nces of change s in food prote in binding capacity cause d by alte rations in bbm composition, it should be inve stigate d whe the r proce sse s of uptake and intrace llular processing or signal transduction occur. it is well-known that endocytosis is stimulate d by prior membrane adsorption ( , ) . moreover, diffe rence s of intrace llular proce ssing after uptake of membranebound prote ins or pinocytosis of¯uid-phase molecule s have bee n re porte d for small intestinal e pithelial cells ( , , ) . o ur results clearly indicate that bbm composition in¯ue nces its capacity for speci® c food prote in binding. in this re gard, studie s of enterocytic membrane alte rations possibly involve d in the de velopm ent of food-se nsitive e nte ropathie s would be worthwhile . pre se ntation of peptides and proteins by intestinal epithelial cells murine ente rocyte s can prese nt soluble antigen to spe ci® c class ii-re stricted cd t cells intestinal uptake of retinol: enhance ment by bovine milk b -lactoglobulin me mbrane -bound and¯uid-phase macromolec ules e nter se parate pre lysosomal compartmen ts in absorptive cells of suckling rat ileum rode wald r: evidence for the sorting of endocytic vesicle contents during the receptor-me diated transport of igg across the newborn rat intestine intestinal brush borde r me mbrane function in vivo re sponses of rat intestinal epithelium to intraluminal dietary lectins postnatal changes in biosynthesis of microvillus me mbrane glycans of rat small intestine: i. evidence of a de velopme ntal shift of te rminal sialylation to fucosylation mechanism of maturational de cline of rat intestinal lactase ± phlorizin hydrolase structure± function relationships in intestinal brush border me mbrane s the uptake of¯uoresce in-conjugated dextran , by the small intestinal e pithelium of the young rat and pig in re lation to macrom ole cular transm ission into blood lactobacillu s casei strain gg reve rse s increase d intestinal perme ability induced by cow milk in suckling rats food proteins and gut mucosal barrie r. ii. differential interaction of cow' s milk proteins with the mucous coat and the surface me mbrane of adult and immature rat jejunum food proteins and maturation of small intestinal microvillus membrane s (mvm). iii. food protein binding and mv m proteins in rats from newborn to young adult age peptic± tryptic dige sts of gliadin: contaminating trypsin but not pepsin interfere s with gastrointestinal binding charact e ristics food proteins and maturation of small intestinal microvillus me mbrane s (mv m). i. binding characteristics of cow's milk proteins and concanavalin a to mvm from ne wborn and adult rats assay of intestinal disaccharidase s a continuous spe ctrophotome tric me thod for me asuring the activity of serum alkaline phosphatase protein me asure ment with the folin phe nol reagent cleavage of structural proteins during the assembly of the head of bacteriophage t electrophore tic transfe r of proteins from polyacrylamide ge ls to nitrocellulose she ets: procedure and some applications a dot-immunobinding assay for monoclonal and other antibodies pe tell jk: re activity of gliadin and lectins with ce liac intestinal mucosa se lective loss of sialic acid from rat small intestinal e pithelial ce lls during postnatal deve lopment: de monstration with lectin-gold techniques gliadin binding to rat and human ente rocyte s uptake of polypeptide fragments by rat intestine in vitro and in vivo effect of surface desialylation on intestinal uptake of proteins in suckling rats me thodological guide for studying epithelial transport with isolated membrane ve sicle s. in cell membrane transport. expe rime ntal approache s and methodologie s. dl yudilevich, r de ves postnatal change s in lectin binding to microvillus me mbrane s from rat intestine deve lopment of gastrointestinal surface. v iii. lectin identi® cation of carbohydrate differe nces banwe ll jg: binding of isolectins from red kidney bean (phaseolus vulgaris) to puri® e d rat brush-border me mbrane s ne onatal and adult patterns of lectin binding to rat small intestinal microvillus me mbrane s crypt± villus differe ntiation re¯e cte d by lectin and protein binding to rat small intestinal brush border me mbrane s tlaskalova -hoge nova h: binding of gliadin to lymphoblastoid, myeloid and epithelial ce ll lines inve stigation of gliadin binding to differe nt se lected proteins using a biotin± stre ptavidin syste m de velopm e ntal ch an ge s in inte stinal glyco syl ation: nu tritionde pendent multi-factor re gulation of the fucosylation pathway at weaning time immunoautoradiographic detection of e pide rmal growth factor receptors after e lectrophore tic transfer from gels to diazo-pape r v isualization of lactotransferrin brush-border re ceptors by ligand-blotting human aminopeptidase n is a receptor for human coronavirus e koe ttgen e: studies on the aetiology of coeliac disease: no e vide nce for lectin-like components in wheat glute n uptake and transport of macromolecule s by the intestine: possible role in clinical disorders pe rmeability of milk protein across the intestinal epithelium in vitro transport of me mbrane -bound macromol e cule s by m ce lls in follicleassociate d epithelium of rabbit pe ye r's patch e ndocytosis and the recycling of plasma membrane e ndocytosis in absorptive cells of cultured human small-intestinal tissue: horseradish peroxidase , lactope roxidase, and ferritin as markers the authors thank dr. a. o sman and dr. t. mothes, institute of clinical chemistry and pathological biochemistry, unive rsity of leipzig, for providing gliadin peptides. the help of dr. h. wolburg, institute of pathology, university of tuebingen, in e lectron microscopy studies and of p.-m. we ber in preparing photographs is grate fully acknowledge d. key: cord- - ugoxns authors: jensen, bent borg title: extensive literature search on the ‘effects of copper intake levels in the gut microbiota profile of target animals, in particular piglets’ date: - - journal: nan doi: . /sp.efsa. .en- sha: doc_id: cord_uid: ugoxns nan background and terms of reference as provided by the requestor . . in the context of the development of the scientific opinion linked to the mandate related to the revision of maximum levels of copper in feed, the experts of the ad-hoc working group (wg) of the feedap panel have considered relevant to evaluate the effects of copper intake levels in the gut microbiota profile of target animals. published scientific papers have addressed this issue and it seems there is a relationship between levels of dietary copper in animals and differences in their gastrointestinal microbiota, which in turn may result e.g. in more nutrients becoming available for absorption; the mode of actions have also been recently studied. a possible outcome of the opinion might be a recommendation of different maximum levels compared to those currently authorised in feed (table ) . therefore it is necessary to know the potential effects of a variation in copper intake levels on the gut microbiota profile of the target animals which might be accounted in the feedap panel opinion. piglets should be particularly considered in this literature search, as this is animal category for which the maximum copper in feed is allowed by commission regulation (ec) no / ; at least, two other relevant animal species/categories (chickens for fattening, dairy cows, fish, cat, dog) shall be included. the project should be accomplished in a structured manner, that is following an extensive literature search (els) process. the steps listed below should be followed and duly documented under the present call for tender: -development of an els protocol, which will be subject to efsa´s approval the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. -databases to be consulted -criteria to select the papers -criteria for data extraction -assessment of the quality of the data -synthesis of the data the purpose of the contract was to provide scientific assistance to the feed unit of efsa in the completion of an extensive literature search on the effects of copper intake levels in the gut microbiota profile of target animals, in particular piglets. the procedure includes the provision of a report collecting, collating, analysing and synthesising the scientific data and information on the els topic. the specific objectives of the contract resulting from the present procurement procedure are as follows: the searches in web of science resulted in hits (shown in appendix a ). the search in cab abstracts resulted in hits of which one (p in appendix a and appendix b) was not among the hits from the search in web of science. consulting the reference list of relevant papers from the search another studies/papers were retrieved (p to p in appendix a and appendix b). search terms and boolean operators (strings): ts=(copper or cu or copper sulphate) and ts=(gut or intestinal or intestine or ileal or digestive tract or gastrointestinal tract or git) and ts=(bacteria or microbiota or microflora or microorganism or microbial community) and ts=(chickens or layer or hen or broiler) the searches in web of science resulted in hits (shown in appendix a ). the search in cab abstracts resulted in hits of which one (ch in appendix a and appendix b) was not among the hits from the search in web of science. no further studies/papers were found by consulting the reference lists from relevant papers from the search. search terms and boolean operators (strings): ts=(copper or cu or copper sulphate) and ts=(gut or intestinal or intestine or ileal or digestive tract or gastrointestinal tract or git) and ts=(bacteria or microbiota or microflora or microorganism or microbial community) and ts=(cow or cattle or rumen or ruminant or bovine). the searches in web of science resulted in hits (shown in appendix a ). the search in cab abstracts resulted in hits of which all were included in the hits from the search in web of science. no further studies/papers were found by consulting the reference lists from relevant papers from the search. effect of copper intake on gut microbiota (pigs/piglets, chickens, dairy cows) www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. for the general approach to complete this els the contractor considered the technical manual for performing electronic literature searches in food and feed safety and the efsa guidance: application of systematic review methodology to food and feed safety assessments to support decision making. the inclusion criteria for the scientific papers were no limitation on timespan, no limitation on language and inclusion of primary research and review articles (the later to get a comprehensive view on the subject). the els protocol was primarily based on primary research. papers on foreign languages, where translation was not possible, were excluded.  the study had to contain a control diet and diet supplemented with one or several copper concentrations in the range of to mg/kg.  studies including the effect of any sources of dietary copper on any aspect of the microbiota in the gastrointestinal tract or faeces (profile, activity, metabolites and ph) were selected. the total number of references retrieved, the references rejected at the title and abstract screening and the references from which data was extracted are shown as a flow chart in annexes a to a . the list of included and excluded references are shown in appendix b. data collected was the effect of dietary copper in the range from to mg/kg on any aspect on the microbiota in the gastrointestinal tract or faeces. copper content: background content of feed, supplemented copper, concentration and source (data given in table for piglet/pigs and in table for broilers/layers). animals: species/category and age (weight) of the animals (data given in table for piglet/pigs and in table for broilers/layers). number of animals; animals per treatment; replicates (data given in table for piglet/pigs and in table for broilers/layers). composition and activity of the microbiota in the gastrointestinal tract or faeces (profile, activity, metabolites and ph). an overview of the data obtained is given in table for piglets/pigs and in table for broilers/layers. the data obtained is narratively described in the text and an overview of the effect of copper concentrations and sources on the concentrations on bacterial populations is shown in tables , and for piglets/pigs and in table for broilers/layer. if available, performance parameters (data given in table for piglet/pigs and in table for broilers/layers). the results are narratively described in the text and shown in tables , , , and , for piglets/pigs and in tables , and for broilers/layers. www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. the study design (incl. e.g. the duration of the study), the conduction of the study and the description of the study was evaluated. it was checked if the number of animals in each group in the studies were adequate. it was checked if the methods used to describe the microbiota profiles were adequate. it was checked if the statistical methods (incl. e.g. randomisation of the assignment of animals in treatment groups) used were adequate. the methodological quality of the selected studies is captured in table for piglets/pigs and in table for broilers/layers. of the references found for pigs and piglets by the literature search, were considered appropriate to be included in the els (annex a ). references were duplicates. of the excluded references, were excluded when screening the title and abstract and after consulting the full paper. the list of included and excluded references is provided in appendix b. of the references found for chickens by the literature search, were considered appropriate to be included in the els (annex a ). references were duplicates. of the excluded references, one full paper could not be retrieved, were excluded when screening the title and abstract and after consulting the full paper. it should be mentioned that out of the included papers were written in foreign languages ( in korean and in chinese) with english abstracts and table and figure legends. the list of included and excluded references is provided in appendix b. of the references found for cows by the literature search, were considered appropriate to be included in the els (annex a ). references were duplicates. of the excluded references, were excluded when screening the title and abstract and after consulting the full paper. a closer examination of the five studies first selected to be included in the els study on cows, revealed the papers not to be appropriate to be included in the els. one of the studies (cow ) was published in polish, two of the studies were dealing with antibiotic resistance (cow and cow ), one was dealing with the effect of copper on parasite control (cow ) and the last one on the effect of copper on abomasa ulcers (cow ). the list of included and excluded references is provided in appendix b. effect of copper intake on gut microbiota (pigs/piglets, chickens, dairy cows) www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. pigs and piglets . . assessment of the methodological quality of the studies table : assessment of the methodological quality of the piglet/pig studies as shown in table the quality of the papers retrieved from the search on piglet/pig was generally judged to be good although some of them were rather old. five out of papers were written in foreign languages ( in german and in chinese) with english abstracts and table and figure legends four types of copper sources were used in the research with pigs (table ) : ) inorganic copper, ) organic bound copper, ) clay bound copper and ) copper-loaded nanoparticles. inorganic copper was used in of the studies. the sources were cuso (concentrations - mg cu/kg feed, in studies p , p , p , p , p , p , p , p , p , p , p , p , p , p , p , p , p , p , p , p , p , p and p ), cuo (concentrations - mg cu/kg feed, in studies p and p ) and elemental copper (concentration mg cu/kg feed, in study p ). organic bound copper was used in of the studies. the sources were cu-aa complex (cupric amino acid complex, concentration mg cu/kg feed, in study p ), cu-cit (cupric citrate, concentrations , and mg cu/kg feed, in studies p and p ), cu-met (copper the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. bbj methionate, concentrations and mg cu/kg feed, in study p ) and cu-gly (copper glycinate, concentrations , and mg cu/kg feed, in study p ). clay bound copper was used in of the studies. the sources were cu-mm (copper-bearing montmorillonite from aluminosilicate clay). it was used in studies p , p , p , p and p at concentrations from to mg cu/kg. copper-loaded nanoparticles were used in of the studies. the source was copper loaded chitosan nanoparticles, it was used at a concentration of . mg cu/kg feed in study p . the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. usa ----- ppm cuso . experiment ----- ppm cuso . ----- ppm cucit . ----- ppm cucit . ----- ppm cucit . ----- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. the microbial characteristics measured in each of the selected studies with piglets/pigs are shown table . eighteen of the studies were done with piglets (p , p , p , p , p , p , p , p , p , p , p , p , p , p , p , p , p , p and p ) and were done with growing pigs (p , p , p , p , p , p , p , p and p ). the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. bbj pigs (hu et al., ) the population of clostridium was significantly reduced in as well si as caecum content in pigs fed mg/kg cu as cu-montmorillonite compared to the control fed pigs; however, although numerically lower, the effect was not significantly different from pigs fed copper free montmorillonite. in study p (kroger et al., ) addition of mg/kg cu as cuo or cuso to diets of growing pigs were shown significantly to reduce pigs containing costridium perfringens in gut content from the small intestine and colon. no effect was found of elementary copper. the effects of cuo and cuso addition were only seen if cu was supplemented until the pigs were slaughtered at kg live weight. if it was withdrawn from the feed at kg live weight no effect was detected when the pigs were slaughtered at kg. in conclusion low concentrations of copper as clay bound copper seem to reduce the population of clostridium both in piglets and in growing pigs. further high concentrations of inorganic copper as either cuso or cuo may reduce the population of clostridium in growing pigs. coliform bacteria. the effect of copper on the population on coliform bacteria was investigated in studies with piglets (p , p , p , p , p , p , p , p , p , p , p , p , p , p ) and four studies with growing pigs (p , p , p , p ). the results from the studies are summarised in table . it may be concluded from the experiments that supplementing piglet (and growing pigs) diet with low additional copper amounts (below mg/kg cu) seems to inhibit the population of coliform bacteria in the gastrointestinal tract. especially clay bound copper seems to be effective. when supplemented to the feed in amounts above mg/kg copper it does not seem to have any effect on the population of coliform bacteria in the gastrointestinal tract of pigs. www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. enterococci. the effect of copper on the population density enterococci was investigated in one study with piglets. dietary doses of mg/kg cu as cuso significantly reduced the counts of enterococci in stomach content of piglets while no effect was seen in content from the si, caecum or colon (study p ). lactic acid bacteria. the effect of copper on the population density of lactic acid bacteria was investigated in one study with piglets. dietary doses of mg/kg cu as cuso significantly reduced the counts of enterococci in stomach content of piglets while no effect was seen in content from the si, caecum or colon (study p ). the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. lactobacilli. the effect of copper on the population density and/or the composition of lactobacilli was investigated in studies with piglets (p , p , p , p , p , p , p , p , p , p , p and p ) and in four studies with growing pigs (p , p , p and p ). the results from the studies are summarised in table . in study p with piglets (højberg et al., ) dietary doses of mg/kg cu as cuso significantly reduce the counts of lactobacilli in stomach content while no effect was seen in content from the si, caecum or colon. in study p (jensen, ) the population of lactobacilli was reduced throughout the gastrointestinal tract in piglets fed mg/kg cu as cuso . in study p (ma et al., ) no effect of addition of mg/kg cu as cumm was detected on the population of lactobacilli in content from the si or colon. in study p (mei et al., ) a numeric reduction in the population of lactobacilli was detected by addition of , and mg/kg cu as cuso to piglet diets when the population density were enumerated using selectively cultivation, however if the population of lactobacilli were quantified by use of qpcr the reduction found for and mg/kg cu as cuso were significant different from the results found in the control fed piglets. in study p (mei et al., ) no significant effect of addition of mg/kg cu as cuso was found on the population of lactobacilli in cecal content. in study p (namkung et al., ) the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. bbj from piglets was found by supplementing the diet with mg/kg in study p (kellog et al., ) . in the study with growing pigs (p , hawbaker et al., ) no significant effect on the population of staphylococci in fecal samples were detected in any of the three experiments carried out with mg/kg cu as cuso . in conclusion the effect of dietary copper on the gastrointestinal populations of staphylococci in pigs seems to be non-existent or very week. streptococci. the effect of copper on the population density and composition of streptococci was investigated in two studies with piglets (p and p ) and four experiments with growing pigs (p , p , p and p ). with piglets no significant effect in the fecal counts of streptococci were found in study p experiment and study p experiment (bunch et al., ) neither by feeding the piglets , or mg/kg cu as cuo or by feeding them mg/kg cu as cuso . there was, however, a numerical reduction in streptococci in both experiments by feeding mg/kg cu as cuso . no significant reduction in the population of streptococci was found by feeding piglets with mg/kg cu as cuso in study p (kellog et al., ) . in study p (varel et al., ) with growing pigs, mg/kg cu as cuso reduced the number of ureoluytic organisms in fecal samples with a marked decrease in the streptococcus spp., which made up % of the ureolytic bacteria in fecal samples from pigs fed the control diet. a marked fall in the number of streptococci in fecal samples was found in study p (fuller et al., ) when growing pigs were fed mg/kg cu as cuso compared to pigs fed a control diet. the extent of the reduction varied but the counts of streptococci in the copper treated pigs were always lower than in the control pigs and the reduction could be as much as from to cfu/g faeces. in study p (experiments , and ), a significant reduction of streptococci in fecal samples of growing pigs was found in experiment and while only a numerical reduction was found in experiment by supplementing the diet of growing pigs with mg/kg cuso . in study p (hendericks et al., ) , it was concluded that cuso (concentration of cu not given) strongly inhibited the growth of streptococci in an ex vivo experiment with si content from growing pigs. in conclusion the results strongly indicate that supplementation with mg cu/kg, or higher, as cuso significantly reduces the population of streptococci in the gastrointestinal tract of growing pigs. the effect of cuso on the population of streptococci in piglets is more questionable. total anaerobe bacteria. the effect of supplementary copper on the population of total anaerobic bacteria is shown in table . no effect on the anaerobic population was observed if the amount of copper added to the diet was below mg/kg copper. however, addition of mg/kg cu as cuso to the diet may reduce the population of total anaerobic bacteria in the colon, while copper as cuo does not seem to have any effect even at cu concentrations of mg/kg. www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. table : effect of copper source and copper concentration on the population of anaerobic bacteria in the gastrointestinal tract of piglets and growing pigs. total aerobe bacteria. the effect of copper on the population of total aerobe bacteria was investigated in two studies with piglets (p and p ) and in one study with growing pigs (p ). in study p experimet (bunch et al., ), piglets were fed either a control diet or diets supplemented with , or mg/kg cu as cuo and a diet supplemented with mg/kg cu as cuso . a significant reduction in the population of total aerobe bacteria in faecal samples was found in the piglets fed mg/kg cu as cuso . in contrast cu as cuo resulted in a significant linear increase with increasing cuo supplementation in the population of total aerobic bacteria in faecal samples. in study p experiment , no significant effect of either mg/kg cuo or mg/kg cuso was found on the population of total aerobic bacteria in piglet faecal samples. in agreement with that no effect on the population of aerobic bacteria in fecal samples from piglets was found in study p (kellog et al., ) by supplementing the diet with mg/kg cu as cuso . in the study with growing pigs (p , hawbaker et al., ) a significant reduction in the population of total aerobic bacteria in fecal samples was detected in all three experiments carried out with mg/kg cu as cuso . in conclusion the effect of copper concentration and source on the population on total aerobe bacteria seems to be very variable. ureolytic bacteria. the number of ureolytic bacteria was investigated in study p (varel et al., ) . addition of copper sulfate to the diet at a concentration of mg/kg copper significantly reduced the number of ureolytic bacteria compared to control fed pigs, in fecal samples collected after , and weeks of feeding the experimental diets, with a marked decrease occurring in streptococcus spp., which make up % of the ureolytic isolates. quantitative real-time polymerase chain reaction (qpcr) has been used in one investigation with piglets (p , mei et al., ) to detect the effect of copper supplementation on bacterial populations (lactobacilli, enterobacteria or total anaerobic bacteria) in gastrointestinal content. it was shown that the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. bbj the population of lactobacilli in caecum content from piglets was significantly decreased in piglets fed diets supplemented with or mg/kg cu as cuso while no effect was seen by a diet supplemented with mg/kg cu as cuso . no effect was found of any of the cuso supplemented diets on the population of enterobacteria or total anaerobic bacteria. use of traditional microbiological culturing methods did also show a reduction in the population of lactobacilli with increasing cuso addition; however these results were not significant. the microbial community was investigated in four studies with piglets (p , p , p and p ). in study p (namkung et al., ) , study p ( the results obtained from the microbial community structure studies are summarized in table . . . in all studies the number of bands per sample was measured and in study p and p the similarity indices for bands between samples were calculated. the number of bands is indicative for the number of bacterial species within a sample; the similarity coefficient is indicative of how similar the bacteria within a treatment group are. table : effect of copper sources and copper concentrations on microbial diversity and microbial similarity obtained from microbial community structure studies. no effect of copper concentration or sources was found in study p neither on the number of species nor on the similarity of the microbiota in faecal samples. however in studies p , p and p it was shown that supplementing piglet diets with high amounts of copper ( to mg/kg) as cuso affect the number of bacterial species in ileal (p ), in caecal (p and p ) and in colonic (p ) digesta. furthermore, in study p addition of mg/kg cu as cuso significantly reduced the degree of similarity of the microbiota in ileal samples compared to pigs fed a diet without supplementary copper addition. as also pointed out by the authors in study p , the combination of faecal samples and the microbial methods used in their study may not have been sensitive enough to detect differences among the dietary treatments. in study p , the similarity analysis further shows that the piglets did restore a diverse microbiota weeks after withdrawal from the high cu diet, but the community structure still seems to be different from that in the control fed pigs. in general, the community structure studies strongly suggest that supplementing piglet diets with to mg/kg cu as cuso change the microbial community in the small intestine, the caecum and the colon. the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. digesta content. the amount of gastrointestinal content was investigated in study p (højberg et al., ) . the addition of high concentration of cuso ( mg/kg cu as cuso ) to piglet diets had no significant influence on digesta content in any part of the gastrointestinal tract compared to piglets fed a control diet. dry matter. the dry matter content in gastrointestinal digesta was investigated in piglets in study p (højberg et al., ) . in contrast to high concentrations of zno (addition of mg/kg zn as zno to the diet) -which significantly increase the dry matter content in the stomach and decrease the dry matter content in caecum and colon-, high concentration of cuso ( mg/kg cu as cuso ) had no significant influence on the dry matter content in any part of the gastrointestinal tract (stomach, si, caecum and colon). ph. the effect of copper on faecal ph and ph of digesta were investigated in three studies with piglets (p , p and p ) and one study with growing pigs (p ). in study p (højberg et al., ) and p (jensen ) no effect of feeding piglets diets supplemented with either mg/kg (p ) or mg/kg of cu (p ) as cuso was found on ph in any segments of the gastrointestinal tract (stomach, si, caecum and colon) compared to piglets fed control diets. in study p (zhu et al., ) a significant effect on ph in caecum and colon content was detected by feeding copper as cu-chitosan ( and mg/kg cu) or as cuso ( mg/kg cu) to piglets compared to piglets fed a control diet. in study p (huang et al., ) the effect of feeding copper supplemented diets to growing pigs on ph in faecal samples taken at the beginning of the experiment and after three and five weeks on the experimental diets were investigated. four different copper supplemented diets were used: either or mg/kg cu as cuso or or mg/kg cu as cucitrate. apart from a small but significant decrease in ph in faecal samples taken after weeks from the pigs fed the diet supplemented with mg/kg cu as cuso (ph . in faecal samples from the control fed pigs versus . in the copper fed pigs), no effect on ph was detected. in general the effect of supplementing pig diet with copper on faecal or gastrointestinal ph seems to be limited. diarrhoea. the effect of copper on diarrhoea incidence was investigated in three studies with piglets (p , p and p ) and in one study with growing pigs (p one where an antibiotic was included in the all diets tested ( mg/kg mecadox) and one without antibiotic in the diets. in both, experiment faecal samples were taken at day for measurement of the odour characteristics. in the study with antibiotic the pigs were kept on the experimental diets through the growing-finishing phase and samples taken after days for measurements of odour characteristics. in samples taken after days from the piglets fed the diets with antibiotics addition effect of copper intake on gut microbiota (pigs/piglets, chickens, dairy cows) www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. of mg/kg cu as cuso and and mg/kg cu as cu citrate significantly reduced two of the all three odour characteristics measured (odour intensity and irritation intensity) while no significant effect were found on the third characteristic (odour quality). no significant effect of diets with mg/kg cu as cuso or mg/kg cu as cuso was found on any of the odour characteristics measured. in samples taken after days from the piglets fed the diets without antibiotics, odour intensity was significantly reduced in piglets fed , and mg/kg cu as cu citrate while no significant effects were found for piglets fed or mg/kg cu as cuso . none of the experimental diets affected irritation intensity. however, mg/kg cu as cuso and , and mg/kg cu as cu citrate all significantly improved odour quality. no effect of mg/kg cuso was found on odour quality. in samples taken after days from the pig fed the diets with antibiotics odour intensity and irritation intensity were significantly reduced by all experimental diets except the diet supplemented with mg/kg cu as cu citrate which had no effect on odour intensity and irritation intensity. odour quality was significantly improved in faecal samples from all pigs fed copper supplemented diets compared to faecal samples from the control pigs. in contrast to the above mentioned results no effect of adding copper ( or mg/kg as cu as cuso or , , or mg/kg cu as cu citrate) to antibiotic supplemented diets were found in study p (armstrong et al., ) on either odour intensity, irritation intensity or odour quality of faecal samples from piglets (weaned at to days) after days feeding the experimental diets. in conclusion supplementing pig diet with or mg/kg as cu citrate or mg/kg as cuso may improve odour characteristics of swine waste. the mechanism of action was believed to be attributed to an antibiotic-like function of copper on the microbiota in the gastrointestinal tract. short chain fatty acids (scfa) concentration. lactate. microbial production of lactate was investigated in two studies with piglets (p and p ). addition of mg/kg zn as zno to the diets in study p significantly reduced the concentration of lactate in digesta in the stomach and si. however in the caecum and colon, where lactate is usually not detectable, a significant accumulation of lactate was observed in the piglets receiving the high zno diet. in contrast, the addition of mg/kg cu as cuso to the feed had no significance on the concentration of lactate in any segments of the gastrointestinal tract, but counteracted the accumulation of lactate found in the high zno fed piglets in caecum and colon. in study p (song et al., ) , the concentration of d-lactate was measured in plasma samples. d-lactate is produced by the microbiota in the gastrointestinal tract and absorbed to the blood. mammals do not have the enzymatic system to metabolise d-lactate so plasma d-lactate may be a measurement of the microbial activity in the gastrointestinal tract. a significant reduction in plasma d-lactate was found in study p in pigs fed mg/kg cu as either cu-camontmorillonite or cu-namontmorillonite compared to the control fed pigs, indicating a reduced fermentation in the gastrointestinal tract in the piglets fed the copper supplemented diets. the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. bbj gastrointestinal tract, but counteracted the accumulation of succinate in caecum and colon found in the high zno fed piglets. absorption of ammonia. effect of copper on ammonia absorption was investigated in growing pigs in study p (yen and nienaber, ) . the addition of mg/kg cu as cuso to the diet significantly reduced the net absorption of ammonia to the portal vein compared to pigs fed a diet without the addition of extra copper. as concluded by the author, that may reflect decreased urease activity and ammonia production by the gastrointestinal microbiota in the pigs receiving the copper supplemented diet. deamination and decarboxylation of amino acids. the effect of copper on microbial formation of ammonia by deamination of amino acids and production of amines (histamine, putrescine, cadaverine, tyramine and phenylethylamine) by decarboxylation of amino acids in the si has been investigated using ex vivo incubations in study p (dierick et al., ) using si content from growing pigs. both processes were severely decreased if mg/kg cu as cuso was added to the incubations, indicating that copper has a sparing action on microbial degradation of amino acids in the small intestine, leaving more amino acids available for absorption. urease activity. effect of copper on urease activity has been investigated in two studies, one study with piglets (study p ) and one study with growing pigs (study p ). in the study with piglets (p , højberg et al., ) urease activity was investigated in content from the stomach, si, caecum and colon in piglets fed diets either added mg/kg cu as cuso or control diets without the addition of extra cuso both diets were fed with or without addition of mg/kg zno. the urease activity was below the detection limit in stomach and si content, highest urease activity was found in the colon. addition of cuso to the diets had no significant effect of the urease activity. in contrast to piglets, a significant effect (p< . ) of mg/kg cu as cuso was found on urease activity in fecal samples from growing pigs in study p (varel et al., ) . atp concentrations. bacterial activity as determined by the concentration of adenosine triphosphate (atp) was measured in study p and study p . in study p (højberg et al., ) no significant effects were found on atp concentration in any of the gastrointestinal segment investigated (stomach, si caecum and colon) by addition of mg/kg cu as cuso to piglet diets compared to a control diet without additional addition of cuso . similar results were found in study p (jensen, ) , where no effect of the addition of mg/kg cuso to a diet containing mg/kg cu was found on the atp concentrations in content from the stomach, three segments from the si, the caecum and three segments from the colon. microbial enzyme activity. the effect of copper on microbial enzyme activity of β-glycosidase and βglucuronidase has been investigated in one study (p , xia et al., ) . no significant effect was found by the addition of mg/kg cu as cuso to the diets on either β-glycosidase or βglucuronidase activity in si or colon content. addition of mg/kg cu as cu-montmorillonite reduced the activity of both enzymes in si as well as colon content compared to the control fed pigs. however apart from the activity of β-glucuronidase in the colon content, the effects were not significantly different from the activities found in pigs fed copper free montmorillonite. feeding high copper diets to germ free pigs has been investigated in one study with growing pigs (p , shurson et al., ) . germ free pigs tended to have higher average daily gain (adg) and average daily feed intake (adfi) than conventionally reared pigs. addition of mg/kg cu as cuso to the feed tended to reduce adg and adfi in germ-free pigs while it increases adg and adfi in conventionally reared pigs. the high copper diets did not appear to make organ weight or intestinal characteristics in conventionally reared pigs different than those of the germ free pigs. high copper diets seem to reduce intestinal cell turnover in germ free pigs while it tended to accelerate intestinal turnover in conventionally reared pigs, perhaps via an interaction with the gut microbiota. www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. coliform bacteria. it may be concluded from the experiments that supplementing piglet and growing pigs diet with low additional copper amounts (below mg/kg cu) seems to inhibit the population of coliform bacteria in the gastrointestinal tract. especially clay bound copper seems to be effective. when supplemented to the feed in amounts above mg/kg copper, it doesn't seem to have any effect on the population of coliform bacteria in the gastrointestinal tract of pigs. lactobacilli. from the results it may be concluded that supplementing pig diets with copper streptococci: in conclusion the results with growing pigs strongly indicate that the addition of mg cu/kg, or higher, as cuso significantly reduces the population of streptococci in the gastrointestinal tract of growing pigs. the effect of cuso on the population of streptococci in piglets is more questionable. in general, the studies on community structure strongly suggest that supplementing piglet diets with to mg/kg cu as cuso change the microbial community in the small intestine, as well as in the caecum and the colon. in conclusion, supplementing pig diets with or mg/kg as cu citrate or mg/kg as cuso may improve odour characteristics of swine waste. the mechanism of action was believed to be attributed to an antibiotic-like function of copper on the microbiota in the gastrointestinal tract. in general, the effect of supplementing pig diets with copper on faecal or gastrointestinal ph seems to be limited. the overall conclusion from the studies with piglets and growing pigs is that copper even at low concentrations (< mg/kg feed) may affect the microbiota in the gastrointestinal tract. especially the population of clostridia and coliform bacteria seems to be affected by low concentrations of copper. in particular, copper bound clay minerals seem to have an effect on the populations of coliform bacteria and clostridia. at higher concentrations (> mg/kg feed) cu as cuso reduce the population of lactobacilli in piglet as well as growing pigs. in growing pigs, the addition of cu as cuso reduces the population of streptococci in colonic and fecal samples, the population of ureolytic bacteria in the colon of which streptococci make up %, the urease activity in the colon, and decarboxylation and deamination of amino acids in the small intestine. however, no effect of cu as cuso on the population of streptococci and on urease activity was seen in piglets. supplementing piglet diets with to mg/kg cu as cuso significantly affects the community structure of the microbiota in the small intestine, the caecum and the colon. effect of copper intake on gut microbiota (pigs/piglets, chickens, dairy cows) www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. bbj chickens . . assessment of the methodological quality of the studies table : assessment of the methodological quality of the chicken studies. as shown in table the quality of the papers retrieved from the search on chickens was generally judged to be low. ten out of papers were written in foreign languages ( in korean and in chinese) with english abstracts and table and figure four types of copper sources were used in the research with chickens (table ) : ) inorganic copper, ) organic bound copper, ) clay bound copper and ) copper-loaded nanoparticles. inorganic copper was used in of the studies. the sources were cuso (concentrations - mg cu/kg feed, in studies). organic bound copper was used in of the studies. the sources were cu-soy proteinate (concentrations - mg cu/kg feed, in studies ch , ch , ch , ch , and ch ), cu-met (concentrations - mg cu/kg feed, in studies ch , ch and ch ), cu-fish meal (concentration mg cu/kg feed, in study ch ), starch cu complex (concentration mg cu/kg feed, in study ch ), starch methionine cu complex (concentration mg cu/kg feed, in study ch ), and na-alginate cu complex (concentration mg cu/kg feed, in study ch ). clay bound copper was used in of the studies. the source was copper-bearing montmorillonite from aluminosilicate clay (cu-mmt). it was used in study ch and ch at concentrations from to mg cu/kg feed. copper-loaded nanoparticles were used in of the studies. the source was copper-montmorillonite nanomaterial (concentrations - mg cu/kg feed, in study ch ) and copper silicate nanoparticles (concentration mg cu/kg feed, in study ch ). the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. the microbial characteristics measured in each of in the selected studies with chickens are shown in table . fifteen of the studies were done with broilers (ch , ch , ch , ch , ch , ch , ch , ch , ch , ch , ch , ch , ch , ch , ch and ch ) and were done with laying hens (ch and ch ). the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. ), a significant increase in the population of bifidobacteria in content from the cecum was found by addition of or mg/kg copper as cuso to the diet both in broilers slaughtered after and weeks feeding the treatment diets. in contrast to that, addition of mg/kg copper to the diet as cuso resulted in a significant reduction in the population of bifidobacteria in cecal content in broilers slaughtered after weeks while no effect was found in broilers slaughtered after weeks. in all studies the population density of bifidobacteria were determined by counting the bacteria on selective media but several studies has shown that no really good selective media exist for the enumeration of bifidobacteria. campylobacter. the effect of copper on the population density of campylobacter was investigated in study ch (aydin et al., ) . no significant effect of an addition of mg/kg copper as cuso to the diet was found on the population density of campylobacter in ileal content. clostridia. the effect of copper on the population density on clostridia in content from the small intestine was investigated in studies with broilers (ch , ch , ch , ch , ch and ch ) and in two studies with layers (ch and ch ). the effect of copper concentration and copper sources on populations of clostridia in chicken gut content is shown in table . a significant reduction in the population of clostridia in si content from broilers were found by the addition of mg/kg cu as cuproteinate in study ch (kim et al., a) the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. cu-proteinate. similarly, no effect on the population of clostridia was found in study ch (min et al., ) by the addition of mg/kg cu as either cuso , cu-methionine or cu-fish meal to the diet; or in study ch by the addition of mg/kg cu as cuso . in the studies with layers a significant reduction of the population of clostridia were found in both investigations (ch and ch ). in study ch (choi et al., ) the population of clostridia was reduced by the addition of and mg/kg cu whatever it was added to the diet as cuso or cu-proteinate, and in study ch (paik et al., ) , by addition of and mg/kg cu whatever it was added as cu-methionine or cu-proteinate. the effect of copper on the density of clostridia in content from the caecum was investigated in two studies (ch and ch ). in study ch (xia et al., ) a significant reduction in the population of clostridia was found by the addition of mg/kg cu as cu-montmorillonite to the diet while no effect was found by the addition of mg/kg cu as cuso to the diet. in study ch (xu et al., ) no effect on the population of clostridia in caecum content was found by the addition or mg/kg cu-montmorillonite to the diet. supplementing chicken (broilers and layers) diets with additional copper seems to reduce the population of clostridia in the gastrointestinal tract of the birds, even at low copper concentrations. in particular, clay bound copper seems to be effective in reducing the population of clostridia. www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. coliform bacteria. the effect of copper on the population density of coliform bacteria in content from the gizzard was investigated in three investigations (ch , kim et al., and ch experiments and , min et al., ) . as shown in the effect of copper on the population density of coliform bacteria in si content was investigated in experiments with broilers and in experiments with layers (table ) . a significant reduction in the population of coliform bacteria was found in study ch (choi et al., ) by the addition of , or mg/kg cu as cuso to the diet, while no effect of an addition of mg/kg cu as cuso was found in studies ch (kim et al., ) , ch (min et al., ) , ch experiments and (min et al., ) ; and of mg/kg cu as cuso in study ch . furthermore, no effect was found in layers (ch , kim et al., b) fed diets containing or mg/kg cu as cuso . in study ch (kim et al., ) a significant reduction in the population of coliform bacteria in broiler si content was found by the addition of mg/kg cu as cu-methionine to the diet while it had no effect at a concentration of mg/kg. no effect was found by the addition of mg/kg cu as cu-methionine in study ch (min et al., ) and no effects were found in layers at concentrations of and mg/kg (ch , paik et al., ) . copper as cu-protionate was shown to reduce the population of coliform bacteria in study ch (kim et al., ) when it was added to the diet at a concentration of mg/kg cu while it had no effect at a concentration of mg/kg. no effect of cu-protionate was found in study ch (aydin et al., ) at a concentration of mg/kg cu or in study ch (kim et al., a) at a concentration of mg/kg cu. cu-propionate at concentrations of and mg/kg cu had no effect on the density of coliform bacteria in si content from layers neither in study ch nor in study ch (paik et al., ) . a significant reduction in the population of coliform bacteria in si content from broilers were found in study ch (ma et al., ) conducted where small intestinal content was incubated for hours with or without addition of copper. in both experiments it was found that mg/kg as cuso reduced the growth of coliform bacteria, while mg/kg cu as cuso or tribasic copper chloride at concentrations of mg/kg and mg/kg had no effect on the growth of coliform bacteria. the effect of copper on the population of coliform bacteria in caecal content has been investigated in seven studies with broilers (ch , ch experiment , ch experiment , ch , ch , ch and ch ). a summary of results from the experiments are shown in table . no effect on the population of coliform bacteria were found by feed concentrations of mg/kg cu as cuso in study ch (kim et al., ) the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. bbj (ch experiment , min et al., ) , or with mg/kg cu as a cu-starch/methionate complex (ch experiment and ch experiment ) or with a na-alginate cu complex (ch experiment ). in general the effect of copper on the gastrointestinal populations of coliform bacteria seems to be rather weak, in most cases where an effect was seen, the concentrations were higher than mg/kg cu; the exception may be copper bound clay particles, especially copper bound nanoparticles that seems to have an effect at concentrations below mg/kg cu (ch and ch ). that high concentrations of copper may reduce the population of coliform bacteria in gut content from chickens is in agreement with the ex vivo experiment studies (ch and ch ) that show that cu as cuso inhibit the growth of coliform bacteria at a concentration of mg/kg cu but not at a concentration of mg/kg cu. enterococci. the effect of copper on the population of enterococci has only been investigated in a single experiment (ch , aydin et al., ) . supplementation of the diet with cu-proteinate corresponding to a cu concentration at mg/kg cu had no significant effect on the population of enterococci in broiler ileal content. lactobacilli. the effect of copper concentration and copper sources on populations of lactobacilli in gut content is shown in table . the population lactic acid bacteria (lab) in content from the gizzard was investigated in three experiments with broilers: ch (kim et al., ) , ch experiment and ch experiment (min et al., ) . no effect of either copper concentration or copper source was found (table ). the effect of copper on the population density of lactobacilli in si content was investigated in experiments with broilers and in experiments with layers. a significant reduction in the population of lactobacilli was found in study ch (choi et al., ) by addition of or mg/kg cu as cuso to the diet, while no effect was found by addition of mg/kg cu as cuso . no effect of the addition of mg/kg cu as cuso was found in studies ch (kim et al ) , ch (min et al., ) , ch experiments and (min et al., ) ; and of mg/kg cu as cuso in study ch (xia et al., ) . in the studies with layers (ch , kim et al., b ) the population of lactobacilli was significantly increased when the diet was supplemented with either or mg/kg cu as cuso . cu-methionat at a cu concentration of mg/kg cu had no effect on the population of lactobacilli (ch , min et al., ) while at cu concentrations of mg/kg, it had a significant stimulating effect on the population of lactobacilli in broiler si content (ch , kim et al., ) . only a tendency to an increase (ch ) was found when it was added to a diet at a concentration of mg/kg cu. in layers fed a diet supplemented with mg/kg cu as cu-methionate a significant increase in the population of lactobacilli was observed (ch , paik et al., ) , while at a concentration of mg/kg it resulted in a tendency to an increase (ch ). addition of cu-propionate corresponding to cu amount of mg/kg to broiler diets resulted in an increase in the population in study ch while no effect was seen in study ch (kim et al., a) . at an addition corresponding to a cu concentration of mg/kg no effect was found of cu-propionate on the population of lactobacilli. in layers addition of cu-propionate corresponding to an addition of mg/kg cu resulted either in a significant reduction in the population of lactobacilli (study ch ) or to a tendency to an increase (study ch ). both in study ch and ch , an increase was detected in the population of lactobacilli when layer diets were supplemented with ppm cu as cu-propionate. no effect on the population of lactobacilli in si content from broilers were found in study ch by addition of or mg/kg cu as cu- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. the population lactobacilli in content from the caecum of broilers was investigated in seven experiments (table ) : ch , ch experiment , ch experiment , ch , ch , ch and ch ). in experiment ch , no effects of supplementing feed with mg/kg cu as cuso were found on the population of lactobacilli in cecal content. the same was the case in study experiments and when feed was supplemented with mg/kg cu-starch, cu starch/met and cu-naalginate; in experiment ch , for supplementation with mg/kg cuso ; and in experiments ch and ch for supplementation with and mg/kg cu-montmorillonite. in study ch , addition of mg/kg cu as cu-montmorillonite-nanomaterial to broiler fed stimulated the population of lactobacilli in cecal content. the same was found in study ch when it was added at concentrations of mg/kg and mg/kg cu as cuso to broiler diets, while cu as cuso at a concentration of mg/kg resulted in a significant reduction in the population of lactobacilli. from the investigation of copper concentrations and sources on the population of lactobacilli in gastrointestinal content it may be concluded that copper concentrations at or below mg/kg seems to stimulate the population of lactobacilli in chicken gut content, while it does not seem to have any effect at concentrations from to mg/kg but has an inhibitory effect at concentrations above streptococci. the effect of copper on the population of streptococci was investigated in three experiments with broilers from two studies (ch and ch experiment and ). in study ch (choi et al., ) the population of streptococci were higher after week but lower after weeks in content from the si of broilers fed either , or mg/kg cu as cuso compared to the control fed birds, while no effect were seen of any of the cu concentrations after or weeks on the experimental diets. in study ch experiment (min et al., ) the effect of the addition of mg/kg cu as cuso , cu-starch or cu-starch/methionine to diets to broilers on the population of streptococci in content from the gizzard, upper and lower si and cecum was investigated. no effect of any of the added copper sources was found on the population of streptococci in any of the investigated git segments. in study ch experiment , the effect of the addition of mg/kg cu as cuso , a cu-starch /methionine complex, a cu-starch/methionine complex (added to a diet where the methionine was reduced with the amount of methionine added with the cu-starch/methionine complex) and a na-alginate cu complex to diets of broilers on the population of staphylococci in content from the gizzard, upper and lower si and cecum was investigated. no effect of any of the added copper sources was found on the population of streptococci in any of the investigated git segments. in general supplementing broiler diets with additional copper dose not seems to have any effect on the population of streptococci in the gastrointestinal tract. total aerobe bacteria. the effect of copper on the population of total anaerobic bacteria was investigated in three studies (ch , ch and ch ). no effect was found in study ch (ma et al., ) the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. the microbial community was investigated in two studies (ch and ch ). in both studies the microbial community was determined by isolating bacterial dna, amplifying the v region of the s ribosomal dna and performing denaturing gradient gel electrophoreses (dgge). in both studies the number of bands per sample and the similarity indices for bands between samples were calculated. the number of bands is indicative for the number of bacterial species within a sample whereas the similarity coefficients indicate how similar the bacteria within a treatment group are. in study ch (thompsen et al., ) broilers were fed either a control diet, the control diet supplemented with mg/kg bacitracin or the control diet supplemented with mg/kg cu as cuso from day to day . at day , six birds per treatment group were slaughtered and the bacterial community structure analysed in samples of ileal content and samples of ileal mucosa. amplicon profiles from the ileal content revealed that dietary treatment had no effect on band numbers or similarity coefficients. likewise, band numbers of the mucosa-associated bacteria were not affected by dietary treatments. the comparison similarity coefficients, however, revealed that the mucosa-associated bacterial communities of birds fed mg/kg cu as cuso had higher similarity indices than either the control or bacitracin fed broilers. the high similarity coefficient observed in birds fed copper might indicate that addition of high concentrations of copper may select for copper resistant bacteria. in study ch (pang et al., a) broilers were fed either a control diet, a diet supplemented with mg/kg cu as cuso or a diet supplemented with mg/kg cu as tribasic copper chloride (tbcc) from hatch to day . on day eight birds per treatment were slaughtered and the bacterial community structure analysed in samples of ileal content and samples of ileal mucosa. neither cu supplementation at . mg/kg nor cu sources affected the number of predominant bacterial species (dgge band number) in ileal content (mean = . ) or ileal mucosa (mean = . ). furthermore, neither cu supplementation at . mg/kg nor cu sources (cuso or tbcc) affected the similarity coefficient of the microbial community structure in ileal content. however supplementation of the diet with . mg/kg cu as tbcc increased the similarity coefficient of ileal mucosal bacteria, while supplementing the diet with . mg/kg cu as cuso did not affect the similarity coefficient of ileal mucosal bacteria. this shows that the mucosa associated microbiota was more similar between individual birds for the tbcc fed broilers, compared to the control and the cuso fed birds. in conclusion the effect of copper supplementation of broiler diets seems to have little effect on the community structure of the microbiota in the small intestine. no effect of supplementing broiler diets with either or mg/kg cu as cuso or mg/kg cu as tbcc were found on band numbers (number of bacterial species) neither in digesta samples nor in mucosal samples. moreover, no effect of copper www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. bbj supplementation was found on population similarity in digesta samples, while mg/kg cu as cuso affected the population similarity in mucosa samples in study ch but no effect of mg/kg cu as cuso was found on the population similarity in mucosal samples in study ch . in study ch , however, an effect of mg/kg cu as tbcc was found on the population similarity in mucosal samples. fecal moisture content. fecal moisture content was investigated in one study (ch , choi et al., ) . it was measured each week during the six weeks of the experiment. the moisture content was significantly higher at week in the chickens fed and mg/kg cu as cuso and numerically higher in the group fed mg/kg cu as cuso compared to the control group ( . , . , . and . % for the control group and the groups fed diets supplemented with , and mg/kg cu as cuso , respectively). no effect on the moisture content of any of the copper concentrations investigated was found from week to . ph. the effect of copper on ph of gastrointestinal or fecal content was investigated in five experiments with broilers (ch , ch , ch experiment , ch experiment and ch ). in study ch (aydin et al., ), no effect of mg/kg cu as cu-proteinate was found on ph of ileal content in broilers slaughtered at day . in study ch experiment (min et al., ) , the addition of mg/kg cu as either cuso , a cu-starch complex or a cu-starch/methionine complex to broiler diets had no effect on ph of content from gizzard, upper si, lower si or cecum taken from broilers slaughtered at day . in study ch (min et al., ) , supplementation of broiler diets with mg/kg cu as cuso , cu-methionine or cu-fish meal significantly reduced the ph in content from the gizzard ( . , . , . and . for the control group and the three cu supplemented groups, respectively) from broilers slaughtered at day . no effects of any of the copper sources were found on ph in content from the upper or lower si or the caecum. in study ch experiment (pang et al., ), supplementation of broiler diets with mg/kg cu as either cuso , a cu-starch /methionine complex, a cu-starch/methionine complex (added to a diet where the methionine was reduced with the amount of methionine added with the cu-starch/methionine complex) and a na-alginate cu complex significantly reduced the ph in content from the gizzard ( . , . , . , . , . for the control group and the four cu supplemented groups respectively) from broilers slaughtered at day . no effect of any of the copper sources was found on ph in content from the upper or lower si, while the cu starch complex and the na-alginate cu complex significantly reduced the ph in content from the caecum ( . , . and . for the control group and the two cu supplemented groups, respectively). in study ch (shao et al., ) , supplementation of broiler diets with mg/kg cu as cu silicate nanoparticles significantly reduce the ph of content from the caecum from birds slaughtered at day ( . and . for the control fed and the copper fed birds, respectively). no effect of copper supplementation were found on ph of caecal content from birds slaughtered at days or on ph of fecal samples taken throughout the experimental period of days. in conclusion the effect of supplementing broiler diets seems to reduce ph in gizzard content while the effect on the rest of the gastrointestinal tract seems to be marginal. ammonia emission. effect of copper on ammonia emission was investigated in study ch (shi et al., ) . supplementation of broiler diets with mg/kg cu as cu silicate nanoparticles significantly reduce the ammonia emission at day , , , , and to about half of the emission found for the control fed birds. gizzard erosion. the effect of copper on gizzard erosion was investigated in five experiments with broilers (ch , ch , ch , ch experiment , and ch experiment ). in study ch (choi et al., ) , gizzard erosion was investigated in broilers fed four different diets (a control and three diets supplemented with mg/kg, mg/kg and mg/kg cu as cuso ). gizzard erosion was measured in three birds per treatment after , and weeks on the experimental diet. gizzard erosion indices were scored from (normal) to (severe). the incidence of gizzard erosion increased as the level of copper in the diet increased and with time on the experimental diets. after weeks on the experimental diet the gizzard erosion indices were . , . , . and . for the birds fed the www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. bbj control diet and the birds fed , and mg/kg cu as cuso , respectively. in study ch (kim et al., ,) gizzard erosion was investigated in broilers in a x factorial experiment including levels of added fat ( % and %) and levels of added copper (no addition, mg/kg cu as cuso .h o and mg/kg cu as cuso . h o). again increasing gizzard erosion indices were evident in birds fed the copper supplemented diets; both in the birds fed the low and the high fat diet. in experiment ch (min et al., ) , gizzard erosion was investigated in birds fed a control diet and three diets supplemented with three different copper sources ( mg/kg cu as cuso , mg/kg cu as cu-methionine and mg/kg cu as cu-fish meal). gizzard erosion was measured as described for study ch in four birds per treatment after days on the experimental diets. again severe gizzard erosion was observed in the birds fed the copper supplemented diets ( . , . , . and . for the control fed birds and the birds fed mg/kg cu as cuso , cu-methionine and cu-fish meal, respectively). in study ch experiments and (min et al., ) , gizzard erosion was investigated for five sources of copper all added to the diets to increase the cu concentration with mg/kg. the five copper sources were cuso , a cu-starch complex, a cu-starch/methionine complex, a cumethionine complex and a na-alginate cu complex. regardless of copper sources, severe gizzard erosion was observed in all broilers fed copper supplemented diets in all four studies where it was investigated. in conclusion, supplementation of broiler diets with copper at concentrations above mg/kg strongly increases gizzard erosion. ammonia concentration. effect of copper on ammonia concentration in fecal samples was investigated in study ch (shi et al., ) . supplementation of broiler diets with mg/kg cu as cu silicate nanoparticles had no effect on ammonia concentration in fecal samples neither on day nor on day . microbial enzyme activity. the effect of copper on microbial enzyme activity of β-glycosidase and βglucuronidase has been investigated on two studies with broilers (ch and ch ). in study ch , broilers were fed a control diet and two experimental diets supplemented with either or mg/kg cu as cu-montmorillonite-nanomaterial (cu-mmn). the diets were fed to the broilers for days. eight birds from each treatment were slaughtered at day and day and the enzyme activity measured in content from the si and the caecum. the activities of β-glucosidase and β-glucuronidase in the small intestine of birds fed on the diet supplemented with both concentrations cu-mmn were significantly lower than the control, both for the birds slaughtered at day and for the birds slaughtered at day . similarly both enzyme activities were reduced in the cu-mmn fed birds compared to the control fed birds in caecal content at day but not at day . in study ch (xu et al., ) , broilers were fed a control diet and two experimental diets supplemented with either g/kg montomorillonite (mm) or g/kg cu-montomorillonite (cu-mm) (resulting in an addition of mg/kg cu to the feed). the diets were fed to the broilers for days. eight birds from each treatment were slaughtered at day and day and the enzyme activity measured in content from the si and the caecum. the activities of β-glucosidase and β-glucuronidase in the small intestine of birds fed on the diet supplemented with cu-mm were significantly lower than the control both for the birds slaughtered at day and for the birds slaughtered at day . β-glucosidase activities were reduced in the cu-mm fed birds compared to the control fed birds in caecal content at day but not at day . the caecal β-glucuronidase was not significantly affected by cu-mm. the enzyme activities in the mm fed birds were somehow between the control fed birds and the birds fed the copper enriched mm (cu-mm). clostridia: supplementing chicken (broilers and layers) diets with additional copper seems to reduce the population of clostridia in the gastrointestinal tract of the birds, even at low concentrations of copper. especially clay bound copper seems to be effective in reducing the population of clostridia. the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. coliform bacteria: in general the effect of copper on the gastrointestinal populations of coliform bacteria seems to be rather weak; in most cases where an effect was seen, the concentrations was higher than mg/kg cu, the explanation may be copper bound clay particles, especially copper bound nanoparticles seem to have an effect at concentrations below mg/kg cu (ch and ch ). that high concentrations of copper may reduce the population of coliform bacteria in gut content from chickens is in agreement with the ex vivo experiment studies (ch and ch ) that show that cu as cuso inhibit the growth of coliform bacteria at a concentration of mg/kg cu but not at a concentration of mg/kg cu. lactobacilli: from the investigation of copper concentrations and sources on the population of lactobacilli in gastrointestinal content it may be concluded that copper concentrations at or below mg/kg seem to stimulate the population of lactobacilli in chicken gut content, while it does not seem to have any effect at concentrations from to mg/kg but has an inhibitory effect at concentrations above mg/kg. in agreement with that, the ex vivo experiments (ch and ) show that mg/kg cu as cuso stimulated the growth of lactobacilli in broiler si content. however no inhibitory effect on the growth was seen by a copper concentration of mg/kg cuso . that no effect of tribasic copper chloride (tbcc) was seen in the ex vivo experiment is properly due to the low solubility of tbcc in water (ch ). streptococci. supplementing broiler diets with additional copper does not seem to have any effect on the population of streptococci in the gastrointestinal tract. aerobe bacteria: only three studies could be found and copper supplementation showed no effect (the effect in study ch may be an effect of the nanoparticles rather than an effect of copper). total anaerobe bacteria: copper supplementation had no effect in most studies (only in one study with high copper concentration). ex vivo studies. mg/kg cu as cuso inhibit the growth of coliform bacteria in chicken si content. no effect of mg/kg cuso on growth of lactobacilli. no effect on growth of either coliform bacteria or lactobacilli by tbcc (properly due to low water solubility). ph. supplementing broiler diets with copper seems to reduce ph in gizzard content while the effect on the rest of the gastrointestinal tract seems to be marginal. community structure. the effect of copper supplementation of broiler diets seems to have little effect on the community structure of the microbiota in the small intestine. neither cu supplementation at . mg/kg or mg/kg nor cu sources (cuso or tbcc) affected the number of predominant bacterial species (dgge band number) in ileal content or ileal mucosa or affected the similarity coefficient of the microbial community structure in ileal content. in study ch , it was found that supplementation of the diet with . mg/kg cu as tbcc increase the similarity coefficient of ileal mucosal bacteria while supplementing the diet with . mg/kg cu as cuso had no effect. in contrast to that, it was found in study ch that supplementing broiler diets with mg/kg cu as cuso increase the similarity coefficient of the mucosa associated microbiota. gizzard erosion. supplementation of broiler diets with copper at concentrations above mg/kg strongly increase gizzard erosion. of the references found for cows by the literature search, were in the first phase considered appropriate to be included in the els. however, a closer examination of the five studies revealed the papers not to be appropriate to be included in the els. one of the studies was published in polish, two of the studies were dealing with antibiotic resistance, one was dealing with the effect of copper on parasite control and the last one on the effect of copper on abomasal ulcers. the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. of the references found for pigs and piglet by the literature search, were considered appropriate to be included in the els. in total different characteristics related to the gastrointestinal microbiota were investigated in the selected studies. the number of characteristics investigated in the individual studies varied from to . the number of studies in which each characteristic was studied varied from to . the characteristic studied could be divided in themes: plate count of bacteria ( studies), qpcr of bacterial populations ( study), microscopic counts of bacteria ( study), community structure analyses ( studies), gut content characteristics ( studies), microbial metabolites ( studies), microbial activity ( studies) and studies in germ free pigs ( study). the copper concentrations used in the studies varied from . to mg/kg feed. four types of copper sources were used in the studies: inorganic bound copper ( studies at concentrations from - mg/kg feed), organic bound copper ( studies at concentrations from - mg/kg feed), copper bound to clay minerals ( studies at concentrations from - mg/kg feed) and copper-loaded nanoparticles ( study at a concentration of . mg/kg). it may be concluded from the experiments that supplementing pig diets with low additional copper amounts (below mg/kg cu) seems to inhibit the population of coliform bacteria in the gastrointestinal tract of as well piglets as growing pigs. in particular, clay bound copper seems to be effective. when supplemented to the feed in amounts above mg/kg copper, the effect on the population of coliform bacteria in the gastrointestinal tract of piglets as well as pigs was marginal. supplementing pig diets with copper concentrations above mg/kg as cuso has a reducing effect on the population of lactobacilli in the gastrointestinal tract of as well piglets as growing pigs. the effect of cu as cuo did not affect the population of lactobacilli at high concentrations ( and mg/kg feed). diets with copper concentration below mg/kg feed seem to have marginal effect on the population of lactobacilli in the gastrointestinal tract both in piglets and in growing pigs. the results with growing pigs strongly indicate that the addition of mg cu/kg, or higher, as cuso significantly reduces the population of streptococci in the gastrointestinal tract of growing pigs. the effect of cuso on the population of streptococci in piglets is more questionable. community structure studies strongly suggest that supplementing piglet diets with to mg/kg cu as cuso affects the community structure of the microbiota in the small intestine, the caecum and the colon. the overall conclusion from the studies with piglets and growing pig is that copper, even at low concentrations (< mg/kg feed), may affect the microbiota in the gastrointestinal tract. especially the population of clostridia and coliform bacteria seems to be affected of low concentrations of copper, and especially copper bound clay minerals seem to have an effect. at higher concentrations (> mg/kg feed) cu as cuso reduces the population of lactobacilli in piglets as well as in growing pigs. in growing pigs cuso reduces the population of streptococci in colonic and fecal samples, the population of ureolytic bacteria in the colon of which streptococci make up %, the urease activity in the colon, and decarboxylation and deamination of amino acids in the small intestine. no effect of cu as cuso on the population of streptococci and on urease activity was seen in piglets. supplementing piglet diets with to mg/kg cu as cuso significantly affected the community structure of the microbiota in the small intestine, the caecum and the colon. www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. of the references found for chickens by the literature search, were considered appropriate to be included in the els. in total different characteristics related to the gastrointestinal microbiota were investigated in the selected studies. the number of characteristics investigated in the individual studies varied from to . the number of studies in which each characteristic was studied varied from to . the characteristic studied could be divided in themes: plate count of bacteria ( studies), community structure analyses ( studies), gut content characteristics ( studies), microbial metabolites ( study) and microbial activity ( studies). the copper concentrations used in the studies varied from to mg/kg feed. four types of copper sources were used in the studies: inorganic bound copper ( studies at concentrations from - mg/kg feed), organic bound copper ( studies at concentrations from - mg/kg feed), copper bound to clay minerals ( studies at concentrations from - mg/kg feed) and copper-loaded nanoparticles ( study at a concentration from - mg/kg). from the plate count investigations of bacterial population it can be concluded that supplementing chicken (broilers and layers) diets with additional copper seems to reduce the population of clostridia in the gastrointestinal tract of the birds, even at low concentrations of copper. especially clay bound copper seems to be effective in reducing the population of clostridia. in general the effect of copper on the gastrointestinal populations of coliform bacteria seems to be rather week, in most cases where an effect were seen the concentrations was higher than mg/kg cu, the exception may be copper bound clay particles, especially copper bound nanoparticles seems to have an effect at concentrations below mg/kg cu. that high concentrations of copper may reduce the population of coliform bacteria in gut content from chickens is in agreement with the ex vivo experiment studies that show that cu as cuso inhibits the growth of coliform bacteria at a concentration of mg/kg cu but not at a concentration of mg/kg cu. from the investigation of copper concentrations and sources on the population of lactobacilli in gastrointestinal content it may be concluded that copper concentrations at or below mg/kg seems to stimulate the population of lactobacilli in chicken gut content, while it does not seem to have any effect at concentrations from to mg/kg. however, it has an inhibitory effect at concentrations above mg/kg. in agreement with that, the ex vivo experiments show that mg/kg cu as cuso stimulated the growth of lactobacilli in broiler si content. however, no inhibitory effect on the growth was seen by a copper concentration of mg/kg cuso . in conclusion the effect of supplementing broiler diets with copper at concentrations of mg/kg either as inorganic or organic bound copper seems to reduce ph in gizzard content while the effect in the rest of the gastrointestinal tract seems to be marginal. in conclusion the effect of copper supplementation of broiler diets seems to have little effect on the community structure of the microbiota in the small intestine. neither cu supplementation at . mg/kg or mg/kg nor cu sources (cuso or tbcc) affected the number of predominant bacterial species (dgge band number) in ileal content or ileal mucosa or affected the similarity coefficient of the microbial community structure in ileal content. in study ch , it was found that supplementation of the diet with mg/kg cu as tbcc increase the similarity coefficient of ileal mucosal bacteria while supplementing the diet with mg/kg cu as cuso had no effect. in contrast to that, it was found in study ch that supplementing broiler diets with mg/kg cu as cuso increase the similarity coefficient of the mucosa associated microbiota. supplementation of broiler diets with copper at concentrations above mg/kg strongly increases gizzard erosion. the overall conclusion from the studies with broilers is that copper even at low concentrations (< mg/kg feed) may affect the microbiota in the gastrointestinal tract. especially the population of clostridia seems to be affected by low concentrations of copper. in particular, copper bound clay minerals seem to have an effect. at higher concentrations (> mg/kg feed) inorganic or organic effect of copper intake on gut microbiota (pigs/piglets, chickens, dairy cows) www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. bbj bound copper also seems to affect the population of lactobacilli, and coliform bacteria, to reduce the ph in gizzard content and to produce severe gizzard erosion. of the references found for cows by the literature search, were in the first phase considered appropriate to be included in the els. however, a closer examination of the five studies revealed the papers not to be appropriate to be included in the els. one of the studies was published in polish, two of the studies were dealing with antibiotic resistance, one was dealing with the effect of copper on parasite control and the last one on the effect of copper on abomasal ulcers. while implementing this extensive literature search some suggestions and remarks were raised:  the quality of the papers retrieved from the search on chickens was generally judged to be low. out of papers were written in foreign languages ( in korean and in chinese) with english abstracts and table legends .  a closer examination of the five studies first selected to be included in the els study on cows, revealed the papers not to be appropriate to be included in the els. one of the studies (cow ) was published in polish, two of the studies were dealing with antibiotic resistance (cow and cow ), one was dealing with the effect of copper on parasite control (cow ) and the last one on the effect of copper on abomasa ulcers (cow ). www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. schole j, szasz e, peters j, eikemeyer j and sickel e, . the total anabolic activity of the blood as a connecting link between the intestinal-flora theory and the intermediary action of growth the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. new bacterium comprising lactic acid bacterium and bacterium of genus bifidobacterium comprising metal nanoparticle bound to its surface, useful e.g. as contrast agent for mri of digestive tract of subject, and for treating cancer contribution to the study of gut hypersensitivity reactions to soybean proteins in preruminant calves and early-weaned piglets ddesaturation of organ lipids and tissue-lipids and influence on depot triglyceride structure by feeding high levels of different copper-compounds composite preblend material for pig capable of improving immunologic function includes ferrous sulfate, copper sulfate, zinc sulfate, manganese sulfate, composite microbial ecological agent, ethoxyquinoline, choline chloride and bran nutritional alternatives for antimicrobial control in pigs scientific opinion on the safety and efficacy of copper compounds (e ) as feed additives for all animal species: cupric sulphate pentahydrate based on a dossier submitted by manica s swine. proceedings of the rd western nutrition conference, optimizing efficiency of animal production how to avoid making mistakes when choosing alternatives to feed antibiotics. svinovodstvo (moskva) silver nanoparticles as a potential antimicrobial additive for weaned pigs utilization of fermented flocculated poultry sludge as a feed constituent for pigs nutritional compound additive alleviates jejunal mucosal structure disruption of piglets challenged with feed containing corn contaminated with mycotoxins this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document antibacterial effects of the cu(ii)-exchanged montmorillonite on escherichia coli k and salmonella choleraesuis antibacterial effects of the cu(ii)-loaded montmorillonite in vitro and its on mechanisms effect of supplementing tylosin and olaquindox or copper on growth, tissue mineral contents and enteric bacteria counts of weanling pigs bacterial resistance to copper in animal feeds feed without antibiotic by microbial fermentation for later period of growing/fattening pigs comprises batch mixture and compound fermented material e.g. lactobacillus acidophilus, aspergillus niger in specific weight ratio microbially fermented piglet early growth feed without antibiotic comprises e.g. bacillus subtilis, aspergillus based fermentation material and composite material action of antimicrobial agents on intestinal bacteria of pigs in vitro gastrointestinal health and function in weaned pigs: a review of feeding strategies to control post-weaning diarrhoea without using in-feed antimicrobial compounds antimicrobial use in 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microbial feed additive for reducing stress of piglet involves preparing culture medium of specified ph, culturing strain to specified bacterial impact of exocrine pancreas on digestion in pigs protective efficacy of azomite enriched diet in oreochromis mossambicus against aeromonas hydrophila effect of pharmacological intakes of zinc and copper on growth performance, circulating cytokines and gut microflora of newly weaned piglets challenged with coliform lipopolysaccharides lysozyme as an alternative to antibiotics improves growth performance and small intestinal morphology in nursery pigs influence of diet on microbial community structure and activity in the intestinal tract of weanling pigs impact of the diet on digestive disorders of pigs, with special emphasis on proliferative enteropathy and swine dysentery gut health in the pig the effect of including additives in feeds for pigs on the appearance of resistance in e-coli prevalence of strains with multiple resistance to 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broiler chickens probiotics preventive nutrition in chicken intensive production practices. lucrai stiinifice -medicina veterinara, universitatea de stiinte agricole si medicina veterinara "ion ionescu de la brad dietary role of phytase to improve minerals bioavailability for bone conformation characterisation and histopathological observations of a selected brazilian precocious line of eimeria acervulina apparent total tract macronutrient and energy digestibility of -to- -day-old whole chicks, adult ground chicken, and extruded and canned chicken-based diets in african wildcats (felis silvestris lybica) effects of dietary supplementation of copper-sulfate and copper-soy proteinate on the performance and small intestinal microflora in laying hens effects of supplemental coppermethionine chelate and copper-soy proteinate on the performance, blood parameters, liver mineral content, and intestinal microflora of broiler chickens effects of interaction of copper sulfates and dietary fat on 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substances of trace elements, vitamins, synthetic amino acids antibiotic growth promoters enhance animal production by targeting intestinal bile salt hydrolase and its producers three stages ecological feed, useful for broilers, comprises fish powder, composite premix, corn and soybean oil and rest of vegetables, where the compound premix comprises microelement premix and feed additive effects of dietary supplementation of quercetin on performance, egg quality, cecal microflora populations, and antioxidant status in laying hens effect of phytate and phytase on the ileal flows of endogenous minerals and amino acids for growing broiler chickens fed purified diets comparative study of the cellular immune response of chickens and turkeys vaccinated with fowl cholera vaccine the effect of administering glycolytic enzymes associated with fatty acids in feed for meat-type fowls. agricultura -revista de stiinta si copper promotes tff -mediated helicobacter pylori colonization performance of 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preliminary results praseodymium and copper cation-exchange capacities of neutral-detergent fibers relative to composition and fermentation kinetics this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author purification and characterization of bacterial cm-cellulase from camel rumen fluid ( camelus dromedarius) studies on the mechanism of toxicity of the mycotoxin sporidesmin . . inhibition by copper-chelating agents of the generation of superoxide radical by sporidesmin protective efficacy of azomite enriched diet in oreochromis mossambicus against aeromonas hydrophila the diagnosis of adult bovine diarrhea -trial to put forward a new technique acute sheep poisoning from a copper sulfate footbath combined control of the principal diseases of sheep in the spring khimioprofilaktika, patogenez i epizootologiya parazitozov sel'skokhozyaistvennykh zhivotnykh phosphorus digestion and metabolism in ruminants: applications to production disease and environmental considerations. production diseses in farm animals th international conferences east lansing copper deficiency in an infant with giardiasis fed with cows milk biogenic amines in animal nutrition: origin, metabolism and physiological aspects uses of plants, animal and mineral substances in mediterranean ethno-veterinary practices for the care of small ruminants prevalence of strains with multiple resistance to antibiotics, and the transferability in vitro of the r factor of strains of escherichia coli and salmonella of various origins. lucrari stiintifice, institutul agronomic isolation of clostridiumperfringens from neonatal calves with ruminal and abomasal tympany, abomasitis, and abomasal ulceration annual report of studies in animal nutrition and allied sciences annual report of studies in animal nutrition and allied sciences. volume parasitic coenoses in the intestine of sheep and their control. ussr, akademiya nauk ukrainskoi ssr, institut zoologii the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. the present document has been produced and adopted by the bodies identified above as author. this task has been carried out exclusively by the author in the context of a contract between the european food safety authority and the author, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author. key: cord- -p sq yg authors: bales, connie watkins; tumosa, nina title: minimizing the impact of complex emergencies on nutrition and geriatric health: planning for prevention is key date: - - journal: handbook of clinical nutrition and aging doi: . / - - - - _ sha: doc_id: cord_uid: p sq yg complex emergencies (ces) can occur anywhere and are defined as crisis situations that greatly elevate the risk to nutrition and overall health (morbidity and mortality) of older individuals in the affected area. in urban areas with high population densities and heavy reliance on power-driven devices for day-to-day survival, ces can precipitate a rapid deterioration of basic services that threatens nutritionally and medically vulnerable older adults. the major underlying threats to nutritional status for older adults during ces are food insecurity, inadequate social support, and lack of access to health services. the most effective strategy for coping with ces is to have detailed, individualized pre-event preparations. when a ce occurs, the immediate relief efforts focus on establishing access to food, safe water, and essential medical services. the most common issues impacting on the nutritional well-being of elderly persons are comprehensively addressed in the preceeding chapters of this edition of the handbook of clinical nutrition and aging. this chapter focuses on a different type of concern, one that can overshadow all other threats to health when a serious disaster strikes. that subject is the welfare of aged persons when catastrophic events pose a direct (or indirect) threat to nutrition and health ( , ) . while there is a large body of literature on the health impact of natural and man-made disasters (e.g., droughts, floods, military conflicts) and associated long-term food shortages in the third world, surprisingly little information is available about the short and intermediate-term consequences of emergency situations in developed countries. in these situations, high population densities and heavy reliance on power-driven devices for day-to-day survival (e.g., electrical power for mass transit, elevators to reach living quarters, medical devices, and refrigeration of foods and medicines) can accelerate the speed with which a catastrophic, health-threatening situation develops. in , the plight of the elderly evacuees from new orleans (pre-storm population approaching , ) following hurricane katrina provided a dramatic demonstration of how essential services can rapidly deteriorate in a well-developed, highly populated urban environment following a major disaster and place older individuals in eminent mortal danger. in order to lay the foundation for this discussion, we begin with some definitions (see table . ). while terms like ''disaster relief'' and ''humanitarian crisis'' may be any of a number of crisis situations that greatly elevate the health risk of individuals in the affected area; examples are natural disasters like floods and earthquakes; urban health emergencies like fires, epidemics, and blackouts; and terrorist acts like massive bombings or poisonings of food or water supplies. resolution of these emergencies requires collaboration between multiple groups. acute protein/calorie malnutrition (pcm) pcm or ''wasting'' is associated with recent rapid weight loss, i.e., as in emergency situations (as opposed to chronic malnutrition). chronic energy deficiency (ced) an intake of energy that is below the minimum requirement for a period of several months or years. in order to achieve energy steady state, the energy expenditure must drop to match the low intake, ultimately leading to underweight and low levels of physical activity. nutritional rehabilitation restoration of weight and healthy nutrition through the provision of appropriate foods based on established protocols. food rations a shelf-stable pre-packaged dry ration that meets minimum daily intake recommendations for calories and other nutrients. used to temporarily meet critical nutritional needs when food supply is inadequate. examples: meals ready to eat or mres ( , kcal) are often distributed in complex emergencies in the united states; general food rations or gfrs ( , kcal) are distributed in many countries in sub-saharan africa. (continued ) more familiar, the most broadly acceptable term for these threatening situations is ''complex emergency'' ( ) . complex emergencies (ces) can occur anywhere and are defined as any of a number of crisis situations that greatly elevate the risk to nutrition and overall health of individuals in the affected area. examples include natural disasters like floods and earthquakes, urban health emergencies like fires, epidemics and blackouts, and terrorist acts like massive bombings or poisonings of food or water supplies (see table . ). ces were originally associated with wars, genocide, and political strife, where innocent civilians were forced to endure loss of access to shelter, food, appropriate clothing, and timely medical care. such emergencies have traditionally been associated with populations in developing nations, not those in the so-called developed countries. however, with increasing a complementary ration to the general food ration is sometimes provided. typically, it consists of fresh fruit and vegetables, condiments, tea, etc. it is especially appropriate when the population of concern is completely reliant on food assistance. ''wet'' feeding food rations prepared and cooked on-site as opposed to rations that are taken home for preparation in the household (dry rations). typically, fortified foods have had supplemental vitamins and/or minerals added. hunger the uneasy or painful sensation caused by lack of food. malnutrition the medical condition caused by an improper or insufficient diet that can refer to undernutrition resulting from inadequate consumption, poor absorption, or excessive loss of nutrients. malnutrition results from an inappropriate amount or quality of nutrient intake over a long period of time. the inability to obtain nutritionally adequate and safe food; or the inability to obtain it in socially acceptable ways food insufficiency inadequate amount of food intake due to a lack of food. epidemics and pandemics an epidemic is a disease outbreak that affects numbers of the population in excess of what would normally be expected in a defined community, geographical area, or season. a pandemic refers to this type of disease outbreak that is occurring over a wide geographic area and affecting an exceptionally high proportion of the population. source: borrel, a. addressing the nutritional needs of older people in emergency situations in africa: ideas for action. helpage international africa regional development centre, westlands, nairobi, . globalization of the world's societies and economies and news coverage documenting world events, it has become clear that ces can and do occur in both developed and developing world locations. nutritional risk is commonly elevated in ces and is most likely to occur when the crisis is protracted or recurrent. table . includes definitions for factors related to inadequate food intake (e.g., food insecurity, hunger), the resulting nutritional problems (e.g., malnutrition, acute protein/calorie malnutrition), and terms used to discuss interventions for undernutrition (e.g., food rations, nutritional rehabilitation). even in the absence of a crisis, older persons are well recognized to be at greater risk than the remainder of the adult population for food insecurity and hunger. some of the many factors that contribute to increased nutritional vulnerability of older adults are listed in table . . in , food insecurity and hunger affected at least . million households in the united states that contained older members ( ) . people in % of those households also experienced hunger, in addition to food insecurity. most of these older persons are suffering from food insecurity due to lack of income or due to their place of residence. residents of the south are more apt to experience food insecurity, as are residents of cities and all elders who live alone ( ). recognizing the day-to-day nutritional vulnerability of its poor and elderly citizens, the u.s. government has a number of programs in place to provide assistance to elders at risk for food insecurity and hunger. mandated by the older american's act, the elderly nutrition program (enp) provides a minimum of onethird of the daily calories required by recipients through daily meals and nutrition services to people aged or older in group settings, such as senior centers and churches, or in the home, through home-delivered meals. the enp provides an average of million meals per day to older americans. these meals are targeted toward highly vulnerable elderly populations, including the very old, people living alone, people below or near the poverty line, minority populations, and individuals with significant health conditions or physical or mental impairments. on an average the meals generously meet the rda requirements, supplying more than % of the recommended dietary allowances (rdas) for key nutrients, thus significantly increasing the dietary intakes of enp participants. the meals are also ''nutrient dense'', that is, they provide high ratios of key nutrients per calories. the most recent evaluation of the enp program occurred in and was conducted by mathematica policy research, inc. (www.mathematica-mpr.com/nutrition/ enp.asp). the resulting report clearly confirms that the enp program recipients are at nutritional risk. it was found that between and % of participants had incomes below % of the poverty level (twice the rate for the overall elderly population in the united states). more than twice as many title iii participants lived alone, compared with the overall elderly population. approximately, twothirds of the participants were either overweight or underweight, placing them at increased risk for nutrition and health problems. title iii home-delivered participants had more than twice as many physical impairments, compared with the overall elderly population. although (and perhaps because) the success of the enp program is well recognized, % of title iii enp service providers have waiting lists for home-delivered meals, suggesting a significant unmet need for these meals. it would appear that even in times of relative calm and prosperity for most americans, there are elderly citizens who are persistently in a state of nutritional crisis. when nutritionally and medically vulnerable older persons encounter a complex emergency, there is an increase in morbidity and mortality rates. this is due to both short-term insufficient nutrition and the resulting long-term increased mental stress and disability, decreased resistance to infection, and exacerbation of chronic diseases ( ), all of which make obtaining proper nutrition more difficult in a cyclic pattern. many different types of ces produce similar challenges. the consequences of a shortage of edible food and/or potable water, regardless of the type of emergency that produced that shortage, are multifold and can lead to increased physical and mental harm to older people ( ) . reduced access to essential medical care heightens the immediate risk. a more extensive listing of the immediate impact of various complex emergencies and the resulting nutritional and health consequences is shown in table . . the likelihood of having to provide care for older persons during a ce is greater than one might think at first. as previously noted, table . provides a list of common ces that have the potential to cause nutrition-related health risks. the impact of these crises on the nutritional state and overall health of older adults is discussed in more detail in the following sections. the hurricane season in the united states, most notably hurricanes rita and katrina, left no doubt that older persons continue to be disproportionately affected by hurricanes ( , ) just as they were with hurricane andrew in ( ). older floridians who were affected by hurricane charley in found that the hurricane not only disrupted their quality of life but also disrupted their medical care ( ) . persons with pre-existing conditions such as diabetes mellitus, heart disease, and physical disabilities were especially affected. approximately onethird of the older residents in the area had a worsening of their conditions posthurricane, including a lack of access to prescription medicine and loss of routine medical care for pre-existing conditions. medically related deaths were linked to the loss of power (resulting in loss of access to oxygen) and to exacerbation of cardiac disease. hurricane iniki in hawaii and the great hanshin-awaji earthquake in japan were associated with an increase in the rate of diabetes mellitus-associated deaths for a year following the disaster ( , ) . in a study of residents in the high-impact area of hurricane andrew, one-third of persons had high levels of ptsd ( ) , which was attributed to variables such as property damage, exposure to life-threatening situations, and injury. tornadoes, while typically more limited in the size of the area affected than a hurricane, are often even more physically destructive. although no research has been published on their specific effects on physical and mental health, it is well recognized that tornadoes can lead to many of the same dangers noted for hurricanes; the disruption of home care services and meal delivery to homebound elderly persons are of concern. the situation can become life threatening not only to the older persons who are critically dependent on these services but also to their dedicated care providers who often risk much to ensure the delivery of food and medical care to their clients (personal communication from area agency on aging of southwestern illinois grantees to nt). floods are a relatively common disaster and are often associated with earthquakes or hurricanes. besides trauma and drowning, the most common conditions associated with floods are an increase in gastrointestinal symptoms. increased preventable conditions following the crisis include gastroenteritis ( ), acute respiratory infections including asthma ( ), and increased post-traumatic stress which can persist for years after the event ( ). in the aftermath of an earthquake, as with the other natural disasters already mentioned, access to basic life-sustaining nutrients and hydration as well as to basic and specialized medical care may be partially or completely disrupted. due to the magnitude and scope of the destruction that occur with a major earthquake, the restoration of infrastructure to fully support the inhabitants of the region may take months or even years to be accomplished. earthquakes result in a three-fold increase in deaths from myocardial infarction, a doubling of the frequency of strokes, increased blood pressure levels, and increased coagulability of blood ( , ) . increased rates of cardiac arrests occurring after loss of power ( ) and deaths due to increased incidence of coronary heart disease ( ) and myocardial infarctions ( , ) are also reported. deterioration of mental health occurs and post-traumatic stress is also prevalent ( , ) . emotional stress can persist for months ( , ) . in particular, the displacement of elderly persons from their places of residence and their social and medical supports can have a dramatic negative effect on health and quality of life (see fig. . ). displacement following a ce has been linked with a significant increase in mortality rates ( , ) . the confusion of the displacement, as well as loss of access to appropriate diet and medications, prevents older individuals from monitoring and treating their medical conditions. inappropriate diet has been directly linked to decreased glycemic control and increased mortality in diabetic patients following an earthquake ( ). the type of naturally occurring ce that is most threatening for older persons in terms of numbers affected each year comes during periods of temperature extremes, especially heat waves, claiming about lives annually in the united states alone, more than the deaths caused by all other disasters combined. at greatest risk are poor persons who live in inner cities, those with chronic illnesses, and those homebound. heat disasters are often aggravated by power outages, which prevent people from keeping cool, bathing properly, and storing food at proper temperatures ( ) . in the heat wave in philadelphia, there was a % increase in total mortality, with a % increase in cardiovascular deaths, particularly in those persons over years of age ( ) . in france, during the period - , there were six major heat waves, resulting in thousands of deaths; the mortality ratios increased with age after years and in the over age years cohort; the death rate was higher for women than for men ( ) . although little research has been published about the health effects of ice storms and blizzards, the loss of power leaves older persons stranded at home, increasing the risk for ingestion of inadequate calories and inappropriately prepared food and/ or spoiled food. the risk of exposure combined with the risk of house fires or carbon monoxide poisoning due to use of unsafe heating devices pose serious threats at a time when emergency services may not available due to the extreme weather conditions. fires increase the extent of cardio-respiratory problems, which results in exacerbation of chronic diseases ( ) . people who already suffer from mental health problems or medically unexplained physical symptoms ( ) and gastrointestinal morbidity ( ) can develop an exacerbation of these problems ( , ) once they become a victim of a fire. even when no injuries result, fires almost certainly force displacement of their victims, adversely affecting quality of life and manifestation of chronic diseases. a serious infectious global pandemic is one of the most threatening of all complex emergencies, and calls back memories of the most devastating infectious disease outbreak on record, the great flu epidemic of - , which killed an estimated - million people worldwide. the spread of this epidemic was linked to the trans-global transportation of soldiers during world war i. today, world travel and the importation of foods and other products are very common. thus, in the event of a serious epidemic in one country, there is a high likelihood of quick transmission to others. the outbreak of sars, a severe acute respiratory illness caused by a coronavirus, was first reported in asia in february and spread to more than two dozen countries in north america, south america, europe, and asia (sickening , and killing ) before the global outbreak was contained (http://www.cdc.gov/ncidod/sars/factsheet.htm). in recognition of the severe strain that a major disease outbreak can place on health systems, the world health organization (who) advocates for an ''integrated global alert and response system for epidemics and other public health emergencies'' that allows for ''a collective approach to the prevention, detection, and timely response'' for these emergencies (http://www.who.int/csr/en/). the who is currently coordinating the global response to human cases of h n avian influenza (bird flu) with regards to the threat of a future influenza pandemic. a widespread illness or intoxication from a food source could also threaten nutritional and overall health. while these outbreaks are typically limited in scope and short lived, the potential for more widespread and dangerous effects exists due to the centralized nature of the us food distribution chain and the clustering of very large populations into a small geographical area. (see more on this topic in section . . . .) while other complex emergencies produce far more damage and deaths each year than are caused by terrorism, the destruction of the twin towers in new york city and a portion of the pentagon in washington dc on september , , focused the attention of americans upon the potentially devastating effects of an intentional man-made disaster. the development of the department of homeland security was a tangible product of the national response to implied threats of bio-terrorism. a terrorist attack such as one causing explosions and collapse of buildings would result in the interruption of basic living functions in a manner similar to previously discussed emergencies like earthquakes, tornadoes, or fires. disruptions to necessities of daily living and loss of power and access to medical care would be major concerns. a bioterrorist attack would have very different potential consequences for the well-being of the elderly, potentially causing widespread illness and/or hunger and dehydration. the propagation of an illness over a wide geographical area could be lethal for a substantial number of older adults, who are typically among the most medically vulnerable. during the anthrax attacks in , all emergent cases involved adults over years old, with the one fatal case affecting a -year-old woman ( ) . intentional contamination of food or water supplies with a toxin or infectious agent also has the potential to cause an outbreak of poisonings or illness over a wide geographical area. in this situation, the outbreak could be slow and/or diffuse and the cause difficult to ascertain, delaying the recognition and treatment of the problem. for example, in , bagged spinach contaminated (unintentionally) by escherichia coli infected over americans (killing three) in states before the strain was isolated and eradicated. similarly, intentional waterborne diseases or toxins would be difficult to detect and could impact a vulnerable population more severely than a healthy population, due to delayed recognition and reporting of the contamination ( ). in the case of deliberate food/water contamination, nutritional health is affected directly (by reducing the availability of safe food and water) as well as indirectly (by the symptoms of illness and the reduced access to an over-burdened medical care system). in fact, the deliberate poisoning of food has already occurred in the united states, when in members of the rajneesh religious cult contaminated salad bars in the dalles, oregon, with salmonella typhimurium. though it was only a trial run for a more extensive attack that was planned to disrupt local elections later that year, the contamination caused people to develop salmonellosis in a -week period. other isolated examples of intentional food contaminations have also been reported in the united states and canada ( ) . coping with complex emergencies due to terrorism is for the most part a new challenge, at least in the united states. despite considerable effort to prepare for these scenarios, our experience in dealing with the aftermath is limited, yet, unfortunately, our experience is likely to grow in the future. experts warn that a major terrorist attack on the united states is very likely ( - %) to occur within the next years (cfr online debate). heat, cold, hurricanes, tornadoes, floods, fires, illness, terrorism, and other disasters endanger health and claim elderly lives. sometimes the effects are immediate, but more often an increase in morbidity and mortality occurs progressively after the disaster as survivors experience a continued decrease in the quality of life and increased nutritional risk due to displacement and a loss of basic resources. these events result in increased disability, which further impairs the ability of older persons to maintain access to safe food and water and sustain proper nutrition and hydration, and so the spiral continues downward. recovery from food insecurity and poor nutrition is more difficult for persons who are poor, socially isolated, cognitively impaired, and/or old. the more risk factors people possess, the faster their decline. all of the disasters described in this chapter threaten nutritional and metabolic health because they disrupt access to food, water, and vital medical treatment ( ) . older persons with pre-existing chronic conditions are particularly vulnerable to these disruptions. preparation for and resolution of the aftermath of these emergencies require collaboration between multiple stakeholders and takes time. there are no easy fixes to ces. the underlying causes of malnutrition in older adults during ces are ( ) insufficient household food security, ( ) inadequate social and care environments, and ( ) poor public health and inadequate health services ( ) . the basis for current governmental and humanitarian responses to nutritional crises builds on lessons learned in the earliest organized relief efforts (circa - ) . during the s, guidelines began to be published following experiences with relief efforts in places like biafra and ethiopia ( ). in the subsequent decades, the experiences of various crises have progressively shaped what are, today, the characteristic challenges, and avenues of support available to older adults who are caught in ce situations in any given country. with increasing recognition that the elderly are uniquely vulnerable to ces, efforts are underway to develop specific recommendations and resources for this population group. table . lists some of the resources available, along with web links. helpage international (www.helpage.org) is a global network of more than not-for-profit organizations in countries who are working for improvements in the lives of older people. this group has published a manual of guidelines for best practice during disasters and humanitarian crises (see table . ). the sphere project minimum standards in disaster response project (http://www. sphereproject.org/content/view/ / ) advocates for the use of community-based systems to implement the care of older individuals in these circumstances. in the united states, a number of national organizations, including the federal emergency management agency (fema), the american red cross, and various branches of the military take responsibility for rescue and relief efforts following a major ce but the contribution of the private sector to the relief effort is traditionally also a substantial one. this type of broad-based support is necessary but makes it more difficult to consistently implement age-related guidelines for relief efforts once they are in the field. coordinating the advance preparation efforts for ces, however, is a more tangible goal. as is true for almost all health issues, the best way to address the nutritional and related health risks that accompany ces is to take preventive measures. in the case of nursing homes and assisted living facilities, many states require that these institutions have a substantial reserve food and water supply and that they have a welldelineated disaster and evacuation plan. the specifics of these requirements vary on a state-by-state basis. however, attention to the development of specialized parish, louisiana, due to a failure to comply with evacuation orders during hurricane katrina, and the bus accident in which houston, texas, nursing home residents being evacuated from hurricane rita died in a fire that was sparked by mechanical problems and fed by the explosions of the passengers' oxygen tanks. beyond the obvious need for institutions and organizations like long-term care and hospice agencies to have detailed plans for evacuations and emergency conditions, there is also a need to identify ''at risk'' older adults living in the community. this would involve developing registries of ''vulnerable populations'' of elders based on degree of factors like contact need, predominant special impairment, and predominant life-support supply need, if any. by doing so, vulnerable elders could be easily identified in the event of a disaster and better supplied with assistance. such registries are currently implemented in some instances (examples are available in california, www.aging.ca.gov, and florida, www.broward.org/atrisk), but a more systematic approach has yet to be employed. these registries will most likely need to be local in origin and maintenance in order that control of sensitive health data would remain confidential. however, it would be preferable for the structure of the databases to be developed in a uniform format in order to facilitate the sharing of important data across local and regional entities. once successful programs and examples are created, their implementation by all interested parties should then be straightforward. emergencies require flexibility and the ability to survive changes in regular routines. this flexibility can be easier to achieve if people have a few necessary and familiar objects with them to assist with performing certain everyday chores, such as eating properly, taking medications, and changing into clean clothes. in order to assist people in getting prepared for the disruptions that inevitably occur during an emergency, the fema and the american red cross recommend that every family have an emergency preparedness kit that contains food, water, clothing, medical supplies, flashlight, and other supplies that will aid their survival for - days. by the time recommended objects are placed in a backpack, the entire kit weighs between and pounds. this is clearly too much weight for an older person to handle safely. of emergency kits for elders the health resources and services administration (hrsa) provided funding to the gateway geriatric education center of missouri and illinois (grant number d hp ) for train-the-trainer programming to teach health-care professionals in the spring of how to create an emergency preparedness kit that was light, compact and specific for older adults. this kit consisted of a small satchel, a flashlight, a photo album (to store copies of prescriptions, insurance cards, evacuation plans, contact phone numbers, and family pictures), a pill box and a pamphlet introducing the fema web site. the trainees were then taught what other materials should be added to the kit to make it appropriate for a particular individual (table . ). upon completion of this training each of the trainees received two complete kits, one to use as an example during their subsequent training sessions of other health-care providers and the other to be given to a disadvantaged older person whom they deemed at risk during an emergency. each participant provided an e-mail address in order to be contacted year following their training to determine the outcomes of their training. one year after training, the trainees were contacted by e-mail. twenty-three of the e-mail addresses were no longer valid. of the remaining trainees, filled out and returned the survey within weeks ( % response rate). an additional surveys were returned after a second e-mail blast ( / , for a final response rate of %). the survey asked if, as a result of their training, had the trainees: . given the extra kit to an older adult? . determined if that kit had been used during an emergency? . used their own emergency kits for training, and if not, why? . used their own emergency kits during an emergency? responses to the quality improvement survey are summarized in table . . the majority of the trainees ( %) had given the extra kit to an older person and many ( ) ( ) of the respondents indicated that the person was either an older relative or a neighbor. however, few respondents ( %) had provided any training to other health-care providers on how to create these kits. barriers cited included lack of money to purchase kit contents, lack of commitment or permission from supervisors, lack of time to provide the training, and lack of time for their colleagues to receive training. the percentage of older adults that were reported to have used their emergency kits by the time of the end point survey was higher than expected ( %), especially given that only % of the (younger) trainees reported using their kits. however, a review of the disruptive weather patterns in the counties in eastern missouri and southwestern illinois where the trainees (and therefore, presumably of the older adults receiving the extra kits) lived, indicated that three area-wide power outages had occurred between august and january . all of these three power failures lasted - weeks, with the rural areas in southwestern illinois being the last to get power restored each time. each of these power failures affected at least a half million citizens each time. numerous cooling or heating stations were set up for older adults, thereby allowing them to evacuate from their homes during the days in august and to receive warm meals during the november and january power failures. multiple public service announcements encouraged people to evacuate their homes completely until power was restored, so many older adults either moved in with relatives who did have power or went to hotels. under those conditions, it is reasonable to expect older persons to take their emergency kits with them. many of the health-care provider trainees reported that they had gone to work daily. a brief second query to trainees who had used their kits and trainees who had not used their kits indicated that both sets had gone to work daily and returned home at night, even if they had no power at home. (these health-care providers worked in facilities with working generators.) several of those that took their kits with them indicated that the kits provided them with some measure of safety while traveling icy roads in november and january. those that had not used their kits indicated no perceived change in their normal safety. this quality improvement study shows that emergency kits for older adults are used during an emergency. community-dwelling older adults appear to be more vulnerable to weather emergencies than are the health-care providers who care for them, as evidenced by the differences in usage rates of the kits by both groups through three lengthy power outages. upon review of the barriers that prevented trainees from providing training to other health-care providers, it is possible that it would have been more appropriate to provide train-the-trainer programs to older adults rather than to health-care providers. peer-to-peer training might have had the added advantage of motivating trainers to find community funding to make kits for distribution because of a greater perceived personal need for the kits. because every emergency event presents a unique challenge, this section offers general information about coping with the major nutritional concerns, namely shortages of food and water and overall loss of access to social support and health-related resources. optimal public health and nutrition relief includes a broad range of interventions and needs to utilize strong programmatic interconnections to meet the aforementioned needs. in the immediate aftermath of a ce, the supplies of food and water may be extremely limited. in this event, food can be more safely rationed than water. a general guideline is that the minimum adult ration be one well-balanced meal per day, with the utilization of vitamin/mineral supplements, protein drinks, ''power bars'', or other fortified foods as meal extenders if available. however, water should not be rationed due to the very rapid effects of dehydration. individuals are advised to drink what is needed today and search for more water on a daily basis. indicators of dehydration in the elderly differ from those in younger individuals; increased thirst, reduced skin turgor are not reliable markers. better indicators include tongue dryness, longitudinal tongue furrows, dry mucous membranes of the nose and mouth, eyes that appear sunken, upper body weakness, speech difficulty, and confusion ( ) . when there is a loss of power to the home, perishable foods are to be consumed first, followed by foods from the freezer. frozen foods should be safe to eat for at least days following the power loss. at this point, nonperishable, staple foods would be the only safe source of nutrients. as conditions stabilize, food aid will begin to become available. the recommended actions to be facilitated for older adults include ( ) achieve/improve access to food aid (rations, supplemental feeding programs, etc.); ( ) ensure that the rations are easy to prepare and consume; and ( ) assure that the rations being used meet the nutritional requirements of older adults ( ) . the usda's food and nutrition service (fns) coordinates with state, local, and voluntary organizations to provide food for shelters and also distributes food packages and authorizes states to issue emergency food stamp benefits to individuals. as part of the national response plan, fns supplies food to disaster relief organizations such as the red cross and the salvation army for mass feeding or household distribution. these organizations, along with other private donors, support the supply of water and food rations to affected areas. there are several concerns related to the access and appropriateness of food aid for elderly individuals (again, see resources listed in table . ). access to the aid is a concern because disabilities and medical problems may prevent elderly individuals from reaching the distribution centers. another concern is the composition of the food rations, which may not be appropriate in consistency for persons who have dentures or who lack teeth and that may not be adequate in nutritional composition. food rations vary in composition; not all are developed for the primary purpose of post-ce relief. in the united states, the meal, ready-to-eat (mre), although first developed for use in the space program and now widely used by the armed forces, is one form of ration that is commonly distributed to civilians who need food following ces. having been designed for soldiers in a high activity situation, the mres are much higher in sodium ( , g) and fat ( g) than is optimal, especially for older adults ( ) . likewise, the texture, packaging, and preparation of mres were not developed with the intention of use by older adults. in an effort to supplement the nutritional needs of elderly citizens and to meet federal recommendations for increased emergency preparedness, the administration on aging (aoa) sought and received special funding to provide shelf stable meals that could be delivered to participants of the home-delivered-meal programs. these meals, which have a shelf life of approximately months, are delivered with instructions to consume them during emergencies when regular home-delivered meal service is disrupted. the program is new so, to date, no evaluations have been done to determine what becomes of those meals (e.g., are they saved for emergencies or eaten to supplement other meals). no policy has been created to determine liability for any sickness caused by consumption of meals that are beyond their expiration date (personal communication from area agency on aging of southwestern illinois and the mideast area agency on aging to nt). obtaining adequate food and water is only one step on the road to recovery where elderly persons are vulnerable to food insufficiency. once food is obtained it must then be stored properly, prepared properly, and then ingested without health risk. in each of these steps, older persons are also at increased risk, compared to the rest of the population. this is because these older persons have additional risk factors for poor nutrition such as functional impairments, social isolation, reduced ability to regulate energy intake, greater susceptibility to depression, decreased ability to taste and smell, poor dentition, and poor health. all of these items (listed in table . ) can lead to malnutrition, if not starvation, in older persons. following a ce, the speed with which basic services such as heating/cooling, shelter, and water supply can be restored will be a major factor in the recovery of older persons. past experience has shown that cold, loss of mobility, access to services, and psychological stress and trauma are some of the most important factors contributing to undernutrition in older people following a ce ( , ) . in particular, the loss of social networks and support systems increases the vulnerability of these individuals ( ) and needs to be corrected as soon as possible to prevent further deterioration as the days following the event go by. the best approach is to utilize programming strategies that address the needs of older adults without undermining their independence and discouraging their ability to support themselves ( , ) . the restoration of medical facilities and the provision of transportation to appropriate medical facilities in unaffected areas are not under the control of the individual clinician or caregiver. these efforts are usually dependent on the local police and military forces who take charge post-ce. additionally, medical facilities will vary in their ability to handle the ce, depending on the type of emergency. for example, the response to a ce such as a hurricane (which would probably slow down access to the facility) would be very different than that required for an infectious disease epidemic (when admissions might very quickly exceed capacity) ( ) . the challenge for the clinician on the front line is to stabilize the older patient until access to more formal support can be restored. thus, the aforementioned preparedness efforts are key in preventing the acceleration of medical conditions from chronic to life threatening. the availability of medical records and prescription medicines, as recommended for the evacuation kits of older adults, can play a critical role in this regard. in summary, the long list of complicated and threatening ces that can affect the nutritional status and overall medical welfare of older adults underscores the fact that all older adults and their care givers, as well as administrators of structured living facilities, should plan for and be physically and psychologically prepared for the event of a serious ce. . home-dwelling elders should be prepared for a ce by stocking a -week safety supply of food, water, and medications, having a carry-away disaster pack with medicines and other essential supplies, and having a delineated evacuation plan. . administrators/medical directors should ensure that nursing homes and assisted living facilities are prepared with food and water supplies and an alternate source of power and have detailed, individualized evacuation plans for each resident. ideally, a multidisciplinary team should utilize age-specific guidelines to design and implement a ce-preparedness plan. . in the future, there is a need for conceptual advances in understanding the causes of undernutrition in older adults during a ce and the development of better advance preparations and response mechanisms. the public health aspects of complex emergencies and refugee situations public nutrition in complex emergencies food security rates are high in elderly households hunger and food insecurity in the elderly food biosecurity morbidity surveillance after hurricane katrina -arkansas public health response to hurricanes katrina and rita -louisiana deaths related to hurricane andrew in florida 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earthquake acknowledgments the authors thank caroline friedman for researching the historic and current events cited here. key: cord- -bamd vps authors: riley, elizabeth; haggard-duff, lauren; long, christopher r. title: using an online learning module to teach nursing students about food insecurity as a social determinant of health date: - - journal: teach learn nurs doi: . /j.teln. . . sha: doc_id: cord_uid: bamd vps currently, food insecurity is a lack of access to enough food for a healthy life that impacts approximately million americans and million people worldwide. these statistics are expected to rise as a result of the covid- pandemic drastically. studies show that healthcare and nursing curricula are currently deficient in providing education to help healthcare providers combat food security and provide patient education. the purpose of this article is to discuss a curricular framework that can be implemented in both nursing and healthcare curricula to offer appropriate training for food insecurity assessment, care, and patient education. several key healthcare organizations, such as the centers for disease control (cdc), world health organization (who) and healthy people , have advocated for community assessment of the social determinants of health (sdoh) by healthcare practitioners. leaders in medical education have recommended that sdoh should be an essential part of the medical education curriculum (mangold, bartell, doobay-persaud, adler, & sheehan, ) . in nursing specifically, the national league for nursing presented a call in for the integration of the sdoh into nursing education curricula (nln, ) . with approximately . million nurses currently employed within the us, the role of nurses in addressing health equity and sdoh must be strengthened and has the ability to make a significant societal impact on population health (thornton & peraud, ) . due to the evergrowing need to enhance nurses' and other healthcare providers' knowledge about the sdoh, more education regarding screening tools for assessment and inter-collaborative care for the sdoh are necessary to integrate within nursing and healthcare education (andermann, ) . the purpose of this article is to describe the use of three major models to aid with curriculum development, framework, and the evaluation process as a potential approach to planning online learning modules to teach nursing students about food insecurity screening, assessment, and care. the use of the continuous improvement process (cip) model will be described to aid with the overall curriculum development and evaluation plan. the paper will also discuss the utilization of the competency-based medical education framework and the search mnemonic. the competency-based medical education framework and search mnemonic help to promote evidence-based learning guidelines into the curriculum using online learning modules to teach nursing students about food insecurity screening, assessment, and care as it relates to the sdoh. the sdoh includes five major domains that relate to conditions that people face based on, and within, their environment (cdc, ; odphp, ; who, ) . the five domains include economic stability, education, health and health care, neighborhood and built environment, and social and community context. economic stability is the sdoh related explicitly to the concept of food insecurity. other areas related to economic stability, which also align with food insecurity, include poverty, employment, and housing instability. a key component of sdoh education is screening for food insecurity (leonard, hughes, donegan, santillan, & pruitt, ) . food insecurity, a condition where a household has limited or uncertain access to adequate food caused by lack of money or other resources, affected . % of us households in (coleman-jensen, rabbitt, gregory, & singh, ) . food insecurity is a strong predictor of diagnosis for many chronic diseases, including hypertension, coronary heart disease, and hepatitis. for many chronic diseases, food insecurity is more strongly associated than is income (gregory & coleman-jensen, ) . food insecurity is described as a lack of "access by all people at all times to enough food for an active, healthy life-is one of several conditions necessary for a population to be healthy and well nourished" (nord, andrews, & carlson, , p. ). food insecurity affects approximately forty million americans and complicates the lives of those with pre-existing chronic health-related conditions, such as type diabetes and cardiovascular disease (american diabetes association, ; nguyen, shuval, bertmann, & yaroch, ; weinfield et al., ) . knowles et al. ( ) found via a grounded theory, qualitative analysis, that several facilitators and barriers exist regarding appropriate food insecurity screening among healthcare providers. the reported facilitators included patient trust, choice of screening methods, and assisting with navigating government benefit application centers. the reported barriers to food insecurity screening included complex administration of screening and referral, stigma and privacy concerns, poor communication about the referral process, and patients being enrolled or ineligible for benefits. based on these research points, nursing educators need to include education in the curricula for students regarding the complexity of food insecurity screening, assessment, the value of communication, and understanding the multifaceted referral process for appropriate resources. to begin the curriculum planning and development phase, nurse educators should include experts in content, curriculum development, and instructional design. appropriate allocation of human expertise in these fields will allow a broad development of the curriculum that will take into account strategic planning and management (khan & law, ) . one method which could be utilized for the planning and curriculum development process is the cip model (park, hironaka, carver, & nordstrum, ). the cip model utilizes five main points when planning for any action plan: ( ) determine goals, ( ) assess institutional rules, roles, and tools, ( ) develop an action plan, ( ) implement the plan, ( ) measure and evaluate (fig. ) . when determining goals within healthcare education, one of the first steps includes the creation of learning objectives. learning objectives are the foundation of the educational module and identify the measurable goals that the students should achieve from the learning experience. in the present instance of developing food insecurity online learning modules, the following learning objectives could be incorporated or revised into any nursing curriculum: a. analyze a food insecurity assessment tool and recognize appropriate resources such as snap and wic, etc. to assist with food insecurity. b. review basic principles of nutrition to manage type diabetes while considering culture and personal food preferences in recommendations. c. identify resources and strategies to access foods in grocery stores that support healthy eating patterns for the client(s). d. recognize collaboration need with appropriate interdisciplinary healthcare providers, community-based resources and other social services to implement holistic care for the needs of families. e. review and assess written dialog with patients about quick, easy, healthy menu planning and food preparation. f. recognize the difference between a food bank, food pantry, and a soup kitchen. g. reflect on their readiness to support the health of food insecure individuals at risk for type diabetes and other chronic diseases. h. identify their intention to include food insecurity assessment related to their practice in their clinical, academic, and/or scientific careers. nurse educators who are considering the development and implementation of a food insecurity curriculum need to assess the institution of implementation for strengths, weaknesses, opportunities, and threats (swot). the use of a swot analysis will allow nurse educators to determine the institutional support, need, benefit, and challenges to implementing the project. additionally, the topic and curriculum can be strengthened by ensuring alignment to the institution's vision, mission, and strategic plan. if the nurse educators plan to gather pre and post-test data for analysis and dissemination, irb exemption should be obtained from the institution before project implementation. the online learning modules could be based on the competencybased medical education framework, which emphasizes ( ) education must take into account patients' health needs and ( ) preparation of health care professionals should blend classroom education and professional practice (carraccio et al., ; frank et al., ) . the use of the competency-based medical education framework is a suitable framework for curricular development of online learning modules covering food insecurity as an sdoh for several reasons. a competency-based medical education framework allows for a consistent approach to curriculum development and design. consistency is vital because nursing educators strive for students to receive the same or similar learning experiences and develop consistent practices regarding food insecurity screening and assessment. second, the use of the competency-based medical education framework allows curriculum developers and experts to ensure the learning experience is authentic, in that students will learn knowledge and information that is genuinely applicable to real-life, clinical scenarios. lastly, a competency-based medical education framework supports the alignment of the learning experience to the identified student learning objectives "through the continuum of medical education" (harris, snell, talbot, & harden, , p. ) . during the development of the online module, the faculty developers should also incorporate assistance from other expert faculty in the field of culinary medicine, population health, and online education if available. students and providers have multiple opportunities to assess food insecurity and provide education for nutrition and community resources for access to healthy foods. therefore, the use of online learning modules can enhance the ability of nursing students to conduct a food insecurity assessment, assess and analyze the results of the assessment, and determine what collaborative efforts are needed to pull in other healthcare providers for the purpose of providing holistic care to an individual patient. additionally, nurse educators should consider implementing patient teaching and education into the curriculum. patient education can focus on interviewing practices to establish rapport and trust. the curriculum should educate the nursing student about how to conduct some basic nutrition counseling surrounding a patient and their family while considering culture and family preferences in modifying diet. the curricular project should utilize the search mnemonic of steps that health care professionals can take to address food insecurity, sdoh, and disease: screen each patient for food insecurity. educate patients at risk for food insecurity about relevant coping strategies. adjust medications that should be taken with food. recognize that food insecurity is recurrent but not always chronic for many patients. connect, normalize, and facilitate patient enrollment in federal and community resources. help other health care professionals understand that food insecurity and poor health often intensify one another. the online learning module should utilize three major phases for learning: screening for food insecurity, appropriate communication and care, and managing referrals for resources. nurse educators should consider the best modalities for the dissemination of the curriculum during the implementation phase. the institutional learning management system may be the best platform for dissemination, but each institution will require individualized planning. the use of the institutional learning management system, if available, could facilitate program evaluation because the grade book can store the pre and post-test grades. the evaluation scores can be easily exported into a spreadsheet, de-identified, and placed as data into the statistical codebook for use in program evaluation data analyses. nurse educators should also work with experts in tool and testing creation to design a pre/post-test. a pre/post-test design can measure student knowledge before and after the online learning module for quasi-experimental data analysis, especially if randomization is not possible. the evaluation phase should provide a comparison of data before and after participation in the online learning modules. the goal of using this format for curriculum development should be to evaluate student learning through measurable means (pre/post-test scores), revise the curriculum based on the evaluation results, and readminister the online learning modules to new students (fig. ) . research is apparent and evident that nursing and healthcare curricula are currently deficient in advancing student knowledge of the sdoh and specifically deficient regarding the training of food insecurity screening, assessment, and referral to resources (mangold et al., ) . research also shows the value of online learning and curriculum development, utilizing validated models and frameworks (nguyen, ) . the use of a validated framework for education, a model for curriculum innovation, and interprofessional experts can aid educational institutions with the integration of appropriate learning resources and modules for nursing students to learn the proper screening, care, and impact of food insecurity as an sdoh. additionally, a curriculum that connects the sdoh to food insecurity and teaches appropriate assessment and care can help institutions meet a long term goal of fostering the quadruple aim and better training nursing students in the concepts of the sdoh. this project has a completed grant proposal, but no submissions due to covid- [ ] . introduction: standards of medical care in diabetes screening for social determinants of health in clinical care: moving from the margins to the mainstream advancing competency-based medical education: a charter for clinicianÀeducators household food security in the united states competency-based medical education: theory to practice food insecurity, chronic disease, and health among working-age adults competency-based medical education: implications for undergraduate programs an integrative approach to curriculum development in higher education in the usa: a theoretical framework successes, challenges, and considerations for integrating referral into food insecurity screening in pediatric settings overlapping geographic clusters of food security and health: where do social determinants and health outcomes converge in the us? ssm-population health expert consensus on inclusion of the social determinants of health in undergraduate medical education curricula the supplemental nutrition assistance program, food insecurity, dietary quality, and obesity among us adults the effectiveness of online learning: beyond no significant difference and future horizons a vision for integration of the social determinants of health into nursing education curricula measuring food security in the united states: household food security in the united states office of disease prevention and health promotion (odphp). ( ) continuous improvement in education. carnegie foundation for the advancement of teaching preparing today's nurses: social determinants of health and nursing education world health organization (who) key: cord- -rtl ut authors: lal, rattan title: home gardening and urban agriculture for advancing food and nutritional security in response to the covid- pandemic date: - - journal: food secur doi: . /s - - - sha: doc_id: cord_uid: rtl ut despite a . % increase in world cereal production in over , the number of people facing severe food insecurity may double from million in january to million by the end of . the problem of food and nutritional insecurity is severe in urban centers, where the global population is projected to increase (%/year) by . , . , and . between to , to , and to , and it will increase overall from % in to % by . the number of megacities (> million people) will increase from in to by . the covid- pandemic has aggravated food insecurity in urban centers because of the disruption in the food supply chain, aggravation of the physical and economic barriers that restrict access to food, and the catastrophic increase in food waste because of labor shortages. thus, there is a need to adopt more resilient food systems, reduce food waste, and strengthen local food production. enhancing availability at the household and community levels through home gardening and urban agriculture is an important strategy. food production within the cities include small land farming in households, local community gardens, indoor and rooftop gardens, vertical farming, etc. home gardening can play an important role in advancing food and nutritional security during and after the covd- pandemic, while also strengthening the provisioning of numerous ecosystem services (i.e., plant biodiversity, microclimate, water runoff, water quality, human health). however, risks of soil contamination by heavy metals must be addressed. the rapid expansion of the covid- pandemic, engulfing countries between december and march , has aggravated risks of severe/extreme food insecurity from million in january to million by the end of (dongyu ) . the severe problem of food insecurity will affect populations in both the developed and developing countries. the hotspots of food insecurity in developing countries are south asia, sub-saharan africa, latin america, and the caribbean, and the pacific region. the twenty-first century is the era of urbanization. the global urban population of % in is expected to be % by (knorr et al. ) , and urbanization is more rapid in developing than in developed countries. urban population as percentage of the total world population in developed and developing regions, respectively, was . and . in , . and . in , . and . in , . and . in , and is projected to be . and . in and . and . in (u.n. a) . the world's ten most populous cities in have populations (millions) of . , . , . , . , . , . , . , . , . , and . for tokyo, delhi, shanghai, sao paulo, mexico city, cairo, dhaka, mumbai, beijing, and osaka, respectively. the majority of the most populous cities are in asia, especially in china and india. asia and africa are two continents which have the most people prone to both under-nourishment and malnourishment, and covid- is aggravating the already serious problems of hunger and the hidden-hunger ( fig. ). at present, there are megacities (hummel et al. ; u.n. b) , of which are in asia. by , two-thirds of the world population will be urbanized and there will be megacities, of which % will be in low to middle-income countries. the future growth of population will almost entirely occur in urban areas of developing countries. yet, cities in these countries are not properly designed to provide sustainable sources of adequate and nutritious food for large population even without the disruptions such as that caused by the covid- virus. major disruptions in food supply chain caused by the covid- pandemic have aggravated the already existing severe problems of hunger and malnutrition along with food wastage. unplanned or adhoc urbanization also has drastic impacts on the environment (i.e., the heat island effect, high runoff, inundation), and these problems are aggravated by the changing climate. a major challenge created by the covid- pandemic is disrupting access to fresh and nutritious food at affordable prices to large and growing urban population. the problem is worsened by the lack of or weak infrastructure and poor institutional support. thus, there is a need to adopt more resilient food systems, reduce food waste along the supply chain, and strengthen the growth of local agricultural capabilities through home gardening and urban agriculture (hgua). the specific objective of this article is to describe: ) properties of urban soils and their suitability for growing food, ) home gardens and urban agriculture for food and nutritional security, ) ecosystem services provisioned by hgua, ) soil management options to reduce risks of contamination of urban soils by heavy metals and other pollutants, and ) the nexus thinking of waste and water management based on the concept of recycling nutrients and water for producing food, and advancing the sustainable development goals (sdgs) of the united nations (u.n. ) through hgua. urban soils are called anthropic soils, anthrosols, or technosols (fao/unesco ) because anthropogenic control of pedogenic processes leads to drastic alterations in soil properties. in general, urban soils comprise of highly disturbed and manipulated materials altered through mixing, filling, transportation, and other perturbations caused by construction-related activities. yet, urban soils vary widely because of differences in site history, population density, and cultural and socioeconomic conditions. urban soil horizons are irregular and comprise a mixture of soils, which may contain high contents of stones, gravels, and artifacts. important attributes of urban ritchie and roser ; who ) soils, in the context of hgua are the following: high heterogeneity, large temporal and special variability, presence of artifacts, and contamination by inorganic and organic pollutants. these soils are characterized by poor physical properties (e.g., high bulk density, low water infiltration rate, low plant available water capacity, and susceptibility to drought), unfavorable chemical properties (e.g., low soil fertility, nutrient imbalance, and low soil organic carbon concentration and stock), and low activity and species diversity of soil biota. therefore, restoration and sustainable management of the physical, chemical, and biological properties of urban soils is critical to improving agronomic productivity and nutritional quality of vegetables and fruits grown on these soils. application of compost, mulch, and other sources of biomass-carbon (i.e., lawn clippings, leaf litter, household waste) is essential to improving soil quality and functionality and alleviating soil-related constraints to hgua. the covid- pandemic has disrupted the food supply chain. thus, it is critically important to strengthen local food production at the household and community levels. the home garden is a farming system which combines different physical, social and economic functions on land around the family home to supplement supply of fresh food at the household level. logistically, home gardens provide easy day-to-day access to fresh vegetables and fruits, leading to enriched and balanced diets by supplementing proteins, vitamins, and minerals (galhena et al. ) . through supply of medicinal herbs and an opportunity for physical activity, home gardens are also important to human health and wellbeing. thus, home gardens can improve food security, diversity, nutritious value, and the microenvironment around the family home. urban agriculture (ua) is defined as all forms of agricultural production (food and non-food) occurring within or around cities (wagstaff and wortman ) . ua strengthens many ecosystem services, such as improving human health, food access to local communities, income and jobs along with economic prospects, aesthetical value and beauty, education about farming, and community resilience (fig. ) (oberholtzer et al. ; santo et al. ; thomas ) . ua may comprise ground-based outdoor urban gardens and farms, hydroponic or aquaponic indoor production through skyfarming, rooftop gardens and farms, landscaping and nursery businesses, and urban livestock (little ) . community gardens refer to spaces that provide agriculture environment within the city limits to grow vegetables and fruits and raise livestock. these gardens are owned or farmed by the members of the community or sub-divided into allotments cultivated by individual members (corkery ). home gardens and urban agriculture for food and nutritional security the conventional system of bringing food into large cities, over an average distance of to km, involves a large amount of energy and is vulnerable to disruptions such as that caused by covid- (altieri ). thus, there is an urgent need for adopting resilient food systems for meeting a partial food needs through a systematic development of hgua. ua is already producing about - % of the world's food supply, and this can play an even more critical role in achieving food security during a global crisis such as that created by the covid- virus. small scale ua can produce high crop yields through judicious management of inputs needed for achieving sustainability (mcdougall et al. ) . the percent of families engaged in ua varies from % in some large cities in north america to % in some smaller siberian and asian cities (thomas ). in , million american households were actively practicing hgua by growing their own food either at home or in community gardens (algert et al. ) . during the covid- pandemic, innovative hgua systems are critical to addressing the following issues both in developing and developed economies: ) large populations living in mega-and gigacities with large food demand, ) high food waste at all steps of the supply chain and long food mileage, ) undernourishment and malnourishment because of the poor nutritional quality of the food (fig. ) , ) disruptions in the food supply chain, and ) low income as a result of the lockdown. a system-based and wholistic approach through hgua can produce food within urban centers, including in and on urban buildings. in addition to the large and growing megacities in developing countries, there are also several megacities in the developed countries of north america, europe, and australia where practicing hgua is as an important solution to the food crisis as it is in developing countries. some large cities and their populations (millions) in developed countries include new york ( . ), moscow ( . ), los angeles ( . ), paris ( . ), london ( . ), sydney ( . ), etc. these cities have specific examples of hgua, including vertical farming, which uses hydroponics and aquaponics (despomier ) . scientific hgua (i.e., vertical farming) has the potential to alleviate food and nutritional insecurity, while not only reducing demands on finite natural resources but also providing urban populations with diverse, sustainable, safe, and nutritious food. soil contamination by heavy metals [i.e., lead (pb), arsenic (as), and cadmium (cd)] and organic pollutants [i.e., polycyclic aromatic hydrocarbons (pahs), antibiotics, and petroleum products] are among the major constraints limiting the use of urban soils for food production (menefee and hettiarachichi ) . these problems must be addressed to produce healthy and safe food. indeed, with adequate management and bioremediation, the pathway from contaminated soil to humans via food can be minimized, and high yield obtained with judicious mana g e m e n t o f i n p u t s ( m c d o u g a l l e t a l . ) . bioavailability of heavy metals and organic pollutants can be reduced by input of soil amendments including compost, mulch, recycling of the biomass and use of engineered media, which enhance soil health and promote activity and species diversity of soil biota. replacement soil can be produced through urban waste that can be added into contaminated soil (brown ). impact on ecosystem services and sustainable development goals of the united nations through nexus thinking about waste management in addition to increasing access to fresh and nutritious food, hgua also strengthen supporting, provisioning, regulating, and cultural/social ecosystem services or ess (fig. ) . site-specific examples of these ess include: ) soil formation and primary production for supporting services, ) food, fiber, fresh water and infra-structure foundation of provisioning services, ) micro-climate modification, flood control, water purification, soil bioremediation and decontamination for regulating services, and ) aesthetical, spiritual, recreational, and social for cultural services (shuster and dadio ) . in accord with the strengthening of ess, hgua has also positive impacts on the sdgs of the u.n. urban waste, a major fig. food, environmental, economic, and ecosystem service benefits of home gardens and urban agriculture environmental hazard and source of pollution, can become an asset by developing a cyclic economy. compost made from waste is an essential amendment to restore soil health, enhance productivity, and improve the nutritional quality of food grown under hgua systems. sustainable management of soils by practicing hgua can simultaneously enhance humanity's culture, civilization, livelihood and health (minami ) and create sustainable communities (sullivan ) . the focus of managing urban soils for hgua is on agronomic productivity, nutritional quality, and the safety of food products. vertical farming, based on a cyclic economy involving aquaponics and hydroponics, is an innovative option (despomier ) . just as in agricultural lands, indiscriminate use of chemicals, water, and other inputs must be avoided. similarly, judicious use of inputs is critical to obtaining high yields and safe produce in home gardening (mcdougall et al. ) . because of heavy human traffic, the risks of soil compaction must be minimized by improving and sustaining soil structure of the surface layer by mulching and use of compost to enhance the activity of earthworms and other biota. scarcity of good quality topsoil can be addressed by using synthetic soils. rather than sprinklers, drip irrigation may be essential to improving water use efficiency. & the covid- pandemic has disrupted the food supply chain and globally aggravated undernourishment and malnourishment, but especially in developing countries & food production within cities by practicing hgua can create resilient food systems while reducing food waste along the supply chain. & restoration of the quality of urban soils, by use of compost and other organic amendments, is important to improving productivity, enhancing nutritional quality, ensuring safety, improving human health and strengthening numerous ess. & soil restoration can be accelerated by using synthetic soils made from biowaste and organic materials. & sky farming; based on circular economy and using aquaponics and hydroponics, is an innovate and new form of urban agriculture. & practicing hgua is an important strategy to advance sdgs of the u.n. conflicts of interest the author declares that there was no conflict of interest regarding this article. community and home gardens increase vegetable intake and food security of residents in how urban agriculture can improve food security in us cities making soils from urban wastes community gardens as a platform for education for sustainability vertical farming using hydroponics and aquaponics senior officials sound alarm over food insecurity, warning of potentially 'biblical' famine, in briefings to security council title soil map of the world: revised legend with corrections and updates. world soil resource report home gardens: a promising approach to enhance household food security and wellbeing. agriculture and food security feeding the future's cities: challenges in an uncertain world food for an urban planet: challenges and research opportunities what is urban agriculture? small-scale urban agriculture results in high yields but requires judicious management of inputs to achieve sustainability contaminants in urban soils: biodiversity and transfer soil and humanity: culture, civilization, livelihood and health urban agriculture in the united states: characteristics, challenges, and technical assistance needs home gardening and urban agriculture for advancing food and nutritional security in response to the covid- pandemic vacant lots to vibrant plots: a review of the benefits and limitations of urban agriculture an applied hydropedological perspective onthe rendering of ecosystem services from urban soils growing greener cities in latin america and the caribbean: an fao report on urban and peri-urban agriculture in the region united nations, department of economic and social affairs, population division crop physiological response across the chicago metropolitan region: developing recommendations for urban and peri-urban farmers in the north central us. renewable agriculture and food systems from indian agricultural research institute he has authored/co-authored refereed journal articles and book chapters and has written and edited/co-edited books. he was included in the thomson reuters list of the world's most influential scientific minds ( - ), and he is among clarivate's highly cited researchers in agriculture key: cord- -lbxmteyn authors: erokhin, vasilii; gao, tianming title: impacts of covid- on trade and economic aspects of food security: evidence from developing countries date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: lbxmteyn the stability of food supply chains is crucial to the food security of people around the world. since the beginning of , this stability has been undergoing one of the most vigorous pressure tests ever due to the covid- outbreak. from a mere health issue, the pandemic has turned into an economic threat to food security globally in the forms of lockdowns, economic decline, food trade restrictions, and rising food inflation. it is safe to assume that the novel health crisis has badly struck the least developed and developing economies, where people are particularly vulnerable to hunger and malnutrition. however, due to the recency of the covid- problem, the impacts of macroeconomic fluctuations on food insecurity have remained scantily explored. in this study, the authors attempted to bridge this gap by revealing interactions between the food security status of people and the dynamics of covid- cases, food trade, food inflation, and currency volatilities. the study was performed in the cases of developing economies distributed to three groups by the level of income. the consecutive application of the autoregressive distributed lag method, yamamoto’s causality test, and variance decomposition analysis allowed the authors to find the food insecurity effects of covid- to be more perceptible in upper-middle-income economies than in the least developed countries. in the latter, food security risks attributed to the emergence of the health crisis were mainly related to economic access to adequate food supply (food inflation), whereas in higher-income developing economies, availability-sided food security risks (food trade restrictions and currency depreciation) were more prevalent. the approach presented in this paper contributes to the establishment of a methodology framework that may equip decision-makers with up-to-date estimations of health crisis effects on economic parameters of food availability and access to staples in food-insecure communities. over the decades, food insecurity concerns have been emerging, along with the growth of the world population. among the united nations sustainable development goals [ ] to be achieved by , ending hunger and establishing food security hold an important place. however, despite the best efforts of the international community to combat food insecurity across the globe, the number of undernourished people has resumed growth in , after a steady decline during the - s. the food and agriculture organization (fao) reports that over million people in the world suffer from hunger, while about two billion people experience moderate or severe food insecurity [ ] . in view of the fact that an additional million people have become affected by hunger since , the number of undernourished people is projected to exceed million by [ ] . in the past, the main reasons for food shortages used to be droughts and other natural disasters. with the emergence of globalization, food security has become an economic rather than an agricultural issue. being a combination of the physical availability of food and economic access to adequate supply [ ] , food security at the national these countries are net importers of food and agricultural products. according to the fao [ ] , out of developing economies and ldcs where recent adverse impacts of the economic downturn due to the covid- pandemic on food security have been strongest, countries rely heavily on agricultural imports. in a situation of disrupting food supply, dependence on imports tremendously threatens the food security of those nations, especially when export restrictions are imposed by the world's leading suppliers like russia, vietnam, and ukraine. as the spread of covid- and strict quarantine measures trigger economic decline, even developed economies experience food price rises unless the governments take preventive actions or retailers absorb some of the costs. since february , the global average price for rice has increased by . %, for meat of cattle-by . %, for meat of chicken-by . %, for potatoes-by . % [ ] . due to a limited capacity to produce staple crops domestically, developing economies are more vulnerable to food inflation and supply shortages. in just the first three months of at the very onset of the covid- outbreak, over fifteen developing countries already experienced an increase in the cost of a basket of food staples (over %) [ ] . at many markets, food prices have been increasing because of local logistical problems [ ] . there is also a dependence of developing countries with their limited resources on a small range of food products exported to a few markets [ ] , many of which have been affected by the covid- outbreak [ ] . in one of the trade scenarios simulated by vos et al. [ ] , a % global economic slowdown due to the pandemic could cause a decline in developing-country agri-food exports by almost %. there is an array of studies that address trade aspects of food supply [ ] [ ] [ ] [ ] [ ] , but the majority of them focus on food self-sufficiency rather than food security. according to the fao [ ] , a self-sufficient country satisfies its needs in food by means of domestic production. although some developing countries of africa (mali and senegal) and latin america (bolivia, ecuador, and venezuela) have embraced the idea of food self-sufficiency in their national policies [ ] , progressing liberalization of food trade over the past few decades has refocused attention from self-sufficiency, a concept that is often related to protectionism and even autarky [ ] , to food security. the latter incorporates a wider range of parameters of food availability, economic access to adequate nutrition, utilization of nutrients, and stability of food supply [ ] . while wegren and elvestad [ ] , meskhia [ ] , clapp [ ] , and saidi and diouri [ ] , among others, argue that food security is about establishing a balance between domestic production and imports, many studies categorize food security as agricultural [ , ] , economic [ , ] , or health [ ] [ ] [ ] issues rather than as a trade one. however, at the height of the covid- crisis, both larger demand gaps and higher food price surges suggest that international trade policies play a more pervasive role in ensuring food security at the national level than previously thought. against the backdrop of the health crisis, an increase in the number of undernourished people is coupled with a global economic slowdown [ ] -a trilemma that has not been adequately explored in previous studies. lockdowns, export restrictions, and quarantine measures exacerbate these problems and call for the investigation of trade and economic impacts on food security in a new reality of food chain disruptions. so far, empirical assessments of the pandemic's effects on food and agriculture sectors have been grouped around international organizations, such as fao (food and agriculture organization of the united nations), who (world health organization), wfp (world food programme), unctad (united nations commission on trade and development), and ifpri (international food policy research institute). in a collective study compiled by the unctad's committee for the coordination of statistical activities [ ] , three dozen organizations and institutions identified the pandemic's primary channels of transmission to food and agriculture sectors, and quantified the potential impacts of covid- outbreak on agricultural input markets, food trade, and food consumption. since the report covered a wide range of topics, it thus was not particularly focused on the analysis of trade-related aspects of food security. in the regional section of the report, the economic and trade impacts of covid- on food security were not detailed for developing economies and ldcs. in the ifpri study that particularly focused on developing countries, vos et al. [ ] applied a general equilibrium model to assess possible impacts of the pandemic on prices, income, and poverty. the impacts of productivity declines on prices of some food products were forecasted, as well as on income of households, but the parameters of food availability and access to food and agricultural products were not addressed. similarly, trade impacts on food supply chains have remained scantily explored across the array of studies on covid- that have emerged in . most of these recent papers have particularly emphasized the aspects of food safety [ ] , agriculture productivity [ , ] , and healthy nutrition [ ] , rather than of food imports and trade balance as dimensions of food availability. the impacts of both international exchange fluctuations and food inflation on the access pillar of food security have also remained under investigated. the link between price increase and access to food has been primarily considered in terms of supply disruptions and shortages along the retail food supply chain [ , ] , not currency exchange rates. to the best of the authors' knowledge, there are no comprehensive studies that link the incidence rates of covid- with either the number of undernourished people or the degree of dependency on food imports. in this study, the authors attempt to bridge the said gaps in the "covid- -trade-food security" agenda by ( ) identifying interactions between the number of covid- cases on one side and availability and access pillars of food security on the other; ( ) assessing the cointegration between the pandemic-induced trade parameters of food availability and the number of undernourished people; ( ) revealing the impacts of food inflation and currency exchange volatilities amid the global health crisis on economic access to food in domestic markets; and ( ) detailing the analysis of above-mentioned health, food security, trade, and economic parameters across an array of developing economies and ldcs. the approach employed in this study is to assess the relationships between the food security parameter, on one side, and health and macroeconomic variables that affect availability and access pillars of food security, on the other. the number of people with insufficient food consumption (y) was used as a dependent variable (table ) . it is defined by the world food programme (wfp) [ ] as a total number of individuals with a poor or borderline level of food consumption. poor food consumption refers to households that are "not consuming staples and vegetables every day and never or very seldom consume protein-rich food such as meat and dairy" [ ] . households in borderline food consumption status are those "consuming staples and vegetables every day, accompanied by oil and pulses a few times a week" [ ] . the value of exports of food and agricultural products less imports of food and agricultural production. month-on-month percentage change in the price of a standard basket of food as calculated from the national consumer price index. the number of confirmed covid- cases (x ) was utilized to show the overall effect of the pandemic on food security. the selection of x ( ) ( ) ( ) variables is based on the wfp's hunger map patterns. balance of food trade (x ) reflected the dependency of a country on food imports and thus demonstrated the changes in the food supply. food inflation (x ) and currency exchange (x ) were used to reveal the influence of changes in access to food and agricultural products on food security. the choice well correlates with the recommendations of huseynov [ ] , who used exchange rate, inflation rate, and food trade as variables to identify short-term and long-term effects on food security. the period of analysis included six months from january (when first covid- cases were confirmed outside china) till the end of june (when many countries gradually lowered health alert levels). the data were obtained from the wfp's hunger map portal [ ] , trading economics [ ] , and the united nations conference on trade and development (unctad) [ , ] . among developing economies, the wfp [ ] reports countries that experience the prevalence of undernourishment (pou), a percentage of people in the total population that are in the condition in which an individual's habitual food consumption is insufficient to provide the amount of dietary energy required to maintain a normal, active, healthy life. the study proceeded with economies where the pou was the highest as of june (table ) . to reveal diverse effects on food security across a variety of macroeconomic environments, the selected countries were distributed into three groups. group included low-income economies defined by the world bank [ ] as those with a gross national income (gni) per capita of $ or less. group comprised lower-middle-income economies with a gni per capita between $ and $ . in group , we included countries with the upper-middle level of gni per capita between $ and $ , . note: * portion in the total population of countries included in the group; ** change in percentage points; "+" parameter increment; "-" parameter decrement. source: authors' development based on wfp's hunger map portal [ ] . to capture potential divergences in both economic and geographical specificities of food security, we selected the countries from six regions of africa, asia, latin america, and the middle east ( figure ). the classification by income group is based on the world bank atlas method [ ] , while that by geographic region-on the world bank country classification [ ] . to capture potential divergences in both economic and geographical specificities of food security, we selected the countries from six regions of africa, asia, latin america, and the middle east ( figure ). the classification by income group is based on the world bank atlas method [ ] , while that by geographic region-on the world bank country classification [ ] . the following hypotheses were established to reflect supposed variations in y-x( - ) interactions depending on the level of income: the covid- pandemic has hurt the entire international community ranging from the least developed countries of africa to the wealthiest economies of europe and america [ , ] . therefore, we hypothesize that: in low-income economies, food shortages and other disruptions of food availability are commonly considered to be the major factors of food insecurity [ ] [ ] [ ] [ ] [ ] . additionally, due to the world's highest portion of disposable income spent on food in low-income countries [ ] [ ] [ ] [ ] , even a slight deterioration in the economic access to staple foods harms the food security status of the households. as the spread of the covid- and lockdown measures trigger economic decline, we suggest that: hypothesis . in group countries, the strongest influence over y is exerted by food availability and food access parameters, x and x , respectively. the following hypotheses were established to reflect supposed variations in y-x ( - ) interactions depending on the level of income: the covid- pandemic has hurt the entire international community ranging from the least developed countries of africa to the wealthiest economies of europe and america [ , ] . therefore, we hypothesize that: hypothesis . x exert a direct strong effect on y across groups - countries without regard to income level. in low-income economies, food shortages and other disruptions of food availability are commonly considered to be the major factors of food insecurity [ ] [ ] [ ] [ ] [ ] . additionally, due to the world's highest portion of disposable income spent on food in low-income countries [ ] [ ] [ ] [ ] , even a slight deterioration in the economic access to staple foods harms the food security status of the households. as the spread of the covid- and lockdown measures trigger economic decline, we suggest that: hypothesis . in group countries, the strongest influence over y is exerted by food availability and food access parameters, x and x , respectively. with a rise in income level, a portion of imported food in consumption increases due to importing higher-quality and pricier products [ ] [ ] [ ] , whereas the fluctuations in world prices and import volumes exert stronger effects on the food security status of the households compared to those of domestic supply. in a situation when global food supply chains are disrupted by currency exchange volatilities and trade restrictions amid the covid- pandemic, we assume that: hypothesis . in group countries, the effects of x and x on y are the highest among the economies included in the study, while that of x is the lowest. across the array of six variables, the four-stage analysis was conducted individually for each of the forty-five countries ( table ) . at stage , a stationary test was conducted to check whether a co-integration existed between the selected variables. to illustrate short and long-run interactions between the variables, the autoregressive distributed lag (ardl) method was employed at stage . then, we applied yamamoto's causality test to reveal the causality directions of the variables. finally, by utilizing the variance decomposition approach, we attempted to predict the future relative strengths of causalities between the variables. table . study flow algorithm. stationary test by augmented dickey-fuller (adf) and phillips-perron (pp) methods. as certainty of cointegration between y and x ( - ) . autoregressive distributed lag (ardl), fully modified ordinary least squares (fmols) and dynamic ordinary least squares (dols). identification of short and long-run interactions between the variables individually in forty-five countries, generalization of the results across three groups of economies by income and seven groups by region. prior to the identification of the relationships between the variables, it is important to understand if the data is stationary [ , ] . the system behaves correctly in the case where static and dynamic properties of the variables remain unchanged and values of the system state belong to an acceptable interval [ ] . a variety of approaches have been developed to check the stationarity and to investigate further the cointegrating interactions between stationary variables. concerning macroeconomic parameters, the most commonly used techniques are the adf test by dickey and fuller [ ] and the pp test by phillips and perron [ ] . they were used by herwartz and reimer [ ] to reveal the relationship between interest rates and inflation across developing economies, by chang et al. [ , ] to investigate stationarity of gdp per capita in the oecd countries, by ranjbar et al. [ ] and su et al. [ ] to study income convergences in developing and least developed countries of africa, and by hoarau [ ] to test the purchasing power parities for real exchange rates in central america. in combination with the adf and the pp tests, aliyev et al. [ ] , humbatova et al. [ ] , and naseem et al. [ ] , among others, used the kpss (kwiatkowski-phillips-schmidt-shin) unit root method to enhance the robustness of the stationary test results. the kpss test has been widely used in macroeconomics and international finance (for instance, by kuo and mikkola [ ] , gunduz [ ] , and tsen [ ] ) to check long-run and functional time series for stationarity [ , ] . in short-run time series similar to those used in our study, the employment of the kpss test might be misleading due to the invariance of the technique to seasonal dummies [ ] and the duality of the level stationary and time trend stationary models used in the test [ ] . to ensure the correct interpretation of data in the short-run, we abandoned the kpss method and utilized the adf and the pp techniques to check the cointegration between y and x ( - ) . after the stationarity of the variables is confirmed, the interactions between the variables may be verified. to identify the relationships between the variables within the two established multitudes, we employed the autoregressive distributed lag (ardl) method elaborated by pesaran et al. [ ] (equation ( )). although the use of this technique in food security studies has been very rare, many scholars have employed the method to identify both short-and long-run relationships between various macroeconomic parameters in developing countries. for instance, Öztürk and Özdil [ ] used ardl to investigate the interplays between economic growth and unemployment in the oecd countries, elian et al. [ ] tested the relationship between foreign direct investment inflows and economic growth across the brics countries, and appiah et al. [ ] studied growth determinants in emerging economies. to the best of the authors' knowledge, we have not been able to track previous applications of the ardl method in studying availability or access-related parameters of food security. however, there are abundant examples of an effective utilization of the ardl in revealing the interplays between domestic supply and imports [ , ] , trade balances [ , , ] , inflation [ , ] , international currency exchange [ , ] , and health [ ] . where ∆ = first difference operator; δ = constant term; δ , δ , δ , δ , and δ = short-run elasticities of the variables; i = ardl model lag order; ect t− = error correction term; ε t = error disturbance; t = time. if f-statistics is larger than the upper critical bounds value [i( )], the series are cointegrated. if it is below the lower critical bounds [i( )], the variables are not cointegrated. as robustness tests for the ardl, we utilized fully-modified ordinary least squares (fmols) and dynamic ordinary least squares (dols). according to phillips and hansen [ ] , testing the ardl results by fmols allows one to correct the system for endogeneity and serial correlation effects. it is a non-parametric method to identify a correlation between the components of model error terms [ ] . the approach was used by narayan and narayan [ ] , abu [ ] , and adebayo [ ] to test the interactions between various macroeconomic variables, including trade volume, inflation, and currency depreciation. the rationale of using fmols in our study is that it allows receiving consistent parameters even in the small samples in the short-run. additionally, it helps to overcome the problems of endogeneity and serial correlation and thus allows for the heterogeneity in the parameters [ , ] . dols has been commonly utilized in combination with fmols as a computationally convenient alternative to fmols estimators. according to stock and watson [ ] , dols is employed to estimate the equilibria that is corrected for potential simultaneity bias among explanatory variables. similar to fmols, dols is applicable to small samples in the short term [ ] . its estimators obtained from least-squares estimates are unbiased and asymptotically efficient even in the presence of the endogenous problem [ ] . echoing the successful application of both fmols and dols in testing the robustness of the ardl results by yuzbashkandi and sadi [ ] , pasha and ramzan [ ] , priyankara [ ] , and adebayo [ ] we consider these two methods as efficient estimators to study serial interactions and examine potential correlations between y and x ( - ) . some scholars, for instance, aliyev et al. [ ] , guan et al. [ ] , yue et al. [ ] , and rahman et al. [ ] , further checked fmols and dols results by employing the canonical cointegration regression (ccr). the method is commonly implemented to remove the long-run dependencies between the cointegrating equation and stochastic regressors, which does not apply to small samples in the short-run used in our study. the utilization of the ardl method allows us to identify the interaction between the variables, but not the direction of causalities. to capture these directions, we employed a causality test elaborated by toda and yamamoto [ ] . this technique has been extensively used by many scholars, including pantamee et al. [ ] , adebayo [ ] , and bilgehan [ ] , to estimate causal relationships between domestic market parameters and exogenous factors across developing countries worldwide. among the drawbacks of the ty causality test is the inability to predict the relative strength of causalities between the variables beyond the period under study. sankaran et al. [ ] , rana and sharma [ , ] , and wang and ngene [ ] suggested to overcome this problem by using the wald or modified wald (mwald) tests, but hayashi et al. [ ] and lemonte [ ] demonstrated that, in small samples when used empirically to search for unimportant parameters, the wald test procedure could be misleading. in furtherance of zhang et al. [ ] , mao et al. [ ] , adebayo [ ] , and chan et al. [ ] , we used variance decomposition instead of the wald test to explore the strengths of inter-variables causal interactions and to reveal potential causality impacts. the method was applied for nine consecutive periods from july till march . the results of the adf and the pp tests across three groups of countries (see supplementary materials to this paper, tables s -s ) demonstrate that all five variables are stationary at a level of either i( ) or i( ). in all cases, the calculated f-statistics values exceed the upper bound (table ). it means that the precondition for co-integration between y and x ( - ) is established in all countries included in the study. the stationarity of the data series along with the revealed co-integration between the variables both confirm the appropriateness of the established data set for the ardl analysis. since the study includes six periods (months), it is mainly centered on explaining the short-run relationship between the number of people with insufficient food consumption and independent variables. the ardl short-run estimates for the three groups of countries are summarized in table , the detailed per-country calculations are provided in supplementary materials (tables s -s ). in group countries, the strongest effect on the growth of y is caused by an increase in food inflation x . this effect is statistically significant across the group. some variables also exert strong direct influence on y, for instance, x in sierra leone and yemen and x in haiti and niger. when other factors remain constant, an increase in the number of registered covid- cases by % results in the growth of y by . % in tajikistan and by . % in mozambique and sierra leone. in niger, a . % increase in the number of people with insufficient food consumption is caused by a % rise in x ( . % in guinea, . % in tanzania, and . % in afghanistan). in group countries, we see kaleidoscopic linkages between y and x . in pakistan and india, the countries of south asia which have been severely hit by the pandemic, an increase in covid- cases by % results in the growth of the number of people with insufficient food consumption by . % and . %, respectively. in east asia, on the contrary, we see that the food security status of the households improves when the number of registered covid- cases goes up (when other variables remain constant). in cambodia and vietnam, where the growth of ∆x in january-june was more moderate compared to some of their neighbors in south asia, we see a negative x -to-y relationship. the lower portion of imports in the balance of food trade has a positive and statistically significant impact on the number of people with insufficient food consumption in cameroon, kenya, tunisia, and india, whereas, in cambodia, the relationship between x and y is negative. the effects of x and x on y are positive in all countries, except cambodia, but not that significant compared to x and x . while the increase in the number of confirmed covid- cases is found to have a significant positive effect on y in the countries of latin america and the caribbean, in the case of many other group countries, there is a negative relationship between these variables (botswana, namibia, libya, jordan, and iran). the strongest impact of x on y is revealed for peru and ecuador, where an increase in covid- cases by % is associated with the growth of the number of people with insufficient food consumption by . % and . %, respectively. statistically strong interplays are reveled between y and x in algeria, botswana, and colombia, between y and x in sri lanka and turkey, and between y and x in ecuador and namibia. the negative influence of x on y is identified to be statistically significant in sri lanka and iran, of x on y-in algeria, dominican republic, iran, and iraq, of x on y-in sri lanka. error correction measure is statistically significant in the case of all three groups of countries. the results of the fully-modified ordinary least squares (fmols) and dynamic ordinary least squares (dols) tests are employed to check the robustness of the ardl estimates (table for a group-based summary, tables s -s for country-specific data). the number of registered covid- cases is confirmed to result in higher food insecurity across three types of economies included in the study, except some countries of sub-saharan africa (burkina faso, chad, ethiopia, zambia, botswana, and namibia), middle east and north africa (yemen, iran, jordan, and libya), and east asia and pacific (cambodia and vietnam). among these twelve countries, for which we see a reverse relationship between covid- cases and the number of people with insufficient food consumption, there are representatives of various income groups. reasoning from this fact, we can assume that in a particular country, the direction of the y-x link does not depend on gni per capita. however, when the relationship between these two parameters is positive, there is evidence of a stronger y-x correlation in group countries compared to that in group low-income economies. the toda-yamamoto test demonstrates the most significant causality flowing from the number of covid- cases to the number of people with insufficient food consumption in group countries of latin america (colombia, ecuador, and peru) and europe (turkey), whereas, in low-income economies, the x →y causality is weaker (table , tables s -s ). similarly to bidirectional interactions between covid- cases and food insecurity across all groups of countries, both the fmols and dols tests confirm divergent relationships between the number of people with insufficient food consumption and the balance of food trade. in group and group , y-x relations are positive (except for cambodia, iran, and sri lanka), while in group , they are negative for almost half of the countries. in sub-saharan africa (burkina faso, chad, mali, niger, and tanzania), an increase in the balance of food trade is identified to be effective at reducing the number of people with insufficient food consumption. from the estimation of the toda-yamamoto causality test (table ) , we see the unidirectional x →y causality in group countries, but the significance of the link is low. the strongest influence of food access on food security is revealed in low-income economies of sub-saharan africa (burkina faso, ethiopia, guinea, mali, mozambique, and sierra leone), as well as some countries of central asia (tajikistan) and middle east (yemen). in some group countries, robustness tests show a negative relationship between x and y when the number of people with insufficient food consumption goes up amid food deflation. we also see examples of such reversal links in upper-middle-income countries of the middle east (iran and iraq), where food prices are to a large extent under government control. confronting hypothesis , in lower-middle-income economies of southeast asia (cambodia, india, indonesia, pakistan), seasonal retreat in food prices does not immediately result in higher food security expectations among people. in these countries, the x →y causality link is weak due to the high portion of locally produced seasonal food in consumption. among group economies, more significant causality flowing from food inflation to food insecurity is revealed for the countries of sub-saharan africa (cote d'ivoire, nigeria, zambia, kenya), where diversity of locally-produced staples is narrower compared to asia. when a portion of marketed food in supply is higher, a deterioration in economic access to marketed products imposes a more significant impact on the aggravation of food insecurity. it is assumed that in the countries where a large portion of the food supply is ensured by imports, food inflation might correlate with currency exchange. however, we see that in low-income economies, where food access strongly correlates with food inflation, the number of people with insufficient food consumption is marginally affected by currency exchange fluctuations. the weaker link between y and x across group stems from the fact that low-income economies import a considerably lower amount of high-quality and expensive food products compared to lower-middle and upper-middle-income countries. as contrasted with low-income countries, group economies are deeper integrated into global supply chains of value-added food products. from this perspective, amid the covid- pandemic, the most significant causal relationships between volatilities in currency exchange and food supply are found in the countries with the highest gni per capita among those included in the study-turkey, colombia, and peru. with the current dynamics of registered covid- cases across three groups of countries, the extrapolation of the short-run ardl estimates to the future forecasts a gradual increase in the proportion of food insecurity variance explained by the effects of the pandemic. variance decomposition of y-x ( - ) interactions (table , tables s -s ) indicates a diversity of potential causality impacts of covid- cases, balance of food trade, food inflation, and currency exchange on the number of people with insufficient food consumption. for group countries, the decomposition analysis suggests a rather stable and weak y-x linkage over a three-quarters horizon (table s ) . only in nepal, yemen, and mali, the food security situation could be significantly predicted by the variations of x . but even in these countries, we see that the expected proportions of x and x in y nearly equal that of x in size. for most of the low-income economies, variance decomposition projects an increase in the proportion of y explained by food inflation ( . % in ethiopia, . % in chad, . % in the democratic republic of the congo) and currency exchange ( . % in burkina faso, . % in mali, . % in niger). in lower-middle-income economies, the number of people with insufficient food consumption seems to be increasingly affected by food availability. by march , in import-dependent kenya and kyrgyzstan, the proportion of y explained by the balance in food trade is forecasted to exceed % (table s ). the weight of food access in establishing food security will grow in the countries of east asia ( . % and . % of y explained by x in vietnam and cambodia, respectively) and sub-saharan africa ( . % in cote d'ivoire and . % in zambia). the projected causality between y and x is the strongest in the countries of south asia. in india, at the current rate of registered covid- cases, almost . % of the proportion of insufficient food consumption will be impacted by the pandemic. it is the highest expected impact of the pandemic on food security among forty-five countries included in the study. in bangladesh, the strength of the y-x linkage will exceed . % by the second quarter of . across sub-saharan africa and east asia, a relatively low number of registered covid- cases allows one to predict the moderate role of x in the explanation of y variations over a nine-month horizon. among upper-middle-income countries, the impact of the pandemic on the number of people with insufficient food consumption is not expected to vary significantly from region to region. the proportion of y explained by x is expected to peak in the countries, where the number of covid- cases per capita in january-june was the highest among group economies. over the entire time horizon considered in this study, the growth in x will most likely and consistently be converted into a higher percentage of the population in food insecurity status in peru, iran, and turkey (table s ) . variance decomposition also projects significant contributions of x to y in colombia ( . %), algeria ( . %), and ecuador ( . %). the revealed interplays between the variables across three groups of countries allowed us to test the hypotheses: hypothesis : not confirmed. the x -y relationship is uneven across group - countries, where the strength of causal interaction between the two variables increases with the growth of income level. the effect of the covid- outbreak on the number of people with insufficient food consumption is observed across the three groups of countries. this finding supports the expectations of the fao [ , ] , the wfp [ ] , and the wto [ ] , as well as the projections of many scholars [ , , ] , who say that the spread of covid- may bring damage to global food security, particularly painful in the least developed and developing economies. according to our results, the number of registered covid- cases is indeed associated with higher food insecurity in many countries included in the study. the y-x linkage is statistically significant in the countries (primarily, middle-income economies) where the number of registered covid- cases per capita is high (pakistan, india, peru, ecuador, turkey). across low-income economies; however, the impact of covid- on food insecurity is much weaker compared to that in upper-middle-income countries. this result well agrees with the fao's estimation that higher-income countries are more likely to face food supply disruptions during the novel health crisis, given their deeper integration in global supply chains and capital-intensive agricultural systems [ ] . in , the wfp [ ] reported yemen, the democratic republic of congo, afghanistan, venezuela, ethiopia, south sudan, syria, sudan, nigeria, and haiti to constitute the worst food crises. confronting the established hypothesis , we see that in most of these countries, the relationship between the number of people with insufficient food consumption and the number of covid- cases is not strong but moderate. for example, in afghanistan, where at least % of the population is in a state of food crisis [ ] , the increase in the number of covid- cases by % results in the growth in food insecurity by only . %. moreover, we see that in several low-income countries, the dynamics of covid- cases is related to y in a negative way. in some countries, where the number of covid- cases remained low during january-june , there is a reversal y-x relationship. in haiti, an increase in the number of covid- cases by % is associated with the improvement in the food security status of the population by . % (by . % in nepal and by . % in chad). such a relationship can be explained by a statistically insignificant correlation between x and y due to the low number of confirmed covid- cases per capita. still, the effects of the pandemic on food security in low-income countries should not be underestimated. even without considering the direct health-related influences of the spreading covid- virus, the fao projects low-income economies of africa to overtake both lower-middle-income and upper-middle-income countries of asia and latin america to become the region with the highest number of undernourished people in [ ] . covid- could exacerbate this trend, while the effects of the current health crisis on food security may be amplified by local outbreaks of other diseases that have been endemic in africa and asia. many scholars, including mouloudj et al. [ ] , bakalis et al. [ ] , poudel et al. [ ] , and siche [ ] , witnessed significant adverse effects of sars, mers, avian and swine flu, ebola, and other outbreaks on both agricultural production and food consumption behavior. on a smaller scale and in a more localized context, endemic diseases cause disruptions across local food supply chains similar to those the covid- pandemic does to the global food supply. according to ceylan and ozkan [ ] , both sars and mers had a downsizing effect on the production and supply of food, as well as on labor demand in agriculture. kodish et al. [ ] and wernery and woo [ ] found movement restriction policies and quarantines introduced during mers, ebola, and other more local outbreaks to have substantial effects on agricultural production, food industry, as well as on distribution and retailing of many staples. dounamou et al. [ ] revealed a significant shift in consumption patterns during ebola outbreaks in west africa. in an attempt to avoid the consumption of wild meat potentially associated with the ebola virus disease, many people tend to switch to domestic meat and fish. in a situation when affordability and availability of alternative protein sources are deteriorated by trade and economic factors (as we see it amid the covid- pandemic), local outbreaks of other diseases may substantially aggravate both health and food security status of broad segments of the population. transmissibility of covid- is estimated to be . compared with . for sars. other recent pandemics had lower basic reproductive rates- . for the influenza pandemic and only . for mers [ ] . despite comparable transmissibility rates, the trajectories of covid- and sars are different. while sars outbreak was contained within eight months with a global total of reported cases across countries [ ] and mers caused reported cases in countries [ ] , covid- is spreading rapidly with over million known cases as the end of june . but the unprecedented spread of covid- throughout the world compared with other pandemics of the past is caused by greater ease of global transportation [ ] and higher population density [ ] the world has achieved by , not exclusively by higher contagiousness or better transmissibility of the novel coronavirus. with the growing globalization, any local outbreak has its chance to emerge to the global pandemic, while climate change and environmental degradation may increase the appearance of zoonotic diseases in humans [ , ] . in ldcs and developing countries of africa, asia, and the middle east, the impact of outbreaks on the food security status of people is particularly severe in transitional food value chains, such as wet markets [ ] . they bring together large numbers of people in crowded spaces at considerable risk of contagion [ ] . according to hasöksüz et al. [ ] and silva-jaimes [ ] , in such traditional food markets where human-wildlife interactions and cross-species infections are frequent, novel coronaviruses are likely to emerge periodically. petersen et al. [ ] also expect a post-covid- pandemic of another coronavirus, an influenza virus, a paramyxovirus, or a completely new disease to be highly likely in the nearest future. due to rather high economic and social costs of bringing local outbreaks under a successful level of control at early stages [ ] , ldcs and developing countries of africa and south asia are particularly vulnerable to the frequency and intensity of disease cycles that may realize their "pandemic potential". on top of the health and economic effects of covid- , there are climatic pressures that often aggravate supply-side food shocks in africa and asia (droughts, heatwaves, locust swarms, etc.) [ ] . in , production declines due to dry weather conditions are expected in morocco and tunisia [ ] . in east africa and south asia, significant rainfall amounts resulted in floods and caused damages to farmland and livestock deaths. zurayk [ ] has recognized locust invasion in the countries of the middle east and east africa as a further destabilizer of the stability of food supply in the times of the pandemic. shilomboleni [ ] prognoses the covid- pandemic to put a further strain on africa's agricultural sector amid the recent desert locust outbreak in the horn of africa. in west africa, covid- lockdowns are limiting population movement and causing local labor supply shortages [ ] . according to fao's crop prospects [ ] , adverse weather resulted in a below-average output in north africa and central asia and near-average cereal harvests in central america and the caribbean. amid such climate-change driven disruptions of food systems, the pressure of both covid- and local outbreaks on food consumption may be intensified by lower harvests and higher food prices in group countries, as well as across a wider community of developing economies. mouloudj et al. [ ] and janssens et al. [ ] expect developing countries of africa and asia in which agriculture contributes significantly to gdp (sierra leone, chad, niger, mali, cambodia, and vietnam) to be affected by both climate and economic effects of the pandemic (suspension of agricultural activities, agricultural labor lockdowns, etc.). according to the fao estimates [ ] , over million people in africa in need urgent food assistance, including million in nigeria, . million in burkina faso, million in niger, . million in mali and sierra leone, and million in chad. with respect to food availability, domestic agricultural production in ldcs and developing countries of africa may be severely affected by the disruption of the supply of various inputs [ ] , including animal feed and ingredients for food product preparation, especially if they need to be imported [ ] . hypothesis : partly confirmed. in group economies, the influence of food inflation over access to food and agricultural products is stronger than that of food trade over food availability. in low-income economies, the food security status of people is significantly influenced by both the physical availability of and economic access to food products. according to fao's most recent food security report, a key reason of growing food insecurity in developing countries is that many people cannot afford the increasing cost of healthy diets, while the nutritional status of vulnerable population groups has been deteriorated due to the economic impacts of covid- [ ] . martin and anderson [ ] and freund and Özden [ ] assumed that protectionist trade policy could bring a risk of additional economic losses for developing countries by insulating domestic markets from global food price fluctuations. the fao's monitoring of food price changes [ ] since february demonstrates that amid the covid- crisis, trade restrictions are imposed against the backdrop of growing food prices. the fao food price index averaged . points in june (by . % higher than in may ) [ ]. zurayk [ ] reports a global price increase in the food basket of % to % with the prices of dairy products, vegetable oils, sugar, and other food and agricultural products rebounded to multi-month highs [ ] . our results indicate that rising food inflation deteriorates food access across group countries as it is tightly linked with the increasing number of people with insufficient food consumption. this correlates with fao's estimation that the cost of a healthy diet in has exceeded the international poverty line, making it unaffordable for the poor and thus fueling food insecurity in most developing countries, particularly in sub-saharan africa and southern asia [ ] . healthy diets have become % less affordable compared to the nutrient adequate diets and five times more expensive than diets that meet only dietary energy needs through a starchy staple [ ] . many scholars, including bakalis et al. [ ] , berkowitz et al. [ ] , gundersen and ziliak [ ] , and garcia et al. [ ] , associate undernourishment with adverse health outcomes, including chronic conditions, mental health challenges, and increased risk of mortality. niles et al. [ ] found that lower economic access to food forced many food-insecure households to disrupt eating, cut meals, eat less to stretch their food, or even go hungry. this link between the cost of a diet and food security status has an important impact on individual health. an increase in food inflation is confirmed to have a significant effect on food insecurity in group countries, thereby supporting hypothesis and confirming previous findings of smith et al. [ ] , power [ ] , sonnino et al. [ ] , esturk and Ören [ ] , and many other authors who linked food insecurity with the level of income rather than with food imports. in our study, the strongest influence of food inflation on the number of people with insufficient food consumption is revealed in low-income economies of sub-saharan africa (burkina faso, ethiopia, guinea, among others), as well as some countries of asia and the middle east. the unctad [ ] also acknowledged the countries of sub-saharan africa to be particularly exposed to demand-side risks of food access during the covid- crisis, including contracting incomes, downturns in economic growth, undernutrition, and micronutrient deficiencies in response to income shocks. food inflation affects demand, but inflation itself is often a product of changing demand patterns. during the economic crisis of - , reduced income made people spend less and resulted in shrinking demand for food [ ] . the novel health crisis is quite a different story. on the back of rising lockdown fears in february-march , food inflation was fueled by higher demand due to panic buying [ , ] . although yuen et al. [ ] , zurayk [ ] , and fawzi et al. [ ] did not account for the level of income as a factor that affected such consumer behavior, we may assume the contribution of panic buying to food inflation to be more significant in group countries. in low and lower-middle-income economies, people have less free money to stock up food, while most cases of panic buying have been evidenced in developed countries [ , ] . in ldcs and developing economies, no significant spikes in food demand have been registered in the first quarter of . on the contrary, the fao [ ] expects the crisis-induced economic downturn to alter dietary patterns in the developing world due to a disproportionately larger decline in consumption of higher-value products like meat, fish, fruits, and vegetables. many scholars [ ] [ ] [ ] have found the likelihood of food insecurity to increase with income inequality. according to the fao [ ] , the inequality-insecurity link is % stronger for low-income economies compared with middle-income ones. this well agrees with our finding of the disproportional effects of food inflation on food insecurity across the three groups of countries. for instance, in mozambique (group ), keeping other variables constant, a % increase in food inflation leads to a growth in the number of people in food insecurity status by . % (by . % in tajikistan, by . % in burkina faso, . % in guinea, and so on down the list of group economies). in group , the x -y link is weaker while that in group is the weakest among the countries included in the study. there are even negative relationships between x and y in some group countries of the middle east and southeast asia. with that said, our study demonstrates that in lower-middle and upper-middle-income developing countries, the causality link between food inflation and food security is weaker compared with that in ldcs. generally, in low-income countries, food supply is for the most part ensured by local staple foods, whereas extensive import is prohibitively expensive. according to the fao [ ] , low-income countries rely more on staple foods and less on fruits and vegetables and animal source foods than high-income countries. as previously found by thome et al. [ ] , ritchie et al. [ ] , and elbushra and ahmed [ ] , weak cointegration between food inflation and food security in low-income economies could be explained by the high portion of locally produced staples in consumption. amid the covid- outbreak, some countries have decreased food purchases from abroad, thus automatically increasing their foreign trade balances due to the lower portion of imports. as more households switched to locally produced staples, their food security status improved. however, as noticed by devereux et al. [ ] and farrell et al. [ ] , a closure of open-air markets and a ban on street vendors (the two most common food outlets in poorer countries) may disrupt food access even in a situation when consumption is reoriented on local products. prior to the current health crisis, many food-insecure households have reported such food coping strategies as, for example, seeking resources from the charitable food sector or relying on social networks for support [ , ] . amidst covid- lockdowns and restrictions, most of the nutrition assistance programs have been frozen. therefore, it is revealed that food availability seems to be strongly related to the food security status of households, but through local supply, not import. following deuss [ ] , martin and anderson [ ] , and hendrix [ ] , we assume that food trade restrictions were more pronounced in the countries with a higher import dependency. according to wood et al. [ ] , for import-dependent economies, both global food chain disruptions and protectionist trade policies on the part of key suppliers could have serious negative consequences for food security. this agrees with puma et al. [ ] , who found that ldcs suffer greater import losses due to disruption of food supply chains through their increased dependence on imports of staple foods. there is a unidirectional x →y causality across group , but the significance of the link is low even in the countries where food availability largely depends on imports (haiti, guinea, tajikistan). these findings do not support hypothesis . with an increase in the level of income, the link between food trade balance and food availability becomes tighter. the strongest effect of x on y is revealed for import-dependent upper-middle-income economies (jordan, lebanon, botswana, algeria, colombia). in most low-income countries, we see how a lower proportion of food imports in trade amid the covid- outbreak is associated with a reduction in the number of people with insufficient food consumption. hypothesis : confirmed. different from the low-income economies, in group countries, the food security status of people is affected by food trade and currency exchange rather than by food inflation. as recognized by wood et al. [ ] and hendrix [ ] , food import is particularly essential to ldcs for meeting the dietary needs of their population during the covid- outbreak. our results; however, suggest that group and group economies rely on less diversified imports compared to group countries which are deeper integrated into global supply chains. for the latter, higher dependence on imports results in a stronger influence of food trade balance and currency exchange on food supply and, consequently, on the food security status of people. while devereux et al. [ ] stated that covid- had not compromised food supply globally, mouloudj et al. [ ] and toffolutti et al. [ ] found food security status of developing countries that depended on imports of staples to be particularly threatened by disruptions of the food supply in the first half of . in import-dependent developing countries, currency depreciation drives up the cost of food imports [ ] . thus amid market uncertainties induced by the covid- crisis, currency exchange becomes a factor of both food availability (more expensive imports due to currency depreciation) and access to food (the higher price of imported food on the domestic market when expressed in national currency). the unctad [ ] revealed heightened risks to food security in those countries of north africa and the middle east that rely on food imports and thus are dependent on currency volatilities triggered by the pandemic. in support of this unctad's estimation, the strongest effects of x and x on y are found for algeria and turkey. in furtherance of hypothesis , we expect an increase in the proportion of y explained by both food trade and currency exchange, particularly, in upper-middle-income countries. in libya, where the dependency on food imports exceeds %, the impact of x on y is projected to be the highest among the three groups of countries ( . %). in namibia, another group country largely dependent on imports, the proportion of x in y will almost reach . % by march . the importance of currency exchange in securing food supply will go up in the countries deeply integrated into global food supply chains. for instance, in turkey, . % of y will be explained by x . the effect of food inflation on the number of people with insufficient food consumption is found to be weaker across upper-middle-income economies compared to that in low-income countries. this finding both supports hypothesis and agrees with frankenberg and thomas [ ] and smith and glauber [ ] , who revealed that higher prices for staple foods aggravated poverty traps for low-income households, but might not have much effect on the food security status of relatively well-off households. on the other hand, domestic price volatility may be exacerbated by trade restrictions that have been implemented by some group and group countries on the backdrop of the covid- outbreak. in the studies on the effects of export restrictions during the global crisis of - , deuss [ ] and djuric et al. [ ] demonstrated that protectionist policies did not achieve their objective of reducing price volatility in the country imposing the restriction. there are also studies that show how trade restrictions resulted in food price spikes during the food crises in - [ ] , - [ ] , - [ , - ] , and - [ ] . dawe and timmer [ ] and abbott [ ] found that, in the short-run, an export ban could be a successful decision to ensure the food security of a country by both establishing a reserve of staples and isolating domestic market from the global price volatility. for instance, in cambodia, that limited exports of certain agricultural products in march-april , we see how both negative balances of food trade and low food inflation resulted in the reduction in the number of people with insufficient food consumption. for vietnam and turkey, on the contrary, their decisions to restrict food export have not brought much success. the ardl analysis demonstrates that in vietnam, a % change in the food trade balance is associated with an increase in food insecurity by . %. in turkey, the x -y relationship is weaker but still positive. in both countries, we revealed substantial causal interaction between x and y ( %→ . % in turkey and %→ . % in vietnam). this result supports the estimations of anderson and nelgen [ ] , giordani et al. [ ] , and rude and an [ ] , who found that trade protectionism might trigger food inflation and thus aggravate food insecurity. irrespectively of any particular economic or food crisis, developing countries with their limited resources are more vulnerable to the deterioration of the macroeconomic environment. food price volatility, no less food trade bans, is particularly detrimental to low-income countries where either a disruption of a supply chain or a contraction of economic access to staples may raise food conflicts. before the covid- outbreak, over two billion of the most impoverished people in the world spent up to % of their disposable income on food. the economic downturn stemmed from the pandemic may result in substantial growth of this figure, since in poorer countries, food demand is particularly linked to income [ ] . in the past, both global (sars and mers) and local (ebola, avian and swine flu) outbreaks had significant adverse effects on not only the health of people but also agricultural production and food consumption patterns across the developing world. the fao expects hunger to increase in developing countries where the economy has slowed down or contracted due to the covid- crisis [ ] . there are threats to the access of the poor to food as a consequence of lost income from lockdowns, trade restrictions, food inflation, and currency depreciation. most ldcs as well as many developing countries also suffer from underinvestment in public health, which may amplify the pandemic's impacts [ ] . this study is the very first try to assess the preliminary effects of the covid- pandemic on the food security status of people across the developing world. in the cases of ldcs and developing countries most vulnerable to food insecurity, the authors attempted to contribute to the nascent array of studies on trade and economic influences of the global health crisis over food availability and access to food and agricultural products. as distinguished from those few studies on covid- effects on food supply chains that have been published so far, we revealed interactions between the number of covid- cases and food security status of people across three groups of ldcs and developing economies. the consecutive application of the ardl method, yamamoto's causality test, and variance decomposition allowed us to assess the impacts of foreign trade, inflation, and currency exchange on the number of people with insufficient food consumption during the global health crisis. three key findings have emerged from testing of the hypotheses in this study. first, the covid- pandemic affects both the food security status of people and the stability of food supply chains in developing countries across the world. the effects are more perceptible in upper-middle-income economies than in ldcs given the deeper integration of the former in global supply chains and capital-intensive agricultural systems. second, in lower-income developing countries, food security risks attributed to the emergence of the covid- health crisis are mainly related to economic access to adequate food supply (represented by food inflation parameter). third, in higher-income developing countries, availability-sided food security risks are more prevalent (represented by the parameters of food trade and currency exchange) (figure ). obviously, the estimations provided in this paper are rather rough. the study is built on a short array of data covering only six months that have passed from the start of the covid- spread. over time, seeding of new data on the number of new covid- cases, dynamics of food trade balances, food inflation rates, and currency exchange volatilities will allow one to use the established methodology framework to obtain more well-grounded quantitative assessments of the pandemic's impacts on food security. as more comprehensive data become available from the reports by wfp, fao, wto, and other organizations, the set of variables should be expanded to capture a multidimensional character of food security, including stability of food supply and utilization of food and agricultural products. we do not know whether the pandemic will decelerate by the fall of or whether the second wave will strike the world in . it is yet hard to predict how effective the containment measures will be in slowing the spread of the virus. that is why the three-quarter variance decomposition projections presented in this study must be tested and adjusted continually to monitor the strengths of inter-variables causal interactions in the long-run. this will equip decision-makers with reliable estimations that may help to design coherent and effective policies to mitigate the impact of covid- on food security across developing countries in various parts of the world. supplementary materials: the following are available online at www.mdpi.com/xxx/s . table s : adf and pp tests results, group , table s : adf and pp tests results, group , table s : adf and pp tests results, group , table s : ardl short-run estimates, group , table s : ardl short-run estimates, group , table s : ardl short-run estimates, group , table s : fmols and dols tests results and ardl long-run estimates, group , obviously, the estimations provided in this paper are rather rough. the study is built on a short array of data covering only six months that have passed from the start of the covid- spread. over time, seeding of new data on the number of new covid- cases, dynamics of food trade balances, food inflation rates, and currency exchange volatilities will allow one to use the established methodology framework to obtain more well-grounded quantitative assessments of the pandemic's impacts on food security. as more comprehensive data become available from the reports by wfp, fao, wto, and other organizations, the set of variables should be expanded to capture a multidimensional character of food security, including stability of food supply and utilization of food and agricultural products. we do not know whether the pandemic will decelerate by the fall of or whether the second wave will strike the world in . it is yet hard to predict how effective the containment measures will be in slowing the spread of the virus. that is why the three-quarter variance decomposition projections presented in this study must be tested and adjusted continually to monitor the strengths of inter-variables causal interactions in the long-run. this will equip decision-makers with reliable estimations that may help to design coherent and effective policies to mitigate the impact of covid- on food security across developing countries in various parts of the world. table s : adf and pp tests results, group , table s : ardl short-run estimates, group , table s : ardl short-run estimates, group , table s : ardl short-run estimates, group , table s : fmols and dols tests results and ardl long-run estimates, group , table s : fmols and dols tests results and ardl long-run estimates, group , table s : fmols and dols tests results and ardl long-run estimates, group , table s : ty causality test results, group , table s : ty causality test results, group , table s : ty causality test results, group , table s : variance decomposition of y over a nine periods (three quarters) horizon, group , table s : variance decomposition of y over a nine periods (three quarters) horizon, group , table s : variance decomposition of y over a nine periods (three quarters) horizon, group . author contributions: v.e. designed the research framework and wrote the paper; t.g. analyzed and interpreted the data. all authors have read and agreed to the published version of the manuscript. sustainable development goals food and agriculture organization of the united nations; international fund for agricultural development united nations children's fund; world food programme; world health organization. the state of food security and nutrition in the world . safeguarding 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no conflicts of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord- - nuhvs authors: attorp, adrienne; mcareavey, ruth title: muck, brass and smoke: policy post-exceptionalism in the agri-food sector() date: - - journal: j rural stud doi: . /j.jrurstud. . . sha: doc_id: cord_uid: nuhvs governance is well recognized as shifting boundaries of responsibilities for doing things among key partners. what is less clear is how exactly power relations are altered and where power is concentrated as new forms of governance emerge. in our article we use the concept of policy post-exceptionalism to critically assess ‘going for growth’, a strategic action plan that, until the recent past, underpinned the northern ireland agri-food industry. the agri-food sector has an important and prominent role in the northern ireland economy. the going for growth strategy illustrates how particular interests within the sector are supported by government, as demonstrated through the renewable heat initiative and a scheme promoting anaerobic digestors. using policy post-exceptionalism to scrutinize the strategy, our research shows what can go wrong when a transition to post-exceptionalism occurs. while going for growth purported to represent the wider interests that one might expect to find in a post-exceptionalist approach to agri-food governance, in fact the concentration of power with corporate actors left little space for the inclusion of wider interests. we conclude that this strategy represented a move towards tense post-exceptionalism, creating at least one political scandal, raising questions of legitimacy and transparency and fundamentally undermining political viability of wider government. it is an extreme case of what can happen when post-exceptionalist policymaking goes wrong. european agriculture has for a long time enjoyed special economic treatment, whereby the rules that generally apply to other major sectors of the economy do not apply to it (greer, ) . this means that it is protected from market forces and receives extensive state intervention (see, for instance, cox et al., ; daugbjerg and swinbank, ; daugbjerg and feindt, ) . consequently, tariffs, subsidies and payments are terms that permeate the agri-food policy domain. however, in recent decades, this special status has been eroded. opposition to the high cost of subsidizing agricultural goods comes from different interest groups including consumers, taxpayers and environmental groups and influences the actions of policymakers and food producers (skogstad, ; carolan, ; hinrichs, ; alons, ; greer, ; daugbjerg and feindt, ) . as a result, farmers increasingly need to attend to issues beyond food production, including the creation of environmental and other public goods, if they are to enjoy financial compensations that were traditionally aligned with food production (marsden and sonnino, ) . the involvement of stakeholders beyond government in the policymaking process is reflective of a wider shift from government to governance across many different sectors including health, education and agriculture. at its simplest, governance is characterized by the erosion of traditional boundaries, relying on new partners including the community, public and private sector, and based on devolved power as a way of 'getting things done' (stoker, ; jessop, ) . the outcomes of governance do not differ from that of government, which is about making decisions and enforcing them, but the way of achieving this is different and it suggests greater power for a wider range of stakeholders (rhodes, ; stoker, ) . the perception of process becomes as important as the policy itself and it is important for stakeholders to feel that they are closer to decision making. effective governance relies on attention towards positive and negative consequences, while also achieving a fine balance between the appropriate and legitimate involvement of different interest groups, often operating at different levels (jessop, ; stephenson, ; westerink et al., ) . gerry stoker pointed out twenty years ago that "[t]ensions and difficulties with the institutions of civil society, as well as inadequacies in the organizations that bridge the gaps between public, private and voluntary sectors may lead to governance failure" ( , p. ) . governance ☆ research conducted for this article was part-funded by teagasc, the enviresearch foundation and friends of the earth (northern ireland). failure arises where institutions are not capable of evolution, learning, adaptation and public defence (goodin, ) . this can result in failures of leadership, lack of shared aspirations and social conflict among key partners (stoker, ) . accordingly, we want to analyse the extent to which modes of governing within the agri-food sector in northern ireland (ni) have led to governance failure. specifically, we use the concept of policy (post-)exceptionalism to critically assess the role of 'going for growth' (gfg) (afsb, ), a strategic action plan underpinning the ni agri-food sector for five years from . it set out a series of priorities and recommendations for that sector and was led by a board which was appointed by government. fundamentally, growth and job creation were major priorities, with an anticipated expansion of turnover by percent to £ bn in and an increase in employment by percent within the sector. this was to be achieved through seven wide-ranging themes, including regulation; market share; and innovation and entrepreneurship. emphasis was placed on growth within specific sectors, notably the pig and poultry sectors, the latter being held up as a "role model of a highly integrated and successful sector" (gfg, p. ) . crucially, the strategy identified the need to overcome barriers to expansion of that sector, namely poultry waste. we return to this important factor later when we also elaborate on the strategy. our analysis contributes to wider debates on policy postexceptionalism that analyse a shift away from agricultural exceptionalism towards what daugbjerg and feindt ( ) have termed 'post-exceptionalism', by illustrating the complexity of post-exceptionalist governance dynamics. agricultural exceptionalism refers to a socio-political climate in which national food security and farmers' economic interests prevail, and farmers receive 'special' political treatment in the form of favourable policies and subsidies (skogstad, ; daugbjerg and feidnt, ; alons, ) . post-exceptionalism is not a straightforward concept and there is no consensus in the literature on exactly what it is. while it involves new actors; shifting roles for the state, with emphasis on market-based solutions; expanded policy issues and policy innovation, ambiguity remains. for instance, is the shift of concentration of power away from primary producers towards food retailers and processors exceptionalism or post-exceptionalism, or is some government intervention likely? neither is there consensus in the literature on whether or not european agriculture has fully transitioned to post-exceptionalism. while some argue that a clear transition to post-exceptionalism has indeed been made (repplinger, ) , particularly within specific arenas such as farm animal welfare (vogeler, ) , others suggest that there has been only a partial transition from exceptionalism to post-exceptionalism, as manifest within the common agriculture policy (cap) (alons, ; greer, ) . in our analysis, we find a transition from exceptionalism, where power remains concentrated in the hands of a few but has shifted away from primary producers towards the corporate sector, namely large food processing companies. this shift is strategically important as these advantageously-placed individuals can manipulate policymaking to realize their own interests (goldstein and keohane, ; in skogstad, ) . not only is this an insidious and hidden form of power (lukes, ) , but we argue that it is a form of post-exceptionalism more akin to what daugbjerg and feindt ( ) identify as 'tense post-exceptionalism' (p. ), where political viability is undermined due to unbalanced involvement of different interests. in doing so, we seek to add clarity to debates on what constitutes post-exceptionalism and what the implications of problematic transitions are. the article is structured as follows: we begin with a general overview of governance and power in food systems, including analysis of the concept of policy (post-)exceptionalism. the gfg strategy is then presented before we critically examine its environmental implications. our analysis moves on to use two schemes that emerged out of the strategy to illustrate asymmetric power relations within the agri-food sector. we show how the sector represents a form of tense post-exceptionalism, effectively limiting the wider interests of society and prioritizing a privileged few. examining the processes of governance and policymaking is critical in understanding relationships between the state and other stakeholders in the agri-food industry. it has been shown how conceding disproportionate power to certain interest groups can lower the effectiveness of policies, not least because those policies may ignore the embeddedness of markets in wider social structures and so omit broader societal interests such as concern for the environment or animal welfare (foord, ; benoit and patsias, ; richardson, ) . in recent years, scrutiny has been directed towards a range of issues within agri-food, including relationships between industry and the state; environmental degradation; the position of more vulnerable groups; and the capacity and sustainability of the system overall (barling et al., ; angus et al., ; clapp and fuchs, ; hinrichs, ; bui et al., ; kirwan et al., ; lang, ) . to investigate this more fully, we examine the overarching approach to governance within the agri-food sector. the european agri-food sector remains a special case in governance terms. exceptionalist policy approaches tend to occur where a sector is perceived to deliver significant benefits to the public good, e.g. health or education (daugbjerg and feindt, ) . it occurs in farming because of the belief that disproportionate state intervention is warranted due to its difference from most other economic sectors. in short, agricultural producers face unpredictable natural and economic risks, and the agricultural sector is seen to contribute to wider national interests such as food security (skogstad, ; daugbjerg and swinbank, ; daugbjerg and feindt, ) . this has long been the case. for instance, in , the selborne committee in the uk recognized the need for "increasing home-grown food supplies in the interest of national security, to consider and report upon the methods of effecting such increase" (cited in cox et al., , p. ) . post-second world war, agricultural exceptionalism was also central to the state-assisted policy paradigm that arose in both europe and the united states (skogstad, ) . the european union's common agricultural policy was a key element of this post-war paradigm, originally using a combination of protectionist tariffs and price supports to support european food security (harvey, ) . in terms of policymaking, the agriculture sector therefore long benefitted from special treatment, or 'agricultural exceptionalism' (cox et al., ; grant, ; skogstad, ) , where farmers were viewed as the sole legitimate 'custodians of the countryside', and a relatively closed network of farm ministries and farm groups were traditionally responsible for developing agriculture policies (clunies-ross et al., ; daugbjerg and swinbank, ; daugbjerg and feindt, ) . historically-close ties between the agriculture sectorfarmers' unions in particularand government prevailed (jordan et al., ; woods, ) . while other groups such as suppliers of agricultural inputs, financial institutions and food processors benefitted from this policy approach, the intention was to support agricultural producers (clunies-ross et al., ) . in recent years there has been evidence of a transition away from traditional agricultural exceptionalism: food processors and retail corporations increasingly assume a privileged position at a global level as they integrate food systems and occupy political and economic leadership roles (lang et al., ; clapp and fuchs, ) , and the idea of agriculture as 'multifunctional' -not just about food productionhas become a central research and policy focus (marsden and sonnino, ; renting et al., ). there has also been a broad "participative turn" in western public policies (benoit and patsias, , p. ), whereby community involvement and participatory approaches to decision-making have been encouraged (prager et al., ; benoit and patsias, ) . this shift has been reflected in the cap, which, under ongoing pressure from the world trade organisation, moved away from legislating protectionist tariffs and price supports towards offering farmers support via less market-distorting measures (harvey, ) . additionally, in response to the release of a seminal eu report on rural society (european communities commission, ) , support for environmental and rural development measures was included in recognition of the multi-functional nature of the countryside. alongside this evidence of a shifting trajectory of agricultural policy in europe, there was much interest in what a paradigm shift away from exceptionalist policymaking would look like (skogstad, ; persson, ) . significant debate and analysis preceded the labelling of agricultural policy as post-exceptionalist in (daugbjerg and feindt, ) . skogstad argues that a shift away from exceptionalism is characterized by deregulation of agricultural markets and "the termination or substantial restraint of government expenditures for agriculture, and a discourse antithetical to government intervention" ( , p. ) . meanwhile, in considering agricultural policy beyond exceptionalism, persson ( ) underlines the importance of policymaking moving away from a productivist discourse to one of environmental concerns as economic and environmental interests are balanced. according to greer ( greer ( , p. , the shift towards post-exceptionalism occurs when new actors and interests are incorporated into the policymaking arena, effectively extending the boundaries of inclusion beyond primary producers. "messy" policy issues such as the environment or climate change become also increasingly important, and the highly interventionist role of government becomes weakened, as reflected in changing policy instruments and programmes. however, post-exceptionalism retains the idea that a sector is special. feindt ( , p. ) articulate how the move away from a "compartmentalized policy arena" is combined with the idea that the agriculture sector still warrants special treatment, albeit with an "updated set of policy ideas" (such as those related to sustainability). they argue that this results in policy innovation. however, a full transition to market orientation does not occur and there remains room for government intervention (daugbjerg and feindt, ) . some maintain that a neat transition to post-exceptionalism has not been made, rejecting the notion that policy instruments have been "reframed" (persson, (persson, , p. to address wider environmental interests (alons, ; greer, ) . writing about the cap, greer ( ) argues that, even though some of the policy mechanisms have changed, agricultural policy retains a key focus on propping up farm income. he argues that a form of "shallow exceptionalism" has emerged instead, with the inclusion of new actors and intuitions alongside changes to policy instruments representing change, but the ideas around redistribution and farm subsidies remaining intact (greer, (greer, , p. . clearly, the transition is not straightforward, and the literature suggests that there are circumstances which fall between the two policy approaches. benoit and patsias ( ), tosun ( ) and mccarthy et al. ( ) highlight how actors who were formerly marginalized within agri-food politics, including processors, suppliers, retailers, ngos and consumers/consumer organizations, have begun to play an increasingly active role in the policy area. similarly, lawrence et al. ( ) argue that increased financialization and corporatization of the agriculture industry have brought various upstream (e.g. financial institutions, input producers) and downstream interests and agencies (e.g. processors, distributors, retailers) into the food value chain. daugbjerg and feindt ( ) state thatin europe, at leastrelatively little is known about the degree to which these players influence policy around food and agriculture but that "post-exceptionalist actor constellations are more complex and contain players from a wider range of backgrounds" ( , p. ). this does not necessarily result is equal power sharing across those new players, but is typically manifest in "strategic positioning" of individuals or partners (skogstad, ) , such as a concentrated role for multi-national food corporations in food systems spanning the local and the global (barling et al., ; clapp and fuchs, ; foord, ) . as a result of this concentration of control, there is wide recognition that prevailing food governance systems are no longer fit for purpose due to questions of legitimacy, power, resources and interactions of relevant actors within agri-food governance (hinrichs, ) . further unease exists over a range of issues including climate change; food safety and quality; and wider systemic inequalities (angus et al., ; clapp and fuchs, ; hinrichs, ) . policy decisions rely heavily on lengthy debates on the nature of the 'problem' to be addressed, and corporate actors are key influencers in how this is framed in public discourse (clapp and fuchs, ; sacks et al., ) . in light of these issues, contemporary research on food systems is concerned with different forms of change (see hinrichs ( ) for an overview), specifically, transition, which "implies a gradual, pervasive shift from one state or condition to something different" (hinrichs, , p. ) and involves adjusting imbalances and addressing "design faults" (richardson, , p. ) . before considering the case of the ni agri-food sector as a means of scrutinizing current transitions, we provide an overview of our approach to the research. language may be used by those in power to advance or impede the way a particular social issue is dealt with in society (fairclough, ; van dijk, ) . we wanted to probe beneath the official policy documents employed in the gfg strategy to get beyond the '''well-intentioned' passive construction of words and sentences" (evans-agnew et al., , p. ) . accordingly, our study is based on a critical discourse analysis of the gfg strategy. rather than traditional discourse analysis found in linguistics, we employed fairclough's ( ) popular approach which has been used to analyse social policy and practice (hastings, ; taylor, ; richardson, ; evans-agnew et al., ) . used in this way, it takes account of language and social practices, the latter referring to behaviour and action. it relates to the complex interactions that occur in everyday life and the way in which people advance their interests. thus, our aim was to employ a simple approach to evaluate the claim made in the gfg strategy and compare these to practice on the ground in terms of what actually occurs within farming and the agri-food sector in ni. our data collection involved scrutiny of policy documents relating to gfg, including the final printed strategy; review of the website that was used to promote that strategy; examination of emerging policy initiatives (namely promotion of anaerobic digestors and the renewable heat initiative), and fourteen semi-structured interviews with individuals involved in the agri-food sector. interviews were necessary to give us insight into the social practices of different actors in the sector. six preliminary interviews were conducted in and , and a further eight were conducted in and . we sought to achieve a range of perspectives and interviewed primary producers, individuals involved in retail, food processing and policymaking, as well as a few academics. some of our respondents wore 'two hats', for instance, being primary producers but also having involvement in food processing. generally, we found that few respondents were universally critical of the strategy, and that most identified most found some good points. for reasons of confidentiality, the interviewees' identities remain anonymous, but between them they represent a poultry farmer, two academics, three environmental ngo employees, four government agency employees and four individuals who are employed in different aspects of the food chain (three of whom are also part-time farmers). interviews explored many different themes relating to food security and safety; export markets; environment; poultry waste; and family farms. not all interviewees agreed to being recorded, but where this was agreed, interviews were transcribed. thematic analysis was undertaken through reading and re-reading transcripts and interview notes, and coding them according to the key themes that arose. consideration was given to discourse, style and genre to show how language and rhetoric are used to advance a particular position. with its focus on text and talk, this approach evaluates how language is used. specifically, it examines what is being said about the strategy and how it is presented, along with opinions about its context, rationale and expected outcomes. ni lies within the jurisdiction of the united kingdom (uk) and enjoys devolved powers on several issues. generally, it maintains a peculiar position within the uk, not only because government in ni is elected under the single transferable vote (a power sharing government), but also because of a history of civil unrest and fractured relations with great britain during the latter part of the th century. connected to this difficult legacy, ni relies heavily on subvention from westminster to a degree that many ailing english regions would welcome. the power sharing government was thwarted in and was not fully restored until january , having been brought down by the renewable heating incentive, a scheme directly connected to the agri-food sector in ni and to which we return later in our analysis. like the rest of the uk, agricultural policy here has been governed by the cap, and although the importance of ni's agri-food industry has declined in recent decades, it remains a significant contributor to the region's economy, accounting for £ . billion ( . percent) of gross value added (gva), and employing . percent of the region's population in ( . percent in agriculture, forestry and fishing; . percent in food and drink processing) (daera, ). the estimated contribution of agriculture and food and drink is significant for the regional economy, each with employment multipliers of . ; over two jobs are generated elsewhere in the regional economy for every job in those sectors (nisra, ). the industry is roughly twice as important for the ni economy as it is for the uk economy as a whole; gva from agri-food is only percent nationally, and only . percent of the uk population is employed in the sector (daera, ). farming in ni is characterized by small, usually family-owned, farms units: the average size is ha compared to ha in the uk ( in europe) (daera, ). nearly percent of the land is categorized as less-favoured and most farms are cattle and sheep ( percent) (daera, ). however, this structure is being eroded with the policy drive to intensify farms and expand production. this shift is evident in the trend of growth within the intensive dairy, pig and poultry sectors and concurrent decline of the (mainly) extensive drystock sector. between and , there was a seven percent increase in the already-significant dairy herd, a percent increase in pig numbers, a percent increase in broiler numbers, and an percent increase in the commercial laying flock. during the same period, sheep numbers increased by only percent, while the beef herd declined by percent (daera, ). gfg is an agri-food strategy that encapsulates the future desired direction for the sector in ni. the strategy has now run its course, having achieved much of what it set out to do (we return to this below). it is unknown what, if anything, will take its place given the disruption arising from covid- and the uncertainty surrounding ongoing brexit negotiations, which continue to make new policy decisions nearly impossible. however, gfg does provide valuable lessons for policymaking more generally, both within ni and more broadly, some of which we consider here. in its - programme for government, the ni executive committed to developing a strategy for expanding the region's agri-food sector in response to what was perceived as a growth in demand for ni's food products. following this commitment, the ni department of agriculture and rural development (dard -now the department of agriculture, environment and rural affairs), the ni department of trade and investment (deti -now the department for the economy), and invest ni (ni's economic development agency) worked together to set up a bespoke agri-food strategy board (afsb) responsible for developing this strategy, now called 'going for growth' (afsb, a). the board was appointed for an initial tenure of three years from . this was extended for an additional two years in february . tony o'neill, then a director at moy park -at the time ni's largest private sector business and one of europe's largest poultry producerswas appointed chair of the board. other members were subsequently appointed via an ostensibly open application process: board positions were advertised widely and applicants from a range of backgrounds were interviewed. in the end, members were appointed: six representatives from some of ni's biggest agri-food businesses; two independent dairy farmers, both former presidents of the ulster farmers union (ufu); one representative from invest ni; three government officials; and one accountant (afsb, b). conspicuous in their absence were representatives from academia, ngos, the environmental lobby and other community interest groups. a quote from one of our interview respondents illuminates this: "i and others of an [environmental] bent applied, and some at least of us were interviewed, but no go. they wanted an 'industry representative' board, no science or [environmental] knowledge required." despite the apparent 'big industry' focus of the board, according to the afsb's now archived website, efforts were made to engage with stakeholders outside of the agricultural industry, as well as with the smaller players within it. the board established nine sectoral sub-groups tasked with considering specific challenges and opportunities faced by each of ni's key agri-food sub-sectors. the afsb reports that more than stakeholders from industry and relevant government agencies were consulted through this process. it also states that further stakeholders were engaged via a public call for evidence, which received approximately responses from individuals representing a range of interests, including farming, food, forestry, and the environment. as well as meeting with wider agencies loosely associated with government, some of this status is derived from the legacy of the ethno-nationalist conflict known as 'the troubles', which began in the late s and ended with the good friday agreement (gfa) in . the gfa set up a series of government institutions between ni and the republic of ireland and between the republic of ireland and the uk. significant funds have been injected into the region by the uk government and the eu to ensure that conflict remains firmly in the past. here, taken to include primary agriculture as well as food and drink processing. in areas designated as "less-favoured", agricultural production or activity is considered more difficult because of challenges such as difficult climatic conditions, steep slopes, or low soil productivity (european commission, nd (carroll, a) . it currently has a network of poultry farms and processes around million chickens each week. including the northern ireland tourist board and the environment agency, the board "engaged with major retail multiples and environmental interest groups" (afsb, , p. ). feedback received from said stakeholders was then "considered by the main board" and it "influenced the strategic action plan" (afsb, a, p. ). although it could be argued that this demonstrates the policymaking arena now includes more players, a key feature of post-exceptionalism, the degree to which the extra players impacted the final report could be contested given the vagueness with which their input is described, their absence on the actual board and the fact that the majority of the report's recommendations benefit big industry while paying little regard to small family farmers, small food companies or the environment. we elaborate on the latter assertion in detail below. the key features of the gfg strategy are described in the report 'going for growth: a strategic action plan in support of the northern ireland agri-food industry' (afsb, ). gfg's premise is to expand supply, secure global markets and reduce costs and it aims to do so by "industry, government and the wider stakeholder base, working together" (p. ). it seeks to bring about a wholesale re-orientation of ni towards an export-dependent strategy based on large-scale industrial agriculture. the executive summary describes how "[t]he industry, moreover, has continued to grow … and to display tremendous potential for sustainable growth through its sharp focus on export sales, innovation and productivity. we have been immensely encouraged by the appetite for growth outside northern ireland…" (p. ). although intensive farming was the order of the day, reference is made to some environmental activities as the strategy describes how the growth of woodlands "would complement intensive agricultural production by providing improvements in soil, water and air quality" (p. ). this reflects many of the features of post-exceptionalism given that "[p] ost-exceptionalism denotes a partial departure from compartmentalized, exclusive and exceptionalist policies and politics which, however, preserves some exceptionalist features and has not led to a complete transformation to market-oriented and performance-based policies" feindt, , p. ) . while the role of markets is recognized in the gfg narrative, overall there is a limited shift towards market-oriented policies and a continued reliance on government intervention. recommendations made under beef and sheep illustrate: the supply chain must seek to deliver greater economies of scale with a particular opportunity to improve communication, technical input and efficiencies through a higher number of larger scale beef finishing units working in partnership with processors. industry and government must develop an action plan to double the number of beef and sheep farms actively engaged in physical and financial performance recording over the next five years. (afsb, , p. ). the document deems economic scale and efficiency to be critical, and identifies government-led incentives as being important in encouraging economies of scale at producer and processor levels. in other words, support bigger farms and agri-food processing businesses. figures are ambitious: grow sales by percent to over £ billion, create , new jobs, grow sales outside ni by percent to £ . billion, and increase value added to £ billion by . the report also references the value of consolidating working and calls for greater integration of the supply chain, including farm producers, food processors, wholesalers, retailers and export businesses. according to gfg, significant government action, along with input from academia, will stimulate an export-oriented strategy geared towards meeting consumer demand in emerging markets, including in the usa, europe, asia and the middle east (agri-food strategy board, ) . of a total of recommendations (p. ), only ( percent) are the sole responsibility of industry. the remaining recommendations ( percent) are directed towards government, either to be delivered in partnership with industry ( recommendations), or by government alone ( recommendations). proposed government commitments were not insubstantial and include a proposed government investment of £ million over three years (to lever an industry investment of £ . million). the shared government-industry recommendations sometimes seemed to be heavily geared towards government. for example, number (p. ) relates to government-commissioned research. the ni executive approved the board's proposed plans as published in april by responding formally in october (ni executive, ) . many of the benefits of gfg are directed towards large corporations in the form of increased sales, rather than towards primary producers, while costs are borne by taxpayers in the form of subsidized grants and other interventions. the strategy offers little tangible support to small business, be they family farms, processors or retailers. indeed, although the report states that family farms are "a major element of our economy", it goes on to say "they also present a significant challenge in terms of long term sustainability" (p. ). the ufu was critical of the gfg chair's position on family farms, publicly registering disappointment with his statement to the agriculture and environment committee that only farmers are needed in ni for food production (macauley, ) . this constellation of actors beyond primary producers, as well as the free market language alongside government intervention, all fit with post-exceptionalist policy. importantly, while the rhetoric refers to the role of markets, gfg actually denotes a shift away from market-based policies, with justification of excessive state intervention. as mentioned earlier, many of the recommendations require government action. rather than the strategy benefiting primary producers, significant benefits are directed towards large scale partners such as meat processors. we contend that gfg does not neatly fit with post-exceptionalism because, although there are more actors in the policymaking process, there is significant tension as the constellation of ideas, institutions, interests and policy "co-exists in an unbalanced way, which undermines its political viability" feidnt, , p. ) . further, there is little evidence of a shift in the nature of policy tools employed, a key feature in the transition to post-exceptionalism but obvious signs of continued reliance on traditional grants and financial incentives coming from government. so, if not a neat form of post-exceptionalism, what does gfg represent? to shed further light on this, we analyse what gfg implies from a sustainability perspective as a means of considering the extent of an evolving policy arena which is a key feature of post-exceptionalism. according to greer ( ) , a shift to post-exceptionalism should include the emergence of "'issue-network' type" actors, including those from backgrounds such as consumer, environmental and animal welfare groups, and slow food activists" (p. ), and broader policy issues such as the environment are brought to the fore (p. ). the ni government adopted gfg wholesale, without conducting any environmental impact assessment (leroux, ) and with very limited involvement of environmental interests in developing the strategy overall, as is discussed earlier. normal rules were not applicable. further, decades of intensive farming have had a significant negative impact on biodiversity and has resulted in degradation of water systems globally, a pattern that is evident in northern ireland (government office for science, ; campbell et al., ; committee on climate change, ; daera, ; friends of the earth, ) . within the eu, introduction of legislation such as the nitrates directive and the water framework directive has begun to somewhat limited agriculture's impact on the environment (van grinsven et al., ) , and recent cap reforms demonstrate a partial attempt to "green" agriculture (harvey, ) . however, gfg's focus on expanding intensive industrial farming in ni runs counter to these efforts and has a range of negative implications. as highlighted above, growth within the ni agriculture industry has, in the past decade, come mainly from poultry and pig production (daera, ). both operate under extremely intensive, integrated models of the kind gfg actively advocates. this is a logical economic model, as growers share costs and risks with the integrator, i.e. the corporate food processor (fao, ) . however, the fao ( ) warns that careful regulation of this model is required to avoid negative externalities such as physical and chemical pollution impacting on growers, employees and wider society. indeed, numerous concerns have been raised about the negative environmental impacts of these kinds of operations, mainly related to the high levels of animal waste they produce and the subsequent release of ammonia (brennen et al., ; friends of the earth, ) . ammonia can have a significant negative impact on both aquatic and terrestrial biodiversity and on human health (apis, ) . ammonia pollution is a particular problem in ni; the region is responsible for percent of the uk's ammonia emissions, despite accounting for only percent of its population. ammonia has contaminated nearly all ni's national protected sites and in some of its ancient woodlands, more than percent of native lichen species have disappeared as a result (carroll, a; friends of the earth, ; leroux, ) . while cattle farming currently accounts for the majority of ni's agricultural ammonia emissions, the poultry industry is responsible for half of the increase since (carroll, a) . thus, it can be argued that further development of these industries is incompatible with delivery of the public goods that are mentioned in the strategy (p. ). greater numbers of intensive chicken and pig production units not only put significant pressure on both ni's water supply and on the biodiversity of its farmland and protected sites, but also change the physical appearance of the countryside due to the visibility of the buildings (blackwood, ; committee on climate change, ; friends of the earth, ; gladkova, ) . this policy outcome favours privileged interests. in the past, in the 'normal' course of exceptionalism, that would have comprised farmers as primary producers (smith, ) , but here we see the interests of the food processing and retail sectors taking precedence. environmental interests were evidently not a major priority for the agri-food strategy. having explained how export-oriented the agri-food sector is, one of our (government agency) interviewees stated: " [gfg] was largely targeted at one particular sector, largely because of the individual who chaired that. so the poultry got a disproportionate focus, and the environment was completely left out of it …. in terms of air quality, in terms of carbon, in terms of biodiversity […] those things were never ever talked about in that going for growth. it was just about pure economics." we pick up this issue of disproportionate focus on the poultry sector, moving on to give concrete examples of how large food processors, particularly within this sector, received special or exceptional treatment. the development of schemes to incentivise particular practices within agriculture demonstrates clear cases of exceptional treatment that allowed large players in the poultry sector to advance their interests. two significant initiatives that led to recent political scandals in ni emerged from the gfg strategy and reflect the central role of agri-food in policymaking in ni. these cases demonstrate the degree to which private interests have benefitted from public subsidy. the (currently) higher profile scandal, dubbed 'cash for ash', surrounds the renewable heat incentive (rhi). the more recent scandal, 'muck for brass', is still developing, but is apparently set to "dwarf" the cash for ash scandal (leroux, ; gannon, ) . more than just evidencing the special treatment that the ni agriculture industry receives from the government, both appear to demonstrate how key industry players directly influenced policymaking to their benefit, using the gfg strategy as a lever. we elaborate on the schemes below. recommendation number of the gfg strategy is that "government must review incentives for renewable energy and ensure policies are complementary to the agri-food industry rather than in competition with it" (p. ). the rhi, which began in , was a ni government-led initiative to encourage businesses and individuals to switch from fossil fuels to renewable energy technologies such as wood-burning boilers (coghlin et al., ) . in line with the gfg recommendation, this scheme was heavily promoted to the agriculture industry. however, due to deep flaws in the scheme, not only did the government make subsidies worth more than the cost of wood pellets used to heat boilers, it did not cap the total subsidy available (brennan et al., ; coghlin et al., ) . thus, what began as a bid to reduce carbon emissions, quickly evolved into a profit-making scheme for many in the agriculture industry. people reportedly scrambled to install boilers and began to run them / . some farmers even heated empty sheds to turn a profit (carroll, b; mcbride, ) . different accounts have emerged about what happened and who was responsible. however, the prevailing narrative is that, despite allegedly being notified by a whistleblower in and again in , ni deti did nothing to stop the scheme, which was in fact continued and extended (bbc, ; carroll, b; coghlin et al., ) . the scheme eventually ended in , but not before £ million in taxpayer money was spent (brennan et al., ; carroll, b; gannon, ) . when the scandal surfaced, it led to the collapse of ni's power-sharing government in january , which, as noted above, was not reinstated until january . a full public inquiry into the scandal was set up in january and its findings were released in march , delivering a scathing assessment of the governance failures related to delivery of the scheme, citing poor leadership, lack of transparency and little evidence of critical scrutiny of material (coghlin et al., ) . more recently, investigative journalists uncovered another renewable energy scandal -'muck for brass' -this time involving government subsidy of anaerobic digesters (ads) (carroll, a; leroux, ; gannon, ) . the expansion of intensive animal farming in ni lies at the core of gfg, particularly through expansion of the pig and poultry sectors, but animal waste was a key limiting factor, as discussed above. one of gfg's key recommendations was that government must "fast track a solution for poultry waste into energy, recognizing the environmental benefits and remove a key uncertainty over the growth of the agri-food industry in northern ireland" (afsb, , p. ) . the solution that industry put forward was ads, and in , the ni government implemented an £ million taxpayer-funded scheme to support the installation of ads on ni farms. ads can turn animal waste into biogas, which is considered a 'green energy'. animal waste processed via an ad before being spread on fields has not historically been subject to detailed scrutiny in terms of its impact on sensitive habitats, thus allowing the agricultural industry to effectively bypass nutrient application limits as set out in the eu nitrate directive (carroll, a; leroux, ) . notably, the ad process does not appreciably change the amount of ammonia (or other nutrients) present in waste (malamis et al., ) , which, once passed through an ad, is still spread on the fields as fertilizer, funnelling ammonia back into the environment (carroll, a; leroux, ) . the ni government was aware of this prior to allowing the scheme to proceed; in a report, the ni agriculture and environment department specifically acknowledged that anaerobic digestion "does not address the fundamental issue of excess nutrients in the manure, as it requires land spreading of the digestate. therefore, it is not an alternative to land spreading" (daera, , p. , in leroux, . despite these reservations, ads were promoted, and big industry players were able to pay contractorsusing taxpayer moneyto install large ads across the countryside . as a result, the poultry industry experienced huge growth, as it was able to 'overcome' the problem of how to dispose of hundreds of thousands of tons of chicken litter and still meet nitrates directive limits (carroll, a; leroux, ) . the ad scheme in ni allowed large agribusinesses to fuel the expansion of intensive practices, and the solution found for one problem led to another: environmental degradation (leroux, ) . brennan et al. ( ) point to the problem of the dominant perception among some of ni's politicians that environmental costs are merely overheads in the business of promoting or supporting economic development and that funding schemes and policies are there to be manipulated for financial gain, something that is clearly demonstrated in the two schemes described above. moreover, both cases exemplify how disproportionate power and government support was afforded the poultry industry. one of the major poultry producers in the region, indeed, in europe, moy park is a powerful actor in the policymaking process and it has enjoyed exceptional treatment from government on more than one occasion. as already discussed, one of its then directors was the chair of the gfg board for a time, and a freedom of information request revealed that, between and , moy park representatives held meetings with officials from ni's agriculture ministry, during which anaerobic digestion was a main focus (leroux, ) . moreover, the ni government approved a £ million loan scheme to build two large ads: one in ni and one in donegal across the border in the republic of ireland. the former was specifically designated for poultry waste from moy park; no other processor was afforded this treatment (carroll, a; leroux, ) . all this despite the fact that the ministry clearly understood that ads would do nothing to mitigate the pollution problems associated with animal waste. more recently, privileged senior moy park executives were apparently given advance notice of the government's plan to end rhi subsidies, and as a result, nearly poultry farmers signed up to the scheme in its final months, most of whom supply moy park (mcbride, ; mcdowell, ; coghlin et al., ) . indeed, moy park has been singled out as acting and being treated differently than other processors. unlike other processors, it is mentioned times across the report's pages (coghlin et al., ) . it has been linked to approximately £ million pounds in rhi claims (mcdowell, ) , and the bbc reports that it was actively pushing its producers to take up the subsidy as it ultimately lowered the price it had to pay them for the chickens they produced (macauley, ) , thus increasing profit for the company. the interests served in the development of the initiatives emerging from and/or supported by the gfg strategy contributed to an unstable post-exceptional process, as one powerful stakeholder wielded undue influence within the agriculture industry. the problem in ni is that, while there are many more interest groups, they have not been properly included in the policymaking arena. there is little evidence of "institutional layering" feindt, , p. ). foord's work with key stakeholders on the challenges facing the ni food system further illuminates this gap in the policymaking process: policy making is viewed as too closed, with some industry stakeholders having disproportionate influence. there is excellent input from a few environmental champions, but there is a perception that the wider environmental sector is marginalized and excluded. one interviewee suggested that policy decisions are often, in effect, made prior to public consultation. there are numerous working groups and fora addressing different food issues (e.g. climate change; food poverty, food waste; etc.) but no holistic, strategic approach that allows joined-up thinking (foord, , p. , p. ) . including interest groups in policymaking is important, for if this is not done, policies tend to be ineffective (richardson, ) and lacking innovation (daugbjerg and feindt, ). as our case shows, post-exceptional policymaking is a delicate balancing act between appropriate inclusion and excessive power. environmental groups were included along the margins, but not in any meaningful way. attempts to involve them were rather shallow; they were given the opportunity to engage through consultation but were not embedded into institutional processes. that is to say, they were not actually part of the decision-making realm. the afsb responsible for the development of the gfg strategy comprised a limited range of industry stakeholders, and little action was taken by this board and the government department to obtain legitimacy across a wider range of stakeholders by inviting new policy actors into the policy arena. further, it seems the ni government encountered another problem: when governments grant interest groups excessive power, policy effectiveness can be compromised (peters, ; richardson, ) . richardson ( ) calls this "a central paradox in government/interest group relations" (p. ). as both the rhi and 'muck for brass' scandals illustrate, the policymaking process facilitated, and to some extent, sought to legitimate the disproportionate benefits and influence afforded a few powerful interests. this was to the detriment of the taxpaying public and ni's natural environment. gfg creates the illusion of a smooth transition to a postexceptionalist policy agenda where we might expect significant representation from 'new' actors such as consumer and environmental groups; greater consideration of issues such as water pollution and climate change; and a shift away from interventionist government policies towards market solutions (greer, ) . the reality is that it creates the conditions that support a concentration of power by a few key actors. rather than power resting with primary producers and other groups that have traditionally benefited from exceptionalist policies, corporate business assumes a privileged position and government remains heavily involved in supporting the industry. further, the strategy fails to identify practical measures for reducing the environmental impact of the agri-food sector. a clear paradox exists as gfg language is in line with change to 'ideational structure' -with consideration of market influences, environmental protection and preservation of the rural fabricwhereas its recommendations are firmly exceptionalist. we therefore argue that gfg represents an incomplete transition to post-exceptionalism, which is in line with other authors' interpretation of recent changes to european agriculture policy (alons, ; greer, ) . while it would be easy to assume that what occurred through the development of the gfg strategy represents a shift back towards exceptionalism, we contend that this is an over-simplification of what has happened. the bottom line is that post-exceptionalism retains the underpinning idea that the sector is special and so warrants some intervention (daugbjerg and feindt, ) . therefore, the fact that the ni agri-food sector has continued to receive 'special treatment' does not necessarily denote exceptionalism. moreover, we argue that there was a desire to make the shift from exceptionalism towards a post-exceptionalist approach, that is, away from the dominant closed policy communities focused on primary producers towards a more open style that involves a wider range of actors with competing interests authors note that a limited number of ad plants are now employing innovative processing techniques to remove a significant percentage of the nutrients present in digestate. however, it will be some time before this is a universal practice (if ever). (greer, ) . however, this article shows that where gfg falls short is that despite intentions to do so, it failed to extend power to a range of stakeholders; it did not succeed in updating the policy agenda, i.e. it did not sufficiently address emerging environmental issues; reliance on government intervention remained strong; and it failed to initiate novel policy solutions. this created at least one political scandal, bringing down the devolved government while also raising questions of legitimacy and transparency. it is an extreme example of what can happen when post-exceptionalist policymaking goes wrong. the shift of emphasis away from primary producers towards large-scale industry and the way in which political viability was undermined due to unbalanced power held by different actors constitutes what feindt term "tense post-exceptionalism" ( , p. ) . this is in line with other literature, which clearly identifies iterations of post-exceptionalism, with varying emphasis on the environment, productivity and the power afforded different stakeholders (alons, ; greer, ) . peters suggests that, where sub-optimal policies have developed, "the role of government then becomes providing the leadership to shape the debate and move decisions away from the lowest common denominator realm into a more socially desirable space" ( , p. ) . this would seem to be very pertinent for ni. already, the gfg strategy is outdated as market circumstances have radically altered since the time the strategy was first envisaged. back then, markets were buoyant, but in the intervening years global prices have fallen. meanwhile, the brexit vote has initiated a significant period of uncertainty as politicians figure out the future agri-food landscape. this is not likely to be sorted quickly (hubbard et al., ) . more widely, the role of the state is critical if progressive, postexceptionalist agricultural policies are to emerge. it has an important function from the outset in ensuring a smooth transition. richardson ( ) suggests that "design faults" are often unwittingly built into policies, a result of either asymmetric power balances at the design phase, or poor problem definition and options choice. this is an important consideration in the successful transition beyond exceptionalism. without awareness of all the pitfalls in policy development and a commitment to an open, inclusive process, powerful interests assume a central position and advance a very particular agenda, with undesirable political and environmental consequences. the processes by which policy is developed clearly have huge implications for all stakeholders involved and the long-term sustainability of the agri-food industry, and should therefore be given as much attention as the policy itself. the task for further research is to uncover the impact of these processes. none. air pollution information system going for growth: a strategic action plan in support of the northern ireland agri-food industry 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coordinated agri-environmental management contesting rurality: politics in the british countryside the authors acknowledge the very helpful comments provided on an earlier version of this article by participants at the trans-atlantic rural research meeting in aberdeen ( ) and at the european society of rural sociology in trondheim ( ). supplementary data to this article can be found online at https://doi. org/ . /j.jrurstud. . . . key: cord- -uh tx jc authors: lim, hui-rang; an, soyoung title: intention to purchase wellbeing food among korean consumers: an application of the theory of planned behavior date: - - journal: food qual prefer doi: . /j.foodqual. . sha: doc_id: cord_uid: uh tx jc studies on consumers’ purchase intentions have been one of the focuses in academia; however, the complex decision-making process in terms of purchase intentions on well-being foods have not been well researched. this study applied the theory of planned behavior (tpb) model using its core constructs to predict consumers’ purchase intentions of well-being food, namely yak-sun. questionnaires were gathered using a convenient sampling method for those who have experienced yak-sun food in september of . a total of responses were used for data analysis. the results of the study aligned with past studies that supported the applicability of the tpb model. all constructs including attitude, subjective norms, and perceived behavioral control were found to have made a significant contribution to the prediction of intention to purchase yak-sun food among korean consumers. perceived behavioral control showed the strongest influence on the behavioral intention of purchasing yak-sun food. based on the results, theoretical and practical implications were suggested. over the past few years,as diseases such as non-communicable diseases (ncd), severe acute respiratory syndrome (sars), african swine fever (asf) and mad cow disease (mcd) spread, consumers became more concerned about their health.these phenomena served as a catalyst for people to have healthy eating habits, which led to greater interest in well-being (strong, mathers, epping-jordan, & beaglehole, ) . the term wellbeing is a broad concept lacking a common definition. however, it seems that it mostly related with health, food, positive emotions, calmness and satisfaction with life. it is worth noting that among the elements involved in wellbeing, food improves people's perceived well-being deliza's ( , ) . food in the context of wellbeing, it generally means food that has health functions (kim, ); food with low cholesterol and low fat; also balanced in nutrition (kim, ) ; is natural and organic food (apaolaza, hartmann, d'souza & lópez, ) . along with well-being trends, research has attempted to understand the role of food in well-being. kapsak, rahavi, child, and white ( ) emphasized functional foods as a type of medicinal food. similarly, in south korea, yak-sun is a well-being food and can be defined as a combination of the word "medicine" and the "food" which is meant to prevent disease and keep the body healthy by being cooked according to the recipes of chinese oriental medicine.simply put, yak-sun is a food made by adding herbal ingredients to general food ingredients and is commonly known as a health-enhancing food.the term "yak-sun"was first used in china and is a concept formed in the course of medical development that has become the philosophy of diet in south korea (park & kim, ) .since it was introduced, korean consumers visit restaurants and eat yak-sun food as a way to protect their health. as interest in and the importance of food has increased, research on yak-sun has received more attention in the literature, especially in south korea. according to cha and park( ) , in china, the home of oriental traditional medicine, there is a yak-sun pharmacy where doctors prescribe yak-sun food after diagnosis which is becoming a popular tourist attraction for asians as well as westerners. seo and yoo ( ) examined the impact of restaurant employee's ability to explain the yak-sun food menu on customers' perceived value and satisfaction. they indicated that marketing strategies are required to increase the value of yak-sun food for the customers who visit yak-sun restaurants. understanding the relationship between food and well-being can contribute to a better understanding of how people's eating patterns and consumption are made. research on this has recently begun to draw attention from academia, but research on food, which plays an important role in the trend of well-being, is insufficient. especially, empirical studies on the relationship of yaksun food as well-being food and consumer purchase intention have been limited. thus, the model of the theory of planned behavior (tpb) proven to successfully predict behavioral intention of individuals was applied in the current study as a framework in order to predict consumers' purchase intention of yak-sun food. this research is significant because the current study can demonstrate that psychological theories such as tpb can be applied to consumer dining behaviors. beyond that, the current study aims to suggest marketing strategies for stimulating yak-sun food consumption by promoting the importance of wellbeing food in the food and beverage industry and providing a rational for consumers to consume yak-sun food more effectively. this study focuses on korean consumers' behavioral intentions towards yak-sun, a wellbeing food that represents south korea. the medicinal diet, yak-sun, uses state-recognized edible ingredients that are based on theories of oriental medicine (park & kim, ) . the importance of yak-sun has long been recognized and applied for the purpose of control of disease symptoms and signs. however, restaurants serving yak-sun food in south korea are focused on improving stamina. interests in yak-sun food are also evident in the academic literature (hwang & lee, ; lee & min, ; lim, ; shin et al., ) . in , lim et al. examined the perception and the possibility of korean foods and yak-sun to be global foods among foreigners living in south korea. the results revealed that "korean dining culture" and "comprehensive menus" are the main components that could contribute to make korean foods as global foods. respondents in their study believed that yak-sun food is an oriental medicinal food, which helps to improve health conditions and prevent disease. among the respondents, americans and europeans revealed the highest interest in the concept of yak-sun. in the study of lee and min ( ) , respondents showed positive attitudes toward yak-sun food in terms of efficacy, taste and nutrition. in the same vein, according to shin et al. ( ) , the main reason of respondents for choosing a yak-sun food when eating out at restaurants was for health improvement. participants in their study also highly agreed that yak-sun food is nutritious with the combination of oriental medicinal herbs which have natural ingredients for the treatment of disease. hwang and lee ( ) emphasized the role of attributes (e.g. nutrition, professionalism, and service) in choosing yak-sun food menus at a restaurant and the results indicated that service attribute significantly influenced on the satisfaction of customers. with the growing awareness of well-being, yak-sun has received remarkable attention in practice and among academics in south korea, but it has not yet received global attention as it is made uniquely using herbal medicines. the theory of planned behavior (tpb) hypothesizes that behavior can be predicted by intention and that people are prone to behave a particular way if they think that certain behaviors will generate particular outcomes that align with values. the theory of planned behavior consists of constructs such as attitude, subjective norms and perceived behavioral control which guide human behavior (ajzen, ) . tpb was first introduced by ajzen in with beliefs constructs and other constructs such as attitude, subjective norms and perceived behavioral control. in , ajzen introduced a modified model of the tpb without thebeliefs constructs, and measured the relationships among attitude, subjective norm, perceived behavioral control and intention in the model. since then such a modified tpb model has been applied widely in previous studies in various settings (al-swidi, huque, hafeez., & shariff, ; alam &sayuti, ; fila & smith, ; kumar & smith, ) . attitude is a way of feeling or thinking developed in a reliable way about things or products, which can be positive or negative. people look for specific groups when developing criteria for judgment. a group or individuals who served as a reference group might serve as an influence for a person's beliefs, attitudes, and intentions due to a person conforming to preferences of a group (moutinho, ) . in order to measure a subjective norm, respondents can be asked to rate the degree to which an important person's approval or disapproval would influence a given behavior. it is also determined by the social pressure recognized by others to act in a certain way and their motivation to follow the views of those people (ajzen & fishbein, ) . different kinds of influential groups can be identified by their ability to contact different groups (schiffman & kanuk, ) . subjective norms are social in nature because whether a person performs an act is on the basis of the opinions of those significant to him/her, which is also influenced by perceptions of social pressure to act in a particular way (hee, ) .the salient referents for purchasing well-being yak-sun elicited in this study are friends, family members, and colleagues. perceived behavioral control describes the ease or difficulty an individual believes will result from performing a specific behavior. there are two notions to explain the relationship between perceived behavioral control and intended behavior. first, perceived behavioral control will cause an increase in behavior intention and increase the probability of the action to be performed. second, perceived behavioral control will directly affect behavior to the extent that perceived control reflects actual control (armitage & conner, ) . behavioral intention is defined as an individual's expected or planned future action (swan, ) . according to fishbein and ajzen ( ) , behavioral intention represents an individual's expectation of a given action in a particular environment and can be used as a possibility of action. a broad range of studies have used the theory of planned behavior (tpb) in predicting intentions and human behavior indicatingthat this theory has proven useful in predicting human behavior and intention especially in the field oftravel destination choices and food choices especially in the context of wellbeing food choices. kumar and smith ( ) found that variables such as concern for local economies, concern for the environment and health consciousnesswere found to be significant predictors of attitude towardspurchasing local food. attitude toward localfood and subjective normswere also found to influence significantly on purchasing local food. sparks et al. ( ) sought to understand food choice behavior focusing on chocolate and meat consumption of customers living in england by applying tpb. in their study, attitudes as well as subjective norms were found to be strong predictors of behavioral intentions for chocolate and meat consumption. according to kassem and lee ( ) , attitude, subjective norm, and perceived behavioral control were found to significantly influence on behavioral intention to drink soft drinks. thus, they suggested that parents or teachers should encourage adolescents to consume other types of healthy drinks. similarly, murnaghan et al.( ) confirmed a significant relationship between attitude, subjective norms and perceived behavioral control to predict consumers' intention in consuming fruit and vegetables. alam and sayuti ( ) applied tpb to examine consumers' purchase intention of halal food in the case of malaysia. the study indicated that attitude, social norm, and pbc were all significant to predict malaysians' purchasing intention of halal food. similarly, cook et al. ( ) indicated that self-identity, subjective norm, perceived behavioral control, and attitude all had significant relationships with purchasing intention with genetically modified (gm) food.thus, it is hypothesized that: h . positive attitude towards yak-sun food will positively influence intention to purchase yak-sun food. h . subjective normwill positively influence intention to purchase yak-sun food. h . perceived behavioral control will positively influence intention to purchase yak-sun food. koreans who have experienced yak-sunfood from september to september , were contacted as a sample usinga convenientsampling method. the reason why convenience sampling was used in this study is that yak-sun food is a traditional korean food, so it is not easily accessible to people everywhere. therefore, the researcher selected two representative yak-sun restaurants in busan, south korea, and surveyed the customers who came out of the restaurant after eating the food.the researcher explained the purpose of the study and the contents of the questionnaire to participants who agreed to take the survey. a selfadministered questionnaire was distributed to participants to complete and questionnaires were returned after questionnaires were distributed ( % response rate). of these, ( . %) were usable and ( . %) were excluded because of incompleteness of the responses. all items measuring the variables in this current researchare based on the theory of planned behavior(tpb) (ajzen, ) . the survey contains questions on the likely outcomes of choosing yak-sunfood (attitude); individualswhose views might affect respondents choosing yak-sun food (subjective norm); factors that could facilitate or hinder respondents' choice of yak-sun food (perceived behavioral control); and likelihood of choosing yak-sun food (behavioral intention).the questionnaire, which was originally developed in english was translated into korean in order to survey korean consumers. a group of korean customers who had experienced having yak-sun food were invited for a pilot study. the cronbach's alpha which indicates internal consistency of the constructs of the pilot questionnaire ranged from . to . , above the satisfactory level of . (nunnally & bernstein, ) . the questionnaire primary consisted of three sections. the first section comprised questions in terms of behavioral attitudes, subjective norms, and perceived behavioral controls and behavioral intention to purchase yak-sunfood. attitude: three items of behavioral attitudes (e.g. "purchasing yak-sun food is pleasurable") drawn from previous research were measured on a five-pointlikert scale (strongly disagree= , strongly agree = ). subjective norms: three statements (e.g. "my acquaintances understand me choosing yaksun food as a wellbeing food.") drawn from previous research were used to measure subjective norms on a five-point likert scale (strongly disagree= , strongly agree = ). perceived behavioral control: three statements (e.g. "i can easily eat yak-sunfood whenever i want") drawn from previous research were used on a fivepoint likert scale (strongly disagree= , strongly agree = ) to measure perceived behavioral control. behavioral intention: three statements (e.g."i will make an effort to purchase more yak-sun food") drawn from previous research zeithaml et al., ) were measured on a five-point likert scale (strongly disagree= , strongly agree = ) to measure the behavioral intention of choosing yak-sun food at a restaurant. the second section was comprised of six items asking demographic characteristics, while three general items on yak-sun food purchase were described in the third section. all of measurement items are illustrated in the appendix. the statistical package for the social sciences (spss) was utilized to analyze data. a frequency distribution of the respondents was used in order to identify general characteristics of the respondents and demographics. cronbach's alpha was also checked for the internal consistency of the construct. since the variables measured in this study were drawn from existing scales, confirmatory factor analysis (cfa) with maximum likelihood estimation was run to evaluate reliability and validity. subsequently, structural equation modeling (sem) using amos wasapplied to validate the research model and test hypotheses. table shows general demographic information of respondents. the majority of respondents were female ( . %) and were married ( . %) with the average age being . over % of respondents were white collar employees, . % of respondents were selfemployed. regarding household income, over % of respondents fell within the categories of $ , -$ , per month ( . %). the highest education level of respondents was university ( . %), high school ( . %), and college ( . %) levels of education. table shows the overall characteristics of the respondents related to purchasing yak-sun food. the purpose of visiting a restaurant of respondents was for 'family gathering' ( . %), 'eating out' ( . %), 'to meet friends' ( . %), 'for business' ( . %), and 'for events' ( . %). slightly less than half of respondents purchased yak-sun food with friends ( %), others purchased it with their spouse ( . %), or their parents ( . %). in terms of expenditure, . % of respondents spent $ -$ individually when they visited a yak-sun food restaurant and . % of respondents spent $ -$ . < insert table here> < insert table here> in order to establish convergent and discriminant validity of the constructsand to measure the measurement model fit, a confirmatory factor analysis (cfa) using amos was undertaken as the results shown in table table here> moreover, as table shown, the average variance extracted (ave) of all constructs was above the minimum standard of . (fornell & larcker, ) , which indicates that a significant portion of that variance has been explained by the constructs. the ave values for each structure were checked for discriminatory validity by comparing them with the square of the correlation between the same constructs as the remaining latent variables. in this study, discriminant validity was supported as the aves were greater than the squared correlations between any pair of constructs.the confirmatory measurement model of four factors has demonstrated robustness of the measurement properties. < insert table here> hypothesis test figure and table presents indices such as gfi, nfi, cfi, and rmr were at satisfactory levels. as table indicated, hypothesis which is that attitude toward buying yak-sun food will positively influence on behavioral intention was supported as the t-value showed . . hypothesis which stated that subjective norm will positively influence on behavioral intention was supported as the t-value showed . . hypothesis which specified that perceived behavioral control will positively influence on behavioral intention was supported as the t-value was . . < insert figure here> < insert table here> although there is no clear definition of what well-being is, this well-being is receiving great attention both in academia and in our daily lives. there have been many factors related to well-being, and studies on food and well-being have been active as food has been shown to have a significant impact on people's perception of well-being deliza's ( , ) . this phenomenon is similar in south korea. people began to exercise or care about consuming more healthy foods to be physically healthy. along with these trends, recently, yak-sun has attracted attention in south korea to meet the needs of consumers who want to purchase safer and healthier foods along with changes in diet amid the trend of well-being. as yak-sun is recognized as south korea's representative well-being food, research on it has been actively carried out. through these studies, it has also been found that people's awareness of yak-sun increases (chung & cha, ; lee & min, ) . therefore, the current study aimed to understand the decision-making process of korean consumers' behavioral intention to purchase yak-sun by analyzing the principal antecedents of intention.to achieve such research objective, the theory of planned behavior (tpb) was applied.a total of customers who had yak-sunat a restaurant in south korea were surveyed. when it comes to the model fit of the measurement model showed that the majority of indices such as gfi, nfi, cfi, and rmr were at satisfactory levels as gfi, nfi, and cfi were above . and rmr was below . . when looking at the relationships between variables, statistically significant relationships were identified. more specifically, attitude was positively related to behavioral intention, which means that if korean consumers have a more positive attitude toward yak-sun food consumption, they will have a stronger tendency to purchase yak-sun food. such a finding is supported by previous research indicating that attitude was found to be a strong predictor of purchaseintention of either gm food or organic food (arvola et al., ; cook et al., ; tarkiainen & sundqvist, ; zagata, ) . a positive relationship between subjective norm and behavioral intention identified in this study is consistent with previous studies (e.g. alam & sayuti, ; kamariah & muslim, ; karijin et al., ; maya et al., ) .this shows that the more korean consumers think they understand about yak-sun food, the more they think that they should eat it. also, the more people around them approve of them eating yak-sun, the more willing they are to purchase it.in other studies, respondents tended to be influenced by what other people think when they purchase organic food (maya et al., ) and halal food (alam & sayuti, ; kamariah & muslim, ; karijin et al., ) . a similar result was found in the study of , indicating that behavioral intention to visit hong kong for taiwanese people was related to perceived social pressure from important people around them. this study also confirmed that perceived behavioral control is a significant predictor and was the strongest predictor of purchasing intention of yak-sun food for koreans.this indicates that koreans make more in-depth efforts to experience yak-sunfood.also, it means that it is up to korean consumers to consume yak-sun, not others, but it is their own decision. in addition, they show strong confidence in buying yak-sun food.the finding was consistent with previous researchwhich showed that muslims are willing to put more effort into trying halal food which emphasized that perceived behavioral control is a significant predictor in influencing consumers' behavioral intention to buy halal food (karijin et al., ; ). according to cook at al. ( ) , perceived behavioral control was found to be a more substantial determinant of behavioral intention than any other construct. regarding gender differences in that study, males tended to be more in control over purchasing gm food than females. similarly, suggested that perceived behavioral control had a significant influence on taiwanese behavioral intention to travel to hong kong. this suggests that certain constraints may reduce respondents' travel intentions to hong kong but not eliminate them at all.this study applied tpb theory to predict korean consumers' behavioral intention to purchase yak-sun food. based on the results, several suggestions are made in the following section. above all, the theoretical implications for this study are the validation of the tpb model and contribution to the better understanding of important components in terms of consumption patterns of those who dine out with empirical evidence. a number of prominent practical suggestions were drawn based on the findings of current study. first, when it comes to behavioral attitude towards purchasing the yak-sun foods, trust has been found to be a crucial factor (han, ; huh, ; seo, ) . foods consumed by consumers are directly associated with their health. therefore, providing accurate information including the basic components drawn from empirical analysis such as certificate mark, information of origin of the food, price, and nutritional values as well as other diverse information will help consumers purchase more yak-sunfood. second, utilizing the concept "food is the best medicine," by following traditional values while developing modern cooking and menus to appeal to the potential customers of wellbeing foods, the invigoration of yak-sun menus are highly viable. with the advancement of marketing and development of such foods, the satisfaction level of customers and the values of farmers and eating-out culture will be elevated as well. third, an important factor influencing behavioral intention to purchase yak-sun food was the subjective norms (perception of influential social connections) on a person'sability to behave a certain way or not. therefore, it would be good to have a system in which people who have experienced yak-sun foods can actively share it with people who have not experienced them and encourage them to try yak-sun foods. or, when promoting yak-sun foods, it would be good to target those who haven't eaten yak-sun foods by sharing reviews of experiences with yak-sun foods. since customers' behavioral intention on purchasing yaksunfood is influenced by people they are with at a restaurant or know, marketing strategies should focus on how to recommend yak-sun food to one's friends and significant others. the limitations of current study and future research directions are as follows. firstly, the theory of planned behavior (tpb) not only identifies behavioral intentions but also actions. this requires the same consumer to be surveyed twice over a certain period of time. therefore, this study only investigated the behavioral intention of consumers who intend to purchase yak-sun food due to the limitations of the survey process. therefore, in future studies, looking at the structural relationships of consumers who actually purchase yak-sun food would be more meaningful. secondly, in terms of sampling, the current study used convenience sampling. this was done because yak-sun food is not the type of food people can eat everywhere as it is a very traditional korean food. thus, the researchers decided to contact customers who came out of restaurants who serve such food after customers finished a meal in order to get enough of a sample. thus, to make up for such a limitation, future research should require a wide selection of regions to randomly select consumers who consume yak-sun food. thirdly, there is an issue related to sample representativeness. current study collected data from residents living in the area called busan, so the sample representation of the area was localized to some extent. however, it is thought that there will be a problem with the representativeness of samples to apply these results to the whole country. therefore, if samples are taken from various regions in korea, such as seoul and gyeonggi province, to complement the representativeness of the samples, then more accurate results can be obtained.fourthly, in many previous studies of the theory of planned behavior, the postconversion pattern of behavior may vary depending on past experience and the addition of variables to past experiences is noted. therefore, it is believed that in future studies, it will also be meaningful to look at changes in purchasing intention due to the presence or absence of past purchasing experiences. zeithaml et al. 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behavior and segmentation approach predicting behavioral intention of choosing a travel destination a survey on the perception of yaksun among school food service dietitians in the chungbuk area a study of attitude toward healthy menu a qualitative study to identify definition of "healthy foods" as provided contract food service companies evaluation of the globalization of korean foods and yak-sun among nationalities of foreigners living in korea organic food consumption in europe: international segmentation based on value system differences consumer behavior in tourism predictors of physical activity, healthy eating and being smoke free in teens. a theory of planned behavior approach psychometric theory studies on development of functional herbal food based on yaksun-focusing on the relevant chinese literature consumer behavior a study of consumers` food choice behavior by comparison of past experience -focus on organic food the study on influence of explanation of yaksun restaurant employee on perceived value and satisfaction perception of yak-sun in the seoul, gyeonggi, and chung-bukarea ambivalence about health-related behaviors: an exploration in the domain of food choice preventing chronic disease. a priority for global health disconfirmation of expectations and satisfaction witha retail service subjective norms, attitudes and intentions of finnish consumers in buying organic food perceived risks ofconventional and organic produce: pesticides, pathogens, and naturaltoxins consumers' beliefs and behavioral intentions towards organic food. evidence from the czech republic the behavioral consequences of service quality purchasing yak-sun food is pleasurable purchasing yak-sun food is favorable . purchasing yak-sun food enjoyable i can easily eat yak-sun food whenever i want ajzen key: cord- -kjs je u authors: martel, cyril; nielsen, gunnar d.; mari, adriano; licht, tine rask; poulsen, lars k. title: bibliographic review on the potential of microorganisms, microbial products and enzymes to induce respiratory sensitization date: - - journal: nan doi: . /sp.efsa. .en- sha: doc_id: cord_uid: kjs je u nan the regulation (ec) no / concerning feed additive applications in europe is based on a safety opinion made by efsa (european food safety authority). the regulation includes an annex ii, which provides the general requirements that should be satisfied by a dossier supporting an application for the use of a product as a feed additive. in particular section iii of the annex ii deals with safety of a feed containing an additive, and this is further subdivided into safety for target animals (section . ), for consumers of the products derived from the animals fed the additives ( . ), for users/workers exposed to the additive ( . ) , and finally for the environment ( . ) . in section . , it is stressed that the allergenic potential and sensitization via the respiratory route is of concern, and should be evaluated. annex iii of that regulation provides the specific requirements concerning specific intended additives depending on the technical nature of the feed additive. in this context, technological additives and zootechnical additives are of interest. thus, in spite of the guidance on toxicological safety component of a feed additive dossier [ ] , efsa is instructing that enzymes and microorganism should be assumed a priori to be respiratory sensitizers unless convincing evidence to the contrary is provided. in order to investigate the potential of microorganisms, microbial products and enzymes to induce respiratory sensitization when used as food and feed additives, we conducted a systematic literature search of all the information we could find linking microorganisms and enzymes to respiratory sensitization. we supplemented this search with references from important reviews in the field of enzymes and microorganisms and occupational health, as well as with interviews with some leading companies in these fields. finally, we conducted a survey of existing regulations on the subject in developed countries. the immune system has evolved to protect individuals from microbial pathogens as well as larger parasites. however, the immune system can sometimes react inappropriately to innocuous antigens. allergic reactions occur when an individual produces ige antibody against such innocuous antigens, or allergens. while other antibodies are free circulating in blood or extracellular fluid, ige is also found in tissues, where it is tightly bound to the mast-cell surface through the ige receptor. exposition to the allergen triggers a cascade of responses initiated by the activation of mast cells by igereceptor cross-linking [ ] . basophils and activated eosinophils can also act in a similar fashion. ige is thought to have evolved as a mechanism to fight off large multicellular parasites, like nematodes and trematodes, less vulnerable to other effector arms of the immune system (like phagocytosis or cd t cells) [ ] . indeed, the typical symptoms of type i hypersensitivity, like smooth muscle contraction, itching and generation of mucus, seem appropriate to dislodge such organisms. however, modern hygiene practices have considerably lessened the population's exposure to parasites in developed countries, and the focus on ige is overwhelmingly set on its role in the pathophysiology of allergy. it is estimated that almost half the populations of north america and europe have allergies to one or more common environmental antigens [ ] . why some antigens lead to ige production and type i hypersensitivity is not fully elucidated. certain antigens and routes of antigen presentation to the immune system are known to elicit preferably a th response charaterized by the production of ige. most allergens are relatively small, highly soluble proteins. the typical presentation of an inhalable allergen involves a transmucosal route and very low doses (as low as microgram per year for some pollen allergies) [ ] . myeloid dendritic cells are the dominant antigen-presenting cells in the respiratory mucosa, and they are known to be very efficient th inducers. exposure to low doses of antigen in general also tends to favor a th response in the absence of th -inducing co-stimulatory signals. unlike pathogens that are usually eliciting the same pathology in a large majority of the population (albeit with difference symptoms or severity), only some of the people who are exposed to common allergens make ige antibodies against them. in addition, there is a clear trend of increase in prevalence of atopic allergy, and of asthma in particular, in developed countries. environmental factors that may potentially explain these trends are changes in the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. exposure to microorganisms in early childhood, environmental pollution, allergen levels, and dietary changes [ ] . alterations in exposure to microorganisms are the most plausible explanation at present for the increase in atopic allergy. this includes exposure to pathogens, but also to a large number of commensal, non-pathogenic microorganisms early in life [ ] . epidemiologically, atopy is negatively associated with a history of infection with measles or hepatitis a virus, and exposure to mycobacterium tuberculosis, but severe respiratory syncytial virus (rsv) infection in children is positively correlated to the later development of asthma. the underlying idea behind this theory would be that th immune response early in life might reduce the likelihood of th responses later in life and vice versa. more recent versions of this theory focus on the role of tregs as opposed to inflammatory th [ ] . broad exposure to commensal bacteria early in life is associated with protection against ige-mediated hypersensitivity. the relationship between environmental pollution and type i hypersensitivity is unclear [ ] . some epidemiological studies have shown a lower prevalence of allergy and atopy in severely polluted cities than in generally cleaner ones. other studies on diesel-fuel particulates show that they trigger symptoms in patients. studies of the effects of exposure to secondhand tobacco smoke or occupational hazards on atopic sensitization have also led to discordant results. similarly, there is no clear evidence that the rising prevalence of allergy is due to any systematic change in allergen exposure or to changes in diet. the most common route of allergen exposure is inhalation. most often, it initially leads to mild allergies causing allergic rhinitis, with sneezing and a runny nose as main symptoms. this results from the activation of mucosal mast cells beneath the nasal epithelium by allergens such as the proteins from pollens [ ] . allergic rhinitis is characterized by intense itching and sneezing, local oedema leading to blocked nasal passages, a nasal discharge, and irritation of the nose as a result of histamine release. allergic conjunctivitis is a similar condition triggered by airborne allergens deposited on the conjunctiva. these reactions are annoying but cause little lasting damage when they are linked to seasonal allergens like pollen. more severe damage can come from activation of mast cells in the lower airways, which leads to allergic asthma [ ] . it is a chronic condition that requires treatment and can be lifethreatening. both allergic asthma and rhinitis can come from constant exposure to occupational allergens as it is the case for fungal enzymes and baker's asthma, but asthma can also be perpetuated even in the absence of further exposure to allergen. the airways become characteristically hyperreactive and factors other than reexposure to antigen can trigger asthma attacks. it is worth noting that, although asthma has potentially more severe consequences, quality of life studies indicate that rhinoconjunctivitis is perceived as worse the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. than bronchial asthma for the patient [ ] . this is probably linked to the fact that asthma is treated more efficiently and more strictly than rhinoconjunctivitis. type iii hypersensitivity reactions are caused by inhalation of soluble environmental antigens that trigger immune responses by precipitated antibodies (mainly igg) and lymphocytes; the characteristics of hypersensitivity pneumonitis (hp) are summarized from recent reviews [ , , , , ] . unlike allergic reactions, they are linked to igg rather than ige production. the pathology is caused by large aggregates of igg:antigen complexes, also known as immune complexes. these immune complexes fix complement and can bind to and activate leukocytes bearing fc and complement receptors; these in turn cause widespread tissue injury to small blood vessels in many tissues and organs, including the skin, kidneys, and nerves. this is thought to be the underlying pathophysiological mechanism in hypersensitivity pneumonitis (also called allergic alveolitis). immune complexes also form in autoimmune diseases such as systemic lupus erythematosus where, because the antigen persists, the deposition of immune complexes continues, and serious disease can result. hp has been described in various settings, often involving organic particles and environments where moulds abound: farming, bird-breeding for example. some chemical compounds have also been shown to be able to act as hapten and cross-link the host albumin to create an allergic particle. common industrial antigens causing hp include isocyanates (paint sprays), plastics (packing plants), mycobacterium avium complex (metal working fluids), aspergillus (agriculture), and thermophilic actinomyces (agriculture). genetic factors are important for development of hp and hp occurs seldom in smokers. the most likely reason why some inhaled allergens provoke igg rather than ige is probably linked to doses of exposure. occupational allergens associated with hp are generally linked with very high levels of exposure, such as in the case of metalworking fluids or farmer's lung. hp can present acute, subacute or chronic forms. the chronic form, with lung fibrosis, can be very severe, and even life-threatening. the -year mortality in chronic hp is as high as %, and in the subset of the fibrotic type of chronic hp, the -year mortality reaches %. in the acute form, respiratory symptoms are lung crackles, cough, dyspnoea, fever, myalgia, headache, and malaise. if the exposure continues, the acute form develops into the subacute (< month of exposure) and further into the chronic form (> month of exposure). during the continued exposure, cough and dyspnoea at exertion gradually become worse. in the acute form, high resolution computed tomography (ct) shows ground-glass lung opacities and micronodules that may progress with addition of air-trapping, emphysema and fibrosis in the chronic form. pulmonary function tests show low carbon monoxide diffusion capacity and typically a restrictive pattern. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. in spite of spores from naturally occurring fungi being described as a common cause of asthma and allergies, there is little description of occupationally induced fungal allergies. microorganisms have been involved in numerous outbreaks of hp in industry, agricultural work and in indoor climate; examples of involved organisms are listed in table . several outbreaks of hp have occurred due to aerosol exposure to water-based metalworking fluids contaminated with microorganisms. in several of these cases, mycobacterium species were considered the offending agents. mycobacteria are ubiquitous in the human environment, including in natural water, drinking water and soil. they are easily aerosolized due to their hydrophobic surface. growth of mycobacteria may have been promoted in metalworking fluids by the use of biocides and disinfectants that have diminished or eradicated competing microorganisms; mycobacteria are highly resistant to quaternary ammonium compounds, formaldehyde, morpholine, chlorine, chloramines, ozone and heavy metals [ , , ] . hp in farmers caused by exposure to mouldy livestock feed is known as farmer's lungs, which is associated with exposures to thermophilic actinomycetes and fungi [ , ] . workers engaged in packing of peat moss, an organic substance derived from sphagnum moss, have also developed hp from contamination by moulds. the peat moss contained high levels (~ x colony forming units/g) of monocillium species and penicillium citreonigrum [ ] . sphagnum vegetation may also contain high levels of mycobacteria as m. avium and m. intracellulare [ ] . hp may be due to microorganisms playing an intended role in production processes. hp in workers cultivating edible mushrooms, mushroom worker's lung, may be due to microorganisms [ , , ] . thus, mushrooms are cultivated on compost that can contain high amounts of thermophilic actinomycetes and moulds, having a role in the production of the compost. the actinomycetal spores can be found in high levels in the air during preparation of the compost, during the spawning (~ colony forming units/m ), i.e. inoculation with mushroom mycelium, or during other work in the mushroom house [ ] . additionally, mushroom worker's lung may be due to the spores from exotic mushrooms [ , , ] . however, no sensitization was observed to the white button mushroom agaricus bisporus in a the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. study in patients with mushroom worker's lung. use of airway protection during spawning prevented respiratory complaints [ ] . mushroom worker's lung and cheese worker's lung are among the types of hp where the microorganisms have a role in the production processes. although not commonly encountered, hp may be caused by unintentional growth of moulds and bacteria in buildings with excessive inside moisture. aspergillus niger is a common antigen accounting for development of serum precipitins and hp. stachybotrys species are commonly found in damp buildings with cellulose material, but it has not been implicated as a cause of hp overall, in cases where hp appeared due to unintended exposures to microorganisms, exposures have often been the related to wet or humid conditions that promoted the growth and thus, resulted in unusually high exposures. also in these cases, the work conditions may have promoted aerosol formation. thus, primary prevention should, where possible, limit wet or humid conditions or otherwise, growth should be controlled. if high exposures cannot be avoided, respiratory protection has to be worn. aerosol formation should always be minimized. where microorganisms have intended roles in a production, process specific risk management have to be introduced. both for unintended exposures and for exposures to intentionally used microorganisms, spore-producing microorganisms are often the cause of hp. the present document has been produced and adopted by the bodies identified above as author(s the present document has been produced and adopted by the bodies identified above as author(s in a case-reference analysis of a cohort of employees in a european detergent factory, chest disease was not increased significantly at ≤ . ng/m of proteases and eye and nose symptoms were not increased at ≤ . ng/m . the authors mention that only the protease level was measured although amylases and cellulose were also used, and that "irritant" dust and non-occupational reactions may have contributed to the findings above these levels [ ] . outbreaks of sensitization, upper airway symptoms and asthma still occurred in the detergent industry where strict exposure controls were not followed. in such a case, the protease level was in the range from to ng/m , several enzymes were used and amylase was found to be a more potent sensitizer than the protease [ ]. allergic reactions were observed in swedish consumers in the early period of use of enzymes in detergents, when products were dusty and enzymes were not encapsulated. a re-creation using the product and the consumer habits at the time suggested that exposure may have been as high as ng/m [ ] . recently, a study was performed in atopic filipinos who had a daily use of hand laundry for several hours; the study lasted up to years. the laundry contained a protease and an amylase. the laundering was with granular products or with bar products that were also used for personal cleansing. exposures were low (≤ . ng/m ) for the granular product, lower (≤ . ng/m ) for the bar product for scrubbing, and below the detection limit (< . ng/m ) for personal cleansing. none of the subjects developed the present document has been produced and adopted by the bodies identified above as author(s overall, taking into account the high number of cases of allergy in relation to exposure to enzymes and the low number of cases with hp, the type i allergy is considered the critical effect and it is inferred that protection against allergic airway diseases will also protect against hp. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. identification of key parameters: microorganisms (the relevant types, forms and species are organisms that are known to be used per se in feed and food) enzymes that are used in feeds and food sensitization (main emphasis on ige-related respiratory sensitization but also allergic alveolitis, and non-immunological hypersensitivity are covered). physiological/immunological mechanisms, distinction between the exposed organ and the target organ/symptoms (i.e. can respiratory sensitization occur via other exposures?) are discussed. it is important to emphasize the ubiquitous occurrence of microorganisms, their products and enzymes in all biological materials versus the deliberate addition in feed or food. in the allergen research of today many allergens from plants and animal sources are cloned and expressed in e. coli or pichia for research purposes. such applications are excluded (but documented) at an early stage of the literature search. to which extent are microorganisms, microbial products and enzymes respiratory sensitizers? to solve this problem three parallel approaches have been taken: • an epidemiological search. the literature on epidemiological data related to respiratory allergies and sensitization will be screened in order to identify descriptions of reactions to microorganisms, microbial products and enzymes. • a clinical/case based search. case stories and descriptions of isolated outbreaks of respiratory sensitizations and allergies will be documented • an allergen based search. literature will be searched for occurrences of microorganisms, their products or enzymes. currently available methods to test respiratory sensitization and their validity the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. • structure-allergenicity-relationships (prediction of allergenicity based on the primarysecondary-tertiary protein structure) • in vitro-models for antigen presentation and sensitization. • animal models of allergic sensitization the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. microorganism: microbiological entity, cellular or non-cellular, capable of replication and/or of transferring genetic material. includes fungi and bacteria (also under the form of spores). viruses, archea, protists, as well as microscopic plants and animals are generally also included in this definition, but have little relevance for this report, as they are not used as food or feed additives. microbial product: pool of organic compounds that are released from biomass growth and/or decay. includes (but is not limited to): humic and fulvic acids, polysaccharides, proteins, nucleic acids, organic acids, amino acids, antibiotics, steroids, exocellular enzymes, siderophores, structural components of cells and products of energy metabolism. enzyme: enzymes are proteins from animal, vegetal or microbial origin that catalyze chemical reactions. relevant enzymes for this report include (but are not limited to): amylases, proteases, trypsin, cellulases, pectinases, xylanases, papain, and lactases. it is agreed upon that this report will focus exclusively on microorganisms, microbial products and enzymes that are added deliberately to food and feed. additionally, those additives need to have been clearly and individually defined to be taken into consideration. the lists of microorganisms and enzymes (appendices and ) were compiled by using the sources listed in table : in order to narrow down our search, we established a list of relevant microorganisms and enzymes of interest. it was agreed that the focus of the report would be on ige-related sensitization, as well as allergic alveolitis and non-immunological hypersensitivity. for each item on these lists, the following pubmed search was conducted: item and (ige or hypersensitivity or rhinitis or conjunctivitis or asthma or urticaria or anaphylaxis or allergic alveolitis) when the outcome of the search was hit, the item was also searched in the allergome database. when the outcome was between and hits, the titles of hits were screened manually to identify articles susceptible to contain epidemiological, clinical or laboratory data. reviews were systematically included. after the title screening, abstracts were then viewed to determine which articles were relevant. when the outcome was larger that hits, the search was narrowed using the following strategies, in that order: use "item" instead of item include only hits containing the item in abstract/title include only hits containing the item in title we used some of the most authoritative reviews in the field of respiratory sensitization and/or industrial use of enzymes and microorganisms to backtrack through isi's web of knowledge the most important articles that they referenced. our subcontractor (gunnar nielsen) made a survey of existing legislation and regulations concerning enzymes and microorganisms in developed countries. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. in order to enhance our understanding of the relationship between food and feed additives and respiratory sensitization, we interviewed representatives of two of the leading companies in the field: chr. hansen a/s and novozymes. the details on these companies are listed in annex . these companies were first mailed a list of our questions (listed in annex ), after which they agreed to meet us, and in the case of chr. hansen a/s, to show us one of their production lines. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. . . state-of-the-art of the test methods the allergenicity of a protein can refer to two properties: either its capacity to induce ige thru an immune response or its capacity to cross-react with ige induced by a previous antigen [ ] . the first case involves interaction with and processing by antigen-presenting cells, but also contacts with epithelial cells that can modifiy the th /th /treg balance towards a given antigen. it is overall a very complex matter, and large parts of the theory behind it remain unexplained. it is therefore difficult to predict, and in-silico attempts to model this have been largely unsuccesful, although numerous hypothesis have been advanced. no common structural feature between allergens can be conclusively pointed at. the only common properties of allergens so far are that they can evade th -suppressing mechanisms and interact with dendritic and mast cells. current allergen prediction algorithms are better suited to predict ige cross-reactivity. past algorithms have focused on the association of unknown sequence with a single allergen motif or an allergen peptide [ ] . however, recent developments are now taking into account the fact that allergens generally contain multiple epitopes [ ] , that these epitopes are very often discontinuous [ ] , and that antibodies have interaction sites to a given antigen [ ] . taken together, these facts have led to algorithms focused on several motifs, with a marked improvement in false positive rates [ ]. as of today, in-vitro models are used to investigate the mechanisms of allergic diseases and the processes of each individual type of cell, rather than the allergenicity of a product. fundamental knowledge is still missing to create an in-vitro model of the various cell interactions that could mimic the human response to an allergen. there is, to our knowledge, no reliable, established in-vitro way to predict allergenicity. in recent years, the ue has supported a large project called sens-it-iv (http://www.sens-it-iv.eu/), whose goal is to develop such an in-vitro model. in , the members from the project published scientific articles on the topic. although promising, this research has not yet reached its goal. respiratory sensitization and the symptoms that it causes require a complex interaction between several cell types, including epithelial cells, dendritic cells, macrophages, cd + t cells, b-cells and mast cells. the variety of in-vivo models used for respiratory sensitization the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. has been thoroughly reviewed by verstraelen et al [ ] , and this section only briefly describes their findings. three main types of epithelial cells have been used as models: primary airway epithelial cells, alveolar cells lines, and bronchial cell lines. primary cells are of course the closest representation of the airway epithelium, but their scarcity and donor variation is a major problem for the reproducibility of the experiments. alveolar macrophages studies often use cells collected by bronchoalveolar lavages for ex-vivo studies. several monocytic cell lines also exist, but like with all cell lines, whether they accurately reflect the behavior of functional primary cells that they ressemble is subject to discussion. monocyte-derived dendritic cells (dcs) have replaced langerhans cells as primary dcs for in-vitro experiments. however, some very satisfying cell lines are also available, such as mutz- , which display all the antigen processing and presentation pathways from a functional dc. due to the importance of interaction and co-stimulation by different cell types, co-culture models have been subject of much interest. successful tri-cultures (macrophages/dc/epithelial cells) show great promise. d cultures, although in need of optimization, are also very interesting alternatives. currently, the most widely used experimental animal for modelling allergic responses in the airways is the mouse. numerous antigens can be used for sensitization, such as ovalbumin, dust mite and a. fumigatus. typical induction of asthma in murine models has requirements: a systematic immunisation to trigger th immunity and a repeated pulmonary allergen challenge. pulmonary challenge only without systemic immunity is not sufficient to elicit pulmonary symptoms [ , ] . the intraperitoneal route is the most common way to elicit th immunity, although repeated instillation in the upper airway can also be used for some antigens. although the mouse model is the most popular in the field of allergy research, it suffers from several flaws that limitate its predictive value. the differences in induction mechanisms, together with physiological and immunological differences between mice and humans might make it more suitable for clinically-oriented studies than for allergenicity prediction. relevant models to study allergenic properties would need to rely on sensitization from inhalation only, the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. and these are rare. interestingly, our discussion with researchers from novozymes a/s is corroborating this line of thought: animal models are out of favor in their labs, and remain only used for relative allergenicity experiments. it is worthwhile to note that in-house research at novozymes a/s has failed to show significant differences in relative allergenicity between different enzymes. this may be due to the fact that physical properties (size, formulation) matter more than sequences and functions, but it could also be another indication of the poor predictability of the mouse model. table summarizes the various models currently used in respiratory allergy research. models of non-respiratory endpoints such as allergic contact dermatitis e.g. the guinea pig maximization test are not included: the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. this section describes the results of the systematic literature search that was conducted on pubmed, together with the extra information that we found by back-tracking references from important reviews through web of knowledge. for each microorganism or microbial product from our list, we listed all the relevant information we could find in the following order: species were found to have relevant information, for a total of relevant articles. only species for which relevant information could be found are listed here. use in food or feed: a. globiformis is used to alter the taste of some food products, for example to metabolize bitter limonin of citrus. epidemiological studies: a study of agricultural workers from poland diagnosed with hypersensitivity pneumonitis showed that a. globiformis was the etiological agent in cases [ ]. case reports: n/a literature arguing against a possible sensitization by the agent: n/a use in food or feed: various strains of the fungus a. niger are used in the industrial preparation of citric acid (e ) and gluconic acid (e ). a. niger also is used to produce enzymes such as glucoamylase and pectinases. epidemiological studies: n/a case reports: a case of hypersensitivity pneumonitis to a. niger was reported in [ ], while several cases of allergic fungal sinusitis, rhinitis and bronchopneumonitis have been reported [ , , ]. it has been suggested that asthma and atopy may both represent a protective response against contained airway infection due to ubiquitous proteinase-producing fungi [ ]. literature arguing against a possible sensitization by the agent: n/a the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. a. oryzae is a fungus used in chinese and japanese cuisine to ferment soybeans or to saccharify rice, other grains, and potatoes in the making of alcoholic beverages. a. oryzae is also used for the production of rice vinegars. it can also be used to produce glucoamylase and alpha-amylase. epidemiological studies: n/a case reports: articles were found describing cases of respiratory sensitization linked to the use of a. oryzae in the food industry [ , ]. both cases involved a high seasonal concentration of spores in the homes of japanese brewers and respiratory symptoms. interestingly, one of these articles referred to the existence of at least other similar cases described in the japanese literature. literature arguing against a possible sensitization by the agent: n/a use in food or feed: b. licheniformis is used to degreade feathers to produce cheap and nutritious feed for livestock. also used as a probiotic in livestock. epidemiological studies: n/a case reports: n/a literature arguing against a possible sensitization by the agent: b. licheniformis spores were found to induce a th type response in-vitro in bal/c mice [ ] . use in food or feed: b. pumilis is used to degreade feathers to produce cheap and nutritious feed for livestock. epidemiological studies: in , bernstein et al [ ] found cases of machine operator's lung, a type of hypersensitivity pneumonitis. those cases all followed occupational exposure to metalworking fluid. at least of those patients presented serum precipitin tests positive to b. pumilis. case reports: n/a literature arguing against a possible sensitization by the agent: n/a use in food or feed: b. subtilis can be used in the commercial production of the japanese food natto as well as the similar korean food cheonggukjang. it can also produce amylase; and is used as a probiotic for livestock. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. epidemiological studies: a cross-sectional study of workers from a herb processing plant showed that they responded with a high frequency % to a skin prick test with extract from bacillus subtilis [ ] . use in food or feed: d. hansenii is generally the predominant yeast in the smear of bacterial surface-ripened cheeses such as munster. epidemiological studies: n/a case reports: a -year-old female was reported to have developed cough, fever and dyspnoea following repeated exposure to a home ultrasonic humidifier [ ] . precipitating test and lymphocyte proliferative response was positive for an extract of d. hansenii. literature arguing against a possible sensitization by the agent: n/a use in food or feed: e. faecium is a probiotic used in feeds for livestock. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. literature arguing against a possible sensitization by the agent: in the atopic dermatitis mouse model, e. faecium suppressed total ige production and induced il- and ifn-gamma production; intraperitoneal injection of strain t inhibited serum ige elevation and atopic dermatitis symptoms [ ] . use in food or feed: this organism is used to produce certain types of yoghurts, especially from nordic countries. use in food or feed: lactobacilli are used in the food for acidification, and/or enhancement of flavor, texture and nutrition. they can also serve as starters or complementary cultures for several varieties of cheese, fermented plant foods, fermented meats, in wine and beer production, sourdough bread and silage, and as probiotics in feeds for livestock. epidemiological studies: n/a case reports: n/a literature arguing against a possible sensitization by the agent: there is ample evidence indicating that lactobacilli (or at least some strains of lactobacilli) alleviate allergic symptoms. such properties were observed for l. brevis in the atopic dermatitis mouse model, where oral administration of the bacteria inhibited ige-production, and skewed the immune response towards th dominance [ ] . l. brevis-fermented kimchi also strongly alleviated symptoms of prurit, anaphylaxis and inflammation in a mouse model [ , ]. l. casei was shown to attenuate lung inflammation and th cytokine profiles in der p sensitized mice, hinting at immunomodulatory properties useful to prevent respiratory allergies [ ]. one study in-vitro in atopic dermatitis patients [ ] and one study in mice [ ] supported similar conclusions about l. fermentum. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. overtvelt et al showed that l. helveticus reduced airways hyperresponsiveness, bronchial inflammation and proliferation of specific t cells in cervical lymph nodes in the murine asthma model and characterized this strain as a probiotic acting as a th /possibly treg adjuvant that potentiates tolerance induction via the sublingual route. in the ova-induced allergy mouse model, nonaka et al [ ] showed that a l. pentosus strain induced il- and il- in-vitro and modulated the th /th balance toward a th -dominant state. in-vivo, serum ige levels were diminished and active cutaneous anaphylaxis reaction were suppressed. splenic il- production from splenocytes of ova-immunized mice was upregulated by oral administration of l. pentosus. in , a double-blind, placebo-controlled, crossover study in children showed that a combination of l. rhamnosus and l. reuteri was reduced symptoms of atopic dermatitis, especially in patients with increased ige levels [ ] . supplementation of l. reuteri during pregnancy was associated with low levels of tgf-beta and slightly increased levels of il- in colostrum [ ] . studies in balb/c mice argued for a role for non antigen-specific cd (+)cd (+)foxp (+) regulatory t cells in attenuating the allergic airway response following oral treatment with l. reuteri [ ] . oral treatment with the live bacteria greatly decreased allergen-induced airway hyperresponsiveness, but a similar effect was not observed with the killed organism [ ]. use in food or feed: l. lactis is used in the early stages for the production of many cheeses including brie, camembert cheese, cheddar, colby, gruyère, parmesan, and roquefort. other uses include the production of pickled vegetables, alcoholic beverages, and other fermented food-stuffs. it can also be used as a probiotic in feeds for livestock. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. epidemiological studies: n/a case reports: n/a literature arguing against a possible sensitization by the agent: two recent studies in mice indicate that treatment with l. lactis to togther with an allegen (blg) decreased il- production and enhanced ifn-gamma production by blg-reactivated splenocytes, suggesting a switch from th -to th -immune response [ , ] . symptoms after intranasal challenge were locally reduced, as evidenced by decreased release of il- in bronchoalveolar lavage fluids. use in food or feed: l. mesenteroides is a bacterium associated with the sauerkraut and pickle fermentations. epidemiological studies: n/a case reports: n/a literature arguing against a possible sensitization by the agent: in an in-vitro study in mouse splenocytes, a strain of l. mesenteroides proved to be a useful th stimulating agent, especially by upregulating ifn-gamma production [ ] . use in food or feed: p. pentosaceus is used as an acid producing starter culture in sausage fermentations, cucumber and green bean fermentations, soya milk fermentations, and silage. epidemiological studies: n/a case reports: n/a animal studies: duchaine et al [ ] showed that p. pentosaceus has a pro-inflammatory effect in mice similar to that of s. rectivirgula, the most common etiological agent of farmer's lung. this was in contrast of a most recent publication by masuda et al [ ] , where they showed that the sn strain of this bacteria increased the production of th cytokines in peyer's patches of allergic diarrheic mice. literature arguing against a possible sensitization by the agent: n/a use in food or feed: p. candidum is used in cheese-processing. epidemiological studies: in a study from , cheese-factory workers out of had airway symptoms, five had asthma requiring treatment [ ] . two-thirds of the symptomatic cheese-workers had precipitating antibodies; compared to only half in the non-symptomatic group. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. case reports: n/a literature arguing against a possible sensitization by the agent: n/a use in food or feed: p. nalgiovensis is the most frequently used starter for cured and fermented meat. epidemiological studies: a study of workers from a sausage factory showed that symptoms of hp such as sneezing, cough, dyspnoea, nasal obstruction, headache, and discomfort were significantly more frequent in workers exposed to p. nalgiovensis [ ] . case reports: a -year-old male pork butcher was reported to experience cough, tightness of the chest, and sibilant dyspnea for years [ ] . episodes were related to the handling of sausages and inhalation of the dust coming from the sausage casings at his work in the butcher's area of a supermarket. the patient had ige to p. nalgiovensis. literature arguing against a possible sensitization by the agent: n/a use in food or feed: p. roqueforti is typically used in the production of blue cheeses. epidemiological studies: n/a case reports: campbell et al [ ] described the case of a cheese factory worker with symptoms of cough, dyspnea, and malaise, and findings of bibasilar crackles, reduced lung volumes, hypoxemia, and bilateral infiltrates on chest roentgenogram. all symptoms resolved after she left the workplace. bronchoalveolar lavage revealed a high percentage of lymphocytes. antibodies to p. roqueforti were detected in serum and lavage fluid. literature arguing against a possible sensitization by the agent: n/a use in food or feed: s. cerevisiae is a top-fermenting yeast, and has been used for brewing and baking for centuries. it is also widely used as a probiotic for livestock. epidemiological studies: a study of subjects, including atopic dermatitis (ad) patients, patients with allergic rhinitis and/or asthma, and nonatopic controls found that a positive spt reaction (> or = + +) was seen in % of patients with severe ad, in % with moderate ad, and in % with mild ad or no history of ad. patients with rhinitis and/or asthma and nonatopic controls displayed a positive reaction in only and % of cases, respectively [ ] . case studies: in , a -year old baker was reported to have hydrorrhea, sneezing, nasal obstruction, wheezing, spasmodic cough, and dyspnea upon exposure to the dried form of the the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. yeast. the patient began to use conventional wet yeast and carried on normal work activity without symptoms [ ] . an interesting case was described in . the patient experienced generalized urticaria and asthma after eating pizza and bread, but only fresh from the oven, and had ige to s. cerevisiae [ ] . if bread, pizza and cakes were eaten more than one hour after preparation, no symptom would occur at all. why the allergen was active only in readybaked foods remains unexplained. literature arguing against a possible sensitization by the agent: n/a the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. this section describes the results of the systematic literature search that was conducted on pubmed, together with the extra information that we found by backtracking references from important reviews through web of knowledge. for each enzyme from our list, we listed all the relevant information we could find in the following order: epidemiological studies: doekes et al [ ] report a prevalence of % of respiratory symptoms among exposed workers in a factory producing premix for feed additives. % of those workers had measurables ige against phytase. zober et al [ ] performed a cross-sectional study on workers from an r&d facility with potential contact with phytase and found symptoms of conjunctivitis, rhinitis, or bronchitis in % of those employees. baur et al [ ] examined employes with occupational exposure to phytase either during largescale enzyme production (powdered form), enzyme laboratory analysis, or animal husbandry. symptoms were reported in % of the subjects, including dyspnoea ( % of the subjects), rhinitis ( %) and conjunctivitis ( %). % of the subjects exhibited ige-mediated the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. sensitization, and % had measurable igg levels. finally, caballero et al [ ] examined workers from two animal feed factories and found that seven of those were sensitized to phytase or -phytase. three of those workers had asthma symptoms, two had asthma and rhinoconjunctivitis, one had asthma and rhinitis, and one had rhinitis only. use in food or feed: accelerate the breakdown of starch, for example to enhance yeast performance in the baking industry. production organism: aspergillus niger, aspergillus oryzae, bacillus amyloliquefaciens, bacillus subtilis, bacillus licheniformis, bacillus stearothermophilus, microbacterium imperiale, trichoderma reesei, trichoderma longibrachiatum (alpha-amylase); barley, soybean (beta-amylase) epidemiological studies: there is a large number of studies of amylase-linked allergic reactions, especially in the bakery industry. in , a cross-sectional study of bakery workers in the netherlands found a positive association between positive skin prick tests to alpha-amylase and work-related respiratory symptoms [ ] , establishing conclusively the strong and positive relationship between alpha-amylase allergen exposure levels in bakeries and specific sensitization in bakery workers. this finding was confirmed years later in a study looking at flour samples from british bakeries [ ] . in , brisman et al [ ] took a closer look at a cohort of bakers and found new cases of chest symptoms, of eyes/nose symptoms, and of positive spt to a-amylase. they showed exposure-response relations for chest and eyes/nose symptoms and for sensitization, and an increased prevalence for chest symptoms in the most exposed workers. similar relations were confirmed one year later in bakery workers in belgium in [ ] . a large study of supermarket bakery workers in south africa revealed that only % of the wrokers had a sensitization to fungal amylase [ ] , underlining the effect of work environment regulations. by comparison, ige antibodies to fungal amylase are found in % of us blood donors [ ] . similarly, it has been observed that alpha-amylase from bacillus amyloliquefaciens did not cause sensitization in a study involving animal feed workers [ ] whereas other fungal enzymes were found to be sensitizers in the same settings. for the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. case reports: since the link between amylases and allergy is well-documented thru numerous epidemiological studies, case studies worth mentioning fall a bit outside of the classical baker's asthma. interesting case reports on amylase include a double sensitization to lysozyme and amylase in a baker with rhinoconjunctivitis and asthma [ ], a sensitization occuring from infrequent contact with the enzyme in a lab technician showing symptoms localized on her hands without nasal or respiratory effects [ ] , and one case of occupational allergic contact urticaria from fungal but not bacterial alpha-amylase [ ] . two cases of igemediated rhinitis have also been reported in hospital and pharmaceutical workers exposed to biodiastase, a prescription drug based on alpha-amylase [ ] . animal studies: it has been shown that amylase from bread crust and rolls crust kept between . and % of the antibody-binding capacity of amylase from dough [ ] . in-silico work: warren et al [ ] have developed a dynamic population-based model for the development of work-related respiratory health effects among bakery workers. the model predicts that non-atopic/non-sensitised workers had probabilities of developing moderate symptoms and progression to severe symptoms of respectively . % ( % ci . to . %) and . % ( % ci . to . %) per mg/m /year of flour dust. these probabilities were twice as high in atopic workers. they also predict that % ( % ci to %) of workers with severe symptoms are sensitised to wheat and % ( % ci to %) to alpha-amylase. allergens of a similar class outside of food and feed area: alpha-amylase from porcine pancreatic extract [ ] and mite amylase [ ] are both respiratory sensitizers. asparaginase ec: . . . -food use in food or feed: converts asparagine into aspartic acid. this prevents the formation of carcinogenic acrylamide during high temperature processes such as cookie manufacturing. production organism: aspergilly niger, aspergillus oryzae. epidemiological studies: n/a case reports: n/a animal studies: n/a in-silico work: n/a allergens of a similar class outside of food and feed area: asparaginase can also be used as a cancer chemotherapy agent. lee et al have reviewed allergy cases of this application and found that reactions have been reported to occur in up to % of treated patients, although serious anaphylactic reactions occur in less than % of patients [ ] . the present document has been produced and adopted by the bodies identified above as author(s). in accordance with the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. in-silico work: n/a allergens of a similar class outside of food and feed area: the major latex allergen hev b is an esterase [ ] . an important allergen from carica papaya pollen also has an esterase activity [ ] . epidemiological studies: sander et al [ ] examined bakers exhibiting symptoms of asthma, rhinitis and conjunctivitis. % of them were found to have specific ige to glucoamylase. case reports: quirce et al [ ] have described four cases of patients (three bakers, one enzyme processing plant worker) presenting symptoms such as cough, shortness of breath and wheezing. all four patients had ige against glucoamylase. in-silico work: n/a allergens of a similar class outside of food and feed area: n/a other routes of exposure: kanerva et al [ ] described the case of a chemical enzyme factory process operator presenting symptoms of itching and dermatitis. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. use in food or feed: glucose oxidase is used for the removal of glucose or oxygen from the foodstuff in order to enhance their stability during storage. production organism: aspergillus niger, aspergillus oryzae, penicillium chrysogenum. epidemiological studies: n/a case reports: simon et al [ ] reported the case of a -year-old man with granulomatous lung disease, employed in the extraction and purification of glucose oxidase from aspergillus niger two years before admission. the link between the symptoms and the enzyme has not been formally proved in this study. animal studies: n/a in-silico work: n/a allergens of a similar class outside of food and feed area: n/a hemicellulase use in food or feed: used in bakery for the enhancement of dough qualities (mechanical handling, stability) and for product optimisation (volume, consistency, storage life), as well as in the production of fruit juice and other beverages, in the production of spirits and in the alcohol industry, in wine production or as an additive to animal feed (to increase digestibility). production organism: aspergillus niger, bacillus amyloliquefaciens or subtilis, trichoderma reesei or longibrachiatum. epidemiological studies: in a cross-sectional study, elms et al [ ] analyzed the serum of bakery workers. % of those workers had ige against hemicellulase, and there was a significant correlation between specific ige and nasal symptoms. case reports: quirce et al [ ] have described four cases of patients (three bakers, one enzyme processing plant worker) presenting symptoms such as cough, shortness of breath and wheezing. two of those four patients had a positive skin-prick test to hemicellulase. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. epidemiological studies: horner et al [ ] examined patients showing symptoms of respiratory allergies and skin test reactivity to at least fungal allergens. % of those patients showed rast reactivity to invertase. lactase or galactosidase (beta) use in food or feed: lactase is used commercially to prepare lactose-free products, particularly milk. it is also used in preparation of ice cream, to make a creamier and sweetertasting product. production organism: aspergillus oryzae, kluyveromyces lactis, bacillus circulans. epidemiological studies: in , muir et al [ ] looked at volunteers from a lactase packaging plant and observed that % had positive results to skin prick test with lactase. the lactase skin test results correlated with nasal and eye symptoms, but not with symptoms suggestive of asthma. in , bernstein et al [ ] found similar results in a study involving pharmaceutical workers occupationally exposed to lactase. % of the workers were skin prick positive, and those were times more likely to have respiratory symptoms than workers with negative skin-pricks. use in food: lysozyme is used as a food preservative due to its antibacterial properties. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. epidemiological studies: in a double blind, placebo-controlled food challenge, concentrated lysozyme was allergenic in a skin prick test, but no patient reacted adversely in the provocation test to fined wine [ ] . the authors concluded that wines treated with fining agents at commercial concentrations did not present a risk to allergic individuals when filtered. similar conclusions were drawn about the contents of lysozyme in grana padano cheese [ ] . however; it has been suggested that lysozyme may present a harmful adjuvant in wine processing for consumers allergic to hen's egg [ ] . [ ] report that while examining patients allergic to russian thistle (salsola kali) pollen, they found that all of them had ige against sal k , a protein from the pectin methylesterase family. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. epidemiological studies: belleri et al [ ] examined workers from a pectinase production factory and showed that % of them had ige to pectinase. % of those workers had both respiratory symptoms and detectable ige against pectinase. case reports: sen et al [ ] reported cases of asthma and conjunctivitis among workers from a fuit salad processing plant. all three had ige against pectinase. it is interesting to note that in this factory, pectinase was used in a liquid form. animal studies: n/a in-silico work: n/a allergens of a similar class outside of food and feed area: ibarrola et al [ ] examined patients with allergy to platanus acerifolia pollen. % of the patients had rhinoconjunctivitis, % had asthma, % had rhinitis, % had urticaria. % of the patients had ige against pla a , a pectinase. in-silico work: n/a allergens of a similar class: a peroxidase from wheat has been reported to be an allergen, with sera from out of wheat-allergic patients reacting to the purified dot-blotted allergen [ ] . the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. allergens of a similar class: phospholipases are very common allergens of venom from bees and other arthropods [ ] . [ ] followed the fao/who decision tree to assess the safety of transglutaminase and found no concern with regard to its allergenic potential. epidemiological studies: in a cross-sectional study, elms et al [ ] analyzed the serum of bakery workers. % of those workers had ige against xylanase, and there was a significant correlation between specific ige and nasal symptoms. in a retrospective study, sander et al [ ] examined bakers exhibiting symptoms of asthma, rhinitis and conjunctivitis. % of them were found to have specific ige to glucoamylase. vanhanen et al [ ] conducted a cross sectional study on workers in four bakeries, one flour mill, and one crispbread factory. % of the workers presented respiratory symptoms, and % had a positive skin prick test to a mix of enzymes including xylanase. in a similar study in the animal feed industry, the same group found that % of exposed workers were sensitised to enzymes to a mix of enzymes including xylanase. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. [ ] report the case of a bakery worker with rhinoconjunctivitis, cough, and shortness of breath. the patient reacted to an inhalative challenge with ≈ . μg of xylanase. merget et al [ ] describe the case of a baker with occupational asthma (nasal congestion, sneezing, running nose, watering of the eyes and shortness of breath). the patient showed significant levels of ige against xylanase. in-silico work: n/a allergens of a similar class outside of food and feed area: proteases are a very well known class of allergenic enzymes, especially but not exclusively in the context of detergent manufacturing [ ] . in addition to their intrinsic allergenicity, proteases have potential effects on several processes involved in allergic diseases: epithelial integrity and permeability, mast cell degranulation, cytokine release from the respiratory epithelium [ , ] . proteases have been shown to interact with receptors from the lining of the respiratory tract, leading to the activation of immunological pathways that can potentially trigger allergic reactions, for example via stimulating epithelial cells to release metalloproteinase and open up tight junctions promoting allergen penetration into the submucosa [ ] . proteases from pollen [ ] , house dust mites [ ] , cockroaches [ ] and fungi [ ] have been shown to have these effects. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. we have conducted a survey of the existing legislation and regulations regarding enzymes and microorganisms and the basis for occupational exposure limits (oels) and labelling. the integrale version of this survey can be found in appendix . it appears from this survey that oels have been set for enzymes (subtilisins) in the uk and the us, but that these limits are bypassed by the limits set "in-house" by the detergent industry. it is also expected that the european regulations will in the future set some derived no effect level (dnel) or derived minimal effect level (dmel) for macromolecular compounds including enzymes. the appendix also includes a list of proteins as airway allergens together with the corresponding labelling and oel, whenever they exist. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. it appears from our research that there is currently no established model to predict the allergenicity of a molecule. although in-silico models can be useful to predict cross-reactivity between allergens, they only take into account the structure of the allergen, which is only one of the many factors implicated in sensitization, and in our opinion only a minor one. in-silico models fail to take into account the context in which the allergen is presented to the immune system. in-vitro models are currently far from being used for predictive studies. although many cell lines are currently used in the lab, research is still trying to understand the role and mechanisms of the cells in the development of allergies, rather than using them to test the allergenicity of various molecules. although co-culture three-dimensional models might someday achieve that purpose, they remain very far from re-creating the complexity of the immune response in a living organism. among in-vivo inhalation animal models, the mouse is currently the best. however, it suffers from several shortcomings that prevent it from being a reliable predictive model: most models require systemic sensitization by injection, followed by multiple respiratory challenges, which hardly resembles the exposure conditions in humans. additionally, most mouse models are strong "atopic-like" responders that can be sensitized to molecules that are not allergenic in humans. in general, exposure to bacterial species leads to a th -type response in humans, increasing macrophages efficiency and leading to the production of opsonising antibodies, two systems very useful to deal with that type of pathogens. in contrast, th responses to bacterial infections are rare, and can sometimes be indicative of a poor prognosis, such as in the case of leprosy. as an illustration of the apparent lack of role of bacteria in allergic diseases, we have been unable to find an example of regulations such as oel to work with such organisms. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. having possible allergic effects. thus, it is not considered a general feature of bacteria to express sensitising properties. although one study reporting type- reactions to b. subtilis extracts was found in our survey, the overwhelming majority of reports were arguing for a beneficial role of bacteria to allergy symptoms, through the induction of th and/or treg responses. this observation is of course partially biased by the fact that lactic acid bacteria were the most studied microorganisms in our list, and these are actually used for their immunomodulatory properties. it is also worth noting that these properties are strain-dependant: only a few strains of a given species have an immunomodulatory effect, while the others have usually no beneficial effect on allergy symptoms. in addition, one recent study introduced the idea that th -inducing bacteria only might not be sufficient for inducing tolerance, but that treg-induction might also be required [ ] . it seems that the best-documented allergic risk linked to occupational exposure to bacteria is hypersensitivity pneumonitis. from our survey, it seems that hp has been linked to exposure to b. pumilis (machine operator's lung), b. subtilis (wood dust) and a. globiformis (agricultural workers). hp remains, however, a very rare disease, and is associated with very specific conditions and high level of exposure. none of the cases described resulted from an intentional use of the bacteria. the case of fungi is quite different. strong evidence of a link between asthma severity and fungal exposure has been previously established. sensitization to fungal species has been shown to be a significant risk factor for severe asthma [ ] . most likely, fungal sensitization can have a causative role in severe asthma [ ] . furthermore, sensitization and exposure to fungi have been linked to hospital admissions and emergency department visits for asthma, life-threatening asthma, admission to icu, and asthma-related mortality. the role of fungi in severe asthma hospitalizations and mortality has been reviewed in [ ] . indoor fungal exposure is particularly relevant to this report. verhoeff et al reviewed studies on indoor fungi exposure and hypersensitivity. the majority of those studies argued for a link between domestic fungal levels and allergic symptoms [ ] . however, it is worth noting that at least one review disputes the studies linking indoor moulds exposure to upper airway allergy (rhinitis), while agreeing with its role in asthma [ ] . it is interesting to see that, as opposed to bacteria; there are regulations regarding the acceptable levels of exposure to several fungi (moulds). the above-mentioned european classification has been applied to (groups of) fungal species: aspergillus fumigatus, candida albicans, coccidioide sinunitis, cryptococcus neoformans var. neofonnans (filobas idiella neofonnans var. neofonnans), cryptococcus neoformans var. gattii (filobasidiella bacillispora), epidermophyton floccosum, microsporum spp., penicillium marneffei. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. our survey of the litterature unveiled species of fungi associated with type allergies, including several studies demonstrating the link between occupational exposure to fungi and hypersensitivity. cases of ige-mediated hypersensitivity as well as hypersensitivity pneumonitis are well documented and involve several distinct genera. in general it seems that fungi can be sensitizers, although allergic symptoms are associated with high levels of exposure compared to other respiratory sensitizers, such as pollen. in contrast to the situation with bacteria, some of the cases that we have presented result from an intentional use of the microorganism. in particular, the cases of p. roqueforti (cheesemaking), s. cerevisiae and a. oryzae are very relevant for this report, as they are directly linked to food production processes. in addition to compiling scientific litterature on the topic, we also contacted one of the leading companies in the field of industrial cultures of microorganisms, chr. hansen a/s. the company claims no cases of allergy related to microorganisms among employees. the only incident involving respiratory symptoms (likely be caused by a toxic/irritative mechanism) occurred when a customer in brazil sprayed the cultures in an indoor environment. this was a highly unusual process, and very different from the intended use of the product. the lack of documented allergic reactions to microorganisms can of course be tied to the comprehsensive preventive measures applied throughout the production process. few workers are directly exposed to inhalable products, and those who do obey strict rules, including wearing personal protection equipment. although very commendable, it is possible that those measures partly hide the sensitizing potential of these microorganisms. sensitizing properties of enzymes have been a cause of concern for several decades in food and feed industry, albeit at lower levels than in the bakery or detergent industry [ ] . allergies to b. subtilis proteases, for example, have been described since the late s [ ] . the most reported cause of respiratory sensitization by enzymes in the food and feed industry is perhaps the case of alpha-amylase and baker's asthma, but other enzymes such as proteases, cellulase and glucose oxydase are also a cause of concern. to compound the problem, industrial enzyme grades are often poor and contain other enzymes from the same production organism, leading to unexpected sensitization and cross-reactions [ ] . studies conducted in enzyme-producing plants have confirmed that enzymes can induce sensitization and allergy [ ] , regardless of their enzymatic activities, or production organism. although not related to food and feed, and therefore out of the scope of this report, the detergent industry also has an extensive experience with enzymes. while respiratory allergies in consumers proved to be a problem in the early years of enzyme addition to detergents ( s), granulated formulations have reduced type- reactions in the general population to the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. virtually nothing [ ] . the problem is now limited to manufactoring processes, and stringent rules in the modern enzyme-and detergent-producing field have contributed to greatly diminish sensitization in workers. like for microorganisms, hypersensitivity pneumonitis to enzymes has been described, for example to phytase [ ] . cases remain however extremely rare, and seem associated with very high levels of exposure. out of enzymes listed as food or feed additive by the amfep, our survey found that were related to allergies. all but one of these were linked to respiratory sensitization. although our survey seems to indicate that the general trend is towards a decrease in exposure levels and sensitization to enzyme in the industry, it is worth noting that studies in the field suffer from inherent selection biases and therefore probably underestimate the true prevalence of sensitization to enzymes. as we did previously for microorganisms, we completed our survey of the literature with a direct contact with a leading producer of enzyme, novozymes. according to the company, less than cases of symptomatic workers are identified every year, and the symptoms/sensitivity ratio has been decreasing due to reduced exposure in the recent years, pointing at a dose-response effect. interestingly, these numbers seem higher than those observed in the case of microbial cultures, although it is difficult to make a comparison between two different production processes taking place in two different companies. no cases have been reported among customers since . novozymes a/s acknowledges the sensitising role of enzymes and relies on stringent personal protection measures to minimize exposure of workers. the use of granulate formulation has led to a steep decrease in exposure levels, with differences beetween formulations (more effective for detergent than bakery uses). the company research has observed no differences in relative allergenicity between enzymes, which seems to indicate that the physical properties of enzymes (formulation, molecular weight…) might be more important than their function or amino-acid sequences. the role of the production organism in allergenicity is currently being investigated. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. when considering the findings on inhalation allergy risks presented in this report, a number of observations stand out: the enzymatic activity in terms of substrate specificity etc, does not seem to explain whether an enzyme has been incriminated as an inhalation allergen or not. neither does the production organism seem to decide whether or not an enzyme has been reported as an inhalation allergen. while it is possible to device sensitization regimes in animals, in particular in mouse, neither these, nor in-silico or in-vitro systems seem to work well in predicting the allergenicity of enzymes in real life. this would suggest that the inherent properties of an enzyme may not be decisive, as to whether it is going to create inhalation allergies. looking at where and when enzyme allergies have been reported, there seems to be a clear gradient from the producers of enzymes, over manufacturers that formulate their products with inclusion of enzymes, to end users that may be exposed to enzyme-containing products (fig. ) . also -and in spite of an increase in the worldwide use of enzymes -there seems to be fewer recorded cases of allergies and sensitizations compared to the situation in the 'ies and 'ies where much higher levels of airborne enzymes prevailed. it seems reasonable to conclude that this reduction is caused by a reduced exposure, which is likely to be caused by different formulations of the raw enzymes which are now dispensed in liquid or granulated forms rather than the former use of powder of small particle sizes. the exact regimens, i.e. temporal concentration profiles, that cause sensitization and may lead to inhalation allergies are not known, but in spite of the fact that in allergy development doserelationships may not always be linear, it is likely that increasing doses of inhaled enzyme lead to increased risks. also -estimated from the lack of reports of enzymes allergies in the general population -it seems that there are thresholds under which exposure does not cause sensitization and allergy. from this follows that setting demands on the formulation (distribution in non-inhalable forms) and designing of the processes in which enzymecontaining (food or feed) products are used, would be a way to reduce the sensitization and allergy risk. if these measures do not lead to consistently low airborne exposure throughout the life cycle of the product, it is necessary to label products and protect exposed persons by personal equipment such as masks etc. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. it is not known whether sensitization always lead to clinical allergy, but based on industrial hygiene experiences and knowledge from other areas of allergy, it must be assumed that sensitization, i.e. the formation of ige antibodies against an enzyme, would be a very strong risk factor for also developing symptoms upon continued exposure. the different steps in developing enzyme allergy and the potential prevention measures are depicted in fig. . the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. figure : flow of enzymes in society, from the producr to the end-user. the shade of darks represent the number of prevalence of sensitization for each category of person exposed. figure : key steps in developing enzyme allergy. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. propionibacterium shermanii the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. [ ] . here the relevant definition of the criteria that should be used for identifying the inhalation sensitising potential is described, i.e. which criteria that should be applied for evaluation of whether a substance is eligible for being labelled with r : the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. substances and preparations shall be classified as sensitising and assigned the symbol .xn., the indication of danger .harmful. and the risk phrase r in accordance with the criteria given below. if there is evidence that the substance or preparation can induce specific respiratory hypersensitivity, where there are positive results from appropriate animal tests, or if the substance is an isocyanate, unless there is evidence that the specific isocyanate does not cause respiratory hypersensitivity. comments regarding the use of r : human evidence evidence that the substance or preparation can induce specific respiratory hypersensitivity will normally be based on human experience. in this context hypersensitivity is normally seen as asthma, but other hypersensitivity reactions such as rhinitis and alveolitis are also considered. the condition will have the clinical character of an allergic reaction. however, immunological mechanisms do not have to be demonstrated. when considering the evidence from human exposure, it is necessary for a decision on classification to take into account in addition to the evidence from the cases: the size of the population exposed, the extent of exposure. the evidence referred to above could be: the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the results of positive bronchial challenge tests are considered to provide sufficient evidence for classification on their own. it is however recognised that in practice many of the examinations listed above will already have been carried out. substances that elicit symptoms of asthma by irritation only in people with bronchial hyperreactivity should not be assigned r . animal studies enzymes and microorganisms as respiratory sensitizers the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. data from tests which may be indicative of the potential of a substance or preparation to cause sensitization by inhalation in humans may include: ige measurements (e.g. in mice), or specific pulmonary responses in guinea pigs. whole microorganisms are different because they are living cells, i.e. biological agents. the above-mentioned directive covers dangerous substances. according to the new eu regulations on chemicals (reach), the definitions of chemicals (substances and preparations) according to reach are: substance means a chemical element and its compounds in the natural state or obtained by any manufacturing process, including any additive necessary to preserve its stability and any impurity deriving from the process used, but excluding any solvent which may be separated without affecting the stability of the substance or changing its composition. preparation means a mixture or solution composed of two or more substances microorganisms such as a bacterium, a yeast cell or spores of these do not fall under the definition of a substance or a preparation according to the eu regulations. application of the classification criteria and labelling rules to the area of microorganisms would thus be by way of analogy with substances and preparations, since they do not seem to be covered by the regulations mentioned above. eu has, however, covered the occupational hazards of working with biological agents in a directive on protection of workers from risks related to exposure to biological agents at work a definition of "biological agents" and "microorganisms appears in / /eec council directive / /eec of november on the protection of workers from risks related to exposure to biological agents at work: the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. biological agents shall mean microorganisms, including those which have been genetically modified, cell cultures and human endoparasites, which may be able to provoke any infection, allergy or toxicity. microorganism shall mean a microbiological entity, cellular or non-cellular, capable of replication or of transferring genetic material. in the biological agent directive [ ] while there are no bacteria classified as having possible allergic effects this classification has been applied to (groups of) fungal species: the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the above-mentioned list formed the basis of national lists in the uk and germany. these are some years newer, and have been slightly revised for virus (sars), but there has been no changes regarding (the missing) classification of bacteria as allergenic, and no further fungal species defined as allergenic. the list from directive / /ec only include organisms in classes , and , but the german list also mention of class organisms [ ] . unfortunately this list does not provide information on potential sensitization. a recent guideline from germany [ ] the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. konzentration zu einer sensibilisierung bis hin zu schwerwiegenden allergischen erkrankungen. (p. thus it is not considered a general feature of bacteria to express sensitising properties. also as indicated in the introduction the regulation on (chemical) substances and preparations does not cover biological agents, thus it is not surprising that there is no mention of microorganisms in this legal complex. in conclusion, no bacterial species per se have previously been considered as allergenic in the european legislation. on the other hand, individual fungi and yeasts have been recognized as allergenic in accordance with the scientific literature as discussed later. occupational exposure limits (oels) are concentrations of products in the air. health-based oels are set by a risk assessment approach, which includes evaluating all hazards (inborn toxicological properties) linked to a compound and establishing exposure-response relationships for the hazardous effects, followed by risk characterization. concentrations below the oels are considered to protect nearly all occupationally exposed individuals against adverse effects, although it is realized that a minor and especially sensitive part of the population may not be protected [ ] . this subpopulation may include individuals highly asthmatic/allergic to the allergen of interest. a prerequisite for establishing a health-based oel is that adverse reactions are exposure-dependent and that there is a concentration where adverse effects no longer appear, i.e. it is possible to establish a no-observed-(adverse)-effect level (no(a)el) for offending effects [ ] . for allergen exposures, risk assessment may be evaluated by means of the airborne concentration per m , as with oels. appropriate analytical methods are prerequisites for establishing exposure-response relationships. airborne allergens are collected on filters by means of a pump and sampling may be enzymes and microorganisms as respiratory sensitizers the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. in the breathing zone by a person-carried filter cassette or it may be by high volume static samplers. the filter content of allergens is then analyzed by immunochemical methods [ , ] . a risk may also be evaluated by means of the allergen concentration per gram of settled dust [ ] . the idea behind this approach is that settled dust can become airborne and thus the concentration in the settled dust can be used as a proxy for the exposure. this approach has been found useful for evaluation of indoor allergen exposures from house dust mite, dog, cat, cockroach, mouse urinary protein and alternaria alternaria [ ] . for toxicological reactions in general, one no(a)el is considered for the key effect. however, for allergic reactions two phases have to be considered. first, exposure to an allergen may induce "sensitization" that implies production of specific antibodies or activated immune cells. sensitization is not per se a disease. second, "elicitation" of symptoms occurs with further exposures to the allergen at a sufficient dose [ , ] . thus, two limits may be set, one where no sensitization is observed and another one that prevents the elicitation of allergic reactions in already sensitized individuals [ , ] . it may be difficult to establish thresholds for allergen exposures due to inter-individual variations in susceptibility to both sensitization and elicitation. those may be caused by genetic differences (atopy versus non-atopy), heterogeneity of immune properties of allergens, age-dependent effects and lifestyle factors (e.g. smoking). there may also be differences between doses that induce sensitization and those that induce elicitation of symptoms [ , ] . co-exposure to endotoxins may also play a role in development of sensitization and asthma [ ] . nevertheless, "practical" noaels have been proposed for several environmental and occupational allergen exposures [ , ] (table ) . the prerequisite of a clear exposure-response relationship has been demonstrated for several airway allergens [ , , ] . this has been shown for indoor and outdoor allergen exposure to house dust mites, cockroaches, pets, pollen and moulds. the exposure-response relationship often shows a monotonous increase in sensitization and development of allergy with increasing allergen exposure enzymes and microorganisms as respiratory sensitizers the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. [ ] . however, cross-sectional studies have suggested a bell-shaped relationship, like in the case of cat allergens, where high exposure levels may induce tolerance [ ] . a similar relationship has been observed in laboratory animal workers exposed to rat allergens, which may be due to a "modified t helper type (th ) response" where specific igg antibodies plays a role [ ] . this is heavily debated though, as a behavioral effect, i.e. "healthy petkeeper effect" cannot be totally excluded [ ] . the general trend that ige sensitization and ige-mediated allergies increase with exposure levels has been substantiated by studies of exposure to enzymes used in the detergent industry [ , ] , of exposure to natural rubber latex allergens and of exposure to flour dust as discussed below. enzymes and natural rubber latex allergens are used as examples of highly potent allergens, where an oel has been set for the proteolytic enzyme subtilisin. flour dust is used as an example of how to set an oel for a low-potent allergen. the exposure-response relationships for allergens have two important features, the steepness of the relationship and the position of the exposure-response curve. thus, different proteins have different sensitization potencies. for example, sensitization to rat urinary allergens occurs in the pg/m range, sensitization to fungal α-amylase in the ng/m range, whereas sensitization to wheat, pig and cow proteins occurs in the μg/m range [ ] . that different allergens seem to have different potencies is also deduced from environmental allergen exposures as only a limited number of allergens are of major importance in the general population [ ] . thus, the number of allergy cases in a population depends both on the potency of the allergen, the presence of adjuvants and the particle size, as well as on the specific exposure levels. in the german population in , the number of occupational asthma cases caused by various exposures was in the order flour>latex>food and feed [ ] . few oels have been set officially for macromolecular biological compounds. they comprise oels for the enzyme subtilisin and for flour dust. however, industry has often set its own internal the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. oels for enzyme, and oels for enzymes have been proposed in the scientific literature with the purpose to protect against ige-mediated allergies (type i reactions). in addition, more of these agents have an eu labelling or have warnings in oel lists. these warnings are based on recognized hazards, i.e. when an increased incidence of allergy has been observed in an occupationally exposed population. hypersensitivity pneumonitis (hp) is caused by immune reactions of precipitating antibodies and activated immune cells. few cases of enzyme-induced hp have been reported. on the other hand, many cases of type i allergies to enzymes have been documented. therefore, the critical effect is considered to be the type i allergy and thus, measures preventing the type i enzyme allergy are considered also to prevent hp. most hp reactions appear from high exposures to airborne moulds and bacteria, where growth has been promoted by wet and humid conditions. in these cases, risk management should limit the wet and humid conditions, or otherwise limit growth of microorganisms. if not possible appropriate airway protection should be used. the subtilisins are proteolytic enzymes derived from bacillus subtilis or closely related organisms. in the early s, the american conference of governmental industrial hygienists (acgih) established an oel for subtilisins as a ceiling level of ng/m of the % active pure enzyme [ ]; a ceiling level being a concentration that should not be exceeded during any part of the working exposure [ ] . thus, for a well controlled working environment, the exposure concentration has to be considerably lower than the ceiling level in general, which is important to consider when comparing the value, for example, with an -hour time-weighted average oels (table ) . the oel was derived from the experiences in the surfactant industry in the late s and the beginning of the s. the main purpose was to minimize the potential for symptoms as sore throat, nasal congestion, cough, wheezing, allergic respiratory sensitization, and to minimize skin irritation [ ] . this value is one of the lowest oels ever established and it still applies [ ] . no oel has been set for other enzymes by acgih [ ] . no oel has been set for enzymes in enzymes and microorganisms as respiratory sensitizers the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. these values are basically bypassed by the much lower exposure levels presently attended by the detergent industry. also, the lower "in house" oels in industry take into account that other constituents of detergents may have adjuvant effects [ , , ] . in the near future, oels will have to be set for many enzymes to fulfil the requirement of the new eu reach legislation. thus, a value has to be based on a noael approach to establish the "derived no effect level" (dnel) or, where a noael cannot be established, the oel has to be based on an acceptable risk to set a "derived minimal effect level" (dmel) [ ] . setting and using oels in relation to unintended development of microorganisms in naturally occurring constituents would not be possible in most cases due to the limited possibility of identifying the offending microorganisms, the limited knowledge about exposure-response relationships, and the limited possibility to implement such values in relation to risk management strategies. in these cases, the risk management strategy should directly address the appropriate prevention of the offending exposure. in the eu, harmonized classification and labelling are adopted for about , compounds (http://www.reach-compliance.eu/english/legislation/docs/launchers/launch-annex- - - -eec.html), which uses a hazard-based approach. of these compounds, very few are proteins, which are known airway allergens (table a . ). in the eu, hazards are described by symbols, e.g. harmful is indicated by "xn" and an irritant is assigned the symbol "xi", and by risk (r) phrases (http://ec.europa.eu/environment/chemicals/dansub/consolidated_en.htm). thus, specific respiratory enzymes and microorganisms as respiratory sensitizers the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. hypersensitivity (asthma, rhinitis and alveolitis) is indicated by the risk phase r : may cause sensitization by inhalation. although animal studies may be used, the evidences are mainly from human studies, where the size of the population exposed and the extent of exposure are taken into account. for α-amylase, β-glucosidase, cellulase, exo-cellobiohydrolase and laccase, respiratory hypersensitivity was the only hazard identified. for the proteases, chymotrypsin, ficin, papain, pepsin a, rennin, subtilisin and trypsin, additionally hazards were identified as expressed from r : irritating to eyes, r : irritating to respiratory system, r : irritating to skin, and r : risk of serious damage to eyes or the combination of these sentences. the eu classification and labelling indicates different risk management approaches by means of no account shall be taken of substances classified as harmful, corrosive or irritant if they exist as impurities or as additives, if their concentration by weight is less than % and if not otherwise specified (http://www.dehp-facts.com/upload/documents/webpage/document .pdf). hazard identifications from organizations setting occupational exposure limits are limited. in germany, no oel is set for the protein allergens, but hazard-based warnings are added to several proteins (table a . ). thus, respiratory allergens are indicated by "sa"or "sah" if it is also a skin sensitizer. only human exposure effects are accepted. sufficient evidence is accepted if specific hyperreactivity has been observed in relation to exposure in more than one subject in at least two independent testing centres and if there is indication for an immunological mechanism. an allergic effect is also accepted from one single case report of a specific hyperreactivity of the airways or the lungs together with other sensitizating effects, e.g. a close structure-effect relationship with known airway allergens [ ] . other examples of warnings to sensitizers are included in table . the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. read-across to establish allergenic properties within a certain type of enzymes may not be possible. for example, sensitization to phytase derived from trichoderma and peniophora species did not show cross-reactions. however, cross-reactions were observed for different types of enzymes derived from the same microorganism [ ] . overall, warning systems about sensitizing properties have to take into account that different allergens or allergenic systems can show highly different potencies and that exposures of humans need to reach a certain level before clinical effects appear. established warning systems take into account that a certain number of observed allergies have been observed in exposed populations. enzymes and microorganisms as respiratory sensitizers the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. : the short-term exposure limit is indicated by "stel" ( -min reference period) and sensitization by "sen"; baur [ ] : "noael" and "loael" for humans, "sen" indicates sensitization and "a" asthma. for further explanations see text. a warning, including a labelling, is relevant when a group of individuals is at a substantiated risk for developing diseases. to be meaningful, a warning about airway allergy or other immunological airway reactions should be based on the incidence of sensitization or the incidence of disease in exposed populations. the highest incidence is expected where process concentrations are highest, which may be in relation to production or downstream use of pure compounds. health monitoring at such workplaces is therefore especially important for hazard identification. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. in general, oels are set to allow exposure control in relation to production of compounds as well as control of exposures in downstream users. setting an oel requires hazard identification as for labelling, but also a quantitative risk assessment. this requires that the adverse effect is exposuredependent and that a level can be set where a potential risk is so low that it is of no concern. thus, a quantitative relationship about the exposure-response relationship has to be established. appropriate analytical methods must be available for this purpose, but also for the control of compliance with the established oel. as for flour dust, the overall dust concentration in the air may sometimes be used as proxy for the airborne allergen concentration, but in most cases, the analytical methods have to address the air concentration of the allergenic protein itself. at present, very few oels exist for the macromolecular biological compounds. in the near future, it is expected dnels or dmels will be set for several industrial enzymes according the european reach regulation and thus providing a new type of oels. for enzymes, the key effect seems to be ige-mediated allergy. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. • how many workers are exposed to each of those categories? • when did your company start to handle those enzymes or cultures? occupational part: • is your company monitoring allergies among workers and/or customers? • are you aware of allergy cases (within the company or with your customers or endusers) related to some of the enzymes or cultures that your company handles? • have your company developed any special formulations that reduce the risk of exposure to cultures or enzymes? • can you pinpoint any products, processes or unit operations that are related to either particularly high risk for sensitization or particularly low risk for sensitization? • does your company take specific measures for working with some of those cultures or enzymes (e.g.: personal protection equipment) within the company or for custormers or end-users toxicological part: • has your work with enzymes or cultures given you an impression on the doseresponse-relationsships in allergy development? • are you able to rank the allergy risk between individual processes or products? • are your company using any methods for predicting a possible risk of sensitization for any particular product? technical guidance on the studies concerning the safety of use of the additives for users/workers. prepared by the panel on additives and products or substances used in animal feed insights into immunoglobulin e receptor signaling from structurally defined ligands the role of basophils in helminth infection characterisation of pollen allergens chapter cumulative environmental changes, skewed antigen exposure, and the increase of allergy immunologic influences on allergy and the th /th balance epidemiological and immunological evidence for the hygiene hypothesis genetic aspects of allergic rhinitis allergic asthma: a tale of many t cells development and validation of a rhinoconjunctivitis and asthma symptom score for use as an outcome measure in clinical trials hypersensitivity pneumonitis hypersensitivity pneumonitis: an immunopathology review hypersensitivity pneumonitis: clinical perspectives exogen-allergische alveolitis -neue erkenntnisse hypersensitivity pneumonitis review of respiratory morbidity from occupational exposure to oil mists induction of th cytokines by leuconostoc mesenteroides subsp. mesenteroides (kctc ) under th -type conditions and the requirement of nf-kappab and p /jnk proinflammatory effect of pediococcus pentosaceus, a bacterium used as hay preservative pediococcus pentosaceus sn inhibits ige production and the occurrence of ovalbumin-induced allergic diarrhea in mice cheese-packers' disease--respiratory complaints at a cheese-packing dairy symptoms and serum precipitins in workers exposed to dry sausage mould: consequences of exposure to sausage mould penicillium nalgiovense as an occupational and contact allergen cheese worker's hypersensitivity pneumonitis skin prick test reactions to brewer's yeast (saccharomyces cerevisiae) in adult atopic dermatitis patients baker's asthma caused by saccharomyces cerevisiae in dry powder form looking for immunotolerance: a case of allergy to baker's yeast (saccharomyces cerevisiae) occupational ige sensitisation to phytase, a phosphatase derived from aspergillus niger response to a case of occupational asthma due to the enzymes phytase and beta-glucanase ige-mediated allergy to phytase --a new animal feed additive occupational sensitization to fungal enzymes used in animal feed industry report of occupational asthma due to phytase and beta-glucanase exposure-sensitization relationship for alpha-amylase allergens in the baking industry occupational allergic contact urticaria from fungal but not bacterial alpha-amylase two cases of occupational rhinitis caused by biodiastase in hospital and pharmaceutical workers is fungal alpha-amylase in bread an allergen? a dynamic population-based model for the development of work-related respiratory health effects among bakery workers a case of occupational rhinitis caused by porcine pancreatic extract developing into occupational asthma mite amylase from blomia tropicalis (blo t ): differential allergenicity linked to geographical regions diagnosis and management of hypersensitivity reactions related to common cancer chemotherapy agents occupational allergy in a researcher due to ole e , an allergenic , -beta-glucanase from olive pollen biochemical changes and environmental factors in manual and semiautomatic bakeries human serum ige reacts with a metarhizium anisopliae fungal catalase comparative genomics of fungal allergens and epitopes shows widespread distribution of closely related allergen and epitope orthologues prevalence of sensitisation to cellulase and xylanase in bakery workers occupational asthma caused by cellulase and lipase in the detergent industry pharyngeal edema caused by occupational exposure to cellulase enzyme occupational contact urticaria from cellulase enzyme occupational asthma and ige sensitization to cellulase in a textile industry worker enzymes and microorganisms as respiratory sensitizers in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document baker's asthma due to xylanase and cellulase without sensitization to alpha-amylase and only weak sensitization to flour maize food allergy: lipid-transfer proteins, endochitinases, and alpha-zein precursor are relevant maize allergens in double-blind placebo-controlled maize-challenge-positive patients atopic allergens of plant foods a chitinase-like protein in the lung and circulation of patients with severe asthma chitinases and chitinase-like proteins in t(h) inflammation and asthma allergenicity of hev b , a major esterase allergen in natural rubber latex (hevea brasiliensis) allergy, does not only depend on its carbohydrate moiety aerobiological and immunochemical studies on carica papaya l. pollen: an aeroallergen from india allergy to aspergillus-derived enzymes in the baking industry: identification of beta-xylosidase from aspergillus niger as a new allergen glucoamylase: another fungal enzyme associated with baker's asthma occupational protein contact 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injury to murine airway epithelial cells by pollen enzymes proteolytic activity of the house dust mite allergen der p enhances allergenicity in a mouse inhalation model in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document german cockroach extract activates protease-activated receptor in human airway epithelial cells alkaline serine proteinase from aspergillus fumigatus has synergistic effects on asp-f- -induced immune response in mice sensitisation to airborne moulds and severity of asthma: cross sectional study from european community respiratory health survey mold sensitization is common amongst patients with severe asthma requiring multiple hospital admissions the link between fungi and severe asthma: a summary of the evidence health risk of fungi in home environments the medical effects of mold exposure sensitisation to enzymes in the animal feed industry papers that have changed the practice of occupational medicine: 'pulmonary disease due to inhalation of derivatives of bacillus subtilis containing proteolytic enzyme incidence of respiratory sensitisation and allergy to enzymes among employees in an enzyme producing plant and the relation to exposure and host factors assessing the risk of type allergy to enzymes present in laundry and cleaning products: evidence from the clinical data the laws, regulations and administrative provisions relating to the classification, packaging and labelling of dangerous substance / /ec of the european parliament and of the council of september on the protection of workers from risks related to exposure to biological agents at work (seventh individual directive within the meaning of article ( ) of directive / /eec) einstufung von bakterien (bacteria) und archaebakterien (archaea) in risikogruppen. bundesarbeitsblatt - : - . enzymes and microorganisms as respiratory sensitizers in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document trba/trgs : sensibilisierende stoffe für die atemwege background, approaches and recent trends for setting healthbased occupational exposure limits: a minireview exposure to airborne allergens: a review of sampling methods detection of mouse and rat urinary aeroallergens with an improved elisa latex sensitivity: an industrial hygiene perspective exposure to multiple indoor allergens in us homes and its relationship to asthma ige-mediated asthma and rhinitis i: a role of allergen exposure? defining occupational and consumer exposure limits for enzyme protein respiratory allergens under reach are we closer to developing threshold limit values for allergens in the workplace? annals of allergy, asthma & immunology : official publication of the american college of allergy exposure-response in occupational allergy exposure assessment of high molecular weight sensitisers: contribution to occupational epidemiology and disease prevention asthma and indoor air: contrasts in the dose response to cat and dust-mite how do we avoid developing allergy: modifications of the th response from a b-cell perspective pet-keeping in early childhood and airway, nose and skin symptoms later in life biological miracles and misadventures: identification of sensitization and asthma in enzyme detergent workers allergic asthma to <i>bacillus subtilis</i> enzyme: a model for the effects of inhalable proteins this contract/grant was awarded by efsa to:technical university of denmark, national food institute, mørkhøj bygade , dk- søborg, denmark. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the company was founded in , and has been handling dried bacteria cultures for years. they produce tons of cultures per year in factories, and handle about different species in the process. this accounts for about % of the world production. they currently have employees active in the production chain. this company produces enzymes for industrial purposes, both from yeast and bacteria and claim to hold more than % of the global market. it has been operating at an industrial scale since the s and employs workers potentially exposed to the enzymes are in the range, each potentially exposed to several products. novozymes a/s monitors allergies among workers thru screening programs, cap-tests, and self-reporting, and also conducts a significant amount of research in the field of allergy.questions to the companies technical part:• which categories of enzyme and/or microbial cultures does your company produce and/or use? • of these categories, which volume does your company handle on a yearly or monthly basis?the present document has been produced and adopted by the bodies identified above as author(s). in accordance with article of regulation (ec) no / , this task has been carried out exclusively by the author(s) in the context of a grant agreement between the european food safety authority and the author(s). the present document is published complying with the transparency principle to which the european food safety authority is subject. it may not be considered as an output adopted by efsa. efsa reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. key: cord- - tdbv on authors: bounie, dominique; arcot, jayashree; cole, martin; egal, florence; juliano, pablo; mejia, carla; rosa, donna; sellahewa, jay title: the role of food science and technology in humanitarian response date: - - journal: trends food sci technol doi: . /j.tifs. . . sha: doc_id: cord_uid: tdbv on background: in humanitarian contexts, ensuring access to safe, nutritious, good quality and culturally appropriate food in the right quantity at the right time and place during an emergency or a protracted crisis is an enormous challenge, which is likely to increase given uncertainties such as climate change, global political and economic instability and emerging pandemics like covid- . several international organizations and non-government organizations have well established systems to respond to food security emergencies. however, the role of food science and technology in humanitarian response is not well understood and is seldom considered in humanitarian circles. scope and approach: the role of food science and technology in humanitarian response and the importance of addressing the requirements of the local consumers within the local food systems are discussed. key findings and conclusions: humanitarian food aid policies focus on immediate and short-term assistance to save lives. the implementation of emergency programs and projects tends to induce dependency on aid, rather than strengthening local food systems and ensuring resilience. transformative change must embrace innovation across the whole food system with an increased emphasis on food science and technology that addresses local food security, generates employment and contributes to the local economy. there needs to be a move beyond rehabilitating and increasing agricultural production to addressing the whole food system with a view to link humanitarian assistance and longer-term support to sustainable livelihoods and resilience. many people around the world are affected by natural disasters, internal or cross-boundary conflicts or large-scale economic turmoil (reliefweb, ) . providing these people with sufficient quantities of safe foods necessary for healthy and sustainable diets at the right time, in the right place, and on a consistent basis, is challenging. furthermore, with emerging pandemics such as covid- , there will be a significant impact on local and global food systems and food security with the poorest people being the most affected. therefore, urgent action must be taken by all stakeholders in mitigating this impact (cfs-hlpe, ) . the right to food guidelines (food and agriculture organisation (fao, ) sharply extended this notion by linking humanitarian assistance to conditions where emergency interventions account for longer-term rehabilitation and development objectives, as well as for concerns for food security, food safety, food culture, local production of food and recipient needs. the report on the state of food security and nutrition in the world (fao et al., ) , illustrates the scale of the problem. the report shows that the key drivers for a severe food crisis leading to food insecurity were climate-related shocks and conflicts. hunger and undernutrition are significantly worse where conflicts are prolonged and local institutional capacities are weak. it therefore requires a conflict-sensitive approach that aligns actions, immediate humanitarian assistance, long-term development and sustained peace. in the sahel region in africa, the worst humanitarian crisis since world war has seen more than million people in four countries facing starvation and famine in with . million children under five years of age suffering from severe acute malnutrition and . million suffering from moderate acute malnutrition. more than billion people worldwide were affected by micronutrient deficiencies mostly due to changes in diets related to economic development (e.g., changes in food production). the world food programme (wfp) of the un has been very active in delivering food assistance to . million people in more than countries in , with % of wfp resources being allocated to conflict environments; million metric tonnes (mt) of food were purchased from countries; . mt of in-kind food donations were received by wfp from donor countries and . mt of food were delivered to more than countries by wfp. organisations (ngos) are well equipped to source and distribute food aid to those affected by food security related crises, very often this food is procured from different countries. as such, this food may not conform to the local sensory and cultural preferences or food habits and/or risks potentially undermining local food systems. food science and technology (fst) can play a key role in the production of foods for affected populations using local raw materials with context appropriate robust technologies while fulfilling nutritional, microbiological, sensory, cultural, environmental and quality requirements. however, it is important to highlight that a multidisciplinary approach is required so that humanitarian activities remain human-centred rather than technology-driven (passino, ) . here, we suggest that 'humanitarian' be understood as 'concerns and behaviours that translate into human-centred activities aimed at mitigating the short-and long-term adverse effects of shocks on individuals and communities and promoting their lasting recovery'. this will apply to both emergencies and development contexts and, therefore, could also help to support the prevention-relief-rehabilitation-development-peace nexus. in this regard, humanitarian food science and technology (hfst) should be considered as a people-centric approach aimed at applying fst to prepare for, respond to and sustainably recover from any external shocks. in this context we can define hfst as 'the application of food science and technology to enhance food security, health, and economic prosperity for global humanitarian purposes'. however, the role of fst in humanitarian response is still not well understood or addressed (sections and ). it is also important to recognise that food systems in affected areas are often not sustainable and that fst could contribute to strengthening local resilience (i.e. 'ability to prevent and mitigate disasters and crises as well as to anticipate, absorb, accommodate or recover and adapt from them in a timely, efficient and sustainable manner. this includes protecting, restoring and improving livelihood systems in the face of threats that impact agriculture, nutrition, food security and food safety', fao, a) and increasing the adaptability of such systems, by creating short to long-term opportunities, in particular for the employment of youth and women. although some evidence on the relevance of post-harvest interventions as a source of livelihoods and revitalisation of local economies is available (hodges et al., ) , no systematic attention has been given so far to elicit guiding principles for their adoption, adaptation, replication and/or upscaling, especially for agro-food processing. there are opportunities to develop hfst-based solutions and responses to enhance the effectiveness of current humanitarian response as well as contributing to lasting food security in the context of internal conflicts, climate change, other natural hazards, increasing poverty, accelerated urbanisation, widespread migration and pandemics. to find effective, innovative, long term solutions to such incidences of food-related shocks across the globe, it is important that industry, ngos, the research community, consumers, aid organisations and donors work together. it is also important that adequate training is given to those engaged in hfst activities in order to develop the required skills. we present here the current status of the role of fst in humanitarian response, together with current gaps. literature specifically addressing the role of hfst is very limited. there is extensive literature on food sustainability and food policy and some literature in the use of technology in disaster management and the use of innovation in humanitarian responses. moreover, effects of food systems disruption due to conflict and climate-related disasters on food insecurity and malnutrition have been addressed in the global report on food crises (fsin, ) . however, the published work rarely refers to the use of innovation or the role of fst in humanitarian response. most of the published work in food security focuses on agriculture to increase on-farm production and productivity and there is less focus on the importance of post-farm processing. eade & williams ( ) of oxfam provide a good analysis of the situation regarding development and relief operations. one of the main limitations in effectively using fst expertise in addressing global humanitarian feeding situations is the lack of awareness and adequate information and training of personnel from different stakeholders working in humanitarian preparedness and response. this limitation, together with the limited published information on hfst, prompted the organisation of an international symposium on hfst in sydney, australia in , where key stakeholders from seven countries representing un agencies, ngos, academia, research institutes, the private sector and governments participated (aifst, ). this symposium was followed by a workshop where contributors to the symposium and other experts in hfst discussed current problems and identified potential opportunities where fst could contribute to humanitarian response. following this workshop, a global hfst group, representing key stakeholders was formed and this group (which includes the authors) has disseminated relevant information to increase awareness of hfst (aifst, ). the framework that we used for making our recommendations is based on a literature review, the outcomes from the international hfst symposium and workshop and the expertise and experience of the global hfst group (fig. ). there are three factors that are not clearly understood by policy makers and by most humanitarian actors. i.e: a) how fst could contribute to go beyond nutritional requirements by developing foods that are 'fit for purpose', i.e., satisfying consumer expectations in terms of convenience, taste, shelf life, enjoyment, preparation, cultural appropriateness, acceptability and value b) how the application of fst could better control the quality and safety of diets and food during processing and along the humanitarian supply chain, while minimizing wastes and energy losses, and c) how fst could contribute to strengthen food systems in disrupted environments and make them more resilient to shocks and inclusive by bringing value to destitute and vulnerable communities as a prerequisite, it is important to recognise that the implementation of any new fst solution, especially in fragile food systems, should be preceded by a careful needs assessment in the affected areas. some of the issues to consider are: what is the targeted population? what are their nutritional needs and what are their food habits (what and when do people eat? where and how is food produced/procured/processed? what local foods should be considered? what fst related experiences, skills and resources exist and who should be supported to do what?). examples of local adaptability references development of new nutritious foods / improving existing foods reformulation: • replacing peanut paste in ready-to-use supplementary foods (rusf) with locally available nuts or pulses (almonds or chickpea -wfp, pakistan); cashew nuts (ivory coast) and bambara nuts. improving bioavailability by reducing phytase activity; improving nutrient density of fortified blended flours using appropriate processes (extrusion cooking, germination, use of alpha-amylase) to reduce consistency improving swallowing ability to achieve fullness in the stomach in infants adding functional ingredients (probiotics, antidiarrheal constituents e.g. new products developed by nutriset) harvestplus ( ) examples of local adaptability references improving shelf-life of snfs using traditional antioxidant products or antioxidant rich natural ingredients or new combined processes kemin industries inc. operates in more than countries with manufacturing facilities in belgium, brazil, china, india, singapore, south africa, thailand and the united states providing advice on health and nutritional solutions to agrifoods, food ingredients, pet food and human health and pharmaceutical industries wfp ( ) improving convenience of snfs i.e. reduced rehumidification during storage, auto heating products, design of more ready-to-use foods wfp has provided 'specialised nutritious foods' sheet as a reference for the various types of formulated foods made available to address undernutrition. understanding and better control of the operating conditions when producing snfs locally control and optimisation of degree of cooking (which affects digestibility) when producing precooked extruded blended flours; selecting the appropriate process for efficiently cooking blended flours; extrusion cooking vs. drum drying or infra-red roasting van hoan et al. ( ); wfp ( ) designing and developing appropriate equipment (low cost, easy to operate and maintain, resistant to wear) containerised food processing units, using alternative energy (solar energy, biogas from waste, biochar) bounie ( ) ; fellows (in aifst, ) improving the safety and quality of foods: use of hazard analysis critical control points (haccp) methodology, traceability systems, rapid-analysis system for on-site quality assessment the 'blue box' to assess in the field the aflatoxin content of maize developed for wfp webb et al. ( ); wfp ( ) although there has been some activity recently on innovation and the use of new technologies and systems in humanitarian response, the focus of innovation in humanitarian processes and practices has been on incremental improvements and it appears that the application of fst in humanitarian response is limited. ramalingam et al. ( ) point out that in innovations within existing humanitarian practices, policies and processes, there is some reluctance to change because of a potential conflict with pre-defined practices and methods. in a policy paper by the un office for the coordination of humanitarian affairs (ocha), betts and bloom ( ) discuss the role of innovation in a humanitarian context. they discuss the challenges in introducing innovation, the innovation cycle for products, processes and technologies, and the importance of collaboration (the human ecosystem). they claim that a better understanding of the potential and purpose of the innovation cycle and developing an innovative mindset could bring significant benefits to the humanitarian system. overcoming hunger (omamo, gentilini, & sandstrom ) , several papers discuss innovation in a humanitarian context, including the role of information and communications technology and logistics to deliver innovations in complex environments in food assistance. several recent initiatives have put innovation at the heart of humanitarian action, including the global alliance for humanitarian innovation (gahi) (gahi, ) and wfp's 'innovation accelerator' (wfp, ) . although innovation has been acknowledged as important in the humanitarian agenda through these initiatives, it should be noted that some of them are no longer operating, are not scalable or are poorly addressing specific hfst concerns. this is unfortunate because research and development (r&d) has always been strong in the food industry and the academic sector and therefore, resources for r & d should be solicited more by hfst to these stakeholders with the aim of finding new solutions to existing problems (webb et al., ) . a report from the world economic forum ( ) has identified key technology applications that may accelerate food systems transformation "to sustainably and nutritiously feed more than billion people while providing economic opportunities in both rural and urban communities". these pioneering technologies, using digital tools, robotics, biotechnologies and genomics, are presented as having, until now, poorly disseminated into current food systems but offering promising results. their application in humanitarian contexts is not addressed, which once again demonstrates that humanitarian situations are not considered as a potential beneficiary from such a transformative program. fst plays a key role in product and process development in humanitarian response. sheeran ( ) discusses the importance of fst in the preparation of convenient to consume, nonperishable foods and examples given to produce ready-to-eat fortified sweet paste in india (with chickpeas and milk powder), high energy biscuits in thailand, and fortified date bars in egypt. the importance of public-private partnerships and wfp's role in humanitarian feeding is also highlighted. guimon and guimon ( ) the most relevant publication with respect to hfst that is in the public domain is by bounie et al. (in omamo et al., ) . this paper discusses how food technology is used at wfp to support different corporate units and country offices to enable the production of safe and nutritious food for humanitarian aid to comply with wfp's mandate and strategy. several examples of producing such food in different countries are given and processes used to produce nutritious, convenient, safe food are explained (including the use of containerized food production units). this paper also outlines the methods used by wfp at that time to manage product safety and quality as well as traceability. the improvement of the safety and quality of foods is an important factor in reducing hunger. food that is safe and of good quality results in improved access to markets, reduced food loss and waste, improved food security and reduced burden of foodborne diseases. this issue disproportionally affects the least developed and developing nations, namely in africa and asia. the world health organisation (who) estimated that the global burden of foodborne diseases by the main foodborne hazards was million disability-adjusted life years (dalys) in and % of this burden was among children under five years of age (who, ) . despite these figures and its effects on socio-economic development, ensuring food safety and quality in developing countries with poor public-sector regulatory enforcement remains a challenge that is only exacerbated by climate change, conflict and other external shocks, such as pandemics. much work in quality control systems in the supply chain of humanitarian feeding systems although there have been some problems in the past with respect to maintaining the quality of food in such a complex supply chain, wfp has taken the lead by introducing a 'quality culture' in the supply chain by changing the approach at wfp to moving from a procurement only (at lower price) approach to a modern 'food quality and safety' approach (menage & salvignol, ) . however, there were some product quality incidents and possible causes for quality problems in the supply chain which have been listed (wfp, ). a major food safety concern in led to a multi-stakeholder collaboration for clarifying specifications and to facilitate process changes by suppliers in order to comply with these new specifications (fao-who, ) . this also highlighted that the main distributors of these products were not ready to handle major food incidents. and quality management system) and proactive fims (food incident management system) decision making process (i.e. initiate-detect-estimate-act-learn (ideal), (bounie, and wfp, ) . this approach has significantly increased the reporting of incidents and over time reduced the number of food safety and quality incidents. these actions require a committed food safety culture, the full and coordinated effort of every stakeholder along the whole food supply chain and the provision of appropriate resources. therefore, it is recommended that donors should do more to support and advocate the maintenance of product quality and safety throughout the supply chain. in addition, quality control should be an independent function from procurement and logistics, in order to avoid any conflict of interest or misunderstanding on quality requirements. the emphasis of most current aid policies is on immediate and short-term assistance where the focus is on coping mechanisms. the implementation of these policies in protracted emergency environments tends to induce dependency on aid (alonso et. al., ) . instead, aid policies should go much further and foster sustainable self-reliance. in this regard, solutions should help the beneficiaries, not only by the provision of relief foods that they need, but also by strengthening local food systems and supporting sustainable interventions. some examples have recently been published showing the link between sustainable energy and food security in humanitarian contexts (caniato et al., ) . humanitarian interventions are often a result of significant disruption of daily life that affects food security and nutrition in the population and needs a timely and targeted response. depending on the severity of the situation and whether the event is considered acute or chronic (fao, ) , available resources are mobilised with a focus more on immediate relief rather than post-emergency recovery. local food systems, already weakened or disrupted, may be affected for a long time by interruption of external drivers that may bring additional disruptive blows. today there is a consensus that humanitarian interventions should be included into a larger prevention-relief-rehabilitation-development continuum, which would result in mitigating future crises by building longer term sustainable solutions. this should be based more on the resilience capacity of the population concerned than on their coping mechanisms. therefore, the fst components of any humanitarian response should account as much as possible, on the main recommendations by fao ( ) for 'increasing availability, affordability, and consumption of diverse, safe, nutritious foods and diets, aligned with dietary recommendations and environmental sustainability'. some of these issues have also been addressed by keding et al. ( ) . only a few documents are available that evaluate the economic feasibility of fst projects implemented in humanitarian contexts. most technical and economic feasibility assessment reports that are available are internal reports, produced by international agencies or ngos submitting their projects to donors. when investing in humanitarian projects, there should be a balance between avoiding 'white elephants' that have so often resulted in undesirable outcomes from humanitarian interventions (e.g. not adapted to local market requirements, local resources not used, not scalable beyond localized pilots), while still promoting local initiatives that would foster the recovery and longer term development of affected communities. harper et al. ( ) have shown that in development contexts, such demand-based and inclusive value chains may be developed and directly benefit the poorest by increased incomes while increasing their resilience capacities and access to safe, nutritious, convenient foods that are available locally. ritchie, has shown that promoting entrepreneurship in refugee settings may boost self-resilience and female empowerment while fostering new socio-cultural dynamics and human security. in such fragile and conflict-affected settings, the years research program 'human security in fragile states' at the is academy, wageningen has attempted to understand the socio-economic recovery at the intersection of strategies to rebuild people's lives, institutional change and aid interventions (is academy, ). transferring such initiatives to humanitarian contexts would require a shift in aid interventions from relief-only to recovery and rehabilitation activities aiming at seeding incentives that would have a leveraging effect on sustainable development schemes. this is an exciting outlook where food scientists and micro, small, and medium enterprises could collaborate to develop new and appropriate processes and use technologies that are accessible to local communities, resulting in positive economic and social outcomes. it should be mentioned, however, that there are significant challenges in setting up and operating local food processing operations, including: • little to no access to sufficient financing for start-up businesses • lack of reliable power • high cost of production equipment • need for intensive management and employee training in both technical and business skills • potential lack of adequate and continuous local sources of some raw materials, packaging and spare parts, necessitating imports • distribution problems due to poor transport infrastructure in a humanitarian context, it is not always possible to quantify the economic feasibility of fst interventions, especially when only short-term impact factors are used. however, such interventions could often be justified because of significant social benefits and of the expected long-term decline in aid dependency. overall feasibility should be assessed in terms of multi-dimensional cost-benefit analyses, while existing good fst practices in the field should be identified, reviewed, supported and utilized. as the world becomes more complex, the best solutions are often planned and delivered through multi stakeholder partnerships and participatory approaches. a good example in a humanitarian context is public-private partnerships because the private sector has significant expertise and resources in food processing, quality control and management, food safety, nutrition, packaging, logistics and r & d that the humanitarian sector could adapt. therefore, there is potential for the humanitarian agencies and ngos to develop partnerships with the private sector and utilise its expertise and the private sector could benefit from the untapped demand and potential commercial opportunities of the humanitarian sector. even though such partnerships are largely encouraged today by major humanitarian agencies and are well documented in development media, there is not much information in the literature on privatepublic partnerships in emergency situations, except the conference in australia in , organised by the crawford fund (sheeran, ) . two other sectors where the humanitarian sector could develop partnerships with and transfer knowledge for mutual benefit are the military and space programs. r&d undertaken in the development of foods for combat forces, astronauts and for populations in humanitarian feeding systems has many similarities with respect to issues of quality, nutrition, safety, stability, shelf-life and packaging. however, a key difference between the applications in military and space programs and the humanitarian sector is that the food for humanitarian feeding must be significantly more cost effective. another difference is that target groups are much more diverse in the humanitarian sector, requiring tailoring to a wider range of nutritional and cultural needs. the u.s. army's combat feeding directorate at the natick soldier research, development and engineering center (nsrdec) and the defence science and technology group in australia (dstg) are addressing the possibility of using the expertise that they have in fst and logistics for humanitarian purposes. at nsrdec, a first comprehensive study (briggs et al., ) was funded by usaid for developing an emergency food product with a focus on product and packaging specifications. barrett & cardello ( ) published a systematic review of u.s. military's approach to the development of ready-to-eat self-heating foods with respect to processing, packaging, testing, and distribution methods with in-depth information on reducing weight, nutrient optimisation and shelf-life extension. beagley (in aifst, ) has reported the link made by dstg between combat rations and humanitarian feeding. the national aeronautics and space administration in the united states has extensive expertise in developing foods for astronauts on long-range space missions and this expertise may be relevant for humanitarian feeding (e.g. extended shelf life, nutritional density of low weight rations, sensory acceptability over long-time consumption). the development of food for astronauts and its multifaceted nutritional and processing challenges, has been reported by cooper et al. ( ) . thus, it is important that the humanitarian agencies have closer indirect collaborations with the military through scientific institutions and with space research agencies so that expertise in food science, technology and nutrition could be transferred from these agencies to the humanitarian sector. sakai et al. ( ) highlight different multi-stakeholder initiatives (civil society, military, state institutions and media) that have been developed in the asia-pacific region for responding to disasters. corresponding mechanisms of coordination in such contexts at central, regional and local levels are described by ocha ( ) . these examples advocate for improved multidisciplinary coordination, but the fst dimension is still poorly addressed. it is also very important that effective partnerships are developed between national and local governments. fao and cfs (committee on world food security) were among the first to highlight the importance of the concept of a food system for understanding the many drivers and interactions that contribute to the incremental shaping of our foods, from field to plate: 'a food system encompasses all the people, institutions and processes by which agricultural products are produced, processed and brought to consumers' (fao, b) . in , cfs sharpens this definition by integrating the inputs and outputs of such activities as well, 'including socioeconomic and environmental outcomes' (cfs-hlpe, ) . in a recent report, cfs also highlights the importance of agroecological and other innovative approaches for sustainable agriculture and food systems that enhance food security and nutrition (cfs-hlpe, ) . this holistic approach clearly outlines the different levels where fst may contribute in improving food safety, quality and acceptability. in humanitarian contexts, where food insecurity is at its highest, it is crucial to look at all local foods and every level of the value chain (from production, processing and delivery to consumption and end-of-life). this goes far beyond looking at the impact of food systems on the nutritional value of foods alone and advocates for investigating how to account for other attributes of food quality (safety, taste, convenience) that may affect food availability, acceptability, utilization and stability. in the same way, inclusive nutrition-sensitive value chains should include representatives not only of smallholders but of all the stakeholders involved in the value chain: producers, processors, transporters and retailers (cfs, ) . through the direct benefit that they may find in maintaining the value chain, they all bring their own contribution to strengthening local food security and the sustainability of the concerned humanitarian food systems (hfs), an emerging concept that we propose to define as described in fig. . hfss require specific attention because they operate quite differently from traditional food systems, some of the main differences being their fragile and disruptive environment and being driven by donors rather than beneficiaries. this has often been a conflicting issue when it questions the competition among ngos for funding and the inclusiveness of beneficiaries. however, this should not justify why hfss have been so poorly studied. this opens promising perspectives for using the need for inclusive and resilient hfss as a comprehensive conceptual framework for studying the potential interest of fst in humanitarian contexts. hfss should not be abstract concepts which evolve aside traditional food systems: both systems should benefit from each other. humanitarian situations foreshadow those that industrialized countries may soon encounter due to the upsurge in climatic, environmental, economic and migratory crises they regularly face today as well as emerging pandemics such as covid- and this could be best addressed by challenging the current hfss. it is interesting to note the current revival of small and decentralized food systems that are revitalizing local food production through processing, with the objective of optimizing better the 'local unused capacities' (gwin & mccain, ) . this so-called 'missing link in sustainable food systems' could inspire and benefit hfss on how they too should invest more in food processing and how these initiatives could be financially viable. most of these key issues of hfst could be captured under the categories of 'products', 'processes' and 'people and systems', encapsulating different attributes in each category, as summarised in figure . as a result of natural disasters and economical and political unrest, the world is facing a humanitarian crisis in an unprecedented scale and millions of people are food insecure and this problem is likely to worsen with emerging pandemics such as covid- . un agencies and a range of ngos are well equipped to source and distribute food to those in need in current humanitarian situations, resulting in significant benefits to affected people. however, the role of fst and the contribution that it could make in addressing some of the problems within the global humanitarian food system is not well understood by relief workers, ngos, donors, governments, academia or the r&d community because this topic has not been sufficiently or methodically explored. in addition, the fst community is not aware of the challenges and opportunities in humanitarian feeding. it is also apparent that the vast expertise of the private sector in the food supply chain is not used to its full potential in current humanitarian supply chains. it is important to take an innovative, multidisciplinary, multi-stakeholder partnership approach in humanitarian food systems not only to cope with emergencies in the short term, but also to build resilience of local communities so that they could secure sufficient, safe and nutritious food in the long term. food scientists and technologists could make a significant contribution to this initiative. such an approach will enable less dependency on food aid from donors and more reliance on local sources of agricultural commodities, post-harvest processing and inclusive human capacities. the proper implementation of innovative solutions for humanitarian systems through multi stakeholder partnerships involving relevant un agencies, donor organizations and ngos, together with the research community and the private sector, is likely to result in tangible outcomes to affected people with significant positive economic, social and environmental impact to the local communities. it is recommended: ) to increase awareness of the critical role and importance of fst in humanitarian response among humanitarian stakeholders and conversely of the challenges and opportunities of humanitarian issues among food scientists and technologists. ) that policy makers, donors, governments, ngos and other humanitarian stakeholders recognise that fst plays a key role in food systems and it should be systematically included in relief and rehabilitation strategies aiming at sustainable and resilient food systems. furthermore, food security interventions need to go beyond food aid and support to farmers and be expanded throughout the whole value chain. such an approach will enable local food security issues to be addressed in humanitarian response, as well as reducing food waste, creating local employment and increasing local resilience through the application of fst. ) that adequate resources are allocated, and investments made in capability strengthening focused on the application of fst to address humanitarian response problems with appropriate, innovative solutions. ) that hfst is recognized as a new academic sub-discipline that should be investigated to build comprehensive multi-disciplinary curricula and new teaching programs. these programs should be taught at a high level to train humanitarian stakeholders implicated in the design and implementation of resilient and inclusive humanitarian food systems, with a strong focus on low-cost, robust and appropriate food technologies. the authors declare no conflict of interest and no competing financial interest. oral presentations at the aifst humanitarian food science and technology symposium optimization of extrusion conditions for the production of instant grain 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agroecological and other innovative approaches for sustainable agriculture and food systems that enhance food security and nutrition. rome: fao, hlpe executive summary n o flyers/hlpe_report_ -executive-summary-a _webres_def.pdf accessed on developing the nasa food system for long-duration missions the oxfam handbook of development and relief voluntary guidelines to support the progressive realization of the right to adequate food in the context of national food security resilient livelihoods: disaster risk reduction for food and nutrition security. rome: fao the state of food and agriculture: food systems for better nutrition. fao microbial safety of lipid-based ready-to-use foods for management of moderate acute malnutrition and severe acute malnutrition. rome: fao, microbiological risk assessment series nutrition-sensitive agriculture and food systems in practice -options for intervention building climate resilience for food security and nutrition. rome: fao global report on food crises building a global alliance for humanitarian innovation how ready-to use therapeutic food shapes a new technological regime to treat child malnutrition use it or lose it: local food, regional processing and the perils of unused capacity commercial and inclusive value chains -doing good and doing well postharvest losses and waste in developed and less developed countries: opportunities to improve resource use facing fragilities: people, aid and institutions in socio-economic recovery production and processing of foods as core aspects of nutrition-sensitive agriculture and sustainable diets note to the executive policy council: wfp food safety and quality management system choice of foods and ingredients for moderately malnourished children months to years of age treatment and prevention of diarrhea: zincfant disaster response in asia and the pacific -a guide to international tools and services innovations in food assistance: issues, lessons and implications humanitarian engineering: advancing technology for sustainable development innovations in international humanitarian action, active learning network for accountability and performance leaf protein concentrate as food supplement from arid zone plants gender and enterprise in fragile refugee settings: female empowerment amidst male emasculation -a challenge to local integration? a comprehensive linear programming tool to optimize formulations of ready-to-use therapeutic foods: an application to ethiopia disaster relief in the asia pacific the un world food program teff: the rising ancient cereal: what do we know about its nutritional and health benefits? harmonization of lipid-based products effect of extrusion cooking and amylase addition to gruels to increase energy density and nutrient intakes by vietnamese infants improving the nutritional quality of u.s. food aid: recommendations for changes to products and programs kemin industries to provide food quality and shelf life stability expertise to wfp blue box training managing the supply chain of specialized nutritious foods wfp innovation accelerator food quality and safety in wfp who estimates of the global burden of foodborne diseases: foodborne disease burden epidemiology reference group jses sionid= ef adbbbac a be e ?sequence= accessed innovation with a purpose: the role of technology innovation in accelerating food systems transformation this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. key: cord- -y ianyqi authors: bamji, mahtab s.; murty, p. v. v. s.; sudhir, parimala diana title: nutritionally sensitive agriculture—an approach to reducing hidden hunger date: - - journal: eur j clin nutr doi: . /s - - -x sha: doc_id: cord_uid: y ianyqi cereal-based diets of the people in developing countries are qualitatively deficient in micronutrients—vitamins and minerals—due to low intake of vegetables, fruits, legumes and foods of animal origin. consumption of nutritious millets has also come down in india. calorie sufficiency may ensure protein sufficiency (though not protein quality), but it does not ensure adequacy of micronutrients. studies in several countries in asia, and india show that with education and advocacy even farmers with small and marginal land holdings can be persuaded to raise homestead vegetables and fruits gardens and increase household vegetables consumption. backyard poultry also has good acceptance and impact on household egg consumption. for best results, the community, especially the mothers have to be educated about the importance of nutrition for health and wellbeing. studies done by the authors in the villages of medak district, of the south indian state of telangana, show remarkable improvement in the knowledge of food, nutrition, hygiene and health of mothers with children under years of age, with education–behavioural change communication. impact of nutrition gardens and backyard poultry with high egg-yielding breeds had positive impact on the household consumption of vegetables and eggs. developing countries like india are facing a double burden of diseases. while pre-transition diseases like infectious diseases and malnutrition persist, there is growing incidence of post-transition non-communicable diseases like obesity, hypertension, diabetes, cardiovascular diseases and cancer. india has become the diabetes capital of the world. nutrition influences both the burdens. malnutrition increases susceptibility to infections and resultant morbidity and mortality. prenatal malnutrition has been shown to affect the growth of the foetus resulting in low birth weight (lbw) babies. intra-uterine malnutrition epigenetically alters body composition with higher fat deposition, which in turn predisposes the individual to adult-onset non-communicable diseases. (barker's hypothesis, foetal origins of adult diseases) [ ] . who has recognised diet as one of the important determinants of health. the eat-lancet commission report has compared the food consumption patterns in india, from different income groups, regions and sectors (rural/urban), with the eat-lancet reference diet and highlighted the deviations [ ] . national sample survey office - data were used for comparison since this is the most recent countrywide data. except for the richest %, of indians, the average daily intake of calorie of indians was below the recommended kcal/capita/day. the consumption of fruits, vegetables legumes, meat, fish and eggs were significantly lower. the share of calories from protein sources was only - %, compared to % in reference diet. though the deficits were higher in the lowest decile of consumption expenditure, even the rich indian households do not consume adequate quantities of vegetables, fruits and noncereal protein foods. these findings are akin to those of the national nutrition monitoring bureau surveys in india, which show that the cereal-based indian diets are deficient in the consumption of micronutrient-rich foods like vegetables, fruits, legumes and animal products [ ] . thanks to schemes such as subsidised sale of rice and wheat to families below the poverty line (bpl), through the public distribution system, the consumption of traditional millets has also come down. millets are rich in fibre, many bcomplex vitamins and minerals. the predominantly cerealbased diets have resulted in rampant qualitative deficiency of micronutrients particularly, vitamins a, b , b , b , folic acid, c and minerals like iron, zinc and calcium. while calorie adequacy may ensure protein adequacy (though not protein quality), it most often fails to quench the hidden hunger. a recent study from the national institute of nutrition, hyderabad, india, shows a high prevalence of vitamin deficiencies, particularly, vitamins a, b , b , b , folic acid and vitamin d, assessed by subclinical status (blood values) and dietary intakes, in an apparently healthy urban adult population [ ] . the overall prevalence of anaemia was %. vitamin deficiencies as judged by blood levels were: vitamin a % (despite much higher dietary deficiency), d %; b %; b %; b %; folate % and active b %. vitamin d deficiency has become a major problem even in tropical countries. the dietary intake of all the vitamins except vitamins b and b were close to or lower than % of indian reference. that of vitamin b was only % and folate %. vitamin c was not examined. the study population had high incidence of overweight and obesity, and high levels of homocysteine-an independent risk factor for cardiovascular diseases for whose metabolism b vitamins like folic acid and b are required. this shows that even the apparently well-fed indians from middleincome group suffer from vitamin deficiencies. mineral status was not examined. the three basic strategies for combating micronutrient deficiencies are: (i) supplementation with micronutrients (the pharmacy-based approach), (ii) food fortification and (iii) dietary diversification-a farm-based approach [ ] . crop biofortification through conventional breeding, marker-assisted molecular breeding, or genetic engineering, is the technological approach to enrich the germ plasm with specific micronutrients [ , ] . this strategy is generally used to combat severe deficiency of one or two nutrients. india has two micronutrient supplementation programmes [ ] . ( ) national nutrition anaemia prophylaxis programme. in this programme, all pregnant and lactating women receive mg of elemental iron and µg of folic acid (ifa tablets daily) for at least days during pregnancy and days in post-partum period. preschool children receive mg of elemental iron plus µg of folic acid daily. due to administrative infirmities and lack of awareness regarding the importance of the programme desired results have not been obtained. education of the community to ensure compliance is very necessary for such programmes to succeed. in , the ministry of health and family welfare, india, launched the national iron plus initiative ( ). ( ) massive dose vitamin a supplementation programme to prevent nutrition blindness. in this programme, first dose of , iu of vitamin a is given to children at months of age along with measles vaccine. this is followed by biannual dose of , iu to children between the ages of and months. blindness due to vitamin a deficiency has become rare all over the world, but subclinical vitamin a deficiency (serum vitamin a < µg/dl) due to dietary deficiency persists. opinion among nutrition scientists in india is divided about the need for the vitamin a supplementation programme. its continuation is however needed at least in areas where signs and symptoms of vitamin a deficiency like night blindness and bitot spots persist. the ultimate effort should be to increase the dietary intake of vitamin a and its plant precursor β carotene. food fortification is done either to restore nutrients lost during processing or to enrich foods with nutrients. food fortification has been defined as 'addition of one or more essential nutrients to a food, whether or not it is normally contained in the food, for the purpose of preventing or correcting a demonstrated deficiency of one or more nutrients in the population or specific population groups' [ , ] . it is a convenient and relatively less expensive strategy with a wide outreach and has been used for nutrients like vitamins a, d and some b-complex vitamins and minerals like iron and zinc. the vehicle to be used for fortification should be a food that is consumed by large segments of population regardless of economic status including poorest of poor, and the bioavailability and stability of the fortified nutrients should be good. one of the successful programmes in india is salt fortified with iodine, which has now become a universal programme. the national institute of nutrition, hyderabad, india, has developed salt double fortified with iodine and iron. its use at present is limited. fat soluble vitamins are often added to oils. wheat flour is often fortified with minerals and b-complex vitamins, and who/fao has provided guidelines for it [ ] . fortifying oil with vitamins a and d is mandatory in many countries, including india. the subject of food-based approach including nutrition sensitive agriculture for better nutrition outcomes has been recently reviewed [ , [ ] [ ] [ ] . this review discusses some of the studies in india and other asian countries on nutritionally sensitive farming to combat micronutrient deficiencies. thanks to the green revolution, india has become selfsufficient in the production of cereals like wheat and rice [ ] . production of millets and pulses has however missed the green revolution, but in recent years this shortcoming is being corrected. india ranks among the top two countries in the world for production of milk (white revolution) and vegetables and fruits (rainbow revolution). even the egg production has gone up markedly. despite this, the dietary intake of these income-elastic foods remains low in all segments of population, particularly among the poor, due to lack of awareness regarding nutritional importance of these foods and high cost. even the farmer who produces them prefers to sell them rather than consume at home, because for resource poor farmers with small or marginal land holdings, income is more important than health and nutrition security. importance of income cannot be denied. behavioural change communication (bcc) is needed to stress the importance of dietary diversification to ensure food and nutrition security. high post-harvest losses add to the problem in developing countries, where facilities for cold storage, and processing are inadequate [ ] . agriculture is generally viewed as a source for income and export-at best to meet calorie and protein requirement. the problem of micronutrient deficiencies (hidden hunger) is not understood. unfortunately, the subject of human nutrition is not in the syllabus of agriculture universities, and hence agriculture extension workers fail to understand the need for leveraging agriculture for nutrition security. the subject of nutrition is also very weakly covered if at all in medical syllabus. one of the earliest studies on homestead vegetables and fruits gardening (term, used to indicate gardens next to the home or in farms) for micronutrient security was aimed at improving the intake of provitamin a, β carotene. it was conducted by the national institute of nutrition, hyderabad, india, in the villages of andhra pradesh, india, and the all india institute of hygiene and public health, calcutta, west bengal, india [ , ] . seeds and saplings of vegetables rich in β carotene (green leafy vegetables (glv), orange and yellow vegetables and fruits) were given to farmers and farmers advised to grow them near their home or in their farms. apart from technical knowhow about growing the plants, food and nutrition education was given. in both the centres there was marked increase in the number of families growing β carotene-rich vegetables and fruits, their consumption and improvement in understanding of the problem of vitamin a deficiency, foods rich in vitamin a and signs (bitot spots, xerophthalmia) and symptoms (night blindness) of vitamin a deficiency. calcutta centre reported reduction in the prevalence of bitot spots but in hyderabad centre the results were equivocal. there was some reduction in the common belief that pregnant women should avoid eating papaya since it causes abortion. hellen keller international has supported an extensive programme of improved homestead gardens and backyard poultry in bangladesh, cambodia, nepal and philippines to increase the production and household availability of micronutrient-dense vegetables and fruits and eggs. nutrition education formed an important part of the strategy [ ] [ ] [ ] [ ] . a significant increase in consumption of vegetables and eggs by mothers and children was recorded, mothers' knowledge of nutrition also improved. bangladesh and philippines observed reduction in the prevalence of anaemia. similar reduction was not seen in cambodia and nepal. families' income also showed some increase through sale of farm produce. ms swaminathan foundation in chennai, india, is currently exploring the food system for nutrition model in few villages of wardha district of vidarbha region of maharashtra, and koraput district of odisha, india [ ] [ ] [ ] . community nutrition gardens were also tested. the components of the model are: ( ) survey to identify the major nutritional problems, ( ) design context-specific suitable agricultural interventions to address the local nutritional problems, ( ) improve small farm productivity and profitability, ( ) undertake nutrition awareness programmes and build a cadre of hunger fighters and ( ) introduce monitoring systems for assessing impact on nutrition outcomes. location specific vegetables and fruits that are rich in mn are introduced in homestead gardens. professor m. s. swamiathan advocates genetic gardens for nutrition security [ ] . recent evaluation of the impact of this strategy on household food consumption showed remarkable increase in the monthly consumption of fruits and vegetables-frequency as well as quantity, as seen from a baseline survey in and end-line survey in of a sample of households in each location [ ] . though the authors mention, health and nutrition education as part of the intervention, no data on its impact are given in the sited paper. urban gardens for food and nutrition related outcomes are yet another promising strategy. it was recently reviewed in [ , ] . for nutrition security there has to be awareness and access at affordable cost to balanced diet and correct feeding practices (food security,) safe drinking water, disease-free environment and health care outreach. this will ensure absorption also. over the past two decades, the authors (msb and pvvsm) have tried to develop strategies for each of these in select villages of medak district in the south indian state of telangana (formerly part of andhra pradesh). (see www.dangoriatrust.org.in.) this narrative will be confined to the experience with homestead gardens and backyard poultry to enrich the household diet with micronutrient-rich foods. three studies have been conducted in different sets of villages of medak district in the south indian state of telangana (formerly andhra pradesh). the population of the selected villages ranged between and . most households had small or marginal landholding, own or leased. water source for farming was ground water-bore wells or rain-fed. though water stressed, paddy and sugarcane were the main crops. in dry season, maize or sorghum were grown. maize was sometimes intercropped with red gram (cajuns cajan). only few families raised vegetables. all the households were bpl and eligible for the indian government's subsidy schemes including subsidised food grains through public distribution system. most families belonged to the hindu backward class category. there were a few muslim households. some villages had tribal settlements called tandas attached to them. all households had proper houses, and access to bore well water. in the past few years, government has sponsored two-pit household latrine construction. so now most households have a latrine and claim to use it when asked. technological intervention was combined with robust, food, nutrition, sanitation and health education to bring about behavioural change [ ] [ ] [ ] . in the first study, march-april to march-april [ ] , villages from four mandals (geographical area) were included. all families interested to raise vegetable and fruit gardens were invited to join. in the subsequent two studies (march-april - , and september to april-may ) covering eight to ten villages (population about , - , ); families with pregnant women and preschool children were specifically targeted. however, a family approach was used, and husbands often came for training in farming and poultry technologies ( [ , ] and proceedings of ivth agricultural science congress, new delhi, india-under publication). seeds of a variety of glv (amaranth-amaranthus gangeticus; ambat chuka-rumex vesicarius; corrriander-coriandrum sativum; fenugreek-trigonella foenum-graecum; 'gogu'-hibiscus, cannabinus; spinach-spinacia oleracea), and other vegetables like broad beans-vicia faba; cluster beans-cyamopsis tetragonoloba; french beans-phaseolus vulgaris; tomatoes-lycopersicon esculentum; ladies finger (okhra)-abelmoschus esculentus and saplings of curry leaves-murraya koenigii; drumstick-moringa oleifera and malabar spinach (bachali)-basella alba were distributed to the target households. glv are very rich in all micronutrients, are easy to grow and need relatively less water. some variety or other can be grown throughout the year. beans are rich in proteins, besides micronutrients. they can fix nitrogen and enrich the soil with nitrogen. fruit plants like guava-psidium cattleyanum; mango-magnifera indica; papaya-carica papaya and lime-citrus aurantifolia were selectively given to families who had assured source of water and performed well. papaya and mangoes are rich in β carotene (provitamin a) and vitamin c and guava in vitamin c. farmers grew vegetables like brinjal (eggplant) and gourds out of choice. few households had one or two trees of plants like papaya, mangoes, guava, drumstick (moringa) and curry leaves prior to intervention. interested women were taught to raise saplings of plants like papaya, drumstick and bachali (basella alba, a creeper). the saplings were purchased from them for distribution. each woman raised - saplings, and earned some money. organic methods of farming like vermicomposting and botanical pesticides-decoction of chilli-garlic paste or neem seed, were also taught to reduce the use of chemical fertilisers and pesticides, mostly the latter. centralised meeting (at the dct campus) and decentralised meetings (hands-on training in the villages) were given. help from subject specialists in agriculture/horticulture was taken as resource persons for conducting the training programmes. cooking demonstrations to teach simple foods for complementary feeding were held by involving the mothers. since the literacy levels in mothers have gone up markedly in recent years, pamphlets with important messages in the local language telugu were distributed. even if the woman was illiterate, there was someone in the family who could read and explain. impact on acceptance of homestead gardens was done by keeping records of land diverted from traditional crops like paddy and sugarcane to vegetables and fruits, approximate quantum and variety grown and utilised-household consumption vs sale. families were specifically explained that the purpose of the project was household consumption of home-grown vegetables, particularly by women and children and not for sale. families were also encouraged to grow pulses and millets. improvement in understanding of food, nutrition, sanitation, child caring practices and health (some common infectious diseases-their cause and management) was assessed through initial and end-line knowledge, attitude and practice (kap) surveys of mothers with - -monthold children using pretested questionnaires. initial survey was done by the project staff and final survey by a local woman with proper training, to avoid investigator bias. household consumption of different foods (weekly frequency, and per capita per day consumption) was assessed by questioning the mothers about food consumed in a typical week when there were no guests and no feasting or fasting [ ] . in india, the integrated child development scheme (icds) facilitates preschool education, infant and child feeding and maintenance of records of birth weight and growth of preschool children. all villages above a population of have one or more icds centres called anganwadis, managed by a trained anganwadi workers. in the last two studies, birth weight and monthly growth records of children under years of age were examined to assess the impact on nutrition. initially less than % of the targeted households grew vegetables or fruits. at the end of the study, % of the households had diverted small bits of land (less than half acre) to growing of vegetables and fruits, despite small and marginal holdings. table gives data on crops grown, in the last quoted study as reported by the mothers in the kap survey. a marked increase in the number of households growing vegetables, pulses, maize and millets and a small reduction in households growing rice was reported. some of these changes in cropping patter may be seasonal effects since the initial survey was done in the month of september and final survey in summer-april-may. comparison of initial and end-line kap surveys showed remarkable improvement in mothers' knowledge (and hopefully practice) of balanced diet, nutrients in foods, causes and signs and symptoms of nutritional deficiencies, food taboos during pregnancy (avoid foods like papaya and banana), infant feeding practice (initiation of breast feeding, and feeding colostrum, age of introduction of complementary feeding), washing hands with soap and water (not just water), right cooking practices (washing vegetables before cutting, not discarding excess water after cooking rice-a common practice) and causes of common infectious diseases like diarrhoea, malaria, tuberculosis, jaundice and their management ( [ , ] and proceedings of ivth agricultural science congress, new delhi, india-under publication). in the first two studies, there was significant increase in the frequency [ , ] as well as daily per capita consumption [ ] of glv. similar significant improvement in the consumption of other vegetables was not seen. the homegrown vegetables replaced what was purchased from the market. however, in the first study where control nonintervention households from the same village were included for comparison [ ] , there was a marked decline in the consumption of vegetables in the control households over time due to sharp increase in market price of vegetables. this suggests that homestead production at least shields against escalating market price. monthly inquiries showed that about - % of home-grown vegetables other than glv were sold in the first study. 'for poor households, economic compulsions outweigh nutritional wisdom' [ ] . this trend decreased in the subsequent studies by reiterating the purpose of the study. in the last mentioned study, remarkable improvement in the consumption of glv as well as other vegetables was observed (proceedings of ivth agricultural science congress, new delhi, india-under publication) ( table ). very little was sold. the results of that study suggest that with sufficient advocacy, education and training, daily requirement of vegetables, particularly glv can be met from homestead gardens despite small and marginal holdings. some incentive like free distribution of seeds and saplings would help. this, however, will not ensure micronutrient security, unless the intake of pulses and animal products also goes up. in that study, some increase in milk consumption was also observed. this may be due to the government scheme of distributing buffaloes at highly subsidised rate. impact on birth weight and growth of children aged - months was assessed through the records maintained by the icds centres. in recent years, almost all deliveries are institutional. the aw worker maintains records of birth weight and monthly growth. scrutiny of these records over the study period was done in the second and third studies ( [ ] , under publication). no effect on mean birth weight was observed. the incidence of lbw was less than % compared to the national average of about %. the incidence of moderate and severe malnutrition (weight/age) showed marked decline from over % to about %. in both the studies, seasonal variation was seen with increase in undernutrition percentage during monsoon. this is a known phenomenon due to greater morbidity during monsoons. egg is one of the most wholesome foods. over the years the consumption of meat has come down in india, but that of eggs has gone up due to marked increase in commercial poultry farms [ , ] . commercial farms have largely benefitted urban areas. backyard poultry is an important option for rural areas, and widely adopted, with nondescript birds with low egg yields- - eggs per year. these birds are well acclimatised, have prominent brooding behaviour and mothering ability. in recent years, improved breeds of byp, which can lay - eggs per year, have been developed [ ] . unlike seeds and saplings, which were given free, poultry birds were sold after immunisation. families bought three birds and one was given free as incentive. proper night shelters had to be built to prevent predation. initially two improved breeds gramapriya developed by the project directorate, icar, hyderabad, and rajasri developed by aicp on poultry breeding, sri venakteshwara veterinary university, hyderabad, were introduced. more recently, older birds of rainbow rooster breed, purchased from indbro research and breeding farm, hyderabad, are being distributed. in all the projects, the frequency per week of egg consumption by the families initially was less than . per capita per week consumption was also less than eggs. subsequent to the introduction of the byp with high eggyielding birds there was significant improvement. thus in the two projects, the weekly frequency of egg consumption increased by % and %, respectively. per capita number of eggs consumed per week increased by % and %, respectively, [ ] [ ] [ ] . to facilitate wider dissemination of the model of nutritionally sensitive and environmentally sustainable farming, and backyard poultry (with high egg-yielding birds), along with bcc in the area of, food, nutrition, sanitation and health developed in the earlier projects, dct has set up a rural hub. this project was initiated in september , with financial support from tata, lock heed martin aero structures ltd., hyderabad, under their corporate social responsibility-csr for a period of year. it was further continued with financial support of dangoria charitable trust. the design is to target five villages with a total population of eight to ten thousand, over a period of months. after a month of planning and initial kap survey of mothers with children under years of age, on aspects of food, nutrition, sanitation and health (as described earlier), four centralised training programmes on topics such as maternal and child health and nutrition; nutrition gardens; backyard poultry and food processing are conducted each month for months. decentralised hands on training are also given. an end-line kap survey is conducted in the sixth month. like in the earlier projects, pregnant women and mothers with children under years of age are the main target. for sustainability the anganwadi workers and accredited social health activists from the villages are involved in the training. planting material for raising gardens is given free to families with a pregnant woman and children under years. high egg-yielding poultry are given to all interested families. families buy at least four to five birds. hitherto two sets of five villages have been covered. impact is assessed from the number of families that have started growing vegetables, acceptance of byp and improvement in mothers' knowledge of food, nutrition, child feeding practices, health etc. as judged from initial and end-line kap, surveys as described in the earlier longer duration studies. all the families (except three families in the initial survey) had own land. the three families also had leased land. but the holdings were marginal- - acres. farming and farm labour (working on each other's' farms) was the main occupation. all the women were literate and % had studied beyond fifth standard. some women had studied up to intermediate. table (second set of five villages) show significant increase in the percentage of households growing vegetables at the end of months. some increase in the number of households having byp was also seen. there was remarkable improvement in the mothers' knowledge of food consumption during pregnancy, reduction in pregnancy associated food taboos, infant and child feeding practices, healthy cooking practices and components of a balanced diet. improvement in knowledge of-nutrients in foods, functions of different nutrients was weak though majority did mention foods rich in vitamin a in the end-line survey. understanding of the cause and management of diseases like diarrhoea (contaminated food and water), malaria (mosquito bite), tuberculosis (through cough) and jaundice (contaminated food and water) showed significant increase. over the years, there has been remarkable increase in women's literacy, antenatal check-ups, institutional deliveries (home deliveries are very rare) and immunisation coverage, in the villages of medak district where the authors work. the path from agriculture to nutrition is generally assumed to go via agriculture income. important as income is; income alone cannot ensure dietary diversification unless the community is educated about the importance a balanced diet, and nutrition, for health and productivity. emphasis of agriculture is generally on providing calories to quench hunger and at best proteins. this tends to be achieved through cereals and some legumes. hidden hunger remains hidden from the vision of not only people but also planners and policy makers. nutritionally sensitive and environmentally sustainable agriculture is a more holistic approach, in a country like india where agriculture is the main occupation of more than % of the households. generally farmers are reluctant to deviate from traditional cropping pattern. yet the studies of the authors and others discussed in this paper show that even small and marginal farmers can be persuaded to diversify into raising homestead gardens of micronutrientdense vegetables and fruits by combining social engineering with technological engineering. some incentive like giving free planting martial helps. since most poor rural women work in fields or go for labour work, they were given money for travel and lunch was served, when they came for the centralised meetings to compensate for the lost wage for the day. as mentioned earlier, homestead gardens may be able to supply vegetables to meet the household requirement, but that alone will not be sufficient to meet the requirement of micronutrients. inclusion of pulses, millets and animal husbandry along with horticulture should be attempted. the authors did advise about growing pulses and millets, and gave seeds of finger millet and iron fortified pearl millet to interested households. small but significant improvement in consumption of millets was seen ( table ). pulse consumption did not show any increase. introduction of poultry did help in increasing egg consumption. in the long duration projects ( years), many families set up vermicompost beds. incentive by way of earth worms was given. only few families used botanical pesticides. the remarkable improvement in the mothers' knowledge of food, nutrition, infant and child feeding practices, sanitation and common communicable diseases, with education, is very gratifying since an informed mother is an empowered mother, and can make a lot of difference to the family's diet, nutrition and health. involving the local health functionaries also helps sustainability. all community-based technological interventions should have robust educational component so that the community understands the importance of the technological intervention. nutrition gardens have recently caught the imagination and attention of many state governments and ngos in india. suri has summarised some of these unpublished initiatives [ ] . this movement needs to gain momentum with a robust information, education and training strategy. the current swatch bharat clean india programme in india will hopefully complement this effort in reducing malnutrition. homestead production of diverse foods to ensure dietary diversity assumes particular significance under the present pandemic of coronavirus, when the mobility of humans and material has become highly restricted. adverse impact on nutrition of not only the traditionally poor people but also low middle income groups slipping into poverty and malnutrition is feared. micronutrients have been shown to stimulate immunity and thus protect against viral diseases [ , ] . to mitigate deficiency, supplementation with immunity stimulating micronutrients has been recommended since a balanced diet cannot be assured [ ] . fetal origins of adult disease comparison of the indian diet with the eat-lancet reference diet diet and nutrition status of rural population, prevalence of hypertension & diabetes among adults and infant & young child feeding practices prevalence of vitamin deficiencies in an apparently healthy urban adult population: assessed by subclinical status and dietary intakes chapter : the challenge of hidden hungermicronutrient deficiencies world health organisation/food and agriculture organisation of un improving nutrition through biofortification: a review of evidence from harvest plus national programmes to improve food security and nutritional status micronutrient fortification of food: technology and quality control food fortification-principles and application combating micronutrient deficiencies: food based approaches. rome: fao and cab international nutrition sensitive agriculture to achieve better nutritional outcomes food based approach to combat micronutrient deficiencies dynamics of food consumption and nutrient security in, india home gardening for combating vitamin a deficiency in rural india food-based strategies to control vitamin a deficiency impact of homestead gardening program on household food security and empowerment of women in bangladesh improving diet quality and micronutrient nutrition food security through homestead vegetable production in the smallholder agricultural improvement project (saip) area homestead food production model contributes to improved household food security and nutrition status of young children and women in poor populations a farming system model to leverage agriculture for nutritional outcomes operationalising the concept of farming system for nutrition, through the promotion of nutrition-sensitive agriculture establishing agriculture-nutrition programme to diversify household food and diets in rural india improving household diet diversity through promotion of nutrition gardens in india the impact of urban gardens on adequate and healthy food: a systematic review diversification from agriculture to nutritionally and environmentally promotive horticulture in a dry-land area impact of enriching the diet of women and children through health and nutrition education, introduction of homestead gardens and backyard poultry in rural india promotion of backyard poultry for augmenting egg consumption in rural households poultry food security and poverty in india: looking beyond the farm gate new delhi: ministry of agriculture nutrition gardens: a sustainable model for food security and diversity. orf issue brief no. . observer research foundation optimal nutritional status for a well-functioning immune system is an important factor to fight against viral infections the role of nutrition in the immune system: should we pay more attention acknowledgements the technical support for the studies conducted by the dangoria charitable trust was provided by n. venkatesh (agriculture and horticulture), p. pentiah (poultry) and k. v. lakshmi conflict of interest the authors declare that they have no conflict of interest. also, the little bit of unpublished recent research reported is original.publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- -xgikbdns authors: Ühlein, e. title: Übersicht Über neue ernährungswissenschaftliche publikationen date: - - journal: z ernahrungswiss doi: . /bf sha: doc_id: cord_uid: xgikbdns nan shoe~taxer, w. c., 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[ ] nr. , -- ( s.) . stn~p~., f., u. c~warz, k.: incorporation of valine-l-x*c into serum and tissue proteins of rats fed torula yeast diets. j. nutrition [ ] nr. , s. / . ton~., d. b., u. co~or, w. e. : the prolonged effects of a low cholesterol, high carbohydrate diet upon the serum lipids in diabetic patients. diabetes [ ] nr. , . ft. ( s.) . *stormont, j. •., u. waterhouse, c. : effect of variations in previous diet on fasting plasma lipids. j. labor. clinical med. [ ] nr. , s. ff. ( s.) . * stuart, a. e., u vity of the heart extract of rats. medlcina exporimentalis [ ] nr. , s. ff. ( s.) . szepsenwol, j.: carcinogenic effect of egg white egg yolk and lipids in mice. prec. soc. exper. biol. med. [ ] nr. , s. ff. ( s.) . *t~cs, l, u. ny~i, i.: effect of saline infusion, acth infusion, and blood transfusion on the hormone excretion of patients with hypereme~is. act~ medics aead. sei. hun. garicae [ ] nr. , s. ff. ( s.) . tanner, j. w.: an external effect of inorganic nitrogen on nodulation. diss. abstr. [ ] nr. , -- ( s.) . --, u [ ] nr. , s. ff. ( s.) . *t~i~er, l., m~az, m., u. cs:menafiov , m. : the effect of glucose and glucose together with insulin on the resistance of fasted rats to trauma in the noble-collip drum. physiologia bohemoslovenica [ ] nr. , s. ff. ( .) . ude~iend, s. : factors in amino acid metabolism which can influence the central nervous systems. amer. j. clinical nutrition [ ] nr. , s. ff. ( . .) vahouny, g. v., moede, a., silver, b., n . treadw~ll, c. r. : nutrition studies in the cold. iv. effect of cold environment on experimental atherosclerosis in the rabbit. j. nutrition [ ] nr. , s. / . van p lsum, j. f., olsen, b., taylor, d., rozyc'ki, t., u voss, r. d.: yield and foliar composition of corn as affected by fertilizer rates and environmental factors. i)iss. abstr. [ ] nr. , -- ( s.) . *vyval,ro, i. g. : the effect of gibberellin on the transformation of substances in germinating corn seeds. i)oldady akad. nauk sssr [russ.] [ ] nr. , s. ff. ( s.) . wao~ei~, g. r., cl~mk, a. j., hays, v. w., u amer. j. clinical nutrition [ ] lgr. , s. ff. ( s.) . the assessment of marginal protein malnutrition. prec. nutrition soc. [ ] mr. , s. ] . --, u. stnp~, j. m. l.: the free ly~ine and amino nitrogen content of liver, muscle, and serum in normal and protein-depleted rats. prec. nutrition soc. [ ] mr. i, s . viii/ix. *watson, w. c.: the morphology and lipid composition of the erythrocytes in normal and essential-fatty-acid-deflcient rats. bri . j. haematology [ ] lgr. , s. ff. ( s.) . waite, r., u. : blackburn, p. s. : the relationship between milk yield, composition and tissue damage in a case of subclinical masticis. j. dairy res. [ ] , nr. , s. ff. ( s.) . *n. n.: paraty ~hoid fever from frozen chinese eggs. brit. reed. j. . ( s.). *n. n. : radioactivity and human diet. chem. ind. , nr. , . . ~q. ~.: eh~digungen dutch konservlerungsmittel bei zitrusfrfichten? dr. reed. wschr. [ ] nr. , s. . *n. n. : salt-poisoning in infancy. lancet [ ] l~r. , s. . n.n.: kouoquium des arbeitskrcises hamburg der gdch-fachgruppe lebensmittelchemic und gerichtliche chemic am . januar . lebensmittelchem. u. gerichtl. chem. [ nr. , s. . *n. n. : smoking and heath disease. new england j. med. [ ] nr. , s. . +hi. n. : toxic components of lathyrus peas. nutrition rev. [ ] nr. , s. / . +n. n. : cariogenic ability of different diets. nutrition roy. [ ] nr. , s. ] . +n. ~.: aminoaeiduria in lead intoxication. nutrition rev. [ ] nr. , s. / . +n. n. : pyridoxine and dental caries. human studies. nutrition rev. [ ] nr. , s. . +n. n.: pyridoxine and dental caries. animal studies. i~utrition rev. [ ] nr. , s. . +hi. n. : rcporb: the prophylactic requirement and the toxicity of vitamin d. pediatrics [ ] nr. , s. ff. (? s.). axrkroa, a.: caesium- from fall-out in human milk. nature [ ] nr. , s. ff. ( s.) . *allcroft, r., u. car~agha~, r. b. a. : groundnut toxicity: an examination for toxin in human food products from animals fed toxic groundnut meal. veteri. rec. [ ] nr. , s. ff. ( s.) . *--, l~wis, g., u. hill, k. ~.: groundnut toxicity in cattle: experimental poisoning of calves and a report on clinical effects in older ca~tle. ve~er. rcc, [ ] nr, , s. ff. ( s. nr. , , nr. , , , , nr. , nr. , influence of calcium and ouabai bain upon potassium influx in human erythrocytes the enzymatic assimilation of nitrate in the tomato plant translocation of '~p, i~n, and ~c in plants einige neue gesiehtspunktr zum caleiumstoffwechsel dis~ibution of water, sodium, and potassium in resting and stimulated mammalian muscle. canad the influence of vitamin bi, on calcium ('sca) metabolism of maxillodental tissues kidney, water, and electrolyte metabolism intermediiirer elektroly~toffwechsel und zellgrenzfl~chenphysiologie im theoretischen zusammenhang mit der krebsentstehtmg. tell i dcr einflul~ yon vollkornbrot auf den calcium-stoffwechsel bei schulkindern recherches sur le m tabolisme du soufre. x. : la non- quivalence de la eystine et de la eyst ine dans la couvcrture des besoins sufr~s du rat adulte potassium-magnesium antagonism in soils and crops low serum iron levels in obese adolescents metal content of human organs studies on the requirements and interaction of copper and iron in broad breasted bronze turkeys to weeks of age iron absorption and excretion in experimental iron deficiency the measurement of exchangeable magnesium in dogs the copper metabolism of warmblooded animals with special reference to the rabbit and the sheep comparative studies of the metabolism of strontium and barium in the rat the utilization of iron in erythropoiesis binding of strontium in blood ~iolybdenum, copper, and zinc contents of mouse liver and sarcoma treated with molybdenum compounds biochemical effects of zinc deficiency in tomato plants excretion of sodium, potassium, magnesium, and iron in human sweat and the relation of each to balance and requirements turnover rate of zinc in the body as determined by the study of szn in rats a study of the iron absorption in mice as modified by various agents funktionsteste des radiojodstoffwechselstudiums und ihre bedeutung in der diagnostik der sehilddrfisenerkrankungen. ~rztl. laboratorium the fate of radioiodine after parcnteral administration a possible humeral regulator of iron absorption beitrag zur kl~rung der ursachen der anreicherung yon caesinm- im rganismus blood-and serum-level of watersoluble vitamins in man and animals significados metabslicos do ~cido ~-lip ico. . o ~cido r e o metabolismo do ferro observations on a magnesium-fluoride interrelationsip in chicks prevention of ,meat anemia" in mice by copper and calcium iron metabolism in experimental pyridoxine deficiency aluminium in soils and plants on the coastlands of british guinea physiology of adolescence. ii. : nutrition -basal oxygen consumption -energy expenditure and balance -nitrogen metabolism -calcium metabolism -iron metabolism -red cell mass and hemoglobin dietary strontium and calcium, and deposition of sr and asca in the bones of rats -~iengenelementansatz wachsender sehweine bei unterschicdiichen cuso -zulagen differences in copper retention in two strains of chickens untersuchungen fiber anreicherung und verteilung yon rubidium in gerstenkcimpflanzen [ ] nr. , s. / . *+lv~ointyr~, i.: an outline of magnesium metabolism in health and disease. a review uptake by the root and subsequent distribution within the potato plant of strontium- leached from the foliage nor zinkstoffwechsel in der schwangerschaft foetal metabolism of caesium- in the rat magnesium metabolism of chickens zinc metabolism in patients with the syndrome of iron deficiency anemia hepatospenomegaly dwarfism, and hypogonadism. labor. clinical mcd c~isium- trod kalium in menschlichen organen und in der milch / l~ole of the genotype in controlling accumulation of strontium- by plants copper and zinc interrelationships in the pig effect of chromium, cadmium, and other trace metals on the growth and survival of mice studies in the metabolism of zinc. iv. some observations on the urinary zine-porphyrin relationship in non-porphyries and in a patient with aeutm intermittent porphyria aastrontium balances in man studies on zinc metabolism. ii.: effect of the diabetic state on zinc metabolism: an experimental aspect effect of diabetic state on zinc metabolism: a clini. cal aspect copper metabolism and the liver iron metabolism and the liver with particular reference to the pathogcnesis of haemachromatosis studies on iron metabolism uber den eisenstoffwechsel. (bemerkung zu t. su~di~, miinchener reed yifinchener reed. wschr. [ ] nr. , s. . c - wirkstoffe -biocatalysts +n. n. : vitamin a in human livers. nutrition biological half.llfe of vitamin b~ in plasma hypervitaminosis a and mast cells. a study of the interrelationship of mast cells and vitamin a in vivo and in vitro evidence concerning the human requirement for vitamin bi~. use of the whole body counter for determination of absorption of vitamin blz vitamin c in plasma and leucocy~s of smokers and non-smokers some factors affecting the absorption of vitamins the determination of vitamin a in animal tissues and its presence in the liver of the vitamin a deficient rat metabolic activities of vitamin a and related compounds in animals. i.: role of vitamin a in intestinal muscular contraction zum vitamin-b--haushalt dcr ratte bei sorbitfiitterung contribution a l'~tude do la relation entre la vitamine big et la glande thyrolde effects of deficiencies of certain b vitamins and ascorbic acid on absorption of vitamin blv amer ascorbic acid metabolism in plants. ii. : biosynthesis dietary and thyroid interrelationships affecting vitamin a status of feedlot beef cattle die wirkung gesteigerter kupferzufuhr auf den vitamin-c-haushalt vom meerschweinchen bei parental zugeffihrter ascorbins~ure kritische auswe~ung der naeh erschienenen arbeiten fiber gebundene ascorbins~ure im tierischen gewebe metabolism and biological activity of vitamin a acid in the chick biochemical studies of vitamin metabolism in poultry urine. ii. : on the excretion of thiamine in poultry urine after subcutaneous and oral administrations of some thiamine derivatives untersuchungen fiber die speiehcrung und fiber die ansscheidung yon vitamin a nach ungeniigender vitamin-a-versorgung bei legenden hfihnern studies on metabolism of vitamin a. .: the biological acticity of vitamin a acid in rats vitamin a and cholesterol absorption in the chicken studies on the interaction of vitamin bi~, intrinsic factor, and receptors. il the possible absorption of intrinsic factor human growth hormone in infant malnutrition macro-and micromethods for the determination of serum vitamin a using trifluoroacetic acid the activation of sulphate by extracts of cornea and colonic mucosa from normal and vitamin a-deficient animals the importance of blood as a pool of vitamin d studies on metabolism of vitamin a. .: enzymic synthesis ~nd hydrolysis of phenolic sulphates in vitamin-a-deficient rats human metabolism of l-ascorbie acid and erythorbic acid tissue distribution and storage forms of vitamin b~, injected and orally administered to the dog relation between vitamin a, tocopherol, and cholesterol serum levels in the elderly interrelationships of vitamin bi~, folio held, and ascorbie acid in the megaloblastie anemias zum wirkungsmechanismns des vitamins e. helvetica physiologica et pharmacologica effect of some physiologic factors on the absorption of vitamin bi~ in rats transport of dietary nitrogen mitochondrial fatty acids of fish and fish-eating birds the biosynthesis of fatty acids influence of age and dietary protein on cerbain free amino acids in chick blood plasma nitrogen metabolism in coldexposed rats ~ber des vermehrte auftreten yon fettsiiuren mit bis c-atomen in den depotfetten siiugender ratteu und den ubergang der linolsi~ure yon den mfittern auf die jungen die bildung yon antiksrpcrn gegen verschicdene kuhmilehproteine bei neugeborenen, kindern, erwachsenen und graviden the myocardial arterio-venous differences of free amino acids and of free fatty acids in healthy individuals, patients with diabetes and with essential hypercholesterolemia urinary amino acids on phenylalanine-tyrosine-supplemented diets difference in the metabolic fate of acetate and ethanol fed to higher plant tissues iiemodynamic relationships of anaerobic metabolism and plasma free fatty acids during prolonged, strenuous exercise in trained and untrained subjects effects of palmitate on the metabolism of leukooytes from-guinea pig exudate the dynamics of plasma free fatty acid metabolism during exercise ~ber die retention, den abbau und die ausseheidung yon -thion-tetrahydro-l. . -thiadiazinen transport systems for amino acids effects of protein intake and cold exposure on selected liver enzymes associated with amino acid metabolism quantitative studies on tryptophan metabolism in the pyridoxine-deficient rat effect of desoxypyridoxine-induced vitamin b~ deficiency on polyunsaturated fatty acid metabolism in human beings studies on the wheat plants using carbon- compounds. xix.: observations on the metabolism of lysine- c. canad genetic defects of amino acid metabolism. pediatric clinics north america metabolism of tryptophan in diabetes mellitus the two-carbon chain in metabolism der einfluss yon vitamin a auf den citronens~urestoffwechsel ~)ber phenolspeicherung und phenolabbau in wasserpflanzen. naturwissensehaften effect of physical exercise on nitrogen balance in obese subjects metabolism of nitrogen compounds in the rumen of ruminants. izvest. acad der intermedli~r-stoffwechsel s~ffweehsel der carotine im hiihnerembryo nucleic acid metabolism of germinating corn seedlings carbon metabolism of ~ c-labelled amino acids in wheat leaves. ii.: serine and its role in glycine metabolism bovine metabolism of insecticides. the metabolism of ~evin in dairy cows stoffweehsel der carotine. wiss. veroff. dr. oes. ern~hrnng metabolism of labelled linolcic-l-tac acid in the sheep rnmen nonessential nitrogen supplements and essential amino acid requirements. nutrition rev vitamin c requirements of man re-examined. new values based on previously unrecognized exhalatory excretory pathway of ascorbie acid studies on the requirements and interaction of copper and iron in broad breasted bronze turkeys to weeks of age water requirements of men as related to salt intake evidence for a high zinc requirement at the onset of egg production effect of lysine and glyeine upon arginine requirement of guinea-pigs the cobalt requirement of subterranean clover in the field fluid and electrolyte, requirements of newborn infants with intestinal obstruction the requirement and availability of dietary iron for young pigs studies on the protein and methionine requirements of young bobwhite quail and young ringnecked pheasants phenylalanine requirement of women consuming a minimal tyrosine diet and the sparing effect of tyrosine on the phenylalanine requirement effects of starvation on the cardiovascular system of the chicken calcium and phosphorus requiremeats of finishing broilers using phosphorus sources of low and high availability water intake of normal children sex differences in the ~ oeopherol requirement of rats as shown by the haemolysis test further studies on protein and energy requirements of chicks selected for high and iow body weight smoking and blood dotting dental caries and trace elements a statement approved by the board of directors of the canadian heart foundation the question of fats. il : fats and disease moldy peanuts and liver cancers vitamin c and healing of wounds berieht fiber die vortragstagung des fachverbandes lehensmittelchemie der chemisehen gesellschaft in der d])r veto . his diet and human depot fat ethanol and plasma free fatty acid in man dietary water and protein efficiency in rats. nutrition rev. [ ] nr. , s. / . +n. n. : nature of the coagulation defect in rats fed diets producing thrombosis or experimental atheroselerosis factors affecting growth depression by raw soybeans bones in undernourished animals. nutrition rev. [ ] nr. , s. . +n. n. : vitamin e and the etiology of muscular dystrophy in the rabbit riboflavin eoenzymes and congenital malformations the thyroid gland in infant malnutrition. nutrition rev. [ ] nr. , s. . +n. n. : a proposed mechanism for the effect of fats on serum cholesterol effect of varying levels of dietary protein on synthesis and excretion of urea dietary phosphates and dental caries folic acid restriction and cancer inhibition changes induced by lipoie acid in normal rat liver vitamin b deficiency and tryptophan metabolism effect of ubichromenol on development of encephmomalacia in vitamin e deficient chicks leucine-induced hypoglycemia nutritional muscular dystrophy in lambs. nutrition rev. [ ] nr. , s. / . +n. n.: amino acid imbalance in cold-exposed rats. nutrition rev. [ ] nr. , s. . +n. n.: milk and athletic performance effect of vitamin a deficiency on the ubiquinone content of rat liver idiopatjaie stea~orrhea gastrointestinal protein loss in iron-deficiency anemia nutritional cirrhosis of the liver. nutrition rev. [ ] nr. , s. / . +n. n. : exercise and heart disease calcium deficiency in the etiology of osteoporosis the relation of dietary fat to the fatty acids in the intestinal wall clot-strength and elot-lysis in rats fed hyperlipemic diets effect of potassium iodide and duodenal powder on the growth and organ weights of goitrogen-fed rats ver~nderungen im stoffwechsel und wachsturn junger tomatenpflanzen nach giberillins~,urebehandiung effect of restricted feeding during the growing period on reproductive performance of large type white turkeys keys, a. l glucose, sucrose, and lactose in the diet and blood lipids in man ambient temperature and survival on a protein-deficient diet some considerations of changes in total body composition in relation to nutritional status the effect of variations in the energy and protein levels of the ration upon performance in the pig studies in choline deficiency. fate of injected - ~c-pal. mitio acid and fatty acid spectra in fasting and refed rats bartou i~ vitamin a requirements of chicks at moderately elevated temperature influence of age and dietary protein on eer~ain free amino acids in chick blood plasma the effects of nicotine on weight increment, activity, food intake, and water intake in weanllng albino rats effect of pyridoxine deficiency upon delayed hypersensitivity in guinea-pigs vitamin a deficiency in chickens ccrebellar encephalomalacia produced by diets deficient in toeopherol vitamin b deficiency in indian infantm plasma liplds in scurvy: effect of ascorblc acid supplement and insulin treatment effect of gibberellin on the variations of the growth-point in winter wheat uptake of dinitrophenol and its effect on transpiration. calcium accumulation in barley seedlings l~[ethylmalonate excretion in vitamin b~ deficiency reduction of plama cholesterol levels in atherosclerosis by diet and drug treatment. australasian ann effects of reduced dietary intake on the activities of various enzymes in the livers and kidneys of growing male rats the effect of feeding d-methionine on the d-amino acid oxidase activity of chick tissues l~etabolic effects of dietary protein level in cold-exposed rats relative effects of rapeseed oil and corn oil on rats subjected to aclrenalectomy, cold, or pyridoxine deprivation metabolic effects of dietary protein level with caloric restriction in coldexposed rats. canad metabolic effects of three dietary protein levels fed isocalorically to coldexposed rats. caned die nolle versehiedener fette im eiweis des organismus. nahrung the bursa of fabricius and xanthine oxidase activity of liver and kidney following dietary supplementation of iodina~d casein to chickens effects of linolsate and dietary fat level on plasma and liver cholesterol and vascular lesions of the cholesterol-fed rat a comparative study of the effect of bile acids and cholesterol on cholesterol metabolism in the mouse, rat, hamster, and guineapig the effects of ruminal and plasma sodium concentrations on the sodium appetite of sheep effect of level and sequence of feeding and breed on ovulation rate, embryo survival, and fetal growth in the mature ewe inhibitory effects of carbohydrates on histamine release and mast cell disruption by dextran fett-s~urestoffwechsel bci the effect of calcium infusions, parathyroid hormone, and vitamin i) on renal clearance of calcium nutritional supplementation during pregnancy effect of level of dietary protein with and without added cholesterol on plasma cholesterol levels in man die schilddrfisenfunktion bei enteralem eiweiflverlust effects of pelleting and varying grain intakes on milk yield and composition fatty acid composition of lipids of serum and aorta in the chicken on different diets rat intestinal suerase. ii.: the effects of rat age and sex and of diet on suerase activity the effect of selenium administration on the growth and health of sheep on scottish farns die wirkung yon vitamin b bei leukopenien effect of energy source and level of alfalfa pellets on growth and tissue hpids of beef calves effect of magnesium deficiency on mast cells and urinary histamine in rats histamine-liberating effect of magnesium deficiency in the rat zur wirkung des wassers bei der seitenwurzelbildung an luftwurzeln influence of the aqueous potato extract and its fractions on growth and spore formation of the b. pumilus and the production of the antibiotic tetaine influence of mineral nutrition on the resistance of peach tree to fusicoceum amygdali de la croix the effect of dietary protein on the course of various infections in the chick bifidus intestinal flora in infants fed on mamysan b. acta paediatriea effect of food fats on concentration of ketone bodies and citric acid level in blood and tissues is there a hemostatie effect of peanuts in hemophilioid disorders? milk allergy in infancy dental effects of fluoridation of water with particular reference to a study in the united kingdom influence of previous feeding with a high-fat diet on liver steatosis produced by acute starvation of growth hormone in mice effect of amino acid imbalance on nitrogen retention. ii.-interrelationships between methionine, valine, isoleucine, and threonine as supplements to corn protein for dogs supplementation of cereal proteins with amino acids. v. : effect of supplementation lime-treated corn with diffe. rent levels of lysine, tryptophane, and isoleueine of the nitrogen retention of young children the interrelation of nutrient supply, leaf nutrient content, and vegetative growth of ilex crenata gastric content of fasted primates. a survey serum cholesterol in vitamin c deficiency in man the effect of carbohydrates on the production of staphylococcal pigment effect of a low dietary level of three types of fat on reproductive performance and tissue lipid content of the vitamin b -defieient female rat effect of magnesium deficiency on synthesis of hear~ and liver mit~chondria phospholipids ~ber den einflub l~nger dauernder ksrperlicher inaktivit~t auf die blutzuckerkurve nach oraler glucosebelasttmg. helvetica medica acts action of trace elements on the metabolism of fluoride zur frage des einflusses yon kondensmilch und einer protein-valerina-polyphosphat-komplexverbindung auf die kreislaufwirktmg des kaffees beim menschen modifications de la croissance de la plantule de lapin blanc (lupinns albns l.) provoqu es par une diminution exp rimentale des r serves influence of the dietary protein level on the magnesium requirement effects of high levels of copper and chlorotetracycline on performance of pigs effect of dietary calcium lactate and lactitic acid on faecal escherichia coli counts in pigs die entwickhing von calcium-mangelsymptomen. z. pflanzenern~hrung, diingung, bodenkde. [ ] nr. , s. / . --calcium-mangelsymptome an hsheren pfianzen copper deficiency in relation to swayback in sheep. i. : effect of molybdate and sulphate supplements during pregnancy long-term, low fat, low protein diets and their effect on normal trappist subjects further studies of the influence of diet on radiosensitivity of guinea-pigs, with special reference to broccoli and alfalfa effects of the infusions of ammonia, amides, and amino acids on excretion of ammonia answirlmngen langfristig fettreicher ern~ihrung auf das plasma-cholesterin the relationship of dietary energy level and density to the growth response of chicks to fats influences of dietary carbohydrate-fat combinations on various functions associated with glycosis and lipogenesis in rats. i. effects of substituting sucrose for rice starch with unsaturated and with saturated fat compensatory carcass growth in steers following protein and energy restriction fatty acid composition and glyceride structure in rats fed rapeseed oil or corn oil. canad influence of selective and nonselective hydrogenation of rapeseed oil on carcass fat of rats. canad studies in serum lipids. with special reference to spontaneous variations and the effect of short-term dietary changes experimentelle untersuchungen zur wirkung yon kaffeefett evaluation of the effect of breed on vitamin be requirements of chicks -iigh salt content of western infant's diet: possible relationship to hypertension in the adult the effect on the serum cholesterol levels of the consumption of a special dietary fat with a high content of unsaturated fatty acids in elderly people effect of dilution of the diet with an indigestible filler on feed intake in the mouse effect of tea and its tannins upon capillary resistance of guinea-pigs food input and energy extraction efficiency in carassins auratns effect of calcium and magnesium upon digestibility of a ration containing corn oil by lambs effects of calorie restriction during the growing period on the performance of egg-type replacement stock effects of insulin on hepatic glucose metabolism and glucose utilization by tissues cellulase and polygalacturonase in tomato fruits and the effect of calcium on fruit cracking effect of nutritional muscular dystrophy and of starvation on amino acid penetration in rabbit tissues plasma protein synthesis in nutritional muscular dystrophy inulin and sucrose distribution in tissues of vitamin e-deficient and control rabbits protein-bound dyes in the serum and liver of rats fed aminoazo dyes vanadium. excretion, toxicity, lipid effect in man the influence of vitamin a status on the proteoly~ic activity of lysosomes from the livers and kidneys of rats disauxie metainfettive e da malnutrizione induced drinking in dogs: comparative effects of hypertonic sodium chloride and sorbitol the influence of early nutrition on brain cholesterol accumulation during growth changes in composition of the saliva of cows on grazing heavily fertilized grass. res. veter changes in composition of the saliva of sheep on feeding heavily fertilized grass efect of varying alfalfa: barley ratios on energy intake and volatile fatty acid production by sheep the influence of calcium on the secretory response of the submaxillary gland to acetyi-choline or to noradrenaline clinical dentistry and fluoride food allergy as a cause of abdominal pain the effect of various dietary levels of ddt on liver function, cell morphology, and ddt storage in the rhesus monkey effect of natural and purified diets on survival of x-irradiated mice effect of autoclaving and ])'sine supplementation of skimmilk-powder diets on growth and caries in rats effects of alcohol intake on subjective and objective variables over a five-hour period nitrogen metabolism of african cattle fed diets with an adequate energy feeding value of fl-caroteno following treatment with n~o~ the relationship of the quantity and quality of dietary fats to serum cholesterol levels in men of different ages and weights effects on girls of greater intake of milk, fruits, and vegetables effect of antioxidant, protein, and energy on vitamin a and feed utilization in steers the growth-maintaining activity of ascorbic acid the effects of an induced pyridoxine and pantothenie acid deficiency on excretions of oxalic and xanthurenic acids in the urine influence of lactose and dried skim milk upon the magnesium deficiency syndrome in the dog. i.: growth and biochem chronic malnutrition in turkey. v. study on serum fatty acids in malnourished children the effect of nutrition conditions on the growth of and nitrogen accumalation by fodder beans when sown together with indian corn effects of a diet high in polyunsaturated fat on the plasmalipids of normal young females citrate and action of vitamin d on calcium and phosphorus metabolism beeinflussung der sportliehen lelstungsf/~higkeit durch eine geeignete er-nehrung effect of dietary erotic acid on liver proteins effect of barbiturie acid and ehlortetraeyeline upon growth, ammonia concentration, and urease activity in the gastrointestinal tract of chicks effects of feeding low levels of dimethoate on milk and whole blood eholinesterase activity of dairy cattle changes in serum lipoproteins after a large fat meal in normal individuals and in patients with isehemic hear~ disease the relationship of specific nutrient deficiencies ~) antibody response in swine. i. : vitamin a. ii. : pantothenie acid, pyridoxine or riboflavin. i)iss. abstr relationship of specific nutrient deficiencies to antibody production on swine. i. : vitamin a relationship of specific nutrient deficiencies to antibody production in swine. il : pantothenic acid, pyridoxine or riboflavin histechemistry of dietary cardiac lesions effect of various levels of fluorine, stilbestrol, and oxytetraeycline, in the fattening ration of lambs uptake of copper and its physiological effects on chlorella vulgarls the effects of a small dose of ethyl alcohol on certain basic components of human physical performance. i. the effect on cardiac rate during muscular work. arch. internat some effects of feeding stilbestrol, chlortetracycline and penicillin with alfalfa soilage on steer performance and carcass quality experimental induction of ciguatera toxicity in fish $hrough diet effects of potassium fertilizer, age of ewe, and small magnesium supplementation on blood magnesium and calcium levels of lactating ewes the influence of higher volatile fatty acids on the intake of urea-supplemented low quality cereal hay by sheep un~emuchungen fiber den umsatz wachsender schweine ab geburt. . mitt eczema and cow's milk. brit. med. j. , nr. , s. . isaacso~, a. : the effects of zinc on responses of frog skeletal muscle effects of zinc on responses of skeletal muscle effect of diet on work metabolism carbohydrate-phosphorus metabolism in the skeletal muscles of epinephrectomized animals durlng treatment with cortisone and vitamins c and p. ukrainskii biokhimichnii zhurnal composition of dietary fat and the accumulation of liver lipid in the choline-deficlent rat nutrition and palatability the incidence of protein-calorie malnutrition of early childhood theories on the mode of action of fluoride in reducing dental decay saccharase deficiency, familial entailing intolerance ~ cane sugar. acts paediatrica raw and heat-treated soybeans for growing-finishing swine and their effect on fat firmness effect of the administration of isoniazid and a diet low in vitamin be on urinary excretion of oxalic acid dietary and thyroid interrelationships affecting vitamin a status of feedlot beef cattle ration effects on rumen acids, ketogenesis, and milk composition. i.: unrestricted roughage feeding the effect of supplements of groundnut flour or groundnut protein isolate fortifed with calcium salts and vitamins or of sklmmilk powder on the digestibility coefficient, biological value and net utilization of the proteins of poor indian diets given to undernourished children a comparison of skin-testing with natural foods and commercial extracts die wirkung yon hungern auf den ammoniakgehalt und das ph der pansenfi(issigkeit sowic auf die harnstoff-, cholesterin-und zuckerkonzentration im blu~. acts veterinaria acad increase of plant virus infection by magnesium in the presence of phosphate effect of intramuscular injection of magnesium sulphate solution on the growth rate and serum composition in rats diskussionsbemerkungen zu referaten fiber sauermilchprodukte auf einer vortragsveranstaltung der gesellschaft fiir eru~ effect of massive sodium bicarbonate infusion on renal function excessive insulin response to glucose in obese subjects as measured by immunoehemical assay die wirkung gesteigerter kupferzufuhr auf den vitamin-c-hanshalt yon meerschweinehen bci paren~ral zugef'dhrter ascorbinsrure the influence of growth hormone on fat and protein metabolism. dies. abs~r. [ ] nr phenolearbons~iuren in mensehlichen nahrungsprodukten. zum vorkommen yon phenolcarbons~uren in mensehlichen nahrungsprodukten und ihr einflul~ auf den intermedit~ren stoffwechsel influence of pregnancy and an oxidized lipid diet on the fatty acid composition of blood and tissue an experimental approach to the mechanisms of weight loss. ii. a comparison of effects of thyroxine, fat-mobilizing substance (fms) and food deprivation in achieving weight loss in mice fat accumulation in the regenerating media of arteries in rats given an atherogenic diet the effect of nutrition on the growth of faseiola hepatica in its snail host the effects of specific viruses, virus complexes, and nitrogen nutrition on the growth, flowering, and mineral composition os strawberry plants body weight and food intake as initiating factors for puberty in the rat the role of catecholamines in the free fatty acid response to cigarette smoking die renale steroidausseheidung bei experimentellem vitamin-e-mangel peculiar features of respiration and redox processes in the rice plants grown under different nutritional conditions der bohnenkaffee und die migrrne repeatability of litter size and weight in the laboratory rat as affected by selection and plane of nutrition wirkungen yon muskelextrakt auf den stoffwechsel. arzneimittelforschung is [ ] nr. , s. / einflul] der silageftitterung auf die qualit~t der butter einflul] der silageftitterung auf die qualit~t yon milch und milchproduk. ten. . mitt.: einflul] von silagefiitterung auf die organoleptischen eigenschaften dcr milch effect of protein intake and cold exposure on selected liver enzymes associated with amino acid metabolism body iron levels and hematologic fin. dings during excess methionine feeding der einttul~ des kulturmediums auf die bildung von streptolysis s durch ruhcnde zellen influence of polyphosphates in chilling water on quality of poultry meat influence of breed-type, feed level, and sex on characteristics of the lamb carcass, and some relationships among live animal and carcass measurements the toxic action of phenothiazine and some disturbances of intermediary metabolism in undernourished sheep efficiency of feed use in beef cattle uber die wirkung der nalmmgsfette auf die blutlipoide, teil i. ernahrungs-umsehau [ ] nr. , s. / . --~ber die wirkung der nahrungsfette auf die blutlipide fette und blutgerinnung. bibliothcca hacmatologiea effect of heavy cigarette smoking on postprandial triglycerides, free fatty acids, and cholesterol role of calcium in fibrin formation glucose- -phosphate dehydrogcnase and aldolase in lenses of lactose-fed rats -effect of riboflavin, choline, pantothenic acid and vitamin a on the excretion of sodium in urine of rats the effect of waterwashed rice in the diet on the growth, excretion of sodium in urine and blood pressure of rats effect of aseorbic acid, vitamin b, and milk on the dark adaption effect of single deficiency of vitamin a, thiamine der einflub yon vitaminen auf die psyehomotorisehe leistungsi'~higkcit beim menschen. naunyn-schmiederberg's arch. exper feeding response of adult tribolium to carbohydrates in relation to their utilization nutritional secondary hyper hieronymi: influence of nutritional conditions on the cellular rna metabolism in rive and in vitro diffusible auxin increase in a rosette plant treated with gibberellin transamination in muscular dystrophy and the effect of exogenous glutamate: a study on vitamin e deficient rabbits, and mice with hereditary dystrophy. canad effect of auxin on the emergence of lateral roots in p. mungo seedlings the effect of nutritive status on oestrus, ovulation, and graafian follicles in merino ewes biologische wirkungcn autoxydierter, epoxydierter und bestrahlter fette s~ure-basen-gleichgewicht mad chronische acidogene und alkalogene eruehrung effect of protein level in milk replacers on growth and protein metabolism of dairy calves effect of sodium bicarbonate in the drinking water of ruminants on the digestibility of a pelleted complete ration sucrose diet and bfliary chelate excretion in rats: with note on procedure for chelate determination eirdlub sauerer milcherzeugnisse auf die darmflora untersuchungen fiber die speicherung und die ausscheidung yon vitamin a nach ungenfigender vitamin-a-versorgung bei legenden hiihnern the effects of low magnesium intake on lactating ewes effect of vitamin a on the content of pyridinnucleotides, pyrovic, and lactic acid and on anaerobic phosphorylation. ukrainskii biokkimichnii zhurnal the pyridine nucteotides. a study of a method of measurement. a study of the alterations in rat fiver under the conditions of diabetes and starvation. a preliminary study of various marine fish tissues with the emphasis on the islet of langerhans iron uptake-transport of soybeans as influenced by other cations hshe und zeitpm~kt der dfingung yon sommerweizen mit chlorcholinchlorid zur vcrkiirzung der halmlange nutritional significance of soluble nitrogen in dietary proteins for ruminants effects of long-term feeding of vegetable fats on atherosclerosis effects of feeding various mile, corn, and protein levels on laying performance of egg production stock some observations on the influence of a magnesiumdeficient diet of rats, with special reference to renal concentrating ability effect of gibberellic acid on flowering of apple trees the effects of dietary fat and energy levels on the performance of caged laying birds motivational producing properties of the feeding system of the rat hypothalamus the influence of diet and age on lipid metabolism of chickens effect of age on the response of chickens to dietary protein and fat absorption and excretion of biotin after feeding minced liver in achlorhydria and after partial gastrectomy variations de la calcsmie du chien normal apr~s ingestion de cholesterol eristallis~ dans l' thanol ou dans rhexane changes in activity of rat epididymal adipose tissue in vitro due to time elapsed since last feeding differences in rat strain response to three diets of different compositions l'alcoolisme ~ l'hspital psychiatrique de colsou (martinique). ann. m~dico-psychologiques nitrogen, lipid, glycogen, and deoxyribonu. eleie acid content of human liver. the effect of brief starvation and intravenous administration of glucose some metabolic and nutritional factors affecting the survival of erythrocytes erythrocyte survival of rats deficient in vitamin e or vitamin b . j. nutrition [ ] nr. , s. / nutrition and lactation the effect of administering sodium chloride, sodium bicarbonate, and potassium bicarbonate to newly born piglets strontinm- and calcium in milk of miniature swine further studies on cariostatic effect of organic and inorganic phosphates urinary excretion of magnesium in man following the ingestion of ethanol the effects of magnesium compounds and of fertilizers on the mineral composition of herbage and on the incidence of hypomagnesaemia in dairy cows behavioral, dietary, and autonomic effects of ehlordiazepoxide in the rat the effect of a high and low sodium diet in a patient with familial periodic paralysis the effect of quaternary ammonium anion exchange resin on plasma and egg yolk cholesterol in the laying hen vitamin e deficiency and ion transpor~ in rat liver slices effect of level of nitrogen on growth and reproductive physiology of young buus and rams influence of low protein rations on growth and semen characteristics of young beef bulls, if treatment of nutritional cirrhosis in rats with choline and methionine; with special reference to fibrogenesis and fibroelasia probleme der beurteilung yon sauermilcherzeugnissen. milchwissen. schaft [ ] nr. , s. / . --antwort auf die diskussionsbemerkungen auf einer vortragstagung der gesellschaft ffir ern~hrungsbiologie e. v., miinehen, am response of early-weaned pigs to variations in dietary calcium level with and without lactose effect of low calcium diet on bone crysta]linity and skeletal uptake of sca in rats response of rural guatemalan indian children with hypocholesterolemia to increased crystalline cholesterol intake source of plasma free fatty acids in dogs receiving fat emulsion and heparin alcoholic intoxication in the newborn infant. bril mcd dental caries of rats fed a rice diet and modifications a study of zinc deficiency in the dairy calf effects of different levels of zinc and phosphorus on the growth of subterranean clover (trifolium subterraneum l) lrber den einflu yon fluor auf den wassergehalt des knochens gegevens ovvr vitamine b,-deficientie, -behoefto en -voorziening the liquefying action of pancreatic, cereal, fungal, and bacterial co-amylases ern~ihrung und endokrines system . mitt.: der einfiul der erniihrung auf die schilddriise the effect of saline water on kidney tubular function and electrolyte excretion in sheep zinc and iron deficiencies in male subjects with dwarfism and hypogonadism but without ancylostomiasis, schistosomiasis or severe anemia die yextriiglichkeit yon xyli~ beim diabetiker einflni der laevulose auf die fu~ionsbrelte. sport~tl. praxis der einflul~ yon vitamin a auf den zitronensi~urestoffwechsel studies on the growth-promoting value and digestibility of passion fruit seed oil ration effects on drylot steer feeding patterns dextrothyroxine on metabolism of cholesterol some effects of feeding lactates to dairy cows copper deficiency problems in south-east scotland bone changes in iron deficiency anaemia a preliminary report on nucleic acid levels in mineral deficient plants metabolism of histidine in protein malnutrition ttypoglycemie effect of l-leucine during periods of endogenous hyperinsulinism nutritional studies with the guinea-pig. viii. : effect of different proteins, with and without amino acid supplements, on growth some effects of sulphur-containing amino acids on the growth and composition of wool effects of hunger and vi value on vi pacing potency of conditioned reinforcem based on food and on food and punishment sfibwaren und karies in theorie und praxis effect of magnesium on the changes of myocardial potassium confent untersuchungen fiber den einflub oral verabreiehten oxytetraeyclins auf leberlipide und serumeholesterin der weil~en ratte further studies on manganese nutrition of tobacco in relation to virus infection and synthesis aminobutyric acid (),-aba)-vitamin be relationships in the brain serum lipids and diet: a comparison between three population groups with low, medium, and high fat intake effects of light and gibberellin on elongation of intact wheat coleoptiles experimental magnesium deficiency in the cow thyroid function in chickens and rats: effect of iodine content of the diet and hypophysectomy on iodine metabolism in white leghorns cockerels and long-evans rats kuhmilehallergie beim sgugling und a rapid method for assessing drug inhibition of feeding behavior variation in, and the effects of vitamins on vertieillinm albo-atrnm influence of high level vitamin a supplement on semen characteristics and blood composition of breeding bulls influence of diet on viral hepatitis der einflul] der stiekstoffdfingung auf die zusammcnsetzung yon karf~ffeleiweib insulin response to fructose and galactose the effect of excess vitamin a on the oxygen consumption of young female rats effect of dietary amino acid pattern on plasma ~mino acid pattern and food intake gibbere/lln: effect on diffusible auxin in fruit development effect of intravenous versus oral fat administration in fat-deiicient dogs plasma vitamin bi~ levels in some nutritional deficiency states nutritional factors influencing the conversion of tryptophan to niacin pancreatic hypertrophy and chick growth inhibition by soybean fractions devoid of trypsin inhibitor production, interior egg quality, and some physiological effects of feeding raw soybean meal to laying hens effect of palm jaggeries on the growth and blood and liver composition of albino rats kept on rice and jowa effects of polyphosphates on water uptake, moisture retention, and cooking loss in broilers untersuchungen fiber den ern~hrungsphysiologischen wer~ yon kasein entgegnung zu diskussionsbemerkungen auf einer vortragsveranstaltung der gesellschaft for ern~ihrungsbiologie e. v., mfinchen, am . juni die erg~nzungswirkung yon dl-methionin allein oder in kombination mit l-lysin beim wachsenden schwein der einflul~ der nahnmg auf den kauapparat der einflu der nahrung auf den kauapparat. teil il changes in bone mass and density in living rats during the manipulation of calcium intake effect of chromium, cadmium, and other trace metals on the growth and survival of mice a study of fermentation in the production of mahewu, an indigenous sour maize beverage of southern africa the vitamin b~ deficiency syndrome in human infancy, biochemical and clinical observations lipids in chick urine: the influence of dietary rapeseed oil effects of dietary nitri~ on the chick" growth, liver vitamin a stores, and thyroid weight influence of radioactive sodium- on higher nervous activity of dogs, when chronically administered into the organism in comparatively small doses the change of erythroeyte blood composition in persons with prolonged complete alimentary starvation (without limiting the water intake) and subsequent feeding dental abnormalities in rats attributable to protein deficiency during reproduction the effect of environment, and nutrition of pathogen and host, in the damping off of seedlings by rhizoctonia solani effect of dietary protein on fructose, citric acid, and -nucleotldase activity in the semen of bulls the effect of fluorine on dairy cattle. v. : fluorine in the urine as an estimator of fluorine intake some effects of diet and therapy on the survival and metabolism of adrenalectomized rats effect of methonine and choline deficiency on liver choline oxidase activity in young rats untersuchungen fiber die wasserlssliehen hemmstoffe aus dem chnittholz der weinrebe (vi~is vinifera l.). i. zur wirkung der hemmstoffe auf die keimlmg mad entwicklung yon rebs~mlingen nutrition and palatability. lancek the effect of feeding fluoride on some enzymes of bovine tissues diet and histamine in the rmninant effect of food reflexes on cholinestera~e activity of cortical tissue. federation essential fatty acid deficiency and rat liver homogenate oxidations the effect of vitamin and antibiotic injections on early turkey poult growth and mortality alimentary production of gallstones in hamsters. . studies with rice starch diets with and without antibiotics nitrogen studies with apple and cranberry the influence of diet on the quality of faecal fat in patients with and without steatorrhoea uber die unterschiediiche beeinflussung des tryptophansteffwechsels dutch vitamin b -mangel in der ratte. hoppe-seyler's influence of vitamin b and its coenzyme upon incorporation in rive of amino acids into tissue proteins in rats relativer vitamin b -mangel hei erkrankungen der schilddriise strukturanomalien der z/ihne bei vitamin d-mangel-raehitis und der vitamin d-resistenten renalen rachitis the effect of fluoride on bone effects of insulin on hepatic glucose production and utilization prevention by hydrocortisone of changes in connective tissue induced by an excess of vitamin a acid in amphibia acute hypervitaminosis a in guinea-pigs. i. : effect on acid hydrolases der einfiu~ yon vollkornbrot auf den calciumstoffwechsel bei schulkindern effect of feeding milk replacers with varying amounts of f~ for hothonsc lamb production egg yolk and serum cholesterol levels: importance of dietary cholesterol intake effect of protein intake on glutamic dehydrogenase and amino acid desruination in rive observations in experimental magnesium depletion effect of gibbercluc acid on growth, gibberellin content, and chlorophyll content of leaves of potato ~ physiological factors influencing growth, reproduction, and production of well-fed dairy heifers. i. age at first breeding. ii. feeding of diethytstilbestrol tm~ influence of diet on the development of parotid salivation and the rumen of the lamb bericht fiber den wissenschaftlichen kongreb der deutschen geseuschaft fiir erniihrung influence of variations in dietary calcium: phosphorus ratio on performance and blood constituents of calves the lack of a consistent chick growth response to norwegian kelp meal some effects of kinctin on the growth and flowering of intact green plants incorporation of [, p] orthophosphate into phospholipids of frog tissues during feeding and stmrvation growth-modifying and antimetabolite effects of amino acids in chrysanthemum a study of techniques used by advertisers in dealing with weight control. a national health problem lipid excretion. .: examination of faecal lipids of rats injected intravenously with serum lipoprotcin containing ~ac-labelled cholesterol effect of diet and diabetes on plasma glucose, fatty acid, and insulin effect of cigaret smoking during pregnancy: study of cases. obstetrics gynecology respiration and phosphorylation in live homogenates from rats exposed to hypoxia and food restriction the influence of mi]l~ fat depressing rations on the yield and composition of bovine milk phosphatides and cholesterol in the rat bed: effects of growth, diet, and age the effect of plant nutrients and antagonistic microorganisms on the damp. ing-off of cotton seedlings caused by rhizoctonia solani kurus l~utrition of gram-negative anaerobic bacilli. nutrition rev. effects of glucose on the production by escherichia coli of hydrogen sulphide from cysteine. j. general iylierobiol. enumeration of psyehrophilie microorganisms vitamin requirements of three pathogenic fungi calorie requirements of rat intestinal microorganisms specificity of the salt requirement of halobacterium cutirubrum influence of the aqueous potato extract and its fractions on growth and spore formation of the b. pumilus and the production of the antibiotic tetaine the relationship between hormonal activity and sugar metabolism in protoparce scxta (joka~sen) and blabcrus craniifer bur~ieister apparent incorporation of ammonia and amino acid carbon during growth of selected species of ruminal bacteria l~ber die wirkung anorganischer st~ube auf das wachstum yon mikroorganismen effect of dietary calcium lactate and lactic acid of faecal eseherichia coli counts in pigs uber den einflul des n~ihrsubstrats auf die hemmung des bakterienwachstums durch cyanid autoradiographic studies of the differential incorporation of glycine, and purine and pyrimidine ribosides by paramecium aurelia correlation between the essential amino-acid requirements of staphylococcus aureus, their phage types, and antibiotic patterns nutrition and metabolism of marine bacteria. xii.: ion activation of adenosine triphosphat~se in membranes of marine bacterial cells carbon dioxide fixation in bacillus anthracis bacterial growth under conditions of limited nutrition interrelationship between temperature and sodium chloride on growth of lactic acid bacteria isolated from meat-curing brines morphological variation and nutrition of a new monoeentric marine fungns feeding stimulants required by a polyphagons insect, schlstocera gregaria vitamin requirements of root nodule bacteria phcnotypic, genotypic, and chemical changes in starving populations of aerobacter aerogenes studies on the d-amino acids. ii.: utilization of d-amino acids by lactic acid bacteria role and formation of the acid phosphatase in yeast der einflub yon co~-partia]druck und glucose-konzentration auf wachsturn und stiekstoffbindung yon azotobacter chroococcum bei~ inorganic polyphosphate metabolism in chlorobium thiosulfatophilum effects of molybdenum, vanadium, tungsten, and cobalt on growth of rhizobia and their hosts nutrition of leptospira pomona. ii.: fatty acid requirements sterilization by beta-propiolactone of solid nutrient media for eultivation of moulds the digestion of natural food protein by the elearnose skate raja eglanteria (bose.) utilization of amino acids during metabolism in escheriehia coil the effect of nutrition on the growth of fasciola hepatica in its snail host cobamide coenzyme contents of soybean nodules and nitrogen fixing bacteria in relation to physio]ogical conditions determination of carbohydrate metabolism of marine bacteria the amino acid requirements of various types of shigella mushroom culture. factors affecting the growth of morel mushroom myecelium in submerged culture lebensmittelzusatzstoffe und mutagene wirkung. vii. : priifung einiger xanthen-farbs~offe auf mutagene wirkung an escherichia coll the biological control of glycogen metabolism in agrobaeterium tumefaeiens the maintenance requirement of escheriehia coll methionine requirement for growth of a species of mieroeoecus ~iorphogenesis and nutrition in the memnionella-stachybotrys group of fungi viable organisms from feces and food-s~uffs from early antarctic expeditions the metabolism of yeas~ sporulation. v. : stimulation and inhibition of sporulation and growth by nitrogen compounds the effect of lipids on citric acid production by an aspergillns niger mutant relationship between deuterium inhibition of growth and glucose catabolism in saecharomyees cerevisiae function of trehalose in baker's yeast (saccharomyces cerevisiae). arch. biochem preparation and lyophilization of colicine suspensions. i. production of eolicines in liquid nutrient media lvber den einflub der kulturbedingungen auf die stramenempfmdliehkeit der glueoseoxydation in baeterium cadaveris nutritional requirements and metabolism of myeoplasma laid-lawil j. gen. microbiol. die wirkung subletaler konzentrationen yon sorbinsi~ure auf escherichia coli und aspergillus niger the genetic analysis of carbohydrate utilization in aspergillus nidulans the amino acid nutrition of respiration deficient and respiration competent saecharomyces. a. van leewenhoek nutritional studies of some membem of mucorales. iv.: . sugars, amino-, and organic acids of the myceaium selektivn~hrboden fiir staphylokokken effects of certain amino acids in anthranilate production in neurospora crassa studies on the polysaccharide-fermenting lactic acid bacteria. in. : nutritional requirements and the existence of fermentation promoting factors for sucrose and inulin the catabolism of proteins and nucleic acids in starved aerobacter aerogenes aerobic fermentation and the depletion of the amino acid pool in yeast cells influence of hydrogen ion concentrations on the utilization of sodium nitrite by fungi oxidative metabolism of glucose in leaf tissues infected with tobacco mosaic virus differential effects of amino acid deficiencies on bacterial cytochemistry nutritional requirements of an aspergiuus niger mutant for citric acid production culture de tissus d'insectes ~, l'aide d'extrait d'embryon de poulet en l'absenee d' h molymphe. c. r. acad utilization of some carbon and nitrogen sources by pseudomorms fluorescens on the selection of microorganisms for use in bacterial fertilizers in vitro and -rive uptake of carbon- labelled alanine and glucose by ascaridia galli, parasitic nematode of chickens growth of psychrophiles. i. : lipid changes in relation to growgh-temperature reductions vitamin requirements of listeria monoeytogenes parasitism and nutrition of gonatobo~rys simplex the effect of alkali metals on the growth of staphylococcus pyogenes the uptake of potassium and rubidium by staphylococcus pyogenes metabolism of nucleic acids and of nucleotides in the course of synchronous development of azotobacter vihelandii studies on the biotin-oleie acid requirements of a lactobaeillus plantarum variant isolated from chick feces unusual response to iron-dextran. brit. *ned. j. , nr. , s. . +in'. n.: tissue trypsin and trypsinogen levels in pancreatitis skeletal development of suckling kittens rate of liver regeneration atherogenesis in the monkey the significance of serum triglyeerides anaemia and parasitism in man physiological mechanisms in nutritionally-induced differences in ovarian activity of mature ewes bone development in suckled pigs production performance of artificiauy and non~r~ifically sired herd-mates in wisconsin search for an unidentified nutrient in mammalian liver. part i.: growth studies with various ox liver preparations proline control of the feeding reaction of cordylo-phora relationship between longevity and production in holstein-friesian cattle circadian adrenal cycle in c mice kept without food and water for a day and a half metabohc pmduc~s form labelled ethanol. iv. : disappearance of ethanol-carbon from morphological fractions and lipids of rat tissues acetate utilization by maize roots vajda, ] . : i~c~sll-rcs of body fat and hydration in adolescent boys some characteristics of a proteolytic enzyme system of pseudomonas fluorescens some metabolic relationships between host and parasite with particular reference to the eimcriae of domestic poultry nucleotide degradation in the muscle of iced haddock (gadns aeglefinns), lemon sole (pleuronectes microcephalus), and plaice (pleuronectes platessa) effect of starvation and -mcthylprednisolone (m_edrol) on the acid phosphatase of rat liver and muscle metabolic patterns in preadolescent children. vii. : intake of niacin and tryptophan and excretion of niacin or tryptophan metabolites biochemical changes in fish muscle during rigor morris studies on ornithine synthesis in relation to benzoic acid excretion in the domestic fowl effect of manual total collection of feces upon nutrient digestibilities polarographie studies on storage of meats. xxii. : influence of proteolytic enzymes on the polarographie wave of beef protein solutions post-mortem changes in chilled and frozen muscle genetic-nutritional interactiions as affecting the early growth rate of chickens effect of unequal milking intervals on lactation milk, milk fat, and total solids production of cows changes with age in glutamic oxalacetic transaminase activity of sonically oscillated tureen juice compared to total steam volatile fatty acids in calves fed different roughages catecholamine metabolism and some functions of the nervous system a study of some of the conditions affecting the rate of excretion and stability of creatinine in sheep urine changes in feeding behavior after intracerebral injections in the rat kanzcrogene substanzen in wasser und boden food additives and contaminants and cancer milk allergy in infancy food poisoning due to salmonella cnteritidis vat the mineral element content of spring pasture in relation to the occurrence of grass tetany and hypomagnesaemia in dairy cows insecticide residues in meat. residues in body tissues of livestock sprayed with sevin or given sevin in the diet over de giftigheid van solanum-alkaloidcn toxic products in groundnuts zur beziehung zwischen lipidcn hepatotoxicity of foods: a consideration of the hepatotoxicity of a few phanerogams and eryptogams. their possible influence in the pathogenesis of cirrhosis and hepatoma food-poisoning potential of the enterococei vanadium. excretion, toxicity, lipid effect in man an institutional food-poisoning outbreak examination of market milk of novokuznctsk for brucellosis an outbreak of food poisoning in a mental hospital food allergy as a cause of abdominal pain radioactivity in the diet the effect of microbial contamination on the requirement of chicks for certain nutrients the acute oral toxicity of cottonseed pigment glands and intraglandular pigments sur l'absorption du edsium radioactif par rorge. c. r. hebd. s ances aead die experimentelle alimentiire lebernekrose a]s empfindlicher indikator bei thermiseher belastung der milch. uber die magermilehtroekntmg the comparative toxicity of ethylene dibromide when fed as fumigated grain and when administered in single daily doses repository polyvalent insect antigen treatment for patients sensitive to hymenoptera. a clinical evaluation precursors of carcinogenic hydrocarbons in tobacco smoke toxin production in naturally separated liquid and solid components in preparations of heated surface-ripened cheese inoculated with clostridium botulinum allergieversuehe am tier zur ~tiologie der sogenannten margarinekrankheit. dr. reed. wschr. [ ] nr. , s. / . --, allergenwirkung oder immunologisohe adjuvanswirkung in der ~tiologie der sogenarmten margarinekrankheit radium- in human diet and bone miodine in the thyroids of north american deer experimental groundnut poisoning in pigs cholesterol as carcinogen safety factors in water fluoridation based on toxicology of fluorides entelo epidemiologische gegevens over her ,planta-exantheen" te rotterdam, verkregen door enquetc-onderzoek planta-~x~ntheem" epidemie te rotterdam in de m~nden ~ugnstu~ en september salmonella-verontreiniging van plantaardige grondstoffen veer voedingsmiddelen van mens en dier increase of strontium- and caesium- sodium fluoride intoxication salmonellosis in the netherlands zwei seltene salmonellenfunde untersuehungen fiber die chronisehe toxizit~t der ascorbins~ure bei der ratte captan in green vegetables rfickst~nde yon pflanzenschutzmitteln, insektiziden mid dergleichen in der nahrung und ihre bedeutung ffir die gesundheit der gehalt der milch an j, ,~co ' u ba _{_ la in der deutschen )iileh in der zeit yon langfristige nutritive anwendung yon antibiotika in der tierern~hrung im hinblick auf die menschliche gesundheit mi~ besonderer beriicksichtigung yon chlortetrazyklin a milk-borne outbreak of food poisoning due to salmonella heidelberg ergebnisse yon schwebversuehen an farbstoffen zur farbmattierung yon tabakwaren nutritional secondary hyperparathyroidism of the cat insecticide residues in fat. a screening method for chlorinated pesticide residues in fat without cleanup untersuehungen fiber die quantitative verteilung radioaktiver falloutprodukte in milch too many vitamins radios~ron$ium removal from milk. determination of apparent equilibrium constants of the exchange reactions of sodium, potassium, calcium, and magnesium with amberlite ir- ern~hrungsphysiologische eigenschaften der margarine. fette, seffen, anstrichmittel smoking and cancer: retrospective studies and epidemlologieal evalution beobachtungen fiber den verlauf der alkoholkrankheit am krankengut einer heilanstalt die verschmutzung yon trinkwasser dutch i)etergentien grain fumigant residues. occurrence of bromides in the milk of cows fed sodium bromide and grain fumigated with methylbromide insecticide persistence. the disappearance of endrin residues on cabbage lebensm ittelchem u. gerichtl reproductive performance of female miniature swine ingesting strontium- daily toxicity of nitrate nitrogen to cattle methods of residues of phosphated insecticides and miticides in foods on bacillary excretion in food toxinfections of salmonella etiology relationships between the deposition of strontium- and the contamination of milk in the united kingdom staphylococci in cottage cheese is~cs and potassium in people and diet. -a study of finnish lapps effect of treatment of seeds with -chloroethanol on the resistance to boron toxicity in wheat seedlings desferrioxamin, eine neue das eisen bindende und eliminierende substanz zur behandlung der rim~rcn und sckund~ren i-i~mochromatose akuter eisenvergiftungen toxic products in groundnuts smoking, arteriosclerosis, and age the incidence of milk sensitivity and the development of allergy in infants einflul] yon fluor und jod auf den stoffwechsel, insbesondere auf die schilddrtise quelques exemples illnstrant la valour et l'utllit des m~thodes de lysotypie clans certaines salmonelloses humaines d'origine alimentaire food poisoning caused by panthogenic halophilic bacteria (pseudomonas enteritis txkikawa): %ep rt of four autopsy cases procaine penicillin g in milk following intramuscular injections comparative subacute toxicity for rabbits of citric, fumaric, and tartaric acids distribution of pesticides in fermentation products obtained from artificially fortified grape musts mercurial fungicidal seed protectant toxic for sheep and chickens the problem of salmonella food poisoning dietary factors in the pathogenesis and treatment of cirrhosis of the liver. med. clinics of north america an outbreak of salmonella food poisoning in l~ehmadabad town, kaira i)istxiet, gnjaxat ~a~e la tossinfezionl alimentarl da salmonella nell' spedale maggiore di milano dal al water intoxication due to oxytocin: reporb of a case c~sium- und kalium in menschlichen organen und in der milch / caesium- in dried milk produets in relation to phytoellmatic zones smoking and oral cancer occurrence of hepatomas in rats fed diets containing peanut meal as a major source of protein nachweis yon mangan- und kobalt- in pflanzen als fo]ge russischer kernwaffenvcrsuche e-ruhr-epidemie durch speiseeis bcricht fiber eine arbeitstagung bei der internationalen atomenergic-behsrde in wien vom . bis . i)ezember . i)t. lebensmittel-rdsch the development of microbiological standards for foods. j. milk food technol a case of breslau salmoneliosis caused by eating chicken internationales rundgespr~ch fiber lebensmittelchemische probleme in wiesbaden und eltvllle a. rh. ( vortragsreferate) staphylococcal infection of raw milk as a cause of food poisoning. monthly bull. ministry health pub carcinogenic effect of egg white, egg yolk, and lipids in mice eczema and cow's milk exitus letalis nach lebensmittelvergiftung dutch bacillus cereus repression of staphylococcus aureus by food bacteria. ii. : causes of inhibition a further report on the radioactive contamination of milk and milk products in japan. determination of strontlum- and cesium- concentrations in milk powder in japan concerning sporadic salmonelloses insecticide residues. extraction and cleanup studies for parathion residues on leafy vegetables salmonellosis epidemiology zur frage der deponierung yon nutrltiven allergenen im organismus. allergic, _~sthma allergic children with various symptoms caused by cows' milk messungen der umweltsradioaktivit~t und der radioak-tivit~t yon lebensmitteln im jahre ein cxperimenteller bcitrag zur tabakrauehkanzerogenese. dr. reed. wschr. [ ] nr. . u n. : contamination of leaves by radio active fall-out insecticide residues in milk and meat. residues in butterfat and body fat of dairy cows fed at two levels of kelthane ( . and insecticide residues in milk. residues in milk from dairy cows fed low levels of toxaphene in their daily rations tier-und pfhnzenerniihrnug _anlrnal and plant nutrition summary of ,tropical crops soil, analysis, and its relation to plant composition and growth fertilisers and plant nutrients ulcers in swine tnfluence of chelating agents on the concentration of some nutrients for plants growing in soil under acid and under alkaline conditions nutritional evaluation of permanent pastures with dairy cattle in louisiana the herbage intake of eattle grazing lucerne and cocksfoot pastures terminology and methods for feeding and weighing animals the effect of feeding on evaporative heat loss and body temperature in zebu and jersey heifers studies on the requirements and interaction of copper and iron in broad breasted bronze turkeys to weeks of age some factors affecting iron uptake by strawberry plants feed consumption during lactation and involution in sprague-dawley-rolfsmeycr rats the effect of variations in the energy and protein levels of the ration upon performance in the pig use of barley in high-efficiency broiler rations. . poultry sci tierarzncimittcl und aufzuchtmittel in der landwirtschaftlichen praxis. gesund. heitliche erwggungen zum schutze des konsumenten bei der anwendung yon tierarzneimitteln und aufzuchtmitteln in der landwirtschaftlichcn praxis, tell ii mechanism for movement of plant nutrients from soil and fertilizer to plant root growth rate of the tea leaf as determined by shade and nutrients. empire j. exper note on induction of flowering in ~railing shoots of clones of saccharum spontaneum effect of level and sequence of feeding and breed on ovulation rate, embryo survival, and fetal growth in the mature ewe evidence for a high zinc requirement at the onset of egg production aufnahme und wirkung des mikronghrstoffs knpfer in ionogencr und ehelatisierter form bei gerste effects of pelleting and varying grain intakes on milk yield and composition the relationship of gibberellic acid to flower initiation in column stock, math~ela incana the effect of selenium administration on the growth and health of sheep on scottish farms the horsebean (vicia faba l.) as a vegetable protein concentrate in chick diets size and feeding of different types of fishes the influence of age of chicks on their sensitivity to raw soybean oil meal influence of the mineral nutrition on the resistance of peach trees to fusicoceum amygdali de la croix granular fertilizer. influence of associated salts on plant response to dicalcium phosphate a comparison of feeding growing pigs once or twice daily the interrelation of nutrient supply, leaf nutrient content, and vegetative growth of ilcx crenata 'green island' effect of rationing grass on the growth rate of dairy heifers and on output per acre, with a note on its significance in experimental design experiments on the nutrition of the dairy heifer. iv.: protein requirements of -year-old heifers grass silage vs. hay for lactating dairy cows hay vs. silage for two to six months old dairy calves weaned at or days effects of high levels of copper and ehlortetracycline on performance of pigs seedlings resistance of corn to leaf feeding of the european corn borer ostrina nubflalis ease of hydrolysis of the hemieeiluloses of forage plants in relation to digestibility bodenkde. [ ] mr. , s. / . --caleium-mangelsymptome an h heren pflanzen effects of frequency of feeding on urea utilization and growth charae%oristics in dairy heifers factors affecting the voluntary intake of foods by cows. . : a preliminary experiment with ground, pelleted hay the relationship of dietary energy level and density to the growth response of chicks to fats salt tolerances of pinus thunbergii compensatory carcass growth in steers following protein and energy restriction a guide to production, care, and use of laboratory animals. federation prec. estimation of essential fatty acid intake in swine automatic dispensing at frequent regular intervals of liquid diet for piglets chelation in nutrition. chelates and the trace element nutrition of corn der einflul yon humuss~ure auf wachstum und ver~inderungen des freien zuekergehaltes bci winterweizenpflanzen, die im dtmkeln kultiviert wurden a comparison of the growth of chicks in the gustafsson germ-free apparatus and in a conventional environment, with and without dietary supplements of penicillin an evaluation of weed competition and the effects of weed extracts and leachates on the development of field corn (zea mays l.) and oats (arena sativa l digestibility of rations containing different sources of supplementary protein by young pigs the effects of urea supplements on the utillzation of straw plus molasses diets by sheep production performance of artificially and nonartifieiallysired herd-mates inwiseonsin dietary phosphorus for laying hens tolerance to acid soil conditions in barley effect of calcium and magnesium upon digestibility of a ration containing corn oil by lambs effects of caloric restriction during the growing period on the performance of egg-type replacement stock untersuchungen fiber die verwertung yon calcium-und phosphorsalzen aus fisehgr~itenmehl einigcr frischfische und fischkonserven bei der verffitt~rung a nut~rient requirement for optimum water absorption by intact root systems preparation of feed for animal nutrition experiments responses of winter wheat to nitrogen and soil nitrogen status studies on calcium requirements of broilers znm problem dcr nahrungspflanzenwabl der aphiden some factors affecting leaf development and longevity and the subsequent yield of corn grain efficiency of energy utilization by young cattle ingesting diets of hay, silage, and hay supplemented with lactic acid the effects of a plant steroid on body weight and feed efficiency of broilers feeding troughs for guinea-pigs beitrag zur ]~ackfruchtmast mit schweinen unter besondercr beriicksichtigung des n~hrstoffgehaltes der beifuttermischungen und der the feeding of thyroprotein to lactating sows zur planung, durchfiihrnng und auswertung yon schweinemastvcrsuchen bei gruppenfiitterung the influence of barbituric acid derivatives on the development of plant roots and root hairs factors affecting the voluntary intake of food by cows. .: the relationship between the voluntary intake of food, the amount of digesta in the retieulo-rumen, and the rate of disappearance of digesta from the alimentary tract with diets of hay, dried grass or concentrates artificial food for oak-silkworm raising the comparative toxicity of ethylene dibromide when fed as fumigated grain and when administered in ingle daily do~ ~ gibberellin at the vineyard oak wilt development and its reduction by growth regulators. i. production and activity of oak wilt fungus pectinase, ecmulase, and auxin. ii. effect of halogenated benzoic acids on oak trees, the oak wilt diseases, and the oak wilt fungus regulating nutrient intake in laying hens with diets fed ad libitum some effects of different soils on composition and growth of sugar beet production of fodder yeast from barley. i. preliminary studies on the use of the waldhof fermenter development and nutrition of new species of thranstochytrium studies on the effect of frequency of feeding upon the biology of a rabbit-adapted strain of pediculns humanus the influence of previous vitamin k nutrition on thromboplastie activity of brain extract the effect of nutrition conditions on the growth of and nitrogen accumulation by fodder beans when sown together with indian corn. i)oklady akad. nauk sssr dutch phenylbors~ure induzierte fragen der resistenzsteigerung in der modernen gefliigelhaltung chelation in nutrition. metal chelates in plant nutrition beziehungen zwischen dcm kupfergehalt und dem zeitlichen auftreten yon kupfermangelsymptomen an hafer in wasserkultur mit kleincn bodenmengen increased tolerance of bean plants to soil drought by means of growth-retarding substances effect of monocaleium and diammonium phosphates on crop yield, and their influence on soil solution movement and characteristics when associated with different salts effect of barbituric acid and ehlortetraeyeline upon growth, ammonia concentration, and urease activity in the gastrointestinal tract of chicks effects of feeding low levels of dimethoate on milk and on whole blood cholinesterase activity of dairy cattle die ziichtung von fleischschweinen und die folgeerscheinungen, die sich besenders im hinblick auf die qualit~t yon fleiseh und fett ergeben the relationship of specific nutrient deficiencies to antibody response in swine. i.: vitamin a. ii.: pantothenie acid, pyridoxine or riboflavin further studies of diet composition on egg weight effect of various levels of fluorine, stilbestrol, and oxytetraeycline, in the fattening ration of lambs studies on the properties of l~ew zealand butterfat. viii. the fatty acid composition of the milk fat of cows grazing on ryegrass at two stages of maturity and the composition of the ryegrass lipids soil potassium and the growth of vegetable seedlings artificial feed for silkworm, bombyx mori some effects of feeding stilbestrol, ehlortetracyeline, and penicillin with alfalfa soflage on steer performance and carcass quality food agric. [ ] nr. , s. / . --, mineral supplements for sheep the influence of higher volatile fatty acids on the intake of urea-supplemented low quality cereal hay by sheep untersuehungen fiber den umsatz waehsender sehweine ab geburt. . mitt growth of edible emorophyllous plant tissues in vitro chelates in agriculture. metal chelation by glucose-ammonia derivatives economic analysis of high-level grain feeding for dairy cows evaluation of the dacron bag technique as a method for measuring cellulose digestibility and rate of forage digestion n~ihrlssungen fiir zuckerriiben in wasser-und sandkultur activity of gibbereuin:'d' on the germination of photosensitive lettuce seeds raw and heat-treated soybeans for growing-finishing swine, and their effect on fat firmness ration effects on tureen acids, ketogenesis, and milk composition. i.: unrestricted roughage feeding a new growth stimulant, ~ growth hormone the effects of specific viruses, virus complexes, and nitrogen nutrition on the growth, flowering, and mineral composition of strawberry plants peculiar feature of respiration and redox processes in the rice plants grown under different nutritional conditions einflul] der silagefiitterung auf die qualit~t yon milch und milchprodukten. . mitt. : einflul] der silagcfiitterung auf die organoleptischen eigenschaften dcr milch effect of grinding and pelleting on the utilization of coastel bermuda grass hay by dairy heifers langfristige nutritive anwendung yon antibiotika in der tierernlihrung im hinblick auf die menschliche gemmdheit mit besonderer beriicksichtigung yon chlor-te~azyklin mode of action of growth retarding chemicals yield of sugarcane in louis-ana as influenced by soil moisture status and climate diss effect of auxin on the emergence of lateral roots in p. mungo seedlings compound mouse diets a semipurified caries-test diet for rats present status of feeding antibiotics to htctating dairy cows effect of sodium bicarbonate in the drinking water of ruminants on the digestibility of a pelleted complete ration semi-purified diets for sheep effect of vacuum-drying, freeze-drying, and storage environment on the viability of pea pollen. ii. : effect of boron, sucrose, and agar on the germination of pea pollen hshe und zeitpunkt der diingung yon sommerweizen mit chlorcholinchlorid zur verkiirzung der halml~nge nutritional signifieance of soluble nitrogen in dietary proteins for ruminants primary signs of nutritional deficiencies of laboratory animals ]~ffe[~b of dlctary pro~in and fat on growth, protein utilization, and carcass composition of pigs fed purified diets trans-fetts~iuregehalt yon schweineschmalz nach fiitterung yon sehweinen mit rindertalghaltigem kraftfutter. (ein beitrag zur quantitativen infrarotspektroskopischen bestimmung yon trans-fetts~uren in fetten effect of liming and potassium fertilization on soil solution and on yield and composition of alfaffa and orchard grass mixtures effects of feeding various milo, corn, and protein levels on laying performance of egg production stock effect of gibberellie acid on flowering of apple trees the effects of dietary fat and energy ]evels on the performance of caged laying birds effect of age on the response of chickens to dietary protein and fat chemical control of flowering. concentration of a floral-inducing entity from plant extracts strontium- and calcium in milk of miniature swine studies on the properties of newzealand butterfat. vii. effect of the stage of maturity of ryegrass fed to cows on the characteristics of butterfat and its carotene and vitamin a contents new radioactive tests show how termites feed mechanisms regulating the feeding rate of daphni~ magna straus influence of low protein rations on growth and semen characteristics of young beef bulls a study of zinc deficiency in the dairy call effects of different levels of zinc and phosphorus on the growth of subterranean clover (trifolium subterraneum l.). australian j. agrie absorption, translocation, exudation, and metabolism of plant growth-regulating substances in relation to residues the effect of the performance of growing pigs of the level of meal fed in conjunction with an unrestricted supply of whey increase in yield of legumes by fer~iliser mixture with lime chemically defined medium for growth of animal cells in suspension dis sieherung der eiweiljwrsotgung in dor l~ndwirt influences of previous calcium and phosphorns intake and plant phosphorus on the requirement of developing turkeys for calcium and phosphorus relationship between isotopicauy exchangeable calcium and absorption by plants effect of adding buffers to all-concentrate rations on fcedlot performance of steers, ration digestibility, and intrarumen environment lysine supplementation of corn -and barley-base diets for growing-finishing swine the effect of gibbereliin on the germination of seeds of arboreal plants effect of physical state of coastal bermuda grass hay on passage through digestive tract of dairy heifers nitrate reduction and carotene stability. effect of nitrate and some of its reduction products on carotene stability, d. agric. food chem chemical preparations for plant protection untersuchungen fiber die ksrperzusammensetzung und den stoffansatz waehsender mastschweine und ihre beeinflussung dutch die erniihrung. . mitt the cobalt requirement of sub-~erranean clover in the field comparing mile and corn in broiler diets on an equivalent nutrient intake basis effect of mineral nutrition on the invasion and response of turnip tissue to plasmodiophora brassicae wor the relation of chlorogenic acid and total free phenols in potato plants to resistance to infection by verfieillium alboafxum nitrogen and potassium as variables influencing soluble nitrogen and organic acid accumulation in soybean (glyoine max). di~s. abstr. bett~r british beef and barley feed. veter effect of nitrogen fertilization upon yield and digestibility of aftermath timothy forages fed to dairy heifers ration effects on dltlot steer feeding patterns effects on zea mays seedlings of a strontium replacement for calcium in nutrient media evaluation of albumen quality in a poultry breeding program nutritional studies with the guinea-pig. viii. : effect of different proteins, with and without amino acid supplements, on growth some effects of heredity and environment on appetite in dairy animals further studics on manganese nutrition of tobacco in relation to virus infection and synthesis amillo acid supplementation of pig diets chelation as a basic biological mechanism der einflu~ der stiekstoffdiingung auf die znsammensetzung yon kartoffeleiweiil z studies on photosynthesis. i. : biosynthesis of sucrose from glycolate. par~ ii. : bicarbonate utilization by washed algae production, interior egg quality, and some physiological effects of feeding raw soybean meal to laying hens alteration of post-mortem changes in porcine muscle by preslaughter heat treatment and diet modification chelation in nutrition. soft microorganisms and soil chelation. the pedogenie action of lichens and lichen acids die ergiinzungswirkung yon dl-•ethionin allein oder in kombination mit l-lysin beim wachsenden schwein untersuchungen iibcr den einflub unterschiedlicher wasservemorgung auf ertr~ge, gehalte an ~therischem , trenspirationsquotienten, biattgrsl~en und relative ~)ldriisendichtsn bei einigen arten aus der familie der labiaten. . teil gehalte an iitherischem , transpirationsquotienten, blattgrsflen und relative -driisendichten bei einigen arten aus dcr familie der labiaten. iii.: blattgrsflen, relative driisendichten, anzahl am haupttricb inseriertcr blattpaare und internodien. liingen cadmium: uptake by vegetables from supcrphosphate in soil studies on the protein and methionine requirements of young bobwhite quail and young ringnecked pheasants chelation in nutrition. evidence for natural chelates which aid in the utilization of zinc by chicks selective fertilization of apple-trees some soils and fertilizer relationships of the cavendish banana (muss cavendlshl lambert) on three different soils in costa rice soil organic phosphorus and the phosphorus nutrition of plants the effect of heat treatment on the nutritive value of milk for the young calf. . : a comparison of spray-dried skim milks prepared with different preheating treatments and roller.dried skim milk, and the effect of chlortetracyclinc supplementation of the spray-dried skim milks the effect of heat, ~reatmen~ on the nutritive value of milk for the young calf. . :the effect of the addition of calcium a biological assay for metabolizable energy in poultry feed ingredients together with findings which demonstrate some of the problems associated with the evaluation of fats feed additives in livestock rations: part i. : urea in dairy rations. part.i/: use of thyroprotein in cattle nutrition diet and histamine in the ruminant synthetic ion-exchange resins as a medium for plant growth nutrition of vibrio fetus theoretical basis of unicellula algae cultivation amino acid supplementation of barley diets for growing swine some effects of . -dichiorophen-oxyacetic acid on swect corn (zea ]~ays rugosa l.) with emphasis on yield, tillering, root development, and exudation of electrolytes from roots and stems. i)iss. abstr feeding and management of broiler strain breeder hens relationships among seven elements in the nutrition of corn in sand culture an external effect of inorganic nitrogen on nodulation influence of enzyme supplements in lamb fattening rations gravenstein and jonathan apples produced with giberellle acid the role of carotene in the dairy cow. wiss. ver ff. dr. ges. ern~hrung vitamin a-wirksamkeit der carotine bei versehiedenen tierarten. wiss. ver- ff. dt. ges. eru~hrung upgrading the indigenous poultry of uganda. i. : the growth rates and feed conversion from hatching to maturity of indigenous poultry crossed with four imported breeds effect of different kinds of litter on growth and feed efficiency in chick rearing investigation of the mineral nutrition of datura innoxia the effect of flooding in the availability of phosphorus and on the growth of rice nutrition of the boll weevil larva ascorbic acid in the nutrition of plant-feeding insects effects on the s~maeh worm, i-iaemonehus contortus, of feeding lambs natural versus semipuriiicd diets yield and foliar composition of corn as affected by fertilizer rates and environmental factors. i)iss. abstr. ~ [ ] nr praktische erfahrm]gen in der carotinoidversorgung yon vsgeln effect of protein-energy relationship on the performance and carcass quality of growing swine the use of quarter samples in the assessment of the effects of feeding treatments on milk composition * calcium and phosphorus requirements of finishing broilers using phosphorus sources of low and high availability amino acid supplementation of peanut meal diets for broiler chicks the effects of feeding various levels of vitamin a on chicks with cecal coccidiosis chelation in nutrition. review of chelation in plant nutrition water use by irrigated arabia coffee in the failure of certain dietary ingredients to affect the incidence of blood spots in chicken eggs dcr einflul~ der anbauverh~ltnisse auf die eigensehaften der kartoffelknolle und der st~rke effect of feeding milk replacers with varying amounts of fat for hothouse lamb production l~hysiologieal factors influeneelng growth, reproduction, and production of wcll-fed dairy heifers. i. ago at first breeding. ii. feeding of diethylstflbestrol results of an experiment ot rothamsted testing farmyard manure and n, p, and k fertilizers on five arable crops. i. : yields results of an experiment at rothamsted testing farmyard manure and n, p, and k fertilizers on five arable crops. ii.: nutrients removed by crops the utilization of carotenoids by the hen and chick some effects of potassium and lime on the relation between phosphorus in soil and plant, with particular reference to glasshouse tomatoes, carnations, and winter lettuce the lack of a consistent chick growth response to norwegian kelp meal further studies on protein and energy requirements of chicks selected for high and low body weight some effects of kinetin on the growth and flowering of intact green plants individual feed consumption of turkey breeder hens and the correlation of feed intake, bocly weight, and egg production crop analysis technique for studying the food habits and preferences of chickens on range supplemental value of turkey protein for wheat herbicides and plant growth regulators preparation of purified ration for chick. parg iv. : preparation of crystalline amino acid diet evaluation of algae as a food for human diets the influence of milk fat depressing rations on the yield and composition of bovine milk the effect of plant nutrients and antagonistic microorganisms on the damping-off of cotton seedlings caused by rhizoetonia solani kukn ki;-;sehe ern~ihrung und di~tetlk clinical nutrition and dietetics a statement approved by the board of directors of the canadian heath foundation radioactivity and human diet probleme der ern~hrung durch gefrierkost. sympomum der d utschen gcgell~ehaft ffir ernghrung veto . bis . mgrz klinische ernghrungslehre" und wissenschaftlicher kongreb der deutschen gesellschaft flit ern~hrung an der johannes-gutenberg-universit~t mainz veto . bis wissenschaftlicher kongreb der deutsehen gesellschaft ftir ern~hrung an der johannes-gutenberg-universit~t mainz am . und ernghrung nnd digit" . deutseher kongreb ffir ~irztliehe fortbildung in berlin veto . bis arbeitstagung fiber klinisebe ernghrungslehre. ern~ foods of the future (forts.). problems in space foods and nutrition. foods for extended space travel and habitation the question of fats. ii.: fats and disease behandlung fettbedingter gerinnungsstgrungen mit lipostabil sugar and dental caries obesity and sugar addiction hunger and malnutrition lancet nutrition and general practice bericht fiber die vortragstagung des fachverbandes lebensmittelchemie der chemischen gesellschaft in der ddr vom arbeitstagung fiber kommission ffir volksern~hrung, lebensmittelgesetzgebung und -kontrolle (eek) zu yi~inden des eidg the national diet-heart study low fat diet in familial mediterranean fever the thyroid gland in infant malnutrition evaluation of fao amino acid reference pattern studies on the physiology of nutrition in surinam rickets in southern israel diet and heart disease maiskeims in ernt~hrung und ditltetik apha conference report safe and nutritious food supply malnutrition and disease expert committee on medical assessment of nutritional status protein malnutrition the fat tolerance curves of patients with hyperllpidcmia and athcrosclcrosis die lactose im rahmen der ernt~hrung effect of environment on nutritional status zur theorie und praxis der zuckerkrankheit. wiener z dietetically induced experimental flous of rats physikalisch-diiitetische therapie yon hautkrankheiten. arch. phys. therapie err~hrungsforschung [ / ] :nr. , s. / . +bo rtiw~l, p. w. : milk-borne disease consumers' reactions to instand foods de voeding van woonwagenbcwoners experimental investigations on nutrition and human behavior. a post-script. amer di~tetische therapie der chronischen herzinsuffizienz construction and validation of the food attitude scale why we have a safe and wholesome food supply use of food in a psychiatric setting stature and nutrition in cystinuria and hartnup disease ])as endokrinologisehe syndrom des proteinmangels urinary excretion of . -dlhydroxyphenylalanine (dopa) in two children of short stature with malnutrition current problems affecting consumption of milk and indnstry's response to them preparedness for emergency feeding fluoridation and public relations dieetprodukten in vlaanderen incorporation of labelled glycine into erythrocyto glutathione of rabbits; effect of nutritional muscular dystrophy hot wcreldvoedselvraagstuk sniker -glycogcen -tandbederf dietary in take in patients with arthritis and other chronic diseases a clinical trial of iron-fortified bread effects of freater intake of milk, fruits, and vegetables joint fao/w/to expert committee on nutrition" fiber eine sitzung in genf vom . his serum cholesterol in a military population. its relation to obesity and the military diet ). ~z~, a. c. some nutritional problems of older age groups neuere biochemisehe untersuchungen zur diagnostik und therapie yon b-vitamin-mangelzust~nden call-harvard nutrition project. iii.: the erythroid atrophy of severe protein deficiency in monkeys cali-harvard nutrition projeet. ii. : the erythroid a~rophy of kwashiorkor and marasmus zur hshe des erwiinsehten fottverbrauehs ern~hrung des sportlers voeding moderne ern~hrungsbedarfsnormen. i. mitt. z. ges. hyg. [ ] nr. , s. . *--~ioderne ern~hrungsbedarfsnormen. . mit~.: z. ges. hyg. a comprehensive home-care program for the chronically ill fat-modified foods for serum cholesterol reduction besonderheiten der ern~hrung alter menschen chronic malnutrition in turkey. v. studies on serum fatty acids in malnourished children prevention of ,meat anemia" in mice by copper and calcium beeinflussung der sportlichen leistungsfdhigkeit dutch eine geeignete er-n~ihrung physiology of adolescence. ii, l~u-trition -basal oxygen consumption -energy expenditure and balance -nitrogen metabolism -calcium metabolism -iron metabolism -red cell mass and hemoglobin ern~hrungsproblemc bei chirurgisehcn kranken. wiss. versff. dr. ges. ern~hrung moderne vitamin b~-therapie: oral, rektal oder parenteral ? a palatable diet for producing experimental folate deficiency in man smoking in hospital was ist hungern und was heibt the cultivation of tflapia. this prolific fish as a fine source of proteinrich food in underdeveloped areas pyridoxine supplementation during pregnancy. clinical and laboratory observations on japanese foods nutritional sequelae of ga~trio surgery koehsalzarme kost und nierenerkrankungen theoretische und praktische grundiagen der ernilhrung in der fett in der diabeteskost foods or supplements? g zur hygiene und ,di~tetik des rauehens zur dis behandlung der uremic anaphylactie shock of the lungs triggered by mieroaspiration of cows' milk: a form of sudden unexpected death in early infancy the food service industry and its relation to the control of foodborne illness die konservative therapie des peptischen gesehwiirs gezondheid op reis addictive aspeeta in heavy cigarette smoking die ern~hrung im rahmen de~ heilvers im kurort the diet in renal faiiure is the rationale for gaetrointestinal diet therapy sound? familie-beruf-ern~hrung die dfiitbehandiung der leberkrankheiten. i)t. reed vom hunger his zum ~beritul -weltweite ern~hrungsprobleme die bedeutung der vitamine in der t~tglichen erniihrung s~ure-und baseniibersehiissige naln'ung. therapiewoehe [ ] nr. , s. / . --ss und chronische acidogene und alkalogene erns z. em~hrungswiss industrial lunches and public health the assessment of nutritional status in man: chairman's opening remarks therapie der essentiellen hypertonie speeifieke voedings-en voorlichtingsproblemen in tropische landen wie kann man unsere kos~ und unsere kostgewohnheiten beeinflussen? neue konzeptionen in der wasser-und salzsubstitution some aspects of the relation of nutrition and pregnancy is coronary heart disease preventable? world hunger demineralization of whey. use of its protein in infant feeding elaidinized olive oil and cholesterol atherosclerosis soziatrischo aspekte dee genul)-und arz~aeimittelkonsums verwendung yon htilsenfriichten in der diabetiker-di~t sanitation and dishes sanitation and dishes. aspects old and new. part ii smoking, arteriosclerosis, and age neue weg~ zur erni~hrungsphysiologi~chen aufwertung yon getreide-erzeugnissen diphyliobothrium latum and human nutrition, with particular reference to vitamin bli deficiency milk and diverticulosis dietary factors in the pathogenesis and treatment of cirrhosis of the liver. ivied. clinies north america zur frage der quanti~tiven charakteristik der ern~hrung der berufst probleme der gemeinschaftsverpflegung aus der sieht des ern~hrungsphysio-logen gegevens over vitamine b,-deficientie, -behoefte en -voorziening use of government-donated foods in a rural community fluoride, teeth, and the analyst eiweil bedarfsnormen im rahmen unserer ern~hrungsrichts~tze physiologic discomforts in navy protective shelter tests di~tvorschl~ige : akute nierenentziindtmg siii]waren und karies in theorie und praxis ernehrtmgsberatung im krankenhaus use of a low-sodium formula as an improved karell diet, with emphasis upon the outpatient management of heart failure and lymphedema pflanzliches eiweil~ fiir die erniihrung des menschen influence of diet on viral hepatitis influence of siblings on student smoking patterns voeding yon leerlingen van een lagere technische school. ii. calorie~n-en nutri~ntenwaarde early use of circulating blood volume, weights, and normal diet in acute renal failure fette in tier nahrung. dr. recd. wschr. [ ] nr. , s. / . *scm~-idt-b~bach, a.: ~j~ber die di~tetik der sauermilch begriff und anfgabe di~tetischer lebensmittel zur ursache yon geschmackskalamit~ten in trinkwassertalsperren psychologische motive im wandel des brotverzehrs improving levels of nutrition through better food practices the vitamin b~ deficiency syndrome in hun~n infancy. biochemical and clinical observations treatmen~ of ,refractory obesry" with ,formula die~ nr. , s. ff. ( s.). elwzea, c. c.: morphologie constitution and smoking prediction the outcome for obese dieters symposium fiber probleme der ern~hrung durch gefrierkost in karlsruhe yore coordination of long-term care of :pku children die di~t bei diabetes meuitus a nutritional supplement (nutrament) for elderly patients dietary intake of five groups of subjects. -hr. recall diets vs. dietary patterns the prolonged effects of a low cholesterol, high carbohydrate diet upon the serum lipids in diabetic patients stand und perspektiven der eiwei~versorgung. zur zielsetzung des verhandiungsthemas de voeding van rijswerkers signification des standards calorieo-azotes utilists en france erg~nzungen veto standpunkt des lebensmittelehemikers zu (dem beitrag) official acceptance of homogenized milk in the united states advances in nutrition and dietetics nutrition of naval recruits during a shelter habitability study hot ombuigen van voedingsgewoonten de voeding van schippemkinderen san boord en in de internaten voeding [ ] iqr. , s. / . --le traitement de rinsuffisance rtnale her zoutarme-eiwitarme dicer ein beitrag zur allgemeinen el problematik, ausgehend yon einer anorexia nervosa rroblem~ in nutrltlon~l supplementation an ~mri~hnl~ut detection of nutritional imbalances theorie und praxis der schwangerenern~hrung die pharmakologisehe beeinflussung yon hunger mad s~ttigung problems in the evalutaion of nutritional status in chronic illness europ~ische di~ttagung in amstercl~m ( . bls entwieklung des brot-und gctreidevcrzehrs in der neuercn zeit nutrition and palatability coehac dis~tse. -biochemical and technological aspects die di~itetik der :fettsucht kinderemll}~mg nutrition of infants and children report on infant feeding childhood nutrition in lapland. :nutrition rev the thyroid gland in infant malnutrition. nutrition rev. [ ] nr. , s. . +n. n.: physical activity of obese girls appraisal of nutritional adequacy of infant formulas used as cow milk substitutes isomaltose intolerance causing decreased ability to utilize dietary starch passagere hypereh]or~mische azidose bei zwei ausgetragenen s~uglingen wghrend s~uremflch-em~hrung ober erfahrungen in der frfihgeborenonaufzucht mit einer neuen bedarfsangepa ten friilmahrung nutritional defects in adolescence g p intravenous glucose tolerance in the normal newborn infant: the effects of a double dose of glucose and insulin ! attitudes towards physical ac. tivity, food, and family in obese and nonobese adolescent girls urinary excretion of . -dihydroxyphenylalanine (dopa) in two children of short stature with malnutrition high salt content of western infant's diet: possible relationship ~o hypertension in the adult vitamin e to premature infants des enzym yon ~'leming (lysozym) und seine bedeutung flit die si~ugllngsern~ihrung. ann investigation on the relation of between-meal eating and dental caries of sixth-year molars in school children studies in infantile malnutrition. i.: nature of the problem in peru chronic malnutrition in turkey. v. studies on serum fatty acids in malnourished children emi~hrnng mad faekalc lysozymaktivitiit beim s~iugiing role of linoleio acid in infant nutrition factors related to the eating behavior and dietary adequacy of girls to years of age. dies. abstr. des vitamin c im jugendalter. ii. mitt.: uber die wirkung yon natiirlichem und synthctisehemvitamin c bei l~ngeren zugaben the incidence of protein-calorie malnutrition of early childhood ein besonderer znsammenhang zwischen dem bedarf an nahrungsfett und dem stoffwechsel in den ersten lebensjahren the effect of supplements of groundnut flour or groundnut prorein isolate fortified with calcium salts and vitamins or of skim-milk powder on the digestibility coefficient, biological value, and net utilization of the proteins of poor indian diets given to undernourished children lysine fortifications of wheat bread fed to haitian school children lrber den -stunden-rhythmus der kalorienerzeugung bei friihgeborenen beitriige zur frage der spezifisch-dyrmmi~ehen wlrkung auf grund yon glykokoll-belastungen bei friihgeborenen. acta paediatriea acad carotine in tier stiuglingserni~hrung. wiss. versff. d$. ges. ernkhrung liver and depot lipids in children on normal and high carbohydrate diets response of rural guatemalan indian children with hypocholesterolemia to increased crystalline cholesterol intake feeding value of soy milks for premature infants early feeding and birth difficulties in childhood schizophrenia. a brief study zusammenh~nge zwischen stoffwechsel und fl~issigkeitsbedarf beim s~ug-ling kuhmilchauergie beim s~ugling und ,cot death". die unspezifische kumulative sensibilisicrung malnutrition and the health of children practical aspects of infant feeding breast-feeding, weaning, ~nd acculturation appetithemmer in der ]~ehandlung der fettsucht bei kindern. miinchener med the effect of different amounts of vitamin d on growth and serum levels of calcium, inorganic phosphorus, and alkaline phosphatase in premature infants partition of urinary nitrogen in children with kwashiorkor treated with animal and vegetable proteins der einflud yon voukornbrot auf den caleiumstoffweehsel bei schulkindern ist eine rektale vitamin blz-behandlung vertretbar? dr ethyl alcohol in the pathogenesis of gout c|e~rance of infused fat emulsion in diabetic dogs praktische durehffihrung der parentcralon ern~hrung die parcntcrale ern~hrung chirurgischor paticntcn. wiss. ver ff. dr. ges. em~hrung verwertung intravenss verabfolgter aminos~,urengemische. wiss. versff. dr. ges die erkcnnung yon fe~-transportstsrungen und ihre bedeutung ftir die intra-ven se fettzufuhr intravenous glucose tolerance in the normal newborn infant: the effect of a double dose of glucose and insulin new intravenous fat emulsion indikationen und kontraindikationen der intraven sen fettzufuhr in der chirurgie anwendung intraven s gegebener aminos~urengemische in dcr p~diatrie ymtravensse fettinfusionen. wiss. versff. dt. ges. ern~rung ~qotwendigkcit und erfolge der parenteralen mad sonder-ern~hrung moderne vitamin blz-therapie: oral, rektal oder p~renteral? mcd anwendung intravenss gegebener aminos~urengemische in der gyn~kologie und geburt~hilfe aminos~ureninfusionen. schweiz. reed. wsehr. klinische anwendung mad erfahrungen bei der verabreiehung intravensser fettemulsionen an ehirurgischen patienten diskussionsbemerkung zum thema: die parenteralo ern~hrung ~tude exp~rimentale de la tolerance d'une solution de graisse vsgstale d'administration intraveineuse ern~hrungsphysiologische grundlagen der parenteralen ern~hrung erfahrungen mit der parenteralen ern~hrung mittels fettinfusionen. helvetica chirurgica aeta nitrogen, lipid, glycogen, and deoxyribonucleic acid content of human liver. the effec~ of brief starvation and intravenous administration of glucose techn~ und indikationen der parenteralen ern~hrung des neugeborenen die praktische organisation der klinisehen infusionstherapie mit zuckerund elektrolytlt)sungen. l ~ed untersuchungen und bcobachtungen fiber intravensse fettinfusionen in der inneren klinik. wiss. versff. d$. ges. ern~hrung l'alimentation parenttrale, mulsions lipidiques. (a suivre) ann intravcnsse ern~hrungstherapie mit fettemulsionen parenteral-und sondeneru~hrte patienten zur rekt~len kaliumsubstitufion parenteraie ern~hrtmg mit fettemulsionen konservierung mad zubereitung yon lebens-und futtermitteln nutritional hygiene, preservation and preparation of foodstuffs and feeds n. n.: vortragsveranstaltung ,fleischhygieno" der th seminar on the use of radioisotopes in nutrition science and of ionising radiation in food technology. strasbourg, st - th october progress of food irradia~on work and programmes in o.e.c.d. member countries ( berichte) safe heat processing of canned cured meats with regard to bacterial spores the role of food science i and technology on the freeze dehydration of foods public health aspects of handling animal products in the txopics fack)rs affecting bacfcrial spoilage of animal products at elevated temperatures. food technol sterilized concentrated millr. food teehnol. [ ] nr. , s. / , . n.n.: foods of the future. now opportunities for flavor modification unrestricted approval for irradiated bacon -a sanitary standards for multiple-use rubber and rubber-like materials used as product contact surfaces in dairy equipment -a sanitary standards for batch and continuous freezers for ice cream, ices, and similarly-frozen dairy foods bericht fiber die vortrag~tagung des fachverbandes lebensmittelchemio der chemischen gesellsch~ft in der ddr vom . bis lebensmittelchem. u. geriehtl. chem. fluoridation in great britain die enzymatische phycinspaltung in geschrotetem getreide in abh~ingigkeit yon der relativen lufffeuchtigkeit the effect of certain antioxidants during freezer storage of pork chops and sausage the mechanics of treating hatching eggs for disease prevention beitrag zur sfil~gerinnung yon kakaotrunk jodophore als desinfektionsmittel in der milchwirtschaft. milchwissenschaft [ ] nr. , s. ff. (? s.). zitat: dr. lebensmittel tierarzneimittel und anfzuchtmittcl in der landwirtschaftllehen praxis. gesundheitliche erwrgungen znm sehutze des konsumenten bei der anwendung yon tierarzneimitteln und aufzuchtmitteln in der landwirtschaftlichen praxis n~ihrwertminderung dureh zubereitung dcr nahrung suue modifieazioni della flora mierobiea dei mollusohi eduli par effetto di eonservazione impropria verlinderungen des inhaltes yon dosenkonserven w~hrend lgngerer lagerung digtbrote aus der sieht ihrer praktischen gestmtung. wiss. versff. dr. ges. ern~hrung l erniihrungshygienische untersuchungen in kindergarten an budapester kindern im alter yon bis jahren. z. ges. hyg. die eignung der bakteriologischen untersuehung yon kannenmilchproben als grundlage eines eutergesundheitsdienstes adequacy of cooking procedures for the destruction of salmonellae zur revitaminierung des mehles bzw. brotes. wiss. versff. dr. ges. er-n~hrung conventionele verwarningsmethoden beitrag zur kenntnis der wechselwirkungen zwischen proteinen und poly. phenolcn der kakaobohnen wtihrend der fermentation nihydrazone feed medication ag~ins~ ar~iiieiaily induced escheriehia eoli air-sac infection foam-mat dried orange juice. i. time-temperature drying studies lebensmittelhygicnische probleme bei der herstellung yon gemeinschaftsverflpegung. . mitt. : z. ges. hyg. lebensmittelhygienische probleme bci der herstellung yon gemeinschaftsverpflegung. . mitt.: z. ges. ttyg. untersuchungen fiber die temperaturvorg~nge im innern yon lebensmittein w~hrend ihrer thermischen zubereitung, erl~uter~ am kochen yon kartoffelklsl~en. z. ges. hyg. zur gewinnung yon niederverestertem pektin aus toehnisehen apfelpektinextrakten mit ammoniak: einflul] der entesterungsbedingungen auf das geliervermsgen hygienisohe beurteilung einer dutch clostridlum verursaehten massen. lebensmittelvergiftung [ungar neuartige teehnik der lebensmlttelverpaekung filr ge. schmaeks-aromastoffe und andere artikel bei ~berdruek studies with a natural source of xanthophylls for the pigmentation of egg yolks and skin of poultry die problematik der tuberkulosebeurteilung in der sehlachttier-und fleischuntersuchung freezing rate of beef as affected by moisture, fat, and wrapping materials ~ber mit komblnier~en konservierungsmitteln hergestellte konfitiiren und consumers' reactions to instant foods. food teclmol effect of supplementing lime-~reated corn with different levels of lysine, tryptophane, and isoleueine on the nitrogen retention of young children effect of freezing on autoxidation of oxymyoglobin solutions the control of gloecsporium album rot of stored apples by orchard sprays which reduce sporulation of wood infections bakteriologische befunde bei der spelseeisuntersuchung im sommer the microbiology of vacuum packed sliced bacon the stability of canned foods in long erm storage the effect of proofing and baling on concentrations of organic acids, carbonyl compounds, and alcohols in bread doughs prepared from pre-ferments nutrients in raw vs. cooked globe artichokes effect of gamma-radiation, chemical, and packaging treatments on refrigerated life of strawberries and sweet cherries. food teehnol beeinflussung der wirkung yon kaffeeinhaltsstoffen dutch be-s~immte behandiungsverfahren der l~hbohne. (eine tierexperimentell-toxikologische studie influence of surface pasteurization and ehlortetraeycline on bacterial incidence on fryers the hydrolysis of grass hemicelluloses during ensilage post-harvest storage studies with selected fruits the science of food technology in venezuela beitrag zur aufbewahrung von sti~rkesirup in verzinkten ge-f~ben inactivation-rate studies on a radiation.resistant spoilage microorganism. ii. : thermal inactivation rates in beef the oceurrence and growth of staphylococci on packed bacon, with special reference to staphylococcus aureus zur verhiitung yon lebensmittelinfektionen in grobklichenanlagen dutch desinfektionsmabnahmen. ~rztl the influence of selected bacteria upon the flavor of a precooked frozen poultry product flour maturing and bleaching with aeyclie acetone peroxides effect of processing conditions on dry-heat expansion of bulgar wheat zur vcrwendung von pentachlornitrobenzol bei der lagerung yon kohl. dr. lebensmittel-rdsch. [ ] nr. , s. los mati~res f cales des pores et les selles des ouvriers d'aba~toir constituent une source permanente de diss mination des salmonella studies on cooking fats and oils aspect sanitaire et l~gal aetuel des aliments conserv&s. rev. d'hyg over de betekenis van postduiven als besmettingsbron van levensmiddelen met salmonella-kiemen. ti]dschr. v. diergeneesk over bet voorkomen van salmonella-kiemen bij slagerijen. tijdschr. v. diergeneesk ursache und entstehung yon brotfehlern les salmonella des oeufs et ovoproduite frangais eg trangers the microstructure of baked products and doughs. food technol tomsto powder by foam-mat drying zitat: dt. lebensmittel-rdsch. [ ] nr. , s. . --die verwendung yon gefrosteter saline zur butterherstellung. teil iv. die ergebnisse der in d~nemark, frankreich und in den l~iederlanden durchgefiihrten praktischen versuche und ihre bedeutung ffir die in der deutschen molkereiwirtschaft erfolgendo verwendung yon gefrosteter sahne bei der butterherstellung tenderne~ of the turkey meat as influenced by pre-cooling before proce~ing and hand masv~ging vortragsmaterialien flit die ern~hrungsproplldeutik. (erlruterungen zu insgesamt groben sehautafeln.) . mitt. : behandlung der tafeln iv bis vi. ernahrungsforschung die unterschiedliehe problematik und ihre konsequcnzen bei der bekrmplung der rinder-und schwefnefinnen salmonellae from flies in a mexican slaughterhouse factors affecting quality of pies prepared from frozen bulkpack red sour pitted cherries zur bedeutung antimikrobiellcr stoffc in der nahrung modified equipment for pasteurizing and deodorizing market milk and for pasteurizing, deodorizing, and slightly concentrating cheese milk adhesion of coatings on frozen fried chicken oob~age eheeae problems in production and sanitation. publle health aspects ~ber den einflub yon licht, auerstoff und tempera~ur auf die hal~barkoib yon verpaektem emmentaler ks in scheiben aktuelle notwendigkeiten -gesetzliche m glichkeiten zur fischkfihlung in eis und seewasser techniques de recherche des salmonella dans les oeufs frais et de conserve food hygiene on board ship safety factors in water fluoridation based on toxicology of fluorides the effect of oiling before and after cleaning in maintaining the albumen condition of shell eggs lebensmi~t~l-aerosole. fette preservation of the natural color in processed sweetpotato products. i.: flakes. food technol temporary inhibition of fermentation in apple juice preservatives and artificial sweeteners the mechanism of the development of rancidity in frozen fresh pork sausage and practicable methods for its inhibition die entwicldung der trinkwasseriinoridierung in den usa microbiological principles in prcpaeking meats st~ndard-kapazit~tstest ffir die bestimmung der desinfektionswirkung yon desinfektionsmitteln in der milchwirtsehaft. internationaler standard fil/ii)f - die anwendung einiger arteu, bzw. st~mme, yon propions~urebakterien zur herstellung bestimmter k~scsorten mit hohem vitamin b -gehalt the extraction of pectins from apple marc preparations zur hygiene und ,di~tetik des rauchens studies on control of respiration of mcintosh apples by packaging methods. food teehnol effects of ingredients used in condermed and frozen dairy products on thermal resistance of potentially pathogenic staphylococci der frisehkllse und seine verpackung studies on the viscosity of mayonnaise. ii.: the influence of addition of vinegar on the vi~co~isy of mayonnaise e~'ec~ of chemical v~lditives on the spreading quality of butter. ii. laboratory and plant churnings studies on browning mechanisms of fruit juice products. i.: changes in chemical composition which accompany browning of commercial concentrated lemon juice during storage ergebnisse der dlg-qualit~tspriifung fiir speiseeis. dr. molkerei-ztg beeinttnssung versehiedenartig verpaekter lebensmittel dureh desinfektion mit formaldehyd grunds~itzliches zur stabilisierung und solubilisierung yon carotin und carotinoidpr~paraten riickst~nde yon pflanzensehutzmitteln, insektiziden und dergleichen in der nahrung und ihre bedeutung fiir die gesundheit absehliebende stellungnahme lebensmittel-rdsch langfristige nutritive anwendung yon antibiotilm in der tierern~hrung im hinbliek auf die menschliehe gesundheit mit besonderer beriieksiehtigung yon chiortetrazyklin nutritional studies on the utilization of distiller's stillage. part l: insolubles of me]lasses-butanol distiller's stillage auswertung der dlg-priifung fiir frischk~ise in verbraueherpaekungen zu den fermentativen eigensehaften der milchs~urebakterien (,laetobacillus meijerinek"), zugleieh ein beitrag zur vermeidung yon fehlfabrikaten bei roh-nnd briihwurst. arch. lebensmittel-hyg microbiological aspects of one-trip glass bottles as used by the carbonated beverage industry de bereiding van bouillon aktnelle milchhygienische aufgaben und zicle des organisation der ~berwachung der umweltradioaktivit~t unter besonderer beriieksichtigung der l~berwaehung des gehaltes yon lebensmitteln an radioaktiven stoffen. dr. lebensmittel bakteriologie der auermilcherzeugnisse l~ber die italtbarkeit yon lebensmittelkonserven preparation of aeid-modifid flour for tub sizing radiostrontium removal from milk. determination of apparent equilibrium constants of the exchange reactions of sodium, potassium, calcium, and magnesium wish amberlite ir- probleme der vitaminierung yon brot the effect of several operational variables on the rate of freeze-drying of beef studies on beef quality. x. effect of temperature, freezing, frozen s~orage, thawing, and p~ on the rate of hypoxanthine production. div. food preservation techn retardation of gelation in high temperature-short-time sterile milk concentrates with polyphosphates nonenzymatic bread browning and flavor. changes in amino acids and formation of earbonyl compounds during baking ttinweise fiir konservierende wirkungen synthetiseher senfslbildner naeh versuehen an fisehen neuo wege zur herstellung haltbarer fisch-pr~iserven behavior of ethylene dibromide, methyl bromide, and their mixtures. i. : in columns of grains and milled materials der einflui~ des wksserns auf die kartoffel irradiation of fruits and vegetables in india effect of storage in nitrogen on the soluble sugar and dry matter contents of ryegrass drying of seaweeds and other plants. v. throughcirculation drying of asophyllum nodosnm in a semi-continuous dryer niacin, thiamin, and riboflavin in fresh and cooked pale, soft, watery versus dark, firm, dry pork muscle nouvelles observations concernant la survie des salmonellae clans les fromages pyroearhonie acid diethyl ester as a potential food preservative the effect of phosphates on moisture absorption, retention, and cooking losses of broiler carcasses gur hygienisehen beur~ilung der trinkwasserverh~ltnisse des oberon vogtlandes -eine hydrobiologische s~udie. z. ges. hyg. studies on preserving quality in market eggs rapid detection of faecal coliform bacteria in the food processing plant. j. milk food technol the relationship between the loss of water and carbon dioxide from eggs and the effect upon albumen quality plastic pacckaging of eggs. study on improvement of digestibility of milk protein. i.: the effect of heating, adjustment of activity of calcium ion, addition of whey protein, homogenization, and elimination of coarse casein micelle from milk by ultracentrifuge on the digestibility of milk especially on the coagulability of it part iii.; the digebtibility of slightly hydrolized milk with proteinase and the preparation of rnill~ which has same eoagulability as human milk. g. agrie, chem. see study on improvement of digestibility of milk protein. part iv. : the nature of coagulation of casein of milk preparation which has same coagulability as human milk the influence of added microorganism on the quality of margarine. i. : the influence of mold inoculation die ilberung yon tafelw/~ssern. dr. lebermmittel-rdsch technological aspects of the radiation pasteurization of foods rapid hydration of dried fruits. food technol untersuchungen fiber polygalakturonase-enzyme aus sehimmelpilzen. . mitt.: eigenschaften der polygalakturonasen aus schimmclpilzen role of individual phospholipids as antioxidants association of veterinary food hygienists symposium on the marketing, transport, and slaughter of calves. iil: scientific aspects. ve~cr ricerche sulla resistenza della brucella abor~us helle salsicce. riv pr senee des salmonelles dans les viandes. donn es frangaises et tran-gbres biochemisehe vorg~nge inl fleisch bei der lagerung einflul des r stgrades yon kaffee auf die extinktion w~briger extrakte und die menge der trockensubstanz die herstellung yon quark und weillk~e unter ansnfitzung ss eiweibstoffe der milch vcrluste yon vitamin b~ und c beim kochen und turmkoehen yon gemfise effect of chilled storage on the frozen storage life of whiting salmonellenfunde in einer importsendung amerikanischer tiefgefrierhiihner. arch. lebensmittel-hyg iron sulfide blackening in canned protein foods: oxidation and reduction mechanisms in relation to sulfur and iron raft research on food preservation by irradiation in poland no~: gas chromatography of chicken and turkey volatiles: the effect of temperature, oxygen, and type of tissue on composition of the volatile fraction l'inaetivation dens l'eau de meret l'eau d'alimentation de eertains entdrovirus de voedingswaarde van aardappelen van versehiuende re, sen en de invloed daarop van bemesting en bewaring effecb of l-arab]nose and d-xylose on dough fermentation and crust browning gelation of egg yolk corn carotenoids: effects of temperature and moisture on losses during storage salmonellenfunde in einer importsendung amerikanischer tiefgefriorhiihner. arch. lebensmittel-ttyg bacteriological examination of unbottled soft drink ~berbliek fiber kunststoff-folien und -kombinatlonen ale verpackungsmaterial in der mflchwirtschaft pigmentierung des eidottem bei gettiigel. wiss. versff. dr. ges. eruiilu'ung s~ beltrag zur bedeutung wasserlsslieher hochmolekularer kohlenhydrate f'tir die verkleisterung der st~irke einfiul ehemischer verbindungen auf die antimikrobielle konservierungs-~toffwirkung. . mitt.: einflub verschiedener stoffgruppen auf die konservierungswirkung gegen aspergillus niger a quantitative s~udy of changes in dried skim-milk and lactose cnscin in the 'dry' state during storage the role of the major sugars of potatoes in ~he browning roa tion during chipping probleme der zuverl~sigkeit yon kunststoffen zur lebensmittelverpackung in europi~ischer sicht bakteriologiseh-hygienisehe beur~ilung yon speiseeis weizenkeime ale wertvoller rohstoff-einige ~ragestellungen und probleme probleme der frischhaltung und haltbarmachung yon brot end backwaren the effect of selected polymers upon the albumen quality of eggs after storage for short periods preparation and quality evaluation of processed fruits and fruit products with sucrose and synthetic sweeteners the microflora within the tissue of fruits and vegetables changes in carbohydrate and phosphorus content of potato tubers during storage in nitrogen preparation of "natural" cow-milk fat globules; preliminary investigation of materials adsorbed at their surfaces lethal doses of gamma radiation of some fruit spoilage microorganisms alteration of post-mortem changes in porcine muscle by preslaughter heat treatment and diet modification ober die msglichkeiten end grenzen eines effects of polyphosphates on water uptake, moisture retention, and cooking loss in broilers flavors imparted to dairy products by phenol deriva aromatisehe crackproduktc yon sterinen. (i). z. ern~hrungs-wiss dose requirements for the radiation sterilization of food berichb fiber eine arbeitstagung bei der internationalen atomenergie-beh rde in wien vom zur bok~mpfung d r rinderfinne zum einfiu]~ handelsfiblicher, in lebensmittelbetrieben gebr~uch-]icher desinfektionsmittel auf lactobakterien; zugleich ein beitrag zur desinfektion in der marinadenindustrie einflu~ chemischer umsetzungen bei trockenen lebensmittelgemischen in hinsich~ auf die lagerfestigkeit. vi. mitt. : lebensmittelgemische mit troekenmagermileh als hauptkomponente. z. lebensmittel-untersuchung u die technologie yon sauren milcherzeugnissen, insbesondere der sauermilcharten und sauerrahmarten effects of several edible coatings on poultry meat quality how to control insects in stored foods. part die antibiotika und die ans ihrer anwendung fiir die ~iilehwirtsehaft sich ergebenden probleme zur haltbarkeitsverli~ngerung empfindlicher l~ahrungs-und genuflmittel dureh abpaeken unter vakuum. fette, seifcn the diffusion of hydrogen through tinplate containers packed with grapefruit juice effect of ice cream stabilizem on the freezing characteristics of various aqueous systems ist die infektion mit trichinen aus amtlich untersuchtem schweinefieisch im liehte der mathematisehen analyse der bestimmungen der fleischbcschau yon schweinefleisch msglieh? hygiene in milk production, processing, and distribution effect of pre-eooling eggs and cartons upon quality after storage a biological after-effect in radiation-processed chicken muscle accounting for farm tank milk factors related to the flavor stability during storage of foam-dried whole milk. iii. effect of antioxidants untersuchungen zur hygienischen beurteihing yon ~ietallverunreinlgungen in lvben~mitteln the effect of bleed time prior to scald and refrigerated storage upon bacterial counts in the axillary diverticula of the interclavicular air sac of chickens techniques de recherche des salmonella darts les viandes the serotypes of salmonella isolated from foods carotinverluste beider zubereitung der nahrung. wiss. vcrsff. dr. gcs. er-n~hrung stability of ascorbie acid in a liquid multivitamin emulsion containing sodium fluoride the effect of storage time and holding temperature on egg interior quality in uganda uber den einflul versehiedener fangverfahren auf die qualit~t und lagerreserve der fische zerst~ubungstrocknung yon tomatenkonzentraten. dr. lebensmittel radiation pasteurization of fresh fruits and vegetables a bacteriological survey of certain processed meat~. part l population studies at packet and retail levels association of veterinary food hygienists symposium on the marketing, transport, and slaughter of calves. l : marketing and slaughter die kombinierte verarbeitung yon kartoffeln auf st~rke und alkohol (fortschrittsbericht) usaec program in radiation research preservation of certain fish and fruits biochemical and quality changes in chicken meat during storage at above-freezing temperatures inleidend onderzoek naar strnctuurveranderingen die ontstaan bi] verhitten van plantaardige produkten veranderingen van hot vetgehalte bij de bereiding van vlces a study on the relationship between the factors influencing the time of cheese salting maple sirup. xxi. : the effec~ of temperature and formaldehyde on the growth of pseudomonas geniculata in maple sap vacuum-tempering corn for dry. milling organoleptische eigenschappen, thiamine-en ascorbinezuurgehalte van enige week-en diepvriesgroenten growth of psyehrophiles. il : growth of poultry meat spoilage bacteria and some effects of chlortctracycline tests of corn stored four years in a commercial bin association of veterinary food hygienists symposium on the marketing, transport and slaughter of calves. ii. : the slaughter and inspection of calves. veter the effect of processing conditions upon the nutritional quality of vegetable oils berieht fiber den wisscnsehaftlichen kongrel der dcutschen gesellschaft ftir ern~hrung ( vortragsrcferate) an objective measurement of the freshness of ready-to-cook broilers the fieldman's responsibilities in milk quality and procurement studies on the bacteria found in the wine during its making. i.: multiplication of bacteria in wine and male-lactic fermentation hydrophilic colloids as additives in white layer cakes the acceptability of cooked poultry protected by an edible acetylated monoglyeeride coating during fresh and frozen storage istes zu vertreten, dal das fleiseh sehwachfinniger rinder auch in gebriitetem zust~nd eingcfrorcn wird? arch. lebensmittel-hyg =[efenlnfit.ierte kondensmilch als ursache yon fehlfabrikation bei schokolade. arch. lebensmittel.hyg. [ ] nr. , s. . m, ober die bedeutung aerober sporenbildner als bombageerreger yon wfimtehenkonscreen. arch. lebensmittel-hyg aluminiumfolio zur verpaekung tiefgekiihlter und gefriergetrockneter lebcnsmittel. fette fiber die milcldtuorierung. bull. schwciz. akad. reed. wiss vitamin stability in diets sterilized for germfree animal~ die trinkwasserversorgung ernliln-ungsstatistlk nutritional statistics african nutrition problems der vcrbrauch yon alkoholisehen getr~,nken in sterreich childhood nutrition in lapland overweight children in stockholm iron deficiency in the finnish population vitamin b deficiency in indian infants the indices of nutritional change in great britain dietary values from a h recall compared to a -day survey on elderly people her vaststellen van de voedingstoestand van sen bevolldng in de tropen en subtropen dental effects of fluoridation of water with particular reference to a study in the united kingdom de voedlng van woonwagenbewoncrs nutritional attitudes of some london housewives de vocdingsgewoonten van bcjaarden in amsterdam community studies of drinking behavior fats and carbohydrates as factors on atherosclerosis and diabetes in yemenite jews nutritional beliefs among a low-income urban population algemene gezondimidsaspccten van de vocding in de ontwikkelingsgcbieden a comparative study of the nutritional adequacy of the morning intake of women clerical workers and women factory workers serum cholesterol in a military population. its relation to obesity and the military diet nutrient intakes of healthy older women analysis of the structures of food consumption by groups in japan thiamin (vitamin b,)-untercru~hrung in deutschland? lvied vortragsmaterialien ftir die ern~hrungsprops (erli~uterungen zu insgesamt groben sehautafeln.) . mitt.: behandlung der tafein iv bis vi. erns [ ] nr. , s. zur ern~ihrungssituation in arbeitexfamilien aus verschiedcnen bezirken der ddr. . mitt. : ern~hrungssoziologischc answertung der lebensmittelverzehrungen in itaushaltungen mit erwachscnen und kindern~ stand studies in infantile malnutrition. i. : nature of the problem in peru zur ~ethodik yon ern~ihrungserhebungen bei der gemeinschaftsverpflegung weight changes in relation to birthweight of papuan, indonesian, and chinese children during the first two weeks of life numbers of tasters required to determine consumer preferences for fruit drinks onderzoek naar de menupatronen in de noordoostpolder smoking habits of medical and non-medical university staff i**cs and potassium in people and diet. -a study of finnish lapps. ann. acad. scientiarum fennicae a ~berbliek fiber die radioaktivit~t der in sterreich im jahre konsumierten lebensmittel diet and plasma cholesterol in bank men der mengenmi~bige getr~inkeverbrauch je einwohner im bundesgebiet predictors of human food consumption use of goverument.donated foods in a rural community bericht fiber die durum-und teigwarentagung der arbcitsgemeinschaft der oetreldeforschung e. v. vorn . bis . miirz voeding van leerlingen van con lagere teehni~eho school. ii. calorie~in-en nutriiintenwaarde nutritional deficiencies in developing countries dietary survey in surinam vitamine a-tekor~en op de aarde schwierigkeiten beim erreichen einer vollwertigcn ern~ihrung in ausgew~hl-ten vcrbrauchergruppen die entwicklung des brot-und getreideverzehrs in der neueren zeit. wiss. ver ff. dr. ges. ern~hrung n~rwert und zusammensetzung yon lebens. und futtermltteln nutritive values, composition of food~tuffe and f physical chemistry of ice cream vitamin e in human nutrition appraisal of nutritional adequacy of infant formulas used as cow milk substitutes enkele gegevens betreffende de calorisehe waarde van klsine hepjes, gerechtcn en maaltijden the public health aspects of the use of antibiotics in food and foodstuffs. report of an expert committee niihrwertminderung dutch zubereitung der nahrung metals and other elements in foods die farbe der nahrungsmittel in anthropologischer sicht the enzymatic destruction of carotene and carotenoids foodstuff flavors. some factors affecting the flavor of sodium caseinate chemical and radiochemical composition of the rongelapese diet the organic constituents of food. i. : lettuce the influence of dehydration of foods on the digestibility and the biological value of the protein a stfidy of two methods of assessing vitamin b nutriture mincraisalze mad spurenelemente in der nahrung distribution of the bound form of nicotinic ac|d in natural material~ the distribution of c~rotenoids in nature and their biological significance zur bedeutung antimikrobieller stoffe in der mahrung die konsistenz yon margarine mad fetten an improved nutrient solution for diploid chinese hamster and human cell lines extraneous materials in foods and drugs the composition of food flavors studies on pantothenic acid intake. i. pantothenic acid content in japanese foods haben wir mangel an essentiellen fettsiiurcn? phonolcarbons~uren in menschlichen nahrungsprodukten. zum vorkommen yon phenolcarbons~uren in menschlichen nahrungsprodukten und ihr einttud auf den intermedi~ren sboffwechscl drugs in feeds relationship between the sulphur/nitrogen ratio and the protein value of diets gums in foods zur definition der begriffe ,aroma" und begriff und aufgabe dii~tetischer lebensmittel valettr vitaminique des carot nes pour rhomme. wiss. versff. dr. ges. ern~hrung internationales rundgespriich fiber lebensmittelchemische probleme in wiesbaden und eltville a. rh. ( vortragsreferate) consumer awareness of texture and other food attributes organisehe und organisierte substanz in der lebensmittelchemie frost resistivity of fruit plants californ'ia association of chemistry teachers : inorganic nutrients in the sea fluoride in food antibiotics in feeds and other products planktorm as foods relation between color of cranberries and color and stability of sauce berieht fiber die vortragstagung des fachverbandes lebensmittelchemie der chemischen gesellsehaf$ in der ddr vom . bis bulletin on tobacco evaluation of algae as a food for human diet~ digestibility of high-amylose corn starch. nutrition red. [ ] nr. , s. / . ~. n. : comparative evaluation of corn mesa and steam-processed whole corn flours the major anthocyanin pigments of vitis vinifera varieties flame tokay, emperor, and red ~alaga peonidin- -monoglucoside in vinifera grapes formation and distribution of amylosc and amylopectin in the starch granule nutrient in seeds. amino composition of some seeds sugar levels in fruits of the lowbush blueberry estimated at four physiological ages the relation of pectic substances to firmness of processed sweet potatoes (ipomoea berates) processed vegetable produc~s the protein composition of different flours and its relationship to nitrogen content and baking performance relationship between 'antitryptic factors' of some plant protein feeds and products of proteolysis precipitable by trichloroacetic acid. g. sci. food agric a thermostable haemolytic factor in soybeans foam-mat dried orange juice. i. time-temperature drying studies bound" growth inhibitor in raw soybean meal leaf analysis as a guide to the nutrition of fruit crops. ii. : distribution of total n, p, k, ca and mg in the laminae and petioles of raspberry (rubns idaeus l.) as influenced by soil treatments nutritive value of pumpkin seed. essential amino acid content and protein value of pumpkin seed (cueur bi~a farinoaa) effect of cooking and of amino acid supplementation on the nutritive value of black beans (phaseolns vulgaris l.) supplementation of cereal proteins with amino acids. iv.: lysine supplementation of wheat flour fed to young children at different levels of protein intake in the presence and absence of other amino acids uber den chemischen total ascorbic acid in potatoes. raw, fresh, mashed, and reeonstituted flakes moisture contents of hard red winter wheat as determined by meters and by oven drying, and influence of small differences in moisture content upon subsequent deterioration of the grain in storage rheological studies with canned tomato juice the chemical composition of maple sugar sand soluble carbohydrate content of varieties of te~raploid ryegrass natiirlicher gehalt und stabilit~t yon carotine und carotinoiden in citrnss~ften ~ber wein und weinuntersuchungen fatty acids and other lipids in mayonnaise cyclic fatty acid yields from linseed oil factors ~ffecting enzymatic solubilization of beef proteins weibulls original ring, en ny medeltidig varvetesort. (a new medium early variety of spring wheat, weibull's ring.) agri hortique genetiea ober die askorbins~uresynthese in zerschnittene kartoffeln die bestimmung der amylaseaktivit~t und einige studicn fiber amylaseaktivit~t in gekeimtem roggen effect of processing conditions on dry-heat expansion of ~ulgar wheat oils, fats, and waxes ~.~ber das der johannisbro~.kerne. fetto, seifen fruit and fruit products uber die variabili~it einiger eigcnschaften der kartoffelstilrke in abhiingigkcit yon witterung a short.term effect of weather on malie acid in pineapple fruit the specific surface of flour and starch granules in a hard winter wheat flour and in its five subsieve-size fractions oranges and lemons factors affecting quality of pies prepared from frozen bulk-pack red sour pitted cherries studies on the consish~ncy of thiamin and protein contents of pure.bred strains of rice a comparison of the nutritional value of protein from several soybean frac ions zum vitamin-und aminos~uregehal~ yon maisquellwasser dark discoloration of canned all-green asparagus. i. chemistry and related factors enzymatic enhancement of flavor peetinestcrase in normal and abnormal tomato fruit storage effects on winter squashes. varietal differences and storage changes in the ascorbie acid content of six varieties of winter squashes grape pigments. concord grape pigments corn meal as a source of ribonuclease banana odor components. volatile components of bananas. part i. isolation of an odor concentrate. part il separation and identification lipids of algae. ill. : the components of unsaponifable matter of the algae chlore]la volatile esters of bartlett pear. ii studies on the nutritive value of raw and cooked soybeans for growing rats and swine and their effect on fat firmness characterization of fruit juices by acid profiles nitrate content of beets, collards, turnip greens lysine fortifications of wheat bread fed to haitian school children studies on the flavor of green tea. par~ iv. : dimethyl sulfide and its preeursor funktionelle eigenschaften yon lehens-mittclst~rken ~)ber das vorkommen yon xylit im speisepi]z champignon ein beitrag zur znsammensetzung yon apfeisinens~ften aus spanischcn und l~iarokko-apfelsinen an examination of the free amino acids of the common onion (allium cepa) a trypsin inhibitor in wheat flour the protein quality, digestibility, and composition of algae, chlorella chemical and color changes in canned apple sauce digestibility of the a-cellulose and pentosan components of the cellulosic mieelle of rescue and alfalfa safeness and serva. bility of meringued pie alcoholic beverages diurnal-nocturnal changes in the starch of tobacco leaves sugar and sugar products modification of flour proteins by dough mixing: effects of suffhydryl-blocking and oxidizing agents ~ber das haferprotein. z. lebensmittel-untersuchung u sodium and potassium in wines and distilled spirits non-volatile organic acids of the dwarf cavendish (chinese) variety of banana~ biological evaluation of soybean meal and cottonseed meal by amino acid digestibility and protein efficiency ratio studies. oiss. abstr. [ ] l~r oxidation-reduction potentials of sak~f and synthetic sak . xi.: on the relationship of the various fermenting processes of sak~ to oxidereduction potentials and indicator time test (i.t.t.) values of sak mash neue wege zur ern~hrungsphysiologischen aufwcrtung von getreideerzeugnissen cereal products ascorbie acid in dehydrated po~es die eiweibqualit~t yon ,getoastetem" (dampferhitztem) und ungetoastetem sojaextraktionssehrot color studies on processed dried fruits studies on the basic amino acid of the soy sauces and the seasoning liquids. ii.: the quantitative changes of l-arginine in the process of soy sauces brewing studies on the flavorons substances in soy sauce. xxii. : the differences between the soy sauce made from soy bean and wheat and that made from defatted soy bean and wheat feeding value of soy milks for premature infants flavors and non-alcoholic beverages fat content and fatty acids in some commercial mixes for baked products sensory examination of four organic acids added f~ wine ber die inhaltsstoffe der robktmtanie und versuehe zu ihrcr gehaltsbestimmung. diss. univ. hamburg, . malt beverages, sirups, extracts, and brewing materials vitamin b and niacin in potatoes. retention after storage and cooking chemical investigation of some wild indian legumes zusatzstoffe der margarine. forte componen~ glyeerides of an indian fresh-water fish fat einflub des rsstgrades yon kaffce auf die extinktion w~$riger extrakte und die v[enge der trockensubstanz gaschromatographische untersuehungen yon fusclslen aus vcrsehiedchen g~irprodukten. . mitt.: problemsteilung und literaturfibemieht de voedingswaarde van aardappelen van versehillende rassen en de invloed daarop van bcmesting en bewaring eleetrophoretic separation of beet pigments studies on the growth-promoting value and digestibility of passion fruit seed oil polycyclisehe und aliphatisehe kohlenwasserstoffe dc~ tabakrauehes carotenoid, oil, and tocopherol content of corn inbreds location and possible role of esterified phosphorus in starch fractions untersuchungen fiber die chemischen u beim a]tern yon r stkaffee. . mitt.: gaschromatographische analyse der leichtflfichtigen aromabestandteile nature, origin, and prevention of hydrogen sulphide aroma in wines the magnesium contents of soil and crops versuehe zur ehemischen differenzierung der eiweibst~ffe des weizens und roggens lemon juice composition. iii.: characterization of california-arizona lemon juice by use of a multiple regression analysis weizenkeime als wertvoller rohstoff -einige fragestellungen und probleme isolation of gram quantities of a rhamnoglucoside of apigenin from grapefruit determination of distribution of water in wheat grains by interference microscopy preparation and quality evaluation of processed fruits and fruit products with sucrose and synthetic sweeteners changes in carbohydrate and phosphorus content of potato tubers during storage in nitrogen chemical composition of some natural and processed orange juices effects of various factors in the candy test zum stand der kenntnlsse fiber die v{eclmelwir-kung zwischen nativer sts und wasser some volatile compounds from cooked potatoes firmness of canned apple slices as affected by maturity and steam-blanch temperature nutritive values of ten samples of western canadian grains proteins of wheat and flour. the separation and purification of the pyrophosphate-soluble proteins of wheat flour by chromatography on dear-cellulose changes in quality and composition produced in wine by s~ gamma irradiation citrus essential oils. iii. evaluation of silician natural lemon oils mineral analysis of plant tissues a. : nature of colloids in clarified cane juices studies on amino acid content of rice. i. : amino acid composition of polished rice glutelln estimated by beckman amino acid analyzer yliichtige carbonylverbindungen in honig neue aminos~iuren in h heren pflanzen studium der wirkung der gammastrahlung auf die l-ascorbins~iure flour liplds and oxidation of sulfhydryl groups in dough zur kenntnls eincr weiteren in der sti~rke vorkommenden kohlenhydrat-komponente. ern~ihrungsforschung lemon juice composition. ii. : characterization of california.arizona lemon juice by its polyphenolic content lemon juice composition. i.: characterization of california-arizona lemon juice by its total amino acid and -malic acid content safflower amino acids amino acid composition of safflower kernels, kernel protein, and hulls, and solubility of kernel nitrogen citrus fruit enzymes. i. : ascorbie acid oxidase in oranges untersuehungen fiber die verf~rbung gekochter kartoffeln an den sorten des kulturlrartoffelsortiments ides instituts ffir pflanzenziiehtung groi~-liisewitz nutritive value of red kidney beans (phaseolns vulgaris) for chicks instability in potable spirits. ii.: rum and brandy effect of size classification and maturity on the protein content of alaska and perfection peas ma~tr~, d. c.: ascorbie acid retention and color of strawberries as related to low-level irradiation and storage time historical aoac data on four fema samples of vanilla extract the acid-extracted pentosan content of wheat as a measure of milling quality of pacific northwest wheats petroleum ether extraetables in tobacco isolation, origin, and synthesis of a bread flavor constituent the protein composition of airclassifled flour fractions * studies on the flavor of green tea. v. : examination of the essential oil of the tea-leaves by gas lipid chromatography nutritive value of starches. iv.; comparison of digestibility of natural starches estimated by a new procedure o c lebensmittel tierischen ursprungs _foodstu~$ o/animal origin n.n.: gdch-faehgruppe ,lebensmib~el. und gerichtliche chemie bericht fiber die vortragstagung des fachverbandes lebensmittelchemie der chemischen gesellsehaft in der ddr yore . bis a taxometric study of the propionic acid bacteria of dairy origin comparisons of the caseins of buffalo's and cow's milk matiirlicher gehalt und stabilit~t der carotinoide in fetten und milchprodukten. wiss. versff. dr. ges. ernhhrung antibiotics in milk vitamin a and d enrichment of nonfat dry milk some characteristics of yolk solids affecting their performance in cake doughnuts. i. effects of yolk type, level, and contamination with white proteine des eidotters post-mortem changes in the muscles oflandrace pigs t~ber den fettgehalt yon flcischkonserven. dr. lebensmittel der einflul~ der verfahrenstechnik auf die ks jahreszeitliche einfliisse alff den gehalt der fischmuskulatur an freien ami-nos~iuren u. deren bedeutung fiir die qualitiit fangtechnik und fisch-qualit~t. fette spcei~c distribution of fatty acids in marine lipids a comparison of pigs slaughtered at three diffcrcn~ weights. i. : carcass quality and performance a comparison of pigs slaughtered at three different~ weights. ii. : association between dissection results, various measuremen~ and visual assessments a note on the effect of heat on the colour of goat's milk chemical and nutritional changes in stored herring meal. .: nutritional significance of oxidation of the oil relation of pork muscle quality factors to zinc con~ent and other properties the chemical nature of the characteristic flavor of cultured buttermilk occurence of vaniuin in hea~ed milks the electrophoretie properties of the proteins in cottage cheese curd the influence of post-mortem glycolysis on poultry tenderness seasonal variations in cod liver oil isolation and characterization of the flavor components of rancid pork some problems in the evaluation of egg albumen quality quality evaluation studies of fish and shellfish from certain northern european waters indices for lamb carcass composition subjective and objective evaluations of prefabricated cuts of beef ils, fats, and waxes die bildung yon eiskristallen in diinnen milchschichten. milchwissensehaft the incidence of bacteria in cheese milk and cheddar cheese and their association with flavour body composition of market weight pigs some factors affecting tenderness of turkey meat ovine bioenergetics and nutritional efficiency, with special reference go forage utilization die ziichtung yon fleisehsehweinen und die folgeerseheinungen, die sich insbesondere im hinbliek auf die qualit~t yon fleisch und fett ergeben. arch. lebensmitgel-ityg n the structure of highly unsaturated fatty acids of fish oils by high resolution nuclear magnetic resonance spectral analysis the fatty acid composition of the milk fat of cows grazing on ryegrass at two stages of maturity and the composition of the ryegrass hpids effect of intrauterine infusion of penicillin-streptomycin and furacin and vaginal deposition of furacin on chemical residues tevei~ in millr beziehungen zwisehen l-aseorbinsaure und milch comparison of chemical and organoleptic data obtained on thawed and unthawed frozen cod, haddock, and perch fillets die ~ m~uosfiurenzusammensetzung der ziegenmflch und des ziegenmileh-caseins food flavors and odors. meat flavor: lamb dairy products de ehemische samenstelling van visen visprodukten chemical studies on the herring (clupen harengus). vii.: collagen and cohesiveness in heat-processed herring and observations on a seasonal variation in collagen content growth and pro~eolycie activity of pseudomonas fluoresccns in eggs and egg products the fatty acid composition of some perirenal and subcutaneous beef depot fats inactivation of peroxidase in milk by homogenization a study of the "cured meat" color producing reaction and the effects of some curing adjuncts t~yoer den fettgchalt yon br'tihwiirsten stress effects, eareass composition, and carcass quality in lambs effect of chemical additives on the spreading quality of butter. ii. laboratory and plant ehurnings preliminary studies on protein and moisture relationship in fresh and proeessed hams die zusammensetzung des kuhmilchfettes in abh~ngig-keit yon der ffitterung. fette chemical characterization of off-flavors in concentrated and nonfat dry milk zur ausseheidung yon xanthindehydrase mid molybdiin in der kuhmilch copper distribution in milk during early lactation die physikaliseh-ehemischen ursaehen der hitzestabilitet yon mileheiweil]stoffen. milehwissenscha sobn~a: ~oer einige verenderungen in den caseinfraktionen normaler und anomaler milch (colostralmilch und milch an lviastitis erkrankter kiihe). milchwissensehaft some characteristics of yolk solids affecting their performance in cake doughnuts. ii. variability in commercial yolk solids zum problem des znsammenhanges zwisehen der konsistenz und der physikalischen struktur der butter. fette relationships between milk fat acidity, short-chain fatty acids, and rancid flavors in milk induced and natural inhibitory behavior of milk and significance to antibiotics disc assay testing. j. dairy sei. [ ] nr. , s. ff. ( s.). --some distribution patterns of cottage cheese particles and conditions contributing to curd shattering natural inhibitory eharacteristies of some irish manufacturing milks thermophylie aetinomycetes in milk and dairy products. mikrobiologiya the free fatty acids of purdue swiss-type eheese die zusammensetzung yon siilzen lind ihre beurteilung im regierungsbezirk diisseldorf not~ on tyrosine production in frozen stored liver studies on the muscles of meat animals. hi. : comparative composition of various muscles in pigs of the three weight groups studies on beef quality. x. effect of temperature, freezing, frozen storage, thawing, and pe on the rate of hypoxanthine production. die. food preservation t~chn increased iodine in milk as a countermeasure for ~liodine time-temperature studies of baked, loaves. meat, fish, and poultry vergleichende untersuehungon an butter und einem butter~hnli-chen umgeesterten fort. forte, seifen, anstrichmittel zur beziehung zwisehen fettgehalt und wassergehalt bei ungewa~ohener s/il~rahmbutter (fritzbutter) variation of ovine fat composition within the carcass studies on the properties of new zealand butterfat. vii. effect of the stage of maturity of ryegrass fed to cows on the characteristics of butterfat and its carotene and vitamin a contents studies on turkey body composition. . poultry sci thermal conductivity of beef studies on turkey body composition. free fatty acid, tyrosine, and ~ changes during ripening of blue cheese made from variously treated milks l : factors influencing the nutritional value of fish flour. il: availability of lysine and sulphur amino acids. canad characterization of flavor compounds isolated from evaporated milk effect of egg yolk size on yolk cholesterol concentration ~tudo immuno~lectrophor~tiquo du lair dans los divers types de mammites. i. milchwissenschaft rdsultats hemmstoffe in der anlieferungsmflch und methoden zu ihrem nachweia eiweibverenderungen gefriergetroekneter muskulatur meat and meat products effect of high doses of vitamin a palmitate on vitamin a aldehyde, esters, and alcohol and carotenoid contents of hen's eggs. brig. j. nutrition [ ] nr. , s. / . --the amounts of vitamin a aldehyde, esters, and alcohol and of earotenoids in hen's eggs and in day-old chicks nutritive value of marine oils i. : ]~lenhaden oil at varying oxidation levels, with and without antioxidants in rat diets a quantitative study of changes in dried skim-milk and lactose-casein in the 'dry' state during storage physico chemical characteristics of canadian milk fat. unsaturated fatty acids collagen content and its relation t~ tenderness of connective tissue in two beef muscles ~ber eine braune verf~rbung yon mariniertem hering. dr. lebensmitbel versuche fiber den sonnenlichtgesehmaek in mit ass markierter milch effect of unequal milking intervals on lactation milk, milk fat, and total solids production of cows wei~re untersuehungen fiber die nitratreduktase verschiedener an der reifung yon rohwurst beteiligter mlkroorganismen nutritive value of leg of lamb roasts. l~oisture, energy, protein, fat, and iodine values ~ber einige gul~sigkai~s~renzen bei konsistenzfehiern yon butter influence of linoleic acid content of milk lipids on oxidation of milk and milk fat fish hydrolysates-iii.: influence of degree of hydrolysis on nutritive value einige beobaehtungen fiber die bildung des durch lieht verursaehten oxydationsgesehmackes s.). zitat: dt. lebensmittel comminuted meat emulsions: factors affecting meat proteins as emulsion stabilizers factors related to the flavor stability during storage of foam-dried whole milk. iil effect of antioxidants upgrading the indigenous poultry of uganda. hi. : shell and egg interior quality relation between carcass composition and live weight of sheep diethylstilbestrol occurence in eggs of subcutaneously injected hens biochemical and quality changes in chicken meat during storage a~ above-freezing temperatures investigations on the allerged goitrogenie properties of milk fish and other marine products bioehemieal properties of pork muscle in relation to curing potassium content of dried milk vergleiehende histometrische untersuehungen fiber den kollagengehalt yon brfihwfirsten a comparison of the volatile compounds of fresh and decomposed cream by gas chromatography studies on the volatile carbonyl compounds in ladino clover and their influence on the flavor of milk aut~xidation of fish oils. ii.: changes in the carbonyl distribution of autoxidizing salmon oils the public health aspects of the use of antibiotics in food and feedstuffs. repor~ of an expert committee composition and digestibility of corn silage as affected by fertilizer rate and plant population factors influencing the nitrate content of forage the component sugars and rate of hydrolysis of forage hemicelhflose as related to digestibility digestibility trials on forages in trinidad and their use in the prediction of nutritive value acetyl-(para-nitrophenyl)-sulfanilamide in feeds distribution of major and trace elements in some common pasture species -dimcthyl -( , , -trichlorophcnyl)phosphorothioate) in feeds feeding value of low-moisture alfalfa silage from conventional silos ovine bioenergeties and nutritional efficiency, with special reference to forage utilization a system for naming and describing feeds, energy terminology, and the use of such information in calculating diets supplemental methionine in a sixteen percent protein diet for laying chickens l : organic arsenicals in feeds cellulose degradation by enzymes added to ensiled forages influence of corn distillers dried grains with sohbles on the feeding value of wheat silage zinc content of certain feeds, associated materials, and water der natiirliche gehalt und die stabilit~it yon carotin und carotinoiden in lieu und silage forage digestibility. benzene-ethanol extracts of forage and faeces as indicators of digestibility the prediction of the metabolizable energy content of poultry fcedingstuffs from a knowledge of their chemical composition factors affecting the metabolizable energy content of poultry feeds. facters affeeting the metsbohzablo energy content of poultry feeds unidentified chick growth factor in fish solubles diet and histamine in the ruminant. occurrence of histamine in silage ethopabate in feeds die isolierung yon apocarotinalen aus luzernemehl isoflavone contents of red and subterranean clovers metabolizable energy of some oil seed meals and some unusual feedstuffs ii methoden der untersuchung yon lebens-und futtermitteln techniques analysis of foodstuffs and feeds n.n.: gdch-faehgruppe analysis of foods by neutronaetivation techniques continuous measurement of dissolved solids in food processes by critical-angle refractometry berieht fiber die vortragstagung des fachverbandes lebensmittelchemie der chemischen gesellschaft in der ddr vom . bis a rapid test for anionic detergents in drinking water fortschritte in der lebensmittelehemio dureh moderne analysenmethoden direct potcntiometrio determination of chloride in cheese modification of the polarimetrie starch determination on hig-hamyloso corn ~iethoden der ]~berwachung des wassers auf radioaktiviuit. btmdes prediction of quality in protein concentrates by laboratory procedures involving determination of soluble nitrogen direct chromatographic analysis of milk die eignung der bakteriologischen untersuehung yon kannenmilchproben als grundlage eines eu~ergesundheitsdienstes. arch. lebensmittel-i~yg nachweis fremder carotinoide in rangensiiften mittels diinnschichtchromatographie. i)t. lebensmit~el-l~dseh determination of phosphate composition of stock food calcium phosphate. . assoe. off. agric. chemists molybdenum in plants and animals. determination of molybdenum in biological materims with dithiol control of copper interference the determination of dissolved oxygen in canned drinks using a vibrating mercury-plated platinum electrode determination of chromium and lead in periodic acid solution and dialdehyde starch the utilization of infrared and ultraviolet spectrometric procedures for assay of pesticide residues ultramicro determination of potassium and sodium in biologic fluids gum quautativen naehweis des pektins und der alginsiiure ein schliffapparat zur abtrennung yon flfichtigcn stoffen mittel~ wasscrdampfdcstillation ~tude par chromatographic on phase gazeuse des acidea gras du beurre fabriqu en italic et clans d'autres pays. application ~, la recherche des falsifications clans le bcurre commercim. ann. falsiticatiorm expertise chim note on the determination of caffeine in coffee a comparison of the press method with taste-panel and shear measurements of tenderness in beef and lamb muscles zur diehtebestimmung der milch mit der neuen milehspindel. lebensmittelchem, u. geriehtl. chem. [ ] nr. , s. / . --aufschlu -.i~thercxtrakt und titrationswert bei der teigwarenunbersuehung als beispiel einer dynamisehen lebensmittelanalyse quantitative measures of carcass composition and qualitative evaluations fruit preservatives analysis. determination of calcium in cherry brines by versenat~ titration: elimination of anthocyanin interference by means of carbonyl reagents, g. agric. food chem allgemeine prinzipien der analytik yon carotinen und carotinoiden zur bestimmung yon ethoxyquin kolorimctrische bestimmung yon dipterex-riickst~nden yon lebensmittein the direct determination of shear stress-shear rate behavior of foods on the presence of a yield stress methods for evaluating bhe feeding quality of meat-andbone meals a paper chromatographic method for determination of vanillin and ethyl vanillin in vanilla flavorings ~drber die anwendung der papierchromatographisehen analyse auf dem fettgebiet. . mitt.: uber ls~iurereiehe samenole. ermittlung der konsti~uierenden fettsiiuren der samensie yon margosa (azadiraehta indies), cashewkern (anacardicum oecidentale) und putranjiva roxburghli. nahrung die jodzahl des riickenspeeks im verhiiltnis zu der qualit~t des futterfettes, dem alter der schweine und dem fettungsgrad bei sehweinen der ditnisehen landrasse determination of parathion, methyl parathion, epn, and their oxons in some fruit and vegetable crops an improved chromatographic method for determining trace elements in foodstuffs determination of guthion residues on fruits techniques used in meat flavor research the analysis of edible oils contaminated with synthetic ester lubricants colorimetrische bestimmtmg yon nitrat und nitrit in biologisehem material confrontation de quelques proe~d s de dosage iodometrique de l'anhydride sulfureux dans les vins zur anwendung der massenspektroskopie zur strukturermittlung yon naturstoffen, mit besonderer berfieksiehtigung der lebensmittelanalytik z lebensmittel cellulose solubility as an estimate of cellulose digestibillty and nutritive value of grasses the -thiobarbiturie acid reagent for determination of oxidative rancidity in fish oils bet die eignung yon daphnia magna zur ermittlung yon riieksti~nden auf frisehem bst und gemfise bemcrkung zum diinnschiehtchromatographischen kakaoschalennaehweis nach the determination of vitamin a in animal tissues and its presence in the liver of the vitamin a-deficient rat elution column preparation of leaf sample for flame photometry. ii. : determination of calcium in tobacco enzymatic-ultraviolet method for determination of uric acid in flour die bestimmung der amyiaseaktivit~t und einige studien fiber amylaseaktivit~it in gekeimtem roggen identification and determination of ascorbic acid (vitamin c) with janus green and its localisation in mitochondria cho]estehnbestimmung im kleinen laboratorlum chick edema factor. iii.: application of mieroeoulometric gas chromatography to detection of chick edema factor in fats or fatty acids bioassay of chick edema factor. collaborative study determination of nih te and nitrate in meat products the measurement of the surface areas of milk powders by a permeability procedure sedimentbeurteilung und sehaim-~iastitis-test als sortierverfahren zur ermittlung yon sekretionsstsrungen bei der ~iassenuntersuchung yon milchproben aoac methods for nutritional adjuncts die ermittlung der ribonucleins~ure im pflanzenmaterial beitrag zur analytischen beurteilung des frischezustandes der pharmazeutisch verwendeten e und fe~te sehnellbestimmung yon kupfer in fe~n applications of oscillographic polarography to the determination of organophosphorus pesticides. ii. : a rapid screening procedure for the determination of parathion in some t~its and vegetables zur standardisierung der vitaminb~-bestimmung in getreide und getreideprodukten eine mikromethode zur bestimmung des fettgehaltes der milch kleiner laboratoriumstiere the determination of organophosphato pesticides and their residues by paper chromatography die l~fikrochemie beim studium yon nahrung und erni~hrung aearicide residues. an improved method for kelthane residue analysis with applications for determination of residues in milk collaborative study of the determination of ethoxyquin in feeds ~rber den naehweis yon quellstoffcn in fleischwaren und m gliche stsrungen durch andere polysaccharide ersatz manueller labormethoden der l sungsspektralanalyse durch den automaten determination of total acids in wines: american society of enologists determination of aldehydes in wines and spirit~ by the direct bisulilte method ~fber einen vereinfachten nachweis des vitamin b mit poteriochromonas slipitata extraction of nys~tin in animal feeds for microbiological analysis zur quantitativen bestimmung der sorbinsi~ure mit dem thiobarbitur-s~urereagenz cottage cheese problems in production and sanitation. quality control in cottage cheese sitzung des arbeitskreises berlin der gdch-fachgruppe lebensmittelchemie und gerichtliche chemie am . . in ]~erlin-dahlem ( vortragsreferate) ein neues elektronisches sctmeuverfahren zur ermittlung der ~risehe yon seefischen fatty acids of lard. a. identification by gas.liquid chromatography oxydative abbauprodukte der l-aseorbins~ure. . mitt. : papierchromatographischer l~achweis analysis of orange juice for total earotenoids, carotenes, and added betacarotene. food technol. [ ] nr. , s. / . u. r~ck~, a. a. : refractometrio measurement of soluble solids in orange juice analysis of iron chelates in plant extracts. il: ferric ethylenediamine'bis'(~ acid) determination of n-aeetylglucosamine- -phosphate and n-aeetylglucosamine in milk arsenic in foods: collaborative comparison of the aminemolybdenum blue and the silver diethyldithiocarbamate methods improved method for testing macaroni products neuere beitri~ge zur chemic der st~rkefraktionen. . mitt.: die mikro-ameisens~urebestimmung bei der perjodat- xydatonsbestimmungsmethode yon stiirke recherche des falsifications dans les extraits de vanille. ann. falsifications expertise chim bestimmung des gesamtstckstoffgehaltes yon milch nach der kjwld~t:l-methode. internationaler standard fil vorteile und grenzen des einsatzes yon markiertem phosphat bei untersuchungen am hiihnerei paper chromatography of carotene and carotenoids determinaton of sevin insecticide residues in fruits and vegetables insecticide residues in meat and eggs. determinaton of sevin insecticide and its metabolites in poultry tissues and eggs bcstimmung der jodzahl yon fetten und en mittels n-bromsuccinimid. . mitt.: l~ber eine !~i gliehkeit zur bestimmung der gesamtjodzahl yon el~iostearins~ure und holz . nahrung [ ] nr. , s. / . kxrr:~e~r, m. a. : ~ ber die anwendbarkeit des thiobarbi~urs~iuretestes boi der untersuchung yon milchprodukten application of gas chromatography to the measurement of gas permeability of packaging materials a sensitive method for quantitative microdetermination of lipids comparison of chemical and microbiological methods for the determination of procaine penicillin in prcmixes and mixed feeds electrophoretc analysis of flour proteins from various varieties of wheat katalytische methode zur bestmmung kleinster manganmengen in lebensmitteln am beispiel der milch eine methode zur papierchromatographischen qualits yon silagen comparison of methods of measuring potassium in pork and lamb and prediction of their composition from sodium and potassium electron capture gas chromatography for determination of ddt in butter and some vegetable oils eine methode zum schnelinachweis yon nitriten in yleiseh-und wurstwaren. arch. lebensmittel-hyg determination ofglyodin residues on pears and peaches eleetrophoretic analysis of flour proteins erstes internationales symposium fiber methoden zur analyse yon lebensmitteln in bordeaux-tatence (frankreich) veto . bis . oktober on the problem of luminescence technique of protein definition in milk beitr~ge zur aminos/iuren-bestimmung in biologischem material aktuelle fragen der lebensmitteluntersuehung, insbesondere der histologischen wurstanalyse untersuchungen yon importiertem tiefgefrorenem tiasenfleisch argentinischer herkunft fish hydrolysates. iv.: microbiological evaluation untersuehungon zum naehweis yon emulgatoren in lebensmit~eln. . mitteilung. forte use of a slice-tenderness evaluation device with pork studies on improvements in quantitative paper chromatography of amino acids in foods. i. : research on procedure of development studies on improvements in quantitative paper chromatography of amino acids in foods. ii.: selection of solvent systems determination of the equilibrium relative humidity of foods untersuchungen fiber die methodik der quantitativen bestimmung yon heizolen und flfissigen treibstoffen im wasser determination of ~-lactalbumin in complex systems hydrogen sulphide in cheddar cheese; its estimation and possible contribution to flavour ascorbic acid measurement. polarographic determination of total ascorbic acid in foods trans-fettsguregehalt yon sehweineschmalz nach fiitterung von schweinen mit rindertalghaltigem kraftfutter. (ein beitrag zur quantitativen infrarotspektroskopischen bestimmung yon trans-fetts~uren in fetten the importance of starch on the microscopic identification of cereal grains in feeds insecticide residues. chromatographic identification of some organophosphate insecticides in the presence of plant extracts chemical and biological estimation of the carotene content in fresh and processed italian apricots sialir acid as an index of the u-casein content of bovine skimmilk foodstuffs analysis. nonvolatile acids of blueberries le dosage de la matibre grasse dans les fromages. ]~tude critique de la m thode en usage au laboratoire municipal la d termination de residus d'insecticides et de fongieides par la m thode polarographique fusel oil determination by gas.liquid chromatography * die brabanter mastitis-reaktion, ein neues verfahren zur ermittlung yon sekretionsstsrungen des euters dutch die kannenmilchuntersuchung uber eine enzymatisehe _&pfels~urebestimmung in wein und traubensaft direct microscopic technique to detect viable yeast cells in pasteurized orange drink die enzymatisehe bestimmung der glucose und saecharose und ibre anwendung in der lebensmittelanalyse a modified zirconium-alizarin method for determining fluoride in natural waters paper chromatography of some cholesterol derivatives determination of moisture by nuclear magnetic resonance and oven methods in wheat, flour, doughs, and dried fruits dye binding by soybean and fish meal as an index of quality the absorptiometrie determination of silicon in water: part l: formation, stability, and reduction of cr and fl-molybdosilicie acids column chromatography of soybean whey proteins enzymatic determination of carbon dioxide in lightly carbonated wines. collaborative study nachweis yon biiffelmilch als verf/flschungsmittel in kuhmilch durch serologisehe methoden photometric determination of phosphate in wines pertinent references to analytical lipid methods published recently, ft spectrophotometric estimation of nucleic acid of plant leaves hemmstoffe in der aalieferungsmilch und methoden zu ihrem nachweis determination of potassium in tobacco determination of chlorides in tebacco phospholipase c determination by egg yolk turbidimetry oher die inhaltsstoffe der rol]kastanie und versuche zu ihrer gehaltsbestimmung mierobiologlcal method for assaying nystatin in animal feeds / ] nr. , s. / . --gaschromatographische untersuchungen yon fuselslen aus versehiedenen g~rproduk-ten. . mitt.: methodik der fusel bestimmung lactose activity measurements. evaluation of laetase preparations for use in breadmaking comparison of methods for determination of lysino in cereals direct determination of calcium in plants, soils, and milk by means of a flame photometer colorimetrie determination of urea in feeds kolorimetrische bestimmung des dihydrox-yacetons fluoride, teeth, and the analyst the quantitative micro-determination of biphenyl in citrus fruit kolorimetrisehes verfahren zur gleichzcitigen bestimmung der weinsiiure und milchsiiurc in wein und most estimation of extra-cellular starch of dehydrated potatoes versuehe zur chromatographischen trennung yon kohlenhydra~en und eiweil en aus dem w~ibrigen extrakt yon roggenvollkornmehl quantitative determination of the amino acid content of rumen fluid from twin steers fed soybean oil meal or urea vemnche zur chemischen differenzierung der eiwei•stoffe des weizens und roggens aromastoffe des brotes. versuch einer auswertung chemiseher gesehacksanalysen mit hilfe des schwellenwertes zur trennung yon sacchariden an kohle]celit~-s~ulen. ern~hrungs-fomchung untersuehungen zur bestimmung der lsslichkeit yon milchpulver * selection of a medium for the isolation and enumeration of enterocoeei in dairy products colorimetric determination of amino nitrogen in corn syrups stxogene und versuche zu ihrem nachweis in gefliigelflelsch. dt. lebensmittel ein beitr~g bert. die verwendung der anatysen-q~arzlampe zu friihzeitiger erkennung der l~anzigkeit colorimetrlsche methode zur bestimmung yon -monoglyceriden in eiskrem determination of fusel oil in distilled spirits zu den m glichen fehlerquellcn bei der histometrischen ermittlung des kollagen-, bzw. gelatine-gehaltes bei briihwiirsten studium der uv-spektren der auf hshere tempcraturen erhitzten e measuring of oil-binding characteristics of flour naehweis der konservierungsmittel mit hilfe cl~r papierehromatographie identification of ch]orogenic acid in castor bean and oranges. canad evaluation of forages in the laboratory. iii.: comparison of various methods for predicting silage digestibility feed microscopy essential oils. determination of botanical and geographical origin of spearmint oils by gas chromatographic and ultraviolet analysis fluorometric determination of chlortetracycline in premixes dfinnschicht-chromatographie yon carotin-und carotinoidgemischen measurement of the sub-sieve particle size distribution of flour chemisehe bestimmung der riickst~nde yon parathion, malathion und diazinon auf blumenkohl, kohlrabi, bohnen und gurken determination of cadmium anthranilate in feeds nachweis yon penicillin und anderen antibiotika in milch microbiological evaluation of protein quality with tetrahymenapyriformis w. .: a simplified assay procedure peanut lipoprotein. ii. : analysis in foods by gas chromatography beitrag zum papierchromatographisehen und spektrophotometrisehen i~achweis fettlsslieher synthetiseher farbstoffe in lebensmitteln und kosmetika elektroehemische sauerstoffbestimmung in olefinischen fetich bestimmung der gesamten sehwefligen s~ure in getr~nken the modified whiteside test. recommended procedures for bulk or blended milk deliveries die bestimmung yon mileheiweib in fleiseherzeugnisscn. dr. lebensmittel zur bestimmung des veresterungsgrades yon pektin a quantitative fluorometrie method for the determination of serpasil (reserpine) in feeds at the micro level fluorimetric mierodetermination of carbohydrates zur l~iethodik der klebrigkeitsbestimmung yon brot frage der papierchromatographischen untersuchung von amylopektin und amylose chemical determination of diethylstilbestrol residues in the tissues of treated chickens gas chromatographic identification of components in m~ple sirup fl~vor extract dark discoloration of canned all-green asparagus. ii. development of a new tin plate for its control thermal conductivity and density of chicken breast mnsele and skim beitrag zur bestimmung der fluoreszenz in spriten microbiological determination of alanine in proteins and foods collaborative study of the method for counting microorganisms in maple sirup glass fiber paper strip charring. a rapid and simple method for monitoring column chromatography of lipids verbesserte mcthode zum serienm~bigcn quantitativen nachweis yon insektizidrficksti~nden bei bst und gemfise use of the shear press in determining fibronsness of raw and canned green asparagus betrachtungen fiber verschiedene methodcn zur bestimmnng des bindegewebeanteiles in rohem fleisch und fleischwaren. arch. lebensmittel-hyg the determination of citric acid in milk and milk sera formaldehyde in maple sirup: an adaption of the nash method polarographische bestimmung dcr ascorbinsiiure und des gesamt-vitamin c untersuchungcn fiber die mbglichkeit zur objektiven beurteilung der organoleptischen eigensehaften yon kokosraspeln analysis of the flavor and aroma constituents of florida orange juices by gas chromatography assay for cyzine in finished feeds dfinnsehicht-ehromatographische trennnngen yon synthetischen lebensmitteffarbstoffen auf ceuulose-schichten evaluation of quantitative methods of determining peroxidase in vegetables. i.: the indophenol and the o-phenylenediamine methods ein beitrag zur untersuchung thermisch oxydierter fette. dt. lehensmittel a more accurate method for determination of caffeine in decaffeinated coffee bestimmung yon vitamin c in friichten, fruchtsiiften, gemiise und konserven naeh der methode naeh tillma~s unter ausschaltung reduzierender stoffe lebensmittelrecht und lebensmitteliiberwaehung nutritional laws and nutritional control briihwiirst~ einfaeher qualit~t, die zu einem kaliber unt~r mm in den verkehr gebracht werden, sind i.s. des w nr. lmg irreffihrend aufgemaeht new regulations under the food and drugs act lebcnsmittel-rdseh orb der kenntlichmaehung fremder stoffe probleme des geltenden lebensmittelrechts glasurmittel ftir r stkaffee beschr~nkt zugelassen food technol. [ ] nr. , s. . n. iv. : revised u. k. preservatives regulations. food teehnol ausschub fiir lebeusmittelrechtliche fragen der fachgruppe lebensmittelehemio und gerichtliche chemic in der geseuschaft dcutscher chemiker vi. t~tigkeitsberieht der eidg. kommission fiir volksern~hrung, lebensmittelgesetzgebung und -kontrolle (eek) zu h~nden des eidg. departementes des i_nnern, umfassend die jahre federal food, drug, and cosmetic act, as amended. selected u. s. government publ. nr. ; h. catalog i~o verkauf yon frikadellen mit brotzusatz in gastwirtsehaften tierarzneimittel und aufzuchtmittel in der landwirtschaftlichen praxis. gesundheitliche erw~gungen zum schutze des konsumenten bei der anwendung yon tierarzneimitteln und aufzuchtmit~ln in der landwirtschaftliehen praxis. teil hi der amtsarzt und das neue lebensmitt~lgesetz. off ist der beschlub des bundesgerichtshofes vom . . - stl~ -geeignet, den vertrieb yon hackfleiseh befriedigend zu regeln ? arch. lebensmittel-hyg zur beurteilung des saccharingehaltes yon meerrettiehzubereitungen. dt. lebensmittel zum begriff ,mai]gebend" in w a abs. des lebensmittelgesetzes aspect sanitaire et ldgal actuel des aliments conservds verbrauchererwaxtung und lebensmitte]kontrolle bei fleiseherzeugnissen bei ger~ueherten fleischwaren. sehwarz-w~lder speck, schwarzw~lder sehinkenspeck, sehwarzw~lder sehinken. arch. lebensmittel-ttyg kampf der wasserverseuchung. aktuelle notwendigkeiten -gesetzliehe ~/isgliehkeiten. ~iiinchener reed. wschr. lebensmittelreehtliehe stellung yon carotin und carotinoiden in der schweiz die lebensmittelgesetzgebung sterreiehs, der sehweiz und der bundesrepublik deutschland. eine vergleiehende untersuchung arzneimittel-lebensmittel dr. lebensmittel-rdseh erwiderung des autors (zur stellungnahme yon f. nitzsc~, d~. lebensmittel-rdseh. [ ] nr. , s. ). i)t. lebensmittel das lebensmittelgesetz und seine auswirkung auf die gummiindtlstrie codex alimentarius austriacus absehliel]ende stellungnahme der ort der kenntlichmachtmg fremder stoffe. dr. lebensmittel-rdsch _rreffihrende bezeiehnung und angaben bei limonade aus mineralamem tafelwasser. dr. lebensmittel zur herkunftsbezeichnung yon lebensmitteln. dt. lebensmlttel aktuelles zur lebensmitteliiberwachung einige beispiele fiir die auswirkung der neuen lebensmittelrechtliehen vorschriften auf erniihrungs-und landwirtschaft auf dem wege zum einheitliehen lebensmittel-rech~ zur ~r yon b. rsssl~: welehe anforderungen sind an alkoholhaltige siigwaren zu stellen? dr die silbertmg yon tafelwiissern mokka-kaffee" auch im handel mit kaffeebohnen keine tterkunftsbezeiehnung [ ] nr. , s. . --zuliissigkeit trod grenzen bildlicher darstellungen yon fleiseh und ylelscherzeugnissen auf paclmngen yon suppen in trockener form. db. lebensmit~el-l~lsch bedeutung und beur~eitung yon galtstreptokokken in vorzugsmileh. arch. lebensmittel-hyg auf clipverschliissen zul~ssig ist die infektion mit trichinen aus amtlich untersuehtem schwelnefleiseh im lichte der mathematischen analyse der bestimmungen der fleischbesehau yon schweinefleiseh msglich? arch. lebensmittel-hyg intema~ionales rundgespr~ch fiber lebensmitte]ehemische probleme in wiesbaden und eltville a. rh. z. lebensmittel-untersuch. u. -forschung. [ ] nr. , s. . --kommission zur priifung fremder stoffe bei lebensmitteln (fremdstoff-kommission) der deutsehen forsehungsgemeinsehaft entwicklung des lebensmittelrechts im nationalen und internationalen bereich entwicklung des lebensmittelrechts im nationalen und inter~ationalen bereich entwicklung des lebensmittelrechts im nationalen und internationalen bereich de warenwet en de hierop berustendc besluiten zum entwurf einer harmonisierung der lebensmittelrechtlichen bestimmungen fiber konservierungsstoffe im gebiet der europaischen wirtschaftsgemeinschaft. er lebensmittelrechtliche stellung yon carotinen und carotinoiden in der bundesrepublik deutschland die instrumente der lebensmittelfiberwachung in osterreich sterreichischer standpunkt zur l~rage der f~rbung yon lebensmitteln mit carotinen und carotinolden. wiss. ver ff. dr. ges. ernkhrung lst es zu vcrtreten, dab das fleisch schwacbfinniger rinder auch in gebr~tetem zustand eingefroren wird? z lrch. lebensmittel-iiyg richtlinien fiber die zulassung yon gegeusachverst~ndigen zur untersuchung yon lebensmittel-gegenproben die ]ebensmittelrechtliche bedeutung yon bildiichen darstellmlgen auf verpackungen diverse problems (education, documentation associations, terminology etc the nutritional education of the food technologist proposed formation of a food engineering panel within the food group studium der hauswirtschafts-und ern~hrungswissenschaften. ern~hrungswirt-sehaft l an information service for the american food industry st international congress of food science and technology. symposium on education and training technically trained people for developing countries lft paces the food frontier un committee on food additives international standardization of fruit and vegetables. food technol terminology and methods for feeding and weighing animals food additives and food standards beitriige zur durehffihrung der umweltsradloaktivitiits- berwaehung training dairy personnel in denmark training opportunities for the sanitarian-specialized in-service training r die benennungen honigkueheniihnlicher oebiieke als lobkuehen und lebzelten sowie als biber und bibenzelten. dt. lebensmittel nutrition and dietetics for the medical student problem of keeping dairy plants supplied with the foreman-type employee literaturdokumentation fiir hochschulassistenf~n a system for naming and describing feeds, energy terminology, and the use of such information in calculating diets a brief sketch of veterinary periodical literature in great britain before the foundation of the veterinary record a conference on nutrition teaching in medical schools the food service industry and its relation to the control of foodborne illness research and educational progress in nutrition informationsm gliehkeiten fiir tieriirzte auf dem measuring readability of health education literature the dai~y literature problem the central food technological research institute the education and function of the nutritionist training in food service for nursing homes. l: tools for evaluation training in food service for nursing homes. iii.: observations on management of twelve units pennsylvania takes a look at nutrition in the orthopedic program zur definition der begriffe ,aroma" und l~ber die notwendigkeit einer priifung for beamtete sehlaehthofleiter. arch. lebensmittel-hyg organisation der dokumentation in einem forschungsinstitut (bundes. forsehungsanstalt f'tir lebensmittelfrischhaltung in karlsruhe). dt. lebensmittel-rdsch on changing the name of our assoziation. for a name change pporbunities in nutrition education questionnaires to identify nursing homes most in need of dietary counsel. publ. health irep lebensmittelwissenschafttiche institute in bulgarien zur stellung des psychiaters in der alkoholfrage naas nutrition chemists. vcter on changing the name of our association. against a name changing begriffe) in sprachen: deutseh, russiseh, polnisch, tsehechisch, slowakisch, ungariseh, bulgariseh, serbokroatiseh, rum~nisch, englisch the role of nutrition in the teaching of medicine key: cord- -zjr csla authors: hillman, john r.; baydoun, elias title: food security in an insecure future date: - - journal: water, energy & food sustainability in the middle east doi: . / - - - - _ sha: doc_id: cord_uid: zjr csla food security in the middle east is directly affected by a challenging combination of ongoing destructive conflicts, a global economic downturn, widespread poverty, high population growth, corruption, intolerance, and the potentially damaging consequences of climate change. many arab countries demonstrate nearly all the features of those countries classified as poor, less developed, or failing to achieve the eight millennium goals. even the economies of the richer oil-exporting countries in the region have been seriously damaged by the downturn in oil and gas prices as new sources come on stream elsewhere and demand falls as a result of renewable sources of energy becoming available. in a previous article , we considered definitions of food security in the modern era of rising global populations, discussing how food security might be attained in terms of security of water and fossil-fuel-derived energy supplies, climate change, rapid urbanisation, changing dietary trends, and modification of the natural environment leading to depleted natural resources, increasing environmental pollution, and the need to introduce modern technologies. the concepts of sustainable agriculture and uncertainty were also addressed, notably in respect of fresh thinking about key components of agricultural systems. these included (babu and blom ) vertical and horizontal integration of farming-related businesses to allow adequate capitalisation for enhanced efficiency measures; (bardshaw and brook ) policy shifts to remove market-distorting subsidies, tariffs, import and export bans, and excessive bureaucracy; improved crop and livestock breeding, including entirely new species; (bolukbasi et al. ) automation in agriculture and horticulture; (breisinger et al. ) protected cropping; (cong et al. ) new-generation agrochemicals; (elasha ) new agronomic practices; (fan et al. ) novel foodstuffs; (fao ) habitat reconstruction and land renovation; (fao ) biofuels and biodiesel; (garland et al. ) periurban and urban agriculture; (grebner et al. ) industrial biotechnology; (grivetti and ogle ) farming the seas and oceans; long-term carbon storage; and (hillman and baydoun ) new ways of thinking about carbon trading. more recently, we reviewed mitigation and adaptation processes and strategies to address the impacts of climate change on food, water, and energy security in the arab middle east (hillman and baydoun ) . here, we consider potential adaptations to an insecure global future generally, and to the concerns in the arab middle east specifically, in the light of the economic realities of wide disparities in wealth, competition for resources, and widespread poverty in many parts of the globe, coupled to a relatively high population growth, on-going conflicts, attempted cultural genocides, potential conflicts, endemic corruption and nepotism, and epidemics of infectious diseases. most arab countries are classified as poor, less developed, or failing to achieve the eight millennium goals of the united nations, and these arab countries share several undesirable features (table ) . even the much richer oil-exporting arab nations are under pressure. after a decade of relatively high oil prices, these nations have accumulated more $ . trillion in sovereign assets reinforced by substantial infrastructural investments supplemented by high levels of spending on imported military hardware. now, however, oil prices are under pressure as global oil and gas prices slumped in and remain depressed, possibly for the medium to long term as new sources of oil and gas come from hydraulic fracturing (fracking) and from iranian exports as the economic blockade on iran is being relaxed, coupled to greater energy efficiency in industry and new sources of renewable energy. this price depression has exposed the degree to which the economies of these arab oil exporters are dependent on oil and their failure in most instances to diversify their economies as their populations continue to expand alongside public expectations of continuing governmental largesse. nearly all of the immediate adaptations arab countries must undertake in order to adjust to a raft of severe insecurity issues require strategic planning and value-for-money infrastructural and civil-society improvements, and any preparatory changes in rural and urban areas will differ in scale and design. longer-term adaptations will be reliant on more stable conditions and a stepwise improvement of educational standards and attitudes. at the time of writing, no arab country is deemed to have acceptable levels of budget transparency according to the latest open budget index released by the international budget partnership (see www.internationalbudget.org). the future is especially insecure because of the persistence in the region of a combination of incompatible political and economic ideologies, religious and ethnic groupings overtly intolerant of others, introvert nationalism and disrespect of others, disconnection from democratic principles, profound cultural divides, ignorance -some wanton, inability to adapt to modernity, and malevolent community and national leaders. from a noble history of toleration, hospitality, and learning, arab society is fragmenting, defiled by the actions of relatively few. arabs are killing arabs either directly or indirectly; arabs are inflicting as-yetuntold horrific crimes on other arabs either directly or indirectly. attacks on arab countries by their neighbours might be used as an excuse to divert attention from their own failing donor-dependent economies or social structures, or most often to steal resources and ensure that the neighbouring country is suppressed from developing normally. at the global level, many would say that future conflicts and insecurity in much of the world are inevitable, simply because of the impacts of expanding global populations and the obvious competition for limited resources. the intensity of this competition must be analysed in context of the alarming table fourteen features of countries classified as poor, less developed, or failing to achieve the eight united nations millennium goals. the listed features are closely interrelated . poverty common in both the urban and especially the rural poor, poverty is sometimes concentrated in regions, often in marginalised ethnic or religious groups, and may relate primarily to girls and women. many of the urban poor operate in the unofficial economy. the rural poor tend to be land-constrained, dependent on rain-fed, low-yield subsistence agriculture with little or no access to modern technology (modern cultivars and livestock breeds, fertilisers, pesticides, automation, agronomy advice, veterinary support), and usually do not own their land. the rural poor encounter barriers to trade (e.g. transport, storage) and are unable to meet quality assurance standards. with no or limited access to social benefits (primarily pensions, child support, education, training, and healthcare), the poor may be hungry, thirsty, suffer ill health and low standards of accommodation, and die early. the poor are susceptible to exploitation. . hunger and thirst access to food and potable water may involve substantial travel on foot, and the basic requirements may only be met wholly or in part by humanitarian assistance. food quality and safety are usually low, and cooking is often dependent on wood for fuel. symptoms of malnutrition are prevalent. . disease slum dwellings, insanitary conditions, poverty, and hunger lead to a vulnerability to pandemics, made worse by poor or no public health provision. high maternal and child mortality and low general life expectancy characterise poverty and there is a reliance on traditional and/or herbal medicine. crops and livestock are subject to catastrophic attacks by pests and diseases. . poor environmental management poor countries suffer a depletion of their natural resources, including freshwater supplies and native flora and fauna. mineral and fossil-fuel resources are extracted to be exploited by industries in other more-developed countries. land, water, and the atmosphere may be polluted with few or no remediation efforts. national, regional, and international environmental regulations are not properly implemented. agricultural soils tend to be subject to erosion, salination, solarisation, desertification, and nutrient depletion. even without climate-change predictions, the general anthropogenic environmental degradation currently taking place increases the vulnerability to flooding, sand storms, ill health, and displacement of peoples. most poor countries are enduring adverse climate trends, and climate-change predictions point to even harsher conditions (erratic rainfall with rising temperatures, heat waves, hot extremes, and storms; rising sea levels and acidification of seas and oceans; increased desertification with effects on agriculture as well as the natural flora and fauna; socio-economic and health implications). . poor infrastructure quantity and quality of the built infrastructure tends to be low, or even absent (e.g. roads, ports, airports, telecommunications and access to the internet, hospitals and clinics, reliable power and fuel supplies, potable water sources, sanitation systems and sewage disposal, protected natural environments, cold and pest-free storage of agricultural and horticultural produce). the cost of living is worsened by relatively high overland transport costs. facilities may be inadequate to meet demand and maintenance neglected. rapid urbanisation and conflicts exacerbate infrastructural deficiencies. . corruption political autocracy coupled to a lack of transparency in government and public services, a weak judiciary, lack of consultation on major issues, and suppressed media enable a climate of corruption and nepotism to permeate all areas of society, including schools, colleges, and universities. a low regard for human rights, democratic processes, health and safety measures, and international law, is made worse by an overburdensome bureaucracy (staffed by poorly paid civil servants and police) dependent on bribery to function. corruption allows laws to be broken with impunity, and protests ignored. in most areas of society, a lack of altruistic leadership and (continued) poor countries manufacture few value-added products, offer little or no advanced training, and lack participation in the global knowledge economy. there is little or no foreign direct investment and free trade is constrained. financial assistance from donor countries is increasingly being audited to ensure compliance with attempts to prevent unauthorised expenditure. many poor countries have not managed to have constructive relationships with potential donor countries, and some try to align themselves with one of the main international political power blocs. unrelieved debt burdens have led to high interest rates on loans and difficulty of obtaining credit. private savings are minimal and the country may be subject to periodic flights of capital. their economies are grossly imbalanced with little spent on healthcare, education, and other social benefits compared with defence and vanity projects. the economy may be damaged by previous and/or ongoing conflicts, and may in any case have limited absorptive capacity properly to manage additional resource inflows and outflows. agriculture, unofficial transactions, and remittances from those working abroad contribute disproportionately to the real economy. . poor education limited or no access to free schooling accounts for a general low level of literacy and numeracy, especially of females. this is reflected in the absence of high-grade internationally competitive universities, colleges, and research institutes, despite a high level of parental financial sacrifice to secure a supposedly good education for their children. science and technology tend to be poorly taught and there is undue influence of religions with regressive attitudes to modernity. a lack of investment in research and development (r&d) and a lack of a critical mass of scientists, engineers, and technologists impede industrial development, and prevent those that remain from joining international consortia, participate in learned societies, access essential literature and training programmes, and have the opportunity to use state-of-the-art instrumentation, software, and laboratory consumables. the best educated and the most talented and entrepreneurial usually emigrate, leading to a brain drain. intellectual property rights are often ignored and little benefit is derived from traditional knowledge and its products tend to be exploited in other countries. crucial demands and needs of less-developed countries are rarely the targets of major international r&d projects. . gender inequality low educational attainment in most girls and women is reflected in female political, economic, and social representation and participation failing to match their proportion of the general population. cultural and religious influences often lead to females being regarded as inferior to males. family planning is limited, and in the absence of social security and reasonable incomes, large families are the norm. . high population growth this is a feature of the poorest social groups, and correlates with low life expectancy and gender inequality. in some countries high population growth may exceed the economic capacity of the country to feed itself, leading to a propensity to generate refugees, displaced persons, and terrorists. . vulnerability to transnational terrorism terrorism often relates to a combination of one or more of the following: poverty, hunger, poor educational attainment, disconnection from democratic principles, susceptibility to indoctrination by intolerant religious ideologies, criminal activities, and psychiatric disorders. poor countries are usually unable to defend themselves from terrorists, and groups of terrorists may receive covert support from other countries and agencies. poor countries may form the battlefield for fighting between different groups of terrorists. recovery from terrorism and conflicts in general may take several generations, and lead to psychological and physiological after-effects in the survivors and their progeny. projected changes and options for adaptation as well as mitigation (curbing emissions) detailed in the latest fifth assessment report of the international panel on climate change (ipcc, www.ipcc.ch/). the immediacy of food security during social instability in the arab region forms the backdrop to this article, rather than the longer-term infrastructural and social transformations needed to mitigate and adapt to climate-changing emissions, transformations that demand political stability and sophistication. the global population is estimated to be around . billion at present and there is an % probability that it will increase to between . billion and . billion in (garland et al. ) , so stabilisation of the population is highly unlikely this century. moreover, human population reduction is not a quick fix for environmental problems, and even a catastrophic event that killed billions of people would have relatively little effect on the overall impact of humans on the environment . weak public sector low salaries, complex and inefficient bureaucratic processes, poor educational attainment, incompetence, widespread acceptance of corruption through bribery and political interference, and the lack of an investigative free media, account for the justifiable lack of confidence in the public sector. a low regard for human rights, legal processes, and justice undermines societal advancement. there is also poor custodianship of cultural heritage and essential infrastructure. . neighbouring countries many poor countries have reliance on and vulnerability to neighbouring countries for access to water, transport and communication networks, foodstuffs, energy, control of environmental issues (e.g. desertification, flooding, biodiversity protection, pollution etc.), and security. neighbouring countries may (a) create security problems by aiding terrorists and insurgents, (b) provide an uncontrolled source of refugees, (c) invade, (d) steal water or other natural resources, and/or (e) issue mendacious media releases or operate diplomatically to undermine the confidence of donor countries, aid agencies, and investors. the more-developed countries rarely understand the sheer difficulty of managing a poor country facing inter-ethnic conflict, and terrorism and poverty. . international agencies, non-government organisations, international media and the united nations poor countries are monitored by a plethora of international and national bodies, and extensive reports generated, but the necessary actions -political and military -to solve the main issues and problems are rarely carried out. unwarranted aggression inflicted on other countries -poor or not, or the suppression of their populations or specific parts of their populations by nation states eventually must be counteracted by military intervention. sadly, poor nations are oftentimes regarded as pawns in international power struggles, and remain either exploited for their resources, or ignored. moreover, economic downturns in donor countries reduce the level of aid and absorption of refugees, made worse by certain countries cynically failing to meet their initially well-publicised aid pledges. (bardshaw and brook ) . population increases could undermine attempts to ameliorate attempts to reduce climate-modifying emissions. climate-change predictions for the arab region are deeply concerning. most scientists support the conclusions of the latest fifth assessment report of the ipcc. formed in by the united nations environment programme (unep) and the world meteorological organization (wmo), and relating closely to the un framework convention on climate change -the main multilateral forum for addressing climate change, ar comprises three working group reports and a synthesis report with its summary for policymakers. the main issues are covered in detail: observed changes and their causes; future climate changes and their risks and impacts; future pathways for adaptation, mitigation and sustainable development; and a more detailed analysis of adaptation and mitigation including policy options, technology and finance. in the arab human development report authored by balgis osman elasha, ( ), the impacts of climate-change projections in the arab region are given in stark detail. in the coming decades, arab societies and their industries will be profoundly and adversely affected by projected temperature increases in excess of c and severely reduced rainfall, threats of increasing frequencies of impacts originating from el nino events, changes in the seasonal distribution and predictability of rainfall, depleted aquifers, reduced river flows, rising sea levels, flash floods, in addition to increased numbers of dust storms and hurricanes. as the arab region itself is a relatively small direct contributor to global greenhouse-gas emissions, although its fossil-fuel exports and its importation of goods that took energy to create are substantial contributors to them, adaptation must be a crucial factor in policy developments in more settled times that will themselves be dependent on stable and peaceful arab countries. questions arise as to whether organisations such as those overseen by the united nations, multilateral groups such as the european union, individual nations and several charities will be capable of initiating and then maintaining peaceful conditions and food security. food and other forms of aid are likely to face increasing demands at a time when the economies of many donor countries are enduring continuing austerity and recessionary conditions, and when there is growing but unjustified cynicism about the effectiveness of these aid organisations. irrespective of the many estimates that total global food production can readily meet the needs of the present global population, political reality is that all countries and people are patently not equal and are unlikely to be so for the foreseeable future. aid can assist in partially rebalancing the inequalities, not least where several countries in the arab region are currently in turmoil and others are deeply troubled. some regard most of the arab world as regressing, out of synchrony with, and lacking sympathy from, the world at large. food costs and poverty are primary concerns, exacerbated by insecurity of energy and water supplies as well as rampaging insurgents and those wishing to impose unacceptable regimes and suppression of minorities, denying their citizens proper democratic freedoms. wars and conflicts are all too easily incited in the absence of strong democratic civil society involvement and usually quickly bankrupt countries; destroy nearly all parts of their economies; ruin infrastructure including homes, businesses, transport and communication networks; disrupt family life and social interactions; generate displaced people and refugees; and attract foreign interference, including active participants. war crimes are commonplace. psychological aftereffects are noted in civilians and combatants long after fighting has died down. populations in the arab middle east have endured asymmetric warfare between countries with vastly different military capabilities, provoking guerrilla tactics, chemical warfare, civil war, and even unconventional warfare through acquiescence, capitulation, and clandestine support for long-term insurgencies. wherever they occur, warfare and conflicts are always associated with the participants having distorted views of history -some drawing on ancient history -with widely diverse concepts of ethics, and complicated by ethnic and profound religious differences. little consensus exists on triggering factors, theories, and outcomes. prodigious sums of money have been expended in the arab middle east on armaments and defence forces to the exclusion of adequate investments in social welfare, education, and research and development. political instability for whatever reason usually leads to food insecurity and conflict. during social disturbances and the onset of widespread conflict, the normal mechanisms underpinning food production, importation, storage, processing, transport and retailing are profoundly disrupted, creating conditions that promote the formation of ghettos, and further stimulate corruption, robbery, and the black market. normal policing and social order collapse, social behaviour degrades, and criminal activities dominate. as the economy collapses, the terms of trade are transformed. disease epidemics become manifest. the restoration of domestic and business normality takes years and may never be achieved within one or more generations. food insecurity itself may lead to political instability, not least in a world of global intercommunications when citizens of a poor country or region can view with understandable envy the lifestyles of those in rich countries or communities. it is therefore a basic duty of political and community leaders to ensure that food security is a foremost priority for those people within their sphere of responsibility. insecurity of food supplies can be created by adverse weather conditions; the depredations of pests, weeds, and diseases; and salt contamination that can be caused by poor irrigation and agronomic practices. around million hectares of hitherto fertile land on earth have been damaged by salt. according to economics of salt-induced land degradation and restoration (qadir et al. ) , only tree planting, deep ploughing, and growing salt-tolerant crops coupled to digging drains and dykes around the affected area can address the problem. neglecting the health of africa's soils, many of which suffer almost irreversible degradation and nutrient deficiency, will lock the continent into cycles of food insecurity for generations to come, according to the montpellier panel report. indeed, was designated the 'international year of soils' by the th un general assembly. since the s, there are particular issues relating to selection pressures on destructive pests, weeds, and diseases in the vast monocultural single-cultivar agricultural systems that are also the present-day main sources of global food aid. many of these main producing areas are experiencing irregular rainfall patterns and failing irrigation arrangements. crop failures in these areas have quick knock-on effects on volatility of the global agricultural commodity markets; this is a situation likely to get worse as the population inexorably increases and demands more food. moreover, the world has yet to experience the sort of dramatic harvest failures that occurred in the s and before. another aspect of the agriculture sector (generally accepted to include crops, livestock, fishing, and forestry) in the developing world is that it absorbs circa % of the economic impacts caused by medium-and large-scale natural hazards and disasters. between and , these events in developing countries affected more than . billion people and caused more than $ billion, but agriculture only received about . % of all humanitarian aid (fao www.fao.org/emergencies/how-we-work/resilience/en/). delegates from fao at the conference announced the launch of a facility that will focus on bringing together technical expertise and financial resources with the aim of building greater resilience of agriculture to natural extreme weather events. the combination of advanced crop and livestock breeding, agrochemicals, automation, better agronomy and livestock husbandry, increases in the land area farmed, and efficient larger-scale better-capitalised production units have collectively prevented malthusian disasters. since , food production has more than quadrupled, using less than % more cultivated land, allowing civilisation to proceed and expand. food security is no longer an issue in many countries, and the global economy, human health, and societal development have been, for the most part, positively influenced by agricultural advancement. in the period - , when the global population increased from around . billion to around billion, average agricultural commodity prices decreased by an average of . % p.a. because supplies rose faster than demand (unpublished presentation by prof. ingo pies in to biennial development meeting of pottinger). nonetheless, feeding any substantial increases in the global population will only be possible by technological innovations because of the ecological limitations on increased water and fertilizer supplies and increasing the area farmed. likewise, various climatechange predictions amplify justifiable concerns about global agricultural productivity. supply and demand market dynamics are complex and ultimately resilient to political interference, although many countries and trading blocs try to manipulate production by tariffs, export bans, subsidies, inhibiting technological developments and market processes. the spikes in prices of traded wheat, rice, maize, and soya in and were initially blamed on speculation, especially the index tracking funds and derivatives markets. yet this type of speculation does not trade physical goods but price risks, and is therefore a form of insurance market. in addition, speculation would be expected to be associated with high stocks as farmers opt for storage rather than sales. in and , however, stocks were very low and caused the price rises. even so, government policy failures, including protectionist export bans and inadequate promotion of agricultural efficiency, contributed to panic buying, as exporters reduced their offer and importers increased their demand in response. calls by civil society groups to ban speculation by index-tracking funds and derivatives markets were always and continue to be profoundly misguided. all countries should have policies to sustain and constantly review food production and supply, especially if there is a significant dependence on food imports. reasonably substantial reserve food stocks are essential cushions to prevent price bubbles and food shortages, but excessive stocks can distort markets such as when they are released in large quantities as general food aid and undermine the operation of normal agriculture markets in developing countries. some price volatility is an essential component of healthy competitive markets, driving adaptation, risk taking and innovation. debates about the environmental costs of different kinds of agriculture, not least in terms of water and energy security in respect of the arab middle east, and in terms of the destruction of natural habitats and loss of biodiversity, as well as cultural and other changes, have stimulated possible strategies to address these concerns. one approach is for each country to have a "roadmap" for its agricultural development, and these roadmaps might be aggregated into a regional roadmap. the us report: a science roadmap for agriculture -cited as task force on building a science roadmap for agriculture, national association of state universities and land-grant colleges, experiment station committee on organisation and policy, "a science roadmap for the future", november (www.nasulgc.org/comm_food. htm) http://agsci.oregonstate.edu/files/main/roadmap .pdf pioneered a way to define the needs of agriculture and help shape the future direction of the various strands of agriculturally relevant science. this impressive us-specific study followed a conceptual framework of needs to (a) be competitive in a global economy; (b) add value in future harvests; (c) adjust agriculture to a changing climate; (d) be good stewards of the natural environment and natural resources; (e) make agricultural enterprises profitable; (f) make families and communities strong; and (g) modify foods for improved health and safety. one important relevant outcome of this work is the obvious requirement to grow crops and practice livestock husbandry in the most appropriate environments, enabling different environmental zones to have a critical mass of expertise and facilities. for the water-constrained arab middle east, this would mean increased reliance on food imports that could also be regarded as a form of water importation. but this would be possible only if there were formal agreements between food-producing and food-recipient countries, and these agreements were economically and politically stress-resistant. to this caveat would be questions of how to pay for imports, and acquiring resources required to redirect the agricultural workforce into other wealth-creating activities. introduction of a logical, science-led agricultural roadmap in the region may be impossible at present but needs to be initiated. on a global level, food commodity and non-food agricultural commodities prices have declined by - % in the period mid-september to mid-september (see the economist commodity-price index ( ) in www.economist.com/indicators), reflecting relatively clement weather conditions in most of the producing areas, greater production efficiency, balance sheets strong enough to bear losses, competition to gain market share, and continuing investments. importing countries, however, are affected by the strength of their currencies amongst other factors, such as social upheaval. unlike other commodities whose prices direct reflect industrial demand, prices of foodstuffs reflect the effects of weather, pests and diseases, the demands of a rising global population, and many kinds cannot be readily stockpiled. a further factor operating at the global level is the domination of farm supplies by six international companies: monsanto (the largest seed producer), syngenta (the largest agrochemical producer), bayer, basf, dow chemical, and du pont). all of these companies have been active in acquiring other companies and patents, thus reducing competition, and potentially reducing innovation as they robustly defend their intellectual property. in this era of low commodity prices and developing resistance to older-type herbicides, farmers are constrained by input costs of fertilisers, seeds, agrochemicals and veterinary medicines that have steadily risen in over the past decade, only partially alleviated by the recent reduction in fuel and lubricant costs. pandemics -epidemics of infectious or contagious disease that have spread through populations across a large region, crossing international boundariesdrastically curtail food production and distribution, aggravating poverty in both the rural and urban poor. pandemic-causing diseases include the ever-present cholera, influenza such as the and h n outbreaks, typhus, smallpox, measles, tuberculosis, plague (yersinia pestis), leprosy, malaria, human immunodeficiency virus infection and acquired immune deficiency syndrome (hiv/aids), viral haemorrhagic fevers (ebola, marburg, crimean-congo, lassa, rift valley, dengue, yellow fever, etc.), and now there are new diseases such as severe acute respiratory syndrome (sars). vaccine development is necessarily slow, and treatment of bacterial diseases is hampered by the rapid development of antibiotic resistance. the propensity of diseases to mutate, acquire new vectoring capabilities, have reservoirs in wild animals, and even persist in spore form, mean that there must be constant vigilance. as one of the major global food-producing bloc of nations, and as one of the major food importers and donors of food and other forms of humanitarian aid, the european union (eu) bears crucial responsibility for the deleterious effects of its complex and highly bureaucratic common agricultural policy. its massive subsidy regimes impact adversely on global markets and its well-meaning but often poorly thought-through environmental regulatory decisions are not based on sound scientific evidence. so-called "greening" policies are being introduced that may be deemed to enhance the environment but are likely to decrease profitable production. social measures to support small-scale inefficient producers also distort the global marketplace. likewise, the series of restrictions being introduced on the use of a wide range of agrochemicals within the eu and for imported commodities, without carrying out proper impact assessments and fast-tracking alternatives, imperil production. in the medium to long term, a more serious issue is the virtual ban in genetically modified (gm)) crops, inhibiting their uptake in countries intending to export to the eu as well as suppressing state-of-the-art research and development and associated investments in eu countries. of particular relevance in this regard is the recent and largest statistically rigorous review of the agronomic and economic effects of the current range of commercially available gm crops on farming (klümper and qaim ) . in examining publications between and march , it is therefore a near-complete survey. in essence, the two main types of gm crop -resistance to insect pests and tolerance to the wide-spectrum weedkiller glyphosate -conferred considerable yield improvements and much higher profits than conventional crops. gm crops and related products in the development pipeline were not considered, and these promise great advances in nutrition enhancement, environmental clean-up, new medicines, new products for manufacturing industries, and improved crop and forest species. moreover, existing gm crops have greater impacts in poorer countries than in richer countries because their insect pests and pernicious weeds are more difficult to control. by including non-peer-reviewed papers (book chapters, working papers, conference papers etc.) as well as peer-reviewed papers for the meta-analysis, it was possible both to correct for academic bias in focusing just on the most dramatic effects, and include data for many ancillary effects, such as the effects of fertilisers. the eu ban on gm crops is therefore denying poor exporting countries from reaping the full benefits in yield, profitability, and commodity quality, in addition to reducing potential eu food-aid exports. one positive feature of the eu is the bureaucratic system to improve and monitor the quality and safety of foodstuffs, from raw ingredients through to ready-meals, and gm crops have been found to be safe. that for many years most of the feed protein in the eu comprises imported gm maize and soya bean, the issue of gm crops should not be ignored for much longer. opposition to the processes of modern genetic modification and ownership of the processes (often deeming them to be "unnatural"), and disregarding the quality, safety, and valuefor-money of the product, actually condemns conventional agricultural practice, and demonstrates ignorance of naturally occurring mutations and horizontal gene transfer. even so, in early november , the newly elected president of the european commission, j-p juncker, in what is widely regarded as a blatant act of appeasement to greenpeace and other so-called "environment" pressure groups, sacked the eu's chief scientific advisor, professor anne glover, for her support of gm technology, compounding this regressive stance with abolition of the post. all countries and trading blocs should have influential and competent teams of chief scientific advisors. research and development in gene identification, construction, insertion, editing, and expression, coupled to high-throughput phenotyping are collectively revolutionising agricultural, horticultural, and forestry sciences. gm technology is not simply the insertion of genes using various technologies from a similar or different species into a recipient organism. it includes the concept of gene silencing -the prevention the reduction of expression of certain genes -a process that can take place at either the transcription or translation cellular processes. it is not the equivalent of gene knockout but is essentially gene knockdown because the methods to silence genes do not completely eliminate the expression of a specified gene. the methods to silence genes include rna interference (rnai or posttranscriptional gene silencing), small interfering double-stranded rna (sirna), and crispr. of special interest is the crispr (clustered, regularly interspaced, short palindromic repeats) toolkit that is derived from research on prokaryotic antiviral systems and currently involving the cas and cpr endonucleases (jinek et al. ; cong et al. ; bolukbasi et al. ) . as viruses constantly evolve to escape from these antiviral systems, bacteria probably evolve new systems. crispr technology is able to recruit heterologous domains that can regulate endogenous gene expression as well as label specific genomic loci in cells, so that is feasible to engineer germ lines and thus the path of evolution. this technique is replacing methods using mutagenic agents, virus vectors, zinc-finger nucleases and transcription activator-like effector nucleases (talens). its relative simplicity and evolutionary significance for all life forms, including humans, means that internationally agreed regulatory frameworks are essential. the technology does not involve implanting genes from one organism into another, and is not therefore creating transgenic organisms; it is gene editing. there is now realistic expectation of new perennial cereals; incorporation of c- photosynthetic characteristics in existing c- crops; enhancement of nitrogen fixation by free-living soil microorganisms in the vicinity of crop roots; tolerance and resistance to biotic and abiotic stresses; and modification of lignification, texture and endogenous components (such as vitamin content, acrylamide in potatoes, antinutritionals, toxins, proteins, oils, and carbohydrates) of a wide range of existing and potential crop species (see www.isaaa.org/kc/cropbiotechupdate). besides the present-day generation of improved livestock species and new forms of husbandry, the use of balanced diets based on competitively priced synthetic amino-acid and fatty-acid products will lessen the need for large-scale soya and maize production. ancillary advances are taking place in mechanisation; diagnostics; predictive modelling and decision-support systems; remote sensing; protectedcropping systems; and weed, pest, and disease control. diminution of abiotic and biotic stresses in the field and under protective cropping is now the focus of major research initiatives. of the circa , species of angiosperms, according to the food and agriculture organisation of the united nations (fao ) , only species provide % of human energy needs and only four species (rice, wheat, maize, and potato) account for % of energy intake, and % of crop diversity was lost in the last century. around % of human calorie intake comes from crop species (grivetti and ogle ) and % comes from just three grasses -wheat, maize and rice (see www.knowledgebank.irri.org/ericeproduction/importanceofrice.htm) dependency on such a narrow genetic base is a threat to food security and is only partially alleviated by investments in in situ and ex situ plant gene/seed banks, germplasm collections, and dna libraries. just species of angiosperms and gymnosperms have been cultivated for human consumption in human history, with around , angiosperm species yet to be discovered. in theory, most angiosperms should be capable of being biotechnologically modified for food and non-food uses. will scientists in the arab middle east fully participate in these exciting developments? valuable collections in the arab region are inadequately respected for their worth under peaceful conditions but are now extremely vulnerable during this period of war-like conditions and enduring financial pressures. coming into force in , the international treaty on plant genetic resources for food and agriculture (international seed treaty) was designed to complement the convention on biological diversity (cbd) and was designed to guarantee food security by (a) conservation, exchange, and sustainable use of all types of plant genetic resources; (b) offering fair and equitable benefit-sharing; and (c) recognition of farmers' rights. critics of the international seed treaty point to great variability across countries of access to collections and interpretation and implementation of farmers' rights. moreover, in adopting the cbd's outlawing of biopiracy -the uncompensated commercialisation and profiteering of seeds, propagules, growing plants, and their products from source areas -has severely inhibited the acquisition and exchange arrangements in collections until better processes come into force. gap analyses are methods to identify gaps in ex situ collections of wild-plant relatives of agriculturally relevant species as a means to guide efficient and effective collection strategies (villegas et al. ) . a gap analysis by the international center for tropical agriculture managed by the global crop diversity trust and the millennium seed bank in kew examined priority gene pools of the globally most important food crops and their wild relatives. most at risk were eggplant, potato, apple, sunflower, carrot, sorghum, and finger millet (see www.cwrdiversity. org/conservation-gaps/). ongoing conflicts and disorder in the arab region justify an independent review of a regional red list index based on the list of threatened species released by the international union for the conservation of nature (www. iucn.org) in order to evaluate the extinction risk of species and subspecies of the natural flora and fauna. certain individual countries in the eu are important donors of humanitarian aid in their own right. according to a recent report (november , ) from the organisation for economic co-operation and development, economic stagnation especially in the eurozone portion of the eu poses a major risk to world growth. if the stagnation were to continue or even get worse, humanitarian assistance would inevitably be reduced, and countries that hitherto were willing donors would become increasingly introverted. as evidenced by growing problems of graft, corruption and authoritarian government in certain (but not all) members of the eu that were formerly dictatorships or in the sphere of influence of the former soviet union, democratic norms (human rights, respect for minorities, tolerance, free press, independent judiciary and rule of law, active civil-society groups, transparency of accounting for taxpayers' money etc.) take time to become bedded into the fabric of society. in considering the medium-to-long-term future of the eu, it is sobering to note that throughout european history, confederations between its diverse nations and subsets have rarely persisted unless full political, legal, monetary, and more profoundly, cultural fusion had taken place. all governments worthy of the title must ensure that there are relief mechanisms to enable the provision of basic food supplies and fresh water together with functioning standby electricity-generating equipment in unsettled times caused by natural or man-made disasters. surely governments have the ultimate responsibility to attend to the needs of their people and not themselves. rarely observed, governments need genuine food, nutrition and agricultural experts as an integral part of the decision-making hierarchy. such experts must have a proper understanding of the pre-conflict or pre-disaster food, fresh-water, and energy supplies and their distribution systems, and how they can be safeguarded, modified and employed to proper effect, and how alternative mechanisms can be deployed. sadly, this aspect seems to be neglected at the present time in the chaotic condition of certain countries in the middle east. much can be learned from countries in europe during the wars that raged in the nineteenth and twentieth centuries. simply standing by and watching the population adapt slowly to acquiring barely adequate water and food supplies inflicts untold misery on innocent people. all governments should have readily accessible emergency supplies (reserve stocks) and transport systems, and be willing to introduce rationing if need be. special protection measures are needed for water supplies and farms to make sure production can continue no matter the degree of impairment. in more settled times, each government should establish a group of experts to construct interactive databases as the foundation of an agriinformatics and metrics organisation. this would collate information on supply and demand changes, supply-chain details, imports, crop and livestock genetics, commodity production levels, labour-force composition, pricing, inputs, availability of decision-support systems, advisors and research bodies, grant funding, biotic and abiotic stress factors, natural resource constraints, predictive modelling of shocks to the agricultural system and disruptive events, etc. other research organisations would interact with this organisation to ensure best practice and enhance agricultural resilience, demonstrate efficient use of inputs, exploit wastes, optimise the use of mechanisation, and foster skills. arab countries still have to utilise fully the international capabilities and potential of (international centre for agricultural research in the dry areas -currently based in beirut given the conflicts in syria) and other members of the cgiar consortium (formerly the consultative group on international agricultural research). the plethora of aid agencies offering humanitarian and development aid encompass those that are organised by a single government, multilateral donors, non-governmental organisations, philanthropic and charitable organisations, businesses, and individuals. reliefweb (www.reliefweb.int) provides a relatively comprehensive directory of humanitarian organisations. fragmentation of the total aid effort is becoming a worrisome issue. the international committee of the red cross, part of the international red cross and red crescent movement along with international federation of red cross and red crescent societies and national societies, is mandated internationally to uphold the four treaties and three additional protocols of the geneva conventions. these conventions are rules that apply in times of armed conflict both within and between countries, and define the rights of civil and military prisoners and protections for wounded people and for civilians. weapons of war are dealt with by the hague conventions and the biochemical warfare geneva protocol. enforcement of the conventions is through the un security council but is rarely invoked, primarily because of profound ideological differences about democracy and human rights between the five permanent members of the security council with veto powers, so there tends to be diplomatic reliance on regional treaties and national laws. parenthetically, there are ten non-permanent members of the security council without veto powers that are elected by the general assembly of the united nations for a two-year period. on november , the un security council pledged to counter the global terrorist threat and increase cooperation to address the perils posed by foreign terrorist fighters such as those that are a notable feature of conflicts in the arab region. the un office on drugs and crime is also involved in this initiative. other international related treaties include the united nations multilateral treaty referred to as the geneva protocol or convention relating to the status of refugees as well as the declaration on the protection of women and children in emergency and armed conflict adopted by the united nations in . humanitarian aid is distinguished from humanitarian intervention, which involves armed forces protecting civilians from violence or genocide. the united nations office for the coordination of humanitarian affairs is mandated to coordinate humanitarian responses, usually in concert with the international committee of the red cross. valuable reference material can be found in (a) grebner et al. ( ) , the state of hunger in developing countries as a group has improved by % since . even so, the level of hunger is still serious with an estimate of million people continuing to go hungry. the highest levels are south of the sahara and south asia. in the ifpri global nutrition report , evidence is summarised to show that improvements in nutrition status will make large contributions to sustainable development goals, namely poverty, food, health, education, gender, and employment investment in nutrition has a highest benefit ratio. projections from the world health organization (who) and unicef demonstrate that the world is not on track to meet any of the six world health assembly (wha) nutrition targets (reducing child stunting, reducing anaemia in women of reproductive age, reducing low birth weight, reducing the number of overweight children, increasing exclusive breast feeding, and reducing child wasting), although many countries are making good progress in meeting nutrition outcomes. the manifestation of malnutrition is changing as countries are now facing complex, overlapping, and connected malnutrition burdens. three of the chapters in the ifpri publication resilience for food and nutrition security (fan et al. ) are germane to this article. breisinger et al. ( ) briefly mention the arab spring and uses egypt, somalia, sudan, and yemen as case studies of conflict-affected countries. mabiso et al. ( ) have specific reference to the syrian refugee crisis, and take a global overview of the complex relationships between refugees and host countries. babu and blom ( ) introduce a model that seeks to delineate the key capacity components of a resilient food system, considering a country's capacity to create, manage, and utilise human resources for a resilient food system. significant challenges to aid provision include (a) harnessing the necessary stream of funding when grandstanding promises by countries are often never met; (b) establishing and coordinating the basic support network; (c) ensuring the logistics arrangements are effective, including communication networks; (d) prevention of resource misappropriation; (e) protection for officials and support workers on the ground; (f) protecting the vulnerable people needing aid; (g) operating with transparency and integrity; and (h) laying the structural and procedural foundations for self-reliance. effective lines of communication with donors and international agencies and charities are pivotal so that emergency arrangements can be established without delay and hindrance. these bodies need to deal with those individuals in the recipient countries truly knowledgeable about the capacity and specific problems facing food and water security, and fast-moving internal developments. the experts in the recipient countries must have the authority to be able to (a) quantify the levels of demand, (b) direct supplies, (c) recommend the siting of depots and distribution centres, and (d) highlight points of accessibility and vulnerability. in poorly governed countries, experts must be prepared to deal directly with these donors, agencies, and charities, difficult as that might be. the complexities of globalisation extend beyond food and water security (lerche ) . when people are deliberately persecuted, and honest law enforcement collapses, then non-partisan protection must be afforded, usually with outside security forces. unfortunately, ideological differences mean that the international community has often been shown to be ineffective in bringing about rapid termination of conflicts by imposing observers or armed forces, although thanks to relatively few major international donors, humanitarian relief has been forthcoming, albeit frequently late and inadequately funded. dealing with refugees and displaced people requires expertise and sympathetic support. housing provision together with monitoring and combatting infectious diseases, usually run in parallel with the issuance of food supplies. governments that prepare for worst-case scenarios are to be commended. even the distribution of authoritative guidance for populations in stress would represent a small step in the right direction, as would reinforcing the institutions that bind civil society, such as voluntary rescue and care organisations. networks of low-temperature clean and secure depots with associated distribution centres should be set up at the outset of disasters and conflicts. even in peaceful times, a marked cut in food waste helps food security. according to m. m. rutten (rutten ) around a third of the food for humans produced annually (about . billion tonnes) is either lost or wasted, and in developing economies the situation tends to be worse, with in excess of % lost during harvesting, processing and storage (fao. . global food losses and food waste -extent, causes and prevention (see www.go. nature.com/um vga). basic needs of refugees, as recommended by the unhcr and related organisations, are modest but are directly applicable to those displaced or besieged in their own country. unhcr recommends each refugee receive more than calories per day, recognising that a lack of food variety and inadequate supply of fruit and vegetables lead to deficiencies in essential vitamins and minerals. calorific intake can be reduced if the provided foodstuffs do not conform to traditional diets, or if the rations are traded to acquire other non-food goods and services. encouragement is needed to set up temporary gardens. fresh-water provision is of primary importance, with a minimum of litres per person. a greater volume is needed, though, to prevent public-health problems of diarrhoea, cholera, and even polio. thus, clean-water sources and pumps are required along with taps within walking distance. vessels are needed for transfer and storage of water. water-purification tablets should be provided. sanitation systems are essential for hand washing and the safe disposal of urine, faeces, sanitary towels, wound dressings, infected and contaminated materials, and for the disposal of dead bodies. monitoring of faecal contamination is recommended. housing refugees and displaced people at short notice demands special expertise to avoid overcrowding and give adequate protection against inclement conditions. overlaying the fundamental needs for food, water, and shelter are meeting basic medical needs, particularly of the young, women, and the old and frail. in addition, within a short time, children require to be educated. host communities and host countries sometimes resist integration of forcibly deracinated people and can grow resentful at the costs incurred, especially if the host economy is weak. most financial assistance from donor countries is given to aid agencies rather than host countries. large-scale influxes of refugees can soon overwhelm the host country's infrastructural resources (chiefly fresh water, energy, housing, hospitals and healthcare systems, education, and waste disposal). other problems arise from combatants embedded in refugee cohorts, spreading the conflict and increasing policing costs. cultural incompatibilities between refugees and the host population create hostilities. refugees can suffer the dire consequences of being rendered stateless. in general, it is fair to say that humanitarian care is not able to sustain basic needs in the medium to long term. as a consequence of a funding crisis for humanitarian aid in the arab middle east, the world food programme was forced to suspend its desperately needed food-aid-voucher scheme for more than . million syrian refugees at the beginning of december , the onset of winter. this suspension meant that refugees were less welcome in host countries and border closures are already being implemented in the immediate area as well as in the european union. axiomatically, just as responsible governments must be alert to and prepared for civil and other forms of unrest, they should always promote food production and remove any impediments to the uptake of improved technologies so that their economies have inbuilt resilience to dreadful events. likewise, governments should have in their ranks, or instantly available for consultation, competent scientists, technologists, and engineers able to advise on food, water, and energy resource distribution and allocation. over the past few decades, public-sector agricultural research and development in virtually all countries have suffered financial reductions and financial resources have been switched to activities regarded as more exciting and with greater wealth-creating potential; history shows this to be monumentally misguided. the urban disregard for agriculture is likely to continue as urbanisation increases, until the point food security threatens social stability. active or benign neglect of food-producing, food-processing, and food-distribution industries as well as of the scientists, technologists, and engineers underpinning its productivity, improvement and efficiency reveal incompetent governance. as an aside, the dearth of scientists, technologists, and engineers in active politics accounts for numerous policy failures. graduates in the arts (such as history and politics) and social sciences dominate politics and the upper echelons of the machinery of government (civil service) worldwide, people with little understanding or appreciation of business let alone of the "hard" sciences and engineering and their essential utility (and limitations) for mankind. perhaps this explains the growing dissatisfaction with the prevailing political classes. the scientific approach is that of the quest for knowledge by constantly questioning, developing and testing hypotheses by experimentation so that opinions change as "facts" change, oftentimes undermining policies that are not evidence-based, whereas many political parties are founded on inflexible belief systems, as are almost all religions. one aspect of food security in times of conflict and community disharmony has been the remarkable resilience of researchers to continue their studies or just maintain libraries, databases, records, laboratories, and genetic resources under the most trying conditions. the pursuit of knowledge is a fundamental feature of humans, as is the search for improvement. when there is blatant disregard of national constitutions as well as united nations treaties, protocols and conventions, and universities, colleges, schools, and research institutes become targets of malevolent forces, then the rest of the world must have no other option than to intervene, regardless of diplomatic niceties, in order to restore at least the vestiges of societal normality. as a first step, food security and the provision of fresh water for the besieged people must be a priority. if and when particularly large, heavily populated countries become embroiled in conflicts and/or major natural disasters, the existing international support efforts are likely to fail. this, in turn, may lead to a series of related conflicts, as opposing ideological pressures culminate in outright wars, invasions, and suffering on a huge scale. throughout the world, history has shown that unless they are relatively rich (and that may not be enough), smaller or militarily weak larger countries are influenced, for good or ill, by their more powerful and sometimes aggressive neighbours. as recent events demonstrate, conflicts in smaller countries rarely bring about rapid corrective measures from the international community, and adverse and damaging propaganda actively promoted in donor countries can prolong the suffering. ultimately though, food and fresh-water security are a prerequisite and eventually underpin stability, peaceful and thriving economies. today, much of the arab world is poorly governed and insecure for its citizens; they urgently deserve a better life. many of the most talented arabs seek a better life elsewhere. the warfare must be ended forthwith. grossly and unfairly misunderstood by much of the rest of the world, arabs demonstrate admirable resilience and stoicism yet retain their sense of humour tempered by understandable cynicism and justifiable suspicion of conspiracies. enemies of the arabs subject them to a tirade of insults and demeaning innuendos, often designed to deny them basic rights and international support. nonetheless, arabs must not be the continuing authors of their own misfortune, and a first step would be an end to internal conflicts followed by an effective region-wide clampdown on corruption at all levels. remember -it is the victor who determines the writing and shape of history. if the level of insecurity in the region were to get worse, then not only the arabs but also the rest of the world would pay a high price, so it is in everybody's interest to help restore peace. bluntly, the solution to their problems lies in the actions of the arabs themselves. in fully grasping the opportunities available through top-quality education , high standards of integrity and tolerance can be demanded from those in leadership roles in communities, organisations, businesses, and local and national government. ignorance can be reduced, even if not eliminated. essential components of democracy can be established, including independent and diverse news media, an autonomous judiciary operating to high standards of justice and unaffected by pressure groups and politicians, freedom of speech, and dynamic humanities and artistic sectors. wealth, and security of food, water, and energy, can and must be assured through the knowledge economy. harmony can be restored to communities suffering deep-seated divisions. furthermore, countries in the arab middle east will then be in a position to interact much more effectively and comprehensively in the international arena so that, if needed, external support and assistance can be fully and timeously harnessed. despite all the odds, this transition must be accelerated from the current dangerous condition to a much more enlightened and prosperous existence. education throughout society has proved to be a slow process, and can be resisted by regressive forces and indolence, so responsible leadership is a prerequisite. arab scientists, technologists, and engineers must contribute actively to this transition, thereby securing a safe, healthy, and buoyant future for all arabs. research and development priorities must be reassessed in the light of worsening nexus of water, food, and energy insecurity, and the desperate need to return to peaceful conditions. in legal jargon: time is of the essence. finally, a buoyant growth potential for the arab middle east is dependent on the fundamentals of demography, education, access to capital, technology, careful custodianship of its natural resources and environment, and social stability; all are threatened by this insecurity nexus. building capacity for resilient food systems human population reduction is not a quick fix for environmental problems the future of universities in the arab world. arab academy of science creating and evaluating accurate crispr-cas scalpels for genomic surgery food security policies for building resilience to conflict multiplex genome engineering using cripr/cas systems mapping of climate change threats and human development impacts in the arab region ( pp.) food-and-nutrition-security food and agricultural organisation of the united nations action to build resilient livelihoods. prepared by the food and agricultural organization of the united nations (fao) for the world conference on disaster risk reduction world stabilization population unlikely this century global hunger index: the challenge of hidden hunger ( pp.) value of traditional foods in meeting macro-and micronutrient needs: the wild plant connection overview of the roles of energy and water in addressing global food security an overview of mitigation and adaptation processes and strategies to address the impacts of climate change on food, water, and energy security in the arab middle east a programmable dual-rna-guided dna endonucleases in adaptive bacterial immunity a meta-analysis of the impacts of genetically modified crops the conflicts of globalization resilience for food security in refugee-hosting communities international budget partnership. www.internationalbudget.org organisation of economic co-operation and development economics of salt-induced land degradation and restoration what economic theory tells us about the impacts of reducing food losses and/or waste: implications for research, policy and practice. agriculture and food security national association of state universities and land-grant colleges, experiment station committee on organization and policy, a science roadmap for the future. www.nasulgc.org/comm_food.htm the economist commodity-price index a gap analysis methodologhy for collecting crop genepools: a case study with phaseolus beans key: cord- -lv fy e authors: dávalos, alberto; henriques, rossana; latasa, maría jesús; laparra, moisés; coca, maría title: literature review of baseline information on non‐coding rna (ncrna) to support the risk assessment of ncrna‐based genetically modified plants for food and feed date: - - journal: nan doi: . /sp.efsa. .en- sha: doc_id: cord_uid: lv fy e this report is the outcome of an efsa procurement (np/efsa/gmo/ / ) reviewing relevant scientific information on ncrna and on rna interference(rnai) that could support the food and feed risk assessment of ncrna‐based genetically modified (gm) plants. information was retrieved through key words and key questions covering the stability and degradation of ncrnas after oral ingestion, the passage of ncrnas from food and feed to human and animal organs and tissues via the gastrointestinal tract and other barriers, as well as the potential effects on the gastrointestinal tract, the immune system or the entire organism.full description of the strategy used for the literature search and for studies selectionis provided and the number of retrieved publications is reported. this report is divided into four partsdiscussing the kinetics of exogenous ncrnas in humans and animals, with focus on ingested ncrnas (part ); the possible effects of ncrnas on the gastrointestinal tract (part ), systemically(part )and on the immune system (part ). this report suggests that some plant ncrnas (e.g mirnas and sirnas) show higher stability as compared to other ncrnas due to peculiar chemical characteristics ( ’‐o‐methylation at ’ end).however, ingested or administered ncrna must overcome many extracellular and cellular barriers to reach the intended target tissue or functional location in sufficient amount to exert any biological effect. literature data indicate that chemically unmodified and unformulated ncrnas exhibit very low stability in the gastrointestinal tract and in biological fluids and, in general, do not elicit major biological effects.this report also provides an overview of the rna content in plant‐derived foods and diets and discusses the controversies on the presence of dietary exogenous rnas in the biological fluids of humans and animals and their effects. finally, gaps in the scientific literature are highlighted and recommendations provided . introduction this scientific report is the result of a contract awarded by the european food safety authority (efsa) to the madrid institute of advanced studies (imdea)-food, under the contract title: "literature review of baseline information on non-coding rna (ncrna) that could support the food/feed risk assessment of ncrna-based gm plants" (contract number np/efsa/gmo/ / ). for the literature review of the available scientific information on foreign (exogenous) ncrnas that could support the risk assessment of ncrna-based gm plants, the following tasks were defined by efsa. based on available scientific literature (narrative review) to review the kinetics profile of foreign (exogenous) ncrna in humans and animals (experimental animals, livestock and pets). this to be based on information from research and development of ncrnas intended to be used as therapeutics and/or from research on biomarkers in humans (pharmaceuticals/medicine area) and focused primarily on the oral route of administration of ncrna, with detailed information on the absorption, distribution, metabolism and excretion of ncrna molecules. other routes of administration, however, not to be excluded. based on available scientific literature (narrative review), to review the effects (physiological, paraphysiological, and pathological) of foreign (exogenous) ncrnas on the gi tract and annex glands (e.g. liver, pancreas, salivary glands) in humans and animals (experimental animals, livestock and pets). this to be based on information from research and development of ncrna molecules intended to be used as therapeutics and/or from research on biomarkers in humans (pharmaceuticals/medicine area). based on available scientific literature (narrative review), to provide information on the possibility of systemic effects of foreign (exogenous) ncrnas in humans and animals (experimental animals, livestock and pets) with focus on gastrointestinal barrier to absorption, and other barriers as relevant (e.g. placenta). based on available scientific literature (narrative review), to assess the plausibility of effects on the immune system of humans and animals (experimental animals, livestock and pets) of foreign (exogenous) ncrnas. gm plants based on silencing approaches by rnai (through ncrna expression) are developed for food and feed purposes and assessed by efsa within the eu gmo regulatory framework. the team considered that pursuing the four tasks defined by efsa to support the risk assessment of gm plants in this regulatory context required gathering preparatory baseline information on ncrna and refinement of the scope of the tasks. therefore, further elaboration on the terms of reference provided by efsa has been conducted and it is described below. it should be emphasized that the available information on ncrnas which could be possibly relevant to food and feed safety, overlaps with and is barely distinguishable from the broader information on rnas. information on rna in general has therefore been included in the search as warranted; when possible, the relevance of distinguishing peculiar ncrnas features is described. the term "foreign ncrna" or "exogenous ncrna" used in this report refers to ncrna molecules to which humans/animals can be exposed through the diet or via therapeutic treatment. similarly, "foreign rna" or "exogenous rna" refers to rna molecules to which humans/animals can be exposed through the diet or via therapeutic treatment. part : kinetics of exogenous ncrna in humans and animals (efsa task ) efsa task : based on available scientific literature (narrative review) to review the kinetics profile of foreign (exogenous) ncrna in humans and animals (experimental animals, livestock and pets) . this to be based on information from research and development of ncrnas intended to be used as therapeutics and/or from research on biomarkers in humans (pharmaceuticals/medicine area) and to be focused primarily on the oral route of administration of ncrna, with detailed information on the absorption, distribution, metabolism and excretion of ncrna molecules. other routes of administration, however, not to be excluded. to address efsa task , preparatory baseline information is provided i) on general features of plant ncrnas including their function, movement in the plant, biogenesis and degradation (section . . ), ii) on their stability (i.e. for how long ncrna molecules retain their original structure, and how they resist degradation over time and in various conditions, both inside and outside the plant), and turnover, also in comparison with turnover of endogenous ncrna in animals (section . . ). if necessary, comparisons between the ncrnas class and other rna classes are made. general information on rnas used/intended for use as therapeutics (including ncrnas) is provided, expanding on the chemical modifications necessary to avoid degradation and to achieve a target effect after administration (section . . ). lessons from rna-based therapeutics as regards the pharmacokinetics of exogenous rna are discussed, with a focus on non chemically modified (naked)ncrnas. in addition, aspects of the pharmacodynamics of rnas as learnt by therapeutics are addressed (section . . ). a description of cellular uptake of rna (in general and with focus on ncrnas), and of the many barriers represented by human/animal cells after oral ingestion is addressed insection . . . further relevant information on dietary exposure to plant rnas (i.e. exposure to plant rnas following dietary consumption) by different diet types, and presentation of the gaps in the literature on dietary plant rna exposure is provided in section . . . efsa task : based on available scientific literature (narrative review), to review the effects (physiological, paraphysiological, pathological) of foreign (exogenous) ncrna on the gastrointestinal tract and annex glands (e.g. liver, pancreas, salivary gland) to address efsa task preparatory baseline information is provided on i) the gi tract barriers to ingested exogenous rnas, including ncrnas (section . . ); ii) experience in rna-based therapeutics for oral (gi) administration, with focus on delivery of naked (non chemically modified) ncrnas (section . . ). biological effects of dietary exogenous ncrnas (plant and nonplant origin) on the gi tract and its annex glands is presented in section . . . www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. to address efsa task , preparatory baseline information is provided on the molecular pathways relevant for the uptake of exogenous ncrnas by human and animal cells and the intracellular trafficking that follows, with description of the effects by exogenous ncrnas once they reach the specific subcellular location (section . . ). to exert systemic biological effects, in most cases the ingested exogenous rna must enter the systemic circulation to reach the target tissues. information is therefore provided on the landscape of exogenous rnas in biological fluids and tissues from humans and animals, with focus on ncrna when possible (section . . ). a description of possible systemic biological effects of dietary exogenous ncrnas is provided in section . . , with details on tissue barriers (i.e. placenta, brain) encountered. a detailed review is made of the contradictory information on the systemic effects exerted by plant-derived exogenous ncrnas. finally, studies on the safety and in general on risk assessment on ncrnas from gmos are reviewed (section . . ). efsa task : based on available scientific literature (narrative review), to assess the plausibility of effects on the immune system of humans and animals (experimental animals, livestock and pets) of foreign (exogenous) ncrna molecules. to address efsa task , preparatory baseline information is provided on ncrna mediated regulation of the immune system in humans and animals. the many pathways of sensing exogenous rnas, both at the endosomal compartment and in the cellular cytosol, and the mechanism of triggering the immune system are reviewed (section . . ). an overview is done of the plausibility of biological effects of exogenous plant ncrnas on the regulation and function of the immune system upon uptake by mammalian cells (section . . ). in addition, since the gut microbiota influences the immune system, a review on the possible effects of exogenous ncrnas as gut microbiota modulators was considered relevant and it is provided (section . . ). in the final section of this report, concluding remarks inform on the gaps existing in the scientific literature, and highlight areas needing further investigations to better understand and support the food and feed risk assessment of ncrna-based gm plants. an extensive search was done to identify as many studies as possible relevant to the literature review questions. to include all possibly relevant information multidisciplinary databases and information resources were explored. unpublished research reports ("grey literature") including dissertations, thesis or other scientific reports were also included, which were retrieved using general search engines (i.e. google). the following information sources, databases or search engines ( table ) were used for the literature review: pubmed (biomedical), world wide science (multidisciplinary), web of science (multidisciplinary), springerlink (multidisciplinary), scopus (multidisciplinary), scielo (multidisciplinary) and biorxiv (preprint biology). finally, the publications reporting the outcome of two efsa procurements aiming respectively at investigating and summarising the state of knowledge on the mode-of-action of dsrna and mirna pathways, the potential for non-target gene regulation by dsrna-derived sirnas or mirnas, the determination of sirna pools in plant tissues and the importance of individual sirnas for silencing ; and reviewing relevant scientific information on rna interference that could serve as baseline information for the environmental risk assessment of rnai-based gm plants ) were also used. www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the methodology used for this literature review process and report preparation followed three basic principles: i) methodological rigour and coherence in study retrieval and selection; ii) transparency; and iii) reproducibility. to ensure that these principles were implemented in this literature review process, the search methodology design, study selection and data and results presentation follow, whenever possible, most of the methods and techniques described in the efsa guidelines on application of systematic review methodology for food and feed safety assessments to support decision-making (efsa, ) . the following section describes the general key steps followed in the literature search methodology; detailed descriptions of the literature search methodology for each topic are also provided in this section. to find a comprehensive set of scientific literature related to exogenous ncrnas and their biological effects on a target organism, either local or systemically, key questions were identified and key words were used as search queries for each task section according to a pre-defined review process. to provide a fit-for-purpose literature search, the team defined key questions based on the efsa tender specifications and their interpretation as above described. to support this phase, the team identified key elements of the questions considering the pico approach of efsa ( ). the key elements identified include the population, in this case humans or animals (experimental animals, livestock and pets) as defined by the terms of reference of efsa. the intervention was identified as exogenous rnas (focusing on ncrnas). the comparator was identified as the control or reference group (not exposed to exogenous rnas) in most studies, whenever possible. the comparator could also be identified as the modified (either chemically or biologically) version of the exogenous rnas when referring to the stability or pharmacokinetic of the exogenous rna. the outcome is the biological effect (if any) as a response to the intervention. other specific key questions are determined for every part of the specific tasks defined by efsa. evidence is generally scarce for most of the topics covered by this scientific review, and in some cases the information was available from not directly related studies (i.e. pharmaceutical industry studies). the literature review was helpful in identifying both knowledge gaps and unexpectedly relevant studies or evidence not previously known to exist. these knowledge gaps are used to make informed proposals for future research designs (section . ). the key methodological steps in the literature search, selection and review process are shown in figure . three phases were defined in this process. the preparatory phase started with team discussions of topics to be included in the literature review. during this phase key elements addressing the efsa tender specifications and their interpretation as above described were identified and key questions were defined. the key questions aimed to to assist the literature search in order to produce a comprehensive overview of the topic that best fits tender specifications. the bibliography search and selection phase included several steps. the initial search in bibliographic databases and search engines was done using task-specific key words. the key words used for the search were derived from the efsa tender specifications and their interpretation (tasks - ) and were complemented with other key words identified in the preparatory phase. identified key words are detailed for each task in section . the final phase of review and final selection involved two additional steps, i.e. a detailed review of all relevant previously selected documents and a systematic evaluation of the final selected studies. a detailed review of the selected documents was done for studies with full text availability (either freely available or available for purchase) and, based on this, a final selection was made of full-text studies most relevant to answer the key questions for tasks ( - ) and apt for review in this report. a systematic evaluation of these final documents was done to develop a comprehensive overview of the topic. conflicting or contradictory results were reported in a neutral way and supported by references and the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. citations of all available evidence, both from the published and grey literature. retracted papers were carefully identified and noted. finally, each section of the narrative review was assessed by one reviewer. if more specific data was needed because of missing or novel information, additional bibliographic research was performed. additional key words that could directly address the specific data needed were identified and used to run a new specific search. the search among full-text studies was focused on obtaining only specific missing or required data (e.g. quantitative data on rnas levels in plants, earlier studies on exogenous rna exposure to mammalian cells). this new specific search generally represented less than % of the literature included in this report and it was performed only once for certain topics. finally, to reduce the risk of introducing bias into the literature review process and to assure reproducibility in the review methodology the following general approach was applied: when the search of the identified "key words" in different databases resulted in a myriad of duplicate documents, manual removal of these duplicates was performed in each section by each team expert; when relevant studies that might answer the identified key questions were identified after the first search run, these were used to further refine the literature search, for example refining the keywords; each selected full-text study to be included in the result section was manually examined by the team. to identify literature relevant to the topic, the methodology described in section . . . ( figure ) was applied, with adaptations. a multiple-step approach was followed based on the expertise of the team members who carried out research in the area. following a first search based on identified keywords, a careful selection of retrieved review studies was done, followed by a search of specific publications referred to in these reviews. additional specific key words were identified, and an additional search was run. this search retrieved a relatively small number of studies; therefore, team members reviewed all these to determine which were relevant to the topic. duplicates, irrelevant or erroneously assigned publications were removed. team members also cross-checked each others' findings, sharing discussing the results of their searches. the following areas were investigated. the purpose of this search was to provide general information on rnas function, movement in the plant and aspects of biogenesis and degradation, with a focus on ncrna (either small or long). by comparing animal and plant ncrna pathways, the aim was to identify similarities between animal and plant ncrna processing machineries that would indicate the possibility of ingested plant-derived ncrnas being processed in animals. in addition, this section was organized to avoid details that were outside the scope of this literature review in the topic of plant ncrna biology. this serves as an introductory chapter allowing easier integration of the knowledge presented in later chapters. the following combination of key words or phrases was used in some of the databases indicated above: plant small rnas; plant and sirna; plant and mirnas; plant and lncrnas; plant and circrnas; plant rna and movement. www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the initial search using the above-mentioned key words or phrases yielded a large number (≈ ) of documents ( table ) , most of which were not relevant to the topic. particularly, the databse web of science retrieved documents not directly related to the topic. to assist and refine the search, studies were further filtered by their relevance to the key questions identified: -what type of ncrnas are described in plants? -what are the main differences between mammalian and plant ncrnas? -what is the function of plant ncrnas? -what is known about the movement of plant ncrnas? title and abstracts were evaluated, and studies further refined using the key questions. detailed study of the most relevant full-text documents answering the key questions, retrieved documents which were finally selected as relevant to give an overview of plant ncrnas. search was then refined by using other key words including "half-life", "turnover", "fate" or "degradation". the identified studies were then manually evaluated by title and abstract and their number further limited due to their low relevance to the below identified key questions for this specific subchapter: -are plant ncrnas more stable than animal (mammalian) ncrnas? -if so, what makes a plant ncrna more stable than its animal (mammalian) counterpart? -why is it relevant to consider ncrna stability outside the organism of origin (plant)? -are certain types of plant ncrnas more or less stable than others? -what is known about the half-life of ncrnas? documents on the stability of rnas (not only ncrnas) were further screened for relevance to the question. most of the studies in the literature describe the stability of a specific class of intracellular rnas (i.e. mrnas). the stability of rnas other than ncrnas (e.g. mrna, trna), unless are used as model of general ncrna stability, is outside the scope of this literature review, since it is very unlikely they would be used as baseline information for food/feed risk assessment of ncrna-based gm plants. these keywords were specifically selected since they describe the kinetic profile of exogenous ncrnas in human and animals. the word "pharmacokinetics" was included in the search because it is a general term that retrieves data on absorption, distribution, metabolism or excretion of any molecule, particularly those intended for use as therapeutics (pharmaceutical/medicine areas). the keywords "increased intestinal permeability" or "increased plasma clearance" are intended to retrieve any study indicating changes in these parameters. although a large number of publications unrelated to ncrnas were expected, these keywords were chosen to initially explore the general aspects of physiological or pathological conditions associated with modification in these parameters. the search was further refined after this initial exploration. the search of the above-mentioned key words on different databases yielded ≈ . entries ( table ) . a quick exploration of titles and abstracts suggested that (as expected) a number were unrelated to or were not useful to appropriately address the topic. it is worth noting that the search in the previous section (section . . . .) indicated that the chemical modifications generally introduced for rna-based therapeutics are normally absent in nature. scientific data that could serve as a baseline to support risk assessment of ncrna-based gm plants should contain primarily information on ncrnas resembling those present in the nature or in gm plants. therefore, studies on naked exogenous rnas were analysed to prepare this narrative review. to promote comparisons between natural and synthetic rnas, a very few examples of slightly chemically modified rnas were included. heavily chemically modified rnas were not considered due to their unlikely existence in nature. only in vivo studies were considered, both in animals (mammals) or humans. studies were further evaluated for their relevance to answer the key questions identified for this section: -what are the pharmacokinetic properties of rna-based therapeutics? -what routes of administration have been used for rna-based therapeutics? -what is it known about the pharmacodynamic properties of rna-based therapeutics? -do disease conditions modify the pharmacokinetic properties of rnas when administered to mammals? the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. after detailed evaluation of the full-text reports, documents meeting the described criteria were finally selected for review. understanding whether and how exogenous rnas are taken up by cells and what barriers are encountered is relevant to study the possible absorption and systemic exposure to ncrnas introduced by food and feed. this topic is reviewed in this dedicated section and excluded from the section on the pharmacokinetics of exogenous rnas (section . . . . above). to search and select the relevant studies concerning the uptake of exogenous rnas in mammals, the following combination of key words was used in some of the databases listed above: rna and cellular uptake; ncrna and cellular uptake; mirna and cellular uptake; lncrna and cellular uptake. these key words were used to screen for studies where "cellular uptake" was mentioned in the title or abstract for any type of rnas. it was also decided to include specific types of ncrnas including "mirna" or "lncrna" to expand the search to literatures where the more general term "rna" was not necessarily used. the initial search of scientific documents using the above keywords yielded ≈ documents ( table ) . these were explored by their relevance (title and abstract), and only studies addressing naked ncrnas were considered for full text analysis, since highly chemically modified rnas are not common in nature. to address the reference terms for task- of this procurement, and after expert discussion for this section (preparatory phase) key questions were identified and the studies then further filtered for their relevance to the these: -are exogenous rnas taken up by mammalian cells? -how does exogenous rnas uptake in mammalian cells occur? -what are the biological barriers to consumed rnas? -what are the biological barriers for the exogenous rnas after absorption and entering into the mammalian circulatory system? only studies where exogenous rnas were evaluated were included in the literature review. after detailed evaluation of full-text reports and expert judgement on their relevance to efsa task , documents were finally selected for review. to select relevant studies for plant rna exposure, the following combination of keywords were used: plant and rna content; plant and mirna content; plant and sirna content; plant and lncrna content; plant and dsrna content; rna intake and vegetarians; vegetables/fruit intake and vegetarians. these specific keywords were used because the wording "rna (ncrna, mirna, sirna, dsrna, lncrna) content" would yield most of the documents related to quantities of rnas in a specific substrate. these were combined with "plant" to retrieve only those studies where plants were used to evaluate rna content. it was also decided to use "rna intake", "vegetable intake" or "fruit intake" to specifically refer to consumption, and to combine this with "vegetarian" to search only for studies where comparisons are made between vegetarian and other types of diets. alternative wordings including "rna amount" or "vegan" were used to search for alternative information. using the above keywords, ≈ studies were retrieved (table ) during the initial search. to more appropriately cover this section and to refine the search, the following key questions were identified during the preparatory phase: -what is the general amount of rnas naturally occurring in edible plants? -what percentage of total plant rnas are ncrnas, mirnas, sirnas, lncrnas or dsrnas? -does exposure to rnas change in different diet types? -do changes in rnase activity, due to pathologies or human polymorphisms, influence dietary exposure? titles and abstracts were evaluated, and studies further filtered using the key questions above. the search was also refined to focus on those studies where quantitative rnas data were mentioned. only in vivo exposure studies were used (either epidemiological or experimental). common types of diets were only considered (i.e. vegetarian, vegan or omnivorous). for rna exposure by different diet types, studies where comparative analysis of at least two different diets (one of which was the general population diet type) were mainly considered. in all cases, full-text studies were evaluated to screen for relevance to answer the identified key questions. a detailed study of the full-text documents resulted in the identification of studies most relevant to address this specific topic of task- , and which were reviewed for this section of the report. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. to identify literature relevant to the topic, the methodology described in section . . . (figure ) was applied. during the preparatory phase key questions were identified to assist in the literature search. the document search was first done using specific key words and then refined according to the key questions. detailed analysis of the full-text documents was done by team members with expertise in the area. search and analysis results were discussed collectively among team members. the following areas were investigated: in this subsection, there is a general description of the biological barriers within the gi tract that exogenous rnas would need to overcome to exert a biological effect, either locally or systemically. to select relevant studies, the following combination of key words or phrases were used: "gastrointestinal tract anatomy"; "gastrointestinal tract physiology"; intestinal transport pathway; physicochemical properties of rnas. an exploration of titles and abstract of the yielded entries (table ) suggested that a large number of documents were unrelated to the topic. only one key question was identified in the preparatory phase: -what are the biological barriers within the gastrointestinal tract to ingested exogenous rnas? the search for relevant studies addressing this key question was based mainly on team member judgement. detailed study of the most relevant full-text documents answering the key question retrieved documents which were finally selected as relevant to this section of the report. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. this search was intended to collect data from rna-based therapeutics employing oral administration (and other gi routes) which could support the search on the possible biological effects of plant dietary exogenous rna and ncrnas on the gi tract and its annex glands. the initial search was done using the following key words on the different databases: ncrna oral delivery; rna oral delivery; sirna oral delivery; aptamer and oral; sirna gastrointestinal delivery; mirna gastrointestinal delivery; oral exosome rna; extracellular vesicle and gastrointestinal. these key words were selected to search for any documents related to rnas and oral administration. any information on oral administration was considered relevant. to expand the search, different terms referring to different types of ncrnas (mirna, aptamer, sirna or others), and a synonym for "administration", i.e. "delivery", were included. the initial search using the above key words or phrases yielded a small number (≈ ) of documents ( table ). the different databases generated similar number amounts of publications, most of which were duplicates. using the key word "lncrnas" in combination with the other key words did not yield any information relevant to the topic. indeed, just the search using "lncrna exosome" identified fewer than documents, but none was relevant to oral delivery or gi administration. the wording "dsrna and oral" produced ≈ documents, but none of them was relevant to mammalian organisms. the documents were selected by relevance, evaluating title and abstract. in this section, only studies in animals (mammals) or humans were considered. when replacing the word "delivery" with "administration", ≈ additional documents were identified, but almost % were unrelated to the review topic. since most of the documents in the literature describe minimally modified rnas for oral use, all chemically modified rnas were considered in this section. these can provide baseline information to support food/feed risk assessment of ncrna-based gm plants. to assist and refine the search, studies were further filtered for their relevance to the key question identified: is the oral route of administration relevant for rna-based therapeutic development? -what types of formulation (delivery vehicles) are tested for rna-based therapeutics for the oral route of administration or other gastrointestinal tract routes of administration? the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. -do exogenous ncrnas (naked rnas) resist the conditions of the gastrointestinal tract environment? -could ncrnas-based therapeutics -delivered by oral administration or other gi tract routes of administration-exert a biological effect in the gi tract or its annex glands? -are there any natural vehicles for oral administration of exogenous ncrnas? from the initial ≈ entries identified using the above key words and after filtering for relevance to the key question with evaluation of titles and abstracts and detailed study of the full-text reports, documents were selected for review in this section. twenty ( ) of these documents reports selected examples of local effects of nucleic acids-based drugs (mainly exogenous rnas) within the gi tract, using oral administration. since efsa required a literature review also including livestock species, an additional specific search was run for birds and fish. this search was intended to compile information on administration of exogenous ncrnas in either fish or birds, regardless of administration method, exerting any biological effects in vivo. the initial search was done using the following key words on the different databases: exogenous rna and fish; exogenous rna and bird; rna oral delivery and fish; rna oral delivery and bird; ncrna administration and fish; ncrna administration and bird. to expand the search, different terms referring to different types of ncrnas were used (sirna, mirna, circrna, or dsrna). the initial search using the key words or phrases produced a small number (≈ ) of documents (table ) in most of the databases. to assist and refine the search, only one key question was identified during the preparatory phase for this subsection: -are exogenous ncrnas also used to exert rnai effects in fish or birds? from the initial ≈ entries identified using the above key words, and after filtering for relevance to the key question, and evaluating titles and abstracts and detailed study of the full-text reports, documents were selected for the review in this subsection. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. this chapter provides baseline information supporting food/feed risk assessment of ncrnas-based gm plants. in the effort to cover the widest amount of literature containing relevant scientific data on exogenous ncrnas and their possible biological effects, the following key words or phrases were used in the search: dietary plant non coding rnas; food plant non coding rnas; exogenous plant non coding rnas; diet plant micrornas; food plant mirnas; breast milk exosomes; breast milk mirna; breast milk ncrnas; breast milk lncrnas; breast milk rna; dietary exogenous rna. these key words were selected to cover most, if not all, available studies on the topic ( table ) . the search of other common examples of exogenous ncrnas (non-plant origin) consumed by oral intake was focused on breast milk ncrnas, due to their relevance to human nutrition (table ) . almost all documents yielded by the three databases (pubmed, scopus or web of science) were duplicates. in this section, studies reporting local effects (in the gi tract or its annex glands when consuming exogenous ncrnas) were preferentially (but not exclusively) evaluated. other databases including the preprint server for biology (biorxiv), scielo or search engines (i.e. google) were also used. the initial search in some databases using the above key words yielded a number of entries (table and ) not exceeding ≈ documents. because this specific topic is especially salient to future understanding of the possible food/feed risk assessment of ncrnas-based gm plants, all the identified studies were further evaluated by title and abstract and their relevance to answering the identified key questions: does the literature describe the effect of exogenous plant-origin ncrnas when consumed orally? -does the literature describe negative results or contradictory results regarding the possible biological effect of ncrnas when consumed orally? -are ncrna stability properties under gi tract conditions normally evaluated? -are exogenous ncrnas evaluated quantitatively? -are exogenous ncrnas consumed in an amount sufficient to exert a local biological effect?are there other common examples of exogenous ncrnas (other than plant-origin) that could exert a biological effect on the gi tract and its annex glands when ingested orally? local effects (in the gi tract or its annex glands) are mainly described in this section. the possible mechanisms of plant exogenous ncrnas cellular uptake, their intracellular trafficking and systemic biological effects (including plasma levels) are reviewed in another section (section . .). of the initial ≈ documents retrieved using the above key words, and after filtering for relevance to the key questions by evaluating titles and abstracts, and detailed study of the full-text reports, documents were selected for the review in this subsection. from these, documents were selected for plant-origin ncrnas and for non-plant origin (breast milk) ncrnas. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. in line with the methodology described in section . . . . (figure ), a multiple-step approach based on the expertise of the team members responsible for this section was applied to identify literature relevant to the possible systemic effects of exogenous ncrnas. the document search was first done using specific key words in the databases and refined based on the appropriate key questions. detailed analysis of the full-text documents was done by team members and the results discussed collectively. the below areas were investigated. the search objective was to obtain information on basic molecular cellular uptake pathways of exogenous ncrna, including proteins involved in this process (if any). a review was also done on several other aspects of intracellular trafficking, once an exogenous ncrna is internalized, and how it exerts a biological effect. tissue barriers to exogenous ncrna function were also investigated. the content of this section deepens on molecular pathways previously described in section . . . to assist the search the following key words were used in the different databases: exogenous ncrna and mechanism and absorption; ncrna and mechanism and absorption; sidt (sid transmembrane family member ) and ncrna; sidt (sid transmembrane family member ) and ncrna; ncrna and uptake; intracellular trafficking and ncrna. these key words and terms were selected to identify any document related to the mechanisms of uptake and intracellular trafficking of ncrnas exerting a biological effect. the search was expanded by adding and combining different terms for exogenous ncrnas (see table ), including the general term "rna", www.efsa.europa.eu/publications efsa supporting publication : en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. or specific ncrnas such as "mirna". the initial search using the above key words or combinations thereof produced a moderate number of documents (table ). the different databases generated similar amounts of documents, most of which were duplicates. the largest proportion of the references was obtained using the key wording "ncrna and uptake" (≈ ). however, most of these had no relation to this specific section. the search was refined by filtering for relevance to answering the identified key questions: is there any clear transport of exogenous ncrnas into mammalian cells? -are orthologous of environmental rnas transporters in lower organisms (i.e. sid family of proteins) involved in the mammalian exogenous ncrna mechanism of uptake? -what molecular mechanisms are involved in exogenous ncrnas trafficking inside the cell? -what is the cellular fate of exogenous ncrnas once inside the cell? -what are the specific tissue barriers to exogenous ncrna function? very few documents evaluate the molecular mechanism of exogenous ncrnas uptake, intracellular trafficking and function. from the initial ≈ documents retrieved using the above key words, and after evaluation of their titles and abstracts and filtering for relevance to the key question, less than documents initially seemed relevant to the topic and were finally selected for review after detailed study of the full-text reports. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. this subsection is intended to retrieve available information on the presence of exogenous rnas in human and animal biological fluids (i.e. blood, plasma, serum or any other biological fluids) and tissues. the search focused on the presence of dietary plant-derived exogenous ncrnas, due to their relevance to the overall literature review. to cover the largest possible portion of the relevant literature, the following key words were used in the search: exogenous rna and human plasma; exogenous rna and serum; plant ncrna and human tissue; plant lncrna and human plasma; plant mirna and blood; plant mirna and tissue; plant rna and tissue. to expand the search, the above key words were used in different combinations for the same search (i.e. blood, serum or plasma for biological fluids) ( table ). the general wording "rna" was also incorporated into some searches. specific types of ncrnas were also added, including "mirna" or "lncrna", to avoid missing documents possibly related to these specific molecule types. the search using these key words or phrases in different databases yielded more than ≈ . publications (table ) . a quick exploration of the titles and abstracts suggested that only few studies were related to the review topic. only one key question was identified as relevant which was related to the presence or absence of evidence of exogenous ncrnas in biological fluids and tissues. since these findings are important for the risk assessment of ncrna-based gm plants, the key question was presented in its positive and negative forms as follow: are there studies describing the presence of exogenous rnas in the biological fluids and tissues of humans and/or animals? -are there studies contradicting the presence of exogenous rnas in the biological fluids and tissues of humans and/or animals? after a detailed assessment of the full-text, documents were finally selected for review. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. this search primarily aimed to gather information relevant to understand the possibility of systemic effects of dietary exogenous ncrnas after intake (oral administration) by humans and/or animals (mammals). information on the possible passage through specific biological barriers (i.e. placenta or brain) was also searched. the search was guided by the following key words to identify studies providing any data on the possibility of systemic effects of dietary exogenous ncrnas: plant ncrna and diet; plant exogenous rna and diet; plant rna and diet, plant environmental rnai and diet; plant rna and placenta; plant rna and brain; dietary rna and cross kingdom. these key words were used to guarantee that every single document potentially providinginformation on the possibility of systemic effects of exogenous ncrnas was found. to widen the search, other wording such as "environmental rnai", "cross kingdom" or "mobile rnas" were used. although the wording "systemic effects" was not used in the key words during the search, the above key words were used to retrieve any documents in which a biological effect (local or systemic) might be reported. different wording for the term ncrnas was also used (including lncrna, circular rna, mirna, or dsrna). the initial search in some databases using the above key words produced a small number of entries (table ) . the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. approximately ≈ documents were initially identified using the above key words (table ) . after filtering for their relevance to the key question by detailed assessment of the full-text reports, documents were finally selected for review. within this specific subsection, the selected documents are mainly grouped as studies that "support the evidence" or studies that "contradict the evidence" of systemic biological effects of dietary exogenous ncrnas in humans and animals (mammals). although not specifically included in the scope of this literature review, search for toxicological effects of dietary exposure to exogenous ncrnas in humans or animals is relevant to risk assessment. this search was aimed at identifying information on possible toxicological effects of plant-derived exogenous ncrnas following food/feed consumption. the initial search was conducted using the following key words in the different databases: the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. few documents were initially retrieved and after a quick evaluation of titles and abstracts, it became evident that very little information is available in this area. therefore, different terms were used to refer to exogenous ncrnas, including circular rna, lncrna and mirnas. the search using the above key words yielded a small number of documents (table ) . only in vivo studies were considered, both in animals (mammals) and humans (if available), with focus on dietary plant-origin exogenous ncrnas. the key questions identified to refine the literature search for this specific topic were: -is there evidence of any toxicological effects of plant-derived dietary exogenous ncrnas? -are the toxicological effects related to rnai-mediated interaction with the human or animal genome? -are there possible interactions related to unintended rnai-mediated gene regulation? approximately documents were identified using the above key words. after filtering for relevance to the key questions, and assessing the full-text reports, only documents were finally selected for review. a systematic and comprehensive review and collection of the literature relevant to the topic was performed with the aid of the team members' expertise. an extensive search using key words was initially done on multidisciplinary databases to avoid publication bias, followed by a grey literature search using general search engines. the resulting documents were screened by title and abstract to determine relevance to the topic and refined using the identified key questions. after full-text analysis of the documents, irrelevant documents were eliminated. all stages of the screening process were independently assessed and, in case of uncertainty, discussed with other experts to avoid personal biases. the methodology followed the key steps described in section . . . . (figure ) and a total of papers were identified, investigating the areas below described. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the final goal of this search was to identify relevant information on ncrnas-mediated processes associated with innate and adaptive immune responses. this section serves as an introduction to the studies presented later, and it is based on the results of the seach described in the next paragraph. sixty-four ( ) documents were reviewed for this section. the search was aimed primarily at gathering state-of-the-art knowledge on the possible biological effects of exogenous (plant) ncrnas on the regulation and function of the immune system. to cover this specific section, a combination of the following key words was used in the different databases: exogenous rna and immune and human/mice/rat; exogenous plant rna/mirna/sirna/lncrna/dsrna/transgenic rna and immune function/inmmunity and human/mice/rat; genetically modified plants and immune function/immunity and human/mice/rat; exogenous plant rna/mirna/sirna/lncrna/dsrna and primary cells and lymphocyte/monocyte/macrophage; exogenous rna/genetically modified plants and immune function/immunity and zebrafish. the key words were designed to identify all publications that use in vivo, including non-mammalian animal models, and in vitro ncrnas testing to evaluate the influence on tolerance processes as well as immune cell function. the search also included publications on in silico methods. the different key words were entered one by one into the search field 'topic' of the databases ( table ). the search was designed to identify documents including methods that could use non-mammalian animal models (i.e. zebrafish embryos). all search terms within one key word were combined by the operator 'or' and 'and' copied in a second or third search field. 'review' and 'meeting' documents were excluded. a search for grey literature was done in general search engines (i.e. google) using the different key words in the 'search' function of the respective websites. all the information on in vivo studies, using mammalian and/or non-mammalian organisms, and in silico studies was collected. these key words were chosen because this section aimed to describe the possible effects that exogenous ncrnas, specifically of plant dietary origin, might exert on the immune system of humans and animals. the search yielded ≈ entries (table ) . publications were excluded if one of the following criteria was met: the biological effect could not be unambiguosly attributed to ncrnas; the publication addressed immunodeficiency or autoimmunity; the publication reported no immunity (innate or adaptive)-associated endpoint or it is not specific for immune function and/or homeostasis evaluation; evaluation of exposure of and/or effect on cells other than immune cells (e.g. epithelial cells); the study was unable to measure processes related to immune function and/or homeostasis; the study reported data on potentially immunocompetent cells not fully differentiated as mature immune cell; no ncrnabased plant was tested in the publication; and the publication did not address plant-derived exogenous ncrna. the unexpectedly low number of publications retrieved using the key words proved a challenge in the selection process. for example, selection for in vivo studies produced only articles after title/abstract screening. to expand the number of documents, additional key word searches were included and less conservative criteria were set for the title/abstract screening. retrieval of grey literature was also based on information containing "preliminary results" or on-going projects that could possibly answer the key questions. www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. studies were further evaluated for their relevance to answering the key questions. the key questions identified using the above key words were: -which test methods or approaches are available to investigate the possible role of plant-derived exogenous ncrnas on the immune system of humans or animals? -what human or animal immune response(s), innate or adaptive, are possibly associated with administration of plant-derived exogenous ncrnas? -which mediators in humans and animals have been identified and/or ascribed to immune response(s) possibly mediated by administration of plant-derived ncrnas? -which innate immunity mediators (i.e. chemokines, cytokines) have been identified in humans and animals as associated to effects of plant-derived ncrnas? -which human or animal cells (i.e. lymphocytes, macrophages, myeloid) are possibly involved in immune responses mediated by plant-derived ncrnas? after the selection of the full-text documents, publications were excluded if not providing sufficient information (i.e. endpoint, exposure time), if investigating a mechanism other than immune-related processes, or if describing an operational procedure or guideline rather than a research study. from the initial ≈ documents identified using the above key words, and after filtering for the relevance to the key questions and detailed study of the full-text reports, documents were finally selected for review in the three sections of part (efsa task ). of these, documents were selected for review in this section. gut microbiota is important for the function of the immune system, therefore the purpose of this additional search was to provide general information on the effect of dietary exogenous ncrnas on the gut microbiota and the possible consequent secondary modulation of human or animal immune systems. this would serve as an introduction to identifying information gaps and experimental needs for future studies relevant to food/feed risk assessment of ncrna-based plants. selected full-text studies were analysed for their relevance to answering the following key question: -is there evidence for influence of exogenous plant ncrnas on the gut microbiota related to the immune system? five documents were finally selected for review in this section. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. results are presented narratively. when appropriate, tables and figures are included to allow better understanding of the topic covered by the literature review. some sections of this review provide only limited amount of quantitative analysis due to the nature of the available evidence and the key questions identified for each subchapter. at the end of each subchapter, a short summary presents the general points identified in the reviewed literature. gaps in the literature and open questions identified in the field are presented in a subchapter of certain sections. these gaps in the literature may serve as suggestions for further research in each topic. part : kinetics of exogenous ncrnas in humans and animals (efsa task ) ncrnas are transcripts that are not translated into any functional peptides or proteins. these transcripts include structural (transfer, ribosomal, small nuclear, and small nucleolar rnas) and regulatory ncrnas. the latter comprise both small and long ncrnas that can regulate gene expression by acting on chromatin, transcription, rna processing, rna stability and translation. this part of the report introduces general features of regulatory ncrnas including their function and aspects of their biogenesis and degradation. it also establishes possible comparisons between animal and plant ncrna pathways. this can be considered background information to clarify the possibility of plant ncrna biological effect in humans and animals that ingest food/feed from ncrna-expressing gm plants. in addition, ncrna movement inside the plant is also described. specific details on the structural ncrnas and the broad topic of plant ncrna biology are outside the scope of this literature review. following an extensive literature search as described above and based on the team expert decisions on the topic, this section is a review of scientific documents. small ncrnas (srnas) srnas are common to both plants and animals. two major classes of srnas are found in eukaryotes: micrornas (mirnas) and small interfering rnas (sirnas). they function as regulators of endogenous genes or as defenders from invasive nucleic acids. they are characterized by the double-stranded nature of their precursors, and differ from the less abundant piwi-interacting rnas (pirnas) which derive from fragmentation of single-stranded rnas (juliano et al., ) , and are primarily found in animals; they have not been described in plants. pirnas exert their functions in germ and stem cells through interaction with piwi-proteins (juliano et al., ) . by contrast, both mirnas and sirnas are bound to argonaute (ago) proteins, where they identify 'target' rnas by base-pairing interactions, and act in both somatic and germ cells. all srnas in plants are modified at the ' -terminus by '-o-methylation, including mirnas and sirnas, which lack this modification in animals. '-o-methylation is essential to conferring stability and protection from ' uridylation and degradation (borges and martienssen, , ) . mirnas and sirnas are distinguished by their origin and biogenesis (figure ) . mirnas are derived from processing of single-stranded precursors with a hairpin structure, whereas sirnas are generated from long, fully complementary double-stranded rna (dsrna) precursors (carthew and sontheimer, the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. endonucleases (dcls) that excise rna precursors into short double-stranded fragments, - nucleotide (nt) long, with -nt ' overhangs; and argonaute proteins (agos) that engage these duplexes and support their silencing activies based on target complementarity (carthew and sontheimer, ). further details on sirnas and mirnas are provided below. sirnas several different classes of sirnas with specialized biological roles have been identified in plants. the most abundant class consists of heterochromatic sirnas (hetsirnas), which are usually - nt long and originate from the repetitive and intergenic regions in the chromosome and transposable elements. hetsirna are crucial in dna methylation and chromatin modification through a process known as rnadirected dna methylation (daxinger et al., ) . hetsirnas are processed by dcl nuclease and preferentially loaded into ago . mature ago -sirna complex can interact with complementary noncoding nascent rna polymerase triggering the recruitment of dna methyltransferase (domains rearranged methyltransferse ) to silence target loci at the transcriptional level via dna methylation and repressive chromatin modifications (vaucheret, ; lee and carroll, ) . these hetsirnas may account for approximately half of a plant's total mass of srnas. another class of sirnas are naturalantisense transcript sirnas (natsirnas) which can be generated from dsrna precursors through hybridization of independently-transcribed complementary rna strands (vaucheret, ) . in addition, secondary sirnas generated as a "secondary effect" of mirna-mediated target cleavage are found in plants (axtell, ; vaucheret, ) . the mirna-mediated cleaved target is occasionally used by rna-dependent rna polymerase (rdr) to produce secondary sirnas, which can either give rise to a phased set of sirnas (phasirnas) or trans-acting sirnas (tasirnas) with the ability to target genes different from their loci of origin. this secondary pool of sirnas can greatly amplify and sustain a systemic silencing throughout the organism. recognizable rdr-encoding genes are present in the genome of many rnai-competent eukaryotes, with the notable exceptions of insect and vertebrate species in which these secondary sirnas are absent (carthew and sontheimer, ). the lack of these secondary sirnas might have a positive effect on specificity (as sirna amplification can lead to the silencing of multiple transcripts, specifically if they share a highly conserved sequence or a common exon) and a negative effect on the amplification of rna silencing in these species. plants have more diversified and specialized sirna-based pathways than other organisms, which are thought to contribute to plant plasticity . it is generally accepted that these pathways evolved as a cellular defence mechanism against rna viruses and transposable elements, which were later adapted to regulate the expression of endogenous genes. this is consistent with the fact that most small rna classes have a recognized role in defence responses, as well as in epigenetic regulation, and that plants have larger and repetitive genomes (borges and martienssen, ) . the diversification of srna-directed silencing pathways in plants occurred through the expansion of the rdr-polymerases, dcl and ago proteins. rdr genes are found in rna viruses, plants, fungi, protists and some animals, but are absent in flies, mice and humans; this is consistent with the fact that the vast majority of srnas in humans are mirnas (kurzynska-kokorniak et al., ) . absence of rdr activity may also justify the lack of intercellular spreading of rna silencing in vertebrates, whereas systemic silencing is a phenomenon widely reported in plants and nematodes. dicer or dicer-like proteins in plants constitute a four-member gene family, whereas vertebrates have only one member (mukherjee et al., ) . the diversification of agos has resulted in development of distinct gene-silencing processes based on differential ago affinities to small-rna duplexes (borges and martienssen, ) . www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. mirnas mirnas are well-studied srnas deeply conserved over long evolutionary distances, even between the plant and animal kingdoms. however, there are substantial differences between these two kingdoms with regard to mirna biogenesis, and mechanism and scope of mirna-mediated gene regulation (jones-rhoades et al., ) . detailed pathway comparisons and species information are described elsewhere . transcription of mirnas is typically performed by rna polymerase ii, and transcripts are capped and polyadenylated. in animals, most mirnas are derived from longer hairpin transcripts (pri-mirna) by the consecutive processing by the rnase iii-like enzymes drosha and dicer, whereas in plants only dicer (particularly dcl ) is responsible for mirna processing. thus, the biogenesis of most mirnas in plants occurs in the nucleus, whereas in animals it requires the sequential cleavage of pri-mirna in the nucleus and then in the cytoplasm by distinct rnaseiii enzymes (rogers and chen, ) . once processed, one strand of the hairpin duplex is loaded into an ago protein to form the core of the mirna-induced silencing complexes (miriscs). miriscs silence the expression of target genes predominantly at the post-transcriptional level (ptgs). the targets to be silenced are recognised through base-pairing interactions between the loaded mirna and mrna target, which contains a partially or fully complementary sequence (huntzinger and izaurralde, ) . plant mirnas recognize fully or nearly complementary binding sites, which are generally located within the open reading frames (orfs) of the mrna target. of importance is that mirna nt - are usually engaged in base pairing, which allows target cleavage by ago proteins (between nt and ). by contrast, animal mirnas recognize partially complementary binding sites, which are generally located in ' utrs. in both plants and animals, complementarity to the ' end of the mirna (the 'seed' sequence, containing nt - ) is a major determinant in target recognition and is sufficient to trigger silencing. for most mirna-binding sites complementarity is limited to the seed sequence (seed-matched sites) or to the seed sequence plus mirna nucleotide . however, in some rare cases complementarity to the ' region of the mirna might contribute to target recognition, particularly when the mrna has a weak seed match. even for these sites, however, mirna nucleotides - generally bulge out, preventing endonucleolytic cleavage by agos. in both animals and plants the mirna ' terminal nucleotide is buried in the mid domain of agos and is not available for pairing with the target (huntzinger and izaurralde, ) . therefore, there is an important difference in complementarity between plant and animal mirnas and their targets; this is less extensive in animals than in plants. in both animals and plants mirnas can move from cell-tocell. while in mammalian cells mirnas and other types of rnas can be transferred through secretory vesicles (ruvkun, ; valadi et al., ) , in plants they mostly use a different mechanism (kobayashi and zambryski, ) (see section . . . . for details). however, recent evidences also suggest that plants can send small rnas in extracellular vesicles to pathogens to silence virulence genes (cai et al., ) . regarding the silencing mechanism, mirnas were initially thought to inhibit translation in animals and to predominantly promote target endonucleolytic cleavage in plants. however, recent evidence has changed this view by showing that mirnas can trigger translational repression and mrna destabilization in both kingdoms. in both plants and animals, the current evidence suggests that target mrna degradation provides a major contribution to silencing by mirnas (huntzinger and izaurralde, the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. next generation sequencing approaches have revealed a new transcriptional landscape in which many novel lncrnas have been identified. these are transcripts longer than bp without any clear protein coding potential. lncrnas are transcribed either from intergenic regions (lincrnas), introns (incrnas) or the opposite strand to protein-coding genes or other lncrnas; they are thus natural antisense transcripts (nats) (ariel et al., ; chekanova, ; shafiq et al., ; yamada, ) . as a confirmation of their widespread nature and possible biological relevance, lncrnas have been identified in plants, fungi and animals. in fact, lncrnas are involved in diverse biological processes across the eukaryotes, ranging from regulation of mating type in yeast to the pluripotency of embryonic stem cells in mammals (zofall et al., ; flynn and chang, ) . in plants, lncrnas play key roles in flowering time regulation, gene silencing, root organogenesis, seedling photomorphogenesis, and reproduction (ariel et al., ; chekanova, ; shafiq et al., ; yamada, ) . although plant lncrna biological characterization is still limited, detailed analysis of over arabidopsis thaliana transcriptome data sets identified , putative lncrnas, including approximately , nats and over lincrnas. both in plants an mammalians (jin et al., ; liu, j et al., ) these lncrnas do not show association with small rnas and are also expressed at lower levels ( -fold to fold less) than mrnas. plant nat-lncrnas can overlap completely ( %) or have complementary sequences in the ' or ' regions of mrnas. they accumulate in a tissue-specific manner and many are modulated in respond to biotic or abiotic stresses, suggesting fine-tuning regulatory roles wang et al., ; ben amor et al., ; xin et al., ) . nat-lncrnas also accumulate under specific environmental conditions such as light exposure, and their expression overlaps with accumulation of histone acetylation marks, suggesting some transcription regulation effect . in plants there are other types of lncrnas. such is the case of the lncrnas involved in: ) the rna-dependent dna methylation silencing pathway (rddm); and ) the lncrnas generated from phasloci which serve as precursors of -nt and -nt secondary phased phasirnas in many plant genomes (zhai et al., ; fei et al., ; zheng et al., ) . however, the function of most plant lncrnas is still unknown (yamada, ; shafiq et al., ; ariel et al., ) . the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. many lncrnas in mammals and yeast originate from specific genomic locations such as the regions around transcription start sites (tsss), enhancer regions, intron splicing sites, and transcription termination sites. most of the studied lncrnas are expressed around the tss, including exosomesensitive yeast cryptic unstable transcripts (cuts) and stable un-annotated transcripts (suts) (xu et al., ) , and upstream antisense rnas (uarnas) (flynn et al., ) , among others. many mammalian non-polyadenylated lncrnas also correspond to divergently transcribed, exosome-sensitive ernas mapped to enhancer regions (andersson et al., ) ; so far plant ernas have not been reported. although most plant lncrnas are transcribed by rna pol ii, there are two plant-specific rna polymerases, pol iv and pol v, that also produce lncrnas (wierzbicki et al., ; li et al., ; yamada, ) . like many yeast and mammalian lncrnas, most plant lncrnas are polyadenylated, although non-polyadenylated lncrnas do exist (heo and sung, ; shin and chekanova, ; kim and sung, ; andersson et al., ) . in fact, hundreds of non-polyadenylated lncrnas induced by specific abiotic stresses were identified in arabidopsis . the expression of lncrna is regulated at transcriptional level and in combination with the pathways involved in their biogenesis, ' end processing and degradation. the main '- ' exoribonuclease complex may regulate lncrna levels since various groups of polyadenylated ncrnas were originally identified in arabidopsis exosome mutants (chekanova et al., ) . rna exosome is an evolutionary conserved cellular rna processing/degradation complex (lange and gagliardi, ). some of these lncrnas originate from the tsss of protein-coding genes, resembling cuts, or they overlap with the ' ends of protein-coding transcripts and extend into the first intron (chekanova et al., ) . gene expression can be regulated by lncrnas (either in cis or in trans) by sequence complementarity or homology with other rnas or dna, and/or by their structure; lncrnas can thus form specific scaffolds or platforms for assembly of specific complexes (chekanova, ) . most lncrnas regulate transcription. in animals this can be achieved by: ) modulation of transcription factor dna-binding activity; ) control of rna pol ii pausing; or ) recruitment of chromatin modellers, which will ultimately affect chromatin topology and nuclear organization (bonasio and shiekhattar, ) . in plants, there are two lncrnas (hid , apolo) that associate with chromatin, promote loop formation, and modulate transcription ), (ariel et al., (figure ). some lncrnas act at the post-transcriptional and translational level (chekanova, ; jabnoune et al., ) . specifically, lncrnas can act as "decoys" or mimics by blocking certain rnas and/or dnas to access their protein regulators (e.g. ips ) (franco-zorrilla et al., ; huang et al., ) . bioinformatics analyses have also identified other putative mirna target mimics in animals that act similarly to plant mirna sponges (chekanova, ) . another plant lncrna (asco) also acts as a decoy of nuclear speckle rna binding proteins leading to different alternative splicing events and consequent altered root development (bardou et al., ) . other lncrnas with biological function are the enhancerrnas (ernas), described in yeast and mammals, but still unknown in plants. these ernas can act in cis as scaffolds to recruit co-activators and thus promote chromosome looping between enhancer and promoter regions; they can interact with other lncrnas to form specific chromosome structures to control gene expression. ernas are regulated by the exosome which can affect either rna synthesis or degradation in these regions (pefanis et al. ) . the exosome can also protect ernas from genomic instability by resolving r loops, which are stable rna-dna triplexes naturally formed during transcription, which can persist in regions that have divergent transcription, eventually becoming deleterious (skourti-stathaki and proudfoot, the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. action of ernas and exosome can control gene expression and nuclear organization in these enhancer regions. interactions between lncrna and chromatin modifiers can be either dependent or independent of srnas. in animals they are srna-independent and occur via the trithorax complex (h k trimethylation) ; or prc (polycomb repressive complex , that regulates h k methylation) (tsai et al., ) . in plants they are -srna-dependent, with the rna-dependent dna methylation pathway (rddm) (matzke and mosher, ) (see below).further details on specific aspects are provided below. the rddm pathway seems to be a plant-specific pathway that relies on lncrnas transcribed from pol iv that will produce nt sirnas. in parallel, lncrnas produced by pol v act as a scaffold that can then recruit the sirna-ago complex by sequence complementarity (matzke and mosher, ) . however, pol v-dependent lncrnas are difficult to identify probably due to their low accumulation rates. nevertheless, the few identified lncrna are non-polyadenylated and can be either tri-phosphorylated or capped at their ' end (wierzbicki et al., ) . in addition, pol v also seems to collaborate with pol ii to promote rddm (zheng et al., ) . another group of regulatory ncrnas that are pol iv -rdr dependent were identified at intergenic regions overlapping mostly with transposons or sequence repeats. these ncrnas are also non-polyadenylated and at their ' end have a monophosphate instead of ' tri-phosphate or cap (zheng et al., ) . the arabidopsis exosome is involved in metabolism or processing of these lncrnas generated by pol iv, v and also some from pol ii (chekanova, ) . also worth mentioning is that the exosome is constituted by different subunits that are functionally diverse and can affect metabolism of smrnas and dna methylation (chekanova, ) . lncrnas and regulation of flowering some of the best characterized plant lncrnas are those involved in regulation of flowering upon "vernalisation" (the need of plants to experience a period of cold -winter-to enable flowering in spring). therefore, transgenic plants expressing any of these lncrnas may have biotechnological value. to assess the future relevance of these lncrnas it is important to understand the molecular mechanisms behind their function, since they are quite different from those of srnas (sirnas and mirnas).the best studied lncrnas in this process are: ) coldair (heo and sung, ) ; ) coldwrap (kim and sung, ); ) coolair (swiezewski et al., ) and asl (shin and chekanova, ) . all these lncrnas modulate the flclocus, which encodes a transcription factor able to repress flowering (berry and dean, ) . interestingly, these four lncrnas originate from different regions within the flclocus (promoter, first intron, and ' end antisense) suggesting a function in cis. they all contribute to prevent flc transcription by recruiting the prc silencing complex and the accumulation of repressive chromatin marks (crevillén and dean, ; csorba et al., ; rosa et al., ; sun et al., sza; swiezewski et al., ; liu, f et al., ) . of interest is that certain aspects of this regulation are similar to that of the mammalian lncrnas hotair and xist. it has been proposed that some of these lncrnas could directly bind to prc components, but findings showing that mammalian prc can bind very strongly to unrelated rnas (davidovich et al., ) question the need for specific lncrnas in this recruitment step. the study of components of the arabidopsis exosome (rrp l and rrp l ) revealed their role in coolair and asl expression or processing, although this seemed to occur independently of the exosome core complex. both rrp ls could process the ' end of coolair and promote asl accumulation, similarly to xist in humans (shin and chekanova, ; ciaudo et al., the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. regulate the levels of different lncrnas and probably act in different mechanisms to silence flc (chekanova, ) . lncrnas and r-loop formation coolair transcript levels are decreased due to r-loop formation at its promoter (sun et al., b) , which could promote exosome recruitment through the ' end processing pathway (chekanova, ) . this function is also seen in mammals where the exosome also resolves/degrades deleterious r loops (pefanis et al.) . surprisingly, in mutants affected in r loop formation, coolair may accumulate together with flc, suggesting that this regulation is still not fully understood (chekanova, ) . lncrnas and nuclear architecture animal lncrnas are involved in tethering rna, dna and proteins, and thus affect nuclear d structure (engreitz et al., ; quinodoz and guttman, ; hacisuleyman et al., ) . in plants, extensive evidence supports a similar role, either within the rddm pathway (moissiard et al., ) , in the regulation of flowering time (hepworth and dean, ) or in auxin signalling and root development (ariel et al., ; ariel et al., ) . plant and animal lncrnas can be intergenic, intronic or natural antisense transcripts, depending on their location in the genome. although only a few lncrnas have been characterized in detail, they are known to have different modes of action, ranging from chromatin modifications including prc recruitment, to promotion of translation, mirna target mimicry, hijacking splicing factors and formation of chromatin loops. adapted from (ariel et al., ) . not all processes occur simultaneously. different types of lncrnas are shown schematically. circrnas earlier studies of rnas structure proved that viroids (existing as uncoated rna molecules and are known to infect plants) have circular rna (circrna) molecules. the nature of covalently closed circular rna molecules was determined due to: i) the inability to phosphorylate at the '-terminus; ii) resistance to metaperiodate oxidation or borohydride reduction of the '-terminal ribose; or iii) resistance to venom phosphodiesterase degradation (sanger et al., ) the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. al., ), plants (daros and flores, ) , and mammals (nigro et al., ) including humans memczak et al., ) , and across the eukaryotic spectrum. circular rnas' lack of coding potential was identified early on by the inability of circular mrna (kozak, ) or rna (konarska et al., ) to assemble/adhere to eukaryotic ribosomes. circular rnas are also unable to be translated in plants extracts . as with other ncrnas, circrnas in plants exhibit tissue-specific expression, have a considerable number of isoforms, alternative backsplicing (canonical and noncanonical) and alternative circularization patterns (lu et al., ; sun et al., ; wang et al., ; darbani et al., ) . the biogenesis of circrnas is a conserved feature in animal and plant cells. transcribed by rna polymerase ii and backsplicing reactions of pre-messenger rnas, they occur in the spliceosome and require a repeated sequence and rna-binding proteins. spliceosome formation is initiated by sequential assembly of small nuclear ribonucleoproteins onto a specific region of the pre-mrna downstream of the ' donor splice site (dinucleotide gt) and upstream of the ' acceptor site (dnucleotide ag). thus, exonic or intronic circrnas are generated depending on the initial small nuclear ribonucleoprotein binding site (lee et al., ; sun et al., ) . although their mechanisms of action in plants are still unclear, some studies in rice suggest that they do not imply any significant enrichment (as occurring in humans) for mirna target sites, and that circular rna and its linear form may act as a negative regulator of its parental gene (lu et al., ) . other studies have shown that fluctuations in circrnas do not correlate with the levels of their parentalloci encoded linear transcripts (darbani et al., ) . some circrnas have also been shown to contain putative mirna binding sites lu et al., ) and have been identified as mirna sponges (zuo et al., ) . by binding to mirnas, and consequently repress their function, circrnas act as mirna sponge to regulate the response to stress . recent data suggest that circrnas in plants may affect plant response to abiotic and biotic stress. for example, circrnas may be involved in chilling injury in tomato (zuo et al., ) , or may respond to imbalances in iron and zinc (darbani et al., ) . in another study, tan and colleagues (tan et al., ) showed that overexpression of a tomato circrna derived from phytoene synthase (psy ), reduced psy mrna abundance, and lycopene and β-carotene accumulation. this was likely due to the continuous highly expressed circrna and/or the low abundance of linear rna from the overexpression vector. similar results were reported for another circrna derived from the phytoene desaturase gene (tan et al., ) . their role in developmental processes has also been established (cheng et al., ) , including their possible role in different aspects of development and senescence in arabidopsis cheng et al., ) . other biological processes such as photosynthesis (dou et al., ) or mitochondrion function (darbani et al., ) have also been proposed as involving circrnas. circrnas are a popular topic in animal research because of their potential as post-transcriptional regulators (memczak et al., ; piwecka et al., ; guarnerio et al., ; hansen et al., ; ashwal-fluss et al., ) , their recognized function as mirna sponges, as sponges for rna-binding proteins or their competition with linear splicing; and their role as diagnostic markers (zhao et al., a; zhao et al., b) . indeed, circrnas have also been found in biological fluids including saliva (bahn et al., ) , seminal fluid (dong et al., ) and plasma . research in plants is just emerging and functional studies are still lacking. it is unknown if this type of novel ncrnas could resist gastrointestinal tract conditions, due to their expected high stability, and have a biological effect on an organism. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. ncrnas can regulate many biological processes through their impact on gene expression by acting on chromatin structure and affecting transcription, rna processing, rna stability and translation. among these, srnas are produced by cleavage of dsrnas intermediates, either from hairpin precursors (mirnas) or from the synthesis of dsrnas by rdrs (sirnas); most lncrnas regulate gene expression without being processed. despite size and biogenesis differences, most ncrnas share sequence-specific inhibitory functions. important differences are present between plants and other organisms in srnadirected silencing pathways, which are highly diversified and specialized in plants through the expansion of rdr, dcl and ago proteins that mediate srnas biogenesis and function. the vast majority of small regulatory rnas in humans and animals are mirnas. in contrast to plants, no evidence for systemic spreading of rna silencing in humans and vertebrates have been found. although very few plant lncrnas have been studied in detail, they seem to share with their animals' counterparts the ability to recruit chromatin modifiers and thus regulate gene expression. in the same context, very few studies are available on plant circrnas. their functional characterization will bring novel insights into their possible role as a novel class of noncoding regulators. when considering the potential presence of plant ncrnas in food or feed it is important to determine the mobility potential of these molecules inside the source plant (figure ). there are several comprehensive reviews (chitwood and timmermans, ; dunoyer et al., ) addressing sirna/mirna movement in detail. it has been hypothesiezed that srnas may move throughout the plant. although the initial model would suggest non-cell autonomous (one whose action extends beyong the cell producing the signal) rna silencing by srnas, other intermediates could also account for this signal: dsrnas produced by rdr activity (plant specific), or fold back rna acting as silencing trigger (dunoyer et al., ; dunoyer et al., ; himber et al., and smith et al., ) . these intermediates could also diffuse from one cell to another and be processed again by dcl , which has been associated with nt sirna movement (dunoyer et al., ) . in detail, secondary sirnas processed from dsrna by dcl could move cell-tocell to propagate silencing by signal amplification. it has been shown that dcl expression from phloem companion cells is critical to the short-term spread of the silencing effect of a sirna duplex. this was reported in a study in which the viral suppressor p was found to be expressed in phloem companion cells and able to bind to nt small dsrna (vargason et al., ) . dcl -dependent sirna movement has also been shown to occur within certain organs, such as leaves, to create gradients (chitwood et al., ; levine et al., ) . other dcls-dependent sirnas are involved in sirna movement and these can also be sorted into different risc complexes (montgomery et al., ; mi et al., ) . other examples of mobile sirnas could be the ta-sirnas and dcl -dependent nt sirnas, also acting through ago . dcl processing of long dsrna substrates generated by pol iv (a plant-specific rna polymerase) and rdr (another plant-specific protein) leads to production of nt sirnas that are incorporated into ago and will transcriptionally silence transposons (chapman and carrington, ; mi et al., ) . in fact, sirnas derived from transposons or methylated regions in the genome have been shown to be associated with chromatin silencing. these -nt mobile sirnas could then promote epigenetic changes transmissible to following generations. when transgenes are expressed in plants, the generated dsrnas can be processed by dcl and dcl . another dcl, dcl , processes dsrnas into nt sirnas which can induce gene silencing of viral origin or from transgene expression (deleris et al., ) . sirnas may also function as mobile signals able to promote epigenetic modifications. grafting experiments with roots from dcl dcl dcl mutants and shoots expressing gfp sirnas could the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. indicate that sirnas to nt long move throughout the plant, but still unclear if in free or proteinbound form (i.e. bound to ago or other proteins) (molnar et al., ) . within the plant, sirnas are known to move in a source-to-sink direction and into growing meristems (molnar et al., ; palauqui et al., ; schwab et al., ) . their accumulation in reproductive cells could promote epigenetic changes in subsequent generations. in fact, slotkin et al. (slotkin et al., ) showed that dcl dependent sirnas generated by transposon activation in the pollen vegetative nucleus can silence transposons in pollen sperm cells. these cells are then able to transmit genetic material to the following generation. a similar effect may occur if maternally-derived sirnas in the endosperm moved to the embryo and influence genome integrity or even lead to the creation of new epialleles (molnar et al., ) . similar findings of sirnas silencing transposable elements in the animal germ line have also been reported in an animal cell line and tetrahymena (malone and hannon, ). considering that plant development relies more on positional effects than cell lineage, the role of mirnas in the control of several developmental processes has to be strictly regulated at the mobility level (chitwood et al., ; levine et al., ) . for example, as small rnas diffuse into regions of low mrna (targets) expression, it eliminates target molecules therein, but cannot affect regions of high mrna levels (levine et al., ) . as mentioned previously, dcl processes imperfect hairpins into nt mirnas, with a ' u nucleotide incorporated into ago , and cleavage the mrna targets. ago can also incorporate these mirnas (brodersen et al., ) . while sirna movement is better understood, this is not the case for mirna movement. mirnas can be isolated from phloem sap (mir , mir , mir ) but it is unclear if they can leave the phloem (buhtz et al., ; pant et al., ; yoo et al., ) . some reports support both endogenous mirna and artificial mirna movement (chitwood et al., ; schwab et al., ) . it has been shown that mirnas can move from below the shoot apical meristem into the meristematic layers (chitwood et al., ) , and, similarly to sirna movement, from the phloem towards the root meristems (molnar et al., ) . although initial evidence suggested sirna mobility, with only dcl responsible for this, it is now accepted that almost every known rnai pathway in plants has non-cell autonomous activity. movement has been shown for srnas ) of viral origin; ) induced by transgene expression; ) ta-sirnas; ) mirnas and ) repeat-associated sirnas (dunoyer et al., ; carlsbecker et al., ; chitwood et al., ; molnar et al., ; slotkin et al., ) . however, it is still unclear if srnas can move in a free state or associated with specific proteins, and in a single or double strand form. whereas some reports suggest that the srna molecule movement happens in a duplex form, the strand bias found in the srnas present in dcl dcl dcl grafted roots suggests that single strand sirnas can also diffuse (molnar et al., ) . unlike in animals, in which sirnas can move from cell-to-cell through secretory vesicles (ruvkun, ; valadi et al., ) , in plants the size of small rna would allow cellto-cell movement through plasmodesmata channels connecting different plant cells (kobayashi and zambryski, ) . this movement seems to occur in a source-to-sink direction, and could be regulated in some tissues through the formation of sirnas-ago complexes (molnar et al., ; schwach et al., ) . www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. plant small rnas (srnas) can move either cell-to-cell or long distance. cell-to-cell movement occurs through plasmodesmata (green arrows) that allow spreading of srnas from the cell where they are generated to - neighbouring cells (a). this cellto-cell movement can be extended over the surrounding cells by signal amplification (b). in this case, srna targets will be converted into new dsrnas by the combined action of dcls and rdrs. several grafting experiments have demonstrated that - nt sirnas can move over long distances in the plant (c). whether they move as ssrna, dsrna or associated with proteins is still unclear. adapted from (dunoyer, p. et al., ) , (melnyk et al., ) and (molnar et al., ) . in terms of mirna mobility, it is still unclear if all mirnas, or only a subset, can diffuse. different mobility could be associated with different tissues/structures, and/or the size and stability of the passenger strand mirna (a.k.a. mirna*, star strand). in addition, mirna movement regulation could involve subcellular compartmentalization (by nuclear export proteins such as hasty (park et al., ) ) and sequestration via ago proteins (e.g. mir / can be sequestered by ago and affect shoot apical meristem differentiation (liu et al., ; tucker et al., ) ). most of the information is available for srnas since they represent the most studied class of ncrna to date. in addition to the role of srna movement when considering ingestion of transgenic plants expressing altered levels of srnas, it is also important to address the issue of their biogenesis and turnover to assess their temporal availability when ingested. this is especially important since transgenic plants expressing rna interference constructs will accumulate the different srna intermediary forms (pri-mirnas, pre-mirnas, mature mirnas, drnas, sirnas), which may also be processed outside the plant when ingested. several reviews published in high-impact journals (rogers and rogers and chen, ; or scientific reports the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. view of the processes of mirna maturation and degradation in plants. it is important to consider the homology between the mirna biogenesis pathways in plants and animals as well as mirna stability. this knowledge allows understanding ) whether any aspect of animal metabolism or other biological processes could be modulated by plant mirnas; and ) if mirnas can survive for long periods after ingestion. as typical pol ii transcripts, pri-mirnas are stabilized by addition of a ' -methylguanosine cap (xie et al., ) and a ' polyadenylated tail (jones-rhoades and bartel, ; zhang et al., ) . mirna genes are also subjected to transcription factor regulation and can be alternatively spliced. the size of these transcripts varies and their processing normally occurs in a base-to-loop direction (rogers and . in plants, there are multiple dcl endonucleases that possess dexd/h-box rna helicase, duf , paz, tandem rnaseiii, and dsrna-binding domains. dcls cleave the dsrna precursor generating a -nucleotide ' overhang (margis et al., ) . processing of the pri-mirna requires at least two catalytic cycles to free the mirna:mirna* duplex. in animals, this requires sequential cleavage of the pri-mirna in the nucleus first and then in the cytoplasm by different rnase iii enzymes. the biogenesis of most mirnas in arabidopsis requires dcl (park et al., ; reinhart et al., ) , although other dcls may be involved, but are not essential (xie et al., ; gasciolli et al., ) . in contrast to animals, all plant mirna processing steps occur in the nucleus (papp et al., ) . dcl activity will result in mature mirnas of - nucleotides (nt), although variations in size can occur (rogers and chen, ) . confirming its fundamental biological relevance, dcl mutants are lethal (golden et al., ) . other dcl proteins that function in different srna biogenesis pathways might also have minor roles in mirna biogenesis. for instance, several mirna genes are partially processed into - -nucleotide mature mirnas species whose accumulation depends on dcl (vazquez et al., ) . in the absence of dcl , mature -nucleotide mirnas can accumulate due to dcl activity. in contrast, processing of mir , mir , and mir depends primarily on dcl , probably as a consequence of highly complementary fold-backs in these pri-mirnas (ben amor et al., ; rajagopalan et al., ) . dicer cleavage of animal pri-mirnas is facilitated by the action of dsrnabinding domain (dsrbd) proteins (drbs) (jiang et al., ; parker et al., ) . in arabidopsis, there are five drbs that have been shown to bind dsrna in vitro (hiraguri et al., ) . the best studied member of this family is hyl (hyponastic leaves ) which is involved in pri-mirna processing, but also in pri-mirna intron splicing (laubinger et al., ; szarzynska et al., ) . hyl seems to increase the accuracy of dcl processing of most, but not all, pri-mirnas, suggesting that other mechanisms may also be involved (liu, c et al., ) . from the same family, drb and drb are also involved in pri-mirna processing, by associating with dcl (rogers and . another protein involved in mirna biogenesis is serrate (se), which can interact with hyl and dcl (lobbes et al., ; machida et al., ) . like hyl , se also seems to increase dcl pri-mirna cleavage efficiency (dong et al., ) . of interest is that these two proteins (hyl and se) can be regulated by phosphorylation. although hyl phosphorylation can decrease its activity (manavella et al., ) , the biological relevance of this modification in se is not known (rogers and . another regulator, dawdle (ddl), a phosphothreonine-binding forkhead associated (fha) domain protein, seems to stabilize pri-mirnas, possibly by direct binding (yu et al., ) . like se and hyl , ddl can also interact with dcl , but does not seem to be involved in pri-mirna processing. ddl most likely facilitates dcl access or recognition of pri-mirnas. in addition, ddl can recruit phosphorylated se or hyl to the pri-mirna. the human homologue of ddl, snip , seems, among other functions, to be involved in mirna biogenesis and interacts with drosha (yu et al., ) . ddl could therefore be an evolutionarily www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. conserved factor in mirna biogenesis. other examples of conserved srna biogenesis machinery include ago, dicer, hen and exportin (yu et al., ) . two components form the cap structure of rna pol ii transcripts in plants: cap-binding proteins (cbps) and . there is substantial overlap among cbp , abh /cbp , and se mutants in terms of: ) the specific pri-mirnas affected; ) the specific mrna splicing defects observed, and ) a bias for accumulation of first introns (laubinger et al., ) . this connection between pri-mirna processing and pre-mrna splicing seems to converge at se and cbps. in fact, splicing defects are also observed in cbp and abh /cbp in plants. in animals, the cap and its associated cap-binding complex are essential for the correct splicing of the first intron (lewis et al., ) . the connection between pri-mirna processing and splicing also converges in tough (tgh), a g-patch domain rna-binding protein. the tgh mutant accumulates pri-mirnas in vivo and has been shown to affect processing of pri-mirnas into -nucleotide mature mirnas (ren et al., ) . tgh may have either a structural or a regulatory role in pri-mirna processing. tgh binds both pri-and pre-mirnas in vivo, but this probably occurs via association with the loop structure since tgh binds ssrna but not dsrna in vitro (ren et al., ) . tgh paralogs have been described in metazoans (calderon-villalobos et al., ) , but their roles in mirna biogenesis are still unknown. a human tgh paralog is reported in spliceosomal preparations (jurica et al., ) . a conserved connection may exist between tgh and splicing and possibly pri-mirna processing (rogers and chen, ). mirna processing seems to occur in specific subnuclear regions. hyl , se and dcl can make pairwise interactions that occur in certain subnuclear particles (fang and spector, ) . tgh can also interact with dcl , hyl , and se in subnuclear foci (ren et al., ) . these foci seem to be zones of functional pri-mirna processing (fang and spector, ; fujioka et al., ; manavella et al., ) . some of these components (dcl , hyl , se, tgh) also co-localize with components of the splicing machinery, further strengthening the connection between the two processes (calderon-villalobos et al., ; fang and spector, ; fujioka et al., ) . processed mirna:mirna* duplex will leave the nucleus to carry out its function in the cytoplasm. several components have been implicated in this transport and function and are described below. nucleo-cytoplasmic transport hasty (hst) is a member of the importin-ß family of arabidopsis that accumulates in the nuclear periphery (bollman et al., ) . hst is a paralog of human exportin- involved in pre-mirna transport. hst can participate in dcl -dependent mirna:mirna* duplex export (zeng and cullen, ) . but this is probably not the sole mechanism for mirna nucleocytoplasmic transport, since passive diffusion via the nuclear pore may also occur (jacob et al., ; park et al., ) . ema /sad is another importin-ß family protein involved in mirna function. ema is an orthologue of human importin- which facilitates nuclear import of ago and reduces its association with target mrnas (weinmann et al., ) . it is still unclear if ema ) sequesters mirnas; ) is involved in transport of other risc loading factors or; ) affects loading of certain mirnas into risc (rogers and . the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. after leaving the nucleus the mirna:mirna* duplex is loaded into ago, a risc component. the arabidopsis ago family consists of members that associate with small rnas possessing specific ' nucleotides (mi et al., ; takeda et al., ) . in plants, the slicer activity of agos has been shown for ago , ago , ago , ago , and ago (rogers and . ago seems to have a predominant role since it preferably associates with 'u small rnas (most common ' nucleotide in mirnas) (mi et al., ; takeda et al., ; vaucheret et al., ) . however, other agos can also associate with specific mirnas depending on mirna length or even their accumulation in different tissues (ebhardt et al., ; rogers, kestrel and chen, xuemei, ) , suggesting a certain flexibility in this association. in plants, mirna guide strands generally accumulate in higher levels than mirna* strands, although the exact mechanism for strand selection is still not fully understood (rogers and chen, ). hyl (drb) seems to be involved in this process (eamens et al., ; manavella et al., ) . in animals, loading of sirnas into risc requires the cytosolic drb protein loq, but loading of mirnas into risc requires dicer rather than loqs (liu et al., ; liu, x et al., ) , suggesting different mechanisms in plants and animals. hyl is predominantly nuclear, therefore its association with the mirna:mirna* duplex suggests that ) hyl may be transported to the cytoplasm together with the processed mirna duplex; or ) loading may also occur in the nucleus. in addition, other risc loading mechanisms can exist (eamens et al., ). in animals, sirna passenger strand unwinding requires ago slicer activity; mirnas duplexes are unwound by a slicing-independent mechanism (matranga et al., ) . in plants, ago slicer activity removes sirna passenger strand but this function is not required for mirna passenger strand removal (carbonell et al., ; iki et al., ) . as occurs in animals, plant mirnas use an alternative slicerindependent unwinding mechanism. ago loading seems to require heat shock protein (hsp ) too (iki et al., ) . in addition, via hsp , ago is able to interact with squint (sqn) and the phosphatase pp (iki et al., ) . these interactions seem to regulate ago loading and consequently risc activity. ago phosphorylation has been detected in arabidopsis (de la fuente van bentem et al., ) in manner similar to human ago . apparently, phosphorylated ago exhibits reduced srna binding (rüdel et al., ) . phosphoregulation by pp or other proteins may modulate arabidopsis ago loading capacity. unlike in animals, in which mirna biogenesis occurs in the nucleus and cytoplasm, the mirnas in plants are generated in the nucleus in a mostly dcl- -dependent manner. studies confirm that several of the major components are evolutionary conserved, such as the dicer, ago, hen and exportin paralogs involved in nucleocytoplasmic transport of the mirna:mirna* duplex. however, shared pathway components among the different species do not reflect totally identical processes, such as, loading of mirnas into risc which occurs differently in plants and animals. one interesting common aspect remains the pri-mirna processing and pre-mrna splicing which seems to occur both in plants and animals. www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. following a systematic literature search as described in section . . . and following the methodology described in section . . . ., a total of publications were selected as relevant to the stability and turn-over of non-coding rnas. of these, only four analyse ncrnas stability at a genome-wide scale, and one (enuka et al., ) simultaneously addresses the stability of several circrnas. using these studies, the stability of small ncrnas, lncrnas and circrnas can be compared. while earlier studies report the degradation of plant nucleic acids when exposed to hard conditions (i.e. cooking), six recent studies suggest that some ncrnas (i.e. mirnas) from plants can resist these conditions. turnover of ncrna molecules in plants and mammals depends both on their stability and degradation rate and it is described that chemical modifications can increase stability of different types of srnas (e.g. sirnas, mirnas). in mammalian cells, artificially introduced -o-methyl groups can stabilize sirnas without affecting their rna interference activity (czauderna et al., ) . considerable work has been done to address the issue of mirna modifications and how these affect their stability. among these, '-o-methylation has been identified as relevant. plant mirnas have a naturally occurring methyl group on the ' nucleotide ribose ( figure ). in this case, methylation does not require guide rnas, since hen (hua enhancer ) can methylate mirna:mirna* duplexes. this hen -dependent '-omethylation on the ' terminal ribose is a mg + dependent methylation mechanism that will ultimately stabilize mirnas (abe et al., ; molnar et al., ; yu et al., ; yang et al., ) .the hen mg +-dependent methylation mechanism relies on its two dsrbds binding the substrate duplex, and the la motif-containing domain interacting with the ' end of the substrate strand (huang et al., ). this methylation step occurs after dcl processing creates the mirna:mirna* duplex but before duplex www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. unwinding and selection of the mirna guide strand. however, it is still not clear whether hen can methylate free mirnas or can bind hyl , dcl and ago , although it has been shown to interact with hyl and dcl . in animals, the hen homolog has a different structure since it does not possess the dsrbd and la motif-containing domains. therefore, the animal hen homolog methylates singlestranded srnas associated with ago or piwi proteins (saito et al., ; horwich et al., ) . the degradation of ncrna molecules in plants and mammals is mediated by ' nucleotidyl transferases and exoribonucleases. the arabidopsis hen suppressor (heso ) belongs to the dna polymerase β gene family (zhao et al., ; ren et al., ) . in other organisms, heso putative homologs are ribonucleotidyl transferases that are able to add specific nucleotides to the ' end of different rnas (martin and keller, ) . arabidopsis heso can also add nontemplated nucleotides to the ' end of unmethylated mirnas in vitro and exhibits a preference for uridine (ren et al., ; zhao et al., ) . analysis of hen and heso mutants indicates that this ' oligo uridylation triggers degradation of mirnas (ren et al., ; zhao et al., ) . the arabidopsis family of small rna degrading nucleases (sdns) of '- ' exonucleases has similarity to the yeast rex exonucleases. sdn has '- ' exonuclease activity versus short ssrnas but is not active against longer or double-stranded substrates (ramachandran and chen, ) . in plants, ' truncated mirnas can be modified by the addition of ' oligonucleotide tails (see above) (ibrahim, fadia et al., ; li, j et al., ; lu et al., ). in addition, these ' truncated mirnas also seem to associate with ago . this interaction delays their degradation and allow addition of the ' oligonucleotide tail leading to their degradation at a later stage (zhao et al., ) . whereas '-o-methylation may protect against ' oligouridylation by heso (see above) and consequent targeting to degradation, this modification would not protect against sdn . it is possible that sdn can promote mirna ' truncation and then facilitate subsequent ' polyuridylation by heso . however, after ' polyuridylation sdn would be unable to degrade these tailed mirnas, suggesting the existence of other nucleases (ramachandran and chen, ) .for instance, the addition of ' polyuridylated tails in mirnas seems to attract exosome-mediated degradation in algae (ibrahim, f. et al., ) , but in arabidopsis this regulation has not been addressed in detail (rogers and rogers, kestrel and chen, xuemei, ) . another possible mechanism would include loss of ago association and protection of mirnas with long ' tails due to heso activity. in addition, ' polyuridylation may act as a nucleases recruitment platform, thus promoting mirna degradation. nevertheless, ' polyuridylation and nuclease processing seem to be interconnected events that will ultimately result in degradation of the tagged mirnas. the overall turn-over of rnas is mainly described using half-life studies in both plants and animals. most of the available reports assessing ncrna half-life focus on the role of ' truncation, ' uridylation and consequent degradation (see above) as the main processes regulating mirna turnover in plants. however, a recent report identifies the enzymes (sdn and sdn exonucleases) responsible for ' truncation in vivo and its relationship with ' tailing (uridylation). also of importance, this report shows the opposite role of ago and ago in mir / degradation by sdns, specifically sdn . ago promotes mir degradation by sdn , an unexpected role for a plant ago which has been associated with a protecting role in mirna stability (yu et al., ) . this function of ago (enhancing mir degradation) keeps mir out of the stem cell niche in the shoot apical meristem (where ago is not expressed). accumulation of ectopic mir in the shoot apical meristem fails to maintain the stem cell population. this kind of mechanism is thus needed to clear mir since this particular mirna can move between cell layers (see mirna movement section, above). another report evaluates the activity of nucleotidyl transferases in ' uridylation of mirnas and in vitro assays indicated a fast enzymatic process (tu et al., ) . also, xrn - nucleases that affect mir homeostasis in c. elegans do not www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. seem to process mature plant mirs but rather the by-products of pri-mirna processing (ji, lijuan and chen, xuemei, ) . in summary, there are no specific studies on mirna half-life in plants. the reports mentioned here evaluate mirnas levels at steady state in different mutants, for example, when either the exonucleases and/or nucleotidyl transferases involved in mirna turnover are deleted. the half-life of mirnas in mammals has been addressed in studies of dicer ablation in mouse embryonic fibroblasts showing that mirnas are highly stable inside the cell. indeed, turnover assays revealed that the average mirna half-life is h (i.e. ≈ days) (figure ). although some mirnas have a shorter half-life, these data generally indicate that mirnas are much more stable (≈ x more) than messenger rnas. (gantier et al., ) . several features have been described that might explain this high half-life for mirnas. for instance, partial pairing of mirna and the mrna target site generally produces translational repression, while extensive pairing of mirna and mrna produce a mrna cleavage (pasquinelli, ) . in the former case the mirna remains stable, but in the latter it degrades. further studies in mammalian cells have also shown that argonaute proteins stabilize mature mirnas in a slicing-independent manner, increasing mature mirna stability (winter and diederichs, ). for specific mirnas, it has been found that certain rna-binding proteins (i.e. roquin) can enhance mature mirna- stability by reducing its ' end uridylation (srivastava et al., ) . while intracellular levels of mirnas are mostly affected by cell division (ghosh et al., ; gantier et al., ) , mirna activity and turnover can also be controlled by subcellular distribution of microribonucleoproteins; that is, polysome sequestration contributes to an increase of cellular mirna levels, but without an increase in mirna activity (ghosh et al., ) . plant small rna duplexes can be '-o-methylated at their ' terminal ribose by hen , loaded into ago and protected from uridylation and degradation by '- ' exonucleases. ago -bound unprotected small rnas, however, are uridylated by heso and degraded by sdn . adapted from (borges and martienssen, ) and (ji and chen, ) . the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. widespread variation of mirna decay in slow-dividing primary macrophages. bone marrow derived macrophages from when analysing lncrnas stability in mammals at a genome-wide scale, lncrnas half-life generally varies over a wide time range, comparable to, although on average less than, that of mrnas (clark et al., ) . in a study of all transcripts, including mammals, it was found that the range of half-lifes for ncrnas (all types) was similar to that of the mrna half-life (tani et al., ) . indeed, a large number of ncrnas transcripts have a half-life of less than h (tani et al., ) , which agrees with the < h half-life for hundreds of unstable lncrnas (clark et al., ) . however, although there are lncrnas with extreme stability (half-life > h) they are still much less stable than mirnas (gantier et al., ) (see above), but more stable than protein-coding rnas (wang, l et al., ) . circrnas have a covalently closed loop structure with neither '- ' end nor a polyadenylated tail, which confers high resistance to rna exonuclease or rnase r treatment when compared to that of their linear sequence counterparts (memczak et al., ) . indeed, earlier studies of the structure of rnas from viroids, which were found to be circular, suggested that the nature of covalently closed circular rna molecules confers certain properties including resistance to metaperiodate oxidation or borohydride reduction of the '-terminal ribose; the inability to phosphorylate at the '-terminus; or resistance to venom phosphodiesterase degradation (sanger et al., ) . in mammals, some studies have evaluated the stability of circrnas compared to that of their linear isoform derived from the same host gene. for example, circrnas were found to be less abundant and dynamic than their counterparts (enuka et al., ) . calculating the half-life of circrnas and their linear counterparts, enuka et al., showed that the media half-life of circrnas of mammary cells ( . - . h) was at least . times longer than the median half-life of their linear counterparts ( . - . h). this suggests that cirrnas are generally more stable and static compared to linear species (enuka et al., ) (figure frame a). in a stability study on some circrnas it was found that while the associated linear transcripts exhibited a half-life of < h, the circular rna isoforms were highly stable, with transcript half-life exceeding h (jeck et al., ) . in plants, covalently circularized exogenous rna incubated with wheat embryo cell extract in vitro have shown that the circular rnas exhibited considerable stability compared to the linear version (makino et the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. al. , ) . while linear rna degraded within the first few minutes, its circular counterpart was stable for more than min in vitro (figure frame b). by contrast, circularization dramatically reduced the translation capability of the rna, which was restored to some extent after linearization. plant srnas are naturally methylated at their ' nucleotide ribose. this modification depends on hen and protects srna from degradation. unmethylated or truncated srnas can be uridylated by heso and thus be targeted for degradation by '- ' exonucleases of the sdn family. although ago binding to mirnas was believed to protect them from degradation, recent reports suggest that ago in particular may promote mirna degradation by sdns. differently from the plant situation, animal srnas are not methylated. a) mcf a cells were metabolically labelled using su, for or h. the rna was then extracted, biotinylated and purified on streptavidin magnetic beads. flow-through rna was also collected. next, rna was reverse transcribed and quantified using highthroughput real time pcr (fluidigm). the half-lives of circrnas and their corresponding linear counterparts are shown. halflife values were calculated from two samples, labelled with su for or h and then averaged. all data were corrected for any bias introduced due to low uridine (short length) of rna species (see 'materials and methods' section). the circrnas (red dots) and their linear counterparts (blue dots) were sorted from high to low according to the difference between their half-lifes. error bars represent standard errors. source: from (enuka et al., ) . b) stability of circular rnas in the wheat germ cell-free translation system. a denaturing polyacrylamide gel separating the synthesized circular and linear rnas with a (gaaa) sequence after incubation with the wheat embryo extract for the indicated time periods. untreated rna is in lane n. positions of circular, linear, and ribosomal rnas are indicated as c, l, and rrna, respectively, on the right. source: from . compelling evidence supports the significant contribution of srnas to communication between hosts and some eukaryotic pathogens, pests, parasites, or symbiotic microorganisms. (baulcombe, ; (ghag et al., ; koch et al., ; vega-arreguín et al., ; helber et al., ) . srnas or dsrnas, efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. for example, can be transferred from plant to pests such as insects that eat leaves or nematodes that infect roots. in fact, transgenic plants can be created that express dsrna homologous to essential genes of insect pests or nematodes and thus control them (baum et al., ; fairbairn et al., ; mao et al., ) . thus, this silencing transfer mechanism is very relevant for the food and feed risk assessment of ncrna gmo plants, highlighting the need to evaluate the stability of ncrnas outside the plant. earlier studies suggested that food nucleic acid content was hydrolysed when cooked (colling and wolfram, ) . most of ncrnas, including srnas and lncrnas have been discovered in the last years, and thus new data has been added to the body of knowledge. in a study of srna stability under cooking conditions, plant mirnas were detected after cooking although at significantly lower levels when compared to fresh plant tissues (see table ) (zhang, lin et al., ) . differences were observed for mirnas from different food/feed sources (rice, cabbage, wheat or potato), ranging from nearly undetectable values to almost % persistance of mirnas after cooking. levels of mirnas were monitored with a stem-loop quantitative reverse transcription polymerase chain reaction (qrt-pcr) assay using the u snrna for normalization, a commonly used housekeeping gene in mirnas analyses. the same study found that most of the plant mirnas and mammalian mirnas could survive under acidic conditions that mimic the gastric acidic environment. of note is that the degradation rate of mammalian mirnas under acidic conditions was similar to that of their synthetic form (without '-omethylated ' ends), whereas plant mirnas had a much slower degradation rate compared with their synthetic form (without '-o-methylated ' ends), suggesting that methylation had a protective effect on the stability of plant mirnas (table ) . another study reported that endogenous mirnas can be detected by qpcr analysis in rice and soybean plant materials after storage, processing and cooking (philip et al., ) . for processing and cooking, soybeans were soaked in rnase-free water with . % w/v nahco overnight at ºc, then separated from the soaking liquid, rinsed in fresh rnase-free water, and then boiled in rnase-free water for www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. min until they became soft in texture. by constrast, a synthetic mirna showed a significantly higher susceptibility to simulated food processing conditions as compared to plant mirnas, as well as high molecular weight rnas (total rna). the synthetic mirna used for comparisons was the cel-lin- , which is a caenorhabditis elegans mirna. the synthetic mirna was synthesized without '-o-methylated ' ends (philip et al., ) . these results suggest that the methylation and the small size of plant mirnas make them more resistant to degradation than synthetic (not chemically modified) mirnas. in addition, the study showed significant plant mirna stability in a simulated digestion system for min prior to absorption or transport into the blood stream. however, this study provided most of the quantitative data from q-pcr analysis without normalization, and data should be considered as relative compared to the treated control in the experiments. studying the stability of plant srna in vitro, liang and colleagues exposed total rna ( µg), isolated from brassica oleracea, to freshly drawn serum from mice. in serum, a large amount of srnas survived after h of incubation at ºc, but after h only about % of the rna could be detected. the authors also exposed the plant rna molecules to fecal suspensions at ºc. after h incubation significant amounts of srnas were still detectable, but after h rna molecules were undetectable . suggesting that srnas were more resistant to degradation in the presence of serum suspension than in fecal suspensions. these results were produced by gel electrophoresis of srnas, which is known to be less sensitive than qrt-pcr or rna sequencing methods. this study also reports that, when orally ingested, plant mir (chosen because it is the most highly enriched plant mirna from b. oleracea) can pass intact through the gastrointestinal tract in mice (a maximum of . % recovered from the stomach of some individuals), and can be detected in the blood, liver, spleen and kidney. levels of mir were monitored by qrt-pcr using a taqman probe, which can distinguish differences of one nucleotide. since only one mirna was evaluated, the above findings cannot be generalized to other mirnas. other studies have reported mirnas to be stable in watermelon and mixed fruit juices produced by simple extraction without additives . plant mirnas were detected by stem-loop qrt-pcr using taqman probes and some were validated by northern-blot analysis. to reduce the nonspecificity signal of qrt-pcr, no-template controls were used. yang and colleagues studied artificial in vitro digestion systems that simulate mammalian gastric and intestinal conditions, and found that mir was between - fold more stable than other mirnas . this effect was observed for cabbage extracts when compared to either the 'o-methylated or the non-modified form. detection was also done by qrt-pcr. the same research group reported recently that several plant mirnas, including mir , were degraded during storage at ºc in cabbage extracts obtained by mechanical maceration . degradation of these mirnas correlated with that of s rrna, whereas mir accumulation was increased over -fold after hours of storage, and then gradually decreased over a span of days. mirna (mir ) increasing in macerated tissues (rather than degrading) is uncommon for most mirnas. indeed, the authors indicated that, in terms of genesis and amplification, mir is an atypical mirna, which could explain the disparity in serum detection with respect to canonical plant mirnas. thus, mir was shown to be derived from s rrna and processed in a dcl -independent manner, meaning that when s rrna is degraded mir is produced. this study presents the possibility that certain ncrnas can have non canonical features for synthesis or stability, and should be evaluated individually. in another recent study, the in vitro stability of curcuma longa mirna (clo-mir ) was assessed. when exposed to foetal bovine serum (fbs) for up to h, the mir exhibited high resistance . in summary, food nucleic acid content are generally hydrolysed during processing, with some studies suggesting that mirnas from plants may be more resistant to degradation than synthetic or animal www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. mirnas due to endogenous modifications ( '-o-methylated ' ends). however, these findings are not consistent with mirna stability studies in the animal gastrointestinal tract, and further research is required. although there are many studies on plant ncrnas stability (see . . . .), these mainly focus on ncrna stability within the plant itself. mammalian ncrna stability differs from that of plants because lack the natural '-o-methylation at the ' ends occurring in plant ncrnas, mostly in mirnas (yu et al., ) . very few reports were identified in which plant ncrna stability is investigated in a mammalian organism ) (see sections . . and . .) . understanding the molecular basis that confers plant ncrna stability is of vital importance and needs to be further evaluated to better inform on the relevance of plant ncrna for food and feed risk assessment. for instance, modifications plant mirnas not occurring in mammals, such as the methyl group located on the ' nucleotide ribose, could hypothetically have an impact on plant mirnas stability in mammalian systems due to the lack of the appropriate enzymes for their recognition and degradation, or due to increased stability to mammalian rnases . should this be the case, plant mirnas could manifest a much longer than expected half-life in mammalian organisms when compared to mammalian mirna, which could increase the probability of encountering target molecules. the literature contains descriptions of possible in vitro interaction of plant mirnas with mammalian mirna silencing complexes which may trigger target repression chin et al., ) . however, this hypothesis needs to be experimentally validated since there are gaps in the literature. moreover, it needs to be determined if sufficient levels of ingested plant mirnas reach a target cell to determine an effect in mammalian cells. for instance, in mammalian studies it has been suggested that the threshold for target gene regulation is between and copies of mammalian mirna per cell . accumulation of plant exogenous ncrnas has not yet been reported, but recent next generation sequencing studies have reported a plethora of plant mirnas and other rnas in circulating in the human organism (see section . ). the biological significance of their presence is still unknown. it remains unknown if under certain pathological conditions (i.e. compromised intestinal permeability or renal function) exposure to these plant ncrnas could change. all these gaps in the literature would need to be experimentally validated. to determine the half-life of plant ncrnas in mammalian cells would require experiments utilizing labelled plant ncrnas, first transfected into mammalian cells (in vitro studies) and then orally administered to experimental animals (in vivo studies). the markers used for these experiments could be radioactive probes or labelling molecules of very low molecular weight, such as biotin or fluorescein, to prevent distorting the actual size of the plant ncrna under study. due to their small size, this is important when studying mirnas stability. there is evidence that certain plant ncrnas can induce silencing in some eukaryotic pathogens, pests, parasites or symbiotic microorganisms as a defence strategy. in return, various pathogens develop mechanisms to evade this defence system, proving the existence of a two-way sirnas traffic between pathogens and their plant hosts. plant ncrnas stability outside the plant and in animal systems may play a role in cross-kingdom effects but has received limited attention. the resistance of plant ncrna to the gastrointestinal environment or processing has been partly investigated but more research would be needed. efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. following the methodology described in the section . . . and based on a literature search as described in section . . . . , a total of documents were selected as relevant to describing the state of the art in the field of ncrnas used/intended for use as therapeutics in humans (pharmaceuticals/medicine area). this constitutes valuable preparatory material on the pharmacokinetics (and pharmacodynamics) of ncrna, as required by task . of these publications at least indicate that to ensure the biological activity of exogenous rnas for therapeutic requires numerous chemical modifications and delivery methods. although composed mainly of only four basic building blocks, rnas form simple to very complex structures. its intrinsic base-pair property, enhanced by the ability of the extra hydroxyl groups in the ribose sugar to form hydrogen bonds, are the foundations of its diverse structure and functions (lu et al., ) . rna can fold into various secondary structures including stem, loop, bugle, pseudoknots, gquadruplex and kissing hairpin. it can perform a wide range of biological functions, ranging from regulation of gene expression at various levels to catalysing chemical reactions which closely depend on the ribonucleotide chain's spatial structure. other rnas, such as ribozymes (doudna and cech, ) , can form tertiary structures with catalytic activity. certain rnas can also undergo transformation between alternative structures, depending for instance on binding to specific ligands or environmental changes, as is the case of riboswitches (mironov et al., ) . riboswitches are noncoding rna structures located within mrnas that bind endogenous ligands to regulate gene expression or rna splicing events (cheah et al., ) . the sirna mechanism of action involves dicing of endogenous dsrnas from longer rnas transcripts by dicer and loading into the protein complex of the rna-induced silencing complex (risc). argonaute (ago) proteins are the catalytic core of the risc complex in plants and animals (tolia and joshua-tor, ) . one strand (the passenger strand) is discarded and the guide strand is paired to a complementary mrna sequence via the risc complex. gene silencing can be achieved mainly through post-transcriptional gene silencing (ptgs) or transcriptional gene silencing (tgs). in ptgs mechanisms, the mrna undergoing translation can be sequence-specific cleaved by the risc complex and degraded when the target mrna is perfectly complementary to the sirna. when the interaction is partial or only limited complementarity exists, translational repression and rna degradation occurs, which is a mechanism exerted by mirnas. the mechanism of action for mirna differs somewhat. the mirnas are endogenous encoded singlestranded rnas of about nt long that are important post-transcriptional regulators of gene expression by pairing through a sequence-specific complementary binding to the ' utr of the target mrna. this is usually mediated by a sequence of - nucleotides, known as the seed region, at the ' end of the mature small rna (bartel, ). however, mirnas can also bind to other mrna sites including ' utr or protein coding exons (forman and coller, ) . depending on the degree of sequence complementarity, the interaction will result in mrna degradation and/or translational repression (ameres et al., ; bartel, ) , with destabilization of target mrna being the predominant efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. mechanism to reduce protein output exerted by mammalian micrornas (guo et al., ) . most animal mirnas are transcribed by rna polymerase ii into a long primary transcript (pri-mirna) containing a stem-loop structure. the pri-mirna is then processed by a multiprotein complex containing the nuclear rnase iii drosha into a ≈ nt long hairpin-shape precursor (pre-mirna) and exported to the cytoplasm via an exportin- and ran-gtp-dependent mechanism. the cytoplasmic rnase iii dicer further processes the pre-mirna by removing the terminal loop to produce a small rna duplex, containing the functional microrna and the passenger (*) strand (mirna/mirna*). the duplex mirna is then separated and the functional mirna incorporated into ago proteins within the rna-induced silencing complex (risc), guiding it to the target mrna to induce its translational repression or mrna destabilization (krol et al., ; bartel, ). in , zamecnik first reported the use of an exogenous synthetic oligodeoxynucleotide complementary to the rous sarcoma virus s rna as a potent inhibitor of protein translation (stephenson and zamecnik, ) and virus replication (zamecnik and stephenson, ) . since then, the ability to use exogenous (synthetic) agents to control gene expression has revolutionized many aspects of biological research and catalysed the development of a new promising class of exogenous molecules to treat human diseases. however, despite the obvious promise of this approach, progress has been slow because of the need to overcome myriad technical hurdles, particularly those related to the pharmacokinetics, pharmacodynamics and delivery of antisense molecules. indeed, as most antisense-based potential therapies have not yet produced significant clinical results, very few rnabased or dna-based antisense drugs have been approved for clinical use. in , the u.s. food and drug administration (fda) approved the first aso-based therapeutics for the treatment of a human disease. in , fomivirsen (marketed as vitravene) was approved for clinical use by the european medicines agency (ema) for the european market for treatment of cytomegalovirus (cmv) retinitis in immunocompromised patients. fomivirsen is a synthetic -mer aso (dna) that binds complementary to the sequence of the mrna encoding the ie protein from cmv. the first rna-based therapeutic approved for clinical use was pegaptanib (marketed as macugen), which was approved by both the fda (in ) and ema (in ), for treatment of neovascular (wet) age-related macular degeneration. pegaptanib is also the only approved single strand rna aptamer drug, and it targets the vascular endothelial growth factor as an antagonist. in both cases, fomivirsen and pegaptanib, the route of administration is intravitreal injection, and the unique properties of this route provide benefits in terms of pharmacokinetic and immunological response. in , the fda (but not the ema) approved the second rna-based therapeutic, mipomersen (marketed as kynamro) for treatment of homozygous familial hypercholesterolemia. mipomersen is a dna-rna aso that binds to the mrna of apolipoprotein b (apob), thus reducing apob protein and concomitantly ldl cholesterol levels. antisense oligos like fomivirsen (dna) and mipomersen (dna-rna) act by binding to a complementary sequence of a mrna, thus preventing production of its encoded protein. nusinersen (marketed as spinraza) approved by the fda (in ) and ema (in ) as an orphan-drug for treatment of spinal muscular atrophy is a rnabased aso that increases the production of the full-length survival motor neuron (smn ) protein. eteplirsen ( the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. (bobbin and rossi, ) and many others, which suggests that exogenous rnas can be delivered to humans and used to modify gene function, protein accumulation and treat human diseases. the ability of nucleic acids, both dna and rna, to form duplexes by base complementarity, has been used to develop oligonucleotide-based drugs for gene silencing. in principle, an oligonucleotide binds a target rna through watson-crick base pairing and exerts gene silencing through different mechanisms (kole et al., ) . a single strand antisense oligonucleotide (aso) binds to the mrna, which is also single-stranded, and is translated into proteins. different molecular mechanisms to either block gene expression or degrade the rna duplex formed by watson-crick base pairing have been described. cleavage of the rna strand of dna•rna hybrids is predominantly mediated by the enzyme rnase h (walder and walder, ) , which is an abundant enzyme in both the nucleus and cytoplasm of eukaryotic cells (wu et al., ; ten asbroek et al., ) . asos can also bind rna and block ("steric blockers") gene expression rather than facilitating rna cleavage (dias et al., ) . also considered to be within the aso family are peptide nucleic acids (pnas) or phosphorodiamidate morpholino oligomers (pmos or "morpholinos"). their modification usually acts through this mechanism (michel et al., ) , which in some cases exerts high efficacy in vivo (iversen et al., ; kole et al., ) . exogenous rna molecules or asos can alternatively target and bind a splicing site on the target pre-mrna and thus modify its exon content (mayeda et al., ; skordis et al., ) , which results in the production of alternative splicing products with potential applications in exon skipping therapy (goemans et al., ) . because many of these asos contain dna with multiple modifications, they are not discussed here in detail. the present literature review focuses mainly on ncrna and particularly on exogenous ncrnas. the discovery of rna interference (rnai) (fire et al., ) increased the interest in using exogenous chemically-synthesised rnas for silencing genes in mammals, and promoted their potential usage in human therapeutics (song et al., ) . to achieve therapeutic results, rnai can be administered via delivery to the cell of small exogenous rna duplexes -including short interfering rnas (sirnas) (zuckerman and davis, ), mirnas mimics (bouchie, ), short hairpin rnas and dicer substrate rnas (dsirnas) (foster et al., ; kim et al., ) -to the cell for further processing into an rna interfering silencing complex. although double-stranded rnas have been widely used for sirna therapy, single-stranded sirna (ss-sirna) is capable of activating the rnai pathway and exerting rnai effects (holen et al., ; lima et al., ; prakash et al., ) . moreover, singlestranded mirna mimics have also been shown to activate the mirna pathway (chorn et al., ) . in principle, then, both dsrnas and ss-sirnas can trigger gene silencing of complementary messenger rna sequences (holen et al., ) . other small rnas with imperfect matches have also been described to repress mrna translation (saxena et al., ) . for mirna therapeutics, different pharmacological tools have been developed which involved either inhibiting or enhancing mirna function (van rooij and olson, ; janssen et al., ) . approaches to inhibiting mirna function include small-molecule inhibitors; mirna masking; mirna sponges; and aso, such as anti-mirs, locked-nucleic acids (lna), or cholesterol-modified antagomirs (krutzfeldt et al., ) . the latter's complementarity allows them to bind to mirnas, inducing duplex formation or mirna degradation. the lna therapeutic approach successfully led to the first mirna-based clinical trials for the treatment of hepatitis c (miravirsen; santaris pharma, denmark) with promising results (janssen et al., ) . there are also approaches that can be utilized to enhance mirnas function called "mimic". these include small-molecule activators of mirna expression and mirna mimics, which are www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. exogenous mirnas delivered by several methods aiming to repress the function of their endogenous targets. they are also referred to in the literature as "mirna replacement therapy". as proof of concept, a synthetic version of mir- a (mrx , mirna therapeutics), delivered using a liposomal delivery formulation, was the first mirna to enter a clinical trial for cancer (beg et al., ) . the literature also describes other types of rnas that can exert physiological functions similar to that of mirnas and sirnas. for example, a -nt long guide hairpin rna (ghrna), that might not require ago or dicer, has been shown to exert mirna or sirna activity in vivo (ohno et al., ) . this novel rna interference technology may act as a novel platform for rna-based therapy. indeed, systemic or local injection of the ghr-form mirna- a (ghr- a) suppressed tumour growth in a mouse model of ras-induced lung cancer. understanding the manifold mechanisms of rna function requires detailed knowledge of the rna tertiary structure (magnus et al., ) , which can lead to therapeutic development (digiusto et al., ; strobel et al., ) . indeed, different experimental (lu et al., ; weinreb et al., ) and computational methods (magnus et al., ) have been developed to predict rnas structure and interactions. the capacity of rna to fold in various ways can generate unique three dimensional secondary structures capable of specific molecular recognition of their target cognate (zhou and rossi, ; tuerk and gold, ) . aptamers are short single-strand rna molecules ( - nt) with a defined structure that can specifically bind to a molecular target via tertiary structures. aptamers can be rationally designed using selex technology (tuerk et al., ) , and can therefore be incorporated into chemically modified rnas with high nuclease resistance properties suitable for animal and clinical studies (sullenger and nair, ). unlike other ncrnas therapeutics, aptamers can target soluble extracellular proteins or extracellular domains of cell-surface receptors. the latter characteristic is unique and can be used to deliver sirnas, mirnas or other compounds to target tissues, binding them to a cell-specific aptamer (zhou and rossi, ) . aptamer therapeutics have rapidly progressed to clinical studies, and some are already in phase clinical trials (sullenger and nair, ; zhou and rossi, ) . the unique properties of aptamers led to development of the first therapeutic aptamer and the first rna-based drug approved for clinical use, pegaptanib. however, aptamer and other ncrnas therapeutics are not free of adverse effects (lincoff et al., ) . when compared to sirna, dsirna was found to be comparable in potency and duration of effect. however, dsirna was found to be more immunostimulatory when compared to the shorter sirnas (foster et al., ) . preclinical studies suggest that when administered in lipid nanoparticles (lnp) dsirnas can exert biological effects in different mouse models with tumours of diverse origin (ganesh et al., ) . although preliminary data in nonhuman primates suggest acceptable tolerance for this specific lnp formulation (ganesh et al., ) , the dsirna therapeutic arena still needs to demonstrate its efficacy and safety in humans. catalytic rnas, the so-called ribozymes, are another family of rnas for which therapeutics have been actively developed (kobayashi et al., ) , reaching advanced clinical trials (burnett and rossi, ; mitsuyasu et al., ), but this review will not focus on this type of rna molecules. unmodified nucleic acids have been shown to possess limited stability in biological media and are subject to rapid enzymatic-mediated degradation (braasch et al., ; . there are three major classes of intracellular rna-degrading enzymes (houseley and tollervey, ) (a.k.a. ribonucleases or rnases): (i) endonucleases acting within the rna chain, ii) ' exonucleases and iii) ' exonucleases degrading rna from the ' or ' end respectively. very large amounts of nuclear rnas efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. are rapidly degraded (brandhorst and mcconkey, ) , this being considered either as translation noise (struhl, ) or part of the biological function of ncrnas. instead, most cellular rnas are modified to resist to exonuclease degradation (ren et al., ) . most genomes encode a plethora of rnases, often with overlapping activities, making redundancy a general feature of rna degradation systems, presumably with the goal of enhancing the overall efficiency and robustness of these degradation pathways (houseley and tollervey, ). normal physiological degradation of endogenous rna molecules or degradation of endogenous rna molecules with defects in processing, folding or assembly are not addressed in this literature review. abundant rnase activity has been described in different tissues, including human body fluids (blank et al., ) (weickmann and glitz, ) and with differential catalytic properties (leimoni et al., ) . different tissues contribute to body fluid rnases (neuwelt et al., ) , supporting the cellular defence system against, for instance, viruses (barrangou et al, )(gupta et al., . the mammalian ribonuclease a family seems to contribute to this host defence by exerting antimicrobial activity (harder and schroder, ; dyer and rosenberg, ) . rnase , for instance, is a rnase a superfamily member with potent ribonuclease activity that is secreted by epithelial tissues including skin, respiratory tract, genitourinary tract, and the gut (harder and schroder, ) . the abundant rnase a produced in humans very probably functions to reduce rna contamination, whether endogenous or exogenous, preventing entry into unwanted rna-processing pathways (houseley and tollervey, ). as above described, unmodified rnas (naked) are generally unstable in biological systems, due to the large amount of ubiquitously expressed nucleases. thus, several chemical modifications have been tested for exogenous rna developed for in vivo therapies to increase resistance to nucleases, enhance binding affinity, facilitate cellular uptake, improve the pharmacokinetic and pharmacodynamics profiles, and reduce immunological response or toxicity (wan and seth, ; bennett et al., ) . there are several sites of an exogenous ncrna molecule susceptible to chemical modification ( figure ) without interfering with its ability for base-paring or enhancing its drug-like properties. the several sites on rnas that can be modified include the base, the sugars, and the backbone. this allows them to conjugate with a wide variety of molecules. different chemical modifications have been tested in the context of developing rna-based therapeutics aimed at increasing the pharmacological properties of exogenous rnas and allowing their successful use in different pathologies/targeted therapies. the following section briefly reviews the types of rna modifications included in different studies in the available literature. nucleobase modifications can affect base-paring properties, binding affinity or specificity for the target mrna, as well as exert adverse effects due to competition with natural nucleotide pools or interfere with polymerases (wan and seth, ). replacement of adenosine in the sirna guide strand with adenosine analogues has been found to modify immunomodulatory activity. watson-crick face-localized n-ethylpiperidine triazole modification has been found to be less reactive than the hoogsteen edge modification, and the ' end was more effective at blocking cytokine production than those placed at the ' end (valenzuela et al., ) . c- substitution in pyrimidines in the rna guide strand increase thermal stability of sirna duplexes. indeed, smaller -methyl group substitutions resulted in better sirna activity (terrazas and kool, ). major groove modifications have also been found to increase the serum stability of sirnas (terrazas and kool, ). -position purine modifications, where the major groove edge (i.e. the hoogsteen face) is modified, have also been tested. thiazole modifications of guide strand sirna at position is well tolerated in sirnas, but -ethynyl at this location reduces efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. potency (ibarra-soza et al., ) . several other nucleobase modifications have been evaluated to modify thermal stability of the sirna duplex, hydrogen bonding and sterics, or off-target effects (peacock et al., ) . although not exactly a base modification, movement of the nucleobase from c- to another position on the ribose (i.e. isonucleosides) in sirnas has been evaluated (zhang, j et al., ) . while maintaining binding capacity to rna and stability toward nucleases, passenger strand modifications with isonucleoside at the ' or ' terminals can retain the silencing activity and minimize the passenger strand specific off-target effect (zhang, j et al., ) . chiral inversion of the natural d-forms (spiegelmers) of rna has also been tested in aptamers, leading to their clinical evaluation (ludwig et al., ) . increase nuclease resistance modify plasma protein binding prevent rapid renal excretion improve pharmacokinetics enhance rna-binding affinity enhance thermal stability increase nuclease resistance enhance rna-binding affinity enhance cellular uptake reduce renal filtration enhace delivery to certain tissues modulate protein binding enhance specific cellular uptake increase possibility of formulations for specific tissues/mucosal mebranes ability to traverse biological barriers using extracellular vesicles ´to d irection sites susceptible for modification on an rna molecule. exogenous rnas for therapeutic use can be subjected to different chemical modifications without interference on their base-pairing ability and enhancing their drug-like properties. conjugates at the ´-end or the ´-end may have the same objectives. earlier studies showed that the '-oh of the rna ribose sugar is not required for sirna activity (chiu and rana, ) and '-modifications influence the sugar to adopt a '-endo sugar pucker due to the gauche effects between the o '-and '-substitutes, improving affinity properties (egli et al., ) . therefore, the furanose ring structure at the ' position of rnas has been extensively modified to efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. achieve pharmacological properties including increasing nuclease resistance, stability and efficacy (egli et al., ) . the '-o-methyl ( '-ome) or '-o-methoxyethyl ( '-moe) modifications increase resistance to nucleases and duplex melting temperature (lamond and sproat, ; prakash and bhat, ) , and have been widely used to develop mirnas (meister et al., ) , sirnas (judge et al., ; choung et al., ) or aptamer-based (burmeister et al., ) therapies. for example, '-ome in sirna has been shown to selectively protect the particularly vulnerable '-end of the guide strand against exonucleolytic degradation in human blood serum (hoerter and walter, ) . moreover, '-ome is a naturally occurring modification of rna found in trna and other small rnas. '-ome has also been used to modulate rna splicing ( toxicity related to lna modifications has also been described (swayze et al., ) . although sugar-modified oligonucleotides or exogenous rnas, including sirnas or antimirs, are more effective rna inhibitors than their unmodified counterparts, they are still susceptible to serum in addition, the phosphorothioate linkage promotes plasma protein binding (srinivasan et al., ; wan and seth, ; sands et al., ) . this increases pharmacokinetic benefits by reducing rapid renal clearance (sands et al., ) and facilitating tissue delivery, binding to cell surface proteins and cellular uptake (miller et al., ; overhoff and sczakiel, the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. binding affinity (tm) for its target complementary nucleic acids (≈ . ºc/linkage) (freier and altmann, ) including mrnas and mirnas (krutzfeldt et al., ) . thus, the use of a mixture of phosphodiester and phosphorothioate bonds may be preferred over all phosphorothioate bonds for in vivo applications (ghosh et al., ; krutzfeldt et al., ) . also, the phosphorothioathe linkage confers chirality at phosphorus and might be relevant for sirna activity (jahns et al., ) . although initial studies have shown exogenous homologous rna uptake by cell suspension, there was very rapid degradation after uptake (shanmugam and bhargava, ) . duplex rnas may be more stable than single-stranded rnas, even in the absence of phosphorothioate modifications (braasch et al., ) . indeed, '-ome hairpin-designed antimir oligonucleotides do not seem to require phosphorothioate modification to exhibit in vitro activity (lennox and behlke, ). minimally-modified phosphodiester aso has been reported to have less (brigui et al., ) , similar or superior activity than its complete phosphorothioate counterparts (uhlmann et al., ) , but sugar modifications in phosphodiester backbones can compensate the loss of activity (monia et al., ) . some adverse effects related to phosphorothioate modifications, compared to their phosphodiester backbone counterparts, have been described in aso and sirnas, including nonspecific protein binding (brown et al., ) , the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. (dsrna). alpha-tocopherol conjugated sirnas can be delivered to liver tissue (nishina et al., ) or the brain when administered locally (uno et al., ) . other lipid conjugates of rnas have been evaluated including bile acids, long-chain fatty acids, and medium-chain fatty acids (murakami et al., ; lorenz et al., ; wolfrum et al., ) . conjugation with specific peptides has also targeted sirnas to specific tissues (hsu and mitragotri, ; yamayoshi et al., ) . another approach includes conjugation with high-molecular-weight polyethylene glycol (peg) to overcome renal filtration. this strategy was used in rna aptamers either approved (macugen) or in advanced clinical trials for ocular disorders (zhou and rossi, ; drolet et al., ) . the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. rna delivery to a target tissue for appropriate and specific cellular uptake is currently a main hurdle in rna therapeutics. several synthetic non-viral methods for rnas delivery have been developed for local and systemic rna therapeutics ( multiple studies have suggested that exosomes, naturally-released extracellular vesicles, can deliver rnas (mrnas, mirnas, lncrnas) to recipient cells (zhang, l et al., ; . due to their ability to traverse biological barriers, the use of exosomes or exosome-mimetic nanovesicles for rna delivery is an open field for future rna therapeutics (lunavat et al., ; zhou et al., ) . indeed, preclinical studies suggest that exosome-mediated delivery of rnas is feasible in vivo (didiot et al., ; el-andaloussi et al., ) . different rnas have been found in milk exosomes from different species, including humans zhou, q et al., ) , but whether these vesicle-protected exogenous rnas are bioavailable is still in debate (zempleni et al., ) . it is important to note that most of the above described chemical modifications are not found in nature and have been developed generally to increase the drug-like properties of rnas and other nucleotides. to the best of our knowledge there is no evidence of clinical trials using unconjugated naked or unmodified exogenous rna for human use with any administration route. efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. early studies suggested that rnas were poor drug candidates due to their relatively high instability, relatively short half-life in vivo, immunomodulatory effects and the many hurdles to their cellular absorption caused by their negative charge. however, several improvements in stabilization chemistry have been identified in recent decades. indeed, a number of chemical modifications and conjugation strategies have improved their rna-binding affinity, in vivo nuclease stability and pharmacokinetic and pharmacodynamic properties. an exogenous rna can be amenable for chemical modification without interfering with its base-pairing ability. several parts of the exogenous rna molecule can be chemically modified including the nucleobase, the backbone or the ribose (sugar). rnas can also be conjugated with a variety of molecules which can exert different biological properties. in addition to these, chemical and biological approaches can be applied to deliver exogenous rna to cells or specific tissues. although many aspects are still to be fully understood in the field of chemical modification of exogenous rnas for therapeutic use, several exogenous rnas (sirnas, aptamers, mirnas, etc.) have entered advanced clinical trials for human use. adams the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. following a systematic literature search as described in section . . . and . . . ., a total of papers were reviewed on the pharmacokinetics of foreign exogenous ncrnas used/intended to be used as therapeutics (hereafter referred as exogenous ncrnas). this section focuses on the pharmacokinetics of exogenous ncrnas (naked, i.e. nonchemically modified or minimally chemically modified) other than those consumed orally from plants; these will be covered in chapter . . moreover, only in vivo studies, in mammals and humans, are reviewed here. of the documents included here, were used for review of ncrna pharmacokinetics in disease and other conditions, which may be relevant to risk assessment considerations. although not specifically requested by the mandate, information on pharmacodynamics aspects of ncrnas was considered. pharmacodynamics is the study of a drug's effect on an organism, meaning its biological effects and other aspects of its xenobiotic action, (efficacy, potency, and toxicity) and this is considered relevant for ncrnas (see . ). pharmacokinetics is dedicated to determining the fate of substances administered to a living organism. it describes the trajectory of a xenobiotic (in this case exogenous ncrna) after delivery into an organism, and encompasses from the movement of administration, to its movement through the organism, to its complete elimination; in other words, absorption, distribution, metabolism and excretion. a drug's pharmacokinetics depends on an individual's physiology (patient-related factors, i.e. renal function, sex, age) or pathology (i.e. renal failure, hepatic failure), and drug chemical properties. pharmacokinetic relevant parameters include: dose, the amount of drug administered at a single point in time; dosing interval, the time between drug dose administration; c max , the peak plasma concentration of a drug post administration; t max , the time to reach c max ; elimination half-life, the time required for the drug concentration to reach half its original value; area under the curve (auc), the integral of the concentration-time curve (after a single dose or in steady state); and clearance, the volume of plasma from which a substance is completely removed per unit time. pharmacokinetics modelling is done using noncompartmental or compartmental methods; the former estimate exposure to a drug by estimating the auc of a concentration-time graph, and the latter estimate the concentration-time graph using different kinetic models. considering an organism as a homogeneous compartment (monocompartmental model) implies that a drug is distributed equally throughout the entire body (tissues and fluids). therefore, blood plasma drug concentrations are a true reflection of drug concentration in other fluids or tissues, and drug elimination is directly proportional to its concentration in the organism. not all tissues in an organism receive the same blood supply and different drugs have different characteristics (i.e. variation in drug passage through natural barriers, such as the brain blood barrier, due to a drug's biochemical properties), meaning other models are sometimes needed. the two-compartmental model assumes that there is a compartment where distribution is more rapid (central compartment) and another compartment www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. (peripheral compartment) consisting of organs with a lower relative blood flow, which consequently exhibits a slower drug distribution rate. saturation of the enzymes responsible for drug metabolisation, the presence of active transmembrane transport mechanisms independent of drug plasma concentration, and many other factors not taken into account by the two-compartmental model, require the use of multi-compartmental models. very few studies have focused on the pharmacokinetic profile of exogenous rnas (naked or unmodified), with most of the knowledge on the absorption, distribution, metabolism and excretion profile of ncrnas coming from the development of antisense oligonucleotides therapeutics (dirin and winkler, ) . scaling dosing from preclinical animal studies to humans (i.e. based on body weight or surface area) is challenging and apparently depends on the mechanism of clearance. for example, the pharmacokinetics of a naked sirna formulated into polymer-based nanoparticles in mice, rats, monkeys and humans exhibited blood c max shortly after intravenous administration and rapid elimination across all species in correlation with the body weight (zuckerman et al., ) . the pharmacokinetic profile investigated during the development of exogenous rna therapeutics has shown to be influenced by the route of administration, as described below. a comprehensive summary of available information of in vivo studies and related pharmacokinetics of exogenous rnas is provided in table . most studies on exogenous ncrnas have focused on iv administration. studies in mice have shown that naked unconjugated sirna ( µg/kg) injected intravenously disappears from peripheral blood min after administration, restricting the likelihood of accumulation to peripheral organs (gao et al., ). similar results were found following iv administration of naked sirna ( i labelled), which distributed to the kidney and liver within the first minute, peaking in the kidney, liver and bladder within the first minutes (braasch et al., ) . although distribution of sirna ( i labelled) decreased markedly after h, it persisted in the kidney and liver up to h, and lower concentrations were observed in the lung, spleen and heart (braasch et al., ) . in rats, sirnas were distributed to the kidney and excreted into the urine one hour after injection (van de water et al., ) . exogenous mirna iv administration has also been tested in animal models and entered human clinical trials. in this case (mirna mimics), they are either chemically modified dsrnas formulated in different nanoparticles (xue et al., ) to preferentially target a tissue (trang et al., ), or incorporated into naturally circulating extracellular vesicles (bala et al., ) . for example, mirnas mir- and let- b formulated in a neutral lipid emulsion have been iv administered to mice and have shown to exert a biological effect (kasinski et al., ) . the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. administration site for less than one day, while in a chitosan-formulated version it persisted for up to days (ma et al., ) . peptide-modified and chemically modified sirnas applied topically to the skin have been found to exert a local biological effect, as compared to the sirna alone (hsu and mitragotri, ) . mirnas formulated with transfection agents or nanocomplexes have also been injected intradermally (srivastava et al., ) , or subcutaneously (urgard et al., ) , and demonstrated to exert local biological effects. intranasal administration of sirnas in rats for brain targeting has resulted in very low levels of radioactive sirnas in the brain or plasma when naked sirnas were administered compared to a formulated version (perez et al., ) . mirnas administered by intranasal injection using transfection reagents reached the dorsal root ganglia and the olfactory bulb (cheng et al., ) and, using another nanovector delivery system through intranasal administration (as drops), it reached the brain, exerting a local biological effect (zhuang et al., ) . due to ncrnas susceptibility to degradation, very few studies have focused on exogenous ncrna administration in the gi tract. non chemically modified naked sirna administered by oral gavage to female mice ( µg in total), was found intact and at high levels (analyzed by northern blot and by quantitative pcr analysis) and hours after dosing in the stomach, small intestine and colon when formulated with chitosan nanoparticles (ballarin-gonzalez et al., ) . by contrast only low sirnas levels were observed in the stomach, intestine and colon of mice hour after oral administration of the non formulated naked sirna. at this timepoint intact sirna was almost exclusively present in the stomach while partial degradation products were observed in the proximal and distal regions of the small intestines. further reduction of sirna levels was observed hours after administration, with traces only found in the colon (ballarin-gonzalez et al., ) . orally administered sirnas, formulated using specific vehicles including thioketal nanoparticles ( µg kg - d - the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. counterparts were present in all epithelial cells (martirosyan et al., ) . oral administration of exogenous exosomes containing mirnas of bovine origin has been shown to attenuate arthritis in mice models. bovine milk derived extracellular vesicles were administered daily by oral gavage starting at week till week after birth and arthritis was induced by collagen gavage. animals receiving exosomes ameliorated the clinical condition, although no clear mechanisms for this effect have been described . enteral (large intestine) sirna administration for therapeutic gene silencing targeting the liver (via the lymphatic route) has also been described, but using chemically modified and formulated sirnas (murakami et al., ) . enzyme-and ph-responsive microencapsulated nanogels are also being developed for oral sirna delivery, as reported in recent in vitro tests (knipe et al., ) . naked sirna formulated in a water-in-oil microemulsion has been administered via the rectal mucosa to mice along days ( - µg sirna/kg, administrations) and has reached the brain where exerted a biological effect through downregulation of the prion protein expression (lehmann et al., ) . prion infected mice presented an improvement of some neuropathological conditions after receiving the formulated sirna following the rectal mucosa route of administration. being the eye the target for the first rna-based therapy, sirna intraocular administration has been investigated. intravitreally injected naked sirna (slightly modified, dtdt) distributed throughout the eye (vitreous, iris, retina, retinal pigment epithelium and sclera) of rabbits when administered at mg/eye, and the pattern of ocular distribution was similar in male and female rabbits ( . conjugated or formulated sirnas have also been tested in animal models (zhang et al., ; janout et al., ) . intravitreal injection of mirnas has been described in the literature using either naked mirnas in mice , rats (qin et al., ) or using transfection reagent in rats (mcarthur et al., ) or exosomes in rats (mead and tomarev, ) . some studies have evaluated ip administration of naked sirnas (slightly modified, dtdt) in animal models (wilcox et al., ; shimizu et al., ) . the half-life of ip administered naked sirna (dtdt) was found to be ≈ times lower than the formulated version (perepelyuk et al., ) . sirna (dtdt) was also quickly excreted into the urine compared to a formulated version (shimizu et al., ) . in a comparison of a formulated (complexed) and naked sirna after ip administration in mice it was found that after min the formulated version was detectable in muscle, kidney, liver and tumour tissue, while the naked sirna was completely absent (urban-klein et al., ) . while not a common administration option, chemically modified sirnas formulated in ph-responsive nanoparticle complexes have been administered in the submandibular gland of mice (by retroductal injection) and found to exert rnai effects (arany et al., ) . the monitoring of the distribution of the chemically modified sirna h post-administration indicated that the formulated sirna was internalized www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. in the cytoplasm of duct cells via the endosomal pathway. at h post-administration, the signal was concentrated in the acinar compartment as well. after h, ≈ % of the submandibular gland cells were positive for the sirna. the delivery of the sirna formulated in nanoparticles was more efficient compared to that of naked sirna (arany et al., ) . in another study, iv administration of chemically modified sirna ( . mg/kg) was shown to accumulate remarkably in the submandibular gland just min after injection, and had a half-life in this tissue of ≈ . h, but did not have a rnai biological effect . in contrast, direct local injection of liposome-encapsulated sirna ( . mg/kg) into the submandibular gland was shown to have strong gene-silencing effects, while naked sirna injection ( mg/kg) did not . few studies have focused on this administration route. senn and colleagues compared central nervous system administration of sirna vs. aso (senn et al., ) . compared to phosphothioate and 'methoxyethyl protected aso (up to µg), naked (slightly-modified, dtdt) sirna ( µg) administered to rats via icv was not found in any brain region, including the area around the injection site. in contrast, h after aso injection it was distributed in the thalamus and hypothalamus. the naked sirna clearly exhibited very poor distribution and uptake in the brain compared to the aso. although aso exhibited a capacity to reach different brain structures, its administration at a total dose of µg over two days produced no rnai effect. in the same context, icv administration of sirna (up to µg/rat/day) on two consecutive days did not exert rnai effects. however, in another study, a sirna chemically modified to allow for delivery in the absence of transfection reagents (accell sirna) was administered via the icv route at µg/rat. the sirna was incorporated into different types of neurons, although not glia, where it exerted a biological effect in regions like the cortex, the caudate subregion of the striatum and in the pyramidal cells of the hippocampal ca subregion (nakajima et al., ) . in a different study, a mirnas mimic (chemically modified double-stranded rnas) administered by icv ( pmol/g body weight, mixed with cationic lipid dotap) was found to increase forty fold the level of this mirna in the brain (stary et al., ) . several chemically modified mirnas (agomirs) were also found to be active when administered via this route in rats (huang et al., ; ge et al., ) . a double-stranded modified pre-mirnas was also reported as active in rats (davis et al., ), but a naked mirna (double-stranded -bp rna) injected by icv ( pmol) in this study was unable to increase its levels or exert a biological effect, suggesting that the naked mirna had a higher susceptibility to rnase degradation (davis et al., ) . lipid-complexed naked sirna is reported to be absorbed by mouse epithelial and lamina propria cells of the vagina and ectocervix (palliser et al., ) . however, uncomplexed and unmodified sirnas were immediately degraded (< min) when exposed to genital wash fluid (wu et al., ) , suggesting high rnase activity in the cervicovaginal secretion. also, slightly modified but still naked sirna (dtdt) was unable to exert a clear biological effect (zhang et al., ) . in summary, different administration routes have been tested during ncrna therapeutics development. the administration route used for exogenous ncrna delivery clearly influences pharmacokinetic profile of chemically synthesized ncrna. no matter the administration route, it seems that naked and unformulated rnas rapidly degrade and exert very limited or no biological activity. very few studies have evaluated the distribution profile of administered naked oligonucleotides in organs and tissues or compared it to the distribution profile of their chemically modified counterparts. using the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. imaging techniques in baboons (positron emission tomography -pet -and [ f]-labelling) it was shown that naked oligonucleotides are poor drug candidates due to limited distribution into organs and tissues and very rapid elimination (tavitian et al., ) . compared to '-o-methyl or phosphorothioatemodified oligonucleotides, naked oligonucleotides were found in the heart, liver and kidney and, to a lower extent, in other tissues min after iv injection. at that timepoint, naked oligonucleotides were already found in the bladder suggesting that naked oligonucleotides are very rapidly eliminated compared to '-o-methyl or phosphorothioate ones. moreover, one hour after injection, almost all naked oligonucleotides were found in the bladder or residually in the kidney, while the phosphorothioate oligonucleotides were found largely in the liver and kidney, and the '-o-methyl ones were in an intermediate distribution (tavitian et al., ) . kinetics studies with radiolabelled oligonucleotides also showed a dramatic reduction of naked oligonucleotides in the plasma within the first min, while '-o-methyl and phosphorothioate-modified ones showed a much slower reduction during the first min. naked sirna have been reported to distribute to the kidneys and bladder of mice min after iv administration (braasch et al., ; naeye et al., ) . intravenous administration of mg kg - partially-modified unconjugated sirna (partial phosphorothioate backbone and '-o-methyl sugar modification) or cholesterol-modified sirna in mice resulted in a broader tissue distribution (liver, heart, kidney, adipose and lung) of the cholesterol-conjugated sirna h after injection (soutschek et al., ) . in another study, naked sirna (free sirna) iv administered (retro-orbitally) was found in the kidney min after injection (naeye et al., ) . ip administration of synthetic sirna formulated with low molecular weight polyethylenimine resulted in its presence in muscle, liver, kidney and tumour tissues min after injection, while the naked counterpart was completely absent (urban-klein et al., ) . in rats, chemically modified naked sirnas were distributed in a similar manner to those of '-o-methyl or '-f modified sirnas (viel et al., ) , even though the circulation time of the '-f was increased. in other studies with rats, iv injection of sirna (chelated to indium- ) resulted mainly in renal distribution hour after exposure (van de water et al., ) . some liver distribution of sirnas have been also reported in mice, when using either the two phosphodiester rna strands duplexes or one phosphodiester strand and one phosphorotioate strand sirna duplex (braasch et al., ) . orallyadministered naked sirnas ( µg sirna) were found to be present in the stomach, proximal and distal small intestine and colon tissues hour after administration but at very low levels, further lowering hours after administration (ballarin-gonzalez et al., ) . the same sirna formulated with chitosan nanoparticles was found to distribute systemically and reach the liver, spleen and kidney (ballarin-gonzalez et al., ) . in an experimental model of arthritis in mice, iv administered naked sirna ( µg) was found to distribute to arthritic joints immediately after injection, but disappeared within hours, compared to that of specific formulations (komano et al., ) . overall, these finding suggest that naked sirna, although distributing at very low levels and with short residence times compared to other formulated counterpart versions, does distribute to the gi tract when administered orally or other tissues when administered systemically. www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. formulation type (i.e. cationic lipids, neutral lipids, or others) can drive preferential distribution to specific tissues. as described for certain mirnas, a neutral lipid emulsions (nle) formulation has been shown to distribute to the lung after iv injection ( µg) (trang et al., ) . the lack of cationic lipids in the nle seems to bypass some of the shortcomings that can be attributed to the charge, including formation of aggregates in biofluids, filtration by the liver, adherence to the endothelium or uptake by scavenging macrophages. the result is excellent distribution to lung tissues (trang et al., ) . extracellular vesicles (exosomes)-formulated synthetic mir- was found to distribute to liver, adipose, lung, muscle and kidney tissues min after iv injection (bala et al., ) . administration of exosomeloaded mir- resulted in its detection by isolated hepatocytes and liver mononuclear cells, suggesting cellular uptake (bala et al., ) . in summary, naked oligonucleotides, including ncrnas, rapidly distribute to the liver, lung and kidney after iv injection. within the first minutes they are found in the bladder, suggesting rapid renal elimination. chemical modifications or formulations increase their distribution to other tissues or delay clearance. exosome-loaded rnas have recently been shown to be an alternative tool for distribution to different tissues. ncrnas by oral administration seem to distribute to the gi tract or, if formulated, systemically. there are few studies which have evaluated the metabolism of exogenous rnas administered to animals or humans, most of which only investigate their degradation. naked sirnas seem to be rapidly degraded when administered iv (viel et al., ) , decreasing by ≈ % within the first min, although certain chemical modifications (i.e. 'f, 'ome) can slightly increase this time. stability of naked sirna was reduced (< min) compared to that of other chemically modified or formulated sirna when administered by iv injection in mice (gao et al., ) . indeed, incubation of naked sirna with plasma or foetal bovine serum causes a very rapidly degradation of the genetic material (jiang et al., ; braasch et al., ; urban-klein et al., ) . unmodified aptamers in general are also very rapidly degraded (≈ min) (zhou and rossi, ) . when naked sirna is administered as formulated (i.e. nanoparticles) it was shown that the renal filtration barrier can separate the sirna from its carrier (naeye et al., ; zuckerman et al., ) . in the eye, sirnas are degraded by endonucleases without preferences for one side of the duplex (as observed also for chemically modified sirnas) (beverly et al., ) . early in vitro studies also showed that exogenous rnas taken up by cells are rapidly degraded (shanmugam and bhargava, ) , and exogenous rna injected into the blood is rapidly degraded to nucleosides, ribose phosphate and free bases (sved, ). the renal filtration barrier owns an effective size cut-off of ≈ Å (batsford et al., ; bohrer et al., ) , but is also influenced by net molecular charge discrimination (brenner et al., ) . this is supposed to facilitate rapid renal clearance of small molecules and free sirna (zuckerman et al., ; naeye et al., ) since aso, sirnas and aptamers are commonly smaller than this cut-off (huang et al., ) . by comparing naked sirnas and ribose-modified sirnas ( '-o-methyl or 'f) using pet scans in rats and mice, the kidney was identified as the main organ for sirna elimination (viel et al., ) . however, it is worth noting that also the liver participates in sirna elimination. in other studies, sirna appeared to accumulate in the bladder shortly after administration (hatanaka et al., ) . this was also the case for modified sirnas (lna) compared to their versions conjugated with peg administered in mice, in which their levels peaked in the bladder min post injection and they were found in the urine as soon as min after injection (iversen et al., ) . efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. some studies have described rapid elimination of naked sirna and renal excretion after iv injection at doses including µg (jiang et al., ) and µg/kg (gao et al., ) in mice or rats (van de water et al., ) . other studies using dynamic imaging techniques or radiolabelled sirnas have confirmed that most of the naked sirna (free sirna) administered to mice was found in the bladder after just min up to min, faster than the formulated counterparts (naeye et al., ; zuckerman et al., ) . the literature mostly addresses chemically modified rnas (dyke et al., ) in clinical trials (zhou and rossi, ) . the small size of rna aptamers renders them susceptible to rapid clearance by renal filtration which has driven efforts to increase their size by conjugation for therapeutic use (healy et al., ; haruta et al., ) . overall this indicates that naked exogenous small rnas are rapidly cleared from systemic circulation and excreted in the urine. iv injection of a cocktail of four different plant-based small rnas (mir , mir a, mir a, and mir ; pmol each) showed them to be rapidly cleared from circulation (< min) . the exception was mir , which peaked min after injection compared to the other mirnas administered at equal dosages, and then dramatically decreased at min. when compared to other small rnas, anomalous or atypical stability and genesis were proposed for this specific mirna. efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. although scarcely described, there may be several conditions in which, theoretically, the pharmacokinetic properties of exogenous rnas could be modified. increased intestinal permeability has been described in different conditions including consumption of nonsteroidal anti-inflammatory drugs, celiac disease, crohn's disease or other intestinal inflammatory disease (oman et al., ; sundqvist et al., ; michielan and d'inca, ) . for instance, absorption may be altered in cases where vasculature permeability of the gut is increased, as it has been observed in murine models of ageassociated inflammation (jeong et al., ) . increased intestinal permeability ("leaky gut") has been described in alcoholism, contributing to the extra-intestinal tissue damage caused by alcohol (bjarnason et al., ) , including liver damage (keshavarzian et al., ) . similarly, leaky gut has been linked to liver steatosis in obese patients ( theoretically, leaky gut may increase the possibilities of passively absorbing larger amounts of exogenous rnas with consequent release into the circulatory system. however, very few studies are available in which sirnas, aptamers, mirnas or other exogenous ncrnas have been tested under these conditions. absorption of naked sirna formulated into nanoparticles following intrarectal administration was tested in mice models of dextran sulphate sodium (dss) induced colonic inflammation. uptake of sirna (observed mainly in epithelial cells, lamina propria lymphocytes, and cells from the mesenteric lymph nodes including dendritic cells and t cells) was increased in mice suffering from acute colitis compared to uptake (in the same cell types) under healthy conditions (frede et al., ) , suggesting that inflammatory conditions may alter ncrna absorption. although there are no studies using naked unmodified exogenous ncrnas, this topic deserves further attention. acute kidney injury or chronic kidney disease are important public health issues. the kidneys play a key role in elimination of xenobiotics and metabolism products and thus renal clearance should be considered in drug discovery and drug interaction research (feng et al., ) . very few studies have focused on the clearance of exogenous ncrnas in pathological renal conditions. for example, plasma clearance of chemically modified sirna administered by iv injection ( mg/kg) was slightly reduced in renally impaired rats than in normal animals (thompson et al., ) . although sirna concentration in residual kidney tissue of partially nephrectomised animals was slightly greater than the mean in normal animals, the differences did not result in appreciably greater sirna distribution into other organs (thompson et al., ) . in general, similar results, but using asos, were observed in rats after cisplatin-induced renal injury (masarjian et al., ) . also in a study of an aso against mirnas, it was recently reported that in end stage renal disease patients, only relatively modest increases in aso plasma levels were observed when compared to control subjects (http://regulusrx.com/wpcontent/uploads/ / / -aasld-rg- -pk-and-safety-in-esrd-vs-normal.pdf). also using asos, distribution within the kidney was found to be altered in a mice model with chronic kidney disease (ckd) compared to controls (donner et al., ) . moreover, concentration of `-moe asos in the liver of mice with ckd was elevated as compared to mice without ckd, suggesting that a reduction of renal function and aso excretion can potentially influence the systemic delivery of asos (donner et al., ). www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. liver disease may also lead to alterations in drug pharmacokinetics, and thus the potential effects of hepatic impairment are considered in drug development (allen et al., ) . although exogenous ncrnas have not been analysed quantitatively, one study showed that chemically modified and formulated sirnas in lipid nanoparticles were found to be distributed and similarly accumulated in pathological or normal liver tissue from mice (yu et al., ) . other physiological, pathological or lifestyle factors, such as aging (cohen, ) and exercise activity (van baak, ) , may influence the pharmacokinetics of exogenous molecules. however, no information is yet available regarding exogenous rnas and their behaviour under these conditions. pharmacodynamics refers to the relationship between the concentration of a drug at the site of action and the resulting effect, including the time course and intensity of therapeutic and adverse effects. there is scarce data on the pharmacodynamics of naked unmodified exogenous ncrnas. some information is available on chemically modified rnas (or nuclease-stabilized rnas, the latter being outside the scope of this literature review). for example, in a mouse model of viral hepatitis the administration (hydrodynamic injection) of naked or chemically modified (methyl-modified) sirnas was associated with clear dose-related effects of various rnai constructs (peng et al., ) . in this study the naked sirnas had the highest inhibitory effects, but these rapidly declined (shorter-lasting inhibitory effects); in contrast, the methyl-modified sirna duplexes were more stable inside cells and exerted their effect over a longer time period (peng et al., ) . non-compartmental analysis of rna therapeutics is used in most preclinical studies when analysing pharmacokinetic and pharmacodynamic parameters. for example, a non-compartmental model was used to estimate the properties of intravitreal injection of slightly chemically modified sirna (dtdt) (dejneka et al., ) . also, in a mirna mimic therapy by iv administration of a liposomal formulation, a non-compartmental model was used to evaluate different parameters (beg et al., ) . systemic delivery of naked sirna has generally failed to produce significant biological effects (gene silencing). no biological effects have been reported when naked sirna ( µg/eye) was administered by intravitreous injection in rats . few studies report gene silencing effects following local administration, although some of the tested rnas were slightly chemically modified (i.e. dtdt overhangs). intrathracheal administration of naked (but slightly modified, dtdt) sirna was effective through gene silencing effects in a mouse model of haemorrhagic shock and sepsis (perl et al., ) . in non-human primates, naked (but slightly modified, dtdt) and unformulated sirna administered intranasally was effective in severe acute respiratory syndrome sars coronavirus infection reducing viral load and host symptoms (li et al., ) . it looks that naked ncrnas require proper formulation to attain efficacy. naked sirna administered intranasally to mice was effective in reducing viral replication when complexed with lipofectamine (fulton et al., ) . naked sirna formulated in ph-triggered nanoparticles exerted gene silencing effects when administered by iv injection in mice ( mg/kg) (kolli et al., ) . a formulation of naked sirnas using cyclodextrin-containing polycations and transferrin, as a targeting ligand for delivery to transferrin receptor-expressing tumor cells, also showed gene silencing effects when administered by iv injection ( . mg/kg) in a mouse model (hu-lieskovan et al., ) . when administered orally efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. ( µg/kg) to a mice model of thioglycollate-elicited inflammation, a formulated sirna reached macrophages in the peritoneum, spleen, liver and lung, exerting a sirna effect (aouadi et al., ) . a liposome-formulated naked mirna iv administered twice a week was efficacious in clinical trials (beg et al., ) . a cationic liposome formulated dicer-substrate sirna (dsirna) (a solid dsirna core in an envelope of cationic lipids and cholesterol) was found to be efficacious in mice when administered by iv injection ( mg/kg) (ganesh et al., ) . preliminary results within this formulation demonstrated a tolerability profile in non-human primates upon repeated administration (ganesh et al., ) . when comparing the naked sirna and to a highly formulated sirna in cyclodextrin-containing polycations with surface peg and transferrin as the targeting ligand, only the formulated version ( . mg/kg iv) was effective in reducing the expression of the ews-fli gene and tumour engraftment, while the naked version exerted no biological effect (hu-lieskovan et al., ) . similarly, in a mouse model of concanavalin a-induced hepatitis a reduction of hepatic injury by liver-specific induction of rna interference was observed upon iv administration a of galactose-conjugated liposome nanoparticles (gal-liponp) bearing naked sirna, while no effects were noted following administration of the unformulated naked sirna (jiang et al., ) . in a collagen-induced arthritis mouse model and using systemic administration, naked sirna (dtdt) was used against tnf-α, and was completely unable to repress tnf-α mrna expression, whereas a formulated version repressed it (komano et al., ) . in a mouse tumour model, intraperitoneal injection of naked sirna exerted no rnai effects, while its complex-formulated version did (urban-klein et al., ) . while developing a model to study sirna pharmacodynamics, intramuscular administration ( µg) of naked sirna (chemically stable) in mice showed no effects without use of electroporation (stevenson et al., ) . there are several ongoing clinical trials using sirnas, rna aptamers, mirnas and other noncoding rnas intended for use in humans to treat diseases including cancer, cardiovascular disease, inflammation, ocular disease and others (zuckerman and davis, ; li and rana, ; bobbin and rossi, ; zhou and rossi, ; sullenger and nair, ) . most of these ncrnas are chemically modified or formulated. adverse effects were identified in some of these studies. the delivery component of the formulation (i.e. liposomes), rather than the naked sirna component, was primarily responsible for the adverse effects observed in different preclinical toxicity studies (zuckerman et al., ) . for the mir- a mimic, adverse effects in humans have been reported including acute renal injury, back pain and fatigue, all likely attributed to the liposomal carrier rather than the mirna (beg et al., ) . liposomerelated toxicities are considered due to activation of the complement and have been well characterized with the most frequent symptoms observed being flushing, rash, dyspnoea, chest pain, back pain and subjective distress (szebeni et al., ) . in non-human primates, repeated iv administration of escalating doses of a non chemically modified sirna led to increased il- and inf-gamma levels, as well as kidney and liver toxicity at the highest dose tested ( mg/kg) (heidel et al., ) . in several clinical trials on rna therapeutics, dexamethasone premedication was required to reduce infusion-related adverse effects or reactions (i.e. hypersensitivity, flushing, oedema, etc.) (beg et al., ) . for some sirnas used in the clinic, a predosing hydration protocol has been used to protect the kidneys (zuckerman et al., ), thus reducing in humans the toxicities observed in animals. there are also animal studies in which no toxic effects are reported. for instance, when highly formulated naked sirnas were administered by iv route at . mg/kg, no apparent liver or kidney toxicity, immunogenicity-related toxicity or organ damage were detected in a murine model of metastatic ewing's sarcoma (hu-lieskovan et al., ) . no histological toxic effects were seen in liver, kidney, lung, heart and spleen in the same model following repeated treatment with the same formulation the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. (twice weekly for weeks) (hu-lieskovan et al., ) . the same results were obtained for the naked sirna administered at the same dose and for the same duration (hu-lieskovan et al., ) . in addition, when administered daily via oral gavage ( µg sirna/kg) for days in mice, sirna nanoparticles in galactose modified trimethyl-cysteine conjugates were reported to have no histological toxicity in major organs (brain, heart, kidney, lung, liver or spleen) (han et al., ) . since there are so few studies in the current literature on the pharmacokinetics of naked/unmodified rna molecules, this section included studies of other, minimally-modified, exogenous rnas to compare their pharmacokinetic and pharmacodynamic properties to that of naked rnas, when possible. the findings suggest that naked or unmodified rnas are rapidly cleared from circulation and have been reported in the kidney and urine immediately after administration (generally intravenously). in general, no major gene silencing effects have been observed for naked rnas when compared to chemically modified or formulated ones. this lack of efficacy has probably discouraged studies investigating the toxicity and safety of naked unmodified rnas. while limited studies have reported minor biological effects of certain naked rnas in animal models (very much dependent on the route of administration), the lack of studies in humans prevents scientists from understanding the kinetic profile of exogenous rnas and developing effective therapeutics. finally, scientific literature on toxicological or safety studies provides no evidence for concern about the systemic toxicity of naked exogenous small rnas under normal physiological conditions. allen the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. following a systematic literature search as described in section . . . . and following the methodology described in the section . . . , a total of papers were selected as relevant to reviewing the topic of rnas uptake. information on naked (non chemically modified) exogenous rnas is mainly presented in this section. of these publications, support the uptake of exogenous ncrnas. one study reports no intestinal absorption of rna (baintner and toth, ) , and three others suggest that rna is degraded before absorption (loretz et al., ; o'neill et al., ; sonoda and tatibana, ) . uptake of plant exogenous rnas, after oral intake is not included here, and will be reviewed in chapter . ; and uptake of exogenous rnas from the pharmaceutical/medicinal area is described in section . . . herein, uptake refers to passage of the molecule (in this case a ncrna) through the cellular membrane as a part of the absorption process. an important feature for the possible biological effect that exogenous rnas, including ncrnas, may have within an organism is their cellular uptake. because of their size and negative charges, exogenous rnas cannot easily passively cross cell membranes (see below). however, earlier studies suggested that exogenous rnas, either homologous (shanmugam and bhargava, ; galand and ledoux, ; sirdeshmukh and bhargava, ) or heterologous (i.e. from e. coli, yeast or others) (natural academy of sciences, ; herrera et al., ; galand et al., ) , could be taken up by mammalian cells (bensch and king, ) . intact, rna may be present inside the cell but is reported to degrade rapidly in some studies (herrera et al., ; shanmugam and bhargava, ) . extracellular ribonuclease activity seems to inhibit uptake (shanmugam and bhargava, ) or function (niu et al., ) of exogenous rnas. uptake of exogenous rna is apparently not due to altered membrane permeability, impaired cell viability, or ribonuclease degradation of the macromolecule during incubation experiments (herrera et al., ) . radioautographic evidences (radioactive assays) have shown the uptake of macromolecular rnas by normal and neoplastic mouse cells, but degradation was also shown to occur prior to or after rna uptake (schwarz and rieke, ) . although intracellular degradation may occur, early studies also described biological actions in response to uptake of exogenous rnas (niu et al., ; niu et al., ; ; esposito, ) , suggesting that once taken up by a cell, rna could eventually exert a biological effect. studies on other types of cellular uptake of exogenous rnas, such as transfer rnas, either homologous or heterologous (depending on donor rna and recipient cell type) have been conducted (gallagher et al., ; sakai and cohen, ; crooke et al., ) . however, as noted in rna therapeutics development (see section . . . ), the large number of barriers encountered by rnas from intake to cell uptake needs to be considered when evaluating possible exogenous rna bioavailability (figure ). the gi tract offers a large surface area potentially relevant for ncrnas cellular uptake and following systemic release, since it contains a large variety of cell types at different maturational levels (e.g. stem cells in the crypts of lieberkühn) located only a few microns from an extensive capillary network (lozier et al., ) . however several barriers exist that could prevent ncrnas uptake by mammalian cells (o'neill et al., ) . for example, in a study conducted in neonatal pigs, no intestinal absorption of rna was observed (baintner and toth, ), suggesting possible rna degradation or an inability to cross the intestinal barrier. gastrointestinal barriers can be distinguished in extracellular and cellular barriers and are presented below. efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. orally ingested exogenous ncrna would have to pass different barriers in the human gi tract. for clarity, only the general barriers are shown. gi barriers to the uptake of orally ingested rnas. the first environment encountered by any orally ingested rna is the oral cavity, where lytic enzymes such as amylase or lipase are secreted in the saliva, and the ph ranges from . to . . the stomach is a more acidic environment (ph . - . ) (dressman et al., ) , and nucleic acids are known to be denatured and depurinated (hydrolysis of nucleic acids to release purine bases) over time in acidic gastric fluid (loretz et al., ) . the gastroenteric fluid flow and peristaltic activity in the gi tract could reduce the contact time between ncrnas and the epithelial layer, therefore diminishing the opportunities for cellular uptake, while nuclease enzymes present in the gi lumen could degrade nucleic acids before any cellular uptake (o'neill et al., ) . indeed, purines and pyrimidines in nucleic acids are believed to be absorbed mainly in the form of nucleosides (sonoda and tatibana, ) . the gut flora, predominant in the distal ileum and in the large intestine, produces a range of enzymes that could degrade ncrnas as well. the gi tract is lined by a viscous sticky layer of mucus entrapping foreign particles before reaching the underlying epithelium (figure ) . this "trapping" effect could be mediated by mucus composition, which confers a net negative charge to the mucous layer. since nucleic acids present a net negative charge as well, this mucus could represent an electrostatic barrier difficult to overcome by rnas, and particularly ncrna, if not properly delivered or chemically modified. furthermore, mucus turnover efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. (secretion, shedding and discard) happens in a relatively short time period ( - min) (lehr, ), preventing rnas from traversing the mucous layer and to reach the underlying epithelium. in conditions such as ulcerative colitis this mucus layer can be reduced or missing in areas of acute inflammation (pullan et al., ) , which would allow nucleic acids to reach the epithelial cell layer. another barrier is the glycocalyx, a glycoprotein and polysaccharide layer ( - nm thick) associated with the apical cellular membrane of enterocytes (frey et al., ) . this layer prevents the access of certain viruses, bacteria and particles (such as rnas) to the underlying plasma membrane by acting as a size-selective diffusional barrier. the intestinal mucosa is structured as a three-layer barrier: a single layer of epithelial cells, the lamina propria ( furthermore, the epithelial cells (enterocytes), which represent approximately % of the epithelium, have a short lifetime of - days, and are continuously shed and replaced (quastler and sherman, ; jung et al., ) . the enterocyte apical membranes are characterized by a high number of microvilli, structures approximately mm long and nm wide (johnson, ) . since endocytosis occurs primarily at the base of microvilli (jung et al., ) , particles with a diameter greater than nm could not be efficiently endocytosed (uduehi et al., ) . m-cells (cells dedicated to trans-cellular transport and associated to intestinal lymphoid follicles) are fewer in number than enterocytes, but, due to their role in the transport of foreign material from the lumen to the immune cells of the lamina propria, are characterized by a high endocytic activity. moreover, m-cells have microfolds in their apical membrane, and are covered by a reduced glycocalyx and mucous layer. this determines a low breakdown capacity (e.g. low alkaline phosphatase activity, and a lower number of lysosomes) so intracellular degradation of ncrnas could be spared. conversely the capillary network underlying the m-cells is less dense and less permeable (o'neill et al., ) . although the literature has described these cellular barriers when studying several molecules, there is little specific data (o'neill et al., ) on the relevance of these to exogenous rna molecules. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. assuming that ncrnas could overcome the gi barriers and reach the circulatory system, they would still encounter other biological barriers before reaching the appropriate machinery to exert any effects. significant degradation occurs of sirna duplexes (non chemically modified) in min when they are incubated in foetal calf or human sera (haupenthal et al., ; urban-klein et al., ) . sirna in human plasma is rapidly degraded, with nearly % degraded within min (layzer et al., ) . nuclease activity in plasma and tissues is relevant to degrading rnas, including ncrnas. the major activity in plasma is a ' exonuclease, but cleavage of internucleotide bonds can also take place (juliano et al., ) . encapsulation methods, which protect rnas from degradation, include exosomes, microvesicles and apoptotic bodies, all of which are extracellular vesicles distinguished by size, biogenesis and cargos (ela et al., ; van niel et al., ) . exosomes, for instance, contain various species of rna, conferring them protection against degradation and providing them a vehicle for cellular uptake of rnas by endocytosis (cui et al., ). the reticuloendothelial system (res) is comprised of phagocytic cells, including circulating monocytes and tissue macrophages, whose physiological function is to clear the body of foreign pathogens, remove cellular debris generated by tissue remodelling, and clear cells that have undergone apoptosis. additionally, the res plays an important role in uptake and clearance of individual "free" oligonucleotides. phagocytic cells of the res, particularly the abundant kupffer cells in the liver and splenic macrophages, express a number of cell surface receptors, including integrins and scavenger receptors, that are potentially involved in uptake, although the role of scavenger receptors in uptake of free oligonucleotides is somewhat controversial (juliano, ). following internalization of an oligonucleotide, the phagosome fuses with lysosomal compartments, where the contents are subjected to enzymatic degradation by proteases and hydrolases that operate efficiently in the low-ph lysosomal environment. tissues macrophages are most abundant in the liver and spleen, and both these tissues receive high blood flow (juliano et al., ) . the capillary lumen is surrounded by a layer of endothelial cells interlinked by adherence junctions (vecadherin containing) and by tight junctions (occluding and claudin-containing) and tightly adherent to the underlying extracellular matrix. this structure forms a barrier between blood and the parenchymal space. molecules in the blood can be transported across the endothelial barrier by two routes. paracellular transport occurs through the junctions between cells and is limited to molecules of approximately nm diameter or less; only micrornas would be able to transit this barrier by this method. caveolar-mediated transcytosis carries large proteins across the endothelium within vesicles of about nm. in some tissues, such as liver and spleen, there are gaps or fenestrations of - nm diameter between the endothelial cells, which allow egress of larger molecules (juliano, ). endothelial permeability is also increased in sites of inflammation and in some tumours, in which increased permeability is associated with fenestrations between the endothelial cells that result from rapid and disorganized angiogenesis in the tumour. this is known as the epr effect (enhanced permeability and retention), although some argue that this is mostly due to poor lymph flow in the area the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. and many minutes to several hours for the elimination phase; (ii) oligonucleotides are accumulated in most tissues, particularly in kidney and liver, but not in the central nervous system (probably due to the blood brain barrier); (iii) the major route of elimination is via the kidneys; and (iv) although the most detailed studies have been performed in rodents, the pharmacokinetic behaviour of the modified oligonucleotides in humans is similar to that observed in lower animals (juliano et al., ) . the pharmacokinetics and biodistribution of sirna duplexes is similar to that of single-stranded antisense molecules, with the highest uptake in the kidney followed by the liver (juliano et al., ). sirna and uncharged oligonucleotides do not bind extensively to plasma proteins, and are thus cleared by the kidney much more readily than modified oligonucleotides and tend to accumulate at lower levels in tissues (juliano, ) . typically, molecules with sizes of - nm or less can be ultrafiltered by the kidney; micrornas could therefore be rapidly excreted by the renal route, unlike long ncrnas. in fact, sirna molecules intravenously injected can be visualized in renal filtrate within seconds of injection (molitoris et al., ) . plasma sirna concentrations are reported to decline by more than % within min (relative to levels at min post dose) and decline by more than % within h (thompson et al., ) . only about - % of the iv administered dose is absorbed by tissues and the majority of this uptake occurs in the kidney (thompson et al., ) , most of it being cleared from tissues within h of administration . to reach their target, ncrnas must enter mammalian cells and arrive at the appropriate subcellular location (the nucleus or the cytoplasm, depending where the target molecules are located). like other large, polar and charged biological macromolecules, ncrnas are internalized by endocytosis and then trafficked through multiple membrane-bound intracellular compartments. the ability of ncrnas to reach their targets depends on both cellular internalisation (uptake) and intracellular trafficking. (figure ). there are five major classes of endocytosis: (i) the clathrin-coated pit pathway; (ii) the caveolar pathway; (iii) the noncaveolar, clathrin-independent pathways (clic pathways); (iv) phagocytosis (mainly taking place in "professional phagocytes" such as macrophages and granulocytes); and (v) macropinocytosis (in which internalized macromolecules are simply dissolved in the ambient medium) (juliano et al., ). non-coding rnas (ncrnas) can enter cells via different endocytic pathways, including micropinocytosis. internalized ncrnas can traffic from early endosomes (ee) to late endosomes (le) and to lysosomes. ncrnas must escape endosomal organelles to reach the cytosol and nucleus and act on the target molecules. some proteins may direct ncrna to non-productive pathways. the micropinocytosis pathway may represent a non-productive pathway for naked ncrnas. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the first four classes often involve a cell surface receptor and are collectively termed receptor-mediated endocytosis. these pathways are mainly utilized in cellular delivery of oligonucleotides. in general, receptor-mediated endocytosis includes three major steps. (i) receptor binding and internalization represents the primary barrier for oligonucleotide transport; the ligand-receptor binding determines which target cells and tissues oligonucleotides are delivered to. (ii) sequential intracellular trafficking leads oligonucleotides into a variety of low ph endomembrane compartments, including early/sorting endosomes, late endosomes/multivesicular bodies, and lysosomes. in some cases, receptors/ligands can traffic to the golgi complex. in many instances, receptor and ligand are dissociated in the low ph endosome environment. vesicular trafficking can prevent ncrnas from reaching their targets, for example, by sorting to secretory or lysosomal vesicles which may lead to export of ncrnas out of cells or degradation in the lysosomes. (iii) ncrnas must exit from the endosome to reach the site of action in the cytoplasm or nucleus. endosomal trapping represents an important barrier for ncrnas final functional objective. on the other hand, oligonucleotides are able to continuously shuttle between the nucleus and the cytoplasm mediated by nuclear pore structures, and do not require classical nuclear localization signals (juliano et al., ). the available data clearly describe several barriers to be considered when evaluating exogenous rna absorption, circulation, cellular uptake or intracellular trafficking. exogenous rna must overcome numerous biological barriers to reach its intended target within mammalian cells. considering oral administration as the most relevant for exogenous plant ncrnas, the first major limiting step to exogenous rna bioavailability is the gi tract itself. the gi tract encompasses both extracellular and cellular barriers. the extracellular barriers include the presence of enzymes in the lumen, such as amylase or nucleases, a harsh environment with ph ranging from . to . , and a net negative charged mucous layer with a very rapid turnover ( - min). the cellular barriers include a single layer of epithelial cells, the lamina propria and the muscularis mucosa, constituting the threelayer intestinal mucosa barrier. ncrnas could cross the epithelium between cells but this is limited by the presence of tight junctions. pore size in the human intestine would prevent passage of all ncrnas other than mirnas, the smallest ncrnas. ncrnas could also cross this epithelium through transcytosis by traversing the cells; this mechanism implies exposure to intracellular nucleases, recycling of ncrnas back to the lumen and nuclear uptake. many biological barriers and environmental conditions between the gi epithelium and the target tissue are then encountered by ingested rnas. ncrnas would be exposed to nucleases both in the plasma and in the target tissues. once inside the circulatory system, these rnas would be subjected to distribution and elimination, accumulating mostly in the liver and kidney. due to their small size, mirnas are especially rapidly cleared by the kidney, unlike long ncrnas. therefore, a very small percentage of rnas could actually be absorbed by tissues. furthermore, ncrnas would need to escape the reticuloendothelial system, the function of which is to clear the organism of foreign molecules. then rnas must cross the vascular endothelial barrier to reach the target tissue. for ncrnas to exert their functions they must enter the target cells. rna cellular uptake is achieved by endocytosis after which they would enter the intracellular trafficking system through multiple membrane-bound compartments. ncrnas would need to exit these compartments to reach their functional sublocation within the cell, be it the cytosol or the nucleus, while simultaneously escape degradation in the lysosomes. efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. seeds, corn kernels and rice grains, all of which are common food and feed, and numerous endogenous plant srnas are reported to have perfect complementarity to genes in humans, and other animals . however studies in mammals and humans with sirna indicates that the exposure levels required to produce regulatory effects exceed the levels achieved following ingestion . all animal and plant-related foods and feeds contain naturally occurring coding (i.e. mrnas) and ncrnas. early (srivastava, ; lassek and montag, ) and more recent studies ) have estimated that the total rna content in plants is about mg/g plant tissue. plants contain an array of ncrnas, including highly abundant transfer rnas (trnas) and ribosomal rnas (rrnas), single-stranded antisense rnas, and the mirnas and sirnas that trigger rnai and their precursor dsrnas . long dsrnas from non-plant, exogenous sources are particularly common in plants, including plants used for food and feed, due to infection from rna-containing viruses. animalderived foods are generally richer in rna than plant-derived foods, and are likely to contribute significantly to overall rna consumption (jonas et al., ) . of the mg/g tissue of total rna content in plants, relative percentages (by weight) of the major rna forms are approximately % rrna, - % mrna, and - % trna, with srnas accounting for less than % of total rna in plants . srnas are present at levels of up to . µg/g of conventional soybean grain (average = . µg/g grain) and comparable amounts are present in the grains of conventional corn and rice . in tobacco plants engineered to overexpress a dsrna under the control of a constitutive promoter, sirnas levels in leaves reached about . % of total rna (chau, b. l. and lee, k. a., ) . total exposure to construct-derived srnas from a putative biotech soybean product was estimated to be µg/kg/day in the general population and µg/kg/day for children aged six and under . using these same assumptions for rna expression levels in sweet corn, consumption of corn at the highest possible rate would result in an estimated intake of µg/kg/day in the general population and µg/kg/day for children aged in the absence of encapsulation or chemical stabilization to prevent degradation or without the addition of penetration enhancers, the absorption of rna -including sirnas -across the gi tract is described as negligible (akhtar, ; jain, ) . one study suggests that activity could be possible for certain highly expressed plant mirnas following food intake (zhang et al., a) . this study reports that in mice fed a diet consisting entirely of cooked rice (i.e. human equivalent of about kg/day of cooked rice) , several rice mirnas were detectable in mouse serum and liver. some of the results presented in this study were contested in later studies (chen et al., ) . petrick et al. clearly stated the unlikelihood of achieving such high concentrations of mature plant mirnas in the serum, plasma and organs of humans or animals via food intake since the high levels of rice administered the experimental animals did not reflect anticipated dietary exposure levels. in another study, it was concluded that plant mirnas identified in animal srna sequencing data can originate from artefacts of the sequencing process (zhang et al., b) . even in the case of -mer oligonucleotides modified to increase their stability, oral bioavailability in rats was only . % (nicklin et al., ) and intestinal absorption was less than % in a model that bypasses the gastric acidic environment. most of the labelled oligonucleotide was associated with the luminal epithelial cell membrane and very little efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. was localized intracellularly (khatsenko et al., ) . regarding the possibility of dietary sirnas and other dsrnas effects on gastrointestinal tissues, studies with radiolabelled or immunostained dna oligonucleotides demonstrate that these are primarily located extracellularly within the intestinal tract (lumen and luminal wall) (khatsenko et al., ; nicklin et al., ) , and are thus presumed to be minimally absorbed (negligible bioavailability, < %). it has also been observed that absorption decreased as the oligonucleotide length increased (from to nt) (khatsenko et al., ) . the only published quantitative data on srnas content in plant-derived foods ) (detailed above) indicate that . µg of srna is obtained per gram of soybean, rice seeds or corn kernels. as total rna content in plant-derived foods appears to be around mg/g tissue (lassek and montag, ), srnas could therefore represent . - . % of plant seed materials. the amount of sirnas in plants genetically modified to carry hairpin transgenes is estimated at about ng sirna/ µg total rna/g tobacco leaf tissue (chau, bess l. and lee, kevin aw, ) . the resulting estimated human dietary exposure to plant small rnas from rna-based biotech crops was derived from this (table ). . (b) assuming % of the specific food is consumed from a biotech crop, with total rna levels of ≈ mg/g grain and . % of these small rnas derived from the transgene. for details see . these doses are significantly lower than those required to elicit adverse effects in rodents or monkeys ( or mg/kg of chemically-stabilized sirna, respectively) by iv administration (thompson et al., ) . moreover, high mirna concentration is required to target suppression, and levels below copies/cell mirnas have little regulatory capacity (mullokandov et al., ) . according to snow et al., dietary plant mirnas are present at less than one copy per cell in target organs assuming reliable quantification . in another study the calculated dietary exposure in humans of a specific dsrna (dvsnf ) was estimated to be around . x - µg/kg/day in the us population (petrick et al., b) . the same study reported that mg dvsnf /kg/day in a -day repeated dose oral (gavage) toxicity study in mice did not produce any toxic effects (petrick et al., a) . levels for this specific dsrna in this biotech crop were reported to be ≈ . x - µg/g grain tissue on a dry weight basis for corn food, and ≈ . x - µg/g in the whole plant on a dry weight basis . of note is that there is little information on the impact of intended rnai in gm plants on the coding and non-conding plant rna. knowledge of which other rnas are modified, or how other rnas are compensated or desregulated in the gm plant needs to be experimentally evaluated for each specific case. different studies have evaluated the amount of plant-derived foods consumed by the general population. in a study of cohort of women in the uk, the difference between the mean intake of overall fruit and vegetables consumption was three times greater in high consumers vs. low consumers (pollard et al., ) ; vegans and vegetarians were the highest consumers of fruit and vegetables. in an efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. evaluation of the flemish population it was observed that vegans, while having the lowest total energy intake compared to omnivores, have the highest total fruit and total vegetables consumption. the intake of fruit, nuts and/or legume about twice in vegans, using either the healthy eating index (clarys et al., ) or total mean intake (clarys et al., ) . in the epic cohort study, which includes ten european countries, mean daily consumption was between and g/day vegetables and between and g/day fruit (agudo et al., ) . although not homogeneous among countries and centres, the ratio between the highest and lowest consumers was around . for vegetables and for fruit (agudo et al., ) . countries in southern europe had the highest vegetables and fruit consumption. for example, consumption of vegetables and fruit in healthy adults in spain (epic data), considered higher than most european countries and the usa, was g ( . servings) of vegetables and g ( . servings) of fruit (agudo et al., ) , equal to ≈ g/d vegetables and fruit. in the united states (us) the total vegetable and fruit intake has increased slightly (up to ≈ . servings/day) in all consumer categories from the late s (krebs-smith and kantor, ) and remained stable over the last decade (rehm et al., ) . actual quantities, however, are around . servings/day (rehm et al., ) , that is . for fruit and . for vegetables (eaton et al., ) . in cup-equivalents, this is . cup equivalents for vegetables and . cup equivalent for fruit (moore and thompson, ) . mean total vegetable intake in the us for vegetarians is reported to be around g/day and that for non-vegetarians as g/day. total fruit intake was around g/day for vegetarians and g/day for non-vegetarians (haddad and tanzman, ) . in other words, there is less than two-fold difference in the amount of fruit and vegetables consumed between vegetarians and non-vegetarians in the general us population. in a specific population (i.e. the adventist health study) in the us, daily mean consumption of fruits was higher (≈ g/day) for vegans than for other types of vegetarians or non-vegetarians (≈ g/day). the same trend was observed for daily mean consumption of fruit which was higher in vegans (≈ g/day) than other vegetarians or non-vegetarians (≈ g/day) (orlich et al., ). based on these data, dietary exposure to rnas from plants can in general be assumed to be higher in vegans and vegetarians than omnivores. although total rna content in plant-derived foods varies (lassek and montag, ), a person consuming an estimated daily dose of total fruit and vegetables ≈ g/day would theoretically ingest mg of total rnas assuming about mg/g of plant tissue. this value agrees with the dietary rna intake, which typically ranges from . - g/person/day (jain, ) . considering that srnas represent up to . % of plant seed materials ), estimated daily intake in the general population would be around . mg srnas. since vegans and vegetarians normally consume higher amounts of vegetables and fruits (see above), they could be exposed to an average of three times more plant exogenous rna ( . mg/day). no pharmacokinetics studies were identified in these groups. changes in rnase activity can occur in physiological or pathological conditions, this possibly impacting exposure after dietary intake. for instance, increased serum rnase activity has been observed in pancreatic carcinoma, pancreatitis, and renal failure (peterson, the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. et al., ) . human argonaute (ago- ) is a catalytic core component of rnai machinery. ago- mediated gene silencing has been proposed to be linked to the mitogen activated proteine kinase signalling pathway (zeng et al., ) , which is activated in response to cellular stress. since various kinds of stress on human cells induce formation of stress granules, ago- can be recruited to these granules, modifying its intracellular localization and the efficacy of rnai activity (detzer et al., ) . ago- is thus regulated at both the transcriptional and post-translational levels, suggesting that ago- levels can influence cellular mirna activity (adams et al., ). it has also been proposed that inactivation of mitochondria could lead to a strong decrease in mirna-mediated rnai efficiency, and, to a lesser extent, to sirna-mediated rnai (huang et al., ) . due to the interaction of p-bodies with mitochondria, reduced ago- activity could be due to changes in location of endogenous ago- from pbodies (huang et al., ) . association of ago- with cytoplasmic rna granules is known to regulate the translational repression activity of the protein, but phosphorylation of certain residues may prevent this inhibition, allowing the protein to remain active in the cytoplasm (lopez-orozco et al., ) . overall, it seems clear that ago- activity can be modified by cellular stress conditions. however, whether this can influence the function or the exposure to dietary ncrnas remains unknown and would benefit from further research. most studies have been focused on mirnas since these ncrnas were the first to be described. these studies have consequently extended to transgenic dsrnas as these have increasingly used to induce gene silencing. as mentioned previously, little is known about dietary exposure to other ncrnas. given the role of lncrnas in plant physiology, it is important to better understand human and animal exposure to these ncrnas. further research is needed on how transgenic ncrnas affect expression levels of other ncrnas, and other rnas such as mrnas. alteration of the expression levels of certain ncrnas within the plant may modify the levels of other ncrnas due to putative compensatory circuits and codifying rnas. this in turn could lead to changes in protein and enzymatic content, with putative consequent alteration of the modified plant's nutritional value. controlling for these changes would require complete transcriptome sequencing, and comparison of rna levels in unmodified to those of the altered plant . another point to consider is whether special diets (e.g. vegetarian or vegan) modulate ncrnas uptake throughout the gi tract, possibly leading to increased exposure. humans and animals have been continuously exposed to naturally-occurring plant rnas. estimated amounts of ingested plant ncrnas contrast with the much higher doses administered to experimental animals and in clinical trials to humans. although some reports on the presence of plant mirnas in serum, plasma and organs of humans or animals do not agree, the extremely low reported concentrations prevent them from being functional, even in the case of rnas modified artificially to augment their bioavailability. humans following special diets, such as vegetarians and vegans, have high intake of plant rnas, but their increased estimated exposure to such rnas is barely on average fold greater than in omnivorous diets. there are no specific studies determining the effects of increased dietary exposure to plant ncrnas. adams bd, claffey kp, white ba. . argonaute- expression is regulated by epidermal growth factor receptor and mitogen-activated protein kinase signaling and correlates with a transformed phenotype in breast cancer cells. endocrinology , - . efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. to exert a biological effect, exogenous ncrnas need to overcome the physical and biological barriers present in both the gi tract and the circulatory system, reach the target tissue, and enter the appropriate intracellular pathway at sufficient dose. this section describes the obstacles and challenges encountered by exogenous ncrnas following oral intake. following an extensive literature search, and based on expert judgement in the topic, publications were reviewed for this section. rna molecules are large, hydrophilic and negatively charged. even the smallest rna molecules (mirnas) have a high molecular weight (∼ kd) and their net charge is negative (akhtar and benter, a; akhtar and benter, b) . due to these physicochemical properties, rna molecules are highly water soluble with low membrane permeability, thus falling into class iii of the biopharmaceutical classification system (fda, ; amidon et al., ) . like many other class iii compounds, they are not absorbed at all or only to a very small degree. being highly charged species, rna molecules resist partitioning across lipid bilayers, and higher molecular weights effectively restrict their movement by function of the tight junctions present in the gi tract epithelium (tillman et al., ) . in vitro and in vivo preclinical studies have assessed the use of medium chain fatty acids ( - carbon atoms), as well as bile salts, as absorption enhancers to cross the intestinal mucosa (gonzalez ferreiro et al., ; tillman et al., ; raoof et al., ) . orally introduced rna molecules encounter relevant obstacles in the gi tract, these precluding their absorption and activity. in general oligonucleotides are rapidly degraded in the harsh biological milieu of the acidic stomach and enzyme-rich gi tract, as described previously, and show poor transcytosis across the gut (akhtar, ) . in humans the ph in the gi lumen can vary from in the stomach to in the intestine (gamboa and leong, ) . exposure to these ph values can cause ph-induced oxidation or de-amination of rna, resulting in loss of activity (pridgen et al., ) . in addition, nucleases present in the gi lumen for digestion of biological molecules enzymatically degrade rna molecules too (gamboa and leong, ; kriegel et al., ) . the presence of a rich bacterial population, mostly in the intestines (the human microbiome project consortium, ) may also contribute to degradation of these molecules, as bacterial degradation of ribonucleic acids through the secretion of extracellular nucleases has been early described (nishimura, ; eaves and jeffries, ) . finally, if the above-mentioned obstacles are overcome, rna molecules still face the intestinal extrinsic and intrinsic barriers (see also . . ). the extrinsic barrier consists of the mucus layer covering the epithelial cells. this is a complex hydrogel material composed of proteins, carbohydrates, lipids, salts, antibodies, bacteria, and cellular debris (o'neill et al., ; pridgen et al., ) . it consists of loosely and firmly adherent layers that vary in thickness along the gi tract and can fluctuate based on diet. the mucus is secreted by cells presenting a rapid cell turnover, approximately - days in the small intestine in humans (gamboa and leong, ; o'neill et al., ; atuma et al., ) . among other functions, the mucus layer protects www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. epithelial surfaces by trapping pathogens and foreign particulates, and rapidly clearing them. penetration of this mucus barrier is necessary to reach the absorptive epithelial cells. several mucuspenetrating and mucoadhesive materials can be used to enable penetration of molecule to the mucus layers, increasing residence time and contact of the delivered molecules to the epithelium (pridgen et al., ) . the intrinsic barrier consists of the epithelial cell monolayer, constituting the greatest barrier to material from the intestinal lumen to the lamina propria and bloodstream. cells maintain this barrier by forming tight junctions, whose permeability can be modulated through specific combinations of different proteins (o'neill et al., ) . there are several possible pathways across the intrinsic (epithelial) barrier (figure ).  the transcellular pathway passes through the apical and basolateral cell membranes, as well as the cytoplasm. this pathway is very restrictive to the passive flow of hydrophilic solutes such as rna molecules, because of the lipid bilayer membrane and its impermeability to large molecules. transport mechanisms for this pathway can be passive for hydrophobic molecules, or active with membrane pumps for specific molecules such as ions.  the paracellular pathway is the major passive permeation pathway and allows diffusion of small molecules in the space between epithelial cells. the tight junctions regulate permeability of this pathway based on molecules' size and charge.  finally, transcytosis is an active transport pathway that relies on molecule-specific receptors guiding the molecule through the cell without entering degradation pathways. because of their large hydrodynamic size, macromolecules such as rnas are restricted to this pathway (pridgen et al., ) . the m cell transcytosis pathway is the most extensively studied for oral delivery of rnas. this pathway, which is used to transport antigens across the epithelium for immune surveillance, is attractive because m cells lack mucus secretion and have a sparse glycocalyx, among other features. however m cells are closely associated with immune cells in the lamina propria and peyer's patches, such as dendritic cells and macrophages, this from one side limiting the ability of the delivered molecule to reach the bloodstream and on the other side increasing the risk of triggering an immune response (florence, ; kriegel et al., ; pridgen et al., ) . moreover, m cells only make up a small percentage ( - %) of the non-absorptive epithelium in humans. the surface properties of m cells, as well as the number of peyer's patches vary among species, which could make difficult extrapolating animal model data to humans (pridgen et al., ) . an additional obstacle is represented by the immune system, which is intimately associated with the epithelium. numerous types of immune cells patrol the lamina propria, including t cells, macrophages and dendritic cells. if the ingested rna molecules reach the bloodstream, they must also evade the mononuclear phagocytic system (reischl and zimmer, ; pridgen et al., ) . the presence of endogenous and luminal nucleases, together with gi ph conditions, in general determine rapid degradation and low rna molecules' biological half-life (bhavsar and amiji, ) the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the paracellular pathway allows diffusion of molecules in the space between epithelial cells and is regulated by intercellular tight junctions. the transcellular pathway passes through the apical and basolateral cell membranes and cytoplasm. it is restricted to hydrophobic molecules or molecules transported by membrane pumps. the transcytosis pathway is an active transport system that relies on molecule-specific receptors guiding the molecule through the cell escaping degradation pathways. transcytosis pathways are found in both epithelial and m cells. from pridgen et al, . transepithelial transport: paracellular, transcellular and transcytosis pathways. first-pass elimination occurs when a compound is metabolised between its site of administration and the site of sampling for drug concentration measurement. this greatly affects the bioavailability of orally administered compounds since the concentration of the active substance reaching systemic circulation is decreased. the liver is usually assumed to be the major site of first-pass metabolism of an orally administered drug, but other sites are the gi tract, blood, vascular endothelium and lungs (pond and tozer, ) . in fact, the obstacles previously described for rna molecule absorption in the gi tract can be considered a first-pass effect. rna molecules reaching the circulatory system must avoid filtration by the kidneys, accumulation in non-target reticuloendothelial system (res) of the liver, kidney, lungs and spleen, degradation by endogenous nucleases, aggregation with proteins in the serum, and uptake by non-targeted cells such as phagocytes (kriegel et al., ; reischl and zimmer, ). once cellular uptake has taken place in the potential target tissue (surmounting the obstacle of crossing the vascular walls and the lipid bilayer cellular membranes), nucleic acids have to undergo efficient intracellular trafficking to ultimately produce the intended pharmacological effects. this includes endosomal transportation (escaping endolysosomal degradation), cytoplasm release, and efficient incorporation into the relevant intracellular pathways such as risc loading (for sirna, mrna, and mirna) or nuclear uptake (for lncrna) kriegel et al., ; pouton and seymour, ) . www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. rna molecules are large, hydrophilic and negatively-charged molecules. to achieve effect via the oral route, these molecules need to overcome the physical and biological barriers present in both the gi tract, where they encounter variable and harsh conditions along with degrading nucleases, and the circulatory system. rna molecules must reach the target tissue, escaping endo-lysosomal degradation, and enter the appropriate intracellular pathway in sufficient doses to exert their effects. www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. following a literature search as described in section . . . . and based on the methodology described in section . . . , a total of documents were selected as relevant to a general review of rna-based therapeutics administered by gi route. of these documents, at least report the use of specific vehicles for gi administration of exogenous ncrnas (i.e. nanoparticles). six of these documents simultaneously evaluated formulated exogenous rnas and their naked version, and reported either rapid degradation under gi conditions, or reduced or absence of biological effect of the naked version compared to the formulated one (table ) . twenty ( ) of these documents provide specific examples of local effects of rna-based drugs administered orally. in addition, papers were selected as relevant to inform on administration of exogenous ncrnas in either fish or birds and possibly exerting biological effects. orally delivered rna has been used as a dietary supplement or empirical therapeutic agent since s (jain, ). for example, yeast rna supplementation as a source of dietary ribonucleic acids has been used in different animals (choudhury et al., ; jha et al., ) including mammals (sukumar et al., ; heaf and davies, ) and in human studies (gianotti et al., ; tepaske et al., ) . in human studies, up to g per day (in divided doses) of exogenous rnas have been administered (for - days), producing an increase in plasmatic uric acid levels (zollner and grobner, ; zollner, ) . the absence of attempts to study the gi absorption of pure rna in these studies suggests that its effects, if any, could be related to rna molecules as a source of nucleotides. indeed, nucleotide supplementation in rats has been shown to affect the healing of ulcerative conditions, ameliorating indomethacin-induced ileitis and aggravating the severity of dextran sulfate sodium (dss)-induced colitis (sukumar et al., , sukumar et al., . also, a study of body fluid composition of rats orally administered yeast rna, mixtures of its constituent nucleosides or its constituent bases and ribose was performed (heaf and davies, ) . the authors showed that ingestion of rna increased intestinal levels of ribose, inorganic phosphate, uridine, pseudouridine, uracil, inosine or uric acid. the effect of orally administered mixed nucleosides on blood and urine composition was similar to that of rna, while some differences were noted for some equivalent mixture of free bases (heaf and davies, ) . this study showed that the dietary rna-phosphate passed to the urine from the gut, suggesting that most of the rna-ribose was probably metabolized (heaf and davies, ) . it has been shown in a murine model of staphylococcus aureus infection that the oral administration of rna was ineffective while the intraperitoneal nucleoside-nucleotide mixture was more effective in maintaining host resistance against bacterial infection (adjei et al., ) . supplementation with nucleotides has also been shown to exert biological effects, including expression regulation of certain genes (sanchez-pozo and gil, ; gil, ) , although the mechanisms of action are still unknown. it is generally assumed that nucleotides are not essential nutrients, but under certain conditions (i.e. low dietary intake, tissue needs increased or stress) dietary nucleotides may play a role as conditionally essential nutrients (jung and batal, ; carver and walker, ) . in this context, dietary supplementation with yeast rna promoted ulcer healing in a rat model of indomethacin-induced ulcerative ileitis (sukumar et al., ) . similar effects were observed when nucleosides and nucleotides were administered intravenously (veerabagu et al., ) . in both cases, the possible mechanism of action was partly due to increased cell proliferation in the damaged tissue (sukumar et al., ; veerabagu et al., ) . similar effects were observed when rna was administered orally or its constituents (nucleotides) were injected iv, suggesting that the effects are due to the absorbed nucleotides. dietary nucleotide supplementation in formula-fed infants efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. has been shown to improve gut microbiota composition (singhal et al., ) . in studies on certain fish model, supplementation with dietary rna at a range of concentrations ( . - . % of nucleic acids in the diet compared to the non-suplemented control group) enhances immunological response (choudhury et al., ; jha et al., ) . in human studies, postoperative enteral diet supplementation with rna, arginine and omega- fatty acids has been shown to modulate the postoperative immune response after surgery for upper gastrointestinal cancer (senkal et al., ) , overcoming more rapidly the immunologic depression after surgical trauma (kemen et al., ) . also in humans, oral supplementation with rna (from yeast) during days before surgery improved host defence in patients undergoing cardiac surgery (tepaske et al., ) or gi cancer surgery (gianotti et al., ) . in both cases, rna supplementation was also accompanied with arginine and omega- fatty acids administration. in summary, the specific contribution of orally administered rna to these effects cannot be ascertained. the instability of orally administered rna molecules and the presence of a large array of rnaases within the gi tract (see sections . . and . . ) suggest low absorption, if any. exposure to a highly active enzymatic environment in the gi tract, extreme ph conditions, and the existence of a mucosal epithelial barrier are the main challenges for oral delivery of rna therapeutics (martirosyan et al., ) . although a considerable amount of food rna is ingested, which varies widely between individuals but is typically in the range . - g/person/day, it is assumed it is degraded and absorbed in minimal amount (jain, ) . however, further data are required to document the extent to which this conclusion pertains to rna molecules with complex structures. to overcome the multiple barriers encountered by exogenous rnas for oral delivery, several strategies in the laboratory or clinical trials have been developed (see . . . below). the oral administration route is advantageous because it increases patient compliance and comfort over injection, provides for simple, repeatable administration, and offers a large surface area for absorption (forbes and peppas, ) . rna delivery may also benefit from advances in the oral delivery of aso for animal (raoof et al., ; raoof et al., ; . indeed, polymeric nanoparticles containing alginate, dextran, chitosan, polyethylenimine, polyethylene glycol, polylactide, yeast derived β-glucans and/or several other natural or chemically synthesized molecules have been tested by the pharmaceutical/medicine field. the literature describes several strategies for the oral delivery of rna oligonucleotides. the target is to stabilize and protect rnas during gi transit, enable cellular uptake in the intestine, and in some cases, promote endosomal escape and increase biological action. thioketal nanoparticles (tkns) were formulated from a polymer, poly-( , -phenyleneacetone dimethylene thioketal) that degrades selectively in response to reactive oxygen species ( the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. (plga) nanoparticles were also tested in the same study, but with no efficacy in diminishing tnfα expression. to obtain efficient mucus transportation, targeted cellular uptake and endosomal/lysosomal escape, different nanoparticles have been tested ( nanoparticles of galactosylated trimethyl chitosan-cysteine containing sirna against map k were tested and found to target activated macrophages in colonic tissue (zhang et al., b) . compared to nanoparticle-protected sirnas, naked sirnas were completely degraded by the intestinal fluids. when administered orally ( µg sirna/kg) for days, nanoparticles improved the dss-induced model of colitis in mice (zhang et al., b) . other ternary polymeric nanoparticles formed by thiolated trimethyl chitosan with tripolyphosphate have been tested in mice and found to efficiently deliver sirnas to the intestine and other tissues when administered orally (zhang et al., a the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. ( %, % and %) were also evaluated in trimethyl chitosan-cysteine conjugate nanoparticles . in a mouse model of ulcerative colitis, the mannose density of % was the most effective for sirna knockdown of tnfα following oral administration ( µg/kg) of '-o-methyl-modified tnfαspecific sirna duplex . the use of supramolecular self-assembly nanoparticles (ssnps) -which contain oleyl trimethyl chitosan, poly(γ-( -(((piperidin- -yl)ethyl)amino)methyl)benzyl-lglutamate), oleyl-peg-mannose, oleyl-peg-cysteamine, and sodium tripolyphosphate -with specific functions of mucoadhesion, transepithelial permeation, membrane penetration and active targeting have also been tested ( however, not all nanoparticle types can efficiently deliver rnas. in a study evaluating the ability of unassisted epithelial entry of nucleic acids as a consequence of nanocarrier contact with mucus, antisense oligonucleotides but not sirna (naked) were shown to be delivered to mouse intestine when formulated with nanocarriers composed by chitosan (martirosyan et al., ). multi-compartmental formulations -consisting of one or more internal compartments surrounded by protective external compartments -have been developed to surmount the many barriers to oral rna delivery (kriegel et al., ; . one example is the "nanoparticles in the microspheres oral system" (nimos), a solid-in-solid multi-compartmental system (kriegel et al., ) . gelatin nanoparticles entrapped in poly(epsilon-caprolactone) microspheres were prepared carrying tnfα sirna (slightly chemically modified dtdt) to treat dss-induced colitis. oral administration of sirna ( . mg/kg) to female balb/c mice decreased colonic tnfα expression and supressed the expression of proinflammatory cytokines (kriegel, c and amiji, m, ) . when combined with sirna against cyclin d (naked sirna, also at . mg/kg/day), the silencing effects were more potent than with tnfα sirna alone (kriegel c and amiji mm, ) . dectin- recognizes beta- , and beta- , linked glucans rich particles and intact yeast and is particularly expressed on the monocyte/macrophage and neutrophil lineage (herre et al., ) . β- , -d-glucan has been used to deliver exogenous rna targeting macrophages (aouadi et al., ). delivery of β- , -d-glucan sirna particles containing µg/kg unmodified sirna by oral gavage to mice for days reduced map k expression in different macrophages from different tissues and protected them from lipopolysaccharide-induced lethality (aouadi et al., the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the cd gene was the target of the antigen-presenting dendritic cells and oral administration of the recombinant yeast. short hairpin rna delivered in lactobacillus casei have also been tested to target the intestine (kuwahara et al., ) . other organisms, including attenuated salmonella typhi, were used as vectors to deliver rnas, even ribozymes (bai et al., ) or sirna (jiang et al., ) , using oral administration in mice to target either local or systemic effects (bai et al., ; jiang et al., ) . the the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. extracellular vesicles are a heterogeneous family of vesicles delimited by membranes. these can be classified by their size as i) exosomes ( - nm in diameter), which originate from the endosomal system, ii) microvesicles ( - nm) formed by budding out of the plasma membrane, and iii) apoptotic bodies (> nm) formed by blebbing of the plasma membrane during apoptosis (reviewed in yanez-mo et al., ; colombo et al., ) . increasing evidence suggests that extracellular vesiclemediated communication can take place in vivo, but the nature of the extracellular vesicles involved in these effects remains to be clarified (reviewed in tkach and thery, ; pitt et al., ) . exosomes, which are formed in multivesicular compartments, are secreted when these compartments fuse with the plasma membrane (kowal et al., ; abels and breakefield, ) . exosomes have been shown to contain or transport a myriad of molecules including proteins, carbohydrates, lipids, and a variety of genetic material including dna, mrna and ncrnas (reviewed in choi et al., ; abels and breakefield, ) . exosomes are also described as participating in intercellular communication (costa-silva et al., ; pironti et al., ; nojima et al., ) , delivering their parental cell-derived molecular cargo to a recipient cell. some of these processes are thought to be mediated by ncrnas, including mirnas thomou et al., ) . detailed information on how all these biological processes occur is outside the scope of this review. given the above characteristics of exosomes, these vesicles hold promise as delivery vehicles for therapeutics (munagala et al., ; van der meel et al., ) . indeed, exosomes have been used to deliver sirna to different tissues when administered systemically, including the brain (alvarez-erviti et al., ; cooper et al., ; didiot et al., ) . mirnas have also been delivered via exosomes to different tissues including xenograft breast cancer tissue (ohno et al., ), brain and other tissues when administered systemically or locally (zhang, d et al., ) . interestingly, oral administration of exosomes or extracellular vesicles has also been described in animal models agrawal et al., ; oliveira et al., ; oliveira et al., ) . however, their biological effects were not related to transport of ncrnas. some extracellular vesicles have been shown to resist digestion under in vitro simulated gi conditions (benmoussa et al., ; , particularly those from bovine milk (vashisht et al., ) . moreover, milk exosomes seem to exhibit cross-species tolerance and are not described to induce adverse immune and inflammatory responses (munagala et al., ) . however, whether exosomes or other extracellular vesicles resist the harsh in vivo conditions of the gi tract and the digestive process remains poorly described and needs to be studied (tomé-carneiro et al., ) . exosome-like nanoparticles from plants have been isolated from different species including ginger, grape, grapefruit and carrot (mu et al., ; ju et al., ; zhang et al., ) . some authors indicated that the approximate amount of exosome-like nanoparticles in these edible plants were reported to be ≈ mg/ g edible plant (mu et al., ) , while other authors reported only ≈ mg/kg ginger . most of these studies reported the presence of rnas, either small or large, including ncrnas (mu et al., ; zhang et al., ; ju et al., ) . the amount of rna present in these exosome-like nanoparticles was reported to be ≈ µg rna/ mg exosomelike nanoparticles for grape and grapefruit, and ≈ µg rna/ mg exosome-like nanoparticles for ginger and carrot (mu et al., ) . the in vivo biological effects of these nanovesicles have been assessed. oral delivery of ginger nanovesicles during days at a dose of . mg/day was found to target the colon, to be taken up by epithelial cells and macrophages, and to reduce dss-induced colitis in mice . treatment for weeks with the same dose also exhibited antiinflammatory activity in a mouse model of chronic colitis . ginger-derived lipid vehicles have also been generated from ginger lipids and loaded with sirna-cd (zhang m et al., www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. ). oral administration of these ginger-derived lipid vehicles targets the colon tissue and they are effective in treatment of induced ulcerative colitis in mice. grapefruit exosomes at a dose of mg/kg per day for days also ameliorated the dss-induced colitis targeting intestinal macrophages . when administered orally at a dose of mg of nanovesicles/day, grape exosomes-like nanoparticles were also found to protect mice from a dssinduced model of colitis by induction of intestinal stem cells (ju et al., ) . local intestinal macrophages and stem cells from the small and large intestine were also found to be the target of these exosome-like nanoparticles when administered by oral gavage ( mg/day) (mu et al., ) . even though mirnas were reported to be present in these exosome-like nanovesicles (ju et al., ; mu et al., ; zhang et al., ) , the biological effects of these ncrnas were not evaluated. whether these mirnas resist the gi tract conditions remains unknown. a main hurdle in rna-based therapeutics is the successful delivery of naked rna (non-chemically modified) molecules to specific (target) tissues in the gi tract. the literature contains few studies in which exogenous rnas are administered in vivo using routes of administration other than oral, and most are in the field of inflammatory bowel disease. an amphiphilic cationic cyclodextrin (cd) vector was developed for a complex sirna against tnfα, where the complex was concentrated to µg/ µl in % glucose (mccarthy et al., ) . cd.tnfα.sirna was found to be efficient against dss-induced colitis in c bl/ mice treated twice (day and post-dss) by intrarectal administration with the test solution ( µl). cd.sirna administration reduced tnfα and il- expression as compared to the non-silencing sirna control or the naked tnfα sirna (not delivered in formulated cyclodextrin). enteral delivery of sirnas for systemic effect was also tested. a nuclease resistance and chemically modified sirna against apolipoprotein b was conjugated with α-tocopherol and was administered ( mg/kg) as lipid nanoparticles in the large intestine of mice. the lipid nanoparticle was composed of mixed micelles comprised of linoleic acid and peg- hydrogenated castor oil. the sirna efficiently reached the liver and other tissues using the chylomicron-mediated pathway via the lymphatic route (murakami et al., ) . delivery of sirna into hepatocytes was markedly reduced when the sirna was not bound to α-tocopherol, indicating that conjugation with α-tocopherol was essential to this delivery system using this route. a calcium phosphate (cap) core coated with sirnas and encapsulated in poly(d,l-lactide-co-glycolide acid) (plga) nanoparticles containing an outer layer of polyethyleneimine (pei) was developed for intrarectal delivery (frede et al., ) . in a dss-induced model of colonic inflammation, intrarectal administration ( µg/day) of nanoparticles containing ng sirna against either tnfα, ip- or kc from day to after % dss treatment, ameliorated the colitis. indeed, while intestinal epithelial cells, dendritic cells, macrophages and t cells could uptake the tnfα sirna nanoparticles, reduction of tnfα was only detected in epithelial cells and t cells (frede et al., ) . the stability of sirna within the cap/plga/pei nanoparticles against enzymatic nucleases under colonic conditions was evaluated. while the sirna-loaded cap/plga/pei nanoparticles were detectable after h incubation at ºc with colonic fluid or homogenate, the same sirnas not formulated in nanoparticles was not detected and was assumed to be degraded. even after exposure to colonic homogenate for h at ºc, the nanoparticles retained biological activity. since the supernatant of the homogenate subsequently incubated with a cell line, still reduced the expression of tnfα by % (frede et al., ) , suggesting that sirna-loaded nanoparticles retain its biological activity compared to that of nacked sirnas (not formulated). www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. other alternatives for rna delivery have been tested. ultrasound-mediated rna delivery has been efficiently achieved in mice (schoellhammer et al., ) . chemically modified sirna against tnfα ( ng sirna in µl water) was delivered in the rectum using ultrasound exposure to khz for . s and after a -day treatment tnfα was efficiently repressed in colonic tissue of a mouse model of induced colitis. in the same study, a mrna (≈ kda) complexed in lipid nanoparticles (lnps) was administered in the colon ( µl lnps solution) with ultrasound and found to be successfully translated locally in the colonic tissue (schoellhammer et al., ) . oral administration of exogenous rnas to exert a biological effect, either locally or systemically, is successful if combined with specific delivery technologies, such as vehicles developed for pharmaceutical/medical purposes. nanoparticles have been designed to release their cargo in specific regions of the gi tract (i.e. where inflammation occurs) or to resist the gi conditions. in contrast to other routes of administration, where normally highly chemically modified rnas are used, oral delivery normally involves use of naked rna or minimally modified rnas formulated with complex delivery vehicles. achieving the local desired effect (i.e. targeting inflammation in the colon) has contributed to the development of delivery technologies and the usage of other routes of administration different than the oral as described above. however, the available literature also suggests that naked or unmodified exogenous rnas are rapidly degraded when exposed to the gi conditions without incorporation into delivery vehicles. extracellular vesicles are natural lipid particles released by many cell types with the potential to mediate cell-to-cell communication. these extracellular vesicles have a tremendous potential as delivery vehicles for therapeutics. however, there are still very few studies evaluating their resistance to the harsh conditions of the gi tract following oral administration. knowledge of their biological effects as transporters of exogenous ncrnas is still very limited. nucleic acid-based therapeutics have the potential to treat numerous diseases by correcting abnormal expression of specific genes. as indicated previously, the oral route of drug administration poses serious delivery challenges due to the gi degrading environment, as well as the need to overcome other barriers preventing nucleic acid delivery. because of these obstacles, efforts in developing oligonucleotide-based therapeutics using the oral route have focused on local gastrointestinal delivery, i.e. directly delivering the drug to the target tissue for localized effects, and, therefore, increasing local bioavailability and maintaining doses low while diminishing possible effects to non-target tissues kriegel et al., ) . crohn's disease and ulcerative colitis are the two principal forms of ibd, characterised by being a chronic relapsing inflammatory condition of the gi tract. the pathogenesis of ibd is dependent on the interaction between local immune and environmental factors in genetically-susceptible individuals (o'neill et al., ) . inflammation in crohn's disease is characterised by high production of the cytokines interferon (ifn)-gamma, il- and tnf-alpha, representing a t helper (th )-th response. in ulcerative colitis, the immune response is characterised by th and an atypical th , with high production of il- , il- and il- (o'neill et al., ) . conventional treatment consists of antiinflammatory and immune-suppressive drugs but, while some medications are effective to combat inflammation in the acute phase, they are ineffective in maintaining remission due to toxicity, dependency and higher relapse rates (kriegel, c and amiji, m, ) . the goal for ibd treatment is local delivery of therapeutics to intestinal immune cells. initial approaches involved il- supplementation www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. due to its huge potential in blocking proinflammatory cytokines and inflammatory tissue damage. but human clinical trials have not proven that systemic il- supplementation can help prevent or improve the ibd symptoms, probably due to il- low mucosal levels . separate studies have used gene therapy to increase il- mucosal availability by engineering il- plasmid dna, and achieving more success in rodent models (barbara et al., ; steidler et al., ; lindsay et al., ; bhavsar and amiji, ) . deregulation of tumour necrosis factor (tnf)-alpha production, a proinflammatory cytokine primarily produced by activated macrophages along with other cell types, is associated with the onset and progression of a number of inflammatory diseases (such as ibd, rheumatoid arthritis), alzheimer's disease and psoriasis . the harmful effects of tnf-alpha are thought to be mainly mediated by activation of nf-kappab, therefore regulating expression of over genes. systemic blockage of tnf-alpha is accompanied by several side effects that can be avoided if local inhibition occurs. rnai-mediated local suppression of tnf-alpha can be beneficial for overcoming many of these side effects. different groups have developed various delivery systems for sirna molecules targeting tnf-alpha expression in the gi tract, assaying them both on cells and several rodent models for ibd (wilson et al., ; kriegel, c and amiji, m, ; kriegel, c and amiji, mm, ; laroui et al., ; yin et al., ; he et al., b, a; he et al., ) . even though therapeutic rnai development is in its infancy, current approaches and tools for delivery of these biomolecules via the oral route are improving. in fact, recent reports describe the effects of an oral smad antisense oligonucleotide in a randomized, placebo-controlled, double-blind, phase clinical trial in patients with crohn's disease (monteleone et al., ; monteleone et al., ) . although in this instance the biomolecule used is an antisense oligonucleotide and not a sirna, the design of the oral formulation could be very similar. iron is an essential metal required for numerous physiological functions, but in excess it is a well-defined risk factor in the pathogenesis of several diseases, including cardiovascular and neurodegenerative diseases. since there is no recognised active pathway of iron excretion, disposal of excess iron from the body is the primary therapeutic goal of treating patients with iron overload. use of iron chelators is limited due to nonspecific distribution in non-target tissues, which results in a number of serious side effects and toxicity . another way to treat iron excess is by limiting absorption of exogenous iron. the divalent metal transporter (dmt ) protein plays a well-established role in iron absorption. the primary site of dmt activity is the intestinal epithelium. dmt expression is regulated in response to body iron levels, with expression enhanced when iron stores are low and, conversely, reduced when iron stores are high. oral delivery of sirna-encapsulated nimos to selectively suppress intestinal dmt could decrease intestinal uptake of dietary iron, thereby mitigating iron overload and preventing iron-mediated toxicity . celiac disease is caused by a t-cell mediated immune response in the small intestine against deamidated cereal gluten peptides modified by the enzyme transglutaminase (tg ). the only way to prevent celiac symptoms is strict adherence to a gluten-free diet. the pathophysiology of celiac disease involves a combination of environmental, genetic and immunological factors. among several immune mediators, enzyme tissue tg and the proinflammatory cytokine interleukin- (il- ) have emerged as key players in promoting inflammatory responses against dietary gluten. given their important role in the pathophysiology of celiac disease, sirna mediated silencing of intestinal tg and il- (i.e. by oral administration using nimos) may result in neutralizing proinflammatory effects and could therefore alleviate disease symptoms . efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. colorectal cancer is one of the most common forms of cancer, and rnai therapy has great potential in the treatment of local intestinal cancers. however, rnai therapy faces major challenges since the genotypic footprints of the various cancers differ widely, even from individual to individual. depending on the tumour, several different sets of genes may be misexpressed, making it extremely difficult to determine a common/unique "culprit" gene. moreover, mice and rats do not generally spontaneously develop colon cancer, so induction of tumour growth is required. but these developed animal models do not reflect the genetic changes observed in human tumours (o'neill et al., ) . genetic mouse models that spontaneously develop intestinal cancer have also been developed. mutations in the apc gene are associated with development of colon cancer as well as a condition called familial adenomatous polyposis (fap). fap is an inherited condition characterised by development of numerous polyps in the colon. some of these polyps can subsequently become malignant adenocarcinomas (o'neill et al., ) . regarding fap and human gene therapy, one study explored oral delivery of escherichia coli expressing shrna against beta-catenin, and found significant silencing activity in healthy mice (xiang et al., ) . the gi tract provides the possibility of acting at systemic level by targeting local resident cells, such as m cells. m cells can take up encapsulated biomolecules to be phagocytosed by macrophages. in fact, aouadi et al. reported that glucan encapsulated sirna particles (gerps) loaded with sirna were phagocytosed by the underlying gut-associated lymphatic tissue (galt) macrophages and then translocated to distal organs of the reticuloendothelial system such as the liver, spleen and lung (aouadi et al., ) . another report claims functional cd shrna expression delivered into dendritic cells in mice by oral administration of recombinant yeast (xu et al., ) . in this manner, the targeted cells located in the intestine can undergo sirna-mediated gene silencing and migrate into tissues throughout the body. when successfully administered, rnai is a very useful therapeutic strategy for efficiently modulating gene expression. orally administered local rnai therapeutics have great potential due to the increasing bioavailability of the therapeutic biomolecule at the targeted tissue or cell type, coupled with simultaneous evasion of systemic side effects and immunogenic reactions. most advanced studies are focused on inflammatory bowel disease, although other potential diseases are being explored. the current main challenge is development of suitable encapsulation methods to protect the rna molecules from the harsh and varying conditions of the gi tract. the literature on rna delivery in fish and birds is scarce, with some examples of dietary delivery of exogenous rnas. in birds, most of the studies have been done using central nervous system administration of sirnas. for example, in the zebra finch bird, sirnas (three - nt long sequences against tyrosine kinase b, trkb) administration via direct injection into the brain was effective in reducing the volume of the high vocal centre by diminishing the robust nucleus of the arcopallium and the relative number of cells within it (beach et al., ) . in another study, direct administration of sirnas in the brain of white-crowned sparrows reduced resting time, spontaneous production of complex vocalizations, and stimulated brief agonistic vocalizations (ubuka et al., ; ubuka et al., ) . in the japanese quail, central administration of the same sirnas against gonadotropin-inhibitory hormone the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. sirnas for rna interference in chicken embryos has also been used to target marek's disease virus in vivo (chen et al., ). in fish models, systemic exosome-mediated sirna delivery to zebrafish resulted in effective crossing of the brain blood barrier and localization in the brain in vivo (yang t et al., ) . exosome-delivered sirnas decreased fluorescence-labelled tumour cells in the brain more than fourfold by inhibiting vascular endothelial growth factor (vegf) in a xenograft zebra fish brain tumour model (yang t et al., ) . these results suggested that brain endothelial exosomes could be used to deliver exogenous sirnas to the target site in the brain for treatment of brain cancer. the proposed higher delivery efficiency, lower immunogenicity, and better compatibility than existing foreign rna carriers have promoted the possible use of exosomes for exogenous rna delivery (mei et al., ) . several other studies have evaluated systemic delivery of sirnas to fish animal models, including delivery to the heart using peg-pla nanoparticles (diao et al., ) or using a neutralized non-charged polyethyleniminebased system . the literature describes other examples of sirna delivery into zebrafish embryos to inhibit specific gene function (gruber et al., ) . in the context of other types of ncrnas, direct injection of mir- a mimic rnas at the one-cell stage of zebrafish embryos resulted in inhibition of formation of the caudal vein plexus by means of targeting the endothelial cell bone morphogenic protein smad signalling (icli et al., ) . also in the zebrafish model, injection of a mir- mimic into embryos at the one-cell stage to deliver mir- ubiquitously resulted in protection against sterile inflammation (hsu et al., ) . dsrna microinjection administration to zebrafish embryos ( - cell stage) at a concentration of - pg rna/embryo resulted in rna interference, an effect that was diminished when ssrna was used (wargelius et al., ) . in cultured european sea bass, intramuscular injection ( weeks, µg of dsrna per dose) followed by in vivo electrically mediated dsrna delivery resulted in a reduction of myostatin gene expression (terova et al., ) . delivery of exogenous rnas has also been tested in lower aquatic organisms. in the crustacean red claw crayfish cherax quadricarinatus, systemic injection of sequence specific dsrnas against viral protein b of macrobrachium rosenbergii nodavirus (mrnv) was conducive to rnai effects that were able to functionally prevent and reduce mortality in infected individuals (hayakijkosol and owens, ) . dsrnas (intramuscular injection) have been used to induce antiviral immunity in invertebrates as they can also recognize dsrna as a virus-associated molecular pattern, resulting in activation of an innate antiviral response (robalino et al., ) . oral administration of encapsulated dsrnas (inactivated bacteria expressing dsrna) in the prawn macrobrachium rosenbergii fed twice daily at a rate of % total biomass for days resulted in their protection against white tail diseases caused by mrnv (naveen kumar and karunasagar, ) . dsrnas designed against the capsid and b genes of mrnv reduced the mortality of prawns by ≈ % due to sequence specific-mediated silencing of the viral genes (naveen kumar and karunasagar, ) . injection of viral protein -targeted dsrna (≥ µg dsrna/g shrimp body weight) into shrimp resulted in a high level of nt sirnas mapping across the entire white spot syndrome virus genome after virus challenge, which resulted in protection against the virus (nilsen et al., ) . in planarians, ingestion of bacterially-expressed dsrnas or direct microinjection into the animals can inhibit gene expression through rna interference (newmark et al., ) . efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. mongersen, an oral smad antisense oligonucleotide, and crohn's disease. n engl j med , - . mu j, zhuang x, wang q, jiang h, deng zb, wang b, et al. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. - . zollner n. . purine and pyrimidine metabolism. proc nutr soc , - . zollner n, grobner w. . influence of oral ribonucleic acid on orotaciduria due to allopurinol administration. z gesamte exp med , - . following a literature search as described in section . . . and based on the methodology described in section . . . , a total of documents were selected as relevant to reviewing the effect of dietary exogenous ncrnas on the gi tract and annex glands. very few studies have focused on the gi tract and their annex glands. four documents specifically evaluated the resistance of plant-derived srnas to simulated in vitro digestion system, ex vivo digestion system or in vivo digestion samples (philip et al., ; yang, et al., a; and reported that the percentage of unaltered mirnas after digestion might be below . %. due to their relevance in early human nutrition, literature on breast milk ncrnas was chosen to describe the biological effects of dietary exogenous ncrnas of non-plant origin, for which full-text reports were studied and reviewed. zhang et al. were the first to report on the transfer of mirnas from food plants to the mammalian circulatory system causing effects on recipient cells . this study reported the detection by high-throughput sequencing of plant srnas in human serum, as well as in tissues of the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. humans, mice and calves. the plant mirnas were distinguished from human mirnas by their '-omethyl modification, which made them resistant to periodate whereas the human mirnas having free ' hydroxyl were periodate sensitive. it was then assumed that the identified plant mirnas were coming from the food uptake. two rice mirnas named osa-mir a and osa-mir a were particularly abundant in human serum samples, since rice is common in human diets. additional in vitro experiments showed that these plant mirnas can endure conditions that mimic the acidic environment of the gut, suggesting that plant mirnas can survive being eaten and digested, pass through the mammalian gi tract and reach target organs. the authors also showed that diet-derived plant mir a can target the low density lipoprotein receptor adapter protein (ldlrap ) mrna based on sequence complementarity. this mirna was able to reduce the ldlrap protein level in the blood and liver of mice fed rice, and eventually increase their plasma low-density lipoproteins (ldl) content. this publication raised questions about whether food-derived srnas could play an active role in human/animal health. however, it was controversial and its results were questioned due to nutritional imbalances in the test-diet studies or lack of rnai-mediated modulation of ldlrap protein levels in mouse liver (witwer and hirschi, ; chen et al., ; . scientists from the monsanto and miragen companies were unable to reproduce these findings . measuring ldlrap protein levels in the liver of mice fed with mir a-containing rice diets by elisa instead of western-blot analysis, dickinson and colleagues did not detect any protein change modulated by mirna a-diets. although changes in the ldl plasma levels were indeed detected, the authors concluded that ldl increases resulted from nutritional imbalances rather than from a mir consumption mediated effect. additionally, plant mirnas including the highly abundant and stable osa-mir a were not detected in liver and plasma samples of mice fed under different rice-based regimes by srna sequencing with the hiseq illumina system . other independent research groups failed to detect dietary plant mirnas in plasma and tissues when conducting controlled feeding studies in humans and in animal models using different detection methods, such as real time quantitative pcr (rt-qpcr), droplet digital pcr (ddpcr) and next generation sequencing (ngs) analysis . these studies provide contradicting evidence of mirnas dietary absorption. in all the attempts, plant mirnas were detected at substantial levels in the diets but were undetectable in animal fluids and tissues. snow and colleagues studied three plant mirna species (mir a, mir a, and mir a) highly abundant in fruits routinely ingested by a group of ten healthy athletes. examination of the athletes' plasma by rt-qpcr analysis using taqman probes revealed high levels of endogenous mirnas but not the three dietderived plant mirnas . the same results were obtained with mice fed vegetarian diets rich in these mirnas. furthermore, using a mir null mutant mouse they showed that none of the dietary mirna including mirna was detected in blood and body tissues, suggesting that dietderived mirnas were not absorbed or maintained in mouse body fluids or organs. another group reported negative results on dietary mirna absorption in non-human primates . using qrt-pcr analysis and the same timeframe of as in zhang's report a, plant-specific mirnas were undetectable in tissues from macaques given a vegetarian diet. another feeding study in humans showed no significant differences in the levels of the plant mir a and mir in the plasma after consumption of broccoli sprouts highly rich in these two mirnas (baier et al., ) . more recently, a different research group using by ngs analysis failed to detect plant mirnas in the plasma of healthy volunteers that normally consume olive oil . the possibility that the plant rnas detected in human tissues and body fluids in some studies were contaminants remains a serious concern . by searching the composition of srna-seq data generated by the zhang's team from amphioxus animals, www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. it was found that the amphioxus data contained rice mirnas as previously reported for human serum. given that amphibia have an exclusive algae-based diet, this strongly suggests that the rice mirnas in both studies are the result of samples contamination . spurious detection of such sequences could arise due to contamination during sample handling, library preparation or sequencing, or result from errors in data analysis. since next-generation sequencing is very sensitive, just a few molecules could cause a false positive detection. more recently a comprehensive meta-study surveying for the presence of cross-species mirnas in sequencing data sets from various human tissues and body fluids indicated that xenomirs (cross-species mirnas) are technical artefacts rather than the results of dietary intake . a bioinformatics study identified plant mirnas in human and porcine milk exosomes . by searching publicly available ngs datasets, the authors identified several plant mirna species, most of them belonging to evolutionarily conserved and highly abundant mirna families. the target prediction suggests that these mirnas may interact with mrnas coding several transcription factors, protein receptors, transporters and immune-related proteins, thus potentially influencing biological functions in humans. of note is that the plant mirna profiles found in mammalian breast milk were similar to the composition in human blood presented by zhang and colleagues . liang and colleagues reported positive results on the absorption of food-derived mirnas from feeding studies in mice using cabbage (brassica oleracea) . they showed that mir , the most abundant mirna in cabbage, was detected in blood and various organs after cabbage consumption. however, there was no absolute quantification of mir or a description of an endogenous control for normalization of qrt-pcr data. a more recent study by zhang's group described how plant mirna from honeysuckle (lonicera japonica) inhibited influenza a virus replication in mice when entering through the gi tract, and they hypothesized that this mirna might be the active component in the traditional chinese medicine based on honeysuckle herb to treat influenza infection . the authors demonstrated that mirna is highly stable in honeysuckle decoction by solexa sequencing and northern blot analysis. they also showed that mir levels increased in mouse peripheral blood and lung following continuous honeysuckle decoction intake (drinking) or gavage feeding, as measured by qrt-pcr using taqman mirna probes. additionally, luciferase reporter assays and in vivo experiments showed that mir was able to target the influenza a virus, and consequently inhibited its replication and reduced mice mortality. the same authors reported that plant mirnas can be found in human umbilical cord blood and amniotic fluid, transferred from mother to the foetus, and that these influence foetal development and health . they showed that mir content increased in the maternal plasma and foetal liver of mice fed honeysuckle. a fluorescently labelled sirna was used to trace the transplacental transmission through feeding. furthermore, they showed that after feeding mice with different amounts of sirnas targeting the alphafetoprotein mrnas the levels of this protein were down regulated in foetal tissues. these results suggest that dietary sirnas delivered from the mother to the foetus could regulate foetal gene expression. more recently, the anti-proliferative effect of a plant mirnas on breast tumours was demonstrated in feeding experiments in mice (chin et al., ) . the plant mir , particularly abundant in broccoli, was found in sera from women, and its levels were inversely correlated with breast cancer morbidity and progression. in human sera, mir was detected in extracellular vesicles by qrt-pcr using a taqman probe. transfection of breast cancer cells with a synthetic mimic mir was shown to reduce their proliferative growth by targeting the transcription factor mrnas. more importantly, oral administration of synthetic mir significantly inhibited the growth of xerograph breast tumours in mice. these results agree with a previous report in which oral administration of a cocktail of three www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. tumour suppressor mirnas that were '-o-methylated to mimic plant mirnas reduced colon tumour burden . additional research is needed to address discrepancies among different studies and verify whether plant srnas derived from diet are absorbed at functional levels in animal species. most of the available data suggests either that gastrointestinal absorption of dietary plant mirnas does not occur in healthy consumers or mirnas levels in blood and tissues of consumers are too low to have a biological impact. however, the biological activity of food mirnas may be more dependent on their accumulation in exosomes than on their abundance per se, because of their reported low concentration. development of sensitive sensors to help to detect the functionality of low-level absorbed mirnas would facilitate assessment of the effects of dietary mirnas in consumers. future studies are needed to establish how exogenous ncrnas absorption and tissue distribution occurs, as well as to address their bioavailability and their biological function. reported that increased mir was detected in sera and urine after consumption of particular foods (i.e. honeysuckle), and disappeared h after the honeysuckle was removed from the diet; this supports the idea that these small rnas were of dietary origin. the role of kidney damage in mirna retention in the animals was also evaluated. using two models of acute renal failure (baliga et al., ) , i.e. the cisplatin (a chemotherapeutic agent) and the glycerol-induced models, it was observed that only mice receiving cisplatin exhibited measurable levels of dietary mirnas in sera and urine. this suggests that kidney damage alone did not lead to enhanced mirna retention in the mouse circulatory system . of interest is that cisplatin treatment, but not glycerol treatment or honeysuckle feeding, disrupted the organization of small intestine epithelial cells as shown by histological analysis. in this study, yang et al. used droplet pcr to demonstrate that the amplified products were likely to be specific and not due, for example, to nonspecific amplification of endogenous rnas . whether particular foods and/or alterations in intestinal permeability could improve the capacity to absorb small rnas from the diet or influence the biological effect within the gi tract, annex glands and systemically is poorly described, but still relevant for risk assessment of exogenous ncrnas in a subset of population. no studies specifically report the biological effects of dietary exogenous plant ncrna on the gi tract. only a few studies (described above) report the possible biological effects in their annex glands, including the liver . for gastrointestinal tissues or the liver, liang et al. reported that icr mice (a strain of albino mice) fed plant total rna ( - µg) extracted from brassica oleracea showed detectable levels of mir in the stomach (up to ≈ copies), intestinal (up to ≈ copies) and faecal content (up to ≈ copies), with the maximum amount present at to h after feeding . estimation of the proportion of orally administered rna that survived digestion suggested that the stomach contained . - . %, the intestines . - . % and the faeces . - . %, while the blood contained about . - . % and the spleen about . - . % . the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. which was similar to that of their synthetic form (without '-o-methylated ' ends) . whereas plant mirnas had a much slower degradation rate compared to their synthetic form without '-o-methylated ' ends. it is important to note that extreme ph conditions are not the only physicochemical or biological condition within the gi tract (see section . . . . for details). using a simulated human digestion system in vitro, philip et al. evaluated the resistance of soybean and rice mirnas to simulated gastric fluid early stage digestion (philip et al., ) . the study found continual survivability of plant mirnas in an in vitro simulated digestion system for over min without any significant decrease in their levels (philip et al., ) . mirna levels have been analysed qualitatively by real-time pcr using taqman mirna assays. stability of the plant-derived small rna mirna was also assessed using an artificial in vitro digestion system that simulates mammalian gastric and intestinal conditions . yang et al. compared three samples which contained a) ml cabbage extract with pmol plant-derived mir (measured by qrt-pcr), and pmol spiked-in synthetic '-o-methylated mir a and artificial mirna termed c ; b) ml phosphate buffered saline (pbs) with pmol each of synthetic '-o-methylated mir , mir a and c ; and c) ml pbs with pmol each of synthetic mir , mir a and c without the '-o-methylation. time course analysis during both gastric and intestinal phase digestion showed that most mirnas displayed modest resistance in the acidic gastric environment (up to min), while in the intestinal phase the levels of all mirnas were drastically reduced after five minutes (figure ) . regardless of synthesis origin and '-o-methylation, the digestive stability of mir was up to -fold higher than that of the other mirnas. the most stable form of mir was the plant-derived form in the cabbage extract, since . % survived, compared to . % for the '-o-methylated form, and . % for the non-modified form. similar results were observed when pmol of synthetic '-o-methylated mir , mir a and c were digested in vitro using the ex vivo intestinal fluids ( figure ) . indeed, mir appeared to be more stable after -hour digestion than the other tested mirnas. finally, by directly measuring mir levels in vivo in the small intestines of mice fed the plant-based diet (daily dietary mir intake pmol) it was observed that this particular mirna reached level more than -fold higher than those observed in the animals consuming a single pmol dose of the synthetic mir . mir a, a mirna also present in the plant-based diets, was also detected in the small intestines at a level times lower than that of mir . using transgenic arabidopsis lines expressing the artificial mirna amir-rice, the murine mirna mmu-mir- a or their controls, yang et al. studied gastrointestinal digestion and bioavailability of transgenic mirnas (yang et al., b) . levels of transgenic mirnas in plants (qrt-pcr quantification) were similar ( . and . fmol/g of fresh weight for amir-rice and mmu-mir- a, respectively) to that of srna mir ( - fmol/g in fresh shoot tissue). however, in diets stored at room temperature, the abundance of amir-rice and mmu-mir- a decreased gradually by ≈ -fold (≈ fmol/g diet) while that of the srna mir increased ≈ fold after h. in vitro gastric and intestinal simulated digestion of the synthetic forms of the plantbased transgenic mirnas showed that amir-rice and mir had similar digestive stability, while mmu-mir- a was significantly less stable. the surviving percentage in the intestinal phase after min was . % for mmu-mir- a compared to ≈ . % for mir or amir-rice (figure , frame a). the surviving percentage in the in vivo assays (gavage-fed pmol of synthetic srnas) further decreased the stability of the mirnas, reducing their level to . % for amir-rice and . % for mir (figure , frame b) . however, the levels of mirnas in the small intestines were higher for mir ( fmol/mouse) than amir-rice ( . fmol/mouse), while mmu-mir- a levels were undistinguishable from the host mouse mirna (figure , frame c). amir-rice was not found in serum (neither are mirnas reported in previous studies and present in transgenic plants) while mir was found only in the serum ( . fm, or . x copies per mouse) of mice fed the plant transgenic diets (yang, j. et al., b) www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. altogether, these results suggest that the plant-derived mir might be more stable than other plantbased small rnas. whether this exceptional stability could be generalized to other ncrnas is unknown. however, recent evidence, including some studies evaluating mir and mir , suggests that there may be some misidentified alternative mirnas . indeed, several other rarer but consistently mapped plant mirnas also have % or near % matches to human transcripts or genomic sequences (i.e. rrna), and some do not map to plant genomes at all, suggesting artefactual results of plant mirnas in mammalian sequencing datasets. this emphasizes the need for rigorous filtering strategies when assessing possible dietary exogenous mirnas . indeed, the small rna mir is derived from s rrna and does not undergo canonical mirna processing, as it does not depend on dcl (yang, j. et al., a) . mir is also inefficiently assembled into the risc complex in human cells and modestly regulates gene expression. this suggests that this exogenous srna is different from the canonical plant-based mirnas (yang, et al., b) . these results highlight the need to evaluate other ncrnas as they could originate from precise processing at the ' or ' end of mature or precursor rnas generating other abundant small rnas (lee et al., ) . also, the rna degradome is a crucial component of the total cellular rna pool of plants (nowacka et al., ) . they can be stable degradation intermediates present in a high copy number, or they can derive from various rna species including trna, rrna, mrna and snrna (addo-quaye et al., ; nowacka et al., ) . among the few examples in the literature of possible biological effects of exogenous non-plant origin ncrnas, milk has been studied because it constitutes a rich source of secreted mirnas. human breast milk is an essential source of nutrition for new-borns. in addition to its nutritional function, breast milk contains myriad biologically-active components that influence the development of the the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. more than % of the unique mirnas identified in porcine milk exosomes (gu et al., ) or % in other studies (chen et al., ) . in human exosomes, the ten most abundant mirnas account for % of the unique mirnas identified . lncrnas previously reported as being important for developmental processes were found in human breast milk extracellular vesicles (karlsson et al., ) . maternal factors such as the mother's diet seem to influence mirna expression in the breast milk fat globule (munch et al., ) or exosomes (sun j, ) . maternal weight (xi et al., ) also seems to influence mirna expression. certain mirnas found in breast milk have also been found in placenta tissue (munch et al., ) , although their physiological role is unknown. other studies have shown that colostrum mirnas (early lactation period) are more abundant than in the later lactation period (gu et al., ; xi et al., ; sun et al., ) . bovine milk mirnas isolated from the colostrum whey fraction were more abundant than in the mature milk whey fraction (izumi et al., ) . immunerelated mirnas expression is reported to be higher in colostrum than mature milk (izumi et al., ; na et al., ) . in vitro studies of human milk mirnas using either rnase digestion, freeze-thaw cycles, low ph or other gi conditions have shown that these mirnas are relatively highly stable (kosaka et al., ; liao et al., ) . similarly high stability of mirnas was found when using one or all of the above mentioned hard conditions for milk from cow (hata et al., ; izumi et al., ), pig (gu et al., or panda . indeed, it has been proposed that rna in milk is present in microvesicles and is protected from rnases and the other gi conditions by surrounding membranes (hata et al., ; gu et al., ; . however, technological conditions such as pasteurization (golan-gerstl et al., ) have been shown to reduce mirnas abundance in cow and goat milk by up to ≈ %, or up to ≈ % for certain mirnas (howard et al., ) , and in human exosome (personal communication, faseb conference ). microwave heating also reduces the amount of certain mirnas (howard et al., ) , while ultrasonication influences exosome membrane integrity and thus increases cargo instability (sun et al., ) . among dairy products, mirnas concentrations varied considerably, but were generally lower than the concentration in pasteurized whole milk (howard et al., ) . the exception was fresh cheese ("queso fresco") dip, which contained higher concentrations of mirnas than observed in pasteurized milk (table ). in vitro studies using mirnas isolated from breast milk exosomes, either human or bovine, were found (liao et al., ) , and crl , k or lim (golan-gerstl et al., ) . when subjected to proteinase k treatment or when the vesicle structure was destroyed, uptake or transport of these exosomal mirnas was compromised (kusuma et al., ; wolf et al., ; sun et al., ) . different studies have attempted to quantify the amount of rnas present in breast milk. rna content in microvesicles isolated from cow milk has been estimated to be ≈ ng for colostrum and ≈ for mature milk when isolated from ml sample (hata et al., ) . in human milk, total rna was estimated to be ≈ ng/ cells of the milk cell fraction and ≈ ng/µl fat from milk fat (alsaweed et al., c) . exogenous plant mirnas have also been found in panda milk exosomes , the whole milk or exosomes of human breast milk the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. et al., ). however, levels of mirnas or total rnas were very low (golan-gerstl et al., ; alsaweed et al., c) compared to that of breast milk. indeed, alsaweed et al. reported that the total amount of rna found in bovine milk-based infant formula was ≈ . ng/µl formula ( human mirnas detected) as compared to . ng/µl for a soy-based formula ( human mirnas detected) (alsaweed et al., c). in terms of possible breast milk mirna absorption, plasma levels of mirnas were found to be higher in colostrum-fed piglets compared to mature milk-fed piglets (gu et al., ) . in humans, plasma mirnas (mir- b and mir- c) increased when different doses of cow milk were consumed (baier et al., ) . in contrast to the studies above, the literature also describes several studies that show either different or contradictory results regarding uptake of exogenous rnas from breast milk. auerbach et al. re-analysed a study in which mir- b- p and mir- c- p were found in plasma after bovine milk ingestion by healthy humans (baier et al., ) and found no significant altered mirna levels after milk ingestion (auerbach et al., ) . these results were confirmed by qpcr and rna-sequencing. several technical issues including low mir- b expression, use of control mirnas (normalization), and variation level may have contributed to these discrepancies (auerbach et al., ) . piglets fed cow milk for weeks showed very low levels of cow-specific mirnas in the bloodstream, which were compared to the levels measured from animals fed maize, which also showed similar counts of cow-specific sequences , suggesting a lack of transfer of exogenous small rnas. using a transgenic mouse model that overexpresses mir- b precursor in the mammary epithelial cells, and thus increases levels of mir- b in milk (≈ -fold), no differences were found in blood, liver, small intestine, kidney or lung tissues of pups from these dams when compared to pups from wild type dams (laubier et al., ) . interestingly, the level of mir- b was ≈ -fold higher in the stomach of mice consuming the transgenic milk. oral ingestion of . µg and . µg of total rna from porcine milk exosomes administered daily during three weeks to mice, significalty increased villus height and crypt depth of the duodenum and jejunum relative to the control group, suggesting an effect improving the development of the gi tract in mice . using genetic knock-out (ko) mouse models for mirnas mir- and mir- c/ , title et al., evaluated the uptake of maternal-milk derived mirnas using the foster mother offspring exchange model to prevent the confounding effects of mirnas derived from tissues of suckling offspring . wild type (wt) offspring consuming mir- ko milk at day exhibited basal levels of mir- in milk from the stomach, which likely comes from stomach epithelial cells. at day of suckling, it was confirmed that most mir- /mir- c came from the milk itself rather than the offspring www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. genotype, because there was no significant difference between wt pups and ko pups receiving wt milk. evaluating different parts of the gi tract (jejunum, ileum and colon), no evidence of uptake was observed because there was no measurable increase in mir- levels in enterocytes of ko pups receiving wt milk compared to ko milk. moreover, no changes in plasma, liver or spleen levels of mir- were observed in ko pups receiving wt or ko milk . similar effects were observed at day of treatment and upon evaluating mir- c on day . when the fate of milkderived mirnas downstream of the stomach was analysed, the levels of mir- in the intestinal content of ko pups receiving wt milk was seen to dramatically decrease compared to that of the stomach contents. these data suggest that milk mirnas are being degraded by the digestive system (since no evidence of uptake was observed). indeed, when the spike in cell-mir- was tested, it was degraded more rapidly than milk mir- , suggesting that milk mirnas exhibited a certain degree of resistance (perhaps because of their exosome content). but less than % of mir- copies remained after h incubation of intestinal content, suggesting a possible digestive enzymatic degradation of the milk-derived (exosomes) mirnas . observational studies also suggest that human breast milk mirnas are not related to preventing atopic dermatitis in infancy months postpartum . in general, rna contamination has been proposed as the main source of controversy in mirnas studies reported in the field of breast milk (bagci and allmer, ) . the literature contains very few studies on the biological effects of dietary exogenous ncrnas in the gi tract and its annex glands. indeed, these few studies only report a biological effect in the liver. the available literature suggests that dietary exogenous plant small ncrnas seem to resist the harsh conditions of the gi tract. however, the stability of plant mirnas under gi conditions in vitro, ex vivo or in vivo is low. moreover, these studies suggest that the percentage of surviving mirnas in the gi tract in the best-case scenario is around ≈ %, although this depends on the specific small ncrnas evaluated. several studies report the presence of dietary exogenous mirnas in breast milk of different mammals, including humans. some protected mirnas (i.e. transported in extracelluar vesicles) have been found to be stable under in vitro degradative conditions. while some evidence suggests a possible absortion through oral feeding, other studies indicates a very limited biovailability or lack of accumulation within the gi tract or its annex glands. recent evidence supports the significant contribution of srnas to communication between hosts and some eukaryotic pathogens, pests, parasites, or symbiotic microorganisms. this silencing transfer phenomenon is very relevant to food and feed risk assessment of ncrna gm plants. although this section (efsa task ) will focus on studies related to the possible trafficking of ncrnas between plants and humans and animals, studies supporting the movement of rna-silencing signals between plants and pathogens are also reviewed. virus-induced gene silencing represents the model of gene silencing in the host by exogenous sirnas. in this case, the sirna specificity determinant is derived from viral rnas. typically, with a discrete length of nt they form perfect duplexes which are produced in plants by dcl and dcl . virusinduced gene silencing is a very effective defence system, and, consistently with the normal dynamics of host-pathogen interactions, all viruses encode silencing suppressors as a counter defence (baulcombe, ) . www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. cross-kingdom rnai implies that a translocation of gene silencing signals occurs between hosts and these organisms. this implies a two-way traffic of sirnas between pathogens and their plant hosts. several studies report that rnas produced in a host plant can be transferred to a fungus or oomycete, symbiont or pathogen, to induce rna silencing in the interacting microorganism (ghag et al., ; koch et al., ; vega-arreguín et al., ; helber et al., ) . transgenic plants carrying a rnai construct, usually with a sense-intron-antisense palindromic structure that produces dsrnas and sirnas, can induce silencing of the targeted transcripts in the interacting organism. furthermore, treatment of fungal conidia with dsrnas of essential genes led to fungal growth inhibition, demonstrating rna interference from environmental silencing signals (koch et al., ) . conversely, the rna produced in a fungus can affect a host plant's defence system (weiberg et al., ) . remarkably, scientists have developed an effective disease control strategy, called host-induced gene silencing (higs), by generating transgenic plants that express exogenous rnai triggers to successfully silence essential genes in pathogens and pests (weiberg et al., ) . in this context, transgenic plants expressing dsrnas or hairpin rnas targeting vital fungal genes of fusarium sp. developed resistance to these important phytopathogens (ghag et al., ; koch et al., ) . small rnas or dsrnas can also be transferred from plant to pests, such as insects eating leaves or nematodes infecting roots. indeed, transgenic plants that express dsrna homologous to essential genes of insect pests or nematodes became resistant to these specific parasites through the silencing activity produced within the target organism when srnas expressed from the plant transgenes is consumed (baum et al., ; fairbairn et al., ; mao et al., ) . many aspects of these cross-kingdom rna interference phenomena are still poorly understood. one of them is how these rna molecules 'travel,' sometimes over long distances through diverse cellular boundaries between plants and interacting organisms. these silencing signals may utilize conserved cell-to-cell as well as systemic rnai pathways present in plants and animals, and may also use organismspecific pathways. rna-protective factors such as agos, other rna-binding proteins, or encapsulation into extracellular vesicles likely play important roles in protecting mobile rnas against degradation during transport (weiberg et al., ; lefebvre and lecuyer, ) . another important question is how these srnas use the target cell rna interference machinery to convey the silencing effect. based on current knowledge, rna-mediated gene silencing seems to be an ubiquitous phenomenon that exists in almost all eukaryotes, and which always follows the principle of complementary nucleotide base-pairing between regulatory srna and mrna sequences (weiberg et al., ) . despite the tremendous differences present in the structural features of regulatory rnas, and the completely unrelated or highly divergent rna gene-silencing mechanisms and pathways that have evolved in diverse organisms, complementary sequence matches seem to be sufficient enough to trigger cross-kingdom gene silencing, as exemplified by plants-parasites, bacteria-to-worms and other lower organism interactions (weiberg et al., ) . following a literature search as described in section . . . and based on the methodology described in the section . . . , a total of documents were selected for review of the topic molecular mechanisms of exogenous ncrna uptake and function. the uptake of exogenous ncrnas is described from the molecular mechanisms point of view (i.e. the presence of a specific transporter, if any). efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. although plant-derived exogenous ncrnas are the main topic of this subsection, some other examples of general molecular mechanisms of exogenous ncrnas uptake, intracellular trafficking and function are included as relevant to understanding the possible fate of plant-derived exogenous ncrnas. other general aspects of rnas uptake are reviewed in chapter . . , and the uptake of exogenous rnas from the pharmaceutical/medicinal area is covered in section . . . as previously mentioned in section . . , cellular uptake of ncrnas presents great challenges due to the physicochemical properties of these molecules. their size and negative charges prevent their easy entry into mammalian cells. cell membranes pose a major barrier to ncrnas entrance since entry into cells is tightly controlled and regulated (mcerlean et al., ) . the anionic lipophilic bilayer prevents entry of macromolecular anionic nucleic acids in their naked form, both restricting their binding to and passive diffusion across these lipophilic cell membranes . furthermore, even though their internalization may depend on the endocytic pathway, endosomal entrapment and lysosomal degradation can be major issues because of the reduced accessibility of ncrnas to their sites of action (nucleus, cytoplasm or mitochondria) (won et al., ; . many different carrier molecules have been developed to achieve the entrance of ncrnas (mostly mirnas and dsrnas) into target cells (bolhassani, ; lindgren and langel, ; mao et al., ; ragelle et al., ; rudzinski and aminabhavi, ; shum and rossi, ) . exogenous ncrnas must be carried by polymers, synthetic cationic lipids or cell-penetrating peptides neutralizing the negative charges of the nucleic acids. most of these cationic lipids tend to form liposomes when dispersed in an aqueous phase, such as blood. endocytosis has been suggested as the main pathway for this nucleic acids-cationic lipid complex internalization by the cell (el ouahabi et al., ) . most reports suggest that so-called cell-penetrating peptides (cpps) bind initially to negatively-charged proteoglycans at the cell surface and are internalized into endosomes (juliano et al., ) . there are multiple pathways of endocytosis (see also section . . ). i. the clathrin-coated pit pathway is the archetype of endocytosis pathways. cell surface receptors and their associated ligands interact with adapter proteins and accessory factors, clustering the receptors into specialized membrane areas subtended by a network of clathrin triskelions. the clathrin network is invaginated by means of membrane curvature promoting specialized proteins, giving rise to a clathrin-coated endosome. this endosome quickly uncoats, generating an uncoated vesicle that will begin its intracellular journey (juliano et al., ) . ii. the caveolar pathway implies the presence of small cell membrane invaginations rich in cholesterol and sphingolipids containing caveolin . cavins, which coat proteins helping to stabilize caveolar structures, are present in these invaginations. there is controversy as to whether caveolae generate independent intracellular vesicles or whether they remain as tubular structures linked to the plasma membrane; however, some data suggest that caveolae generate vesicles able to participate in intracellular traffic, generally presenting a smaller size than other forms of endocytotic vesicles (juliano et al., ) . iii. a number of clathrin-and caveolin-independent pathways have been described. these pathways are often defined in terms of the morphologies of the vesicles they generate or in terms of the cargo that is preferentially internalized. for instance, the flotillin pathway involves the presence of flotillin-rich membrane microdomains, where flotillins are membrane-inserted proteins that may be involved in ordering lipid domains and subsequent endocytosis, similar efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. to caveolin (juliano et al., ) . another such clathrin-and caveolin-independent pathway is the clic/geec pathway, which seems to be particularly important for fluid phase endocytosis. clic/geec stands for clathrin and dynamin independent carriers/gpi-ap enriched early endosomal compartments. this pathway gives rise to high-volume tubular endosomes rich in gpi-proteins and that typically contain fluid phase markers such as dextrans (juliano et al., ) . additional clathrin-and caveolin-independent pathways exist, some involving dynaminmediated disjunction of vesicles from the plasma membrane (juliano et al., ) . iv. macropinocytosis is a process by which cell protrusions pinch off large volumes of extracellular fluid and is therefore an important pathway in fluid phase endocytosis. it is also involved in internalization of clustered, activated receptor tyrosine kinases. v. phagocytosis and entosis are large-volume internalization mechanisms as well. they come into play in specialized cells or unusual circumstances but do not play much of a role in oligonucleotides processing in most cell types (juliano et al., ) . vi. the actin cytoskeleton plays an important role in most of the endocytotic processes described above, although certain arenaviruses enter cells by a pathway independent of clathrin, caveolin, dynamin and actin. it has been reported that phosphorothioate antisense oligonucleotides seem to enter the cells by this pathway as well (juliano et al., ) . there have been many attempts to identify endogenous receptors for antisense or sirna molecules. however, no direct evidence for their involvement in oligonucleotide trafficking has been provided (juliano et al., ) . integrins of the beta- subclass as well as scavenger receptors have been suggested as candidates, but this is controversial. toll-like receptor (tlr) family members seem to be the most convincing examples of cellular receptors for oligonucleotides; tlr binds dna having cpg motifs, tlrs / binds single-stranded rna, while tlr binds double-stranded rna. although these tlrs are usually found within endosomes rather than at the cell surface, in some cases they seem to be able to assist in accumulation of oligonucleotides by cells (juliano et al., ). one interesting candidate as a receptor for oligonucleotides is the mammalian homolog of the doublestranded rna (dsrna) transport protein sid- found in caenorhabditis elegans (feinberg and hunter, ) . the human homolog of this protein, sidt , has been described as facilitating rapid contactdependent intercellular small rna transfer (elhassan et al., ) and as selectively binding long doublestranded rna (li, w et al., ) . another member of the sid transmembrane family, sidt , has been shown to take up extracellular double-stranded rna in drosophila s cells (mcewan et al., ) via endocytosis, although in mammalian cells this protein has been located in lysosomal membranes (jialin et al., ) . in fact, some authors have proposed that sidt could mediate cellular rna degradation inside lysosomes through a novel type of autophagy called rnautophagy (aizawa et al., ) . another research group recently reported that sidt is required to transport internalized dsrna from endocytic compartments into the cytoplasm for immune activation (nguyen et al., ), while others have described that this protein mediates "gymnosis", facilitating uptake of naked single-stranded oligonucleotides into living cells (takahashi et al., ) . a more recent report indicates that both sidt and sidt not only do not transport rna, but are involved in cholesterol transport (mendez-acevedo et al., ) . once an oligonucleotide has entered a cell in an endosome, it encounters a complex maze of intracellular pathways leading to multiple destinations and regulated by an intricate protein machinery. key subcellular membrane bound compartments include early and recycling endosomes, late www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. endosomes/multi-vesicular bodies, lysosomes, the golgi apparatus and the endoplasmic reticulum. intracellular trafficking is not a random process, but rather a carefully orchestrated choreography that allows the cells to transport endogenous and exogenous materials to the most appropriate places. for nucleotides to exert their function, they need to leave the membrane bound compartments and access the cytosol and/or nucleus (juliano et al., ) . knowledge as to how endocytotic cargos are delivered to subcellular compartments is still partial. many of the internalization pathways previously described converge at the stage of early endosomes, raising the question of how the differentially internalized components traffic to different destinations. certain evidences suggest that membrane domains originating from different internalization pathways maintain their identity within early endosomes, thus providing the means for specific sorting and trafficking to distinct downstream destinations (juliano et al., ) . all membrane traffic proceeds through the same basic steps: i) a coated vesicle is pinched off from a larger donor membrane compartment; ii) the vesicle uncoats, allowing display of the tethering and fusion proteins; iii) the vesicle is carried to its destination along "tracks" provided by actin-or tubulin-based cytoskeletal structures; iv) the vesicle recognizes its target membrane compartment using tethering proteins and then utilizes snare proteins to complete the fusion process and deliver membrane and contents to the target compartment (juliano et al., ) (figure ). ncrnas must escape from the endomembrane compartments and reach the cytosol to exert their function. as mentioned above, intracellular trafficking involves a highly dynamic flux of membrane vesicles engaged in a multitude of fusion and disjunction events. there are a few key points in these processes to be considered when designing non-viral oligonucleotide delivery strategies: ) fusion involves localized stress on the fusion partners, including formation of non-bilayer lipid domains; ) non-bilayer regions of membranes can be much leakier than bilayer regions; ) many enveloped viruses fuse with cells via specialized membrane interacting proteins that, while differing in sequence, act in a manner similar to cellular snare proteins; in many cases these proteins can also induce increments in membrane permeability. therefore, there is an intrinsic relationship between the fusion events inherent to intracellular trafficking and transient leakage of vesicular contents. thus, the innate activity of oligonucleotides taken up by cells is likely due to a modest amount of continuous leakage from endomembrane compartments spontaneously occurring during intracellular trafficking (juliano et al., ) . some ncrnas function is exerted in the nucleus, although nuclear entry may not be the rate-limiting step for oligonucleotide action. studies have shown that oligonucleotides, particularly those with phosphorothioate backbones, are able to continuously shuttle between the nucleus and cytoplasm. this is an active process mediated by nuclear pore structures but does not require classic nuclear localization signals. for phosphodiester oligonucleotides, both passive diffusion and active transport have been described as nuclear entry mechanisms (juliano et al., ) . in terms of the uptake and trafficking of "free" or "naked" oligonucleotides, the co-existence of both productive and non-productive uptake routes has been suggested. the non-productive pathway seems to involve trafficking to lysosomes, while the pathway that results in rnase h-dependent antisense effects eventually leads to interaction with cellular pre-mrna (koller et al., ) . other studies have involved so-called "gymnotic" uptake of antisense oligonucleotides modified with lna (locked nucleic acid) moieties (stein et al., ; zhang et al., ) . subcellular distribution studies surprisingly suggested that the deoxy lna compounds became associated with p-bodies that are usually thought to be sirna action sites (stein et al., ) . unlike the study performed with phosphorothioate www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. oligonucleotides in which the concentrations used were in the nanomolar range, the antisense effects of "naked" lna required micromolar concentrations (juliano et al., ). as described in section . . , exogenous ncrnas must overcome a series of barriers to be functional at systemic level. in addition to the extracellular barriers specifically related to oral absorption, defensive humoral and cellular barriers efficiently prevent the intrusion of exogenous entities into the organism (jeong et al., ) . systemically-administered nucleic acids are rapidly degraded by nucleases in a few minutes and, even in nucleic acid drug therapy using positively-charged polyplexes, they readily interact with serum components to form larger aggregates, resulting in rapid clearance by res or phagocytes (jeong et al., ) . if the nucleic acids survive in the blood stream, they must still reach the appropriate tissues and enter the target cells. in systemic nucleic acid therapy, continuous endothelial walls in the microvasculatures are one of the main barriers limiting the access of oligonucleotides to target cells. in certain pathological cases, such as cancer, the presence of leaky vasculatures in the vicinity of highly penetrating solid tumours allows nanoparticulates to penetrate and accumulate in tumours due to the enhanced permeation and retention effect (jeong et al., ) . caveolae-mediated transcytosis has been considered one of the important mechanisms of macromolecules transport across the endothelium (schnitzer, ) . another possible limiting barrier is the extracellular matrix consisting of various proteoglycans, which are proteins covalently cross-linked with carboxylic or sulphated glycosaminoglycans (gags) (ruponen et al., ) . since gags, such as heparin sulphate, chondroitin sulphate and hyaluronic acid, are polyanions, they may repel the negatively-charged oligonucleotides, affecting mobility of the nucleic acids in the tissue extracellular matrix and therefore limiting their access to target cells. in the case that oligonucleotides reach the target cell membrane, they must enter the cell. the first barrier is the anionic plasma membrane itself, and the second is cellular uptake via endocytosis (see section . . ). without a specific ligand-receptor interaction mechanism, the entrance of ncrnas results in a lack of cell specificity (jeong et al., ) . once taken up by cells, the nucleic acids are localized within the endosomal compartments, where the ph rapidly drops to about by the action of membrane-bound atp-driven proton pumps. the endosomes mature to lysosomes where the oligonucleotides can be degraded by various enzymes (jeong et al., ) . as previously indicated, any surviving nucleic acids must then escape from the endosome to exert their functional effects. in nucleic acid drug therapy, certain endosomal disruptive agents, such as lysomotropic chloroquine, fusogenic peptides and ph-sensitive neutral lipid, are used to facilitate or promote endosomal escape through membrane disruption (jeong et al., ) . after endosomal escape, ncrnas should move through the cytoplasm to encounter their molecular targets, or to the peri-nuclear space where nuclear translocation takes place if the nucleus is the target compartment. passive diffusion of high-molecular weight macromolecules is limited in the cytoplasm. a complex network of microfilaments and microtubules, highly concentrated proteins and various subcellular organelles provide the cytoplasm with a high fluid phase viscosity and mesh-like structure with to Å pores from, making the diffusion process size-dependent (jeong et al., ) . in fact, microinjection of plasmid dna into the cytoplasm showed that normal dna was practically immobile in the cytoplasmic space (dowty et al., ) . however, dna molecules with less than base pairs seem to undergo free diffusion in the cytoplasm (lukacs et al., ) , suggesting that small oligonucleotides (i.e. mirnas) do not face limitations regarding their intracellular trafficking, contrary to large ncrnas (i.e. lncrnas) which might encounter more restrictions reaching the peri-nuclear space. finally, some ncrnas need to enter the nucleus to be functional. the nuclear envelope consists of a double-layer membrane with nuclear pores. the nuclear pore complex allows free diffusion of ions and small molecules, but restricts passage of macromolecules with molecular efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. weights greater than kda, unless accompanied by a nuclear localization signal peptide (nls) (jeong et al., ) , which is not the case with lncrnas oligonucleotides are initially accumulated in an endomembrane compartment (the donor compartment, e.g. early endosomes) and are then trafficked by shuttle vesicles to various other endomembrane compartments (the recipient compartment, e.g. the trans-golgi). the first step ( ) involves disjunction ('pinching off') of a shuttle vesicle under the influence of a coat protein as well as other accessory proteins. at this stage there are non-bilayer regions at the junction between the membranes of the donor compartment and the shuttle vesicle. this provides an opportunity for some oligonucleotides to escape into the cytosol. step involves uncoating of the vesicle; and rab proteins can contribute to this step. step comprises movement of the shuttle vesicle toward its destination along cytoskeletal tracks. motor proteins such as various myosins (for the actin system) or dyneins or kinesins (for the microtubular system) propel the vesicle. rab proteins are involved in forming the appropriate linkages to the cytoskeleton. step entails recognition of the recipient ('target') compartment by the shuttle vesicle. tether proteins work with rab proteins to provide interaction specificity while v-snare proteins in the vesicle membrane interact with t-snare proteins in the recipient compartment membrane to provide firm bridging, as well as contributing to specificity. in step the snare proteins undergo major conformational changes, and, with the assistance of accessory proteins, trigger fusion of the shuttle vesicle membrane with the membrane of the recipient compartment. at this stage non-bilayer regions exist at the junction between shuttle and recipient membranes potentially allowing oligonucleotide escape. reprint with permission from (r l juliano, x ming, o nakagawa. cellular uptake and intracellular trafficking of antisense and sirna oligonucleotides. bioconjugate chemistry : - ). copyrigth ( ) american chemical society. figure : proposed mechanism of vesicular trafficking of oligonucleotides some research has been done on cellular uptake, trafficking and tissue distribution of oligonucleotides without specific targeting or carrier mechanisms. in terms of tissue distribution, certain cell types exhibit a preferential in vivo uptake, particularly kidney proximal tubule cells and liver kupffer cells for phosphorothioate (ps) antisense compounds and sirna (juliano et al., ) . however, only one report has studied systemic level uptake and function of orally administered mirnas . these authors studied intestinal uptake of maternal milk-derived mirnas by new-born mice employing genetically-modified models to distinguish endogenous mirnas from milk-derived exogenous mirnas. their analysis of the intestinal epithelium, blood, liver and spleen revealed no evidence for mirna www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. uptake, even though milk in lactating mothers has been shown to be a particularly rich source of secreted mirnas. sequencing and microarray analysis of mirnas in the milk of various mammalian species has led to the discovery of hundreds of mirnas in cow, pig, rat and human milk, which are derived from exosomes and cellular components. furthermore, their study revealed rapid degradation of milk mirna in intestinal fluid, indicating that mirnas in the milk play a nutritional rather than a generegulatory role in new-born mice . there are certain tissues containing special physical structures that can function as additional barriers to ncrnas entry. such is the case of the central nervous system (cns), where delivery of nucleic acids is particularly challenging because of its anatomical and physiological complexities. the cns is protected by the blood-brain barrier (bbb), which consists of tightly joined capillary endothelial cells, restricting access of large molecules into the brain. the cns extends to include the spinal cord, which is protected by the blood-cerebrospinal fluid barrier (bcsfb), made up of choroid plexus epithelial cells limiting the free diffusion of molecules into the cerebrospinal fluid (csf). the bbb and the bcsfb express numerous transporters and receptors which contribute to the transfer of essential nutrients such as glucose and amino acids into the cns. within the cns, different cell types exist including neurons, astrocytes and other glial cells. entry of nucleic acids into neurons is notoriously difficult for unclear reasons, although it is likely related to their post-mitotic nature, as well as the complex structures and intricacies of neuronal networking (o'mahony et al., ) . for instance, variances in the uptake of sirna lipoplexes (liposome and nucleic acid complexes) were reported at different parts of the neuron structure, with greater uptake efficiency at the cell soma compared to the neuritis, which may occur because of different membrane compositions in these domains (o'mahony et al., ) . circumventing the bbb is only possible by direct administration of ncrnas to a target region of the brain or by administration to the spinal cord where trans-synaptic retrograde transport to the brain is possible. some delivery systems exploit the receptor-mediated uptake of molecules such as transferrin, lactoferrin and insulin receptors by attaching a ligand for the receptor to the non-viral delivery system, or promoting a transient mechanical disruption of the bbb (o' mahony et al., ) . in certain neurological diseases, and in particular in brain cancers, anatomical and physiological changes occur that can impact bbb integrity and the cns accessibility. delivery to the csf to bypass the bbb presents its own obstacles, including rapid clearance from the csf, the bcsfb and limited diffusion from the csf into the brain parenchyma (o'mahony et al., ) (figure ) . another specialized barrier is the placenta. the placenta serves as the interface between the maternal and foetal circulatory systems, and regulates the transfer of oxygen, nutrients and waste products. when exogenous substances are present in the maternal bloodstream, the extent to which these affect the foetus is determined by transport and biotransformation processes in the placental barrier. this barrier is formed by fusion of the outer blastocyst trophoblast cells facing the uterine epithelium into multinucleated syncytiotrophoblast. proliferation of syncytiotrophoblast is mediated by the fusion of precursor cytotrophoblast cells. maternal blood in the intervillous space and foetal blood in the villous capillaries are separated by a continuous layer of syncytiotrophoblast, a discontinuous layer of cytotrophoblast cells, basal lamina, connective tissue, and foetal endothelial cells (al-enazy et al., ) . the placenta undergoes several changes as pregnancy progresses. overall, the placental barrier becomes thinner over time, the distance separating the maternal circulation from the foetal circulation decreasing from - µm in the second month to only - µm at term. passive diffusion across the placenta is favoured for lipophilic substances, allowing them to cross the phospholipid bilayer. smaller compounds tend to cross the placenta more readily, with compounds having a molecular weight less than da crossing it most easily (al-enazy et al., ) . since nucleic acids are polarized, negatively charged molecules, it is unlikely they would be able to cross the placenta by passive diffusion. nevertheless, the placental syncytiotrophoblast is capable of efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. endocytosis (al-enazy et al., ) . no reports refer to exogenous ncrnas entering the placental barrier. however, the presence of placental mirnas has been described in the blood circulation of pregnant women. these mirnas have been reported to be actively secreted into microvesicles and exosomes. these specific exosomal mirnas may be important for embryo implantation, playing a significant role in the intercellular communication pathways that potentially contribute to placentation and development of maternal-foetal vascular exchange (mitchell et al., ) . since exosomes can cross the blood brain barrier, meaning they can cross several layers of cells, it has been speculated that exosomes could directly move from maternal to foetal tissues, and vice-versa, during pregnancy (record, ). the the molecular mechanisms of exogenous ncrna cellular uptake have been inferred from studies performed when developing strategies for nucleic acid delivery in therapeutics. few studies have been done with "naked" oligonucleotides, and even in these cases, the oligonucleotides were chemically modified. these molecular mechanisms of cellular uptake include the different types of endocytosis mechanisms known to date. the existence of receptor-mediated uptake of oligonucleotides through the sidt and sidt proteins has also been described, although their function has been contradicted since they have been described as cholesterol transporters. among the numerous challenges ncrnas must overcome once taken-up by the cell, escaping the endosomal compartments is the most relevant and significant, although reaching their site of action is also crucial to exerting their function. specialized barriers such as the blood-brain barrier or the placental barrier present further obstacles to overcome. www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. zhang y, qu z, kim s, shi v, liao b, kraft p, et al. . down-modulation of cancer targets using locked nucleic acid (lna)-based antisense oligonucleotides without transfection. gene ther , - . zhou g, zhou y, chen x. following a literature search as described in section . . . . and based on the methodology in section . . . ., a total documents were selected for reviewing the landscape of exogenous rnas in biological fluids of human and animals. using public databases of rna sequencing datasets, several documents report the application of in silico bioinformatics analysis (table ) clearly describing the widespread presence of exogenous ncrnas in biological fluids(from multiple sources, including diet) wang et al., ; beatty et al., ; yeri et al., ; . however, four documents suggest that exogenous ncrnas present in the public datasets may represent contamination from the laboratory environment since their abundance is extremely low, or they are of non-dietary origin, or could originate from technical artefacts or contamination bagci and allmer, ) . five documents report the development of bioinformatics resources to either predict transportable mirnas, predict functional analysis, or list and compare the exogenous mirnas found in samples chiang et al., ; zhang et al., ; zheng et al., ) . the generalized use of highly parallelized next generation (nexgen) sequencing technologies has promoted the use of sequencing to study complex biological systems, including human and animal biological fluids and tissues. initial studies evaluating the possible presence of exogenous ncrnas in biological fluids were done in silico using public databases of rna-seq results. several studies report the presence of exogenous rnas (i.e. dietary plant ncrnas) in the biological fluids of humans and animals. initial studies of the srnas spectra in human plasma showed that a small fraction of sequence reads from plasma mapped to human mirnas (≈ . %) or human transcripts and human genome sequences (≈ %) . this fraction increased by up to ≈ % when a higher sequence mismatch tolerance was allowed (under two mismatch allowance). surprisingly, a significant number of the unmapped reads aligned with various bacterial and fungal sequences (i.e. ribosomal rnas and trnas). also, many processed reads mapped to common food items, the most abundant being rna sequences from corn (zea mays) and rice (oryza sativa). compared to data from a serum sample from a chinese individual, the sequence abundance between corn and rice was reversed , suggesting the influence of dietary habits. other sequences from other foods in human plasma samples included soybean (glycine max), tomato (solanum lycopersicum), grape (vitis vinifera) and others. including exogenous mirnas, various common household insects were identified . treating plasma samples with dnase, protease, triton x- , and additional rnase reduced the total number of reads compared to the addition of rnase alone, suggesting that some of the exogenous rna molecules are probably associated to circulating protein and/or lipid complexes . in the same study, a lower percentage of exogenous sequences was observed in mouse plasma samples compared to human samples . another study evaluating a larger number of human plasma samples (n= young male athletes) reported exogenous srnas from different bacteria, but very few srnas were consistently detected in all samples (yeri et al., ) . in a study on public srna datasets from various tissues from mammals, chicken and insects, plant mirnas were found in out of datasets analysed, with mir- being extremely over-represented efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. . in datasets ( humans, mice, pig and others) the plant mirnas reads ranged from ≈ . - . % of the total animal mirna reads. insects fed with plant foods containing mir- , did not show accumulation of mir- when evaluated by northern-blot. however, in a very few samples sequencing data detected plant mirnas not present in the food source, including mir- , in addition to mir- at a moderate read, suggesting that plant mirnas observed in some public srna databases may be artefactual and due to sequencing methodology . plant mir- a from monocots was also found to be the most abundant exogenous plant mirna, in most cases, in other srna sequencing datasets studies with levels typically < % of human mirnas . but when analysis was performed in the absence of any known sources of plant contamination, plant mirnas were not detected. this suggests that precaution should be taken to prevent cross-contamination of the samples due to the high sensitivity of next-generation sequencing methods . other human public srna sequencing datasets have also been questioned for the presence of exogenous plant mirnas . of analysed human plasma samples, plant mirnas were found when compared to the genome of different plant model organisms (arabidopsis thaliana, triticum aestivum, oryza sativa, zea mays, and brachypodium distachyon). at least one read was present in selected samples. peu-mir- , found in all samples, is a singular mirna found in selected samples with more than counts. mir- is found in zea mays and conserved in fruits and vegetables including melon, sorghum, tomato, tea and oil palm. other highly-expressed plant mirnas found in up to hundreds of copies in selected samples include peu-mir- (found in samples), peu-mir- (found in samples), and tae-mir- (found in samples) . plant mir- (found in samples) and mir- a (found in samples) were detected in relatively small amounts (less than copies). using bioinformatics tools, the same study showed that seed sequences of mir- and mir- are similar to hsa-mir- and mir- - p for the former and has-mir- - p for the latter, and thus potentially target several gene targets of their human mirna counterparts . other studies have also reported in mouse plasma samples the presence of exogenous rnas matching exogenous species including bacteria, fungi, viridiplantae and food items . these included mir- d and mir- a (corn or rice as the most likely source), and mirnas from worms and insects . abundant non-human rnas were found in other healthy individuals human plasma samples (n= ) assigned to metazoan, bacteria or fungi (beatty et al., ) . several exogenous srnas were found that could potentially derive from food items including fragaria vesca, medicago truncatula, lotus japonicus, glycine max, arabidopsis thaliana, and solanum lycopersicum (beatty et al., ) . twelve public srna sequencing databases were analysed for the presence of plant exogenous mirnas. breast milk exosomes from humans ( samples, . million reads) and pigs ( samples, . million reads) were analysed. although plant mirna species belonging to mirna families ( samples) were found, they showed low abundance (< read counts for the highest expressed mirna). zma-mir- a, zma-mir- a, ath-mir- a, ath-mir- b and ptc-mir- d showed the highest abundance levels, while in humans only samples contained plant mirnas from mirna families (< read counts, for the highest expressed mirna, average of samples). ath-mir- a, pab-mir- , pc-mir- a, bdi-mir- , aly-mir- d, osa-mir- b. and zma-mir- a showed the highest abundance level in human samples . however, bagci and allmer reanalysed the data from lukasik and zielenkiewicz study and found that exogenous plant-derived mirnas in milk are likely to be contamination (bagci and allmer, ) . in a later observational study, lukasik et al. evaluated plant mirnas mir- a, mir- a, mir- a, mir- a and mir- a and reported the presence of plant mirnas in human (n= ) breast milk, both in whole milk and exosomes . out of mirnas, only were found in exosomes (mir- a and mir- a). while the human has-mir- a was found in all samples in a concentration range of . - pm for whole milk efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. and . - . pm in exosomes fractions, plant-derived mirna mir a was found in all samples at a concentration of - fm (≈ -fold higher than other plant mirnas) . compared to endogenous mirnas, the levels of exogenous plant mirnas were rather low and varied significantly between the samples . kang et al. analysed public sequencing srnas datasets from various human tissues and body fluids (n= ), including from serum and plasma samples, from exosomes, from cerebrospinal fluids, from liver, from blood cells and from brain . of note is that exogenous mirnas (xenomirs) were only found in % of the tissue samples (from total samples), with several studies being completely void of any xenomirs. xenomirs were absent from most human tissues samples, or present at very low abundances (with a median of . read counts). no enrichment of xenomirs was found in tissues relevant to dietary intake (i.e. hepatocytes and blood cells). by contrast, out of human body fluids datasets, xenomirs were found in % of samples, although at very low levels (median of read counts). even though the blood brain barrier separates the cerebrospinal fluid from the bloodstream, xenomirs were found in comparable quantities in both , suggesting no depletion (as expected by the presence of the barrier) of xenomirs in body fluids separated from the main bloodstream. moreover, the lack of co-occurrence of xenomirs in cerebrospinal fluid and serum of the same individuals, do not support that xenomirs detected in cerebrospinal fluid samples have entered through the bloodstream, and thus do not support a dietary origin of xenomirs. the most common xenomirs in body fluid samples belonged to the clades for rodents ( %), dicots ( %), insects ( %) and euphyllophytes ( %), suggesting that xenomirs composition does not reflect human food sources. from billion sequence reads (all samples), xenomirs were in low abundance, comprising only . % of the total reads ( , ). the same study reported a controlled feeding trial in rats and piglets (see section . . below for details). shu et al. ( ) used bioinformatics tools to characterize the structural characteristics of exogenous mirnas that can contribute to cross-species transportation and thus be transferred into human circulation . thirty-four thousand ( . ) mirnas sequences were compiled from species (from five kingdoms including animal, plantae, fungi, protista and viruses), including dietary mirnas ( mirnas) from types of common food species such as cow milk, breast milk, tomato, grape, and apple. using a support vector machine (smv)-based feature elimination strategy, features based on sequence, structure, and physicochemical properties were analysed to distinguish human circulating mirnas from the remaining sequences. predictions were made for features (categorized into groups) to better predict transportable mirnas in human circulation. known human plasma mirnas were ranked among the top of the list (dominated by animalia origin). only dietary mirnas were ranked among the top mirnas, five of which have a sequence identical to that in humans (bta-mir- b, bta-mir- , bta-mir- , gga-mir- a- p, gga-mir- b- p) . while only one mirna from plantae ranked among the top mirnas, plantae mirnas ranked in the top as possibly transportable , suggesting that animal-borne mirnas may be subject to more significant absorption in humans than in plant mirnas . it is important to note that this study of evaluated , animalia mirnas and plantae mirnas, whether this discrepancy in the original number of evaluated mirnas may have biased the smv-based classifiers to mammalian transportable mirnas was not addressed. in the same context, a database called "dietary mirna database" that describes different dietary mirna parameters and functional analysis has been described and is freely available. additional databases for exogenous mirna discovery using rna-seq data are also available in the scientific community . using bioinformatics tools (i.e. rnahybrid database), other studies have also predicted the potential function of dietary mirnas in the human body . in a bioinformatics study of plant mirnas, some similar functions between human and plant target genes were identified, such as ion transport and stress response . efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. analysing public srna sequencing datasets from humans ( ), mice ( ), pig ( ), chicken ( ), fly ( ), c. elegans ( ) and many other nematodes, protozoa or prokaryota, zheng et al. developed a database (exo-mirexplorer) for exploring and comparatively analysing exogenous mirnas (zheng et al., ) . two hundred and thirty-seven ( ) plant-derived mirnas were detected in sequencing samples. common mirna families included mir- , mir- , mir- , mir- and mir- . mir- a was the most frequently found mirna, and was detected in human samples from different studies (zheng et al., ) . the average abundance of mir- a was , . reads per million. in total, mir- a was found in samples from multiple species. mir- a is another frequently observed exogenous mirna from plants, and was detected in samples with an average abundance of . read per million (zheng et al., ) . regarding other biological fluids, exogenous rnas of bacterial origin were found in (urine) and (saliva) samples from young male athletes analysed for srna-seq (yeri et al., ) . plant small rna mir- was detected in urine of mice fed honeysuckle decoction (yang et al., b) . mir- a has been also detected in serum when honeysuckle was supplemented with pmol synthetic mir- a. mir- and mir- a were detected in the urine of mice that had received cisplatin treatment (cisplatin administration produces acute renal failure) and consumed a honeysuckle decoction alone or supplemented with synthetic mir- a. the increased detection of plant small rnas was attributed to disruption of the organization of small intestine epithelial cells produced by cisplatin treatment or longterm consumption (pre-fed) of honeysuckle (yang et al., b) , by mechanisms as yet unknown. mir- levels in urine reached ≈ fm. in tissues, the overall percentage of exogenous sequences in human lung tissue (normal lung rna samples), was found to be less than % . in spermatozoa samples, using public srna sequences datasets, tosar et al. found high amounts of exogenous sequences in three samples . however, in their own analysis of three spermatozoa samples they found no detectable traces of any plant mirnas, suggesting that exogenous mirnas present in the public datasets may have been caused by laboratory environment contamination . in terms of the possible passage of plant mirnas through the brain-blood barrier, kang et al. analysed samples from cerebrospinal fluid (csf) (from one study), which is separated from the bloodstream by the brain-blood barrier, and brain samples (from studies) . in general, xenomirs were absent from most of the human tissue samples, and, when present, they were found at very low abundance ( % of analysed tissues). although the brain-blood barrier would relatively protect the brain from dietary molecules, xenomirs were present in similar fractions in the exposed liver and in the relatively protected brain samples , suggesting, according to the authors, a nondietary origin . xenomirs were present in more body fluids samples (≈ % of samples) than tissue samples (≈ % of samples) and were identified in comparable proportions in the serum and cfs. this study does not provide support for the dietary origin of xenomirs (including plant exogenous rnas) meaning it may originate from technical artefacts . efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. in addition to mirnas reported by the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. very few studies have reported the influence of dietary or physiological factors on levels of exogenous ncrnas in biological fluids. in a small study (n= per group), wang and colleagues compared some abundant exogenous mirnas species identified in plasma samples from healthy subjects, colorectal cancer and ulcerative colitis patients . although ulcerative colitis patients apparently had increased levels of circulating mirnas of certain species (i.e. from a bantam family), a large variability of mirnas levels were observed among subjects of the three groups , suggesting that health/disease status may influence the presence of circulating mirnas in human plasma. tissue injury produced by excessive consumption of common pharmaceutical drugs can also influence exogenous rnas levels in plasma . wang et al. showed that acetaminophen overdose in a mouse model produced liver injury, and an increase of rna concentration in plasma compared to the control group was observed (from ≈ to ≈ ng/ml of total rna h after treatment). plasma ncrnas levels were affected by acetaminophen overdose, both endogenous and exogenous. plantderived exogenous mirnas levels were reduced, and this drop in plant rna was related to the observation that mice lose appetite after acetaminophen injection , suggesting the influence of diet on plasma plant-derived mirna levels. levels of exogenous rnas can be affected in case of drug-induced kidney damage. sera and urine from mice treated with cisplatin, a chemotherapeutic agent also producing small intestines epithelial cells disruption, showed increased plant exogenous ncrnas (i.e. plant mirnas), not observed in untreated mice (yang et al., b) . the effect was not observed in a glycerol-induced model of acute renal failure (which does not affect small intestine organization). detection levels of exogenous plant mirnas, including mir- and mir- a, were below background levels in mice pre-fed with chow diet devoid of honeysuckle. however, when mice were pre-fed with honeysuckle and honeysuckle was administered (alone or mir- a-supplemented) dose-dependent levels of mir- a was detected in serum and elevated serum levels of mir- were observed (yang et al., b) . the study shows that long-term honeysuckle feeding potentiates absorption of dietary mirnas through a mechanism that likely differs from cisplatin treatment, suggesting that particular diets can modify the capacity to absorb small rnas, and that altered or damaged guts resulting from illness and/or therapeutic treatment may enhance dietary rna uptake (yang et al., b) . while comparing the presence of exogenous srnas in three human plasma samples, beatty et al. reported that the largest proportion of reads matching plant sequences were found from one individual who reported following a vegetarian diet (beatty et al., ) , suggesting that the diet can influence levels of exogenous srnas of food origin. in another study comparing human breast milk for mirnas derived from plants, no significant differences were observed for exosomal breast milk plant-derived mirnas (mir- a and mir- a) between vegetarian or non-vegetarian volunteers . in the whole milk an increase in plant mirna mir- a was observed in non-vegetarian versus vegetarian diet volunteers . although some studies (see above) have reported the presence of exogenous rnas in human and animal circulation and tissues, very few have focused on quantitative data relevant to risk assessment. wang et al. estimated the concentration of rna in plasma to be < . pm based on an average of ng/ml of rna in plasma with an average of nt in length and a selected rna (i.e. mirna) sequence representing less than . % of the total rna population. after days feeding of herbals, yang et al. reported an increase of mir- in the sera of mice from fm ( -fold higher than control chow-fed animals) following ginseng intake to fm ( -fold higher than control chow-fed animals) following honeysuckle intake . the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the lack of enrichment of plant-derived small ncrnas in samples to be analysed by rna-sequencing (i.e. through periodate oxidation) might also influence the low enrichment of these exogenous sequences in biological fluids. however, although '-o-methyl modification of synthetic rna oligonucleotides '-ends can affect ligation activity of the t ligase in srna library preparation and may potentially result in srna sequencing bias and under-representation of srna with '-o -methyl '-ends in quantification experiments (munafo and robb, ) , others suggest a broad capability to detect plant mirnas during the sequencing procedure of small rna library construction . the available literature clearly suggests the widespread presence of exogenous rnas from multiple species, including plants, microbiota and many others, in human and animal biological fluids. evidence for plant-origin ncrnas, possibly relevant to risk assessment of ncrna-based gm, suggests that plantderived mirnas can be found in the biological fluids of humans and animals. whether these sequences are directly derived from dietary sources has not been clearly demonstrated. their overall low abundance, lack of enrichment in tissues most exposed to dietary changes, and their high variation between samples suggest that some may have originated as technical artefacts or contamination, as indicated by some authors. although few reports were available in this area, recent evidence also suggests that the levels of exogenous plant ncrnas in biological fluids may be influenced by diet, subject physiological or pathological conditions, or certain therapeutic treatments. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. following a literature search as described in section . . . . and based on the methodology described in the section . . . ., a total of papers were selected as being relevant to review of the systemic effects of dietary exogenous ncrnas. very few of these studies ( ) provide supporting evidence (in favour) that dietary exogenous ncrnas can be detected in biological samples and/or exert a biological effect after dietary ingestion. by contrast, studies provide contradicting evidence (against) that dietary exogenous ncrnas are either bioavailable or exert a systemic biological effect. one study provides evidence of the possible transfer of small ncrnas through the mammalian placenta . in addition, following a literature search as described in section . . . . and based on the methodology described in the section . . . , papers were selected as relevant to review toxicological effects of dietary exposure to exogenous ncrnas in humans or animals. the first report of systemic effects of dietary exogenous mirna in animals was published in by . plant mirnas were detected in human chinese healthy donors, among which mir- a and mir- a were highly expressed. these mirnas were also detected in calves and mice. plant mirna levels were relatively lower, but at a similar concentration range as endogenous mammalian mirnas present in serum. periodate oxidation, which oxidize mirnas but not plant mirnas (which are '-o-methyl modified), confirmed that these mirnas were genuine plant mirnas as most mammalian mirnas in human sera were oxidized and failed to be sequenced by solexa . the plant mirnas mir- a and mir- a were also detected in different mice tissues, while plant mir- a was not, although it was present in the sera. both mir- a and mir- a were primarily detected in microvesicles in c bl/ j mouse plasma. foods were found to contain the plant mirnas mir- a, mir- a and mir- a, including a chow mice diet at a concentration of . , . and . fmol/g, respectively. fresh rice contained between to -fold higher amounts than the chow diet. plant mirnas were detected in other foods including chinese cabbage, wheat and potato. plant mirnas were found to be stable in cooked foods. plant mir- a and mir- a were higher in the sera and liver of mice after h feeding with fresh rice. mir- a also increased in the stomach and small intestines, but not in the kidney, of mice fed a chow diet or fresh rice. mice fed with total rna extracted from rice or synthetic mir- a (methylated) showed an increased level of mir- a in serum and liver h after feeding. in vitro stability assays suggested that plant mirnas had a much slower degradation rate than their synthetic form (without '-o-methylated 'ends), suggesting that methylation has a protective effect on the stability of plant mirna . of note efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. is that mir- a targets the liver-enriched gene low-density lipoprotein receptor adapter protein (ldlrap ), which plays a role in facilitating the removal of ldl from the circulatory system (garcia et al., ) . direct binding of mir- a to exon of ldlrap , which is in the orf (open reading frame), was demonstrated by luciferase reported assays. transfection of both pre-mir- a and mature mir- a resulted in decreased ldlrap protein expression (but not that of mrna) in hepg cells. moreover, transfection of the intestinal epithelial caco- cell line with mir- a produced microvesicles with plant mir- a which can be taken up by hepg and reduce ldlrap protein expression. mir- a seemed to be associated to ago protein and other cells like t cells which were also able to package mir- a in microvesicles and then deliver mir- a into hepg . injection (iv) of antisense oligonucleotide against mir- a into mice during fresh-rice feeding reduced mir- a levels in the liver and reversed ldlrap repression. mice were finally fed with fresh rice for days to evaluate the physiological function of food-enriched in plant mir- a. serum and liver mir- a levels were induced already at day of feeding and the liver ldlrap protein was repressed after , and days. consequently, ldl levels in mouse plasma were significantly elevated on days and after fresh rice feeding. administration of an antisense oligonucleotide against mir- a reduced plasma levels of mir- a, repressed reduction of ldlrap in the liver and blocked the rice-induced elevation of plasma ldl levels, suggesting that elevation of fresh-rice derived mir- a in the mouse liver specifically decreased liver ldlrap expression and that this caused elevated ldl levels in mouse plasma (figure ). this study provides the first overall evidence of cross-kingdom regulation of gene expression through dietary plant mirnas. the authors further tested a mature mammalian mir- added to the chow diet for mice, and reported an increase in serum and liver levels of mir- after three days , leading to downregulation of liver c-myc expression . the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. by analysing western human sera samples from female stage ii-iii breast cancer patients, chin et al. detected multiple plant mirnas from arabidopsis thaliana and soybean (glycine max), but with sparse counts (chin et al., ) . among the detected plant mirnas, ath-mir- a, gma-mir- a- p and gma-mir- e- p had the highest counts (≤ read counts) and were over times more abundant than other plant mirnas. circulating mir- was more abundant in female healthy donors (n= ) than breast cancer patients (n= ) as analysed by qrt-pcr. moreover, circulating mir- was less abundant in patients who relapsed with metastatic disease, suggesting that human serum mir- levels inversely correlate with breast cancer incidence and progression (chin et al., ) . mir- in human serum was detected in an extracellular vesicle-enriched serum fraction obtained by ultracentrifugation and was resistant to sodium periodate oxidation, suggesting its plant origin due to '-o-methylation of the ' end (which makes plant mirnas more resistant to periodate oxidation). in situ hybridization confirmed the presence of mir- in tumour samples, suggesting that mir- in human serum is capable of entering breast tissue (chin et al., ) . the authors analysed several plant food items for the presence of mir- and found that broccoli is particularly rich in this mirna and most of this mirna was still present after cooking (boiling for min, > % remained stable, compared to fresh). in vitro studies showed that synthetic mir- (both double-stranded and '-o-methylated) reduced cell proliferation in breast cancer cell lines but not the non-cancerous breast cell line. extracellular vesicles from healthy human donors also have a similar effect. luciferase assays determined that mir- targets transcription factor (tcf ) and binds to two different sites within the ' utr. tcf is a transcription factor of the wnt signalling pathway and is upregulated in breast cancer. in vitro assays also showed that mir- inhibits breast cancer cell growth by targeting tcf . oral gavage of synthetic '-o-methylated mir- ( mg/kg mir- or scramble control oligos, daily) reduced tumour growth from day of treatment until the end of xenograph experiments ( weeks) (figure ) , an effect that was lost when tumour cells stably overexpress tcf without the ' utr (chin et al., ) . mir- was detected in xenografts of tumours by in situ hybridization analysis. overall, these experiments suggest that plant mirnas can inhibit cancer growth in mammals. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. liang et al. evaluated and quantified plant mirnas in human plasma after consuming a single dose of watermelon juice or a mixture of fruits (liang et al., b) . using taqman probe-based qrt-pcr assays and appropriate non-template controls, sixteen plant mirnas including ath-mir- a, mir- a, mir- a, mir- a, mir- a, mir- a, mir- a, mir- a, mir- a, mir- a, mir- a, mir- a, mir- a, mir- , mir- and mir- were evaluated and a standard curve generated for quantification. mirnas concentration ranged from . pm for mir- a to , . pm for mir- in watermelon juice, and from . pmol/kg for mir- a to , . pmol/kg for mir- in the fruit mixture. watermelon juice was orally administered to nine healthy male adult volunteers and plasma samples were taken . , , , and h after drinking . l of juice. different mirnas followed different peak time or appearance kinetics in plasma after administration (liang et al., b) . using six plant mirnas ( table ) that showed typical kinetic absorption curves, the total amount of plant mirnas absorbed by the body was calculated. using the plant mirnas concentration in watermelon juice and the areas under the plasma concentration-vs-time curves (auc) of plant mirnas, the total uptake amount, total absorption amount and absorption rate for each plant mirna was calculated (table ) . absorption rate ranged from . % to . %. mir- a, mir- a and mir- a were found almost exclusively encapsulated in microvesicles. mirnas were validated in watermelon juice or plasma by northern blotting. using the same protocol, a fruit eating study was performed. each subject consumed an equal portion of watermelon, apple, banana, orange, grape, mango and cantaloupe ( . kg in total). while mirnas concentration varied, the kinetics of plant mirnas after fruit administration appeared similar to the kinetics after juice administration (liang et al., b) . the authors also suggest that the real concentrations of plant mirnas may be underestimated and, for instance, the real concentration of mir- a in the watermelon juice might be six times higher and its plasma levels four times the previously calculated (table ) concentration (liang et al., b) . adapted from (liang et al., b) in a comment (correspondence) to the editor, the results of above article were criticized as being either a result of technical artefacts or a contamination problem, due to the presence of mir- in monocots and not in the dicot watermelon (witwer, ) . in a reply letter, the original authors indicated that mir- also exists in dicots and that the mirnas display a dynamic physiological kinetic absorption curve in human plasma, supporting the concept of uptake of food-derived mirnas by humans and animals (liang et al., a) . efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. analysing mir- by qrt-pcr in dried flowers and herbs used in chinese medicines or as tea, yang et al. reported different levels in different products including: sophora (≈ fmol/g), honeysuckle (≈ fmol/g), chamomile (≈ fmol/g), blue mallow (≈ fmol/g), ginseng flowers (≈ fmol/g) and as low as . fmol/g in hibiscus . herbal feeding of male mice for days increased plasma circulating levels of mir- compared to that of chow-fed animals. honeysuckle increased -fold ( fm) in sera levels, while chamomile increased -fold ( fm), sophora -fold ( fm), lavender -fold ( fm), blue mallow increased -fold ( fm), ginseng increased -fold ( fm) and no significant changes were detected in hibiscus ( fm). post-feeding urine levels of mir- ranged from -fold higher ( fm) for honeysuckle, and -fold higher ( fm) for chamomile and to -fold higher ( fm) for lavender . however, when chemically synthesized mir- ( '-o-methylated, plant-specific) was administered after single dose feeding of pmols, mice serum levels were elevated roughly -fold within min after gavage but decreased to background levels ≈ h after gavage . mir- was not associated with ago in sera and remained in the unbound fraction. clearance of mir- and other plant-derived synthetic mirnas (mir a, mir a and mir ) were analysed in mice by tail vein injection of fmols. sera collected from mice ( min, min, h, h and h post injection) showed that most mirnas were rapidly cleared from circulation. compared to the other mirnas administered at equal doses, mir- levels were substantially higher at min after injection but after h the apparent clearance of all srnas tested was complete . in the same study, gut microbiota did not seem to influence mir- absorption despite its -fold increase in their microbiome titre after honeysuckle consumption. honeysuckle feeding of mice was also found not to influence gut permeability, discarding its possible absorption due to changes in gut permeability . rapeseed (brassica campestris) bee pollen was evaluated for the possible absorption of plant mirnas in male mice after pollen oral feeding ( g/kg). mirnas were analysed by srna sequencing after or h in mice serum ( µl). from ≈ m clean reads, only reads were plant mirnas, which belonged to mirnas. of the plant mirnas, bna-mir- a ( reads) and bna-mir- ( reads) showed the highest levels in mouse blood and were mapped to the rapeseed genome. the rest of the plant mirnas had ≤ reads, of which mirnas had ≤ reads. both mirnas, mir- a and mir- , were also detected in the rapeseed bee pollen as evaluated by qrt-pcr, with higher abundance for mir- a. serum levels of mir- a after h of rapeseed bee pollen ingestion versus a control were ≈ pm for treated animals while in chow diet fed animals it was ≈ . pm, suggesting that plant mirnas from rapeseed bee pollen can be absorbed by mice by oral ingestion and detected in systemic circulation . evaluated herbal medicine honeysuckle mirnas before and after decoction (boiling for min, ≈ . g/ml water). from ≈ m reads, ≈ . m reads of mirnas were obtained, from which osa-mir- g, peu-mir- and peu-mir- contained more than . copy numbers. most mirnas were degraded by decoction (i.e. mir- g degraded from . to reads), while mir- remained high ( . reads) reaching % of total mirnas in the final honeysuckle decoction. concentration analysis of mir- showed a reduction from . pmol/g in honeysuckle to . pmol/ml in decoction when analysed by qrt-pcr, or from ≈ . pmol/g to . pmol/ml when assessed by northern-blot . compared to other plant mirnas, the apparent high resistance to boiling of mir- was also supported by its high resistance to rnase treatment, which was dependent on its unique sequence and high gc content. oral administration (n= per group) of a single dose ( µl) of honeysuckle decoction (mir- concentration ≈ . pmol/ml) resulted in a maximum peak level in mice plasma and lung tissues h after ingestion (i.e. plasma levels increased from . to . fm). most plasma mir- was found in cell-derived microvesicles and associated efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. to the ago complex. continuous drinking of decoction during three days ( . pmol/ml, ≈ ml/day) increased plasma levels from . to fm, while no changes were observed in the control mice (from . to . fm). levels of mir- in lung and liver tissues increased from to -fold, while the intestines and kidneys remained unchanged. synthetic mir- administration ( nmol/ml, µl given once per mouse, n= per group) resulted in an increase at peak ( h) from . to . fm in plasma and also an increase at peak ( h) in lung tissue, suggesting overall that atypical dietary mirna mir- is absorbed and delivered to tissues . studying its possible biological function, zhou et al. found influenza virus h n encoded mrnas targets of mir- , i.e. virus-encoded proteins pb and ns , which are relevant for viral replication (zanin et al., ) . luciferase activity assays confirmed that mir- binds to pb and ns , which is lost by point-mutation of mir- binding sites of the individual viral gene sequences. in vitro h n replication was reduced by synthetic mir- or total rna extracted from honeysuckle decoction. the inhibitory effect was abolished by co-transfection with anti-mir- antagomir. moreover, no effects in viral replication were observed when pb and ns mutant virus were used with synthetic mir- or honeysuckle decoction rnas . in vivo administration of honeysuckle decoction or synthetic mir- ( . nmol per day) by gavage one day before and during days after inoculation reduced weight loss and viral titre in lung tissues. these results were abolished when the anti-mir- antagomir was used concomitantly. moreover, weight loss and high viral titre were not affected when pb and ns mutant virus were used, and synthetic mir- or honeysuckle decoction administered . the authors also showed similar effects for synthetic mir- or honeysuckle decoction with other influenza viruses, including h n and h n , tested in vitro and in vivo (figure ) . the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. regarding this particular mirna, yang et al. observed a different bioavailability of plant-derived mir- vs. its synthetic '-o-methylated counterpart . oral administration of cabbage extract containing . pmol of mir- per µl gavage volume was compared with a -fold higher dose of synthetic '-o-methylated mir- ( pmoles per mouse). after gavage, mice plasma levels of cabbage mir- reached an approximately -fold increase (≈ fm) versus that of synthetic mir- (≈ fm), suggesting that mir- derived from plants is more bioavailable than synthetic rnas . whether this observation can be generalized to other dietary plant mirnas is unknown. the authors also showed that mir- was not present in exosome vesicles that were proteinase-k resistant in circulation . du et al. evaluated the presence of srnas in hong jing tian (hjt, rhodiola crenulata), which is a chinese herbal medicine. male c bl/ j mice were fed with hjt rnas by gavage for three days ( µg/kg per day) and lung tissue collected at , , or h (n= mice per time). the srna sequences of lung tissues (top eight ranked) that were also present in the plant hjt had ≈ k read counts . one of the small rna (hjt-srna-m ) was effective in reducing in vitro transfected gene expression vectors for α-sma, fibronectin and collagen type i α (col a ) in a tgf-β induced fibrosis model. although the type of srna is not clearly described, hjt-srna-m targets the ' utr of these three genes. using the hjt-srna-m agomir (cholesterol-conjugated srna), by intratracheal administration ( mg/kg in µl of saline) (n= mice per group), the authors showed that fibrosis was reduced in a bleomycin-induced fibrosis mouse model . due to the relevance of liposomes in delivering rna molecules, the authors evaluated the possible formation of liposomes during decoction (boiling for min) with plant lipids. they found that phosphocholine lipid molecules were also present in the decoction and suggested that liposomes may be formed that might facilitate the entry of rnas from plants to human cells and tissues; this was not tested . in another study, mlotshwa et al., described oral administration of a cocktail of tumour suppressor mirnas (normally downregulated in colon cancer) and a reduction of tumour burden in the apc min/+ mouse (c bl/ j) model of colon cancer . mir- a, mir- and mir- were chemically synthesized with the same mice sequence, but with a methyl group on the ' position of the ribose at the ' end, which is a chemical characteristic of plant mirnas (see section . . ). for days (starting at weeks of age), mice (n= per group) received either total plant rna spiked with the mix of the three mirnas, total plant rna alone (from a. thaliana) or water. oral dose was µg of total plant rna alone or plus . to . µg (corresponding to . to . nmole) of each species of tumour suppressor mirnas. tumour burden was dramatically reduced in mice receiving the mirna mixture. moreover, mice receiving the plant rna alone also showed a reduced tumour burden, although it was not statistically significant. after periodate oxidation, intestinal levels of mir- a were -fold higher than that of the group receiving water alone . mir- and mir- intestinal levels failed to be detected due to high background of endogenous mice mirnas after periodate oxidation. although the study does not directly evaluate the mirnas produced by the plant, mirnas designed to mimic small rnas produced in plants seemed to be taken up by the digestive tract of apc min/+ mice upon ingestion and exert a biological effect . oral ingestion of total rna isolated from brassica oleracea ( µg) resulted in the detection of plant mir- (the most highly enriched exogenous plant mirna in b. oleracea) in blood of icr mice between h and h after feeding . mir- was also detected in the spleen ( . - . % recovered of orally administered mir- ), and merely detected in the liver or kidney. no evidence of sex differences was reported . at lower doses of total rna ( µg or µg), no mir- was detected in the blood of mice . efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. using pigs as experimental animals, luo et al. evaluated the detection of plant-derived mirnas in the serum and tissues after feeding fresh maize to pigs (sus scrofa). jinhua female pigs consumed a fresh maize diet and water ad libitum for days (n= ), and blood and different tissue samples were obtained for plant-derived mirna analysis. eighteen maize mirnas were evaluated ( were detected) in serum and tissues, and exhibited relatively low abundance in the pancreas and longissimus dorsi muscle tissue . periodate oxidation treatment of the samples confirmed the detection of zma-mir- a- p, zma-mir- e- p, zma-mir- a- p, zma-mir- a- p, and zma-mir- a- p (while the rest were completely degraded), suggesting that these mirnas are bona fide plant mirnas (figure ). in a separate experiment, female pigs were fed one meal with fresh maize ( kg per pig) after overnight fasting. serum was collected at different times (i.e. , , , , , and h). after h, pigs were provided with fresh maize diet ad libitum, and serum collected at , , and days and tissue collected after sacrifice at days. the serum levels of some of these mirnas (mir- a- p, mir- a- p, mir- e- p, mir- a- p and mir- a- p) gradually increased after one feeding of fresh meal, reaching peak values at or hours within the first hours and maintaining stable detectable levels (by qrt-pcr) in the serum following days of access to fresh maize. the changes in mirna expression at all measured time-points in most cases were modest (≈ to -fold increase). the five mirnas were primarily present in serum exosomes (≈ . % of concentration in the serum) ( figure ). using bioinformatics, potential targets were determined within the porcine mrnas for zma-mir- a- p. using in vitro luciferase assays with porcine kidney cells, the authors showed that zma-mir- a- p binds to three of these potential target genes including cspg , otx and plagl , an interaction lost when their mutant constructions were used, suggesting overall that dietetically-absorbed mirnas can target endogenous porcine mrnas . the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. several of the above-mentioned studies have reported the presence of dietary plant mirnas in circulation associated to extracellular vesicles or exosomes (chin et al., ; liang et al., b; . this could be relevant for their possible biological effects, as extracellular vesicles can deliver a cargo to several tissues, including crossing the blood-brain barrier, and other biological barriers such as the placenta (matsumoto et al., ; yang, t et al., ; jayabalan et al., ) . their presence in microvesicles could modify their function, for example, it has been described that in some cases delivered naked mirnas cannot exert the same effects as those exerted by delivered exosomal mirnas (thomou et al., ) . also, exosomes as therapeutic drug carriers and delivery vehicles are gaining relevance in therapeutics (aryani and denecke, ; ha et al., ) . recently, it has been described that edible plant-derived exosome-like nanoparticles can be isolated from these plants (ju et al., ) , can transport ncrnas (i.e. mirnas) (mu et al., ) and can exert a biological effect (raimondo et al., ) , highlighting their role as therapeutic nanoparticles . it is still unknown if these exosome-like nanoparticles contribute to the resistance of ncrnas in the harsh conditions of the gi tract and to the absorption of plant ncrnas or the formation of exosomes circulating in biological fluids. regarding other biological barriers, only one study has reported on the transfer of small ncrnas through the placenta. li et al. found that exogenous plant mirnas were consistently detected in the umbilical cord blood and amniotic fluid of healthy chinese pregnant woman . this belongs to foetal circulation system, suggesting that mirnas may transfer through the placenta to the foetal side. three hours after gavage feeding of synthesized mature mirnas of the influenza virus to pregnant mice (at last -day pregnant and with mature placenta) increased mirnas levels were detected in the maternal plasma. an increase of exogenous mirnas levels in the foetal liver was also observed . to determine if mature plant mirnas can pass through the placenta and efficiently enter foetal organs, the traditional chinese herbal honeysuckle was tested. mice were gavage fed with . ml honeysuckle decoction ( . pmol/mice of mir- ) and maternal plasma and foetal liver collected h after gavage feeding. plant mir- levels were elevated ≈ . -fold in the maternal plasma (reaching fm), ≈ -fold in the placenta and ≈ . -fold in the foetuses, suggesting that plant mirna mir- in honeysuckle can efficiently transfer through the placenta to enter the foetal liver (figure ) . the amount of circulating mir- increased only in microvesicles, suggesting that circulating mir- was primarily present in microvesicles and that transplacental transmission may involve a microvesiclesmediated pathway . the same study also tested gavage fed synthetic sirnas ( nmol), which were found in the plasma and foetal liver. protein targeting of the sirna was dramatically reduced, suggesting that exogenous sirnas delivered from the mother to the foetus by trasnplacental transmission may regulate foetal gene expression. direct injection of microvesicles loaded with sirnas also reduced their mrna target in the foetus liver, suggesting overall that exogenous small ncrnas can be transplacentally transmitted from the mother to the foetus. although outside the scope of this review, other non-plant derived exogenous ncrnas have also been reported to exert systemic effects in animals. bovine milk-derived extracellular vesicles (bmevs) were orally administered to il- ra -/mice on the balb/c background, which spontaneously develop polyarticular arthritis, from week to week . drinking water was also supplemented and administered to a collagen-induced arthritis (cia) dba/ j mice model starting at week before immunization to day . mice receiving the higher dose of x bmevs (≈ micrograms/ml) showed a considerable delay in disease onset in the il- ra -/mice model. moreover, in the cia model the higher dose administered in drinking water . x /ml (≈ microgram/ml) reduced arthritis incidence and severity, accompanied by reduced expression of inflammatory cytokine il- and mcp- . although bmevs contained mirnas mir- a, mir- and mir- a, it is unclear if they are efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. responsible for the observed biological effects. in a similar study, oliveira et al. administered bmevs (particle concentration of . x /ml or . x /ml) in the drinking water to female dba/ j mice for weeks and observed an increase in osteocyte numbers. moreover, the highest concentration of bmevs increased the percentage of woven bone compared to the pbs group, and a reduction of the adipocyte area in the bone marrow (oliveira et al., ) . although the bmevs also contained mir- a (oliveira et al., ) , its implication in the biological effects is unknown. exogenous plant-derived ncrnas can pass the placenta and reach the foetus. by analysing small rnas components in royal jelly, honey, beebread and pollen collected during the cabbage (brassica campestris) flowering stage, zhu et al. found that honeybee srnas were present at a far higher level in royal jelly than in beebread and pollen, while the abundance of cabbage small rnas gradually increased from royal jelly to honey, beebread and pollen . several mirnas were detected in the samples, the plant mirnas occurring at far higher concentrations. moreover, beebread and polled mirnas were at a much higher concentration and their composition of individual mirnas was highly similar. the plant representative mirnas with the highest concentration were mir- a, mir- a, mir- a, mir- a, mir- a, mir- a, mir- g, mir- a, mir- a, mir- a, mir- c, mir- a, mir- a, mir- , mir- and mir- a. the same analysis in samples collected during the camellia (camellia japonica) flowering stage showed similar results and out of the enriched mirnas were similar, suggesting that plant mirnas in beebread and pollen may not be very diverse between different sources . absolute concentration of the selected plant mirnas ranged from < . fmol/µg of total rna (almost undetectable) in royal jelly and honey, to a maximum of ≈ fmol/µg total rna in pollen and beebread. feeding experiments to larvae with either rna purified from cabbage pollen (levels of mirnas similar to natural beebread mirnas levels) or a efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. synthetic mix of the plant mirnas, increased whole body accumulation of the representative plant mirnas and developed worker bee-like characteristics (reduced weight and size, extended pre-adult development time and decreased ovary size). ninety-six honeybee genes were predicted to be targeted by the plant mirnas, some of which are known to influence the developmental fate of honeybees (i.e. apis millifera tor, amtor). luciferase assays showed that mir- a directly targets aptor mrna. dietary supplementation of larvae food with synthetic mir- a decreased amtor mrna levels in honeybees and showed reduced body weight, size and ovary size . similar experiments were performed in drosophila melanogaster (dm) with total pollen rna, a synthetic mirna pool or mir- a alone, and in all cases similar phenotypes were obtained (delayed drosophila development, reduced final size, ovary size and fecundity). dmtor was also a target of mir- a. overall, this study implies that plant rnas can be transmitted between species of different kingdoms. the literature also describes some in vitro studies of plant mirnas and their possible effects on mammalian cells. for example, exposure ( h) of plant mirnas extracted from a glycyrrhiza uralensis decoction to human pbmcs produced apparent cell aggregation and increased cell number and hla-dr+ cell proportion (shao et al., ) . in silico studies have also attempted to predict possible plant mirnas with potential targets in humans . as described before (see section . ), in contrast to mammalian mirnas, plant mirnas possess a '-omethylation at the '-end that stabilizes and provides resistance to rnases and oxidation. this characteristic has been used to improve the quantification method for mature exogenous mirnas from plants in biological mammalian matrices . thus, periodate oxidation and βelimination were introduced to evaluate the origin of exogenous mirnas. male c bl/ mice were fed with corn/soy-based rodent chow diet for weeks. plant mir a, mir a and mir a were evaluated. these mirnas were detected in abundant amounts in a corn/soy-based chow diet, but after periodate oxidation and β-elimination . %, . % and . % of mir a, mir a and mir a were determined to be in methylated forms ( . , . and . fmol/g of diet, respectively). the control diet showed no differences between the diet and non-template control ct values after periodate oxidation/β-elimination. this study also suggests the use of exogenous rnas (spike-in), both methylated and un-methylated forms of mirnas, to ensure appropriate periodate oxidation/β-elimination . no detectable levels of plant mirnas were found in plasma, liver or faeces samples from the mice fed the corn/soy-based chow diet, since no differences occurred between the diet and the non-template control after periodate oxidation/β-elimination . this suggests that false positive results can be resolved using treatment with periodate oxidation/β-elimination. plant mirnas from extra virgin olive oil (evoo) and beer have also been evaluated by small rna sequencing. however, very few sequences (≤ reads) were identified, and most aligned to soybean and orange . a feeding study of a single dose ingestion of ml of evoo in healthy adult volunteers (n= ) was performed. mirnas analysis at baseline and after h ingestion was performed. no plant mirnas were detected in plasma after single ingestion of evoo . only one read count was found for other species mirna vvi-mir - p from grape, while two read counts were found from medicago trunculata, grape or brachypodium distachyon when mismatches were accepted . this suggests that beer or evoo do not contain mirnas that contribute to dietary intake, even though mirnas were reported in the pulp of olive (olea europaea) (donaire et al., ) . efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. dickinson et al. evaluated a controlled mouse feeding study with rice-containing chow diets (modified ain -g with . % of rice or rice-based with % of rice) or with a purified synthetic chow devoid of plant grain or forage for , and days (figure ) . the "synthetic chow" had negligible levels of osa-mir- a, the "balance rice chow" ( . % of rice) contained reads, while the rice grain contained reads. the concentration of osa-mir- a in each diet was . , and fmol/g of diet for synthetic chow, balance rice chow and rice chow, respectively. plasma and liver analysis of mice fed the diets did not reveal measurable uptake of any rice grain mirnas, including osa-mir- a. indeed, fewer than ten reads were detected in five out of eight samples from mice fed on rice-containing chow and four out of five samples from mice fed on synthetic chow . since the synthetic chow contained no grain or forage from plants, this low number for rice mirnas-mappable reads can only be explained by sequence errors or cross-contamination. in agreement with , the authors indicated that animals fed a chow containing high levels of uncooked rice (%) had significantly increased plasma low-density lipoproteins (ldl) levels at and days after treatment initiation. however, this increase in ldl was not observed in the balanced rice/chow group ( . % rice), which contained fmol/g osa-mir- a. the increase of ldl was attributed to nutritional imbalances between the test and control groups . ldlrap protein was also evaluated by elisa in mouse liver samples, and no changes in levels were observed in any group at any time, suggesting that dietary intake of osa-mir- a (from to fmol/g) does not produce rnai-mediated modulation of ldlrap protein levels in mouse liver . efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. a commercially available plant-based, plant mirna-rich substance containing soy and fruit materials, but not animal products, was administered by gastric gavage (≈ % of estimated blood volume for each animal) to male macaques (macaca nemestrina). relative abundance of plant mirnas mir- , mir- , mir- , mir- , mir- and mir- were analysed by qrt-pcr in the plant-based dietary substance. for instance, for mir- a consistent and efficient amplification through at least pcr cycles was detected. plant mirnas were analysed in plasma samples of macaques (n= ) before and after , and h oral gavage of plant rich mirnas. qrt-pcr results indicated late amplifications of some plant mirnas, but results were highly variable. mir- did not amplify before cycles, and mirs- , - , and - had a median cq greater than . mir- non-template controls also showed regular amplification within the same cq range. mir- exhibited a tendency to increase after ingestion, but was highly variable, and cq cycles were greater than . this was not the case for endogenous animal mirnas or the spike-in control, supporting the case that the late apparent amplification of plant mirnas in plasma was non-specific . moreover, droplet digital pcr analysis showed that counts from plasma were generally very low and of variable intensity, as occurs in non-specific amplifications. this even occurred in mir- (plant mirna with relatively high apparent count by qrt-pcr), which showed large number of counts but with variable intensity plots ("rain" appearance) (figure ) , and is consistent with non-specific amplification . overall, the study (though only subjects were included) suggests that the detection of plant mirnas in plasma does not support a general and consistent uptake of dietary plant mirnas . : substantial levels of mirna in oral diets consumed by macaque but negligible steady-state presence of diet-derived mirnas in plasma or organ tissues. snow et al. ( ) analysed the presence of exogenous plant mirnas after regular intake of a western diet containing fruits in healthy human subjects, and mir- in plasma or organ tissues of mir- -/mice . the conserved plant mirnas mir- a, mir- a and mir- a were highly the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. expressed in many fruits common in the human diet such as ripened avocado, apple, banana, orange and cantaloupe. mir- a and mir- reached up to , copy numbers/mg food. the conserved animal mirna mir- was expressed at substantial levels (≈ , copies/mg food) in meat but not in fruits. mouse vegetarian and soy-enriched diets also contained high quantities (up to , copy numbers/mg food) of mir- a and mir- a, but not mir- . in contrast, mouse diets enriched with animal products contained elevated levels of mir- , suggesting that conserved plant and animal mirnas are commonly present in oral diets for various animal organisms. although the dietary record of of the healthy adults reported the intake of fruits replete in mir- a, mir- a and mir- a the day prior to plasma harvest, these plant-derived mirnas were undetectable in plasma samples. following -week feeding with a custom animal lard diet containing mir- no detectable levels of mir- were found in plasma samples of mir- -/mice, while high quantities of this mirna in plasma were seen in control wild type mice fed the same diet . in tissues (liver, lung, kidney and stomach) mir- was either not detected or detected at exceedingly low levels corresponding to less than one copy of mir- per cell (assuming that the mammalian cell expresses roughly pg of total rna). wild type-mice showed only a non-significant trend toward increased plasma levels of mir- a after consuming either a vegetarian or soy-enriched diet when compared to mice fed a lard diet for the same period ( -week) ( figure ) ; however, levels were very low. indeed, mir- a was detected in organ tissues (liver, lung, kidney and stomach) but at levels of less than one copy of mirna per cell and regardless of diets. mir- a and mir- a were not detected at all. fresh avocado containing three specific plant mirnas was also fed to mice ( . g per mouse over h). even though the three mirnas were found in the stomach content of mice at high levels, very low levels were found in plasma and organ tissues, reaching levels lower than one copy mirna per cell in tissues. this provides no evidence of substantial steady-state presence of these plant mirnas in organ tissues after dietary intake . assuming that, on average, at least copies per cell (> copies/pg srna per cell) are necessary to achieve canonical target gene repression (brown et al., ) , at least copies of a given plant mirna must be ingested and delivered for widespread biological activity in humans (the average human body contains ≈ cells). based on the concentration in ripe cantaloupe (≈ x copies mir- a/mg fruit), an individual would need to consume , kg of cantaloupe just to release this number of copies in the gi tract . in terms of srnas, the literature describes the threshold for target gene regulation to be between and copies of mammalian mirna per cell . in an analysis of activity for hundreds of mirnas, only the most abundant mirnas in cells were found to mediate targeted repression and a large amount of mirnas had no discernible activity (mullokandov et al., ) . this suggests that only a minimum amount of mirnas need be reached to exert a biological activity, although this will also depend on the amount of target transcripts. a study mentioned above the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. analyses of other common plant mirnas reported by others to be bioavailable were not successful. this implies that although the transgenic mirnas had resistance to degradation comparable to that of mir- and high expression levels in plants, they were not readily bioavailable . huang (huang et al., ) analysed the possible bioavailability of orally-ingested corn mirnas in mice when incorporated into a rodent diet and consumed for days. in an initial experiment, male c bl/ mice (n= per group) received either water (control), random nucleotides ( µg, equivalent to the same amount of small rnas) or purified small rnas isolated from corn kernel ( µg, equivalent to the same amout of random nucleotides). in the second experiment, mice received either a control diet (ain- m), ain- + % autoclaved corn kernel powder or ain- + % fresh corn kernel powder. mirna levels in the isolated rna contained . pg mir- a, . pg mir- a, and . pg mir- a per µg corn srna isolates. the diet supplement with fresh corn powder contained pg mir- a, pg mir- a, and pg mir- a per gram of diet. autoclaving the corn powder at ºc for min reduced the amount of initial mirnas by more than %. in the first study, liver and whole blood sample mirnas (analysed by qrt-pcr), showed no differences in ct values between the three groups. after periodate oxidation followed by β-elimination, no differences were detected between the no-template control group and the experimental groups. similar observations were made in the liver and whole blood in the second study using fresh corn powder. also, after periodate oxidation followed by β-elimination, no differences were detected between the no-template control group and the experimental groups in the liver and blood samples. analysis of corn mirnas in cecal and faecal samples www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. showed similar results after periodate oxidation, although certain minor differences remained between the no-template control group and the experimental groups. in all cases, less than . % of total the mirna tested in both studies was recovered from the faecal samples. moreover, analysis of the mirnas in the content collected from different parts of the mouse gi tract from the animal studies administered via gavage or dietary intake showed that calculated recovery accounted for less than . % of the content originally ingested in the stomach, less than . % of that originally ingested in the intestine and faeces, and less than . % of that originally ingested in the colon and cecum (huang et al., ) . further experiments using in vitro digestion system suggested that after the gastric phase, over % of corn mirna mir- a from the diet or from the extract were degraded, suggesting overall that significant degradation of corn mrnas occurred during digestion, which resulted in minimal uptake of corn mirnas after oral intake (huang et al., ) . witwer re-analysed the plasma data evaluated by liu et al., and found that only one putative plant mirna mapped above a median cut-off ( reads), which was the plant mirna peu-mir- . this implies that all rnas -including previously reported exogenous mirnas (xenomirs) such as mir- a, mir- a and the plant ribosomal degradation fragment mir- -are below the level of background noise. it is not clear if mir- is a real mirna as it is found in the highly conserved and expressed subunit rrna of plants . moreover, the mir- sequence is not only a fragment of plant rrna, but also has a % coverage and % identity match with human s rrna, while others do not map to plant genomes at all . perhaps more analyses are needed when assessing possible xenomirs. after in silico xenomirs analysis using public sequencing datasets (see section . . for details), kang et al. performed controlled feeding studies to detect the transfer of exogenous plant mirnas to rat blood or from bovine milk sequences into piglet blood . adult rats (n= per group) followed a -day controlled feeding study with supplementation in three different diets: monocot plant material (rice); dicot material (potatoes); and husbandry chow containing a defined mixture of grains, cereals, vitamins, minerals and fats. small rnas were isolated from serum and sequenced. most samples showed either a lack of plant xenomirs in rat serum, or three or less read counts in certain samples . these extremely low numbers suggested a probable false positive result. in the same study, piglets were fed either cow milk or soy milk for weeks followed by weeks of feeding with maize. few cow-specific sequences were found ( reads) in the piglets fed cow milk, while piglets fed maize as well did show cow-specific sequences ( reads). this suggests likely false positive results. both studies provide no evidence of dietary transfer of xenomirs . the abovementioned studies are summarized in table . although outside the scope of this literature review, pollen plant mirnas ingested as part of a typical diet of adult honey bees were not found to be robustly transferred across the epithelial barrier under normal conditions (masood et al., ) . for example, despite the high levels of plant mir- a in pollen or its detected levels in the bee digestive tract ( . copies per pg total rna in the midgut), less than . copy per pg total rna was found in abdominal tissue (masood et al., ) . www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. large amount of plant mirnas mir- a, mir- a and mir- a detected in vegetarian, soy-enriched, or avocado diets (i.e. ≈ x copies for vegetarian soy/diets or ≈ . x copies for avocado diet of mir- a after h), but very low levels found in plasma and less than copy per/cell in tissues. after weeks mir- rich diet in mir- ko mice, no plasma levels and less than one copy of mir- per cell detected in tissues. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. after periodate oxidation, no major differences observed in mir- a, mir- a, or mir- a among treatment, control groups or no-template control in liver and blood. in cecal and fecal samples no major differences observed among control and treated groups. mirna analysis in the gi content collected from different parts of mouse showed that the recovery (calculated) account for less than . % of originally ingested in the stomach, less than . % of originally ingested in the intestine and feces, and less than . % of originally ingested in colon and cecum. in vitro digestion experiments suggested that after the gastric phase, over % of corn mirna mir- a from the diet or from the extract is degraded. (huang et al., ) the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. exogenous plant mirnas found in umbilical cord blood and amniotic fluid of healthy chinese pregnant women. plant mir- increased in plasma of the mothers, placenta and foetus liver h after oral gavage ( . nmol/mice). exogenous sirna gavage ( nmol) increased plasma levels of mother and foetus liver. protein target in foetus repressed. direct injection of microvesicles loaded with sirnas also increased its levels in foetal liver and reduced mrna expression of its target. exogenous small ncrnas can be transplacentally transmitted from mother to foetus. n.d., not determined. ko, knock out; wt, wild type; mirna, microrna; srna, small rna; dsrna, double-stranded rna; col a , collagen type i α ; α-sma, alpha smooth muscle actin; hjt, hong jing tian; www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as author(s). this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author(s). the available evidence presents several examples of systemic effects of plant-derived exogenous ncrnas when administered orally. however, there are also several reports that do not support these findings and contradict the hypothesis of cross-kingdom regulation. in either case, the essential question concerning the existence of this possibility is still heavily debated. important aspects such as the precise mechanism of transport of plant ncrnas from food to the circulatory system, the amount of exogenous ncrnas reaching tissues or the molecular mechanism of cellular uptake need to be understood. it remains unknown if such a transfer could be modulated in particular context (i.e. specific diet, disease status, medication). the available evidence also suggests that plant ncrnas can directly target mammalian genes through rnai effects when they are exposed in in vitro systems. without considering other physiological parameters, if a synthetic plant mirna is exposed to its mammalian target, it can effectively bind by base complementarity and exert a biological effect (i.e. gene repression). however, whether the exogenous plant ncrna can bypass all the biological barriers to reach and interact with the possible target remains to be clarified. apparently, exogenous plant-derived ncrnas are found in exosomes or macrovesicles. it is not yet known how they reach these types of structure in biological fluids, or if novel plant exosome-like nanoparticles participate in any of these processes. www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as author(s). this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author(s). immune cells were mainly from studies in human and mouse isolated lymphocytes. however, these studies were descriptive/not comprehensive, reporting specific effects of ncrnas in proinflammatory cytokine production using human cells, and would not allow identifying specific endpoints that can be used to evaluate changes in the regulation of immune function and homeostasis by ncrnas. retrieval of grey literature using the key words 'thesis plant rna immune' provided numerous results (i.e. google = . ), mostly regarding the function of mirnas and rna silencing in plant immunity. for instance, a document could be chosen based on title selection because it included the terms 'plant, double-stranded rna and systemic immunity' (https://uknowledge.uky.edu/plantpath_etds/ ). however, this study was not further considered since it refers to plant immunity. after analysing the documents and refining by key questions, a large number of screened publications were discarded because they refer to the role of endogenous ncrna (human and animals) as well as viral infections in relation to the immune function, which is outside the scope of this literature review. as an example, within original in vivo publications related to the key words, only studies were considered relevant for the proposed review questions. in summary, from the literature search, papers were finally selected as relevant to review of the effects of ncrnas on immunity. very few studies analyse the direct relationship of exogenous plant ncrna with immune function and homeostasis of humans or animals. albeit controversial, exogenous ncrnas derived from plants and microorganisms have also been described in human blood (detailed in section . . .). overall, the results indicate that there is scarce information on the specific impact of plant ncrnas on activation of specific immunocompetent cells. of these references, documents were used for reviewing the general features of ncrnas in immune function and immunity in humans and animals (section . . .), were used for the effect of exogenous plant ncrnas on immune system (section . . .) and for the additional section on the effects of exogenous ncrnas on gut microbial composition (section . . .) ncrnas have been shown to play important roles in immune cell development and function in normal and disease conditions (ansel, ) . human and mouse studies demonstrate that mirnas play a critical role in the regulation of immune cell development and their function. there is also evidence of the relevance of neonatal mirna-mediated immune activation (kosaka et al., ) . here, mirna molecules of maternal origin appear to be stable in the infant's gut conditions, allowing dietary intake and transfer of mirna (kosaka et al., ) . ncrna have also been identified as regulators of metabolic shifts within microbial communities (paul et al., ) . thereby, ncrnas may significantly influence the critical roles of gut microbiota on health and disease. this part of the literature review (efsa task ) presents the current knowledge on the role of exogenous ncrna molecules on the immune system of humans and animals and aims to provide information on the possible effets of dietary ncrnas on the regulation and function of the immune system. in addition, since the gut microbiota influences the immune system, a review on the possible effects of exogenous ncrnas as gut microbiota modulators is provided this chapter provides background information on the modulatory effects of ncrna on the immune system of humans and animals and serves as a general introduction to explore the possibility of dietary plant ncrnas effect on the immune system after dietary intake. sixty-four ( ) documents were finally used to review this section. when activated, the immune system tightly regulates innate and adaptive response(s), aiming at restoring homeostasis, and preventing autoimmunity. the 'amplitude' (i.e. intensity and duration) of the www.efsa.europa.eu/publications efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as author(s). this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author(s). interaction with the t-(tcr) and b-(bcr) cell receptors determines cell fate decisions. in the periphery, regulatory t cells (tregs) play a key role in restraining the activity of mature b and t (th , th and th ) cells, and preserving tolerance mechanism(s). these responses depend on transcriptional and epigenetic regulation including regulation by mirnas. emerging systems for measuring mirna activity during immune activation revealed the complex network of genes that may be simultaneously targeted by mirnas to tune distinct cell fate decisions (wells et al., ) . rnas exhibit an intrinsic property of base pairs that is crucial in defining their structure and, thereby, their physiological role (lu et al., ) . plant mirnas are '-o-methyl modified on their terminal nucleotide, making them more difficult to be ligated to the cloning adapter. the inhibitory effect of '-o-methyl modification at the ' end of the rna substrate for the mammalian nuclease family member nef-sp has been described (silva et al., ) . as described elsewhere, most mammalian mirnas require 'pre-processing steps' to become physiologically active. nucleotide sequence complementarity appears as a critical feature driving the predominant result exerted by mirnas. notably, it has been reported that a modification pattern involving alternating '-o-methyl rna bases improves dsirna in vitro stability and evades activation of the innate immune system (collingwood et al., ) . these data were obtained with isolated peripheral blood mononuclear cells (pbmcs) as a mixed 'lymphocyte' population of immune receptors that are encountered in vivo. however, the authors do not provide any molecular mechanism for the observed effects. sirnas have been shown to be potent stimuli of interferon- production by plasmocytoid dendritic cells (hornung et al., ) . this sirna technology induced systemic immune responses in the same range as the toll-like receptor (tlr)- ligand 'cpg', including activation of t cells and dendritic cells in spleen. notably, immunostimulation by sirna was absent in tlr -deficient mice. there is a lack of data related to the effects of plant ncrnas on pge production, implicated in immunosuppression by tlr via cox . several distinct classes of lncrnas are transcribed from different dna elements or are derived from long primary transcripts with noncanonical rna processing pathways, generating new rna species with unexpected formats. these lncrnas can be processed by several mechanisms, including ribonuclease p (rnase p) cleavage to generate mature ' ends, capped by small nucleolar rna (snorna)-protein (snornp) complexes at their ends, or the formation of circular structures. recently, it was reported that several lncrnas mediate their regulatory effects through binding to specific rna-binding proteins . in addition, expression of lncrnas has been defined as highly cell-type specific (guttman et al., ; washietl et al., ) . this high specificity has been reported to be critical for the development and activation of immune lineages. however, lncrnas-mediated regulation of innate immune activation (i.e. il- production) has not been tested for function in vivo, but only evaluated in vitro (roux et al., ) . the regulation of inflammatory mediators or cytokines by lncrnas is still poorly understood. synthetic nucleic acids, such as dsrnas, have been reported to be recognized by toll-like receptor (tlr)- and can stimulate the innate immune system and trigger a type i interferon response (marques et al., ; mian et al., ) . in plants, it has been described that dsrna with ' overhangs contributes to endogenous and antiviral rna silencing pathways (fukunaga and doudna, ) . earlier reports defined a structural basis (i.e. ' overhangs) to cause nonspecific effects on the ds-rna-activated signalling pathways through the interferon responsive factor (irf)- (marques et al., ) . similarly, immune activation by the subcutaneous route with a viral mimic dsrna (poly i:c) of c bl/ mice during neonatal early or late brain development differentially affects depression-related behaviours developed in adolescent and adult mice (majidi-zolbanin et al., ) . the present document has been produced and adopted by the bodies identified above as author(s). this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author(s). specific molecular interactions of the exogenous rna triggering immune responses have been reported. several studies have demonstrated the role of components of innate immunity, including toll-like receptors (tlrs), the retinoic acid-inducible gene i/melanoma-differentiation factor (rig-i/mda ) and the interferon response effectors protein kinase r (pkr) and rnase l, as well as mirnas in the recognition of viral or synthetic dsrna (malathi et al., ; urcuqui-inchima et al., ) . tlrs are a family of proteins recognizing different pathogen and damage-associated molecular patterns, pamps and dmaps, respectively. rig-i/mda , pkr and rnase l constitute cytosolic rna sensing proteins. the pathways responsible for these defined signalling processes can be largely separated (figure ) , despite the existence of some degree of crosstalk between them where the engagement of interferon regulatory factors is a common feature. tlrs play an essential role in innate immune responses in mammals. in humans, ten different tlrs recognize distinct molecular patterns, where tlr- , - , - and - stimulate innate immune responses upon interaction with nucleic acids weber et al., ) . tlr is located on the plasmatic cell membrane, while tlr- , - and - display endosomal localization. it has been reported that tlr recognizes dsrna, viral or the synthetic poly i:c, and sirna has also been identified (in the presence or absence of delivery systems) as a relevant ligand . notwithstanding, rna interference is considered an unlikely mechanism to be engaged for viral sensing (cullen, ) . gurich rna from viruses or synthetic single-stranded (ss) oligoribonucleotides displays an apparent preference for stimulating human tlr / -mediated immune effects (heil et al., ; forsbach et al., ) . a minimum of four nucleotides, uugu, found in the gu-rich region are reported as necessary to stimulate cytokine responses. endogenous or exogenous rnas are internalized into the endosomal compartment. the rna sensor system is composed of i) several innate immune 'toll-like' receptors (tlrs) located at the endosomal compartment that trigger different signalling pathways engaging adaptor distinct molecules (myd and trif), and ii) a cytosolic system (rig-i/mda- ) that coordinates its signalling with tlrs. antigen processing will lead to rearrangement of mhc molecules to activate the adaptive immune response(s). type i interferons (ifn-α/β) are expressed rapidly after infection and serve as a link between the innate and adaptive immune responses. : schematic representation of the eukaryotic rna sensor (single-stranded rna and short/long double-stranded rna) and its relation to innate immunity. the present document has been produced and adopted by the bodies identified above as author(s). this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author(s). two classes of ssrna motifs have been described that either preferentially activate tlr -mediated or tlr / -mediated immune responses. au-rich oligoribonucleotides stimulate tlr -but not tlr mediated immune activation (forsbach et al., ) . rna motifs activating tlr -associated signalling fail to induce ifn- from tlr -expressing plasmacytoid dendritic cells but induce the secretion of th like and proinflammatory cytokines from monocytes or myeloid dendritic cells. in addition, rna motifs activating the tlr / -associated signalling pathway stimulate cytokine secretion from both tlr -and tlr -positive immunocytes (forsbach et al., ) . differences in the protein sequence of tlr- between different mammals (human, monkey, chimpanzee, cattle, porcine, mouse, and rat) can be found, and species-specific recognition of ssrna via tlr / had been described (heil et al., ) . the tlr -specific rna sequences are unable to trigger cytokine responses from mouse, rat, and porcine immune cells (forsbach et al., ) . a dual function has also been suggested for the murine coreceptor cd to enhance tlr- , - and - signalling (baumann et al., ; lee et al., ) . however, further studies showed evidenced that human cd did not appear to function as a co-receptor for tlr- or tlr (weber et al., ) .the innate immune system detects rna lacking nucleoside methylation (m c, m a and m u) or otherwise (i.e. pseudouridine or '-o-methyl-u) modified as a mechanism to selectively trigger immune responses to nucleic acids from necrotic tissues or of exogenous origin. a recent systematic study on transcriptional and, especially, post-transcriptional regulation of stressresponsive lncrnas in oryza sativa showed that hundreds of lncrnas with down-regulated polyadenylation are highly conserved in stresses . in the ascidian ciona intestinalis a novel alternative polyadenylation signal activated by the prototypical tlr agonist (i.e. lps) has been described (vizzini et al., ) . moreover, alternative polyadenylation has been identified as a regulatory mechanism during the innate antiviral immune response in macrophages (jia et al., ) . these authors showed an enrichment of polyadenylated genes and mrna abundance change in tlrs as well as rig-i-like receptor, jak-stat and apoptosis-related signalling pathways. studies conducted on the crystal structure of the sensing tlr- ectodomain allowed definition of dsrna recognition of at least bp (liu et al., ; leonard et al., ) . it was concluded that tlr assembles on dsrna as stable dimers and that the minimal signalling unit is one tlr dimer. recognition by secondary structure 'alone' has been reported, independently of the sequence motif, by tlr . this dsrna length is larger than the typical helix occurring in normal mirnas and sirnas. tlr- and - have been found to recognize single-stranded rna (ssrna). the existence of a similar double horseshoe structure for tlr- , - and - upon activation has been proposed, although their binding modes to their ligands remain unclear . often, in a partial view, tlr is considered as the ssrna-sensing tlr and as complementary to tlr . however, higher structural features have been identified as important aspects in tlr rna sensing (jöckel et al., ) . in addition, small molecules that may be viewed as nucleoside analogues are able to activate tlr and/or tlr (hemmi et al., ; lee et al., ) . it has not been defined if the recognition mode for small molecules, including srnas, resembles that of tlr for rna recognition. besides tlrs, rig-i is a cytosolic multi-domain protein sensing viral rna associated to n-terminal caspase activation and recruitment domains (cards) to transmit signalling but preventing it in the absence of rna. the identification of rig-i/mda as cytoplasmic sensors for dsrna, associated to facilitators such as pkr and '- '-olygoadenylate synthetase, suggests that additional 'aspects' (i.e. dependence on atp) other than dsrna structure or short size influence innate immune responses to srnas (i.e. sirnas and mirnas). these aspects remain unclear. the present document has been produced and adopted by the bodies identified above as author(s). this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author(s). current information on mirnas points to clear differences in cellular recognition of endogenous and exogenous dsrna. here, '-triphosphate and dsrna represent molecular patterns enabling rig-i to discriminate exogenous from endogenous rna (myong et al., ) . dsrna products as short as - bp are sensed by rig-i independently from the '-termini (marques et al., ) . similarly, the ifninducible '- '-olygoadenylate synthetase (oas) requires dsrna that must be at least nucleotides long for activity, and no modification of the ′-hydroxyl group is tolerated (sarkar et al., ) . the oas family requires synthesizing di-, tri-, and tetrameric '- '-oligoadenylates ( - a), which in turn bind and activate rnase activation of rnase l together with pkr, irf and c-jun-n-terminal kinases, constituting pro-apoptotic mediators in response to dsrna. moreover, human oas may also enhance rig-i mediated signalling by mimicking polyubiquitin . further structural and mechanistic studies identify a key role of domain duplication in the oas family, thus revealing different functions of oas- and oas- in sensing dsrna (donovan et al., ; . rna interference (rnai) as well as antisense oligonucleotides and aptamers have been postulated to exert immune stimulatory effects in mammals (agrawal and kandimalla, ; cullen, ; mustonen et al., ) . however, at present, there is still an important open debate about agents exerting physiologically relevant functions at systems level biology (cullen, ; kleinman et al., ) . moreover, clinical trials of sirna demonstrated that the only population carrying the ff coding variant for tlr was protected from sirna-induced cytotoxicity (kleinman et al., ) . this study concluded that, because multiple cells express surface tlr , the therapeutic approach with sirna might induce unanticipated vascular or immune effects. here, anti-angiogenic innate immunity triggered by sirna was found to occur without the induction of inf-α/β via trif activation being biased toward nf-ĸb rather than irf- . side effects, for example, the immunosupressive effects of t regulatory cell function are inhibited by ifn-α- β (yu et al., ) , are still only vaguely understood in association with exogenous ncrnas administration. naturally occurring mammalian rnas do not display a stimulatory potential on innate immune responses through tlr- , - , - and - in dendritic cells and tlr-expressing cells (karikó et al., ) . by contrast, it has been shown that major innate immune responses to chemically synthesized sirnas are mediated by tlr and/or tlr . notably, replacement of uridines with their '-modified counterparts in the sirnas, reduced immune activation (sioud, ; barik and lu, ) . studies conducted on synthetic sirnas have shown results directly dependent on the nucleotide sequence (judge et al., (judge et al., , hornung et al., ) , and not to silencing effects of a target gene. putative immunostimulatory motifs allowing definition of ifn-α induction by β-gal control sirna or its constituent sense (gu-rich) and antisense ssrna oligonucleotides (judge et al., ) have been identified. these studies were performed in pbmcs, and therefore lack a clear demonstration of these effects at the organism level. intravenous administration of encapsulated sirna induced substantial dose-dependent ( - g sirna) ifn-α responses in outbred institute for cancer research (icr) inbred mice. in this line, reports also exist of increased hepatotoxicity of asos containing locked nucleic acid modifications (swayze et al., ) . in addition, asos carrying '-o-methoxyethylribose modifications showed no cytotoxic effects but were able to reduce targeted mrna. by analysis of sequence variants of either ss or ds sirna, uridine-rich immunostimulatory motifs within sirna were identified in human peripheral blood cells via tlr (sioud, ; jurk et al., ; judge et al., ) . there is a report of sequence-and targetindependent angiogenesis suppression induced by sirna via tlr (kleinman et al., ) . a minimum length for dsrna of about -nucleotide or -nucleotide luc sirna, but not truncated versions the present document has been produced and adopted by the bodies identified above as author(s). this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author(s). suppressed by choroidal neovascularization have been observed in wild-type mice (kleinman et al., ) . recently, it has been established that nuclease-resistant aptamers can play a 'dual' role in immune signalling pathways (gefen et al., ; rajagopalan et al., ) . these aptamers seem to possess a unique feature acting as both agonist and antagonist depending on their degree of oligomerization (nozari and berezovski, ) . aptamers are ss oligonucleotides ( - nucleotides) capable of recognizing, in a specific manner and with high affinity, several types of target molecules by means of a three-dimensional folding of their chain. preclinical studies in murine models have highlighted distinct regulatory points that may be influenced by oligonucleotide aptamers, including clusters of differentiation (cd) (pastor et al., ) , cell-to-cell communication such as immunoglobulins (gefen et al., ) and interleukin (il) signalling (rajagopalan et al., ) . the cd molecules can act in several ways, often acting as receptors or ligands important to the cell initiating signal cascades or serving as adhesion molecules. here, cd is one of the main co-stimulatory receptors responsible for proper activation of t lymphocytes that could be manipulated to modulate the immune response (pastor et al., ) . further studies reported enhancement of t cell functions by specific t cell immunoglobulin- aptamers through negative regulation of ifn- secretion by cd + and cd + cells (gefen et al., ) . positive effects attributed to oligonucleotide aptamer have also been associated to attenuation of il- signalling in cd + cells (rajagopalan et al., ) . while sirna and dsrna in cultured cells have been shown to trigger an interferon response (alexopoulou et al., ; sledz et al., ) , the administration of naked (dtdt) synthetic sirnas ( . mg/kg) to mice (either intraperitoneally or iv via low pressure or high pressure injection) induced no interferon response (heidel et al., ) . this suggests that sirna administration in vivo may elicit little or no immune response. also, modification of nucleotides within rna molecules was shown to reduce immune response (durbin et al., ) , which is relevant when applying nucleotide modifications to rna therapeutics. for example, n- -methyladenosine (m a) and pseudouridine seems to reduce the retinoic acid inducible gene i triggering of the innate immune signalling (durbin et al., ) . thus, rna modification seems to influence recognition of exogenous rnas, for example, ribose '-o-methylation of mrna at the '-end provides a molecular signature for the discrimination of self and non-self rna (züst et al., ) . prior to immune cells performing their immunological action on target cells, they need to receive a suitable 'maturation' signal to enhance clonal expansion and acquire the effector function. activation signals occur in peripheral lymphoid organs through a concerted interaction with mhc molecules. the major histocompatibility complex (mhc) regulates the cell-mediated immune response(s). there are recent reports on the regulatory role of mirnas on mhc class i and ii molecules (wongfieng et al., ; xie et al., ) . for instance, mhc class i chain related protein b present in natural killer (nk) cells was associated to cell-mediated antitumor immune response through engagement with the nkg d receptor (xie et al., ) . the expression level of this receptor has been shown to be regulated by exogenous mir- c mimics in nk cells . based on the temporal and spatial regulation which determines the expression patterns of mirnas, that suggestion was made for the participation of complex regulatory networks composed of several transcription factors influencing the expression level of 'each' mirna. the mhc class ii complex has been identified as a target in mammalian mirnas regulation (wongfieng et al., ) . in addition, some lncrnas have been identified as candidates to be translated into peptide fragments (guttman et al., ) suggesting, as several other 'indirect' lines of evidence, the the present document has been produced and adopted by the bodies identified above as author(s). this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author(s). participation of ncrnas-derived peptides on mhc complexes (yewdell, ; mellman et al., ) . peptides bound to mhc molecules serve as recognizing fragments of antigen for the tcr. here, it has been shown that mirnas can influence the amplitude of tcr signalling modulating t cell fate decisions towards survival and maturation wells et al., ) . here it is worth noting the recently defined dual role of mirna in maintenance of the naive phenotype of cd t cells or clonal expansion, where modulation of let- mirnas levels is required (wells et al., ) . in a similar way to mhc class ii for t cells, bcr determines the fate of developing b cells allowing their adequate maturation or the development of self-reactive b cells leading to immunodeficiency of b cell malignancy. the mirnas set threshold for lymphocyte development targets several genes in the pi k pathway (simpson and ansel, ) . it is also important to highlight that pi k displays an inhibitory interaction on tlrs-induced production of il- , therefore limiting excessive th polarization and suggesting a potential immunoregulatory role for mirnas. a few relatively recent studies address the potential regulatory role of 'specific' mirnas in treg functions (jeker et al., ; warth et al., ) . these studies have shown that inhibition of mirna- a in c bl/ j mice led to reduced foxp expression dependent on the levels of mediators such as tgf and/or retinoic acid (ra) (jeker et al., ) . another study reported induction of treg cell differentiation regulated by a mirna 'network' influencing the promoting factor mtor (warth et al., ) . these studies revealed that the underlying molecular mediators responsible for the mirna regulation of t cell signalling pathways remain unknown. unlike animals, plant mirnas have not been associated to tgf nor ra. intersecting the rapidly emerging field of treg function, it has been discovered that ra controls both the homing and differentiation of treg. in addition, computational and systems biology approaches have identified mtor as a potential pathway to explain the cross-kingdom mirnas-mediated regulatory potential of camptotheca acuminata ). although many reports can be found regarding the immunomodulatory role of endogenous and viral ncrnas, very few evaluated the impact of plant ncrnas on immune function and homeostasis when ingested/absorbed by animals and/or humans. thus, this section was reviewed using scientific documents. however, no studies were found that directly evaluate the effect of plant exogenous ncrna and their effects on the immune system following dietary intervention trials. recent reports highlight the shortcomings of existing mirna measuring systems (i.e. qpcr) in comparison to sequencing procedures to explore mirnas in biological fluids chen et al., a) . these studies point out the considerable number of unmapped ncrnas as a major factor limiting the use of qpcr techniques. notably, the abundance level of identified exogenous rna sequences in biological fluids (i.e. human plasma and breast milk, and serum from mice) was rather low. in addition, the role of food matrix on ncrna delivery to their cellular or tissue targets has not been defined. although the identification of exogenous ncrnas in biological samples led to considerations on their role as cross-kingdom regulators of immune-related processes, the impact (i.e. influence and regulatory role) of exogenous plant ncrnas on immune function and homeostasis is inferential. exogenous rnas sequences have been found in plasma , serum (chen et al., b) and breast milk ) from humans and/or animals. these studies reported the presence of ncrnas in biological fluids, although their impact on immune function remains to be fully clarified. the recent discovery of blood circulating rnas originating from foods seems to indicate that certain dietary plant mirnas can be absorbed at significant levels . however, the potential contribution of distinct 'plant food matrices' on ncrnas the present document has been produced and adopted by the bodies identified above as author(s). this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author(s). absorption has not been addressed as it has been described for viral rnas (seljelid et al., ; zou et al., ) . the existing studies show that adequate antigen-processing processes at the intestinal level can be avoided by ncrnas bound to coadjuvant molecules (i.e. polycations, cationic lipids, phospholipids) (seljelid et al., ; zou et al., ; vertzoni et al., ) . notably, phospholipid homeostasis is central in the response to toll like receptors (tlrs) activation through a type i interferon 'autocrine-paracrine' loop (song et al., ) . in biological samples, rna sequences have been reported from most common gm food matrices, including corn (zea mays), rice (oryza sativa japonica group), soybeans (glycine max), tomato (solanum lycopersicum) and grape (vitis vinifera) . the identification of rice mir- a at fm concentration level in various mouse tissues may indicate the possibility of a cellular active uptake system for circulating rna . these data are in agreement with the role of defined food matrices as effective delivery systems protecting ncrnas from interaction with macrophages, dendritic cells, b-lymphocytes, and t-lymphocytes found in peyer's patches and other sites of gut-associated lymphoid tissue. however, several other studies contradict these results (see section . . . for details). enrichment of mirnas with targets related to immune response has been observed in colostral milk . colostrum represents a primordial food driving the first immunization of offspring and provides the nutritional needs of their immature organs in the earliest stages of life. the facts that immune-related mirnas from host, and exogenous plant mirnas (from bamboo diet to milk exosomes of giant panda) targeting synapse organization, neuron migration or axon guidance are enriched in giant breast milk of panda (restricted to a diet primarily comprising bamboo) indicate that breast milk may facilitate dietary intake of plant mirnas by infants for possible regulation of postnatal development ). very few studies address feeding plant ncrnas to animals (i.e. weaning, adult and old age) to evaluate induction of specific adaptive immune response(s) (i.e. th , th or th ). similarly, there is a lack of data on the impact of exogenous plant ncrnas on expression of mhc-ii molecules to assess the potential allergenicity of these rnas. additionally, the different immune response(s) induced by the administration of distinct exogenous plant ncrnas and well-known weak or strong immune inducers by different routes (intraperitoneal or intragastric) have not been tested. understanding of the allergenic functions of exogenous plant ncrnas is comparatively meagre in relation to proteins. the homology of distinct ncrnas could elicit different immune response(s) as proteins showing homology values up to % on their amino acid sequences induce different igg and igg responses (adel-patient et al., ) . for example, the literature search identified one study on safety assessment of the possible effects of gm-triticale on the immune system using a murine c bl/ model (krzyżowska et al., ) . immunoblotting analysis in serum showed significantly increased il- levels, but not those of ifn-γ. it was concluded that multigenerational use of feeds for rodents containing the gm-triticale leads to expansion of the b cell compartment in the secondary lymphoid organs not associated to allergic response(s) (krzyżowska et al., ) . however, this study did not report the ncrna content in gmtriticale. efforts over the last decade have focused on elucidating the role of ncrnas in immune function. although no immunogenic potential has been found, ncrnas implications in pathways regulating the production of inflammatory mediators (witwer et al., ) , the development of hematopoietic cells (satpathy and chang, ) , regulation of tlrs signalling (carpenter et al., ) and changes in t cells needed to support clonal expansion and growth have been highlighted. papers on ncrnas-mediated regulation of the amplitude and quality of immune response(s) could not be found. the present document has been produced and adopted by the bodies identified above as author(s). this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author(s). at the moment, knowledge on the role of ncrnas in immune responses at systems-level remains incomplete. earlier reports defined significant differences in the effects of dsrna (poly i:c) in innate immune responses as a function of 'length' ( . - . kb and . - . kb), depending on cell type (i.e. splenocytes, pbmcs, raw . and thp- ) (mian et al., ) . notably, it was reported that the 'shorter' dsrna caused higher immunomodulatory effects. poly i:c, a synthetic analogue of viral dsrna, has long been known as a strong inducer of innate immune responses by interacting with tlr in the endosome. following ligand recognition, specific ligand cascades involving interferon regulatory proteins and nuclear factor kappa b (nf-b) are activated to produce inflammatory mediators (démoulins et al., ) . similarly, signal-specific lncrnas have been reported in dendritic cells (dcs) stimulated with tlr agonists, % of which clustered with nf-b signalling components (guttman et al., ) . further approaches also identified upregulated responses in a long intergenic noncoding rna (lincrna) in response to tlr- , - , - and - , but not tlr- in macrophages (carpenter et al., ) . specifically, lincrna-cox was found to mediate both activation and repression of immune response genes dependent on interactions of lincrna-cox with heterogeneous nuclear ribonucleoprotein a/b and a /b . a further study determined that lincrna-cox plays a key role as a coactivator of nf-b for the transcription of late-primary inflammatory response genes in macrophages through modulation of epigenetic chromatin remodelling (hu et al., ) . due to the relevance of gut microbiota in immune system development and homeostasis, the possibility of modulating the gut microbiota through dietary exogenous ncrnas was reviewed. as described in section . , during the preparatory phase this novel topic was identified as relevant to this literature review. this additional section serves as a general introduction to emphasize the relevance of the possible modulation of the immune system by dietary exogenous ncrnas through the gut microbiota, and to identify gaps pointing to needs for future studies relevant to food/feed risk assessment of ncrnabased gm plants. specific details of the possible mechanisms of action, if any, are outside the scope of this review. due to the novelty of this topic and the lack of information on the scientific literature, only documents were reviewed for this section. the intestinal tract harbours a complex community (microbiota), which has an enormous impact not only on the nutritional, but also immune status of the host. a balanced gut microbiota composition confers benefits to the host, while microbial imbalances are associated with metainflammatory disorders. the dynamic processes initiated upon birth define the microbiota composition that co-evolves with the host and its environment. thus, colonization of the intestine in early life seems particularly important as it represents one of the major environmental stimuli for immune system maturation. particularly, breast feeding is crucial to influencing early intestinal colonization. as previously indicated, development of emerging 'next generation sequencing technologies' has allowed identification of a significant fraction of the circulating rna in human plasma that originated from exogenous bacterial and fungi species . this study, based on microarray profiling results, reported that plasma can contain ncrnas from common foods influencing the expression profile of a number of genes in the cells. however, several other studies suggest that the quantitative amount of ncrnas are irrelevant for influencing gene expression (see section . . . for details). though the interaction between humans and their environments, particularly microbes, raises the possibility of some sort of feedback signalling process, it is still not fully understood. the literature search showed how few publications address the role of ncrnas in shaping gut microbiota. emerging the present document has been produced and adopted by the bodies identified above as author(s). this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author(s). evidences point out interactions between environmental factors and inter-species gene regulation facilitating host control of the gut microbiota choi et al., ) . however, the impact of exogenous plant ncrnas on gut microbiota modulation remains elusive. increasing evidence demonstrates that a significant number of ncrnas are found in the extracellular media, and it is apparent that mammalian cells release srna that might carry functions which transcend the confines of single cells (valadi et al., ) . few studies have identified changes in mirna expression in human stool. overall, they provide an inconsistent association between their level and dietary habits and lifestyle (tarallo et al., ; . in this context, the survival of exogenous (orally administered) plant mirnas in faeces from mice has been observed . although the amount of particular mirnas such as mir- that survived the gi tract reached a maximum of . %, this study does not support consistent survival rates for distinct ncrnas. a recent study identified mirnas secreted by intestinal epithelial cells in intestinal contents and supports their role in modulating gut microbiota composition . this study reports the potential of host mirnas to enter bacteria and co-localize with microbial nucleic acids. similarly, exogenous plant mirnas that were present in animal faeces were indicated as being primarily acquired orally . recently, bacterial rnas comparable in size to mirnas have been identified that could serve as signalling molecules mediating bacteria-to-human interaction (choi et al., ) . these data were obtained from outer membrane vesicles produced by periodontopathogens and were able to exert 'slight' immunosuppressive effects on t cells cytokine production (il- , il- and il- ). mirna expression levels and amount in stool appear to be modulated by diet (micro-and macronutrients, phytochemicals) without excluding the possibility that the results were affected by other lifestyle factors; however, the influence of gm plant exogenous ncrnas has not yet been exhaustively studied in animals or humans. distinct innate immune mediators participating in the recognition and discrimination between the distinct nucleic acids have been identified; thus, additional definition of the dynamic interplay between the different 'sensors' (i.e. tlrs, rig-i/mda , the interferon response effectors protein kinase r and rnase l) in response to ncrnas have to be clarified. the chemical modifications observed in plant ncrnas highlight the need to address the detection and measurement of exogenous plant ncrnas in body fluids, as well as the sensitivity and specificity of these rnas to cellular and tissue targets. although many reports focusing on synthetic ss-and dsrna mimics can be found in the literature, scientifically assessed direct hazardous impacts of food and feed on fauna and flora are scarce and conflicting. notably, there is a need to evaluate the effects of exogenous plant ncrnas at the system biology level and in human trials. current knowledge on the immune functions of exogenous ncrnas is comparatively lacking. most studies use cell models based on isolated cells that could not mimick the whole set of players that determine immune response(s), which are necessary for mechanistic studies, but need approach cell-to-cell communication in target tissues. additionally, these studies should focus on the relationship of immune responses to production of ifns since tlrs signalling converge on the production of this immune regulatory factor. to better understand the impact of exogenous ncrnas in host microbiota composition and diversity, further studies are needed to establish the microbial targets and their effect on physiological conditions. understanding the basic biological aspects of plant-derived exogenous ncrna (including their half-life and stability), gathering information on human and animal exposure by diet to these molecules, their subsequent bioavailability and possibility to exert local or systemic effects, and reviewing the experience from the development of rna-based therapeutics are relevant aspects for the risk assessment of ncrnabased gm food and feed. the literature includes very few studies evaluating the half-life of plant-derived ncrnas. while no specific studies on plant mirnas and lncrnas half-life were found in this review, the studies on plant circrnas half-life suggest that they exhibit considerable stability as compared to linear rnas (section . . . ). in mammals, the few reports related to ncrnas half-life suggest that mirnas and circrnas are generally much more stable than mrna, while lncrnas have a half-life like that of mrna. however, when assessing the stability of plant ncrnas outside the plant (section . . . .), compelling evidence exists that plant mirnas are highly stable under different conditions including food storage, processing, cooking, or simulated digestion. moreover, they seem to survive after long incubation in serum, or are detected in the gastric content of mice, suggesting that plant mirnas are more resistant to degradation than synthetic or animal mirnas. this high resistance has been attributed to the unique characteristics of plant mirnas (and sirnas), in contrast to mirnas from mammalian and other organisms; the '-omethylation at their ' end which confers plant mirnas more resistance to degradation (section . . . ). efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as author(s). this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author(s). the experience from development of ncrna therapeutics (section . . ) shows that unmodified nucleic acids (i.e. rnas) exhibit very low stability in biological media and are subjected to rapid nuclease mediated degradation. indeed, a plethora of rnases are encoded within most genomes, often with overlapping activities, making redundancy a general feature of rna degradation systems. consequently, different chemical modifications or conjugations have been introduced to potential rna-based therapeutics (section . . . ) to improve their rna-binding affinity, their in vivo nuclease stability and their pharmacokinetic and pharmacodynamic properties. the available literature also suggests that naked or unmodified rnas parenterally administered (e.g. iv) are rapidly cleared from circulation and their presence in the kidney and urine has been reported immediately after administration (section . . ). similarly, following oral administration naked or unmodified exogenous rnas are rapidly degraded when exposed to the gi harsh conditions, and different delivery vehicles for exogenous rnas have been developed. in general, and in contrast to chemically modified or formulated rnas, no major biological effects have been observed for naked rnas, which has probably limited further evaluation in humans (section . . . ). although certain disease conditions may influence the pharmacokinetics of exogenous rnas, there are no studies that specifically evaluate this for naked unmodified exogenous ncrnas. to exert a biological effect, an exogenous ncrna first needs to reach the intended target tissue in sufficient quantity levels, this implying the necessity to overcome many biological barriers (section . . ). considering the oral intake as the main possible entry point of exogenous plant ncrnas into both animals and humans, the first major barrier is the mammalian gi tract, which encompasses a group of extracellular and cellular barriers. extracellular barriers include the presence of different enzymes (i.e. nucleases), the harsh environment and a net negative charged mucous layer. the cellular barriers include a three-layer (epithelial cells or enterocytes, the lamina propria and the muscularis mucosa) barrier known as the intestinal mucosa. possible ncrnas passage between cells is limited by the presence of tight junctions and the pore size in the human intestine would prevent the passage of all but mirnas, which are the smallest ncrnas. although crossing the cells by transcytosis may be possible, this mechanism implies facing new intracellular barriers, such as nucleases, recycling of ncrnas back to the lumen and nuclear uptake. however, m-cells, present in the gut epithelium interspersed between enterocytes, present certain characteristics that would make them more amenable for rna uptake. a second barrier is represented by a set of obstacles during the passage from the intestine to the target tissue, which encompasses plasma and tissue nucleases. once in the circulatory system, exogenous ncrnas are subjected to distribution and elimination. for example, small rnas would be rapidly cleared by the kidney due to their small size. furthermore, ncrnas need to escape the reticuloendothelial system, the function of which is to clear foreign pathogens. finally, they would have to cross the vascular endothelial barrier to reach the target tissue, facing hurdles like those in the enterocytes. packaging or incorporation of ncrnas into extracellular transport systems (i.e. exosomes/microvesicles or inclusion in ribonucleoprotein complexes) would confer certain resistance to nucleases and other barriers. ncrnas must enter the target cells to exert their functions. the molecular mechanisms of exogenous ncrna cellular uptake have been inferred from studies performed when developing strategies for nucleic acids delivery as therapeutics and is also largely derived from invertebrates, with little data reported in mammals. descriptions exist of receptor-mediated uptake of oligonucleotides through the sidt and sidt proteins, although this is now in doubt since they have been described as cholesterol transporters. due to the charged nature of rnas, cellular uptake could be achieved by endocytosis after which they would enter the system of intracellular trafficking through multiple membrane-bound compartments. ncrnas must exit these compartments to reach their functional sublocation within the efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as author(s). this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author(s). cell, either the cytosol or the nucleus, while simultaneously escaping degradation in the lysosomes. specialized barriers such as the blood-brain barrier or the placental barrier represent additional obstacles to overcome. while rna content in plant-derived foods varies (≈ mg/g of tissue), it could be estimated that when consuming a daily dose of total fruit and vegetables of ≈ g/day, humans theoretically ingest mg of total rnas (dietary intake of plant rna may typically range from . - g/person/day) (section . . . ). humans following special diets, such as vegetarians and vegans, have higher intake of plant origin rnas, but estimated exposure to such rnas implies only a -fold increase on average (section . . . ). it has been estimated that small rnas make up far less than % of total rna in plants, suggesting a very low exposure to plant ncrnas under normal conditions. whether sufficient levels of exogenous plant ncrnas can be consumed in the diet to exert a biological effect is also another aspect that needs to be evaluated. some examples in the literature suggest that for certain plant mirnas (i.e. mir- a) a person would need to consume kg of cantaloupe to reach the copies of mirna per cell possibly determining an effect. these aspects should be evaluated for each plant ncrna (on a case basis), considering that some plant-derived mirnas have shown unexpectedly high resistance to degradation and greater bioavailability. the available literature indicates a widespread presence of exogenous rnas (including plant derived ncrnas, i.e. small rnas) in the biological fluids of humans and animals (section . . ). whether these rnas are derived from dietary intake is unclear. their generally low abundance and lack of enrichment in tissues mostly exposed to dietary changes (i.e. liver) suggest that some of may have be originated as technical artefacts or through contamination. very few studies address biological effects of dietary exogenous ncrnas in the gi tract and its annex glands (e.g. liver) (section . can directly target mammalian genes through rnai effects, but still clarification is needed if exogenous plant ncrnas can overcome all the biological barriers to reach and interact with their possible targets. exogenous plant-derived ncrnas have been found in exosomes or macrovesicles. how they reach these types of structures in biological fluids is unknown. in summary, supporting and contradicting evidence concerning the existence of systemic effects of dietary plant-derived exogenous ncrnas is heavily debated. important aspects such as the precise mechanism/s of transport of plant ncrnas from food into the systemic circulation, the amount of exogenous ncrnas reaching tissues or the molecular mechanisms of cellular uptake need to be determined. while several in vitro studies cover the participation of exogenous ncrnas in the dynamic network to modulate innate immunity responses, few tackle the immunomodulatory effects of plant ncrnas in adaptive immune response (section . ). none of these studies have considered the potential impact of exogenous dietary plant-derived ncrnas at the systemic level. since the first publication suggesting a possible cross-kingdom effect by dietary ncrna (through rice mir- a) the knowledge on exogenous ncrnas, and particularly plant-derived exogenous ncrnas, on efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as author(s). this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author(s). their fate when ingested has increased. however, the knowledge useful to support the assessment of dietary ncrna such as ncrna-based gm food and feed still faces several gaps. an important aspect needing further investigation is the stability of plant ncrnas. the meagre available literature contains a very few studies of the half-life of plant ncrnas (i.e. mirnas, lncrnas and circrnas) both inside the plant cell and outside the plant. specifically, the stability of circrnas should be assessed due to their apparently high stability. moreover, very few reports focus on assessment of plant ncrnas stability in mammalian systems, when ingested. understanding the molecular basis that confers plant ncrnas stability is of great importance and needs to be further evaluated. for instance, plant mirnas and sirnas carry modifications that do not occur in mammals. these modifications, such as the presence of a methyl group located on the ' nucleotide ribose, could hypothetically have an impact on the plant mirnas stability in mammalian systems/cells due to either the lack of the appropriate enzymes for recognition and degradation of plant mirnas by mammalian cells, or the increased stability to degradation by mammalian rnases. the circularized structure of plant circrnas would hypothetically confer them increased stability to mammalian rnases. if this is the case, plant mirnas and circrnas could exhibit a much longer half-life in mammalian systems than expected, especially when compared to mammalian mirna or circrnas. this would increase their chances of reaching the appropriate target tissue and encountering suitable target molecules within the cells. the half-life of plant ncrnas within mammalian cells is also an important aspect to consider. experiments are needed with labelled plant ncrnas, first in transfected mammalian cells (in vitro studies) and then orally administered to experimental animals (in vivo studies). radioactive probes or molecules of very low molecular weight, such as biotin or fluorescein, should be used, in order to prevent distorting the actual size of the studied plant ncrna; this is important when studying mirnas stability due to their small size. another aspect possibly relevant for risk assessment is to understand whether and how ingested gm plant-derived ncrnas can affect the expression levels of other ncrnas and other rnas, due to putative compensatory circuits and codifying rnas. whole transcriptome sequencing, comparing the rna levels of unmodified (wild type) to those of modified (transgenic) plants coul be useful to this aim. although available information suggests that many biological barriers exist in mammalian system to ingested plant exogenous ncrnas preventing these to exert a possible local or systemic effect, several gaps are still present. putative pathways of dietary exogenous ncrnas after ingestion and the many transporters potentially involved (i.e, in cellular uptake, or barrier passage transport pathways) in the transit from the gut to the target tissues should be characterized using standard molecular biology gainof-function and loss-of-function approaches. also, the many routes of mammalian intracellular trafficking to the specific intracellular target should be studied. to this aim, ncrnas isolated from human diets should be used preferentially, since most of the incomplete current knowledge comes from the rna-therapeutics field or is derived from the invertebrate world. which molecular mechanisms support the possible passage through specialized barriers (i.e. blood-brain barrier or the placental barrier), is another critical aspect requiring further studies. while there are in vitro studies describing the interaction between plant mirnas and mammalian mirna silencing complexes possibly leading to target repression, these findings need to be experimentally validated in vivo. therefore, more studies are needed to understand the possibility of processing plant ncrnas in mammalian cells. it is also unknown if ingested plant mirnas reaches or needs to reach a necessary level to exert a biological effect. for instance, studies in mammals suggest that the threshold for target gene regulation is > copies per cell for a certain study; however, another study suggests around to . copies of mammalian mirna per cell. clearly, a minimum amount of small rnas efsa supporting publication :en- the present document has been produced and adopted by the bodies identified above as author(s). this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author(s). would be required to achieve biologically relevant effects on gene expression. on a case by case basis it would be useful to evaluate the amount of consumption of a given ncrna in a normal diet. it is also relevant to study if exposure to these plant ncrnas could change under certain pathological conditions (i.e. compromised intestinal permeability or renal function) or dietary patterns (i.e. vegetarian or vegan diets). although tissue accumulation of dietary plant exogenous ncrnas has not been reported to date, it seems clear that plant mirnas and other exogenous rnas are present in biological fluids from humans and animals. the biological significance of their presence is still unknown and needs to be addressed. methods that do not require amplification for detection should be used. more quantitative approaches to determine the levels of plant-derived exogenous ncrnas should be determined both in biological fluids and tissues to understand the magnitude of presence. for example, this could be partially obtained from studies reporting the presence of exogenous rnas in biological fluids using public small rna-seq databases. in the case of plant-derived mirnas, the use of sodium periodate oxidation of samples could be a good start to verifying the presence of genuine plant-derived mirnas from diet in human and animal biological fluids. the immunomodulatory effects of exogenous rnas have been widely described in the literature. however, there is no in vivo information regarding the immunomodulatory effects of dietary exogenous ncrnas. these types of studies should be performed both in vitro and in vivo to determine if the different types of ncrnas consumed in the diet can affect the immune system. in the case of target gene repression by plant ncrnas investigations in specific animal models could be considered. expression levels of other ncrnas and rnas, which may be modified due to putative compensatory circuits could be evaluated in these models, as well as information on the stability and half-life of the specific ncrna in specific cells and systemically following ingestion. genome-wide high-resolution mapping of exosome substrates reveals hidden features in the arabidopsis transcriptome genome-wide identification of circular rnas in arabidopsis thaliana a lariat-derived circular rna is required for plant development in arabidopsis pattern formation via small rna mobility small rnas are on the move literature review of baseline information on rnai to support the environmental risk assessment of rnai-based gm plants identification of circular rnas from the parental genes involved in multiple aspects of cellular metabolism in barley a group i plant intron accumulates as circular rna forms with extensive ' deletions in vivo toward a consensus on the binding specificity and promiscuity of prc for rna a stepwise pathway for 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exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document alternative mirnas: human sequences misidentified as plant mirnas in plant studies and in human plasma transfer and functional consequences of dietary micrornas in vertebrates: concepts in search of corroboration: negative results challenge the hypothesis that dietary xenomirs cross the gut and regulate genes in ingesting vertebrates, but important questions persist real-time quantitative pcr and droplet digital pcr for plant mirnas in mammalian blood provide little evidence for general uptake of dietary mirnas: limited evidence for general uptake of dietary plant 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fungi within the order hypocreales are ubiquitous in human plasma dietary microrna database (dmd): an archive database and analytic tool for food-borne micrornas lack of detectable oral bioavailability of plant micrornas after feeding in mice survey of + data sets from human tissue and body fluid reveals xenomirs are likely artifacts plant mirnas found in human circulating system provide evidences of cross kingdom rnai detection of plant mirnas abundance in human breast milk in silico identification of plant mirnas in mammalian breast milk exosomes--a small step forward? optimization of enzymatic reaction conditions for generating representative pools of cdna from small rna computational characterization of exogenous micrornas that can be transferred into human circulation mining of public sequencing databases supports a nondietary origin for putative foreign mirnas: underestimated effects of contamination in ngs the complex exogenous rna spectra in human plasma: an interface with human gut biota? the spectrum of circulating rna: a window into systems toxicology detection of an abundant plant-based small rna in healthy consumers oral administration of bovine milk derived extracellular vesicles attenuates arthritis in two mouse models exosomes as a nanodelivery system: a key to the future of neuromedicine? endogenous microrna can be broadly exploited to regulate transgene expression according to tissue, lineage and differentiation state identification of dietetically absorbed rapeseed (brassica campestris l.) bee pollen micrornas in serum of mice lack of detectable oral bioavailability of plant micrornas after feeding in mice high-throughput sequencing of rna silencingassociated small rnas in olive (olea europaea l.) plant-derived phosphocholine facilitates cellular uptake of anti-pulmonary fibrotic hjt-srna-m autosomal recessive hypercholesterolemia caused by mutations in a putative ldl receptor adaptor protein exosomes as therapeutic drug carriers and delivery vehicles across biological membranes: current perspectives and future challenges extensive degradation and low bioavailability of orally consumed corn mirnas in mice an improved method to quantitate mature plant microrna in biological matrices using modified periodate treatment and inclusion of internal controls this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document cross talk between adipose tissue and placenta in obese and gestational diabetes mellitus pregnancies via exosomes grape exosome-like nanoparticles induce intestinal stem cells and protect mice from dss-induced colitis survey of + data sets from human tissue and body fluid reveals xenomirs are likely artifacts cross-kingdom regulation of putative mirnas derived from happy tree in cancer pathway: a systems biology approach small non-coding rnas transfer through mammalian placenta and directly regulate fetal gene expression assessing the survival of exogenous plant microrna in mice reply to dr. witwer's letter to the editor effective detection and quantification of dietetically absorbed plant micrornas in human plasma plant mirnas found in human circulating system provide evidences of cross kingdom rnai detection of dietetically absorbed maizederived micrornas in pigs negligible uptake and transfer of diet-derived pollen micrornas in adult honey bees the transport mechanism of extracellular vesicles at the blood-brain barrier unsuccessful detection of plant micrornas in beer, extra virgin olive oil and human plasma after an acute ingestion of extra virgin olive oil a novel chemopreventive strategy based on therapeutic micrornas produced in plants interspecies communication between plant and mouse gut host cells through edible plant derived exosome-like nanoparticles high-throughput assessment of microrna activity and function using microrna sensor and decoy libraries milk extracellular vesicles accelerate osteoblastogenesis but impair bone matrix formation corn rootwormactive rna dvsnf : repeat dose oral toxicology assessment in support of human and mammalian safety a -day oral toxicity evaluation of small interfering rnas and a long double-stranded rna targeting vacuolar atpase in mice citrus limon-derived nanovesicles inhibit cancer cell proliferation and suppress cml xenograft growth by inducing trail-mediated cell death this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document ineffective delivery of diet-derived micrornas to recipient animal organisms adipose-derived circulating mirnas regulate gene expression in other tissues uptake and function studies of maternal milk-derived micrornas contamination or artifacts may explain reports of plant mirnas in humans alternative mirnas: human sequences misidentified as plant mirnas in plant studies and in human plasma real-time quantitative pcr and droplet digital pcr for plant mirnas in mammalian blood provide little evidence for general uptake of dietary mirnas: limited evidence for general uptake of dietary plant xenomirs detection of an abundant plant-based small rna in healthy consumers anomalous uptake and circulatory characteristics of the plant-based small rna mir bioavailability of trasngenic micrornas in genetically modified plants exosome delivered anticancer drugs across the blood-brain barrier for brain cancer therapy in danio rerio molecular basis of mammalian transmissibility of avian h n influenza viruses and their pandemic potential exogenous plant mir a specifically targets mammalian ldlrap : evidence of cross-kingdom regulation by microrna honeysuckle-encoded atypical microrna directly targets influenza a viruses plant micrornas in larval food regulate honeybee caste development to evaluate oral toxicity of exogenous ncrnas in mice, petrick et al. administered for days a repeated oral dose of sirnas and dsrna and evaluated several parameters including body weight, food consumption, clinical observations, clinical chemistry, haematology, gross pathology, or histopathology endpoints it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author(s). signs (mortality, abnormalities, and sign of pain and distress), body weight and food consumption, haematology, organ weight, or pathology results. the minor differences observed in certain parameters were limited to single intervals, were not dose-related, and were attributed to interanimal variability torula yeast rna (rna negative control) at mg/kg/day or a control vehicle were used. ten animals per sex and per group were used. no treatment-related effects were observed on clinical signs (mortality, or sign of pain and distress), body weight and food consumption, haematology, organ weight, or pathology results. minor changes in selected parameters in selected groups were observed, but these were attributed by the authors to normal variability and not treatment-related effects this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document ecological risk assessment for dvsnf rna: a plant-incorporated protectant with targeted activity against western corn rootworm literature review of baseline information on rnai to support the environmental risk assessment of rnai-based gm plants a comparative evaluation of the regulation of gm crops or products containing dsrna and suggested improvements to risk assessments endogenous small rnas in grain: semi-quantification and sequence homology to human and animal genes literature review of baseline information to support the risk assessment of rnai-based gm plants corn rootwormactive rna dvsnf : repeat dose oral toxicology assessment in support of human and mammalian safety a -day oral toxicity evaluation of small interfering rnas and a long double-stranded rna targeting vacuolar atpase in mice rnai technologies in agricultural biotechnology: the toxicology forum th annual summer meeting no impact of dvsnf rna on honey bee (apis mellifera l.) adults and larvae in dietary feeding tests microstructure and ultrastructure of highamylose rice resistant starch granules modified by antisense rna inhibition of starch branching enzyme a -day toxicology study of high-amylose transgenic rice grain in sprague-dawley rats a three generation reproduction study with sprague-dawley rats consuming high-amylose transgenic rice high-amylose rice improves indices of animal health in normal and diabetic rats studies performed with human cells were mainly carried out ex vivo using lymphocytes and, to a significant extent, macrophages. from the studies retrieved during the screening phase on immune cells in relation to exogenous ncrna %) from rat and ( . %) from mouse. and within the studies on immune cells other than lymphocytes (i.e. macrophages), the studies were allocated into ( . %) from human, ( . %) from rat, and ( . %) from mouse. all these data clearly show that studies retrieved in relation to ncrnas and www this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document immunological and metabolomic impacts of administration of cry ab protein and mon maize in mouse role of toll-like receptors in antisense and sirna recognition of double-stranded rna and activation of nf-kappab by toll-like receptor rna regulation of the immune system therapy of respiratory viral infections with intranasal sirnas cd is a coreceptor of toll-like receptors and a long noncoding rna mediates both activation and repression of immune response genes identification of dietetically absorbed rapeseed (brassica campestris l.) bee pollen micrornas in serum of mice identification of dietetically absorbed rapeseed (brassica campestris l.) bee pollen mirnas in serum of mice chemical modification patterns compatible with high potency dicer-substrate small interfering rnas is rna interference involved in intrinsic antiviral immunity in mammals? poly (i:c) induced immune response in lymphoid tissues involves three sequential waves of type i ifn expression structural basis for cytosolic double-stranded rna surveillance by human oligoadenylate synthetase structural mechanism of sensing long dsrna via a noncatalytic domain in human oligoadenylate synthetase rnas containing modified nucleotides fail to trigger rig-i conformational changes for innate immune signaling this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document identification of rna sequence motifs stimulating sequence-specific tlr -dependent immune responses dsrna with ′ overhangs contributes to endogenous and antiviral rna silencing pathways in plants a tim- oligonucleotide aptamer enhances t cell functions and potentiates tumor immunity in mice ab initio reconstruction of cell type-specific transcriptomes in mouse reveals the conserved multi-exonic structure of lincrnas ribosome profiling provides evidence that large noncoding rnas do not encode proteins chromatin signature reveals over a thousand highly conserved large noncoding rnas in mammals lack of interferon response in animals to naked sirnas species-specific recognition of single-stranded rna via toll-like receptor and small anti-viral compounds activate immune cells via the tlr myd -dependent signaling pathway sequencespecific potent induction of ifn-alpha by short interfering rna in plasmacytoid dendritic cells through tlr lincrna-cox promotes late inflammatory gene transcription in macrophages through modulating swi/snf-mediated chromatin remodeling microrna a marks regulatory t cells the role of alternative polyadenylation in the antiviral innate immune response the '-o-methylation status of a single guanosine controls transfer rna-mediated toll-like receptor activation or inhibition design of noninflammatory synthetic sirna mediating potent gene silencing in vivo sequence-dependent stimulation of the mammalian innate immune response by synthetic sirna immunostimulatory potential of silencing rnas can be mediated by a non-uridine-rich toll-like receptor motif suppression of rna recognition by toll-like receptors: the impact of nucleoside modification and the evolutionary origin of rna sequence-and target-independent angiogenesis suppression by sirna via tlr microrna as a new immune-regulatory agent in breast milk this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document the effect of multigenerational diet containing genetically modified triticale on immune system in mice cross-kingdom regulation of putative mirnas derived from happy tree in cancer pathway: a systems biology approach double-stranded rna-mediated tlr activation is enhanced by cd molecular basis for the immunostimulatory activity of guanine nucleoside analogs: activation of toll-like receptor the tlr signaling complex forms by cooperative receptor dimerization mir- a is an intrinsic modulator of t cell sensitivity and selection assessing the survival of exogenous plant microrna in mice structural basis of toll-like receptor signaling with double-stranded rna the host shapes the gut microbiota via fecal microrna in silico identification of plant mirnas in mammalian breast milk exosomes--a small step forward? exosomal micrornas in giant panda (ailuropoda melanoleuca) breast milk: potential maternal regulators for the development of newborn cubs microrna- c promotes natural killer cell cytotoxicity via up-regulating the expression level of nkg d neonatal immune activation during early and late postnatal brain development differently influences depressionrelated behaviors in adolescent and adult c bl/ mice small self-rna generated by rnase l amplifies antiviral innate immunity a structural basis for discriminating between self and nonself double-stranded rnas in mammalian cells cancer immunotherapy comes of age length of dsrna (poly i:c) drives distinct innate immune responses, depending on the cell type oligonucleotide-based pharmaceuticals: non-clinical and clinical safety signals and non-clinical testing strategies cytosolic viral sensor rig-i is a '-triphosphate-dependent translocase on double-stranded rna aptamers for cd antigens: from cell profiling to activity modulation cd aptamers as powerful immune response modulators influences of diet and the gut microbiome on epigenetic modulation in cancer and other diseases this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document aptamer-targeted attenuation of il- signaling in cd + t cells enhances antitumor immunity catalog of differentially expressed long non-coding rna following activation of human and mouse innate immune response. front immunol , long noncoding rna in hematopoiesis and immunity the effect of poly-l-lysine on the uptake of reovirus doublestranded rna in macrophages in vitro characterization of the mammalian rna exonuclease /nef-sp as a testis-specific nuclear ' → ' exoribonuclease microrna regulation of lymphocyte tolerance and autoimmunity advances in rna sensing by the immune system: separation of sirna unwanted effects from rna interference activation of the interferon system by short-interfering rnas type i interferons function as autocrine and paracrine factors to induce autotaxin in response to tlr activation antisense oligonucleotides containing locked nucleic acid improve potency but cause significant hepatotoxicity in animals microrna expression in relation to different dietary habits: a comparison in stool and plasma samples interplay between dengue virus and toll-like receptors, rig-i/mda and micrornas: implications for pathogenesis exosome-mediated transfer of mrnas and micrornas is a novel mechanism of genetic exchange between cells dissolution media simulating the intralumenal composition of the small intestine: physiological issues and practical aspects lps injection reprograms the expression and the ' utr of a cap gene by alternative polyadenylation and the formation of a gait element in ciona intestinalis the complex exogenous rna spectra in human plasma: an interface with human gut biota? induced mir- a expression represses mtor cooperatively with mir- to promote regulatory t-cell differentiation evolutionary dynamics and tissue specificity of human long noncoding rnas in six mammals toll-like receptor (tlr) immune modulation by unformulated small interfering rna or dna and the role of cd (in tlrmediated effects) homology modeling of human tolllike receptors tlr , , and ligand-binding domains modulation of let- mirnas controls the differentiation of effector cd t cells this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document microrna regulation of ifn-beta protein expression: rapid and sensitive modulation of the innate immune response . '-utr and '-utr regulation of micb expression in human cancer cells by novel micrornas microrna- is downregulated by histone deacetylase inhibitors and confers resistance to natural killer cytotoxicity in hepatocellular carcinoma cells ncrna-and pc methylation-dependent gene relocation between nuclear structures mediates gene activation programs plumbing the sources of endogenous mhc class i peptide ligands infalpha- b inhibitory effects on cd (+)cd (+)foxp (+) regulatory t cells in the tumor microenvironment of c bl/ j mice with melanoma xenografts stress-responsive regulation of long noncoding rnas' polyadenylation in oryza sativa exogenous plant mir a specifically targets mammalian ldlrap : evidence of cross-kingdom regulation by microrna antiviral activity of human oligoadenylate synthetases-like (oasl) is mediated by enhancing retinoic acid-inducible gene i (rig-i) signaling lipid-mediated delivery of rna is more efficient than delivery of dna in non-dividing cells ribose '-omethylation provides a molecular signature for the distinction of self and non-self mrna dependent on the rna sensor mda the present document has been produced and adopted by the bodies identified above as authors. this task has been carried out exclusively by the authors in the context of a contract between the european food safety authority and the authors, awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the authors. the present document has been produced and adopted by the bodies identified above as author(s). this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author(s). (zhou et al., ) . twenty female and ten male rats per group in the first generation (f ) were fed the different diets. their pups, weanling/female/group and weanling/male/group were randomly selected as an f generation. the f generation was acquired by using the same procedure described above. at weaning, f generation rats were chosen, and rats/sex/group provided the corresponding diets and observed for weeks. no major differences in animal survival, health status, behaviour, body weight, food consumption, or reproductive capacity were observed with the different diets. some statistically significant differences were observed in animals given the transgenic rice diets compared to those receiving the standard diet for certain clinical chemistry parameters, in certain generations (alt, alkp, ldh, cholesterol, hdlc, ldlc). these changes were not considered adverse or biologically significant (zhou et al., ) . moreover, no evidence of altered incidence or altered severity of background changes was observed in any organ or tissues of the rats fed the three diets (zhou et al., ) . although minor changes in the mean relative weight of epididimides in male f adults was observed in rats fed the rice diets compared to the control group, no difference was observed between the transgenic rice fed rats and their near-isogenic line controls, suggesting overall that the transgenic line was unlikely to cause any risk to rat health in reproduction or development, even when consumed for up to three generations (zhou et al., ) . however, these studies did not evaluate any aspect related to rnai.heinemann et al. compared the history of risk assessment of gmos producing dsrnas in australia, new zealand and brazil, with a focus on regulatory context (heinemann et al., ) . the authors suggested some processes to properly assess the safety of dsrna-producing gm plants before their release or marketing. these include i) bioinformatics analysis to identify any likely, unintended targets of the dsrna in human and animals; ii) experimental procedures that would identify all new intended and unintended dsrna molecules in the gm product; iii) testing animal and human cells in tissue cultures for a response to intended and unintended effects of dsrnas from the product; iv) long-term testing on animals; and possibly v) clinical trials on human volunteers (heinemann et al., ) . in response to this article, the regulatory agency food standards australia new zealand (fsanz) published a document addressing regulation of gm crops and foods developed using gene silencing (http://www.foodstandards.gov.au/consumer/gmfood/pages/response-to-heinemann-et-al-on-theregulation-of-gm-crops-and-foods-developed-using-gene-silencing.aspx). this document criticised some of the comments of the above risk assessment review. some key points included the lack of weight of scientific evidence (published up to ) to support the view that small dsrnas in foods are likely to have adverse consequences in humans; the lack of a scientific basis for suggesting that small dsrnas present in gm foods have different properties than naturally-occurring ones; or the adequate acknowledge of many barriers (in the uptake, distribution and targeting) during oral development of small dsrna therapies, among others. the overall suggestion was that there was no need to consider additional studies as proposed by heinemann et al. ( ) .commentary documents reviewing scientific meetings in the context of rnai technologies in agricultural biotechnology discuss some of the aspects reviewed in this document .additional relevant documents of baseline information to support the risk assessment and environmental risk assessment of rnai-based gm plants can be obtained from efsa external scientific reports the present document has been produced and adopted by the bodies identified above as author(s). this task has been carried out exclusively by the author(s) in the context of a contract between the european food safety authority and the author(s), awarded following a tender procedure. the present document is published complying with the transparency principle to which the authority is subject. it may not be considered as an output adopted by the authority. the european food safety authority reserves its rights, view and position as regards the issues addressed and the conclusions reached in the present document, without prejudice to the rights of the author(s). key: cord- -buis y authors: henry, robert title: innovations in agriculture and food supply in response to the covid- pandemic date: - - journal: mol plant doi: . /j.molp. . . sha: doc_id: cord_uid: buis y nan in human history, the long-term expansion of populations has been limited by the availability of food and constraints of disease (diamond, ) . the domestication of plants and animals has facilitated the development of human societies and the resulting larger human populations have increased the risk of major disease outbreaks (pandemics). the recent covid- pandemic resulted from the emergence of a disease caused by severe acute respiratory syndrome coronavirus (sars-cov- ). this has caused major disruption to economic activity with severe restrictions on international travel. the impact on agriculture and global food security will be complex (torero, ) and many of the consequences are yet to be identified and understood (jámbor et al, ) . despite growing stocks of foods such as cereals (fao, ) , it has been estimated that the number of people facing a food crisis will grow from million to million by the end of (anthem, ; figure ). the pandemic has added to the food security challenges posed by climate change and major conflicts, both of which have been major factors, contributing to recent food insecurity. plant scientists need to determine how investment in innovation needs to change in response to the pandemic. concerns about shortages of labour and food safety will intensify efforts to use automation at all stages in the food production system to ensure supply. the response to transport and trade disruption may prompt accelerated efforts to develop protected cropping to support food production much closer to the point of consumption. both of these trends will add to the demand for new crop varieties that satisfy the growing demands of consumers and drive additional research efforts including accelerated application of emerging plant breeding technologies (henry, a) for production in these rapidly evolving agricultural environments. the management of the current pandemic to date suggests little impact on global food demand due to human population loss. the impacts on the food security of people in the developed world have been relatively minor so far but more serious problems are emerging in developing countries (somner et al, ) . in developed countries, demand for some stable foods, such as rice, was initially very high with consumers purchasing large supplies as a response to fears of food shortages. some food consumption patterns have changed due to people being restricted to eating at home rather than in restaurants (torero, ). in many developing countries, covid- has severely impacted on employment and incomes creating a major food crisis for growing numbers of people unable to afford food. demand for emergency food supplies is likely to grow. disruption of food supply is a major challenge resulting from covid- . labour for harvesting, processing, transport and distribution has been threatened by restriction on movement and management of risks of the spread of the virus. the closing of national borders has limited the availability of migrant workers. food processing facilities have been closed due to infection of workers with the virus. longer-term impacts of the pandemic are possible if agricultural and food supply chains are managed more conservatively to retain high stock levels as a buffer against future pandemics. international air transportation (international transport forum, ) has been severely disrupted by covid- and the movement of some high value food shipped by air has been more difficult. the long-term policy implications of the pandemic for global food trade remain unclear. the pandemic has focused attention on the critical importance of continued food production and distribution and some of the approaches developed to ensure food supply might be retained in the longer term. the covid- pandemic has been disruptive of agricultural and food research. many research labs have closed and many global research conferences have been cancelled. reducing direct contact between researchers. researchers have responded by working on line as much as possible and adjusting laboratory working environments to have lower numbers of researchers per unit area of laboratory space. increased shift work has allowed researchers to work at different times of the day and continue to have laboratory access. one short term impact has been the diversion of researchers to covid- research projects (capell et al, ) . agricultural researchers with appropriate skills have been tasked with supporting research such as developing vaccines, assessing anti-viral treatments, improving or deploying diagnostic tests, and supporting contact tracing of people infected with the virus. the pandemic will result is some resetting of research priorities to focus on making agriculture and food production more resilient to such events. the long term impact of covid- on the progress of agricultural and food research remains unclear. the large global economic impact of covid- may have implications for agriculture and food production (somner et al, ) . the global economy has been impacted severely with economic activity curtailed by people being isolated to minimize spread of the virus. some of the long-term impacts of covid- may be driven by fear of future pandemics. this will result in risk management strategies that could impact on agriculture and food production. people and countries could aim to be more self-sufficient in food production to reduce reliance on food supply from other places or countries. trends that may emerge could include more attempts at self-sufficiency by consumers growing their own food at home, and more home cooking because of experiences during the pandemic. more significant will be the approach of governments to food security with possible impacts on global trade in foods. export of foods maybe blocked and imports restricted to force local production as strategies to protect the food supply in future pandemics. the adverse impact of covid- on the global economy may also result in a renewed risk of accelerated population growth that could add significantly to food insecurity. while economic difficulties result in lower population growth rates in developed countries (sobotka et al, ) , poverty is a major factor contributing in rapid population growth in developing countries (van bavel, ) . if covid- prevents escape from poverty in these countries populations growth may be higher than previously predicted and put more pressure on food security. many responses to the pandemic have resulted in changes in agriculture and food production that may persist in the longer term. in some situations, more emphasis may be placed on automation of food production and processing to avoid the risks of using labour that may be unavailable due to illness or due to the restriction on labour migration. this could result in more investment in automation of harvesting and processing, minimizing manual steps in the whole production chain. risk management strategies in food companies may include automation to minimize reliance of humans that are not available due to illness or migration restrictions. the automation of food production in these systems could also eliminate the risks of contamination of the food during production. covid- contamination of foods has not been a problem but other organisms in future pandemics might pose this risk. the experience of trade disruptions during the pandemic may add to the climate change induced trend towards more protected cropping (henry, b) . all forms of protected cropping including advanced vertical farming may be more capital intensive but have the potential to reduce the risks associated with food production. protected cropping allows production close to the point of consumption regardless of the environment required for the growth of the crop and eliminates the problems of long-distance transportation that may be limited in a pandemic. these innovations may also bring the advantages of automation described above. accelerated deployment of improved crop varieties using emerging genetic technologies could contribute significantly to the delivery of the productivity gains required to ensure food security. the pandemic has added extra urgency to this work that has recently been driven by the need to respond to climate change. gene editing technologies have a chance of being more widely accepted and understood than earlier gm approaches and have the potential for very rapid advances in food production if combined with protected cropping. the use of controlled environments for food production allows genetics to focus on enhancing the nutritional value and consumer attractiveness of the food products. the approach to food product innovation is likely to be one involving iterative cycles of designing and building the target genotype (using plant biotechnology equipped with advanced genomics and gene editing) and production environment (engineering optimal environments that can be created cost effectively) for sustainable and reliable production regardless of climate change or pandemic (pouvreau et al., ) . the need to respond to the pandemic might contribute to wider public acceptance of the use of science and technology to support food security. these advanced strategies will need to be complemented by continued efforts to support traditional subsistence farmers with appropriate extension, policies and technologies for their needs. however, some of these interventions will also be based upon similar technology inputs (e.g. climate resilient crops for small-holder environments). increased investment in agricultural research and development would support enhanced food security. advanced technologies need to be adopted globally in each region to deliver local food production capability that could provide secure sources of food in future pandemics. this will require public and private policies that support regional investment in food production infrastructure and acceptance of new technologies. plant sciences have a major role to play (weng, ) in not only addressing the needs of a post-covid world but also the long term challenges of climate change, population growth, environmental degradation and food security. torero m ( ). without food, there can be no exit from the pandemic. nature : - . van bavel j ( ). the world population explosion: causes, backgrounds and projections for the future. fvv in obgyn : - . weng j-k ( ). plant solutions for the covid_ pandemic and beyond: historical reflections and future perspectives. molecular plant : - . figure . food insecurity increases despite growing food stocks. predicted changes in world cereal stocks (fao ) and numbers of acutely food insecure people in crisis or worse (ipc/ch phase or above). population numbers based upon global report on food crisis from the world food program. numbers at end of (anthem, ) estimated due to the impact of covid- . risk of hunger pandemic as covid- set to almost double acute hunger by end of guns, germs and steel world food situation genomics and gene editing technologies accelerating grain product innovation innovations in plant genetics adapting agriculture to climate change. current opinion in plant biology covid- transport brief from plant metabolic engineering to plant synthetic biology: the evolution of the design/build/test/learn cycle economic recession and fertility in the developed world estimates of the impact of covid- on global poverty cereal stocks (millions of tonnes) severe food insecurity (millions of people) queensland alliance for agriculture and food innovation, university of queensland, brisbane qld australia. robert.henry@uq.edu.au key: cord- -rr y vuc authors: hendrickson, mary k. title: covid lays bare the brittleness of a concentrated and consolidated food system date: - - journal: agric human values doi: . /s - - -y sha: doc_id: cord_uid: rr y vuc nan it has only taken weeks for the covid- pandemic to brutally expose the flaws of our modern food system-flaws documented by scholars for decades. produce destroyed in fields because restaurants and food services are closed. covid- hotspots emerging in meatpacking communities forcing closure of up to % of pork packing in the u.s. farmers in alternative agrifood markets pivoting to online ordering and reorienting their supply away from restaurants and to retail or delivery. low paid grocery store clerks and meat packing workers deemed essential but provided little protective gear or means of social distancing. farmers facing euthanizing animals for lack of slaughter space. food service workers losing jobs overnight fed through pop-up charity dinners. farmworkers unable to cross closed borders in europe or north america. economic disaster forming long lines at emergency food distributions and potentially doubling the number of very hungry people globally to million. what is unique about covid- is the food system is cracking in multiple sectors and multiple locations at once. worker treatment, farmer viability, animal welfare and ecological sustainability were all pressing concerns prior to this moment. the pandemic glaringly illuminates that just-intime food supply chains lack the resilience to effectively respond to such a severe, multi-dimensional shock. this system has shown little capacity to fend off disruption, difficulty in stretching to accommodate change, and little redundancy or overlapping systems that provide fail-safe mechanisms. it has highlighted the lack of diversity in scale, form and organization across the system. our only hope is that the precarity of the system, its potential losing of its core identity as a for-profit food system based on efficiency, specialization, standardization and centralization, will allow transition to a decentralized, diverse, and interconnected food system that can feed all of us now and in the future (hendrickson ) . to build a resilient food system, we have to shine a light on the concentrated power of a handful of global firmshousehold names like tyson, bayer or nestle, and less visible power players like the grain-trader cargill (operating in countries) or chemchina (a giant in seeds and agrochemicals) or jbs (the largest meatpacker in the world) (etc group ). in a for-profit system, the boards and management of these companies have more power to decide what, where and how food is produced, who is doing the work, and even who gets to eat it than do farmers, workers, eaters or communities. in this for-profit system, food is simultaneously made cheap through the exploitation of nature, farmers and workers while being too expensive for poor households around the world. covid- exposes the faults of concentrated power in food systems in coping with other slowermoving ecological disasters like soil degradation, decline in water quality and quantity and weather calamities due to climate change (hendrickson et al. ) . the way forward is to reprioritize the main goal of any food system-to provide healthy, nutritious food for all people, now and in the future, in the face of a changing this article is part of the topicalcollection: agriculture, food & covid- . hendricksonm@missouri.edu division of applied social sciences, university of missouri, columbia, usa two issues of the journal of environmental studies and science were devoted to food system resilience and can be accessed here: https ://foodr esili ence.org/. see https ://www.dtnpf .com/agric ultur e/web/ag/news/artic le/ / / /plant s-suspe nd-opera tions -growi ng see https ://www.super marke tnews .com/issue s-trend s/ufcw-cdcmanda tory-covid - -guida nce-neede d-groce ry-worke rs. see https ://www.beefm agazi ne.com/beef/covid - -cuts-meat-proce ssing -capac ity. see https ://www.wfp.org/news/covid - -will-doubl e-numbe r-peopl e-facin g-food-crise s-unles s-swift -actio n-taken . climate and declining natural resources. to do that we must pursue worker rights, animal welfare, farmer viability and ecological sustainability simultaneously because they are all tied together. we gain flexibility and adaptability in a decentralized system of production and consumption, with power distributed from the bottom up. we need a diversity of public, private and cooperative food and farm businesses, both small and large, that are transparently interconnected through multiple networks, to build redundancy and provide fallbacks when some organizations or networks fail. no one approach at any given scale will prove effective. instead we have to create a resilient food system through a combination of actions, strategies and policies at multiple levels that are ecological, democratic, and equitable within and across populations, generations and species. plate tech tonics: mapping corporate power in big food resilience in a concentrated and consolidated food system power, food and agriculture: implications for farmers, consumers and communities key: cord- -vy r zd authors: nan title: abstracts from the (th) annual meeting of japanese association for the stusy of taste and smell (jasts ), kanazawa, japan, october - (th), (the president of the meeting was dr. takaki miwa, kanazawa medical university) date: - - journal: chem senses doi: . /chemse/bjs sha: doc_id: cord_uid: vy r zd nan since umami taste receptors t r and t r have been identified, some reports revealed their structures and functions. umami taste receptors are member of g protein-coupled receptors, belonging to family c with long n-terminal extracellular domain. t r and t r percept umami taste as a heterodimer. we focused on leucine repeats of t r and t r in their transmembrane domains. we have reported the possibility of correlation between the food preference of animals and difference in the length of leucine repeats. poly leucine (polyl) is called homo polymeric amino acid, so called hpaa. it is reported that ; % of proteins in prokaryotic and eukaryotic organisms contain hpaas. it is also suggested that polyl could interact with each other more than with the other hpaas. some inherited diseases are caused by proteins in which hpaas such as polyq, polya are expanded to excessive length. activity of the protein containing hpaas is thought to be increased by expansion of hpaas, but with expansion of more than the threshold, activity of the protein is suddenly decreased. hpaas are one of the structures to be seen frequently. it is suggested that hpaas are important structures for some proteins to function. on the other hand normal function of hpaas remains unclear. from the above point of view, polyl might affect interaction of umami taste receptor t r and t r . we also hypothesize polyl play an important role in the perception of umami. some odorant receptors also have the similar polyl structure, suggesting that under the hydrophobic condition some proteins are dimerized by interactions between leucine repeats. we named a leucine hpaas motif for protein-protein interaction as ''leucine glue.'' we are discussing the effect of polyl on protein-protein interaction by using split gfp assay. # comparative analysis of the umami receptor gene, t r from cetaceans t r and t r are known to act as umami receptor. they are member of g protein-coupled receptors (gpcr) and have seven transmembrane domains. in , it has been reported that the t r gene of giant panda has frameshift mutation, resulting in inactivation of umami receptor. originally, they are used to be a carnivorous animal. it is suggested that the mutation of the t r gene might be associated with their current food preference. we have already analyzed genomic sequences of the t r genes from two different dolphins; lagenorhynchus obliquidens and tursiops truncatus. the results strongly suggested that umami receptor genes, t r from both cetaceans are not functional, because frameshift mutations occurred in their coding sequences. nonsense codon caused by these framshift mutations appeared on their downstream region. in this study, we have also cloned two more t r genes from cetaceans, balaenoptera acutorostrata and balaenoptera physalus. both the t r genes had frameshift mutation and various mutations in their coding sequences. in addition, we have also cloned two more t r genes from cetaceans, b. acutorostrata and b. physalus. both the t r genes had frameshift mutations and various mutations in their coding sequences as well as dolphins described above. especially, in one allele from both b. acutorostrata and b. physalus, we found point mutiations at start codon atg which is a to g substitution, resulting in gtg. by this mutation, t r could not be translated. cell-based expression studies have shown that mammalian t r and t r g-protein coupled receptors combine to form a broadly tuned l-amino-acid receptor. however, contradictory data in t r knockout (ko) mouse models have been reported on taste nerve responsiveness. one study showed that taste nerve responses to amino acid stimuli in t r -ko mice were totally abolished. the other reported reduced but not abolished responses to glutamate in t r -ko mice. in the present study, we have tried to recharacterize the role of t r for the taste nerve responses to amino acids using a wide variety of taste stimuli. we have recorded from whole-nerve chorda tympani nerve responses from t r -ko mice to lingual application of various amino acid stimuli including sweet-and umami-tasting amino acids. whole-nerve recordings of chorda tympani nerve in t r -ko mice showed robust responses to all the tested amino acids. comparing to those from c bl/ wild-type mice, only small reductions of responses to glycine and l-alanine, but no reduction in responses to l-proline, l-serine, l-glutamine and l-glutamate salts have been observed. these results suggest that t r mediated receptor system may play limited role for detection of amino acids. type iii taste cells play to act to receive sour taste and also to act as ''taste integration cell'' to transmit taste information from type ii taste cells through atp. but, it is not known whether a type iii taste cell has both roles and whether two kinds of type iii taste cells share each role separately. using calcium imaging and immunocytochemistry, we revealed that atp activates type ii and iii taste cells and hcl activates type iii taste cells, and also that hcl and atp activate separate subpopulations of taste cells. we also showed that sour-responding taste cells do not have p x and p y as atp receptors in taste buds. moreover, we carried out double cell staining of mice circumvallate papillae using antibodies to atp receptor (p x , p x and p y ) and sour taste receptor (pkd l ) using an antibody to type ii taste cell marker (plcb ) and type iii taste cell marker (pgp . ). it was shown that p x and p x are expressed in taste nerves, p y is in type ii taste cells, and pkd l is in type iii taste cells. no taste cell was stained by both atp receptor and sour taste receptor. although we could not cover all the atp or sour taste receptors, these results suggest that there are the two separate subpopulations of type iii taste cells: the one sensing sour taste and the other accepting the atp released from type ii taste cells. # development of gustatory papillae in the absence of six and six six family genes encode homeobox transcription factors, and a deficiency in them leads to abnormal structures of the sensory organs. in a previous paper, six was reported to be expressed in the taste bud-bearing lingual papillae of mice, and loss of six affected the development of these gustatory papillae. we show here that embryos lacking both six and six revealed more severe abnormalities than those lacking six alone during morphogenesis of their gustatory papillae. by in situ hybridization, six was shown to be broadly distributed in the epithelium of the lateral lingual swellings at embryonic day (e) . , and in the tongue epithelium, mesenchyme, and muscles at e . . from e , six was similar in expression pattern to six , as previously reported; and in the fungiform papillae, six was expressed in the epithelium at e -e . . in the circumvallate and foliate papillae, six expression observed in the trench wall of these papillae at e . -p . although six -deficient mice had no abnormalities, six /six -deficient mice showed distinct morphological changes: fusion of the lateral lingual swellings was delayed, and the tongue was poorly developed. the primordia of fungiform papillae appeared earlier than those in the wild-type or six -deficient mice, and the papillae rapidly increased in size; thus fusion of each papilla was evident. the circumvallate papillae showed severe defects; e.g., invagination of the trenches started asymmetrically, which resulted in longer and shorter trenches. the foliate papillae elevated initially, and showed stunted trenches. therefore, six and six function synergistically to form gustatory papillae during development of the tongue. the life span of taste cells was previously estimated as - days by labeling newly proliferated taste cells with radioactive hthymidine or bromo-d-uridine (brdu) incorporated during dna synthesis. to re-evaluate this observed lifetime of taste bud cells, we repeated the analysis of lingual tissues of mice after incorporation of ethynyl-d-uridine (edu) instead of brdu, followed by detection of edu by a click reaction. we injected edu into adult mice and sacrificed them , , , , , , , , , , or days later. the vallate papillae were fixed, cryo-sectioned, immunostained for plcb (a marker for type ii cells) and examined with a confocal laser scanning microscope with optical sectioning at lm. taste buds were identified in dic images captured in parallel. numerous cells with brightly fluorescent nuclei (edu+ cells) appeared at day near and within taste buds. the number of those cells declined rapidly toward day . however, among type ii cells, very few appeared to be edu+ at day . the number of edu+ type ii cells increased at day , showed a broad peak around day , and then declined. occasional edu+ type ii cells were still detected at day . because labeling of dna with edu is much faster, brighter and more consistent than with brdu, this method will be useful to study proliferating cells in taste buds. by combining edu labeling and immunstaining for approapriate markers, the longevity of taste cell types can be examined. adiponectin is a white adipose protein that plays important roles in glucose homeostasis and lipid metabolism and is involved in cell proliferation and differentiation. the function of adiponectin is mediated by its receptors (adipor and adipor ), which have different expression patterns. in the gustatory system, adiponectin is contained in the saliva; however, the function of adiponectin signaling in gustatory tissues has not been elucidated yet. therefore, we have examined the expression patterns of adipor and adipor in mouse gustatory tissues. reverse transcription polymerase chain reaction assays have revealed that adipor and adipor mrnas were expressed in the circumvallate papillae. using immunohistochemistry, the anti-adipor antibody labeled at the taste hairs in the fungiform, foliate and circumvallate papillae. double-labeling experiments have demonstrated an expression pattern of adipor -positive cells in a subset of basal cells within the taste buds and extragemmal epithelium cells to marker proteins for taste cell types (including types i, ii, iii, and basal cells). for the marker proteins analyzed, only shh was co-expressed with adipor in a subset of basal cells within the taste buds in the circumvallate papillae. these results show that adipor at taste hairs in gustatory tissues may detect saliva adiponectin and may play a role in taste sensing in the taste buds. in addition, adipor may play a role in cell proliferation and differentiation for the shh and adipor expressing basal cells within the taste buds. mash is expressed in subsets of neuronal precursors in both the central nervous system and the peripheral nervous system. however, involvement of mash in taste bud cell differentiation remained to be demonstrated. in the present study, to begin to understand the mechanisms that regulate taste bud cell differentiation, we have investigated the role of mash in regulating taste bud cell differentiation using mash ko mice and forced expression of mash in lingual epithelial cells. in mash ko mice, aadc-ir cells are missing both in the mash mutant circumvallate papilla epithelium and in the taste buds of soft palate. in mash ko/gad -gfp mice, gfp-positive cells (gad expressing type iii cells) are also missing in the taste buds of soft palate. on the other hand, gustducin, a type ii cell marker of taste bud, is expressed in soft palate taste buds in mash mutant mice. these results suggest that mash plays an important role for expression of aadc and gad in type iii cells in taste buds. taste receptor cells are epithelial in sense that they have a limited life span and therefore must be replaced to maintain the structure of the epithelium. therefore gustatory nerves need to make synapse with appropriate taste receptor cells. however, mechanism of recognition of taste receptor cells which express appropriate taste receptor is still unknown. the cadherin superfamily of cell-cell adhesion molecules controls a series of interactions that regulates synapse formation. in this study, in order to test whether the cadherins are required for formation of synapse between gustatory nerve fibers and taste receptor cells, we have investigated expression patterns of cadherin superfamily in the taste buds. # induction of type iii-like taste cells in threedimensional co-culture and analysis of excitability of clonal cell lines derived from murine taste buds we have collected taste buds from a tongue of a p -deficient mouse and established clonal cell lines (tbd cell lines). each of tbd cell lines expresses gustducin and neural cell adhesion molecule (ncam), suggesting that tbd cell lines have characteristics of both type ii and type iii taste cells. to reveal whether tbd cell lines have excitability or not, we analyzed the expression pattern of voltage-dependent sodium channels in one of tbd cell lines, tbd-a cells and performed patch clamp recording. scn a, scn a, scn a and scn a genes coding voltage-dependent sodium channels were detected in tbd-a cells by rt-pcr. patch clamp recording revealed that tbd-a cells had tonic outward currents, but lacked transient inward currents. these results suggest that functional voltage-dependent sodium channels are not expressed in tbd-a cells. next, we tried to establish a culture model mimicking the lingual taste cells of the mouse. tbd cell lines were co-cultured with a lingual epithelial cell line ( a cell line) and a lingual mesenchymederived cell line (tmd cell line). tbd, a and tmd cell lines were maintained in a triple co-culture, in which tbd cells were preseeded as aggregates or in suspension on the collagen gel containing tmd cells and a cells were laid over the tbd cells. tbd cells in the triple co-culture expressed ncam, however gustducin was not immunohistochemically detected in tbd cells. this result suggests that tbd cells in the co-culture exhibited a characteristic of type iii taste cells. this triple co-culture model would be useful to study morphogenesis and functions of the gustatory organ. immunohistochemistry of taste-signaling molecules is useful for the distinction of taste-bud cell types. however, the optimal immunohistochemical detection depends on specimen-preparing conditions. therefore, this study aimed to examine differences in immunoreactivities under various tissue-preparing conditions in rat vallate taste buds for some typical markers of gustatory cells as follows: gustducin, type iii inositol triphosphate receptor (ip r ), synaptobrevin- (vamp ), protein gene product . (pgp . ), and neural cell adhesion molecule (ncam). staining patterns and intensities of immunoreactivities for these molecules varied according to tissue-preparing conditions, especially the fixation. confirming our previous finding, gustducin immunoreactivities were localized to the upper part of the taste bud called taste hairs in case of short fixation, but to the cell body cytoplasm excluding the taste hairs in case of long fixation. the specific immunostaining for ip r was strong in short-time fixation. on the other hand, those for vamp , pgp . , and ncam were intense in long-time fixation. the present data suggest that different experimental protocols cause the discrepancies in immunoreactivities for these markers. further investigations based on this study should provide important information on the classification of the gustatory cell type. # immunohistochemical localization of nk and vpac receptors in the frog fungiform papilla hiroshi ando , osamu tadokoro , naokazu asanuma , mihoko tomida , takami nakamura and eiji kondo department of oral physiology and department of oral anatomy, matsumoto dental university, shiojiri - , japan although the presence of substance p (sp) immunoreactive (ir) nerve fibers and vasoactive intestinal peptide (vip)-ir nerve fibers has been reported in the frog fungiform papilla, the functional roles of these fibers remain to be elucidated. to clarify whether these sp-ir and vip-ir fibers play any efferent roles in the taste disc in the fungiform papilla, we immunohistochemically examined the existence of neurokinin receptor (nk r), which is also a sp receptor, and vip and pituitary adenylate cyclase activating hormone receptor (vpac r), which is also a vip receptor, in the fungiform papilla of the frog, rana catesbeiana. many nk r-ir structures were observed in the taste disc. these were conical in shape in the middle layer of the taste disc and had a rod-like thin apical process toward the upper layer of the taste disc. double-labeling immunohistochemistry showed that only a few nk r-ir structures were located adjacent to the sp-ir nerve fibers in the taste disc. vpac r immunoreactivity was observed in the taste disc cells and the glossopharyngeal nerve bundle beneath the taste disc. vpac r-ir cells in the taste disc had either a thin or thick apical process. vip-immunonegative nerves beneath the taste disc showed vpac r-ir. vip-ir neuronal cell bodies colocalized vapc r in the grossopharyngeal nerve bundle within the tongue.the presence of the nk r and vpac r in the taste disc suggests that sp-ir and vip-ir nerve fibers play efferent roles in the taste disc in the frog fungiform papilla. # cesium-permeable potassium channel in the rod cells of frog taste disc in animal cells, the resting membrane potential is maintained by random open-shut gating of a leaky potassium channel. frog taste disc cells display the resting membrane potential of about - mv. the magnitude is not consistent with the equilibrium potential of potassium (- mv). when internal potassium was replaced with cesium in whole-cell configuration, the rod cells in frog taste disc increased a parabolic outward current gradually and displayed the resting membrane potential of - ± mv (n= ). the wing cells did not possess the outward current and displayed the resting potential of ± mv (n= ) in the condition of internal cesium solution. the replacement of external normal saline solution with cesium saline solution turned the parabolic outward current to the inward current. the inward current reversed at ± mv (n= ) which is close to the equilibrium potential of cesium ( mv). several experiments on cationic replacement showed the permeability ratio of p k :p cs :p na :p nmdg = . : . : . : . . carbenoxolone (cbx, a blocker of pannexin) inhibited the parabolic outward current moderately (ic , lm). the dialysis of lm arachidonic acid in internal cesium solution changed the parabolic outward current to the exponential one and depolarized the membrane potential by mv. the results suggest that the outward cesium current in the frog rod cells may flow through a novel channel different from mammalian cesium-permeable potassium channel. capsaicin, which is the main component of chili pepper and has many physiological functions such as increasing perspiration and energy metabolism, has negative effect of its strong pungency. capsiate was identified from Ôch- sweetÕ (capsicum annuun l.), a non-pungent cultivar of red pepper. like capsaicin, capsiate is thought to enhance energy metabolism by activating the sympathetic nervous system. human sensory evaluation tests demonstrated that capsiate and that analogs (capsinoids) had very weak pungency compared with capsaicin and capsaicin analogs (capsaicinoids), and the difference of threshold level between capsinoids and capsaicinoids was about -fold. however, the in vivo studies focused on the reception of them in oral cavity are few because the reception mechanism of hot taste is unclear, and the reason of weak pungency of capsinoids is not well understood. therefore, this study focuses on the reception of capsinoids and capsaicinoids in the oral cavity. firstly, we performed two-bottle preference tests using rats and confirmed that they began to avoid capsinoids at about times higher concentrations than that of capsaicinoids. in addition, we recorded the lingual trigeminal nerve responses to capsinoids and capsaicinoids and found that capsinoids induced little responses while capsaicinoids evoked apparent intensive responses. such differences were also found in immunohistochemical detection of p-erk in the trigeminal ganglion after stimulation of capsinoids and capsaicinoids. recent studies using animal models of binge eating shows that the accumbal dopaminergic neurotransmission is elevated in bingeing. it suggests that the experience of bingeing modifies the activity of midbrain dopaminergic neurons in the ventral tegmental area (vta). however, few evidences directly clarify whether the activity of the vta is elevated anticipatorily, that is, before receiving the oral (taste) and/or post-oral (viscerosensory) cues of palatable food. to address the issue, we explored possible changes in the activity of the vta neurons in mice bingeing on sugar by immunohistochemical detection of c-fos expression as a marker of neuronal activation. under food restriction, mice were subjected to a binge-type eating training for days (day - ), in which their intake of sucrose solution gradually increased day by day, resulting in its overconsumption. on day , mice were deeply anesthetized and transcardially perfused with % paraformaldehyde before receiving the sugar exposure. brain sections including the ventral midbrain were immunohistochemically processed to detect the c-fos gene expression product, fos protein. the number of fos immunopositive neurons in the vta of trained mice was larger than that of untrained naïve mice. the finding suggests that the activity of the vta is elevated anticipatorily before sugar exposure and contributes to the stimulation of the mesolimbic dopamine system, resulting in sugar bingeing. # activation of output neurons in the basolateral nucleus of the amygdala by a learned aversive taste: a manganese-enhanced mri study tadashi inui , chizuko inui-yamamoto , izumi ohzawa , yoshichika yoshioka and tsuyoshi shimura grad. sch. human sci., osaka univ., suita, - , japan, dept. oral anatomy, osaka dental univ., hirakata - , japan, grad. sch. frontier biosci., osaka univ., suita - , japan and immunology frontier research center, osaka university, suita the basolateral nucleus of the amygdala (bla) is known to play an important role in conditioned taste aversion (cta). anatomical studies have shown that the bla has reciprocal neural projections with many brain regions. it is still unclear, however, which connections are involved in the retrieval of cta. to elucidate the neural circuits for the retrieval of cta, we examined the enhancement of activity of the efferents from the bla by the presentation of learned aversive taste, using a manganese-enhanced mri technique. rats received a pairing of mm saccharin with . m lithium chloride or saline (cta or sham group, respectively). on the test day, thirty min after an injection of mm mncl into the bla, rats were intraorally infused with saccharin. sixty min after the mncl injection, we acquired triple t -weighed mr images at hourly intervals. the signal intensities of mr images, which reflect the movements of manganese by the activated bla neurons, were measured. the cta group showed significant time-dependent increase of signal intensity in the cea than did the sham group, indicating that the retrieval of cta activates efferents from the bla to the cea. furthermore, the analyses based on the injection site of mncl (rostral or caudal) demonstrated the larger movements of manganese toward the cea and cortices (insular and piriform) in the rostrally-injected cta group. therefore, the outputs of efferent neurons in the rostral part of the bla may be separated in two directions, medial (cea) and lateral (cortices). this work was supported by kakenhi ( ). the c isotope-labelled acetic acid breath test is a common clinical method to evaluate gastric emptying and is a non-invasive and repeatable method in rodents. however, the sensitivity of this test to detect changes in gastric emptying of liquid diet in mice has not been studied thoroughly. the present study aimed to validate this method by using bethanechol chloride, atropine sulfate, clonidine hydrochloride, cck- s and phenylthiocarbamide. male c bl- j mice after overnight fasting were placed in the metabolic chamber. commercial liquid diet containing c-acetic acid was used as the test meal. after intragastric administration of the test meal, the expired air was collected at -min intervals for four hours by a fully automated system. the co / co levels were measured by the mass spectrometer. the co excretion data were analyzed for calculation of gastric half excretion time (t / ) as the gastric emptying parameter. t-test was used for statistical analysis (p< . ). bethanechol chloride decreased t / of liquid diet and atropine sulfate and clonidine hydrochloride increased t / . cck- s increased t / and cck receptor antagonist, devazepide, attenuated the delay of gastric emptying by cck- s. bitter tastant, phenylthiocarbamide increased t / . our study indicated that the c-breath test was sensitive to detect difference in gastric emptying of liquid diet induced by pharmacological agents, hormones and tastants. we concluded that this technique could be used to determine the effect of physiological, pharmacological and nutritional intervention on the motility of the gastrointestinal tract. in oral surgery treatments, acrinol hydrate is often used as a disinfectant for oral membranes; however, there are few reports about the effect on taste nerve response to this disinfectant. in this study, we tested if tongue treatment with acrinol hydrate affects taste nerve responses in mice. the chorda tympani nerve responses of c bl/ mice to basic taste stimuli before and after treatment with acrinol hydrate were recorded and compared. the results of the treatment with acrinol hydrate indicated that the chorda tympani nerve response to . m sucrose was suppressed by %; however, there was no change in the responses to . m nacl, . m hcl, . m quinine hydrochloride and . m monopotassium glutamate. the suppression of the sucrose response by this treatment recovered within minute after washing. these results suggest that acrinol hydrate has an ability to suppress sweet taste. some mints, such as peppermint, are used as flavoring substances for foods and toothpaste widely. however, it is not clear whether mints affect the taste receptor mechanisms or not. in the present study, therefore, the chorda tympani nerve responses to basic tastes were compared before and after mixing with types of mints, such as . % peppermint, . % spearmint and . % menthol, in c bl/ mice. when spearmint was mixed with . m sucrose, mm denatonium benzoate, . m monopotassium glutamate (mpg), mm #-inositol monophosphate (imp) and the mixture of . m mpg and mm imp (m+i), the neural responses to these stimuli were suppressed. but mixing of spearmint did not change the responses to . m nacl, mm quinine-hydrochloride and mm hcl. mixing of peppermint or menthol did not change any responses to all tested stimuli in the present study. these results suggest that spearmint may work as a suppressant for some kind of receptors for sweet, umami and bitter. the majority of the experiments for investigating gustatory information processing in the nucleus of the solitary tract (nst) have been performed using rats as experimental animals. although the importance of mice in this kind of study is widely recognized from the view point of recent, rapid advance in gene manipulation techniques, there are very few studies using mice in this academic field. also, it is desirable for physiological studies on neural mechanisms of taste perception to use awake, or at least, weakly anesthetized animals. therefore, in the present study we tried to establish an experimental model for in vivo recording of nst neurons in slightly anesthetized or awake mice. for this, we surgically fixed a head restraining holder to the mouse scull, which made it possible to place the mouse head precisely in a stereotaxic position repeatedly without pain. after the recovery from this surgery, the gustatory area in the nst was localized electrophysiologically under anesthesia. then, single neuron activity was recorded in this area under slight anesthesia, and responsiveness to standard taste solutions (nacl, sucrose, citric acid and quinine hcl) was tested. as a result, gustatory neurons were recorded; of these, , and neurons were classified into nacl-best, sucrose-best and citric acid-best, respectively. furthermore, we found that the mouse could be easily trained to lick taste stimuli with the head restrained in the stereotaxic device. these results indicate that the present method is applicable to the investigation of gustatory information processing in the nst of mice under a physiological condition. # comparison of preference between sucrose and sugar alcohols in c bl/ mice yoshihisa katagawa , toshiaki yasuo , keika gen , takashi yamamoto and noritaka sako department of oral physiology, asahi university school of dentistry, mizuho - , japan, department of health and nutrition, faculty of health science, kio university, nara - , japan and although sorbitol tended to be less preferred compared to palatinit. the present study suggests that the sugar alcohols are less palatable than that to common sugars, such as sucrose, in mice. # novel peptides, dryamide- , dryamide- : comparison in regulatory effects on feeding behavior of the blowfly phormia regina because the drosophila orphan receptor cg is similar to the vertebrate neuropeptide y receptor, we screened its putative ligands and purified two novel peptides: dryamide- and - . to investigate their function, we injected these peptides into the thorax of the blow fly, phormia regina, and observed the subsequent changes in feeding behavior and taste sensitivity to sucrose. the blow fly was used for technical reasons, to facilitate injection. before and after peptide injection, we measured ) the sucrose intake as an indicator of appetite, ) the proboscis extension reflex (per) as an indicator of feeding motivation, and ) the electrophysiological response of the labellar contact chemosensilla to measure the magnitude of the gustatory input inducing per. there was no significant change in sucrose intake after injection. injecting both peptides depressed per and reduced the percentage of flies that performed per. the electrophysiological response of the labellar taste sensillum to sucrose seemed to decrease after injecting dryamide- , but not dryamide- . therefore, once feeding starts, these peptides might not limit the food intake of the fly. nevertheless, the results of the per test suggest that these peptides contribute to feeding initiation. together with other peptides that restrict food intake, dryamide- and - might contribute to the overall regulation of feeding behavior in phormia regina. # stand off effect between the noble bioactive peptide and appetitive odor on feeding behavior in blowfly we compared the behavioral effects of feeding suppression by the two kinds of new peptides (dryamide- , ) in blowfly. both of gustatory and olfactory systems are required to elicit appropriate motor pattern in feeding behavior. feeding behavior was also controlled by internal condition based on many bioactive peptides. proboscis extension response (per) is indicator of feeding behavior that is generally controlled by the chemical cues from the maxillary palps. the behavioral experiment showed that they detect palatable chemical signals increasing their appetite in blowfly, phormia regina. phormia usually have detected the appetite odor like mushroom ( -octen- -ol) by maxillary palps. however, some kinds of newly found peptide have an effect on feeding behavior. therefore, we compared the effect of two kinds of newly found peptides in drosophila. first, we test whether they affect feeding behavior by the amount of sucrose intake. after injection of one kind of peptide, food intake amount was obviously increased. in the next step, we investigated the odor of octen- -ol by maxillary palps did not work as appetitive odor when they are starved sufficiently in behavioral experiments. the results showed that these peptides work as the appetitesuppressant in blowfly feeding behavior, and it did worked as counteractant to odor stimulation. sodium-deficient animals ingest sodium chloride at concentrations normally rejected, and this motivated behavioral state is known as sodium appetite. for neural mechanisms of sodium appetite, there is a line of electrophysiological evidence in rats, whereas there is less evidence in mice. in order to develop a model for sodium appetite in mice, we examined the effects of repeated sodium depletion on salt intakes in c bl/ j mice. adult male c bl/ j mice (n= , weeks, - g at the beginning of the experiment) were used; each animal was housed individually in a metabolism cage during the experiment. a combination of furosemide injection with sodium-deficient diet was used to induce acute sodium deficiency. in of the mice, furosemide was injected in the st week and saline was injected in the nd week. in the remaining mice, the injection order was reversed. this pattern was repeated times over months. after hours following the injection, intakes of . m nacl and distilled water were measured. the furosemide injection shortened the latency of, and increased the amount of, . m nacl intake. furthermore, the increase in . m nacl intake was tended to be enhanced at later furosemide injections. both urine volume and -h urinary sodium excretion were greater after the furosemide injection than after the saline injection, but there were no significant differences of these measures across repeated depletions. these results show that present procedure reliably elicits sodium appetite in c bl/ j mice, suggesting that this is a suitable experimental model of sodium appetite in mice. the sensations of taste and smell are the important determinants guiding preference for foods and fluids. the dried-bonito dashi is a traditional japanese fish broth that enhances palatability of various dishes due to its specific flavor. however, the scientific evidence why dried-bonito dashi is important for japanese dishes is little known. in general, the main stimulus is considered as inosinate (an umami substance) but the dashi is a complex mixture of many taste substances such as lactate (sour), histidine (bitter), sodium (salty) and other minerals (generally bitter) as well as macromolecules (proteins and peptides) and over odorants. here we investigated mechanisms of preference for dried-bonito dashi using -h two-bottle choice tests in adult male sprague-dawley rats. we found that preference for dashi was influenced by current nutrition, i.e., ingestion of high fat or high sucrose diet suppressed preference for dashi. in addition, past experience/learning of dashi ingestion was the most important determinant that could overcome the influences of current nutrition. for example, preference of the threshold concentrations ( . %) of dashi increased gradually during repeated exposure to dashi solution. after the repeated ingestion of dashi solution, ingestion of high fat or high sucrose diet has no influence on dashi preference. in the descending concentration series, the concentration-preference function shifted -fold to the lower concentrations compared with the ascending one. these results suggested that postingestive consequences as well as oronasal sensations guide the preference for dashi solutions that are under the control of current nutrition and past experience/learning. food aversion learning is the long-term memory established after association of the properties of food, such as texture and taste (conditioned stimulus, cs), with visceral malaise (unconditioned stimulus, us). after the acquisition of the learning, the re-exposure to the cs induces the retrieval of the memory and the rejection of the cs occurs. previously, we showed that histamine release in the central nucleus of amygdala (cea) during the re-exposure to the cs was increased in soft pellets-conditioned rats, but not in sweet pellets-conditioned rats. in the present study, we studied the role of the histaminergic transmission in the cea in the retrieval of food aversion learning induced by two patterns of the cs. fos expression, a marker of neuronal activation, following the retrieval of food aversion learning induced by each cs (soft pellets or sweet pellets) and us pairing was examined. few fos-positive cells in the cea were observed by consuming both types of pellets in naïve rats. in the conditioned rats, fos expression in the cea was increased in response to the re-exposure to soft pellets while it was not elevated by the re-exposure to sweet pellets. in addition, the microinjection of h -antagonist to the bilateral cea just before the re-exposure to the cs impaired the aversive response to soft pellets but not to sweet pellets. these findings indicate that the neuronal activation through the histaminergic system via h receptor is involved in the retrieval of texture aversion learning but not in that of taste aversion learning. # food entrained feeding behavior to highly sweet food in non-food deprived mice yasunobu yasoshima, megumi tanibuchi and tsuyoshi shimura division of behavioral physiology, department of behavioral sciences, graduate school of human sciences, osaka university, suita - , japan light-regulated circadian clock in each animal species affects its original feeding rhythm. nocturnal rodents mainly consume food during the dark phase under ad libitum food condition; however, their daily feeding rhythm is entrained to mealtime when they are restricted of food. food-entrainment is suggested to be mediated by increased arousal and food-oriented motivation derived from calorie deficiency, but recent studies indicate that taste palatability seems to be important in food-entrainment. however, the role of taste palatability (hedonic aspect of taste) in food-entrainment remains not fully understood. to study the issue, we developed a new, simple mouse model. ad libitum-fed c bl/ j male mice received daily limited access to highly sweet chow (hsc) containing % sucrose for hours in the light phase ( : - : a.m.). they received the regimen for days as training. the intake of hsc gradually increased and was about -fold greater than their basal intake of normal chow at the corresponding period of time during pretraining phase. on the other hand, the intake of normal chow in another group during the corresponding timing did not increase. intake of normal chow during the dark phase in mice group receiving hsc, but not normal chow, significantly decreased during the training. the entrained increase of hsc intake was also observed in genetically hyperphagic strain, db/db (leptin receptor gene deficiency) mice. these results suggest that taste palatability and/or hedonics of sweeten food play a role in shifting of daily feeding rhythm. # sexual difference of gene expression of androgen receptor in the brain region related to extinction memory after conditioned taste aversion learning in immature mice mice acquire the conditioned taste aversion memory (ctam) by application of the conditioned stimulus (cs) such as a novel taste, sodium saccharin (sac), followed by the unconditioned stimulus (us) such as an malaise induced by an i.p. injection of licl. after conditioned taste aversion (cta) learning, the extinction of ctam is induced by repeated presentations of cs without us. recent studies have demonstrated that the extinction is a process of relearning, where mice acquire the extinction memory of cta. we have reported that the sexually mature male mice (c bl/ ) represented significantly higher retention of extinction memory (rem) than sexually immature male mice. in contrast, the significant difference was not observed in female mice. we have also reported that chronical administration of androgen into castrated mice during prematuration period results in an enhancement of rem in both sexes. here we investigated whether the sex difference of the gene expression of androgen receptor (ar) is observed in the ventral medial prefrontal cortex (vmpfc) and amygdala between sexually immature and mature mice by real-time pcr. the sexually immature male mice presented significantly higher level of ar gene in vmpfc and amygdala than the sexually mature male mice. however, there was no such difference in vmpfc and amygdala of the female mice. these results suggest that the sex difference in maturation process of rem is induced by androgen acting on vmpfc and amygdala during sexual prematuration period in mice. our previous study showed that weanling rats acquired conditioned flavor preference when the flavor was associated with low concentration of sucrose; while flavor aversion when associated with high concentration. the present study aims to confirm and extend this finding with various concentrations of sucrose. wister male -week-old rats were used. half of the rats received unsweetened grape-flavored water on odd-numbered days and sweetened (sucrose) cherry-flavored solution on even-numbered days. the remaining rats received sweetened grape-flavored solution on odd-numbered days and unsweetened cherry-flavored water on even-numbered days. during the acquisition session, the liquid was presented to each rat for min daily across consecutive days. in the following test session, each rat was presented with unsweetened cherry-and grape-flavored water simultaneously for min daily across consecutive days. the rats showed a significant preference for the flavor associated with % or % sucrose, but showed a significant aversion to the flavor associated with % sucrose, suggesting a hedonic shift from positive to negative with increasing the concentration. the association learning acquired at the age of weeks was preserved when retested at the age of weeks. short-term ( min) drinking test showed that the volume of intake was significantly smaller for % than for % and % sucrose, indicating that % sucrose is aversive because of its oropharyngeal sensation rather than its post-ingestive effects. the present study suggests that weanling experience of food is important in the formation of feeding behavior in adulthood. tastes play important roles in detecting nutrients and irritant materials in food. preference for food tastes is critical for ingestive behavior because greater palatability is to evoke greater food intake. animals generally prefer sweetness but not bitterness. such taste preferences are known to be affected by aging which causes changes in the dietary and energy requirements. however, the mechanisms of shift in taste preference by aging still remain unclear. therefore, to elucidate differences in taste preference among the life stages, we measured the amount of intake of taste solutions by the two bottle test. we used juvenile ( - weeks), young-adult ( - weeks), adult ( - weeks), and middle-aged ( - weeks) sprague-dawley male rats. all rats were fed ad libitum during all tests. we used . m or . m nacl, . m or . m hcl, . m or . m sucrose, mm saccharin-na, · - m or · - m quinine-hcl, and . m monosodium glutamate (msg). the preference ratio for . m sucrose and . m msg in middle-aged group was lower than that in juvenile and young-adult groups. on the other hand, the preference ratio for · - m quinine-hcl in middle-aged group was higher than that in juvenile and young-adult groups. there were no significant differences in the preference for hcl and nacl tastes among groups. these results suggest that aging affects taste preferences for sucrose, msg and quinine-hcl which represent sweet, umami and bitter tastes, respectively, in humans. we investigated the effects of furanones as the maillard reaction products flavors on umami and sweet taste preferences in mice. -dimethyl- -hydroxy- , -dihydrofuran- -one; sotolon and -hydroxy- , -dimethyl- ( h)-furanone; furaneol (food-grade certified products, safc supply solutions, usa) were chosen as the maillard-borne odorants. in the short time two-bottle tests, . , . , . , . lg/kg sotolon flavored umami solutions containing mm monosodium glutamate (msg) and sweet solutions containing mm saccharin were significantly consumed more than distilled water. sotolon tended to enhance umami and sweet taste preference in a dose dependant manner. whereas there were no differences of intakes between sotolon flavored water and distilled water. in addition, furaneol and citral flavor agents did not enhance umami solution preferences. these results suggested that sotolon, one of the maillard reaction products, induced enhancement of umami and sweet taste preference in mice. supported by society for research on umami taste and kakenhi ( ). zinc is one of the essential trace elements and its deficiency causes anorexia, growth retardation, and taste disorder. insulin in pancreatic beta-cells is known to be stored as microcrystals of the zinc-containing hexamer, and zinc is thought to be fundamentally important for assembly and release of insulin from beta-cells. however, the effect of dietary zinc on food intake or insulin secretion of model rats of diabetes has not been well elucidated. in this study, we followed the levels of food intake and insulin secretion in type diabetes model gk (goto-kakizaki) rats fed on diets containing different levels of dietary zinc for weeks. all the experimental rats were divided into four experimental groups of zinc-deficient (zn-def, rats fed on . mg/kg diet), zinc-sufficient (zn-suf, rats fed on . mg/kg diet), high-zinc (high-zn, rats fed on . mg/kg diet), and pair-fed (rats fed on zinc-sufficient diet with the same amount of diet consumed by zn-def one day later). food intake in zn-def gk rats followed typical cyclic-pattern seen with normal rats such as sd rats. plasma zinc concentrations and plasma insulin concentrations were found to have positive correlations in high-zn rats. orexins are neuropeptides synthesized mainly in the lateral hypothalamic area and are implicated in the regulation of food intake in addition to arousal. since swallowing is early step of feeding behavior, orexins might modify swallowing. in the present study, we examined the effects of orexins on the reflex swallowing using anaesthetized rats. orexin, which was dissolved in ringerÕs solution, was administered into the fourth ventricle. orexin- receptor antagonist (sb ), which was dissolved in dimethyl sulfoxide, was administered into the fourth ventricle. three ll of drugs were administered using a microsyringe. swallowing was induced by the electrical stimulation ( hz, sec) of the central cut end of the superior laryngeal nerve (sln) and was monitored by recording the electromyogram of the mylohyoideus muscle. the frequency of swallowing during the electrical stimulation of the sln decreased after the administration of orexin-a in a dose-dependent manner. significant reduction in number of swallowing was observed after the administration of orexin-a at the dose of or nmol. the latency of the response tended to be longer in the presence of orexin-a. the administration of orexin-b did not affect the frequency of swallowing. pre-administration of sb attenuated the magnitude of inhibition of swallowing frequency induced by the administration of orexin-a. these results suggest that orexin-a but not orexin-b inhibits reflex swallowing via type receptors situated in the dorsal medulla where swallowing center is housed. this work was supported by a grant-in-aid for scientific research from the japan society for the promotion of science (no: to mk). stimulation of water receptors in the laryngopharynx (lp) with water shortened the swallowing interval in voluntary swallowing in humans. we previously found that excitation of water receptors was due to absence or reduced concentration of clin fluids applied to the lp. unstimulated saliva contains a low concentration of cl -. thus, unstimulated saliva may excite water receptors in humans. the aim of the present study was to evaluate the role of unstimulated saliva in initiation of swallowing in humans. solutions were infused through a fine tube into the lp at a slow infusion rate ( . ml/min) that minimized the mechanical effect of infusion. facilitation of voluntary swallowing by infusion of unstimulated saliva was almost the same as that by infusion of water. topical anesthesia of the throat produced loss of facilitation of voluntary swallowing by both water infusion and unstimulated saliva infusion. the similar effects of water and unstimulated saliva on voluntary swallowing suggest that water receptors are responsible for facilitation of voluntary swallowing by unstimulated saliva. since facilitation by water infusion appeared without mechanical effect of infusion, it is likely that excitation of water receptors in the lp by a small amount of unstimulated saliva precedes excitation of mechanoreceptors caused by a certain amount of unstimulated saliva accumulated in the throat. excitation of water receptors by unstimulated saliva may initiate spontaneous swallowing and spontaneous swallowing probably plays an important role in clearance of the mouth of saliva. therefore, it appears that excitation of water receptors by unstimulated saliva may contribute to avoidance of aspiration. # peripheral chemical stimulation to trigger the swallowing reflex and its neuronal mechanisms in humans kensuke kawamoto , takuya inoue , kaya narimatsu , yuki nakamura , makoto inoue , rika yahagi and yasuyuki kitada faculty of dentistry, niigata university, - gakkocho-dori, chuo-ku, niigata - , japan, division of dysphagia rehabilitation, niigata university graduate school of medical and dental sciences, - gakkocho-dori, chuo-ku, niigata - , japan and morioka taste and swallowing research institute, - - higashi-kuroishino, morioka - , japan initiation of swallowing is mediated by the swallowing central pattern generator (cpg) in the brain stem. both peripheral and central inputs can activate the cpg. previous studies demonstrated that the ability to initiate repetitive voluntary swallowing varies even among healthy humans and proposed that appropriate chemosensory inputs, e.g., activation of water receptors in the pharynx and larynx, may compensate for difficulty in initiation of swallowing. however, whether variation also exists in reflexively evoked swallowing is unclear, and the nature of interindividual variation has not been clarified. the aim of this study was to investigate interindividual variation of swallowing initiated by central and peripheral inputs and to clarify the neuronal mechanisms that cause this variation. voluntary and reflexive swallowing activity was recorded during infusion of fluid (distilled water [dw] or . m nacl solution) into the pharynx and larynx at a very low rate in healthy volunteers. dw and nacl were used to activate and inhibit the water receptors, the activation of which facilitates initiation of swallowing. swallowing intervals (sis) were measured between the fourth and ninth swallows, and facilitatory effects (fes) were calculated by subtraction of the si of dw from that of nacl. there was a significant positive correlation between sis of voluntary and reflexive swallowing with nacl. fes of both voluntary and reflexive swallowing appeared strongly in subjects with longer sis. the present results suggest that interindividual variation in the ability to initiate swallowing depends on the potency of the swallowing cpg. the effects of taste stimuli on the change in regional prefrontal cortex blood flow (rcbf) measured by multichannel near infrared spectroscopy (nirs) were evaluated in healthy women volunteers. the test solutions were sucrose, nacl, citric acid and monosodium glutamate at three different concentrations each. six pairs of source and detector nirs probes were placed on the forehead with a cm separation which allowed the measurement of different channels every . sec. the changes in oxygenated hemoglobin (oxy-hb), which is the most sensitive indicator of changes in rcbf, were analyzed. subjects were positioned in a chair that supported their back and head while wearing a blindfold (eyemask) and headphones to minimize motion, visual and auditory disturbances. the entire oral area was exposed to ml of solution for sec applied using a syringe and rubber tube positioned above the head. another solution was applied after rinsing with deionized water, subjects were tested consecutively for different solutions in random order. each subject was tested for the same solution three times, the data were averaged and the value for the water test data subtracted in order to determine subjectÕs value for a given solution. the taste hedonic tone with a five-rating scale was also measured for the preference test. oxy-hb in all channels increased during all taste stimuli. the increases in oxy-hb and preference scale values showed significant negative correlation. these findings indicate that the prefrontal cortex activation evaluated by nirs is possibly related to pleasant or unpleasant emotions associated with taste stimuli. we receive various different stimulus modalities including tastants and other gustatory and / or somatosensory sensations in eating. sensory information from these modalities would be integrated and recognized as a ÔflavorÕ. it is useful to understand their psychophysiological properties because it may help us to develop new functional foods. we investigated the effects of vanillyl butyl ether (vbe), l-menthol (lm) and carbonated water (cw) to the arousal level of healthy subjects. these stimuli were used as hot, cold, tingling stimulus respectively. the results of contingent negative variation showed that vbe, lm and cw increased subjectÕs arousal level just after ingested by aqueous solution whereas no significant change was observed after the water ingestion. the increase of the arousal level still remained for min after ingesting vbe and lm. on the other hand, the arousal level of min after ingesting cw decreased to the same level as before ingestion. apart of the subjects were asked to rate the general stimulus intensity by point likert scale. all samples including water showed maximum intensity just after ingestion and decreased with time course. however, the significant increase of the stimulus intensity still remained for min after ingesting stimulus solutions. these discrepancies between the arousal level and subjective stimulus intensity of cw suggest that only stimulus intensity itself cannot explain the change of the arousal level. in order to understand the property of each stimulus, we need to look each stimulus into detail in the derived modality of the sensation, intensity, timing of appearance. we had reported that umami taste induced sustained saliva secretion. in this study, to investigate the effect of repetitive taste stimulation on saliva secretion, we compared the saliva weight secreted by single taste stimulation (single stimulation methods; ss) with repetitive taste stimulation (repetitive stimulation method; rs), using fourteen healthy adult subjects. in ss, the subjects sprayed the taste solution (approx. . ml) using a spray bottle into the mouth, and held for seconds and spat the whole saliva into cups at every second for minutes. in rs, the subjects sprayed the taste solution into the mouth, and held for seconds, then, spat the whole saliva into cup, and rested for minute until the next stimulation. after this procedure was repeated ten times, the subject performed the same procedure as ss. the stimuli were mm monosodium glutamate (msg) (umami), . mm citric acid (sour) and mm xylitol (sweet), which had ÔmoderateÕ taste intensity on a labeled magnitude scale. during the repetitive stimulation in the rs of msg, the salivary flow was reduced gradually according to the decrease of umami taste intensity by adaptation. however, the msg stimulation caused a sustained salivary secretion after repetitive stimulation, and there was no significant difference in the minutes saliva between ss and rs. thus, the repetitive umami stimulation did not reduce saliva secretion and could produce sustained salivary secretion. there was no adaptation in rs of citric acid and xylitol, and the saliva secretion pattern of rs was similar to that of ss, with less saliva secretion than msg. dried-bonito (db) dashi is a traditional japanese broth that enhances palatability of various cuisines due to its specific flavor. db dashi contains many components, such as histidine, lactate, inosinate, minerals, and proteins. ingestion of db dashi has been reported to have various physiological functions, e.g., effectiveness against physical and mental fatigues, enhancement of peripheral blood flow, and suppression of oxidative stress. in this study, we investigated the effects of db dashi on gastric electrical activity and hunger-satiety states in healthy japanese males. we performed a randomized crossover study for healthy males ( . ± . yr). subjects were fasted for at least h, and all measurements were performed in the morning. before and just after a single ingestion of ml of db dashi (''hondzukuri ichiban-dashi katsuo'', ajinomoto co., inc., japan) or energy adjusted water as a control, gastric myoelectrical activity was measured by electrogastrography for min. subjective motivation to eat (hunger and satiety) was rated by visual analogue scales before, immediately after, and min after the ingestion. ingestion of db dashi significantly increased both electrogastrographic normogastric power and percentage in postprandial state. in addition, db dashi produced higher satiety sensations at min after the ingestion, compared to the control diet. in conclusion, db dashi intake enhances the gastric motility and satiety in humans. we usually take sweet foods with drinking tea or coffee not only to increase nutrition but also to produce feelings of pleasantness and restfulness that belong category of emotion. when we take sweet foods, comfortable audio-visual environments, e.g. consonant interior decoration, good music and fine view may increase feelings of deliciousness. thus, it is hypothesize that environmental factors modify feelings of deliciousness. comprehensive delicious feelings during having sweet foods might be effectively produced in the comfortable environments by integration of various palatable sensory perceptions. electroencephalograms (eegs) were recorded from frontal region of the scalp of healthy participants under virtual scenes of tearoom and construction work, respectively. the participants were asked to rate deliciousness after the recordings. frequency analyses were performed from the eegs. during having the foods, occupancy rates of beta frequency band between tearoom scenes and construction work scenes were markedly different, but not in other frequency bands. during having no food, in contrast, there was no difference of occupancy rates in respective frequency bands between the two different scenes. with regard to deliciousness during having sweet foods, all participants rated high scores under the scenes of tearoom than those under the scenes of construction work. interestingly, there is a positive correlation between occupancy rates of beta frequency band and scores of deliciousness. these findings suggest that comfortable audio-visual environments play an important role for increasing delicious feelings during having sweet foods, in which beta frequency rhythms may be concerned with producing comprehensive feelings of deliciousness. though it has been reported that capsaicin possesses effects of stomach protection and appetite improvement, the influence of dietary habits of consuming pungent substance such as capsaicin on taste sensitivity has not been investigated. in order to elucidate the influence of dietary intake of capsaicin on taste and pungent sensitivities, we measured the thresholds for basic tastes and capsaicin in thai and japanese, because thai have a dietary habit of much more use of pungent substances for meal than japanese. in addition, we conducted questionnaire study about dietary habits of both groups. regarding the recognition thresholds for basic tastes, the threshold for umami tended to be higher in thai compared to japanese with no differences in other basic tastes. this result indicates that daily high intake of pungent substances hardly affect taste sensitivities. however, the threshold for capsaicin in thai was significantly higher than japanese, which was considered to result from much more use of hot pepper for meal in thai. when the thresholds for basic tastes were measured immediately after capsaicin stimulation, the thresholds for acid and bitter tastes were elevated in thai whereas they did not change in japanese. this difference may be due to the concentration of pretreatment capsaicin because suprathreshold concentration was used in the experiment, showing that high concentration of capsaicin may cause transient impairment in some taste sensitivities. in conclusion, it was suggested that daily high consumption of pungent substances hardly affects taste sensitivities but high concentration of capsaicin causes transient hyposensitivity of some tastes. this study aimed to investigate what flavors show interaction with umami taste. twenty-one female university students participated in this study. solutions of . % msg were used as taste stimuli, and the kinds of flavors were used as flavor stimuli. participants were asked to taste a pair of flavor and msg solution, and to evaluate the intensity of umami taste and the congruency of the flavor with the umami. when the participants taste msg solution with flavor of dried bonito, and of garlic, they evaluated the umami taste stronger than when they taste it without flavors (potentiation effect). when the participants taste msg solution with flavor of tomato, of garlic, and of onion, they evaluated those flavors more congruent with umami taste than when they taste it without flavors. they evaluated congruency of dried bonito and of matsutake less congruent with umami taste. there is a significant, but weak, interaction between the congruency with umami taste and the potentiation effect of umami taste (r= . , p< . ). in general, the flavors that are experienced in our daily lives are evaluated more congruent with umami taste, and have potentiation effect on umami taste perception. preceding studies also suggest that the interaction between olfaction and taste, and perception of umami taste are based on learning. this study also supports the view of ''learned synesthesia'' of olfaction and taste. acknowledgment: this study was supported by society for research on umami taste. eating with someone makes the foods more palatable, and the family ties more strong. on the other hands, eating alone (ko-sho-ku, in japanese) has many problems, such as malnutrition, unbalanced meals, not good at communication etc. ko-sho-ku is very severe problems in modern japanese society. thus, we aimed to study the effect of ko-sho-ku on palatability of the foods. in the study , ratings for taste and palatability of confectioneries were compared between when they were eaten with friends and/or family members and when eaten alone. thirty six female university students participated in this study, and were asked to eat two kinds of chocolate and two kinds of cookies in a laboratory (alone) and in their home (with someone). palatability ratings were higher when they were eaten with someone in their home. in the study , ratings for taste and palatability of jellies were compared between when they were eaten with watching a child eating same jellies in a video and without watching it. fifteen female university students participated in this study, and were asked to eat three kinds of jellies in a laboratory and to rate a questionnaire about their ability of sympathy. students with high sympathy tend to rate the jellies more palatable. these results suggested that human perceptions of taste and food palatability were affected not only by foods but also by contextual and social variables. acknowledgement: part of this study was supported by a grant titled "effects of eating with someone on palatability of foods." from asahi breweries foundation. # taste and smell of the bread made using pre-germinated brown rice sake lees kana kogiso , hiroko nakazawa , yumi yoshioka , akiko sato and mitsuo okazaki faculty of human life sciences, nagano prefectural collage, nagano, nagano - , japan and okazaki brewer co, ltd., ueda, - , japan pre-germinated brown rice is prepared by soaking brown rice in water at o c for - hours to initiate germination of sprouts not exceeding . - . mm in length. in the traditional method of brewing sake, rice bran and embryo bud are separated from brewer's brown rice during sake brewing in order to remove the rough taste. this study tried to use sake lees in fermentation with pregerminated brown rice, since the sake made from pre-germinated brown rice has hardly appeared on the market. also, the use and benefit of pre-germinated brown rice-made sake and sake lees have not been reported. in this study, we made sensory evaluation to measure the difference in taste and smell between bread made using normal sake lees and bread made using pre-germinated brown rice sake lees. the result showed that the bread made with pre-germinated brown rice sake lees had significantly better smell (p = . ) and stronger sake lees smell (p = . ) as well as a stronger sake less taste (p < . ) than the bread made with normal sake lees. the complex flavor (p = . ) and saltiness (p = . ) of the bread made with pre-germinated brown rice sake lees tended to be stronger than that of the made with normal sake lees. female college studentsÕ preference to steamed and cured slices of sweet potato was evaluated to find their sensory characteristics. evaluation was carried out with the sweet potato cultivars and lines, tamayutaka, izumi , hoshikirari, kanto , tamaotome, quick sweet, hitachi red, hamakomachi, purple sweet lord and sakukei in terms of appearance, fragrance, texture and taste by a rank-scoring method. the most preferable cultivars were hoshikirari, tamaotome, and kanto ; sweetness greatly contributed to the taste of the steamed and cured slices of these samples, while appearance and texture somehow influenced their taste scores. fish flakes are one of the traditional japanese ingredients for dashi. various methods are used to extract dashi depending on the thickness of flake. especially, the thick type flake that is often used for soba noodle sauce requires around minutes of cooking time and extracting conditions vary as well. the energy saving has become recent tendency even in culinary field, and we focused on a cooking method using remaining heat. we analyzed the free amino acid and #-imp. sensory evaluation was carried out at the same time. as a result, we can suggest that there is a method for extracting the most effective use of remaining heat for minutes after heating for minutes. we were able to explain the taste improvement from the amino acid composition determined by accq-tag tm ultra method. this condition can be considered effective for both energy saving and flavor improvement of dashi. oolong tea is usually served with oil-rich chinese food. our group has been studying on the mechanism of oil rinsing in the mouth and, in particular, on the interactions between oolong tea components and oil. our previous studies showed that oolong tea had a higher affinity for oil than deionized water, mineral water and green tea did. it may thus be more effective in washing out remaining oil from the mouth. the objective of this study is to determine the effective oolong tea components contributing to removing the residual oily sensation. for the human sensory evaluation, sweetened whipped cream was used as an aliment, and mineral water or oolong tea was used as a washer, with the result that oolong tea more effectively reduced the sense of residual oiliness. an aqueous solution of epigallocatechin gallate (egcg) and epigallocatechin (egc) as tea constituents was used to measure its interfacial tension activity in the presence of soybean oil by a face surface tensiometer. also, we emulsified soybean oil with egcg or egc and examined the resulting average particle size with a laser diffraction particle size analyzer. it was found that egcg and egc did not influence the interfacial tension and average particle size. further studies are required to find some contributory factor. commercial granulated sugars are of . % purity which is almost equivalent to the purity of a guaranteed reagent-grade sucrose. we observed that commercial sugars were different in melting point from one another and the tastes of caramel sauces prepared from these sugars were different. a white coarse bright sugar with larger grain size than that of regular granulated sugar used as an experimental sucrose crystal was milled into powder. in a differential scanning calorimetry of the crystals, a higher peak in the curve of endothermic heat flow shifted to higher temperature side after milling. the powder crystal became more stabilized on heating than the coarse crystal. using the coarse and the powder crystals, caramel sauces (''sauce c'' and ''sauce p'', respectively) were prepared. sensory tests showed that sauce c was more brownish in color and was stronger in sourness, bitterness and acridity. on the other hand, sauce p was better in aroma, stronger in sweetness and more preferable in taste and aftertaste. sauce c was lower in ph, giving stronger sourness. the use of a color difference meter showed a large difference between the two sauces (de= . ). coarse crystal was less stable on heating and sauce c was more brownish in color, having stronger bitterness. in the sensory studies for flavor development, commercial products or trial products are often used as samples, because sensory evaluation is conducted considering usual behavior of eating habit. but in the case of odor-taste interaction studies, it is desired that odorants and tastants are completely separated and presented to subjects simultaneously. in this study, we established a simple and effective way of presenting odor and taste stimuli separately under two model systems: beverage and soup. experiment. : evaluation of sweet/sour intensity in fruit flavor beverage firstly, we prepared simple equipment comprising clear plastic cup with scented papers attached on the upper inside edge. the use of non-flavored solution and flavor on the scented papers allow subjects to evaluate beverage. sugar-acid water solution was used as taste stimulus and, lemon and strawberry flavors were used as odor stimuli. untrained panel (n = ) evaluated intensity of sweet and sour characters. the result showed that lemon flavor enhanced sour character and decreased sweet character when compared with non-flavored condition. experiment. : evaluation for savory -citrus flavor interaction we prepared ordinary soup solution as taste stimulus, with two savory flavor (chicken and dried bonito) and two citrus flavor (lemon and yuzu) as odor stimuli. untrained panel (n= ) evaluated characters (saltiness, umami, sourness, mild, fatty, animalic). the results showed flavor influenced taste intensity as is the case in experiment . in conclusion, we successfully showed the important effect of odor on taste perception by using this study. # added flavorings enhance salivary hemodynamic responses to tastes detected by near-infrared spectroscopy -flavor creation using optical imaging-dried-bonito (katsuobushi) broth, an important seasoning in japanese cuisine, has long been used to reinforce the flavor of appetitive foods. not only the taste but also the aroma components of the broth contribute well to the enhancement. to elucidate the effects of aroma from dried-bonito on broth tastes caused by the central integration of flavor, we performed optical imaging of salivary hemodynamic responses using near-infrared spectroscopy (nirs). when hemodynamic responses to a reconstituted dried-bonito flavored broth were compared to those of odorless broth taste solutions, the flavored broth produced a significantly larger response than the odorless broth. this was the case for five of the ten participants, who felt that the combination of the aroma with the tastes was congruent. in the remaining five who felt the combination incongruent, the flavored broth did not cause the enhancement of responses. moreover, when (z,z)- , -tridecadienal, one of the most important key aroma components of dried-bonito extracts, was added to the flavoring, the latter five as well as the former five participants came to feel congruency of the reconstructed aroma with broth tastes. the reconstruncted flavored broth produced significantly larger hemodynamic responses than the odorless broth in both participantsÕ groups. accordingly, there is a positive correlation between the degree of congruency and increase of the salivary responses. these results indicate that nirs offers a sensitive method to detect the effect of flavoring on the taste-related salivary hemodynamic responses, dependent on the perceptual experience of the combination of aromas and tastes. minty flavors are utilized in foods, beverages, toothpastes and tobacco. minty flavors are considered to have a relaxing effect, which is necessary for us, living in modern and urban societies. the authors have reported that the participants evaluated themselves more relaxing after smelling minty odor, when they were tied out for solving hard puzzles. however, psychological and physiological effects of minty flavors are still unclear. this study was aimed to reveal brain responses to minty flavors and minty odors with nirs (near infrared spectroscopy). sixty female university students participated in this study. they received detailed explanation about the experiment and wrote consent for participating in this study. the three minty stimuli, menthol, spearmint and peppermint and the other three odor stimuli, rose, skatol and orange, were administered to the participants via the olfactometer. the participants were asked to smell the stimuli by an orthonasal or retronasal route or to taste them. brain responses were measured with nirs (bom- , omegawave, co ltd) and recorded with ad converter (powerlab) connected to the imac. the participants were also asked to evaluate the intensity of the odor continuously with the apparatus which outputs ; v being based on the participantsÕ evaluations. the results showed that the stimuli were recognized faster and stronger when the stimuli were administrated via orthonasal and retronasal routes than via oral cavity. the rose odor and orange odor were recognized faster and stronger than the menthol odor. the right forebrain showed greater responses to the stimuli via an orthonasal route than via the other routes, and greater responses to the rose odor than the menthol and the peppermint odors. currently existing odorant sensors are mainly fabricated based on metal-oxide semiconductor devices, conducting polymers, quartz crystal microbalances, or surface acoustic wave detectors. these sensors have been studied for improving on various parameters, such as sensitivity, selectivity, response speed, and portability. however, it has been difficult to develop odorant sensor elements that incorporate a combination of desirable properties. in contrast, living organisms, especially insects, use numerous olfactory sensory cells, which express odorant receptors, to sensitively detect environmental odorants in real time. so far, we have developed a compact odorant sensor that consists of a multichannel fluidic device and xenopus laevis oocytes expressing insect odorant receptors. although this odorant sensor possessed fast responsiveness and good portability, it had some technical disadvantages in terms of the stability of response measurements in the oocytes. here, we report the development of new odorant sensor elements that enable us to acquire stable odorant response measurements. we introduced insect odorant receptors and the olfactory receptor co-receptor (orco) as well as a calcium indicator protein, gcamp , into spodoptera frugiperda sf cells to construct sensor cell lines. when these cells were stimulated with a set of odorants in solution, intracellular calcium as monitored by fluorescence imaging showed sensitive responses in accordance to the ligand specificity of the expressed odorant receptors. these results show that our sensor cells can be applied as odorant sensor elements that detect various kinds of odorants with high sensitivity, selectivity, and stability. with promotion of globalization, our diet are changing in several directions (diversification, mass commercialization, or high quality). because of the change, objective evaluation techniques for taste or odor of foods and beverages are needed for effective r&d and strict quality control. in recent years, biomimetic sensors, such as taste sensor, have been more developed as practical objective evaluation tools for taste or odor. with development of these sensors, development of correlativity evaluation system between objective values (sensor outputs) and subjective values (sensory scores) is needed to realize objective quality evaluation of foods and beverages. mainly developing artificial-lipids-based taste sensors with global selectivity, our research group have studied for realization of Ôtaste-odor fusion biosensor system,Õ which estimates quality (deliciousness and safety) of foods or beverages using several sensor outputs through analysis and evaluation of subjective-objective relation. in the studies, we have estimated relations between each taste sensory and each sensor output, but did not investigate about correlativity among quality of foods or beverages and sensor outputs. hence, in this study, we investigated correlativity among sensory of deliciousness and several sensorsÕ outputs on a particular sample as the next step of realizing Ôtaste-odor fusion biosensor system.Õ as a result, we found that sensory scores of deliciousness were able to be displayed on a superspace as a hyperplane and to be estimated by the hyperplane and sensor outputs. this means that a sensory score on the particular sample can be calculated using sensor outputs and an estimation equation indicating the hyperplane. it has been reported that taste disorder caused by systemic diseases is associated with zinc deficiency. this study included patients with dysgeusia due to systemic diseases: patients with diabetes mellitus (dm), with renal failures, with digestive diseases, with digestive diseases post operation, and with liver failure. taste function was tested by electrogustometry (egm) and filter paper disk method (fpd method) in the area controlled by the chorda tympani nerve. the severe grades of taste threshold before treatment were more than % for renal and liver failure patients. all patients were treated with zinc sulfate. the rates of serum zinc deficiency (< lg/dl) were more than % for all systemic diseases. in patients with renal failure, the symptom improvement rate was the highest, and the curative period was shortest. however, in dm patients, the improvement rate was the lowest, and the curative period was longest. this study demonstrated that zinc deficiency is induced by systemic diseases, and might cause taste disorder. it is also necessary to consider the possibility of taste disorder caused by medication. this study analyzed patients with bms. the threshold of the taste function was measured by electrogustometry (egm) and the filter-paper disk (fpd) method. both basal and stimulated salivary secretions were measured. in addition, the self-rating depression scale (sds) was assessed. serum zinc and copper levels were also measured. the egm threshold was more than db in ( . %) of patients, and the taste threshold measured by the fpd method was more than points in ( . %) of patients. basal and stimulated salivary secretions were less than ml in ( . %) of patients and less than ml in ( . %) of patients, respectively. based on the sds, ( . %) and ( . %) of patients were diagnosed with neurosis and depression, respectively. blood tests showed that the serum levels of zinc were less than or that of copper were more than lg/dl, respectively, in ( . %) of patients. the clinical outcome was cure in . %, improvement in . %, recurrence in . %, unchanged in . %, and dropped out in . %. in this study, basal salivary secretions lower than the normal range compared with stimulated salivary secretions. this suggests that, even if the salivary secretory function is maintained to some extent, the sympathetic nerve activity is predominant due to tension. it is necessary to accumulate more clinical data, such as trigeminal sensitivity of the tongue in comparison with the electric taste threshold. postoperative oral tumor patients show a variety of conditions and often display taste dysfunction resulting from anti-cancer drugs, irradiation and defects of oral tissue. prosthetic rehabilitation should be required for the recovery of oral functional disorders. however, no reports have investigated taste disorder for patients wearing maxillofacial prostheses. the aim of this study was to clarify taste sensation in postoperative oral tumor patients using the filter-paper disc method, salivary secretions measured by gum chewing, serum zinc concentrations by blood tests. we investigated patients who had undergone prosthodontic treatment in the department of prothodontics and oral rehabilitation at iwate medical university dental center. results were as follows: ) taste disorder was seen in % of cases; ) within years after radiation exposure, the degree of taste disorder was severe; ) disease severity did not necessarily accord with awareness of taste disorder, and some patients with serious taste decline were unaware of their taste disorder; and ) patients who were aware of their taste decline also showed declines in chewing score. objective inspection and liaison with other departments to include an otolaryngologist, doctor of psychosomatic medicine, and a dietitian is important. it is known that more than % of patients with taste dysfunction have zinc deficiency. carbonic anhydrase (ca) vi, also known as gustin, is a , -da zinc metallo-protein found in human saliva and is involved in taste dysfunction. it can be detected by enzymelinked immunosorbent assay, but the test takes time. therefore, in this study, we developed a new quick and simple method of diagnosis using an immunochromatography assay to be used as an on-site test. first, reactivity with a serum antibody (prepared using a synthetic peptide designed from a - amino acid chain of human ca vi as a hapten conjugated to keyhole limpet hemocyanin and injected into two new zealand white rabbits) was evaluated and compared to a control (swine antirabbit igg) using a hi-flow plus membrane and detected with colloidal gold. a difference in color development was observed between samples of pbs (-) and the positive control (synthetic peptide). furthermore, it was density dependent, and in serially diluted parotid gland saliva, the color development was seen to be times dilution density from times dilution density. the results suggest that an immunochromatography assay using this novel antibody can be used to quantitatively measure ca vi, which may be useful in the diagnosis of taste dysfunction caused by zinc deficiency. # the epithelium of recessus olfactorius is a part of the accessory olfactory system in the japanese toad (bufo japonicus) hideo nakazawa , kimiko hagino-yamagishi , atsushi c. suzuki and takatoshi nagai the recessus olfactorius (ro) is a small pouch observed in the antero-lateral olfactory epithelium of anurans. ro is mostly covered with the epithelial cells with cilia, which is reminiscent of sensory function. however, if ro is a part of the main olfactory system has not been studied. we studied the epithelium of ro (ro epithelium) in japanese toads regarding central projection, ultrastructure and expression of proteins involved in olfactory transduction. fluorescent carbocyanine dye (dii) was placed on the ro epithelium to show a neuronal projection from ro. fluorescent signal was not detected in the main olfactory bulb, but in the accessory olfactory bulb. in contrast to the olfactory epithelium which does not contain microvillous receptor cells, the ro epithelium contained both ciliated cells and micro-villous cells. the expression of a-subunit of g-proteins (g aolf and g ao ) in the ro epithelium was examined by immunohistochemistry and in situ hybridization. regionally different expression of g aolf and g ao was detected in the ro epithelium, namely expression of g aolf in the apical cell layer and g ao in the basal cell layer. such a pattern of g-protein expression in the ro epithelium was similar to that in the vomeronasal epithelium. these results suggest that the ro epithelium belongs to the accessory olfactory system. however, the ro epithelium contained secretory cells with granules that were not contained in the vomeronasal epithelium. physiological experiments will further clarify if the ro epithelium is functionally similar to the vomeronasal epithelium. in mice, the female memorizes some urinary pheromones of the mating male, thereby preventing the pheromones from inducing pregnancy block. the memory depends on the neural changes in the accessory olfactory bulb (aob), the first relay in the vomeronasal system. microcircuits in the aob include the prominent reciprocal dendrodendritic synapse between mitral cell projection neurons and granule cell interneurons. a previous study has shown that in vivo infusion of a protein synthesis inhibitor, anisomycin, in the aob is able to prevent the pheromonal memory formation. other reports have indicated that antidromical stimulation of mitral cell axons induces long-term potentiation (ltp) at the mitral-to-granule cell synapse in slice preparations of the aob. using aob slices, we measured field epsps derived from granule cells to examine the effects of protein synthesis inhibition on ltp at the mitral-to-granule cell synapse. high frequency stimulation, consisting of a hz, pulse train applied four times at min intervals, induced ltp lasting for min. under bath application of anisomycin ( lm), high frequency stimulation induced short-term potentiation and early-phase ltp, but failed to induce late-phase ltp. the results suggest that protein synthesis underlies late-phase ltp at the mitral-to-granule cell synapse in the aob. the goal of our research is to understand the mechanism of synaptic transmission in the aob that has been demonstrated to be critical to memory formation for male mouse pheromones. by measuring the reciprocal synaptic currents from mitral cells in the aob, we have demonstrated that an agonist for group ii metabotropic glutamate receptors (mglur /mglur ), dcg-iv, suppressed dendrodendritic inhibition (ddi) in a reversible manner while the mglur /mglur antagonist ly enhanced it. the effects of these drugs were markedly impaired by genetic ablation of mglur , indicating that dcg-iv-mediated suppression of ddi is mediated by mglur . in these studies, glutamate release was triggered by an application of a voltage step from - to mv. in the present study, to see whether mglur has similar effects on the ddi elicited by more physiological stimuli, ipsps triggered by spike trains in mitral cells in slice preparations were recorded using the patch-clamp technique in whole-cell configuration. aob slices were prepared from -to -day-old balb/c mice. ly enhanced it. together with previous results, the present result suggests that mglur /mglur can be activated by endogenous glutamate release from mitral cells, which results in the suppression of the synaptic transmission from mitral to granule cells in the aob. phenols are predominant in the total flavor compounds of dried bonito (katsuobushi). the influence of odors of , , -trimethoxybenzene (tm; m= ), , -dimethoxyphenol (dt; m= ), and guaiacol (gu; m= ), which were the chemicals responsible for the katsuobushi aroma, on the production of b-endorphin (be) in the hypothalamus were examined in f male rats. rats ( weeks of age) were exposed to . % of odors dissolved in either ethyl alcohol (etoh: m= ) or triethyl citrate (tec: m= ) for h/ day for one or two weeks. be levels in water soluble extracts of hypothalamus were examined by elisa kits. among three phenols, tm is the most potent odor to increase be levels in rat hypothalamus, followed by dt and gu: the increasing rate as compared with the control was %, % and %, respectively. these phenols may activate glomeruli clusterd in the lateral domain of the dorsal surface of the mammalian olfactory bulb and probably suppress the activities of sympathetic nervous system. these results suggest that the long-term exposure to bonito bouillon-flavored diet enhanced ratÕs preference for bonito bouillon. neurogenesis occurs in the forebrain subventricular zone (svz) throughout life. these neurons migrate to the main olfactory bulb (mob) via the rostral migratory stream (rms), and upon reaching the mob they differentiate into granule cells and periglomerular cells. the information broadcast by general odorants is received by the olfactory sensory neurons and transmitted to the mob. newly generated neurons at the svz play important roles in odor discrimination and odor memory. recent studies have shown that reduction of mastication impairs neurogenesis at the hippocampus and brain functions. in the present study, bromodeoxyuridine-immunoreactive (brdu-ir) structures in the sagittal section of the svz, rms, mob and accessory olfactory bulb (aob) of female adult mice fed a soft diet were studied to explore the effects of reduction of mastication on newly generated neurons at the svz and mob. the numbers of brdu-ir cells in the svz of adult mice fed a soft diet for , , or months were lower than those of mice fed a hard diet. the odor preferences of individual female mice to butyric acid were tested in a plexiglas y-maze preference apparatus. feeding the soft-diet affected the adverse responses of mice to butyric acid. the results suggest that feeding with a soft-diet reduces neurogenesis at the svz, which in turn reduces olfactory function at the mob. epigenetic mechanisms play an important role in memory formation and synaptic plasticity. specifically, histone-associated heterochromatin undergoes changes in structure during the early stages of long-term memory formation. before eye opening young rats depend on somatosensory and olfactory function for survival, as they can learn their damÕs odor and approach her without visual information. in order to establish olfactory learning, the pairing of odor and somatosensory stimulation is crucial. we have shown that synaptic plasticity in the ob underlies aversive olfactory learning. our behavioral pharmacological experiments have shown that long-term olfactory memory requires activation of creb. western blot analyses have revealed that expression of p-mapk/erk is increased for hour after odor-shock training, followed by increase of p-creb lasting for hours. therefore, we examined whether intrabulbar infusion of trichostatin a (tsa), a histone deacetylase (hdac) inhibitor, facilitates olfactory learning in young rats. tsa infusion during odor-shock training enhanced a conditioned odor aversion in a dose-dependent manner. we further tested whether odor-shock training leads to histone acetylation in the ob and defined the time course of the activation. the acetylation of histone h was significantly increased for hour after odor-shock pairing compared with odor only or no stimulation. tsa infusion significantly increased histone acetylation levels as well. these results show that hdac inhibition is associated with aversive olfactory learning in young rats. the endopiriform nucleus (epn) is a large group of multipolar cells located in the depth of the pirifprm cortex (pc). although many studies have suggested that the epn plays a role in temporal lobe epilepsy, the normal function of the epn remains to be elucidated. by using optical imaging with voltage-sensitive dye in slice preparations, we previously found that paired-pulse stimulation to pc and/or gustatory cortex (gc) evoked the excitation propagation to the epn, agranular division (ai) of the insular cortex and further to the claustrum (paired-pulse facilitation). in the present study, we investigated the electrophysiological properties of neurons in the epn, claustrum and ai in anaesthetized rats. in response to electrical stimulation of the olfactory bulb, the evoked potentials with a latency of about ms were elicited in these regions. paired-pulse facilitation of the evoked potential was also observed. of the neurons in these regions tested with odor and gustatory stimulation, ( %) showed excitatory responses to both odor and taste stimulation, ( %) had excitatory responses to odor but not to taste stimulation, ( %) had excitatory responses to taste but not to odor stimulation, and the remaining ( %) had no response. further, we previously found significant increases in the numbers of c-fospositive cells in the pc, gc, epn, ai and claustrum following natural stimuli, such as feeding an apple. these results, together with previous results, suggest that the epn, claustrum and ai are the multimodal-chemosensory regions, where olfactory and gustatory information is centrally integrated. department of science education, faculty of education, chiba university, chiba - , japan we found that a simple and typical association learning of a flower odor with proboscis extension reflex to nectar in honeybees was inhibited by exposure to extremely low frequency (elf) alternating magnetic fields. we postulated that the elf magnetic fields could be detected by magneto-receptors. honeybees have two types of putative magneto-receptors which either contain magnetite crystals, abdominal dark short hairs or abdominal trophocystes. we previously reported that a cutting of the abdomen longitudinal connective nerve between rd ganglion (first ganglion in abdomen) and th ganglion had no effect on the inhibitory action of alternating magnetic fields. and we concluded that the trophocystes had no role in magnetoreception. in this work, we confirmed that the dark hairs had a role in magnetoreception and inhibitory action of olfactory learning by magnetic fields. an exposure to hz alternating magnetic fields of approximate lt inhibited the performance of conditioning learning in intact bees. when all dark hairs were pull out, an exposure to alternating magnetic fields had no inhibitory effects on the conditioning. so, it was shown that the dark hairs had a role in magnetoreception which impaired olfactory learning. # prediction of glomerular activity patterns using the graph structure of odorant molecules zu soh , toshio tsuji , yuichi kurita , noboru takiguchi and hisao ohtake grad. school of engineering, osaka univ., suita - , grad. school of engineering, hiroshima univ., higashihiroshima - , grad. school of natural science and technology, kanazawa univ., quantitative evaluation of odor qualities is an important process especially in the fragrance, food and beverage industries. however, most of the conventional odor sensing systems are unable to assess odor qualities perceived by humans. this study therefore aims to develop an artificial sensory evaluation system that can be used to evaluate odors and support sensory testing. as the first step in the development of such a system, we proposed a neural network model for prediction of olfactory glomerular activity based on the results of previous studies, which reported that odors evoking similar glomerular activity patterns have similar odorant qualities. the proposed model consists of marginalized graph kernels and a multilayer neural network. the former is used to evaluate distances between odorant structures, and the latter converts these distances into glomerular activity patterns. however, a number of parameters included in the model required further discussion. we therefore explored the two parameters that most significantly influenced the prediction accuracy of the model. these were the number of the gaussian units and the number of neuron units in the neural network. the results indicated that optimal prediction ability was achieved when the number of the gaussian units was approximately sixty and the number of neuron units in the hidden layer was approximately double than in the input layer. based on these outcomes, future plans for further improvement of prediction ability were discussed. in food and beverage industries, quantitative assessment of odors is an important process in developing new products. however, conventional odor sensing systems focus on identifying or detecting specific odors, and are unable to assess odor qualities perceived by humans. against this background, our study aims to develop an odor assessment system that can be used to evaluate odors and support sensory testing. toward the development of a model for the evaluation of odor qualities, this study focuses on neural activity evoked by odorant stimuli in the olfactory system. this is because the results of previous studies suggested that odorants prompting common neural activity patterns in the olfactory system had similar odorant qualities. as a first step, we conducted a series of human sensory tests to investigate perceptual similarities between odorants, and then compared the results with activity patterns evoked on the glomerular layer of the olfactory bulb in rats. these animals were chosen because the structure of their olfactory system is similar to that of humans, and measurement data relating to their glomerular activity is available online. we defined three indices (correlation, overlap rate of activation, and sum of squares of difference between histograms) to describe similarities and differences between activity patterns, and also conducted sensory testing to determine similarities to human perception. comparison of the results revealed that each index showed a weak correlation to perceptual similarities. we therefore examined whether similarities between odorants could be predicted by combining the three indices using svm (support vector machine), and the results indicated a certain level of prediction ability. novel esters, alcohols, and ethers containing a tetrahydropyran ring were derived from ( , , -trimethyltetrahydropyran- -yl)acetic acid ( ) or -methyl-( , , -trimethyltetra-hydropyran- -yl)propanoic acid ( ), and their odor properties were investigated. the relationships between the structures of the derived compounds and their odor properties were also examined. the methyl ester of carboxylic acid ( ) had a refreshing, floral, and herbaceous odor, and the methyl ester of carboxylic acid ( ) had a refreshing, woody odor. the propyl ester of carboxylic acid ( ) had an adzuki-bean odor, and the propyl ester of carboxylic acid ( ) had a vegetable and spicy odor. thus, the odor of methyl ester of carboxylic acid ( ) was thus similar to that of methyl ester of carboxylic acid ( ), but considerably different from that of the propyl ester. moreover, the odor of propyl ester of carboxylic acid ( ) was considerably different from that of propyl ester of carboxylic acid ( ). to determine the most stable structures of these esters, the molecular orbital calculation was carried out for each ester using mopac pm . the bulkiness of the side chain of a tetrahydropyran ring of methyl ester of carboxylic acid ( ) was comparable to that of methyl ester of carboxylic acid ( ). however, the side chain of propyl ester of carboxylic acid ( ) was bulkier than that of its methyl ester, and this increased bulkiness prevents the free rotation of the side chain of propyl ester. similarly, the bulkiness of the side chain of propyl ester of carboxylic acid ( ) makes its free rotation more difficult than that of propyl ester of carboxylic acid ( ). thus, the bulkiness and the degree of free rotation of the side chain of a tetrahydropyran ring influence the odor of compounds containing a tetrahydropyran ring. measured odor thresholds depend on both subject sensitivity and method. yet, threshold-methods have received relatively little systematic attention in olfaction. we measured psychometric, i.e., proportion correct detection vs. concentration, functions for acetic acid. a -outof- , forced-choice procedure was used. stimuli were precisely controlled using an air-dilution olfactometer. the design had four factors, all randomized or counter-balanced: ) practiced subjects vs. unpracticed subjects (between subjects); ) -second inter-trial interval (iti) vs. -second iti (within subjects); ) re-sampling allowed (i.e., subjects could smell each of the stimuli presented during a trial as many times as they wished) vs. not allowed (within subjects); ) concentrations presented in ascending order (lowest concentration first, moving up to the highest concentration, then starting again at the lowest concentration after a break) vs. random order (within subjects). a four-way anova (the above four factors) revealed a significant main effect of re-sample condition. these results highlight the importance of methods for measured thresholds, and have implications for laboratory practice. many researches have reported the influence of information to identify an odor. we tried to measure the prefrontal cortex activity during the smelling an odor using functional near-infrared spectroscopy (fnirs) to find out the effects of positive and negative information with a same odor. we used three kinds of odors which have been evaluated as moderately hedonic values by a preliminary experiment. eighteen subjects who had normal sense of odor were presented these odors with visual stimulation on a display. the visual stimulation showed the explanations of each odor with positive or negative information. during the experiment, subjects were measured for their prefrontal cortex activity with channels ( x distributions) by fnirs (foire- , shimadzu corp). these odors were presented by odor-stimulation system through tubes and a mask. the experiment was conducted by the following protocol; pre-resting period ( s), task period ( s), evaluation period ( s) and post-resting period ( s). we had trials ( odors x positive/negative information x trials) and control tasks with odorless. during the evaluation period, subjects evaluated the intensity, pleasantness/unpleasantness and familiarity of each odor. the stimuli were presented by random order. as a result, we showed the different evaluation value on the same odor but different information condition. the positive information condition showed significantly higher pleasant value than negative information condition (p<. ). fnirs data also showed the significantly different prefrontal cortex activation between positive and negative information conditions. we showed the effects of positive and negative information on a same odor. first impression of a stranger is created by several perceptions, such as face, tone of voice, speed of words etc. there are many researches on development of first impressions, but there are few researches that study a role of olfaction on development of first impressions. we wear perfume not only because we like it, but also because we want someone to have good impressions. this study aimed to investigate whether the perfume that we wear affects othersÕ first impression for us. sixty female university students participated in this study, and all of them were not acquaintance of the experimenters. ck one, citrus-floral perfume, and coco chanel, fresh oriental note perfume, were used as olfactory stimuli. the method to investigate for participantsÕ impression for the female model (experimenter) was teg ii (tokyo university egogram ver. ii, published by kaneko shobo). when the model wore ck one, she was evaluated as having stronger sense of responsibility and the makings of leader. on the other hand, when the model wore coco, she was evaluated as having unique personality and strong self-assertion. these results show the perfume that we wear changes othersÕ first impressions for us. the authors are continuing to study about this phenomenon, and confirm it with another models and with another perfumes. # a study of the image congruency between bottle appearance and fragrance of perfume appearance of bottles might influence on the evaluation of perfumes as visual information before sniffing fragrance. we investigated such congruencies/ incongruencies between visual and odor information in the market products of perfume through the two experiments. in the experiment , we investigated broad constructs of image aroused from appearance of bottles and flagrance of perfumes, and reviewed congruencies between bottles and fragrances. we selected products as samples, and used ''napping'' for experiment . in napping, subject sort the samples on the space reflecting sensory similarities. our subjects carried out napping under the two conditions. subjects were asked to sort samples according to similarities of scents. these scents were sniffed actually in the sniffing condition, but in the viewing condition, scents were imagined from appearance of bottles. distances matrixes between samples were measured from results of napping, and were used for multi-dimensional scaling (mds). the result of mds showed that dimension could represent major image of perfumes (for men or female) in the both conditions, and that diman-sion in the viewing condition could represent lightness of scents related to transparencies of bottles. however, we could not find systematic feature change of scents on dimension in sniffing condition. it may suggest complexity of scents sniffed actually. we then examined the qualitative aspects in congruencies/ incongruencies between bottles and flagrancies in the experiment . we selected among perfumes used in experiment , and used descriptive terms to evaluate each of the samples. in the results of experiment , we could not find any relations between terms with perfumes. changes of the physiological parameters (saliva amylase, heart rate, and brain waves) of subjects during the smelling of the bark oil of lindera umbellata were measured. the value of saliva amylase did not change during the smelling of the bark oil. the proportion of the parasympathetic nervous system increased significantly during the smelling of the oil, while that of the sympathetic nervous system decreased. on the other hand, the proportion of b-wave decreased significantly during the smelling of the oil. thus, the bark oil exhibited the relaxation effects for the subjects. the bark oils included monoterpene alcohols ( . %) and ketones ( . %), monoterpene oxides ( . %), monoterpene hydrocarbons ( . %), and others. among of these, linalool ( . %) was the most abundant component. here we investigated relationship between the number of constituent odors and odor pleasantness. we hypothesized that the stability of the olfactory perception depends on the number of odor components and their molecular variability. we especially focused on odor pleasantness, which best explains molecular variability of odorants in the natural world. three different categories of odors, aliphatics, aromatics and terpenoids, were used in this study. we used or odors for preparing multi component odors. odor pleasantness for the multi component odors tended to be more stable against concentration changes than that of the single component odors. notably, multi component odors containing odorants of all categories showed higher stability than odors containing single odor category. future study for large number of components with different molecular variability will reveal rules for the prediction of the odor perception for odor mixtures. # fmri of brain responses to complex odor and visual stimuli one of the most important features of odor perception is the hedonic or emotional component. the purpose of this study was to measure the brain activity associated with human olfaction using functional magnetic resonance imaging (fmri) and to evaluate the influence of the pleasantness of odors by complex odor and visual stimuli. seventeen healthy right-handed subjects ( men; women) with normal olfaction participated in the study. an event-related mri method was used to analyze olfaction-induced responses on fmri. a puff of odorant was delivered to the nose of each subject through a nose mask with electrically controlled pneumatic valves. for the event-related task in the fmri experiment, two odorants (pleasant odor: amyl-acetate, unpleasant odor: iso-valeric acid) and two types of visual stimuli (pleasant image, unpleasant image) were randomly presented. two cross-modal sensual interactions were tested using spm-software for both matching/mismatching conditions and pleasant/unpleasant conditions, respectively. results revealed specific brain areas that were activated by cross-modal interactions with odor and visual stimuli. in advance of the fmri experiment, psychological odor experiments (cross-modal, complex stimuli with a visual and odor evaluation test) were conducted using a subjective judgment method or pleasantness/unpleasantness, respectively. based on the fmri and psychological experiments, we estimated the most suitable conditions for evaluating the pleasantness of odors. from analysis of the fmri experiments, two responses ( : emotional response to pleasantness/unpleasantness, and : response to matching/ mismatching) were obtained with the cross-modal, complex stimuli using odors and images. from the analysis of our experiments, activity associated with the response to pleasantness/unpleasantness was seen mainly in the right orbital frontal cerebrum and the supramarginal gyrus, middle frontal gyrus and amygdala. on the other hand, activity associated with the response to matching/mismatching was seen in areas of the brain corresponding to memory and cognition. thus, cross-modal, complex effects were suggested to be an emotional response to pleasantness/unpleasantness and cognitive and memory responses to matching/mismatching. as otorhinolaryngologists, it is important to grasp the grade of subjective symptoms and quality of life (qol) when we examine outpatients with olfactory dysfunction. however, the influence that the sense of smell exerts on the qol related to health is not clear. therefore, we investigated outpatientsÕ qol using the ''health-related qol measure (sf- ),'' which is widely used around the world. concurrently, we applied a ) visual analog scale (vas) to grade subjective symptoms (the smell of food and drink, perfumes, excreta and gases) and the deliciousness of meals (qol), ) smell questionnaire for daily life, ) t&t olfactometry, ) intravenous olfaction test (alinamin test) and ) card-type smell identification test (open essence). we then analyzed those tests and sf- for correlations. as the results, ''vitality (vt),'' which is a subscale of sf- , correlated weakly with the subjective symptom vas for ''smell of perfume'' (r s = . ) and the t&t recognition threshold (r s = . ). ''role functioning emotional (re),'' which is another subscale of sf , correlated weakly with the subjective symptom vas for each of ''smell of food and drink'' (r s = . ), ''smell of perfume'' (r s = . ) and ''smell of gas'' (r s = . ). no other correlation was found for any of the olfactory tests. these results showed that, although olfactory dysfunction affected the vt and re of the patientsÕ health-related qol, it was very slight. even if olfactory dysfunction develops, the effect on the overall qol of the patient is slight compared with other diseases. this likely explains why these patients are slow to consult a doctor. ½introduction olfactory dysfunction is most commonly caused by chronic rhinosinusitis (crs) in japan. within crs, eosinophilic chronic rhinosinusitis (ecrs) is said to cause severe olfactory dysfunction. however, there have been few reports that have compared ecrs with non eosinophilic chronic rhinosinusitis (necrs). ½patients and methods a prospective study was carried out at three institutions. a total of patients underwent endoscopic sinus surgery between april and march and were pathologically diagnosed with crs. of those, patients ( males, females; mean age: . years) were included in this study because they had undergone olfactory evaluation preoperatively. olfactory dysfunction was assessed using the standard olfactory threshold test (t&t) and subjective symptom score ( ; ). data were analyzed using spss software ver. . ½results the patients consisted of necrs patients, ecrs patients, patients with allergic fungal rhinosinusitis (afrs), patients with odontogenic maxillary sinusitis and patients with fungal rhinosinusitis. t&t found that . % of the total patients had olfactory dysfunction with a mean recognition threshold of ‡ . ( of necrs patients; . %, of ecrs patients; . %), while . % of the total patients had olfactory dysfunction with a subjective symptom score of ‡ ( of necrs patients; . %, of ecrs patients; . %). both the t&t result (or: . ) and the subjective symptom score (or: . ) were significantly worse in the ecrs patients than in the necrs patients. [introduction] we investigated the hypothesis that the prognosis of olfactory dysfunction (od) due to chronic rhinosinusitis (crs) becomes worse as the duration of od becomes longer. [patients and methods] patients ( males, females; age range: - years; mean age: . ± . years) with od due to crs underwent appropriate surgery and postoperative treatment, and were followed up for at least months. a visual analog scale (vas) was used to evaluate their pre-and post-treatment symptoms of od. [results and discussion] patients with an od duration of ‡ years showed significantly less improvement compared with an od duration of < years. the od duration and the post treatment vas showed a significant negative correlation (r s =À. , n= ). it was particularly strong in male patients aged ‡ years (r s =À. , n= ), and in the aspirin-intolerant asthma (r s =À. , n= ), peripheral eosinophil count of ‡ /microl (r s =À. , n= ) and current smoking (r s =À. , n= ) subgroups. multiple logistic regression analysis of patients with severe od even after appropriate treatment identified the following as poor prognostic factors: ) male gender (or= . ), ) od duration ‡ years ( . ), ) age ‡ years ( . ) and ) peripheral eosinophil count of ‡ microl ( . ) (predictive rate: . %). these results indicate that the prognosis of od due to crs becomes poorer as the duration of the disease becomes longer. in particular, patients who have these risk factors should be started on treatment as soon as possible and should be advised to quit smoking. motohiko suzuki, yoshihisa nakamura, hiroshi kawaguchi and shingo murakami causative viruses of postviral olfactory dysfunction have not yet been identified. we investigated causative viruses in patients with postviral olfactory dysfunction. we examined the presence of viruses in nasal discharge and examined the time course, with regard to changes in olfactory dysfunction and nasal obstruction in patients with postviral olfactory dysfunction, using questionnaires, acoustic rhinometry, and olfactory tests. nasal discharge was collected from patients with postviral olfactory dysfunction. rhinoviruses were detected in patients. viral serotypes were identified by nucleotide sequences to be human rhinovirus- , human rhinovirus- , human rhinovirus- , and human rhinovirus- . one of the four patients complained of dysosmia, whereas another complained of anosmia. results of acoustic rhinometry significantly improved in the four patients, although olfactory testing did not show significant improvement. two of the four patients complained of olfactory dysfunction even months after the first visit. coronavirus and parainfluenza virus were detected in one patient each, and epstein-barr viruses were detected in three patients. the present study detected rhinovirus, coronavirus, parainfluenza virus, and epstein-barr virus in nasal discharge of patients with postviral olfactory dysfunction. furthermore, this study suggests that rhinoviruses cause olfactory dysfunction through mechanisms other than nasal obstruction. in this study, we evaluated patients with olfactory dysfunction induced by central nervous damage. six of patients developed hyposmia after head trauma, patients by brain tumor, one patient after subarachnoid bleeding and one patient by encephalitis. five of patients did not sense any smell by venous injection of prosultiamine. psychophysical evaluation of olfactory function was performed by t&t olfactometry, and the average threshold score of recognition was . (severe hyposmia). eight patients got mri brain scans and each of them had one or more intracranial lesions. frontal lobe abnormalities were seen in of patients. intracranial lesions were also observed in temporal lobes and one parietal lobe and one occipital lobe. these mri findings suggested most of the olfactory disorders were come from damage of orbitofrontal cortex in frontal lobe, which is thought to be the olfactory center. on the other hand, out of patients developed taste disorder, despite no pathogenic lesion was found in medullary, thalamus and insula, which are thought to be the central pathway of taste and taste cortex. currently, we have yet to establish effective treatment of olfactory loss caused by central pathway damage. in clinical practice, some of these patients show improvements in olfactory function with several years, thus long-term follow-up of patients is needed to develop new clinical studies. the clinical study of patients with drug-induced olfactory disturbances cases ( . %) of drug-induced olfactory disturbance were investigated. anti-cancer drugs occupied % in the frequency of causative drugs. tegafur was most common in the causes of olfactory disturbance by anti-cancer drugs. we showed the characteristics of drug-induced olfactory disturbance by tegafur. a total of patients were identified. the averaged recognition threshold was . and the averaged detection threshold was . in t&t olfactometry. after treatment, re-examinations were performed in patients. the averaged recognition key: cord- -l tx g authors: dawson, t l title: it must be green: meeting society’s environmental concerns date: - - journal: nan doi: . /j. - . . .x sha: doc_id: cord_uid: l tx g consumers today are increasingly demanding goods which not only conform to the public’s image of being ‘eco‐friendly’ and ‘organic’ but of having been produced ‘ethically’. meeting such high ideals has a down side, both in higher costs and often in that of having to accept more distant suppliers. present trends in the coloration of foods with natural dyes rather than synthetic ones, increasing consumption of organic products (including fibres) and energy‐saving trends in dye application methods, fuels and lighting, as well as the means of capturing solar energy, are discussed. the discovery of some interesting and historic green colours, the wider use of green (in both senses of the word) products and green chemistry’s future role in producing them are also reviewed. in a seller's market, henry ford famously said of his model t car: 'you can have any colour as long as it's black', but present-day customers are increasingly saying to retailers: 'what we buy must also be green'. green in this sense means that the article should have been produced and transported under the best environmental conditions, with minimal energy consumption and, if possible, be made from naturally available materials, preferably from local sources. unfortunately, green issues have become inextricably confused with 'organic' sourcing and production, particularly where food, drink, personal care products, and even to a degree, medicinal preparations involving herbal or homeopathic treatments, are concerned. to many members of the general public 'chemicals', 'synthetics' or 'e-numbers' are bad for us, the corollary being that anything 'natural' or 'organic' must be beneficial. indeed, many people seem to be unaware that some of the most toxic chemicals known (e.g. ricin and botulin) are not manufactured but are natural proteins. with the plethora of ecological and ethical phrases now in common use, caution is needed as to the precise meanings accorded to them [ ] . in fact, because our preoccupation with environmental matters is relatively recent, many eco-phrases have only come into common use since the millennium [ ] . to satisfy an extreme demand, one could now (with difficulty) obtain organically grown cotton dyed with natural dyes, spun, woven and made into a garment by hand. to achieve this end, the cotton crop would firstly have had to be grown without the use of pesticides (at present this is by far their greatest agricultural single usage), although possibly some manual operations would involve child labour. whilst the fabric produced might have been dyed using a natural dye (with a somewhat toxic mordant?), it would have been processed at minimal labour cost and have had to be transported many thousands of miles! transport is indeed a problem with organic food in the uk for, at present, some % is imported giving it a bad 'carbon footprint' [ ] . this is also true in the textile field owing to mass importation of ready-made garments, mainly from the indian subcontinent and china, but there is an increasing trend towards eco-awareness in european, american and australian textile production and fashion design [ ] . the awareness of the textile production industry has differed from that of fashion designers, who can focus on the end product itself, whilst dye-and printworks have had to pay much more attention to environmental legislation regarding the safe use of dyes, auxiliary products and chemicals, and particularly the disposal of works effluent. no supplier can now ignore the apparent needs of a relatively new, but rapidly expanding, market segment of 'natural and ethical consumers' (forecast to double in western markets in the next years) [ ] , but the word juxtaposition in the title of one of the relatively newer journals, green chemistry (published by the royal society of chemistry), might still leave a prejudiced member of the general public a bit puzzled. many large retailers are indeed beginning to publicise their corporate social responsibility (csr) policies. examples are the supermarket chains demonstrating their increased sensitivity to ecological pressures by offering customer rewards for using their own or reused plastic shopping bags (by tesco) and the use of biodegradable bags and packaging (by the co-operative group and sainsbury's) [ ] . some investors are scrutinising csr procedures, whilst socially responsible investment groups take things a stage further by not investing where they doubt a firm's ethical credentials. for their part, many retailers, especially in food and clothing, are members of the ethical trading initiative which requires them to impose a code of conduct on their suppliers backed by independent site visits. in european folklore, green has been variously associated with natural forces involving growth, fertility and regeneration and was personified in mythological characters such as the green man, although there were also more sinister associations with death, sickness and even devils [ , ] . psychologically, in more recent times the hue green has been regarded as denoting something which is natural and safe which is why health and safety regulations specify this colour for first aid and emergency escape route signage [ ] and gas cylinders with green-painted shoulders hold only inert gases. green is also regarded as being cool, calm, restful and natural [ ] and has consequently been adopted as an ecological symbol [ ] . green is indeed the predominant colour of the natural, fertile world and is that of the chlorophyll pigments of foliage that reflect strongly in the green waveband around nm, which is also that of the maximum wavelength for solar radiation flux at sea level. in nature, the chlorophyll pigments are the basis for most photosynthetic processes which have rendered life possible on earth [ ] and, although we are now all familiar with the 'blue planet', the predominant colour of the earth from space, at certain periods of excessive growth of marine plankton it turns a patchy green. in the ancient world, man had to rely on two natural, copper-based, mineral pigments that were green, namely malachite and verdigris [ ] , and these were of relatively low toxicity. such was not the case for some of those that were subsequently produced synthetically. in , whilst investigating arsenic, the swedish chemist carl wilhelm scheele produced a new pigment, copper hydrogen arsenate, which he recognised was very toxic. at that time, artists needed a tinctorially stronger green pigment and this product was manufactured as scheele's green. although a similar but somewhat faster pigment, emerald or schweinfurt green (copper aceto-arsenite) was eventually introduced in , the former pigment remained popular for many years. it is quite probable that the somewhat mysterious death of napoleon whilst in exile on elba may have been accelerated (he had stomach cancer) because scheele's green had been used to print the wallpaper in his apartment. under damp conditions mould could grow on the animal glues then used as adhesives, and this can decompose the pigment to produce a mixture of toxic arsine and di-and trimethylarsine gases, which give rise to a complaint subsequently known as gosio's disease. following a radio programme in , the public were asked whether anyone had a reliable reference to the colour of the ex-emperor's wallpaper. amazingly, someone not only knew it was green but produced a nineteenth century scrapbook they had inherited, with an entry dated ( years after napoleon's death) containing a sample of the actual paper cut from the wall of his room by a visitor. when analysed, this was shown to contain arsenic, as did several keepsake samples of bonaparte's hair. in the late eighteenth century, the production of zinc oxide and availability of the mineral smalt had led to the development of cobalt green (cooaezno), a pigment with superior stability to the former greens, but, although relatively bright, its tinctorial strength was poor and the cheaper copper ⁄ arsenic pigments continued in use. up to the middle of the nineteenth century, the dyeing of textiles was of course based on the use of natural products [ ] , greens being obtained from plants and lichens, but in the discovery of perkin's mauvein and several related products (including perkin's green) marked the birth of the synthetic dye industry [ ] . this was to be followed in by aldehyde green from the firm of meister, lucius, bruning (later to become hoechst). the s also saw the birth of triphenylmethane (tpm) basic dyes such as fuchsine (magenta), followed in the s by methyl green, which was soon to be replaced by malachite green (basic green ) that is still widely used as a bactericide in aquaria despite doubts about its toxicity. peter griess' discovery of the diazotisation of aromatic amines and coupling with naphthols subsequently produced an enormous range of mono-and dis-azo 'aniline dyes' although homogeneous greens were not very common. the first green direct dye in was diamine green b (direct green ), a tris-azo colour based on benzidine and one of several dyes withdrawn in the s because of their potential carcinogenicity. similarly, there were only a few greens obtainable from the azoic combinations on napthol as prepared cloth by coupling with the stabilised diazo fast colour salts. the dyestuff industry in the early twentieth century was dominated by german manufacturers but systematic research in scotland by the firm of morton sundour alongside scottish dyes in produced a vat dye having outstanding fastness properties, namely caledon jade green x (vat green ) [ ] . scottish dyes became part of the newly formed ici in and it was at grangemouth works that the fast blue pigment, copper phthalocyanine (cupc) was developed following investigation of a chance observation of dark insoluble deposits being formed in chipped, enamel-covered, iron trays which had contained molten phthalic anhydride. this led in the s to the equally fast corresponding green pigments based on polychlorinated cupc, the monastral greens. innovation in ici resumed after world war ii, for in the soluble cupc alcian dyes were introduced and yielded very fast bright blue and green shades on cellulosic fibres. these were temporarily solubilised, 'ingrain' dyes which were converted to a pigment by after-treatment with alkali. these dyes became obsolete after the introduction of fibre-reactive dyes (again by ici) in and of the first reactive monochlorotriazine turquoise blue dye, procion brilliant blue h g, which enabled the production of emerald green shades using mixtures with bright pyrazolone yellows. today, there are a score of homogeneous reactive greens of several chemical types which have been introduced. over the last years, chemists and dye technologists have contributed enormously to our colourful world and many of them were themselves colourful people. to take but three of the above examples, much depended upon scientists with enquiring minds turning an apparent failure into a success. william perkin, trying to synthesise quinine at a time when structural organic chemistry was in its infancy, produced a black tar. many would have discarded this and tried something else but, seeing the beautiful colour of an alcoholic extract and finding this dyed silk and cotton he, supported by his family, eventually became a very successful dye manufacturer [ ] . again, when problems occurred at the grangemouth works in the production of phthalimide (used in the manufacture of indigo and produced by the action of ammonia on molten phthalic anhydride) it was observed that black occlusions were produced only in chipped enamel trays. the simple solution was to throw any damaged trays away but again the plant chemist, a. g. dandridge, decided to investigate further and, although early experiments produced only dull colours, eventually a new bright blue pigment, copper phthalocyanine, was born whose chemical structure was eventually confirmed using x-ray diffraction images [ ] . then, years after perkin's discovery, reactive dyes for cellulosic fibres were first marketed. the original work on reactive dyes at ici's technical service laboratories in blackley were for dyeing wool; amongst the more promising experimental dyes tested were the dichlorotriazines but these still did not fix very well. to attain better fixation, a strong alkali appeared to be required, which was of course impractical because it would have severely degraded the fibre. not deterred, the dye technologist involved, ian (later professor) rattee, in present day parlance 'thought outside the box' and decided that such conditions would, however, be quite acceptable for dyeing cotton and, in cooperation with dr w. e. stevens, the first three procion dyes were born [ ] . initially, the 'saltfix' application method involved padding the dyes and then passing the fabric through saturated brine containing caustic soda. in time it was found possible to apply these dyes under much milder conditions and, as they say, the rest is history. in most countries of the world, the use of added colour to foodstuffs has been highly regulated for a considerable time but 'permitted' colours vary from one country to another and these lists are being constantly updated. two important classification systems are those in europe, [ ] . in europe, food additives and colorants are classified by 'e-numbers' with their colour index (ci number) reference. this list includes both synthetic dyes and natural colorants, for example, lycopene and b-carotene, mostly obtained from natural sources, but chemically identical products may sometimes be made synthetically or biosynthetically, which may allow slight structural modifications [ ] . in both the european and the american regulatory systems, the use of some colours is restricted to certain specific outlets such as animal feeds. in the usa, the natural colours listed are, however, classed as exempt from certification. synthetic colours are usually referred to as 'artificial' (or as 'e-numbers') by the general public in the uk and recent years have seen much publicity about certain products, such as tartrazine (e , ci food yellow ) used in confectionary and orange-flavoured drinks and thought to lead to hyperactivity in some children. usa federal regulations on food labelling require that colour products from natural sources, although exempt from certification, must be described as 'artificial' or 'added' colours as the authority maintains that 'natural' colour can only be that originally present in the particular foodstuff. details of all well-established sources and properties of natural food colours can be found in hendry and houghton's 'natural food colorants' [ ] . the efsa (european food safety authority) is at present reviewing data on the presently permitted dyes and will eventually review the legislation, but this process is only at a very early stage. reacting to pressure from consumer groups and general public demand, much has been achieved in the display of data on packaged processed food with regards to its components and nutritional value, as well as there being an indication of the presence of any additives such as preservatives and colours, all identified by e-numbers. e-number products total over , only of which are colours. packaged foods now also display labels with a 'traffic light' system to indicate the levels of salt, sugar and fats based on a 'guideline daily amount' for adults. the recent display on some packaged snack foods of the 'carbon footprint' of its contents in grams of carbon dioxide is, however, somewhat meaningless to the purchaser. in europe, the market for organic foods is estimated at € bn and growing at around % per annum [ ] , whilst in ⁄ the uk showed an even higher rate of increase of about % [ ] . to be certified as organic, products must be grown or manufactured in a manner that adheres to standards set by authorities in individual countries and in the uk these are the organic farmers and growers [ ] and the soil association [ ] . although scientific evidence for the direct benefits to the consumer of organic food are still in dispute [ , ] there are benefits in reduced ecological damage and the overall consumption of energy, if one neglects subsequent transport costs [ ] . many other aspects of the production, nutrition role and safety of organic foods have been recently reviewed [ ] . it does seem likely that more food will have to be grown without the use of pesticides because new european union (eu) legislation looks likely to ban perhaps % of them [ ] . this in turn may increase the need to accept pest-resistant genetically modified (gm) foods. heightened customer awareness to environmental issues has led to strong public resistance to the introduction of gm crops or the sterilisation of food using ionising radiation. there is a particular expectation that if it is required to add any colour to organic food it should be a natural product. those derived from fruit and vegetables such as the betalains (from beetroot) and lycopene (from tomatoes) may thus seem particularly attractive, but only if the customer recognises their origin. there are few problems using natural colours where yellow or orange shades are required but most approved reds and blues are synthetic. the recent rapid expansion of the organic food market has therefore led to a renewed interest in natural colours, developed in modified forms if necessary (table ) . some analysts predict a - % per annum growth for natural colours, which is times that for synthetics. some natural food colours such as the carotenes are surprisingly stable to extremes of ph and temperature, but others are inferior to synthetics in such respects, a specific example being that concerning the colouring of tinned peas. without the use of added colour, the thermal processing of tinned marrowfat and mushy peas would leave the contents with an unappetising olive brown colour and the desirable bright green shade has traditionally been attained using a mixture of green s (e ) and tartrazine (e ). the change of shade during heat treatment of green vegetables is because of the instability to acid of their own natural chlorophyll, which tends to lose its coordinated magnesium and form pheophytin. in fact, it is because of the potential instability of natural chlorophyll (e ) that it is also sold as its copper complex (e ). similarly garden peas and spinach can be treated so as to preserve more of their fresh chlorophyll green colour during the canning process by the introduction of zinc or copper ions [ ] , but in a recent exercise by the co-operative group supermarkets to replace all synthetic food colours with natural ones, it was found impossible to find a sufficiently stable natural colour to replace green s. this retailer has in fact decided to withdraw some product lines which cannot be reformulated satisfactorily using natural colours [ ] . most of the major uk food retailers have since followed this lead and reformulated the colours used in their 'own brand' ranges of food products, some retailers even claiming that their foods will be 'free of e-numbers by ', a statement which further fosters the public misconception that only synthetic dyes carry this designation. natural food colours are manufactured in various forms but principally as water-or oil-soluble (or dispersible) preparations, depending on the required application. a third type of formulation which is required for the specialised printing of food wrappings is pigment dispersions. here, it is clearly a requirement that these do not transfer to the food product itself. few eu-approved pigments are listed but include three iron oxides (all listed under e ), calcium carbonate (pigment white ), titanium dioxide (pigment white ) and lithol rubine bk (pigment red . ); the last named can, however, only be used for colouring cheese rind. it has been argued that if the print on packaging is never in contact with the food and the wrapping is itself impermeable then no contact colour transfer can occur [ ] . the situation in this field is at present unclear because printing inks are not specifically covered by eu legislation other than the general food safety framework regulation (ec regulation no. ⁄ ) and three directives ( ⁄ ⁄ ec, ⁄ ⁄ ec, ⁄ ⁄ ec). other draft directives have long been under discussion but there is still no imminent legislation. general guidance on the selection of pigments for printing packaging can be found in 'colourants for food contact plastics' published jointly by eurocolour, etad (ecological and toxicological association of dyes and organic pigments) and the vdmi (verband der mineralarbenindustrie) [ ] . today, consumers are possibly oversensitive to the 'sell-by' and 'use-by' dates printed on packaged food, for the rate at which the product deteriorates is largely determined by the storage conditions, particularly the temperature. a novel type of label which changes colour according to a time ⁄ temperature function has been proposed [ ] . this consists of a colourless layer containing crystal violet lactone (see scheme ) and a second layer containing an acid donor which is attached only when the food is first packaged. the acid, which is slowly released thereafter, at a temperature-dependent rate, causes an increasing degree of violet colour change until it becomes noticeable. those who feel that present-day regulations may be too stringent, particularly those concerning the very low levels of metal contaminants specified in colorants, might be reminded that despite tight import controls it is still possible for major lapses to occur, as exemplified by the massive recall by mattel of painted children's toys which were manufactured in china [ ] . the problem is that toys which might be handled by very young children may also be sucked, leading to ingestion of potentially toxic metals and hence the very low permitted levels [ , ] . this had to be borne in mind in the rather unusual case of producing for the first time, truly coloured bubbles using dyes which neither stained the skin nor clothing but which were also acceptable environmentally. to achieve this it is not only necessary to select a colorant that associates with the micelles of the chosen surface active agent on the bubble's surface but can also be prevented from staining by including suitable dye blocking agents in the formulation. finally, when the bubbles burst they were to become colourless. this aim was finally achieved by using tpm dyes having a labile leuco form; for example, crystal violet lactone (normally used in carbonless copying papers), which only becomes coloured when the lactone ring opens to yield the carboxy form (scheme ) [ ] . for creating the world's first truly coloured bubbles, the inventor, ram sabnis, was presented with a grand innovation award in [ ] . certain natural colorants are promoted as diet supplements although positive evidence for their efficacy is limited, other than the fact they contain anti-oxidants which are 'good for the heart'. one of the leading causes of blindness in people over is age-related macular disease (amd). some types of amd can be treated by photodynamic therapy, using targeted treatment of the retina by a laser beam of shortwave ultraviolet (uva) radiation. prior to this the patient is injected with a photosensitising drug such as fluorecein or indocyanin green, which accumulates in this location [ ] . lutein and its stereoisomer zeaxanthin are always present in the foveal region of the human eye and are thought to serve as uv filters and as anti-oxidants [ ] . both are recommended as dietary supplements, ostensibly to prevent or delay the onset of amd. both carotene and lutein are used as food supplements in poultry feed as a means of controlling the colour of both egg yolks and the flesh. in animal experiments, a diet containing the chlorophyll derivative, chlorin e , has been shown to double the response of retinal sensors to red light and human trials are now being carried out in the usa to see whether this leads to improved night vision [ ] . other approved natural colorants which are also sold as human diet supplements are b-carotene and lycopene (both antioxidants) and turmeric, an anti-inflammatory. in some cases, it has been shown that the original food from which a supplement drug is extracted (e.g. lycopene from tomatoes) seems more effective than the purified component and more scientific study is needed [ ] . this finding does, however, emphasise the recommendation that for a healthy diet it is probably simpler to try to eat five portions of fruit and vegetables each day as most of these contain natural anti-oxidants. chlorophyllin tablets were once popular as breath fresheners but may also help protect against carcinogenic aflatoxins and mycotoxins [ ] . many drugs in pill or capsule form are surface coloured using food grade products for their identification, which can be recognised by reference to the mims (monthly index medical speciality) colour index [ ] , a commercial cd-rom database displaying thousands of colour pictures of drugs, or its online version from tictac [ ] . there is no set meaning for the specific colours, although different colours do appear to affect people's attitudes, green pills being associated with inducing relaxation and sleep and in general being considered as good for you. bright colours are usually avoided as they can attract children to think the pills are confectionery. the past decade has seen major increases in the cost of energy, with crude oil now trading at over $ a barrel, a higher level (in real terms) even than that which resulted from the oil crisis of the s, and this is being felt by the general public as well as by industry. any possibility of decreasing our overall energy consumption, whether it be by using more fuel-efficient vehicles, increasing the efficiency of heating systems or minimising water consumption, not only decreases direct costs but contributes to cutting our contribution to global warming [ ] . in fact, many of the machinery and process developments on show at the international textile machinery manufacturers' association (itma) exhibition in followed a general theme of energy and water consumption savings. this has been a theme for the past decade in textile processing, with continual improvements in the efficiency of dyeing processes aimed at minimising their environmental impact [ ] . recent examples include: -attaining approaching % dye fixation on cellulosic fibres by batchwise dyeing using poly-functional reactive dyes [ , ] ; -considerably shortening the total dyeing time and energy consumption when batchwise dyeing disperse and reactive dyes to produce blacks on polyester ⁄ cotton blends [ ] ; -more than halving the energy, water and chemical consumption in the continuous dyeing of polyester ⁄ cotton blends [ ] and -a reawakened interest in cold pad-batch dyeing processes using reactive dyes [ , ] . manufacturers have also helped by continual refinement of textile machine design and its control equipment, which together with dye selection and reliable recipe prediction systems in the laboratory have contributed to a high proportion of 'right first time' dyeing [ ] . the upsurge of concern with all things ecological has in extreme circumstances certainly affected some consumers' interest in organic textiles, principally cotton. to be classed as organic the cotton fibre used to produce the fabric must have been grown from genetically unmodified seed varieties, without the use of herbicides or pesticides and with ethical labour employment standards. certain bioengineered cotton varieties have, however, been shown to have good natural pest resistance and in the usa and china have also produced improved yields [ , ] so it seems a pity that such varieties are excluded for what appear to be psychological reasons. one cannot, however, treat this trend as just a fad when major manufacturers such as the levi jeans and nike sportswear companies have been promoting the use of organic fibres in a number of their internationally established brands. through the auspices of an international working group a 'global standard specification' for such goods has been drawn up (http:// www.global-standard.org). minimum colour-fastness standards seem rather low but much more critical analytical data are specified to meet low residues of bactericides, pesticides, formaldehyde and heavy metals. some dye manufacturers are now publishing lists of dyes that have been approved by the institut für marktökologie (imo) in weinfelden, switzerland. a number of authorities have introduced certification and labelling schemes for eco-textiles but most still rely on the imo as the certifying authority. in , the oeko-tex standard was introduced by the international oeko-tex association to provide a scientifically founded evaluation standard for the human ecological testing of textiles [ ] . more recently the oeko-tex standard has been introduced as a means of certifying an acceptable level of environmental and ethical control during the production process. firms that can demonstrate controlled production right from the original fibre through to the final garment can be awarded an ivn (internationaler verband der naturtextilwirtshaft) label. where the natural fibre alone is to be covered by a label scheme, there are those of the organic trade association in the usa, the textile standards of the soil association in the uk and the textile programme of demeter international certification in germany. there is also an eu regulation, eec ⁄ , covering organic textiles and criteria for the award of a community eco-label (eec council regulation ⁄ ⁄ ec). in order to meet the present-day high levels of dye fastness of textiles expected by consumers, it is certainly fortunate that, in all the abovementioned organic certification schemes, there is no mention of a need to use natural dyes, although there is a very small market niche for 'one of a kind' garments [ ] . some designers claim that it is an advantage (as providing originality) when using natural dyes because 'no two dye baths are identical' but for textile coloration it seems unlikely that the question 'is there a future for natural dyes?' will ever be posed again [ ] . in a few cases it may, however, prove possible to produce some dye intermediates from natural sources [ ] . the extensive range of biological staining dyes, among them many 'classical' greens, that have found uses in histology has been recently reviewed [ ] . although the alcian dyes were withdrawn from sale for textile dyeing in the s, the use of green gx (ingrain green ) continues for the staining and identification of mucopolysaccharides [ ] . it has also been used to visualise skeleton structures in the study of embryonic development of animals [ ] . the phenazidium dye, janus green b is used as a diagnostic stain in the study of the endothelial cells of the cornea but is considered too toxic to be used in vivo. green b is also used as a stain for identifying mitochondria [ ] . the tpm dye, fast green fcf has been used for studies on human kidney function but its use is not permitted in the eu or the usa and it has been replaced by green s (food green ). this dye is also used as a third component of gabe's trichrome, a mixed stain which simultaneously can differentiate between nuclei, cytoplasm, collagen and red blood cells [ ] . indocyanin green is used as a stain but has been used in low concentrations as an aid to examinations or surgery on macular holes and the blood vessels of the retina, in conjunction with a scanning laser opthalmoscope or infrared fundus camera [ ] . in this case there is some evidence that the outcome of such treatments is little different without the use of the stain [ ] . there are several examples where luminescent and fluorescent effects can be observed in nature and the colour of the emitted light is often greenish. luminescent effects range from those caused when certain marine dinoflagellates (pyrrophyta) are mechanically disturbed [ ] to the luciferin-based bioluminescence of fireflies and glow-worms [ ] . using a wide selection of dyes, such as substituted fluoresceins and rhodamines, which can selectively complex with specific end groups in protein-like molecules, various techniques for identifying drugs, hormones, antigens and dna fragments, etc. have been devised. much use has been made of genetically engineered forms of the naturally occurring fluorescent green protein [ ] , originally obtained from the jellyfish aequorea victoria, to produce biosensors. when used in living systems, these are much less toxic than the standard fluorescent marker dyes, such as fluorescein isothiocyanate, whose application is confined to in vitro analysis methods such as automated dna (deoxynucleic acid) sequencing, much used in human profiling for criminal forensics and the study of genetic disorders [ ] . fluorescence microscopy [ ] is a relatively simple system in which a sample, tagged with a fluorophor, is examined visually when illuminated with light of a specific wavelength. the emitted light from the sample is imaged electronically, having first passed through a dichroic mirror which excludes the illuminant beam. oregon green (difluorofluorescein) can, for example, be used to measure protein and nucleic acid interactions [ ] . it has been suggested that this relatively simple technique could be used to detect pathogens such as escherichia coli or the severe acute respiratory syndrome (sars) virus using a novel, synthetic dna molecule which is described as a 'tree (y) shaped nanobarcode'. the fluorophor's three 'legs' fluoresce red, yellow and green, respectively, and complex to differing degrees with each pathogen, which thereby enables their identification [ ] . a wide variety of fluorophors, mostly derived from the basic fluorescein structure, are used in the more powerful technique of flow cytometry. this is a system which can selectively separate and identify a range of biological cells from their shape, size and fluorescent responses. modern flow cytometers are extremely versatile as they can operate with up to four laser beams (to excite fluorescence at different wavelengths) as the analyte is passed in a fine jet stream through the laser beam and can measure both reflection and transmission responses in up to fluorescent wavebands [ ] . flow cytometry is thus a very powerful analytical technique which is applicable in an enormous range of sciences, including pathology, haematology, immunology and plant and marine biology. there has been increasing use of 'quantum-dot' fluorophors, which are multi-shell nanoparticles consisting of a phosphor core (typically cadmium selenide ⁄ zinc sulphide or indium gallium phosphide) with a polymer coating and sometimes an outer biomolecular layer. compared with convention fluorescent dyes, these fluorophors, which are now used for fluorescence microscopy, spectroscopy and flow cytometry, have higher quantum yields, brighter fluorescence and greater photostability [ ] . considerable advances have been made during recent decades in reducing the power requirements for illumination and some types of colour display. thus, major savings can be made using modern ultra-bright light-emitting diodes (leds) as replacements for tungsten filament bulbs in traffic lights, by replacing conventional fluorescent tubes in chain stores and warehouses with more economical types and, domestically, everyone is being urged to reduce their carbon footprint by fitting the newer, more compact, energy-saving light bulbs. a recent innovation is the replacement of the conventional xenon flash tube as the d illuminant in spectrophotometers by an led array which is pulsed in synchronism with the measurements of the reflected beam, thus eliminating any effect from ambient light and allowing online colour measurements in continuous coloration processes [ ] . cathode ray tube (crt) picture displays have largely been replaced by liquid crystal displays (lcds), which are more compact and now freely available in large-size displays. lcds now seem able to compete with plasma displays, which had previously dominated the larger-size, flat-screen market. in the uk, the british broadcasting corporation satellite and cable high-definition television (hdtv) transmissions, which are best viewed on a larger screen, started in december and the gradual changeover to terrestrial digital tv transmissions is causing a boost to the sale of 'hdtv-ready' sets. there seems no general agreement as to which main picture definition will be used, the individual programme makers being able to choose between the -and -lines (interlaced or progressive scan) standards. as far as small screen displays are concerned, the demand for multipurpose hand-held equipment, particularly mobile phone and miniature computer displays, continues to be met mainly by lcds, but organic light-emitting diode (oled) displays that are lighter, require no back light and have a wider angle of viewing also consume less power and look particularly attractive for such applications [ ] . sony is the first to market an extremely slim, oled, -inch colour-screen tv receiver [ ] . an astonishing array of inorganic phosphor compounds have been investigated which, when irradiated with varying types of electron beam, produce visible light. table illustrates the types and uses for such compounds, selected from those that produce light in the green waveband, which in tv displays is that carrying the main luminance signal. a energy-saving light sources using one-quarter of the electric power and having five times the life of tungsten filament bulbs; colour temperatures range from (warm white) to °k (daylight) [ ] fluorescent lighting the nature of the light output from a fluorescent tube (which is based on a mercury discharge lamp) is determined mainly by the choice of the phosphor coating on the inside of the tube. tubes can be produced as standard, broadband or narrow tri-band types. compared with a standard tube, the broadband tubes have better colour-rendering properties because they use multiple phosphors, whilst the tri-band types, as their name suggests, have three, narrow-band-emitting, rare earth phosphors which together produce a highly efficient white light. the output can be tuned to a range of colour temperatures; for example, to correspond to the committée internationale d' _ eclairage (cie) d or d standard sources of artificial daylight, depending on the desired industrial application, although the spectral power distribution curves with these tubes are not as smooth as those of the broadband types. the choice of fluorescent tube types is critical where precise conditions are required for colour matching and this is taken into particular account in colour-matching cabinets which normally have the ability to produce 'artificial daylight' (illuminant d ), 'tungsten filament light' (illuminant f), european store lighting (tl ; illuminant f ) and (for optical whites and fluorescent samples) ultraviolet illumination. the properties of these and some other light sources are summarised in table . the colour measurement committee of the society of dyers and colourists (sdc) is currently examining means of identifying when the illuminants in a particular colourmatching cabinet are unsatisfactory and also determining the suitability of colour-matching rooms. greener processes for the manufacture of dyes and related chemicals having accepted that, at least as far as the coloration of textiles is concerned, we must continue to rely on manufactured dyes, there are many possibilities that they may in the future be synthesised using greener chemistry; for example, using less energy, eliminating or more efficiently recycling organic solvents or achieving higher yields with minimal by-product formation. today, green chemistry is a subject in itself and particularly good progress is being made using novel, selective homogeneous, heterogeneous or bio-catalysts, which give high product yields under very mild reaction conditions [ , ] . general examples appropriate to dye manufacture are those involving sulphonation, nitration, halogenation or diazotisation, in which the formation of large amounts of inorganic salts is prevented by replacing the conventional stoichimetric quantities of mineral acids and alkalis. by using recyclable solid acids and bases, which are preferably present in only catalytic amounts, yields approaching % can be achieved. biocatalysis is illustrated by the mitsubishi process, using the nitrile hydratase enzyme, for the production of acrylamide from acrylonitrile, a process which proceeds at °c without the need for a polymerisation inhibitor [ ] . in the case of an improved biosynthetic, enzymic production method for indigo, technology seems to have gone full circle [ ] . another example concerns intermediates for fibre manufacture. the precursor for nylon is -caprolactam, which is produced from cyclohexanone using a two-stage process involving aggressive chemicals and high-reaction temperatures, creating large amounts of ammonium sulphate as a by-product. it has been shown that this conversion can be achieved at low temperature in a single stage with a nanoporous, aluminophosphate catalyst using only air and ammonia [ ] . biosynthetic methods of production of some natural dyes used as food colours, such as b-carotene, riboflavin and phycocyanin, have also been devised. where water cannot be used in a conventional synthesis method, there has long been the aim of avoiding the chance of releasing volatile organic chemicals by replacing conventional organic solvents with supercritical carbon dioxide or ionic liquids [ ] , which, for example, have been examined as solvents for cotton linters, a process that would be much more environmentally acceptable than that at present used for the production of viscose fibres [ ] . it is not, however, always essential to use solvents, for some reactions, particularly those involving the formation of metal complexes, can surprisingly be carried out efficiently in the solid state, simply by ball milling the reactants together [ ] . with the ever-increasing cost of energy, it is natural to try to find improved methods of harvesting the radiation received on the earth's surface (on average w ⁄ m ) to supplement the diminishing natural resources of gas, coal a cri (colour rendering index) indicates the degree to which a particular type of light source renders colours relative to a reference source; values between and oil, in which are stored the energy received from the sun some million years ago. in hot, sunny climates it was possible to use this energy directly for some processes, such as sea-water evaporation in brine ponds to obtain valuable sea salt (another product which the eco-consumer somewhat illogically prefers to mined, recrystallised and purer salt, which is still just as natural). in recent times, there was some use made of a dye, solavap green [ ] , which absorbed, particularly in the infrared wavebands, to accelerate the solar evaporation process. domestic solar pre-heating of water using rooftop heat exchangers is viewed as ecologically desirable, but the climate of the uk means that the payback period is rather long. this is even more the case with electrical solar cells, despite the advances that have been made in their design and efficiency. there remain, however, problems of storing and converting the power for normal domestic consumption. the main applications for arrays of such cells has therefore been to power traffic signs in remote locations (where they are often backed up by small wind-powered generators) or as trickle chargers for batteries feeding low-power electronic equipment. the most efficient solar cells are still based on costly silicon technology, but there has been much research into a completely different system which is inherently simpler and cheaper to produce, namely the use of dye-sensitised, crystalline dispersions of titanium dioxide in so-called grätzel cells, so named after their inventor [ , ] . these consist of very thin ( lm), transparent, layers of titanium dioxide nanoparticles, in a liquid or gel-like medium sealed behind a transparent conductive electrode. in addition, the dispersed crystals of titania are coated with a photosensitiser dye. these dyes may be substituted fluoresceins [ ] , porphyrin compounds [ , ] coumarin dyes [ ] or some novel ruthenium polypyridyl dye complexes [ ] which also absorb light in the infrared and avoid the need for a liquid medium. an alternative to microcrystalline titania, in the form of zinc oxide nanorods, has been proposed [ ] . the efficiency of these cells ranges from ca. % to %, which is not as high as that of the very best attainable with silicon cells (ca. - %), but they will be much cheaper to manufacture, particularly as it has proved possible to 'print' the titanium dioxide layer onto polyethylene terephthalate films. the first commercial application of these is as solar chargers for mobile phones, but uk production of much larger solar panels for domestic use is planned. in america the manufacture of thin film, printed, solar cells based on a cigs (copper indium gallium diselenide) nano-particle material, with an energy conservation efficiency of about %, has started [ ] . there has been considerable recent publicity given to the development of new transport fuels to augment or replace existing oil-based products, the chief contenders being bioethanol and biodiesel. bioethanol, produced by fermentation of the carbohydrates in soya beans, corn (usa) or sugar cane (south america) is now used as an additive ( - % maximum) to petrol engine fuel, whilst biodiesel, derived from seed oils such as corn or rape or made from reprocessed cooking fats, has a small share of the market. biodiesel has already been tested as a jet engine aviation fuel and, from a logistics point of view, the north atlantic treaty organisation (nato) would like to have a common fuel for its air and land transport system [ ] . the problem with making fuels from agricultural crops is the loss of productive capacity for foodstuffs. thus, in , bioethanol production in the usa used % of the entire corn harvest, whilst in brazil it consumed almost half of the sugar crop and shortages have already adversely affected the commodity prices of both corn and sugar [ ] . the process for producing biodiesel from recovered vegetable oils is relatively simple but involves saponification of the glycerides it contains and methanol to esterify the fatty acids produced, whilst leaving the problem of disposing of the glycerol by-product. second generation biodiesel fuels will therefore almost certainly be based on conversion processes using biomass (waste wood, sawdust, straw or even leaves) that will be subjected to high-temperature pyrolysis and the released gases converted via a catalytic fischer tropsch process to biodiesel [ ] . this process was much used in south africa because of import sanctions imposed during the days of apartheid. the fischer tropsch process could also be applied directly to convert the abovementioned glycerol by-product into fuel [ ] . all the above processes are roughly carbon neutral, in that only the same amount of carbon dioxide originally locked in the plant material will be released again into the atmosphere. another more distant possibility is to trap the carbon dioxide emitted from power stations by using the exhaust gas to cultivate certain green algae which produce glycerides, from which a biofuel could then be extracted [ ] . exhaust carbon dioxide has also been used in greenhouse cultivation of crops such as tomatoes which can be grown hydroponically in 'polytunnels', the plastic sheeting for which may be coloured with a green pigment which transmits the two photosynthetically active wavebands around and nm [ ] . for identification and tax enforcement purposes, fuels are often coloured; for example, in the uk and spain agricultural diesel is red but green in norway and in ireland. during, and for a time after world war ii, when fuel was rationed, commercial vehicles used red petrol and this was coloured with solvent red or , which were relatively easy to remove, but the fuel was further tagged with a colourless additive, dimethylamine. this could be detected even in the engine exhaust fumes using test papers impregnated with aniline acetate which gave a red colour reaction. nowadays, red diesel, which has a considerably lower taxation level, is a slightly different distillation fraction containing more sulphur than fuel used in vehicles. in the uk it is illegal to use red diesel for other than agricultural vehicles and machinery, commercial maritime vessels and, until october , privately owned pleasure craft. it is equally illegal to use heating oil as a diesel fuel. in the uk, colourless markers are therefore still in use; for example, quinizarin is added to red diesel and coumarin to heating oil at such a concentration as to be unnoticeable until a fuel sample is shaken with a small volume of aqueous alkali. an equally simple test, in this case shaking with an acid solution, produces a colour reaction when crystal violet lactone is used at low concentrations as a fuel marker. a further approach is to use compounds which can be detected spectrophotometrically by characteristic fluorescence or infrared absorption peaks, but this has the disadvantage of not being applicable for on-the-spot testing. at present in the uk, despite these controls to enforce collection of the appropriate tax, private individuals are surprisingly free to set up a small plant to produce biodiesel from waste vegetable oil which, as long as it is used personally, attracts no taxation from hm customs and excise. for some purposes it is necessary to colour not the fuel but the exhaust gases when a fuel is burned. the fuel may be initially fluid or solid, depending on the application, but similar solvent soluble dyes are used in both cases. to heighten the effect of acrobatic or fly-past displays it has long been the practice to colour the exhaust gasses from jet engines. aircraft smokes are produced by dissolving a suitable dye, such as quinizarine green ss (solvent green ), in a mixture of perchlorethylene and diesel fuel and injecting this into the exhaust of the aircraft's jet engine. similar dyes are used to colour smoke flares and military smoke grenades, the use of which raise more safety issues than aircraft smokes. safety distress flares for maritime emergency use are usually red and contain a solid pyrotechnic mixture with the addition of solvent red or disperse red . military smokes are produced in a variety of forms, but consist of a solid fuel which used to be based on sodium chlorate and sulphur, with sodium bicarbonate added to reduce the burning temperature. more recently these compositions have been modified by replacing sulphur with sugar and sodium bicarbonate with the more effective magnesium bicarbonate. the selection of the dyes (e.g. benzanthrone) used in smoke grenades has also been modified following toxicity testing on animals, although no serious side-effects of the smokes have been reported for human inhalation, the main concern being mainly the possibility of allergic dermatitis [ ] . where wind-tunnel testing of vehicles or model aircraft designs is to be carried out, it has been usual to generate laminar streams of white smoke by feeding an oily, smoke-producing compound onto a series of vertical or horizontal heated wires [ ] . the airflow can then be visualised and, if different colour-producing smokes are produced at different locations, colour photographic records can be obtained for later study [ ] . finally, one rather frivolous application for the production of coloured smoke comes from the usa where, after much experimentation, it proved possible to incorporate a solvent dye into rubber tyre compositions to produce a colourful smoke effect when cars are skidded on the race track [ ] . these tyres are now commercially available for enthusiasts but are not recommended for use on public roads! there seems to be no doubt that the pressures on suppliers and retailers to source their goods ethically and with minimal adverse effects on the environment will continue to increase. these demands arise not only from consumers but from many national and international organisations whose aim is to raise public awareness of such issues, particularly where food is concerned, but they also consider more general factors such as climate change, the ecology, energy consumption, recycling, employment ethics etc. every apparent improvement carries a downside. ethical employment standards ban the use of child labour yet in some countries the alternative for the children themselves may be starvation. buying a 'fair trade' item may make us feel good but, like organically produced food, is more expensive and it is clear that there is a section of the public that simply wishes to buy the cheapest food. nevertheless although eggs produced from battery-reared hens are undoubtedly the cheapest (but the least 'natural' as far as the chickens are concerned) some uk supermarkets are now to sell only barn or free range eggs. as far as food colours are concerned nearly all the major retail groups have already changed (or are actively involved with such changes) from synthetic to natural colours, with the supposed aim of 'eliminating e numbers', but the removal of many other food additives whilst maintaining a product's expected shelf life may prove more problematic. scientific evidence of serious adverse effects with any of the present permitted synthetic colours is very limited, so these changes merely meet a public perception, whilst a more cynical view might be that this is largely another means of promoting a company's image and of course its sales. in many regions of the western world the general level of obesity (with other issues of heart problems and diabetes) is said to be increasing so clear labelling of food with dietary information is of considerable value. several systems are in use and a truly simple, universal mode of display, such as the 'traffic light' one at present recommended by the food standards authority and used by a number of stores, is still desirable. leaflet: 'language report uncovered the ethical consumer the green man: spirit of nature mauve: how one man invented a colour that changed the world natural food colorants the soil association organic farmers & growers (available at the soil association handbook of organic food safety and quality colourants for food contact plastics guidance notes on the uk toys (safety) regulations how to live a low carbon life with our new rapid dyeing technology you are back in the black, thies ⁄ dystar brochure conn's biological stains green fluorescent protein: properties, applications and protocols flow cytometry: principles and applications ionic liquids: industrial applications for green chemistry national research council, the toxicity of military smokes and obscurants rubber world mar electric lighting the author works as an independent consultant in coloration. key: cord- -oninjtsn authors: kowalski, wladyslaw title: commercial buildings date: - - journal: ultraviolet germicidal irradiation handbook doi: . / - - - - _ sha: doc_id: cord_uid: oninjtsn applications for uvgi systems in commercial buildings vary with the type of building, but virtually every type of building can benefit from the use of in-duct air disinfection and many buildings can benefit from the use of other types of uv systems. the health hazards and microbiological problems associated with various types of commercial buildings are often unique to the type of facility. the problem of air quality is paramount in commercial office buildings while the problem of biocontamination is of the highest concern in the food industry. other types of buildings have their own microbial concerns and even their own standards. the pharmaceutical industry has the highest aerobiological air quality standards (and lowest airborne microbial levels) while the other extreme, the agricultural industry, has the highest airborne microbial levels and unique aerobiological concerns. the individual problems of these facilities are addressed in the following sections, and industry experience relating to uv applications are discussed, along with recommendations for how uv systems can be applied. the specific types of uvgi systems are described in previous chapters and these should be referred to for detailed information on such applications. applications for uvgi systems in commercial buildings vary with the type of building, but virtually every type of building can benefit from the use of in-duct air disinfection and many buildings can benefit from the use of other types of uv systems. the health hazards and microbiological problems associated with various types of commercial buildings are often unique to the type of facility. the problem of air quality is paramount in commercial office buildings while the problem of biocontamination is of the highest concern in the food industry. other types of buildings have their own microbial concerns and even their own standards. the pharmaceutical industry has the highest aerobiological air quality standards (and lowest airborne microbial levels) while the other extreme, the agricultural industry, has the highest airborne microbial levels and unique aerobiological concerns. the individual problems of these facilities are addressed in the following sections, and industry experience relating to uv applications are discussed, along with recommendations for how uv systems can be applied. the specific types of uvgi systems are described in previous chapters and these should be referred to for detailed information on such applications. commercial buildings are the single largest and most common type of building in the united states today, in terms of total floor area. many common respiratory infections are regularly transmitted inside these structures due to daily occupancy and the extensive interaction of people within office buildings. proximity and duration of exposure are major factors in the transmission of respiratory infections between office workers (lidwell and williams ) . the risk of catching the common cold is increased by shared office space (jaakkola and heinonen ) . tuberculosis has also been show to transmit in office buildings between co-workers (kenyon et al. ). an association between respiratory tract symptoms in office workers and exposure to fungal and house dust mite aeroallergens was established by menzies et al. ( ) . the recent appearance of sars virus highlights the susceptibility of office workers to the spread of airborne viruses (yu et al. ) . sick building syndrome (sbs), often referred to as building related illness (bri) is a general category for a number of ailments, allergies, and complaints that are due to low levels of pollutants, synthetic irritants, fungi, bacteria or other factors that cause reactions in a certain fraction of building occupants (lundin ) . office buildings become contaminated with microbes brought in with the outside air as well as microbes that hail from indoor sources, including the occupants themselves. accumulation of microbes on the cooling coils and ductwork can contribute to indoor air quality problems (fink ) . the aerobiology of office buildings can depend on both indoor sources (i.e. occupancy and cleanliness) as well as the composition and concentration of microbes in the outdoor air. environmental microbes can enter via the ventilation system, via occupants (i.e. on clothes and shoes), and infiltration, especially from high-traffic lobbies that are under high negative pressure. office buildings provide an environment that sustains microorganisms long enough for them to transmit infections to new hosts, or sometimes allows them to persist indefinitely, as in the case of fungal spores (kowalski ) . the indoor airborne concentrations of bacteria and fungi increase with the presence of occupants, due to the fact that people release bacteria continuously and also because human activity stirs up dust that may contain fungi and bacteria. sessa et al. ( ) measured average office airborne concentrations of cfu/m for bacteria and cfu/m for fungi while levels were about four times lower when there were no occupants. most office buildings use dust filters in the merv - range to filter outdoor or recirculated air but these have a limited effect on reducing fungal spores, bacteria, and viruses. increasing filtration efficiency is one possible solution but retrofitting merv filters in the - range, which can be highly effective against most airborne pathogens and allergens, may be difficult in most buildings because of increased pressure losses and possible reduction in airflow (kowalski and bahnfleth ) . a suitable alternative to replacing filters is to add uv systems in the ductwork, which will not necessarily have any impact on airflow or pressure drop (see fig. . ). in-duct uvgi is the most economic approach to disinfecting the air of commercial office buildings provided there is space in the ventilation system. the economics of in-duct air disinfection can be greatly improved by locating the uv lamps at or around the cooling coils, thereby disinfecting the coils and improving their heat transfer capabilities. cooling coils can first be steam cleaned to remove biological contamination and then a uvgi system can be added to continuously irradiate the coils. this not only prevents existing microbial growth but will tend to restore cooling coils to their original design operating level of performance, thereby saving energy costs (kelly ) . another alternative for improving air quality in office buildings and reducing the incidence of disease transmission between office workers is to locate recirculating uv units or upper room systems around the building to deal with local problems. lower room systems may also be used to control microbial contamination at floor level, especially in hallways or lobbies that see heavy foot traffic. other applications of uvgi in office buildings may include overnight decontamination of kitchens, bathrooms, and storage areas with uv area disinfection units. uvgi may not be a complete solution to aerobiological problems if the cause is due to some other factor like moisture or water damage. for more detailed information on dealing with air quality problems in office buildings see kowalski ( ) . industrial facilities cannot be generalized in terms of the types of respiratory diseases to which workers may be subject because of their wide variety. industrial facilities that handle organic materials have greater microbiological hazards while those that process inorganic products usually have less microbial hazards and more pollution hazards. pollution, however, is a contributing factor in infectious diseases, including respiratory diseases. there are many types of occupational diseases, including asthma, and allergic reactions or hypersensitivity pneumonitis, which are not necessarily due to microbiological causes. air disinfection systems that use uv have little or no effect on non-microbiological contaminants but if pathogens or allergens are the cause of the problem then uv systems may be applied to reduce the hazard. airborne particulate dust in industrial environments may contain organic materials, chemicals, microbes, biological compounds, or inert materials, and form a substrate on which microbes can grow. allergen-bearing airborne particulates are causative agents of lung inflammation via their immunotoxic properties and can induce inflammatory alveolitis (salvaggio ) . occupational asthma occurs in - % of the asthmatic population and respiratory infection can be a predisposing factor for occupational asthma (bardana ) . workers who clean or enter rarely-used rodent infested structures may be at increased risk of exposure to rodentborne viruses such as hantavirus (armstrong et al. ) . industries that process wood or paper, or that make use of paper products, have airborne allergen hazards since cellulose provides a nutrient source for a variety of allergenic fungi. microbiological sampling in furniture factories found the most common airborne microorganisms included corynebacterium, arthrobacter, aspergillus, penicillium, and absidia (krysinska-traczyk et al. ) . microbiologial studies of the air in sawmills were conducted by dutkiewicz et al. ( ) , who found that the most common organisms were arthrobacter, corynebacterium, brevibacterium, microbacterium, bacillus spp., gram-negative bacteria (rahnella) and filamentous fungi (aspergillus, penicillium). inhalation anthrax and cutaneous anthrax still occur occasionally in the textile industry. in a mill in the usa where outbreaks had occurred, anthrax levels were measured at up to cfu/m (crook and swan ) . q fever, which can result from inhalation or exposure to coxiella burnetti, has been reported among workers in a wool and hair processing plant (sigel et al. ) . tuberculosis continues to be an occupational hazard in some parts of the world and is a growing problem elsewhere because of multi-drug resistance. in a study at russian plants by khudushina et al. ( ) the incidence of tuberculosis was highest at a foundry plant at . per , workers and in an automatic-assembly plant at . per , workers. health care workers, prison guards, and prison inmates may all be at higher risk for tuberculosis. a one-year prospective study of inmates in geneva showed that the prevalence of active and residual tuberculosis is - times higher among prisoners than in the general population (chevallay et al. ) . many prisons in the us incorporate filtration and uvgi systems to help control tuberculosis transmissions. occasional outbreaks of legionnaire's disease have continued to be sporadically reported in the work environment, including a large outbreak among exhibitors at a floral trade show where a whirlpool spa was on display (boshuizen et al. ) . water damage in any building increases the risk of workers to allergens if fungal mold growth has occurred. trout et al. ( ) documented extensive fungal contamination, including penicillium, aspergillus, and stachybotrys, in a water-damaged building. control measures for aerobiological contamination in the workplace are similar to those for any buildings in general, including improved air filtration, improved air distribution, and increased outside air combined with energy recovery systems. the use of uvgi for air disinfection can have positive benefits for almost any type of industrial building depending on the nature of the problem. in-duct uv air disinfection systems are likely to be the most economic recourse since they provide centralized control of the air quality, and can simultaneously be applied to the cooling coils (in most applications) to save energy while disinfecting the air. the use of local recirculation units can aid in resolving local microbial contamination problems, and both upper and lower room uvgi systems can be used to control biocontamination. the food industry comprises food and beverage processing facilities, food handling industries, food storage facilities other than agricultural, and kitchens in the restaurant and hospitality industry. there are at least four types of potential health hazards associated with food handling -foodborne human pathogens, spoilage microbes, microbial allergens, and food allergens. foodborne pathogens are generally transmitted by the oral route and almost exclusively cause stomach or intestinal diseases but some foodborne pathogens may be airborne at various stages of processing, storage, cooking, or consumption. the processing and handling of foods may also create opportunities for airborne mold spores to germinate and grow, resulting in secondary inhalation hazards. applications for uvgi in the food industry include both air and surface disinfection, including surface disinfection of packaging materials and food handling equipment. uv has been used for air and surface disinfection in cheese plants, bakeries, breweries, meat plants, for food preservation, and for the decontamination of conveyor surfaces, and packaging containers (koutchma ). one of the earliest applications of uv in the food industry involved the use of bare uv lamps to irradiate surfaces in the brewing and cheese making industries to control mold (philips ) . liquid food disinfection with uv has been approved by the fda but although uv has been highly effective for water disinfection, successful applications in disinfecting other liquids depends on the transmissivity of the liquid. the direct disinfection of food by uv is generally only effective in cases where only the surface of foodstuffs requires disinfection since uv has limited penetrating ability (fda , yaun and summer ) . some foods can be effectively disinfected of certain food spoilage microbes, and uv is most effective on food products that have smooth and clean surfaces (shama , seiler . uv irradiation can significantly reduce the mold population on shells of eggs in only min (kuo et al. ) . studies have demonstrated that uv can reduce levels of e. coli and salmonella on pork skin and muscle, listeria on chicken meat, and salmonella on poultry (wong et al. , kim et al. , wallner-pendleton et al. . begum et al. ( ) demonstrated that uv irradiation can inactivate food spoilage fungi like aspergillus, penicillium, and eurotium but that the type of surface impacted the degree of disinfection. marquenie et al. ( ) showed that botrytis cinerea and monilinia fructigena, two major post-harvest spoilage fungi of strawberries and cherries, could be reduced - logs by uv irradiation by doses of about j/m . stevens et al. ( ) reported that uv could effectively reduce the incidence of storage rot disease on peaches due to monilinia fructicola, reduce green mold (penicillium digitatum) on tangerines, and reduce soft rot due to rhizopus on tomatoes and sweet potatoes. liu et al. ( ) showed that tomato diseases caused by alternaria alternata, botrytis cinerea, and rhizopus stolonifer were effectively reduced by uv treatment. hidaka and kubota ( ) demonstrated a % reduction of aspergillus and penicillium species on the surfaces of wheat grain. seiler ( ) reported increases in mold-free shelf life of clear-wrapped bakery products after moderate levels of uv exposure. treatment of baked loaves in uv conveyor belt tunnels resulted in significantly increased shelf life (shama ) . valero et al. ( ) found that uv irradiation of harvested grapes could prevent germination of fungi during storage or the dehydration process for raisins, using exposure times of up to s. one specialized application of uv in the food industry involves overhead tank disinfection, in which the airspace at the top of a liquid storage tank is disinfected by uv to control bacteria, yeast, and mold spores. condensation of vapors in the head space of tanks, such as sugar syrup tanks, can produce dilute solutions on the liquid surface that provide ideal conditions for microbial growth. two types of tank top systems are in use -systems which draw the air through a filter and uv system and return sterilized air to the tank space, and systems in which uv lamps are located directly in the head space of the tank and irradiate the liquid surface and internal tank surfaces. see fig. . in chap. for an example of an overhead tank uv system. foodborne and waterborne pathogens represent the largest group of microorganisms that present health hazards in the food industry. in general, these do not present inhalation hazards, only ingestion hazards. however, some of these microbes can become airborne during processing and settle on foods, thereby becoming amenable to control by uv air and surface disinfection systems. modern foodborne pathogens are often uniquely virulent and hazardous, like salmonella and shigella, which are contagious and depend on either on excretion in feces or vomiting to facilitate epidemic spread. some agents of food poisoning, like staphylococcus and clostridium, are opportunistic or incidental contaminants of foods. many molds like aspergillus and penicillium are common contaminants of the outdoor and indoor air that can grow on food and although they are not food pathogens they are potential inhalation hazards for food industry workers. foodborne pathogens are predominantly bacteria but one virus has recently emerged and joined this class, norwalk virus. norwalk virus is a waterborne pathogen and has caused outbreaks on cruise ships (marks et al. ) . food spoilage microbes are less of a health hazard than they are a nuisance in the food industry because of the damage they can cause to processed food (samson et al. ) . a wide variety of yeasts may also be causes of spoilage. table . lists the most common foodborne and waterborne pathogens in the food industry along with the type of hazard they present -pathogenic, toxic, allergenic, or spoilage. many of the species listed in table . have uv rate constants as given in appendices a, b, and c. virtually all of the fungal spores listed in appendix c are potential contaminants in the food industry. toxins produced by microbes may be endotoxins, exotoxins, or mycotoxins, and these will grow only if the conditions (moisture, temperature, etc.) are right. the key to controlling these toxins is to control microbial growth and to control the concentration of microbes in the surrounding areas. ambient microbial levels can be controlled by food plant sanitation, adequate ventilation, and by various uv air disinfection technologies. most common food spoilage microbes have the capacity to transport in the air and therefore they are controllable to some degree by ventilation and by uv air disinfection systems. evidence exists to suggest listeria monocytogenes, a cause of many recent outbreaks, can settle on foodstuffs via the airborne route ( ) . studies indicate that salmonella can survive in air for hours (stersky et al. ). if air is recirculated through plant ventilation systems, organic material may accumulate inside ductwork and on air handling equipment, where fungi and bacteria may grow ( ). air filtration can go along way towards controlling the amount of organic debris that accumulates, but uv is an ideal technology for use in controlling microbial and fungal growth inside air handling units, ductwork, and on cooling coils. concerns about the breakage of bare uv lamps and mercury hazards has led to new lamps that are sealed in an unbreakable plastic coating, such as shown in fig. . . mold and biofilms can develop on surfaces and equipment in the food and beverage industry, including tanks and vats, cooking equipment, walls and floors, and cooling coils (carpentier and cerf ) . in general, standard cleaning and disinfection procedures are adequate to contain these problems but alternatives are available, including antimicrobial coatings like copper. uv irradiation of food processing equipment and surfaces, cooling coil disinfection systems, whole-area uv disinfection, and after-hours irradiation of rooms when personnel are not present are all viable options for maintaining high levels of disinfection in food industry facilities (philips , kowalski and dunn ) . uv air disinfection systems may also be useful in controlling airborne hazards that result from hazards are created by industrial food processes that forcibly aerosolize contaminants. pulsed uv light has seen increasing application in the food industry because of its rapid disinfection capabilities -see chap. for more information. educational facilities for children and students are focal points for disease transmission and as such they are ideally suited to uv applications that inhibit the transmission of contagious diseases. the concentration of young people in rooms causes cross-infections when even a single child comes to school with an infection such as a cold or a flu. inevitably children who attend school bring home contagious infections which are then transmitted to family members, thereby continuing the process of epidemic spread in the community. there are basically five types of educational facilities for children and students: day medical schools and colleges have also been subject to outbreaks of mumps and respiratory syncytial virus (rsv). table . summarizes many of the various common infections that have been associated with school facilities, with reference sources as indicated. many of the microbes in table . are susceptible to uv disinfection in air and on surfaces (see the uv rate constants for these species given in appendix a). fungal spores also accumulate in schools and are responsible for a variety of respiratory illnesses including allergies and asthma. the most frequently encountered fungal taxa identified in a study of dust samples from twelve schools in spain were alternaria, aspergillus, and penicillium (austin ) . guidelines for ventilation air in school buildings are provided in ashrae standard - (ashrae ) but many schools do not meet the minimum recommendations either because the buildings are older or because of attempts to save energy costs due to endless budget cutting. one way to make up for the lack of ventilation air is to provide uv air disinfection systems, including upper room systems and in-duct uv systems. a number of studies have been performed in schools to evaluate the effectiveness of uvgi systems on respiratory infections in schools. all of these studies involved upper room systems (see chap. for a summary of the results). most of the studies produced a reduction of disease transmission with a net average reduction in respiratory infections of approximately %, and were effective against measles, mumps, varicella, chickenpox, cold viruses and other respiratory infections. upper room systems can be especially effective in classrooms that have little of no ventilation air and that have high ceilings. there are no studies that have addressed in-duct uvgi systems, which would be likely to prove even more effective if they were adequately designed. materials and books that are kept in museums, libraries, and related archives may be both a source of allergens and a nutrient source for the growth of microorganisms, especially fungi. the growth of fungi and certain bacteria on stored materials contributes to biodeterioration, which is a major concern, and the aerobiology in bahlke ( ) museums and libraries may impact both the occupants as well as the stored materials. most books are made from cellulose and can be degraded by a variety of microbes and insects which may include allergens and a few potential pathogens. over microbial genera, representing species, have been isolated from library materials like books, paper, parchment, feather, textiles, animal and vegetable glues, inks, wax seals, films, magnetic tapes, microfilms, photographs, papyrus, wood, and synthetic materials in books (zyska ) . many of the fungi identified in library materials can produce mycotoxins and cause respiratory and other diseases. table . summarizes the variety of microbes that have been found in libraries and museums, and indicates the type of materials that they can grow on. the term 'deteriogen' in the table refers to microbes that can cause biodeterioration of materials. libraries often use carpeting to quiet the noise of foot traffic, but carpets tend to accumulate fungi and bacteria over time due to the fact that they settle in air or are brought in from the outdoors on shoes and clothes. in one study of carpeted buildings, carpet dust was found to contain , cfu/gm of fungi, , , cfu/gm of mesophilic bacteria, and , cfu/gm of thermophilic bacteria (cole et al. ) . foot traffic tends to aerosolize microbes and causes them to settle in other locations, including on books and materials. aerosolized microbes can also be inhaled, leading to allergies and asthma. carpets have a high equilibrium moisture content that favors microbial growth (iea ) . fabrics kept in museums, especially ancient cloth, are subject to biodeterioration from fungi and bacteria. fungi can grow extensively on cotton fibers at the right humidity and growth rates are highest on % cotton (goynes et al. ) . studies of biodeterioration caused by fungi that grow on paintings have isolated over one hundred species of fungi, with the most common species being alternaria, cladosporium, fusarium, aspergillus, trichoderma, and penicillium (inoue and koyano ) . ultraviolet light is an option for disinfecting surfaces and materials, but it can cause damage and discoloration to pigments and paint and therefore is not necessarily suitable for decontaminating books that are already damaged by microbial growth. uvgi is best used for disinfecting the air and especially for removing mold from air conditioning systems. in-duct uvgi can greatly aid in reducing airborne levels of bacteria and spores and in removing accumulated mold spores from air conditioning cooling coils, which are used extensively to control humidity in libraries and museums. keeping cooling coils disinfected will minimize the spread of spores through a building as well as reducing energy costs (see chap. ). uvgi systems can be used selectively in areas of museums and libraries that do not contain sensitive materials, such as cafeterias. lower room uv systems may also be ideal for hallways and entryways (where no materials are stored) where outdoor spores may be tracked into buildings. for more detailed information on technologies and techniques for dealing with biocontamination of sensitive materials in libraries and museums see kowalski ( ) . agricultural facilities pose a variety of occupational microbial hazards including infectious diseases from farm animals, allergies from animal dander and foodstuffs, and health threats from mold spores or actinomycetes. animal facilities like barns, poultry houses, swine houses, and kennels can have the highest levels of bioaerosols seen in any indoor environments. animal facilities may also include non-agricultural buildings used to house or service animals such as pet shelters and zoos. many animal pathogens can transmit to humans by direct contact or by the airborne route. the microorganisms of greatest concern are those that can become airborne in animal facilities and these are often respiratory pathogens and allergens. allergens can be produced as a byproduct of animal husbanding or from animal waste, animal feeds, or other farm produce. the actinomycetes are particularly common type of bacteria found in agriculture and can grow on moldy hay. farmers may be routinely exposed to very high concentrations of actinomycetes and may inhale as many as , spores per minute (lacey and crook ). farmer's lung represents a group of respiratory problems that often afflict farm workers who receive chronic exposure to high concentrations of actinomycetes (pepys et al. ) . table . lists some of the most common microorganisms that occur in animal and agricultural environments, and that can transmit to man by various routes. the diseases caused and natural source are identified. for information on the uv susceptibility of these microbes see appendices a, b, and c. most of these microbes can transmit by direct contact or by the airborne. table . provides a list of microbes found in sewage, many of which can become airborne. natural ventilation is common in agricultural facilities but mechanical ventilation will generally provide superior control of airborne microorganisms. however, filtration is often necessary to clean both outdoor air and indoor recirculated air. recirculated air in animal facilities can be cleaned more effectively through the use of uvgi combined with filtration, and this approach works well for viruses, which may not filter out easily. other applications for uvgi in animal facilities include upper room systems, and area disinfection systems. after-hours uv disinfection systems are also appropriate for animal facilities provide the animals can be periodically removed from bacteria pathogen the indoor areas in order to disinfect them. such an approach can be more economical than scrubbing with disinfectants, and can enhance the effectiveness of manual scrubbing procedures. for more detailed information on dealing with the complex bioaerosol and dust problems in agricultural and animal facilities see kowalski ( ) . facilities like malls and airports are characterized by large enclosed volumes where large crowds may be concentrated and where heavy cyclical occupancy may occur. places of assembly may include auditoriums, stadiums, theaters, gymnasiums, natatoriums, arenas, town halls, churches, cathedrals, temples, mosques, industrial halls, convention centers, atriums, shopping centers, and other places where large public gatherings may occur indoors. in such buildings infectious diseases may be exchanged by direct contact, indirect contact, or via inhalation, and large numbers of people may be exposed simultaneously. the large volumes of air enclosed in such facilities often ensure good mixing of air, even in naturally ventilated stadiums, and as a result the air quality is often acceptable. however, it is difficult to provide ventilation to all corners and therefore the actual airflow distribution is often uncertain. one of the most famous outbreaks of a respiratory disease in a heavily occupied building was the eponymous legionnaire's disease outbreak at a convention in philadelphia in that resulted in deaths (spengler et al. ) . it was traced to legionella contamination in a cooling tower that apparently wafted from outdoors into a crowded hallway through open doors. an outbreak of measles occurred inside a domed stadium in the minneapolis-st. paul metropolitan area during july that resulted in sixteen associated cases of measles in seven states (ehresmann et al. ) . several tuberculosis outbreaks have occurred in churches and mosques due to a single infectious person. dutt et al. ( ) reports one outbreak of tb in a church where one man exposed % of his congregation. a norovirus outbreak at a concert hall was reviewed by evans et al. ( ) in which a concert attendee who vomited in the auditorium and a toilet. gastrointestinal illness occurred among members of school children who attended the following day. transmission was most likely through direct contact with contaminated fomites that remained in the toilet area. large facilities that use % outside air provide little or no opportunity for the use of uv systems, since outside air is generally clean and free of airborne pathogens, but facilities that recirculate air may benefit from in-duct uv air disinfection systems. large facilities often have high ceilings and this provides an opportunity to use upper room systems for air disinfection, especially in cases where natural ventilation is employed and there is no other means for disinfecting the air. high power uv systems can be safely used in such applications since the uv lamps can be located far from the occupied floor areas. the use of uv area disinfection systems in public toilets is an appropriate means of dealing with potential fomites, or infectious particles left on surfaces. aircraft, trains, cars, and other compact enclosed environments can pose microbiological hazards from extended exposure due to the fact that risks due to proximity are increased regardless of whether the pathogen transmits through the air or by direct contact. large cruise ships may resemble hotels and apartment buildings in terms of their ventilation systems and health risks but smaller craft like cars and planes create extended opportunities for infectious exchanges due to the close quarters, shared breathing air, potentially extended periods of occupancy, and the limited amount of outside air that may be brought in, especially in cold climates. other microenvironments like elevators and city buses are unlikely to play a major role in the spread of contagious diseases due to their brief occupancy times. aircraft are one of the most crowded environments in which people remain for extended periods of time and the potential for airborne disease transmission is fairly obvious, except perhaps to airline owners who fly in private jets. airplanes are potential vectors for the transmission of airborne diseases between continents and play a role in the global dissemination of epidemic diseases (masterson and green ) . airline crews and passengers have a higher risk of contracting infections on long flights (nrc , ungs and sangal ) . respiratory pathogens that have been identified onboard airlines include adenovirus, chickenpox, coronavirus, influenza, measles, mumps, mycobacterium tuberculosis, neisseria meningitidis, and sars virus (kowalski ) . it has been reported that % of newer airplanes have hepa filters (gao ) . however, there is a common practice in the industry of referring to merv filters ( % dsp filters) as 'hepa-like' or 'hepa type' filters, which is misleading. merv filters, while being excellent filters for controlling spores and most bacteria, cannot guarantee protection against viruses and smaller bacteria. coupling a merv filter with a uvgi system can, however, can provide superior performance (kowalski and bahnfleth ) . furthermore, the energy costs associated with using hepa filters may not be justified when a simple combination of a merv - filter and an urv - uvgi system will provide comparable results at lower cost. uvgi systems can be installed in the recirculation ducts of airplanes as well as being located at individual seats (in the overhead 'gaspers'). the transmission of infectious disease aboard ships is a recurring phenomenon, with onboard transmission of some diseases such as norwalk virus and legionnaire's disease being favored. the incidence of respiratory disease aboard military ships increases as ship size decreases (blood and griffith ) . a study of a tuberculosis outbreak aboard a navy ship found that although proximity and direct contact played a role in transmission, airborne transmission of droplet nuclei, including via the ventilation system, was responsible for most of the secondary infections (kundsin ) . it is common for outbreaks aboard ships to consist of multiple viral and bacterial infections, including diarrheal illness and influenza (ruben and ehreth ) . noroviruses are responsible for million cases of illness each year and norwalk viruses have recently caused numerous outbreaks of gastroenteritis on cruise ships. they are largely attributed to fomites on ship surfaces. during , cruise ships with foreign itineraries sailing into us ports reported gastroenteritis outbreaks on cruise ships, of which most were identified as noroviruses (cramer et al. ) . in an influenza outbreak aboard a cruise ship from hong kong in , % of passengers came down with acute respiratory illnesses (berlingberg et al. ) . uv applications for ships include in-duct uv systems to interdict recirculated pathogens and allergens, and surface irradiation systems to control fomites. noroviruses may be particularly susceptible to after hours uv systems placed in hallways, bathrooms, and other locations where occupancy is intermittent. cruise ships can also be irradiated and decontaminated between voyages by portable uv systems. most of the microorganisms associated with waste are either water borne or food borne pathogens and allergens and workers in sewage, wastewater, and waste processing industries are subject to occupational hazards from these microbes. airborne hazards also exist since aerosolization of microbial pathogens, endotoxins, and allergens is an inevitable consequence of the generation and handling of waste material. table . lists the most common microorganisms that have been found to grow or to occur in sewage and waste (kowalski ) . many of these are human pathogens and they include bacteria, viruses, fungi, and protozoa. for information on the uv susceptibility of these pathogens refer to appendix a, which addresses most of these species. many of these species are potentially airborne and can cause respiratory infections, while most of the remainder are either waterborne or foodborne stomach pathogens. wastewater treatment workers are exposed to a variety of infectious agents and khuder et al. ( ) examined the prevalence of infectious diseases and associated symptoms in wastewater treatment workers over a -month period. the wastewater workers exhibited a significantly higher prevalence of gastroenteritis, gastrointestinal symptoms, and headaches over those in a control group but no significant differences were found with regard to respiratory and other symptoms. thorn et al. ( ) , however, found that sewage workers had significantly increased risks for respiratory symptoms, including chronic bronchitis, and toxic pneumonitis, as well as central nervous system problems, over workers in non-sewage industries. reduction of microbial hazards in the sewage and waste industries is probably best approached using source control methods, but there are potential applications for uvgi. in-duct air disinfection can promote healthier breathing air for workers inside plants and both upper room and lower room uvgi systems can provide disinfection of both air and surfaces where mold and bacteria may accumulate. area disinfection systems, like after-hours uv systems, may also provide a means of decontaminating areas during periods when they are not occupied (i.e. overnight). hantavirus pulmonary syndrome associated with entering or cleaning rarely used, rodentinfested structures standard : ventilation for acceptable indoor air quality pathogens in the environment effect of ultra-violet irradiation of classrooms on spread of mumps and chickenpox in large rural central schools occupational asthma and allergies rhinovirus infections in nursery school children inactivation of food spoilage fungi by ultraviolet (uvc) irradiation listeria: a practical approach to the organism and its control in foods acute respiratory illness among cruise ship passengers -asia epidemiology of adenovirus-associated virus infection in a nursery population ship size as a factor in illness incidence among u.s. navy vessels subclinical legionella infection in workers near the source of a large outbreak of legionnaires disease prevalence of mycoplasma pneumoniae in children in diyarbakir, the south-east of turkey biofilms and their consequences, with particular reference to hygiene in the food industry epidemiology of pulmonary tuberculosis in the prison environment biocontaminants in carpeted environments outbreaks of gastroenteritis associated with noroviruses on cruise ships -united states bacteria and other bioaerosols in industrial workplaces high pharyngeal carriage rates of streptococcus pyogenes in dunedin school children with a low incidence of rheumatic fever microflora of the air in sawmills as a potential occupational hazard: concentration and composition of microflora and immunologic reactivity of workers to microbial aeroallergens outbreak of tuberculosis in a church an outbreak of measles at an international sporting event with airborne transmission in a domed stadium an outbreak of viral gastroenteritis following environmental contamination at a concert hall ultraviolet radiation for the processing and treatment of food. food and drug administration mold in air conditioner causes pneumonitis in office workers more research needed on the effects of air quality on airliner cabin occupants seroepidemiological studies on the occurrence of common respiratory infections in paediatric student nurses and medical technology students a study of whooping cough epidemic outbreak in castellon biodeterioration of nonwoven fabrics prospective study of respiratory infections at the u.s. naval academy silent passage of echo virus type together with dyspepsia coli strains in a day nursery school study on the sterilization of grain surface using uv radiationdevelopment and evaluation of uv irradiation equipment an outbreak of scarlet fever, impetigo and pharyngitis caused by the same streptococcus pyogenes type t m in a primary school heat and moisture transfer: international energy agency pleurodynia among football players at a high school. an outbreak associated with coxsackievirus b fungal contamination of oil paintings in japan shared office space and the risk of the common cold frequency of serological evidence of bordetella infections and mixed infections with other respiratory pathogens in university students with cough illnesses shedding some light on iaq transmission of mycobacterium tuberculosis among employees in a us government office prevalence of infectious diseases and associated symptoms in wastewater treatment workers the optimal system of ambulatory examination of groups with high risk of tuberculosis at a large industrial plant transmission of mycobacterium tuberculosis among high school students in korea effects of uv irradiation on selected pathogens in peptone water and on stainless steel and chicken meat current trends in uvgi air and surface disinfection merv filter models for aerobiological applications aerobiological engineering handbook: a guide to airborne disease control technologies exposure to airborne microorganisms in furniture factories airborne contagion uv irradiation of shell eggs: effect on populations of aerobes, molds, and inoculated salmonella typhimurium fungal and actinomycete spores as pollutants of the workplace and occupational illness the epidemiology of the common cold application of ultraviolet-c light on storage rots and ripening of tomatoes on building-related causes of the sick building syndrome evidence for airborne transmission of norwalk-like virus (nlv) in a hotel restaurant inactivation of conidia of botrytis cinerea and monilinia fructigena using uv-c and heat treatment dissemination of human pathogens by airline travel pharyngitis associated with herpes simplex virus in college students aeroallergens and workrelated respiratory symptoms among office workers illness among schoolchildren during influenza season: effect on school absenteeism, parental absenteeism from work, and secondary illness in families the airliner cabin environment and the health of passengers and crew rheumatic fever-is it still a problem? farmer's lung: thermophilic actinomycetes as a source effect of ultra-violet irradiation of classrooms on the spread of measles in large rural central schools public health management of an outbreak of group c meningococcal disease in university campus residents maritime health: a case for preventing influenza on the high seas inhaled particles and respiratory disease introduction to food and airborne fungi prevalence, rate of persistence and respiratory tract symptoms of chlamydia pneumoniae infection in kindergarten and school age children preservation of bakery products microbiological indoor air quality in healthy buildings ultraviolet light q fever in a wool and hair processing plant indoor air quality handbook viability of airborne salmonella newbrunswick under various conditions integration of ultraviolet (uv-c) light with yeast treatment for control of post harvest storage rots of fruits and vegetables work related symptoms among sewage workers: a nationwide survey in sweden bioaerosol lung damage in a worker with repeated exposure to fungi in a water-damaged building flight crews with upper respiratory tract infections: epidemiology and failure to seek aeromedical attention effect of germicidal uvc light on fungi isolated from grapes and raisins foreign body prevention, detection and control the use of ultraviolet radiation to reduce salmonella and psychrotrophic bacterial contamination on poultry carcasses tb in leicester: out of control, or just one of those things reduction of escherichia coli and salmonella senftenberg on pork skin and pork muscle using ultraviolet light efficacy of ultraviolet treatments for the inhibition of pathogens on the surface of fresh fruits and vegetables evidence of airborne transmission of the severe acute respiratory syndrome virus strains of parainfluenza virus type , isolated in a day nursery fungi isolated from library materials: a review of the literature key: cord- -rkadl r authors: macfall, janet; lelekacs, joanna massey; levasseur, todd; moore, steve; walker, jennifer title: toward resilient food systems through increased agricultural diversity and local sourcing in the carolinas date: - - journal: j environ stud sci doi: . /s - - - sha: doc_id: cord_uid: rkadl r biological and agricultural diversity are connected to food security through strengthened resilience to both anthropogenic and natural perturbations. increased resilience to stress via increased biodiversity has been described in a number of natural systems. diversity in food production can be considered on the following three levels: (a) genetic diversity as reflected in the range of cultivars which can be selected for production; (b) species diversity, captured through production of a wide range of crops on each farm; and (c) broad ecosystem diversity, described by the diversity of production between farms and within the broader food system. a network of locally based food producers and entrepreneurs provides opportunity for high diversity at each network stage, with increased adaptive capacity and the ability for rapid response to disturbance. we argue that production techniques that use carefully planned diverse plantings, such as biointensive cultivation, increase resilience by increased water use efficiency, yield and nutrient retention while reducing pressure from pests and pathogens. we present a model for a diverse, distributed food system in the north carolina piedmont and analyze an existing distributed network by a food hub in south carolina. through these models, we argue that a shift in the food network has the potential to increase local food security by having food more reliably available where it is needed and by contributing to local resilience through community economic development. the shift in food production and distribution systems serves multiple goals: when crop loss occurs, other crops still contribute to overall harvest, reducing net loss. diverse on-farm production can support a more distributed network of food aggregators, processors, and markets than the current approach of large-scale consolidation. finally, a distributed food supply network supported with diverse agricultural products can increase resilience by providing access to diversified markets for producers and improved food access to consumers with more food choices, while expanding the need for skilled jobs supporting the regionally based food industry. the term bresilience^has been used in many social, economic, and ecological contexts with varied meanings and interpretations. in its broadest form, the term resilience refers to the ability to recover from or to adjust to change (gunderson ) . uncertainties in an era of rapid change in agriculture have led to uncertainty in the capacity to meet growing food needs. concerns about chronic malnutrition, environmental degradation, livelihood security, food safety and hygiene, and equitable access raise important questions about how and where food is grown and eaten. in this paper, resilience is defined as the capacity for a system to absorb disturbance and to reorganize, while retaining system function and self-organizing processes (gunderson ; folke et al. ; folke et al. ) . resilience can be measured by the magnitude of disturbance that can be absorbed before the system is redefined into a different state (gunderson ) . in the case of agriculture and food security, resilience can be considered from the perspective of food availability with a return to a predictable and adequate supply following a disturbance. in this case, disturbances may occur in production (as with the loss of a crop following a plant disease or pest outbreak, severe weather, or climate change), transportation, processing, distribution, and access/supply. locally based and controlled food production systems with high diversity can provide opportunities for adaptive capacity through the ability to rapidly respond to disturbance and to changing conditions in production and market conditions (hendrickson and heffernen ) . the prevailing perception is that food production is predictable with a constancy of relationships. as anyone who has been involved with food production, processing, and distribution has experienced, uncertainty in food production and post-harvest handling is common-and risks are high. adaptive capacity and adaptive management acknowledge that the system being managed will always change, so humans can respond by adjusting the system quickly (gunderson ) . a growing body of evidence highlights the importance of biodiversity for ecosystem functionality (peterson et al. ; fischer et al. ; kerkhoff and enquist ) . although food and agricultural systems are highly managed, they are still guided by ecological principles through provision of essential natural resources, ecological function, and ecosystem services. just as with natural systems, biodiversity within food systems can be considered across a range of spatial scales from single farms to larger landscapes. food system diversity also includes social dimensions such as food distribution and access. sustaining ecosystem function in agricultural activities is essential for sustaining farm livelihoods and the food supply (tomimatsu et al. ) . functional redundancy within an ecosystem may increase resilience to environmental fluctuations, facilitating successful reorganization of ecological systems. high response diversity may ensure ecosystem functionality, providing a range of ways to respond to environmental change and uncertainty (folke et al. ) . biodiversity in agricultural systems can improve crop protection and soil fertility through these expanded functionalities (altieri ) . below, we discuss two examples of risks from biodiversity loss, the southern corn leaf blight epidemic of and porcine epidemic diarrhea, which demonstrate the negative possible outcomes of genetic uniformity in food systems. building on this, the insurance hypothesis for ecosystem resilience through conservation of functional diversity and responsive scale may be transferable to food systems. in the case of food systems, diversity in farm scale and number, diversity of crops, type of market opportunities, and higher numbers of farms equate to high numbers of species that respond differently to external pressures in ecosystems where diversity provides binsurance^if one component of the system declines or is lost. to overcome such risks, species with similar traits may be functionally redundant; if a crop is lost because of high disturbance sensitivity (drought or disease, for example), other crops will still provide agricultural product (mori et al. ) . some techniques such as biointensive agriculture which emphasize high biological diversity are most easily adaptable to small acreage. a concern can be about yield loss under such production techniques. however, intensively managed biointensive farms can produce yields which are comparable and often greater than conventional methods, while enhancing ecosystem structure and functions such as biogeochemical cycles and pest population controls. the contemporary food system is built on a complex network of related activities, ranging from on-farm production to harvest and sale to distribution, processing, and marketing, ending with consumer access, purchase, consumption and resource, and waste recovery. many related factors including environmental, social, and economic disruptions have the potential to contribute both chronic and acute disturbance to all points in this complex system. it is important to consider resilience at all points in the food system, minimizing vulnerability in each individual sector. therefore, it is crucial to link the shift in food production systems with a shift in the food distribution mechanisms. indeed, greater crop diversity offers opportunities for more diverse markets, and a locally embedded network of markets for food sale and access may provide greater resilience by insuring multiple points of entry for sale and access if the system is disrupted. as the two models below, north carolina central piedmont network and the south carolina food hub demonstrate, decentralized models that link producers to consumers provide opportunities for farmers that utilize high-yield, low input techniques such as biointensive and other agroecological techniques a convenient and reasonable access to markets. since the techniques can be developed both in urban and rural areas on smaller acreage farms, they can reduce the upfront capitalization costs for a start-up farm and also provide access to food related entrepreneurial opportunities and to food for low-income, ethnically and racially diverse consumers. this paper explores the link between diversity and resilience in our food networks-from production to distribution. we first illustrate risks from loss of biological diversity in food production systems and discuss how biointensive techniques can help overcome such risks. we then discuss two models of food value chains in the carolinas and how a shift in food distribution mechanisms built on principles of biological diversity can help build food security and community resilience. we also discuss the challenges of establishing such models on the ground and thus offer guidelines for practitioners on how to establish decentralized/local/ networked food production, distribution, and access systems. conditions of extreme genetic uniformity for production efficiency. the outcome was the epidemic of southern corn leaf blight, causing a crop loss of over $ billion (priced at dollars) (american phytopathological society ). corn leaf blight is caused by a fungus, an ascomycete, cochliobolus heterostrophus (also known as bipolaris maydis, or its name at the time of the epidemic, helminthosporium maydis). the fungus was common across the southern corn production areas, with annual losses of around . % under normal production. cultural practices to reduce leaf wetness and maintain general resistance throughout the corn population were the most affordable and consistently effective means of control. stubble left following harvest was plowed under to enhance decay, with corn production moved to other fields the following year (levings iii ; schumann ) . early in the twentieth century, corn breeders found that greatest yields were produced by progeny from the crossing of two genetically different inbred parental lines (buckner ). production of seed from defined crosses, however, required carefully controlled pollination and removal of the corn tassels. the detasseling process is very labor intensive and must be done by hand before pollen shedding. a genetic factor was discovered that caused plants to become male sterile, the texas male-sterile (tms) cytoplasm (levings iii ) . this meant that plants used for corn production no longer had to be de-tasseled prior to pollination-a huge economic benefit to the corn industry. by , nearly % of the corn produced in the usa contained tms cytoplasm. genetically, two changes occurred simultaneously in the host (the corn) and the pathogen populations. the corn crop now had the new tms gene throughout the population, and a genetic change occurred in the population of the fungal pathogen. a new race, named race t, evolved which had genes to produce a toxin that only affected the tms plants. the fungus could now complete its life cycle more quickly and was able to infect not only the leaves and husks but also the developing ears. for disease to occur, three conditions must be met-a susceptible host, a virulent pathogen contacting the host, and an appropriate environment. the genetic uniformity of the corn with the tms genes introduced the susceptible host. the genetic change in the pathogen, evolved in response to changes in the host genetics, greatly increased the virulence. the weather during the summer of was warm and wet, ideal conditions for disease to develop. the infection started in early summer in the southeastern united states. by early fall, corn across the entire east coast and westward past the mississippi river had become infected, with - % crop loss in many areas. the result was near complete loss of the corn crop that year, with a huge economic impact. fortunately, producers returned to still available non-tms lines of corn, again requiring manual detasseling. with the return to production of corn varieties lacking the tms genes, epidemics of this disease have not returned. however, as current corn production becomes less diverse, similar risks may again become important. most pork producers raise hogs for specific markets, resulting in limited genetic variability. breeds and hybrid lines are often selected for uniformity and product predictability, such as size, feed conversion, time to market, and/or meeting the requirements of the integrator or marketing company (martinez and zering ) . the disease porcine epidemic diarrhea has had widespread and damaging impacts throughout the pork industry. the disease was first confirmed in the usa in april . it is caused by a highly transmissible coronavirus genetically related to strains found in china (stevenson et al. ). this disease can be contracted by pigs of all ages; % mortality often occurs with suckling pigs. the incubation period is only - h. symptoms include vomiting and severe diarrhea, frequently followed by dehydration and death. there are no effective vaccines or pharmaceutical therapies for the disease at this time. the disease is highly contagious and environmentally stable. a tiny amount of material taken from intestines of an infected animal can be highly diluted (diluted - ) and still remain infective. air-borne transmission is under investigation. trucks and trailers used for dead haul, transport of animals to processing plants, feed deliveries, trash removal and other activities on infected farms have likely been associated with disease spread (national pork board ). the toll on the swine industry has been high. of the million hogs in the usa, about million have been lost to this disease (us department of agriculture ). some individual swine farms have lost as many as , pigs. in response to the rapid disease spread, quarantine measures were put into place in fall . farm visits were not allowed, and movement of people and materials between farms and processors was restricted and monitored. biosecurity measures, isolating one farm from another and preventing movement of infectious material between farms, have been the only effective method for control (national pork board ). separation of farms across north carolina and across the country is comparable to high landscape level diversity with species separation in natural systems, similar to the space between farms and sanitation providing a physical barrier to pathogen movement. most hogs are grown by independent farmers, who are producing on contract for sale of the animals to a larger integrator (animal processor). for example, one such integrator has contracts with over independent farmers for swine production across the usa. the integrators are requiring quarantine between farms as part of the contractual agreement. many of these independent farmers are small to mid-sized concentrated animal feeding operations (us environmental protection agency ) . when compared to production on only a few very large swine farms (> , animals), this distributed national network of independent, smaller farms provides opportunities for implementation of the needed biosecurity measures and physical separation. farms can be widely spaced across the landscape, reducing potential for aerial transmission, and strict sanitation measures have been effectively implemented with farm isolation. in addition, risk is distributed across the farmer network, rather than being concentrated in only a few centralized production farms. this suggests that resilience in the hog industry may be dependent on small farms producing animals independently of each other, rather than depending on large, centralized concentrated animal feeding operations. it also argues that genetic diversity between growers and by each independent grower should be increased to add potential disease resistance and resilience within the industry. in agricultural systems focused on local market channels, resilience can be enhanced by a diversification of on-farm products as well as by distribution of more smaller farms across the landscape, as suggested by the above two examples (thrupp ) . on farms, production risk is distributed across the products being grown for harvest and sale. each product represents an ecologically functional group, with varied ranges of tolerance for conditions within the production environment. for example, some crop plants may have a wider or shifted range of tolerance for temperatures or available moisture. based on observations from natural systems, biological and agricultural diversity can be considered from several perspectives: & diversity of markets based on diverse crops and production some crop production techniques mimic and enhance ecological processes and function within agricultural settings. biointensive production is an example of one approach which is focused on application of principles of agroecology (grow biointensive ). biointensive production emphasizes high crop spatial and temporal diversity via crop selection and multi-cropping practices. soil is highly managed for fertility and biological activity through an initial deep tillage and frequent carbon and nitrogen additions through green manures and compost. these techniques are often most suitable for small-scale farming and are able to provide product to the local food supply network for sale and distribution. there is also efficient land use and minimal reliance on mechanized equipment. these options are severely limited in conventional agriculture which is dependent on high acreage, uniform mechanized production (jeavons ) . a number of studies in natural systems have shown a correlation between high biodiversity and pressures from pests and pathogens (janzen ; connell ; wright ; peterman et al. ; terborgh ; bagchi et al. ). in some ecosystems, there is a feedback between pest and pathogen populations and biological diversity, with pests/ pathogen pressures reduced as individuals of each species become more widely separated with increasing biological diversity, reducing the potential for disease and insect spread. production methods which can enhance agricultural diversity such as organic production have been compared to conventional production in a number of studies. two large-scale meta-analysis studies have suggested that high acreage crop yield with organic production is generally lower when conventional methods are used. however, the yield differences between the two methods varied widely and were highly contextual, differing between crop groups, regions, site characteristics, and cropping techniques (di ponti et al. ; seufert et al. ). in addition, organic production can be done in large acreage monoculture, minimizing biodiversity (mission ). in contrast, some techniques that are most easily adaptable to small acreage, intensively managed farms can produce yields which are comparable and often greater than conventional methods, while enhancing ecosystem structure and functions such as biogeochemical cycles and pest population controls. biointensive techniques with high density diverse plantings have shown a - % increase in production with improved water use efficiency, as for tomato, basil, and brussel sprouts (jeavons ; jeavons ; bomford ; grow biointensive ) . in another study evaluating yield of nine onion cultivars, kg/ m were produced with conventional practice compared to kg/ m with biointensive techniques (moore ). in addition, energy efficiency was improved from an energy efficiency ratio of . : with conventional tillage compared to : with biointensive production-meaning . cal of food were produced for cal used for production. with biointensive production, most of the energy input was from direct human input (renewable) rather than from fossil fuels (moore ) . high biological diversity is a characteristic of biointensive production, with at least different types of plants grown together, including food for local consumption, food for sale, and compost crops. one farm in california, woodleaf farm, grows over different crops on ha of land with ha in woodland and meadow, using similar cultivation techniques. this farm notes anecdotal evidence that populations of beneficial insects have increased while pests and pathogens are minimized (woodleaf ). enhanced productivity, water use efficiency, creation of unique microclimates, and pest/pathogen management are also attributed to high crop diversity (woodleaf ). soil management in biointensive systems is directed toward enhancing ecosystem processes (e.g., nitrogen fixation, mineral immobilization) which are associated with soil fertility (perrings et al. ; d'haene ) . common practices include double-digging soils (loosening two layers of soil) to a depth of . m with annual amendments of cured compost and green manures. communities of bacteria acting synergistically can suppress plant pathogens, promoting plant growth and crop production (kinkel et al. ; mendes ; hadar and papadopoulou ; gaiero ) and regulating carbon flux (fitter et al. ) . biologically active soil amended with organic materials will also provide ecosystem services by retaining water in soil, regulating biogeochemical processes, increasing cation exchange capacity to enhance nutrient retention and plant availability and reducing material loss from the production beds (cooperband ) . environmental benefits with biointensive and similar types of agricultural production include (jeavons from to , average farm size in the usa increased from to acres, while the number of farms declined by about , . significantly, the number of small farms, those most suitable for biointensive and similar types of production ( - acres) declined nationally from , to , . the number of large farms (≥ acres) increased from , to , during the same period of time (us department of agriculture ). these trends suggest that agricultural production in the usa has the potential for decreased resilience, as farming becomes more consolidated into large acreage operations growing a small number of crops on each farm. biointensive and similar practices have the potential to greatly enhance the adaptive capacity of the food production network, increasing crop/product diversity, while shortening the supply chain from production to consumption. they also have the potential to increase productivity per unit area, while protecting and enhancing ecosystem health. through more diversified agricultural production, as described above, greater resilience can also be attained within locally based food systems and associated economies. a distributed and regional network of small-scale aggregators, processors, distributors, and markets has the capacity to make venues for sale of farm products more accessible to small farmers, especially as they diversify their crops. greater crop diversity offers opportunities for more diverse markets, especially in specialty and ethnic foods. a distributed network can foster regional job growth within the food system and enhance food access to underserved communities. a distributed network of producers, buyers, processors, and consumers that share adjacency also have more opportunity for sharing information and knowledge such as technical advice, information about buyers and markets, new regulations, market opportunities, and new innovative practices. the distributed network can also support current models of centralized markets by consolidating products from small growers into larger quantities for sale/purchase. currently, large aggregators leave little room for small producers who cannot meet minimum quantities required for sale. they also usually require a substantial supply of single, uniform crops, creating a disincentive for on-farm crop diversification. in contrast, small producers have found much of their success by selling directly to consumers through farmers markets and community supported agricultural (csa) models (low and vogel ) . among us farmers, in , nearly % of farms sold primarily through direct-to-consumer (dtc) markets, including farmer markets and csas while another % used dtc marketing in addition to other venues. the number of american farms with dtc sales increased by % and sales increased by % between and ; however, between and , the number of farms with dtc sales increased . %, with no change in total dtc sales. that dtc sales did not increase may be a reflection that consumer demand has been met (low and vogel ) . effectiveness of these direct market outlets for small farmers can be place-based and the cost of marketing can be high. additionally, most farmers benefit by having a combination of sale approaches and types of crops to market. as in other industries, market diversification in the produce business is a means to minimize risks-a diversity of market connections supports a financially sustainable farm enterprise (izumi et al. ; vogt and kaiser ; us department of agriculture ). additionally, the food system benefits by having a diversity of local and global channels for the distribution, storage, and value-added processing of food through an increased base of skilled labor. in the event of a disruption (natural disaster, economic collapse, contamination of a supply chain), there are multiple alternative channels that can supply a population's food needs, including supplies closer to communities needing food. disaster notwithstanding, the resilience of the local economy may be increased because of the geographically-linked, skilled jobs that are created: farming, logistics, marketing, storage and distribution, value-added processing, equipment maintenance, input supplier, and many other jobs that cannot be outsourced to non-local entities. in the current national food system, where food is grown and harvested several states away and aggregated by large, centralized corporations, these jobs and skills are not available locally. an increase in non-transferable, geographically dependent, skilled jobs increases the resilience of the local economy immediately. according to the the north carolina commission on workforce development, state of the north carolina workforce report ( ), rural areas of north carolina continue to lose employment opportunities, and bmiddle jobs^that supplied a family-sustaining wage for workers with little formal education are disappearing rapidly. the median family income in north carolina is $ , , substantially below the national median of $ , , with % of the population living in poverty. median incomes in rural counties are often % or more below the state median (u.s. census bureau ). central north carolina is also challenged by many communities having limited access to food. north carolina is ranked th in the nation for degree of food hardships, and greensboro, north carolina in the north carolina piedmont, has been identified as the most food-limited metropolitan area in the nation (food research and action center ) . for many small farmers in the piedmont region of north carolina, farm income is a supplemental, yet crucial, part of their household economy. in , about half of the people identified as farmers ( , individuals) in north carolina by the us department of agriculture did not farm full time. of those, , worked more than days off farm (us department of agriculture ). for many of these families, small farm operations provide much needed household income to supplement off-farm, low-wage job earnings (us department of agriculture ). small farming operations also present economic opportunities for partially-or fullyretired growers, as well as opportunities for beginning producers interested in scaling up to full-time farm businesses. when farmers utilize high-yield, low input techniques such as biointensive and other agroecological methods, farming businesses can be developed in both urban and rural areas, as smaller acreage farms (typically . - acres) are proving their viability. reduced land and equipment requirements also reduce the upfront capitalization costs for a start-up farm. one of the barriers that small farmers experience when developing a farm enterprise is identifying convenient and reasonable access to markets for the sale of their products. generally, individual small growers do not have the physical infrastructure (e.g., cold storage), product volume or market access to sell to institutions or buyers that can pay a fair wholesale price and provide a consistent market for their products. there is room for growth and diversification in the local food sector. according to the us department of agriculture, in north carolinians spend $ billion per year on food (us department of agriculture , center for environmental farming systems , a, b). although spending on local foods is difficult to track, cefs is encouraging north carolina consumers to spend at least % of their food dollars on locally produced food. the north carolina % campaign is in the third year of its promotion to bring local foods spending closer to this benchmark. at %, $ . billion would be generated for the local economy, increasing opportunities for entrepreneurial jobs, skilled employment, and healthy foods. at the same time, there is a renewed interest in local foods to foster healthier north carolinians and protect and preserve the rural landscape (curtis et al. ). there is a tremendous untapped opportunity for selling locally grown produce to indirect markets such as stores, restaurants, institutions, and distributors, particularly for small growers that cannot market their produce directly to consumers. developing a marketing network geared toward these small and micro-farmers simultaneously builds the resilience of local economies through job creation, the resilience of the food system through a diversified, decentralized network of small suppliers, and resilience in production through cultivation of diversified crops. many of the jobs that have been created since the end of the recession have been low-wage service jobs. rural areas of north carolina continue to lose jobs, while metropolitan areas slowly begin adding new jobs (forter et al. ) . this slow economic recovery is a reflection of a lack of resilience in the local economy-largely in response to changes in the manufacturing foundation of the region. fostering locally embedded sustainable, high-yield/low-input agriculture and markets for product sale has the potential to replace the former manufacturing economic foundation. potential for distribution, sale and access to locally produced foods in the north carolina piedmont region to assist local governments in fostering sustainable neighborhoods through food, a model was designed to describe a decentralized, produce aggregation network serving smalland micro-producers within the north carolina piedmont (piedmont together ; walker ). questions of economic and food system resilience were addressed by asking: what opportunities exist to build the supply and demand for local produce while engaging and involving rural and urban, low-resource, diverse communities in ways that generate individual and community wealth and security? more specifically, what sectors are not currently engaged in local food system efforts that hold potential for growing their businesses while contributing to a more robust local food system? (walker ) . the economy of the piedmont region of north carolina during the latter half of the th century-dependent largely on low-skilled manufacturing jobs in textiles, furniture, and tobacco in urban areas and tobacco production in rural areasis a prime example of low resilience, as attested by the lingering effects of the recent economic downturn. similarly, while the prevalence and growth of farmers markets across the piedmont is certainly a welcomed addition, a food system dependent on a small number of relatively high-priced, geographically distant markets with limited hours lacks the resilience possible in a food system that includes markets characterized by a high diversity of product, price, location, and methods of sale. the goal of the model designed to address the participation gaps in the local food system described above was to enhance resilient economic development through creative and sustainable diversification of employment opportunities and market types within the local foodshed through opportunities for aggregation, storage, and sale of local food products, exploiting the growing diversity of locally grown agricultural products. figure shows the model developed. dashed boxes, focusing on micro-, small-, and medium-scale aggregators, are assets that could provide opportunities for sale and distribution of local foods from small-and micro-scale producers that currently lack many opportunities for indirect sales of their products. these small-scale aggregators would fill a niche that links a diverse set of producers (part-and full-time, rural and urban) and diverse agricultural products to retail outlets that cater to populations that currently lack access to local food, such as small rural grocers, urban convenience stores, locally owned mid-priced restaurants, and city-and county-managed institutions. diversifying crops also provides opportunities for consumer access to more diverse produce and other foods, such as culturally important or desired foods. this model demonstrates one method by which resilience is increased through supplementing and integrating with the existing, larger-scale food system, not creating a parallel, stand-alone blocal^system. resilience, defined earlier as the capacity for a system to absorb disturbance and to reorganize, while retaining system function, structure, and self-organizing processes, can best be achieved within the food system by more food produced, distributed, and consumed within local geographies, while keeping the larger-even national-structures that fill gaps which cannot be filled locally or where those structures inform and support local efforts. another important concept model is illustrated in fig. , where the inner ring of the diagram shows a direct-toconsumer relationship within a typical local food system. while this smaller model is more highly favored by local food system activists who place a priority on bknowing one's farmer,^it can exclude opportunities for generating community wealth, resilience, and new jobs through the multiplier effect: increasing the number of times a dollar cycles through a community increases the economic impact of that dollar on the local economy (morgan ) . a study by the iowa state university concluded that buying local food has a multiplier effect of . - . throughout the wider local economy, depending on the rural or urban context and commodities and scale of the community economy (swenson ) . additionally, current research suggests that adding one skilled job in the tradable sector generates . jobs in local goods and services, with high potential for the non-tradable sector (moretti ) . the larger circle in fig. illustrates the inclusion of these bvalue-added^industries, including aggregators, institutions and wide variety of retail outlets. the larger circle also illustrates multiple points of entry for community members into a food production/aggregation/processing/distribution network. programs such as farm incubators can provide training and technical assistance in sustainable production techniques (e.g., biointensive, agroecology), access to on-farm resources and infrastructure, initial entry into post-harvest processing/marketing, and land access opportunities to facilitate the start of new businesses. additionally, underutilized facilities such as convenience stores, restaurants, grocery stores, and local institutions can provide the capacity for storage, post-harvest processing, and/or distribution that can serve as points of entry for people interested in starting non-farm food system enterprises. retail outlets such as restaurants, small grocers, institutions, and innovative outlets, for example mobile or pop-up markets, can widen the distribution of the local food network increasing (walker ) access for community members who would not normally be a part of a regional foodshed based only around direct farm-toconsumer marketing. currently, there are a number of projects, programs, and initiatives geared toward assisting mid-scale farmers who wish to enter mainstream markets. for example, started in , the north carolina farm to school program now facilitates sale of locally grown food to of the counties in north carolina. during the - school year, $ , , was spent purchasing fruits and vegetables grown in north carolina, which were then served in schools (north carolina department of agriculture and consumer services ). both approaches are necessary to build a resilient local food system that can absorb disturbances such as natural disasters and disruptions to the national economy and transportation network. the models illustrated in figs. and highlight the opportunities for new, small-scale, locally-based markets that can be the portal for sale of products by locallyconnected producers, thus increasing the resilience of the food system through dynamic, adaptive, and responsive enterprises. to achieve this increase in locally sourced food through decentralized, networked distribution channels, three main issues must be addressed. ) many of the resources for the promotion of local foods development over the past decade have gone to supporting mid-and larger-scale farms within north carolina. large foundations and universities have focused on helping farmers who were affected by the tobacco buyout program transition to other viable crops, as well as the renewed public health focus on obesity, diabetes, and stroke prevention. this led to much public support for getting fresh, local foods into a variety of markets and food access programs. working with larger farmers and distributors has made a difference in the prevalence of local foods available to consumers. however, smallscale farmers are often not able to sell to these markets. for example, during the - school year, the north carolina farm to school program purchased strawberries from only farms and sweet potatoes from farms. for comparison, there are north carolina farms of - acres identified in the us department of agriculture agricultural census, who are also potential suppliers for this program (north carolina department of agriculture and consumer services ; us department of agriculture ). in order to engender greater resilience of the local food system, more attention needs to be paid to the contribution potential for smalland micro-scale farms. ) nationally, the local food movement has often been hegemonic in its lack of inclusion of minority participantsbe they underrepresented racial, ethnic, class, or genders (hinrichs ; jarosz ) . greater attention paid to the barriers for participation by individuals, businesses, and communities that are not currently part of the local food movement will help in creating greater equity of food access, economic opportunity, and environmental health (holley ) . it will also expand the range of products available for production, processing, and purchase, increasing both social and economic resilience within the local network. in the same way that a diversity of scale and market type will strengthen the ecosystem of the local food system in the piedmont region, greater involvement from a diversity of stakeholders throughout the system will engender more dynamism and resilience (page ; holley ) . expanding and diversifying the community of growers and non-farm entrepreneurs will also expand markets and market access to parts of the community now underserved by a centralized food marketing network. ) for many small farmers, resources and equipment that would facilitate sale to a network are not available. for example, the cost of an × ′ cold storage unit is typically $ -$ , . for many farmers who have substantial capital, off-farm income, or access to credit, this is attainable. however, need for capital is a barrier for most low-resource farmers. the local food models outlined above for central north carolina's small and mid-sized farmers and aggregators can be described in a set of five bdesign guidelines^that increase economic, social, and agricultural resilience. these guidelines are intended as a beginning resource for people interested in starting or adding to some aspect of the decentralized aggregation and cold storage local food network. they are suggestions that can be utilized by decision makers, designers, and planners that may be working on other community-wide issues such as transportation, housing, and economic development. having design guidelines that summarize a model of diversification and resilience based on food system localization allows for the inclusion of ideas generated through academic research into practical, applied community practice. guideline # : promote networks and nodes intent: develop a regional food system that utilizes complexity (a system of networks and nodes) as a mechanism for achieving greater economic and food system resiliency. a. look for opportunities to situate aggregation and storage facilities throughout the region and close to production farms, while encouraging strong interconnectedness throughout. b. cluster small aggregation and storage facilities near one another, forming bnodes^of the local food supply chain. fifty miles has been defined as a maximum distance between aggregation facilities in rural north carolina (bruno and hossfeld ) . facilities may be closer in the more urban piedmont. guideline # : engender equity and inclusivity intent: build on the strengths of the piedmont triad region by integrating cross-barrier collaborations into the aggregation or cold storage business initiative. a. understand the political geography of your community. while doing business in a new area may present challenges, new business opportunities, collaborators, and markets also await. b. build new lines of community rapport across racial, economic, class, and language boundaries. c. work to promote access to financing and entrepreneurial assistance for diverse communities that are specific to current trends in food system development. guideline # : plan for appropriate transportation options intent: ensure that the cold storage chain of all produce is maintained from farm to fork and that handling is appropriately documented. each segment of the supply chain should work in tandem with other segments. a. ensure that there is access to a refrigerated truck or trailer to maintain the cold chain. b. know the acceptable upper and lower temperature and humidity limits of the produce being aggregated. c. manage traceability of products. keep all appropriate records regarding the place of origin, place of sale, and storage notes for all produce that moves through the aggregation facility. guideline # : design an effective management plan intent: design a management structure and plan that addresses the goals and limitations of your aggregation or cold storage business, while adhering to all regulatory requirements. a. choose a management structure that fits with your business. a simple cold storage unit leased to several farmers who are marketing their own produce to aggregators will still require facility management, rent collection, and marketing to new farmers. b. ensure that your facility is compliant with all regulatory requirements, including appropriate recordkeeping. track and document temperature and humidity through the duration of the entire supply chain. c. develop procedures that allow access to storage space by clients when needed and ensure that everyone who enters keeps appropriate logs for food safety requirements. guideline # : build appropriately-sized cold storage facilities intent: invest in infrastructure wisely. cold storage units can be re-configured, and their temperature and humidity changed with relative ease if planned for up front. however, there is an economy of scale, even when working exclusively with small-scale farmers and buyers. develop a business plan that helps to determine what and when your enterprise should build. a. estimate how much cold storage space you need based on the amount of produce your suppliers will need to store. b. approximate energy costs ahead of time and investigate alternative energy as a way to lower the utility bill. c. know what the optimal temperature and humidity settings are for each produce type you will store and aggregate. d. determine what storage system you will use within the cold storage units based on the farmers and buyers you are working with. some smaller growers who are storing their own produce to sell at a local farmers' market may prefer industrial shelves where they can store produce boxes, while larger growers may prefer palettes and use palette jacks to move their product around. also, there is a need to consider the storage of certified organic and gap-certified produce, which need to remain segregated from non-certified foods in order to maintain their certification. the distributed network of aggregation and distribution centers proposed for the piedmont of north carolina provides an integrated, regional model, reducing transport needs for farmers and expanding distribution, sale, and access. a south carolina food hub has been successful in making local foods more available, providing an aggregation/distribution/service network to benefit farmers and consumers. growfood carolina is presented below as a case study of a food hub that is helping the charleston food system move toward a fledgling level of resilience. growfood carolina provides a model for one of the nodes in fig. -an aggregation/distribution hub that connects small-scale growers to consumers in the same region. it also has the potential to serve as a central hub networked to smaller aggregation and value-added processing centers throughout the region, like the spokes of a wheel. charleston, south carolina is the center of one of the southeast's real estate development booms, aided by an influx of retirees moving to the area due to its climate and the availability of still-relatively affordable land. charleston county has grown from , in to almost , in , a . % increase (us census ). a corollary to the above growth and international recognition for charleston's reputation is the recent development of a vibrant, local food culture. green grocer farms on wadmalaw island, located outside of charleston is representative of this growing local food culture. in the s, the farm grew a variety of row crops under regional organic certification, which were sold in savannah and atlanta. now, years later, pastured eggs and pastured raw milk are produced, and the farm is unable to keep up with local demand for their products. the growth in demand for local foods is also seen at the charleston farmers market. ten years ago there were approximately five farmers; now there are over twenty-six farms selling a variety of local and regional products, including meat, eggs, milk and cheese, vegetables, flowers, shrimp, rice and fruit. one other area of growth is in the local restaurant industry, where almost every local restaurant advertises that they support local farmers and purchase local food, with one nationally recognized restaurant, husk, advertising a strictly regional menu. growfood carolina-a regional food hub growfood carolina is a working example of how a food hub contributes to resilience in the lowcountry of south carolina. the us department of agriculture defines a food hub as ba centrally located facility with a business management structure facilitating the aggregation, storage, processing, distribution, and/or marketing of locally/regionally produced food products^(us department of agriculture ). food hubs have operational services which can range from aggregation to distribution and sale, including branding, promotion, packaging, and product storage. they can also assist with producer services, ranging from transportation, training, business guidance, value-added product development, and providing liability insurance, to an often key service, linking buyers with producers. food hubs can also help with the promotion of community/social missions, such as distribution of products to food deserts, raising awareness about benefits of supporting local agricultural businesses, providing opportunities to community youth, offering composting and other forms of regionally-appropriate farming/agricultural workshops. growfood carolina is a subsidiary of south carolina's leading environmental advocacy group, coastal league (ccl), started in with the mission to bprotect the natural environment of the south carolina coastal plain and to enhance the quality of life in our communities by working with individuals, businesses, and government to ensure balanced solutions( coastal conservation league ). to realize this mission, in , ccl started two bin-house^policy and advocacy groups to help protect the coastal corridor of south carolina. one group focuses on climate change and energy, while the other group focuses on sustainable agriculture. the ccl sustainable agriculture committee helps ccl's overall strategy of land conservation: if farming is not economically viable, then small and mid-sized farmers will be squeezed out of the market with subsequent changes in land use. thus, ccl actively supports local, sustainable agriculture. to support their mission, growfood was created to provide infrastructural help to regional small-and mid-sized farmers. in , a -ft warehouse in downtown charleston was donated to ccl. after renovating it and hiring a general manager, growfood officially opened for business in . the warehouse contains ft of refrigerated space. although not climate controlled, the building meets leadership in energy and environmental design (leed) standards. growfood also owns a -ft refrigerated truck purchased with funds from a us department of agriculture grant and has an urban garden demonstration plot on site where they host various workshops and school groups. the warehouse is located directly off interstate i- leading inland to columbia, sc, and is close to hwy , a north/south artery. this location is strategic, allowing growfood to meet its mission as a food hub, consolidating production and distribution within a -mile radius. this radius allows growfood to work with farmers growing produce from georgia to north carolina, and ccl has plans to open a second hub in greenville, south carolina that will service the upstate, mountain region of south carolina. farms within the -mile radius contact the growfood general manager, who visits the farm for bfull transparency. restaurants and retail stores, and growfood either delivers the produce, or retail customers come to purchase it from the warehouse. after a sale, % of the purchase price returns to the grower, and % remains with growfood to help cover operating costs. growfood does all sales, marketing, and distribution via a two-person marketing team, and they work with over local businesses, distributing days per week. this requires five fulltime staff and two part-time drivers. in , they had five growers and customers, and as of , they have growers with regular restaurant and retail customers. currently, demand far outstrips supply, demonstrating demand for additional local foods and food hub services in the south carolina foodshed. with farms from to acres in size in south carolina, clearly, there is additional production and distribution capacity (us department of agriculure ). the goal of the ccl staff is to expand both growfood as well as the local farming community, helping them to diversify, increase production and transition to organic production. therefore, besides retail distribution, growfood is an advocate for small-scale, sustainable farming. south carolina currently has certified organic growers, compared to over in north carolina. to expand the number of sc organic growers, ccl does outreach and education about the benefits of sustainable agriculture, focusing especially on the next generation of farmers. the average age of farmers in south carolina is . there are currently not enough young farmers to supply current demand, let alone create new farms that can help meet growing regional food needs. but this also presents an entrepreneurial opportunity for increasing the resilience of the regional food system through creation of new, small, sustainable farms if land, training, and resources for start-up business are made available. dirt works incubator farm on johns island outside of charleston is working to support development of new farmers starting their new farm businesses in the area. growfood as a food hub is helping the community in three important areas. & bthe environment.^use of sustainable production techniques that improves the soil with each cropping cycle and use of the food near the production farms, reducing transportation impacts & bdiversify local agriculture.^smaller farms have the adaptive capacity for increased diversity of crops in production both on-farm and between farms, also increasing nutritional and preference opportunities for consumers. & brural economic development.^as the manager of growfood stated, bcash flow is the most important thing for a grower.^this cash flow allows farmers to be economically solvent, allowing them to continue farming. median income in south carolina is $ , , well below the national average, with % living in poverty. despite the ready support of local restaurants, it is recognized the client base needs to expand, so further goals are to sell to local schools, hospitals, and retail supermarkets, and to advocate for a year-round farmers' market. lastly, their larger goal is to have % of charleston's food come from within the -mile radius of the food hub by . if successful, charleston and the lowcountry will demonstrate a powerful move toward food resilience as a disturbance response. thus, ccl's goal is to develop an aggregated food hub network in the state, as is proposed for the north carolina piedmont in the previous section, while working on education and training, advocating for policy shifts at the state level, and creating food network market resilience. food hubs can potentially add redundancy and resilience at regional scales and across industries (production, distribution, consumption) and thus act as catalysts fostering reorganization of regional food networks. as anyone who has farmed knows, if a farm cannot make money, then there will be no farm. food hubs can become key nodes in food networks, and because they interact with farmers and retailers on a daily basis, they can serve as a platform to quickly disseminate information, creating synergies between and among the diverse members of a food system. rapid information transfer throughout the food network strengthens adaptive capacity for growers, processors, and distributors, allowing rapid response to changes in market and/or environmental conditions. however, a note of caution: food hubs may not be appropriate in all places, and local production may not fill all food needs. even growfood is years away, at best, from helping create a critical mass of local farms that can provide even a small percentage of the lowcountry's daily food needs. the food hub model in south carolina and the proposed model for north carolina may also be appropriate for other regions, extending the capacity of the regional food networks with strengthened resilience. it is an open question as to whether our global food system contains the capacity to respond to a variety of disturbances, which may threaten the integrity of system function and structure and the ability to provide needed food to all people. by definition, if such structure and function were to collapse and be unable to reorganize, such a food system lacks resilience, with potentially severe human consequences. however, adaptive capacity and adaptive management acknowledge that a system being managed will always change, so humans can respond by adjusting the system in response to disturbance and changing conditions (gunderson (gunderson , (gunderson , . in the case of agriculture and food security, resilience can be considered from the perspective of food availability with a return to a predictable, dependable, safe supply following disturbance. this issue of the journal of environmental studies and science grapples with diverse perspectives of this challenge (marten and atalan-helicke ) . while appearing to make agricultural production more consistent and predictable, genetic uniformity also has the potential to increase risk from pests, pathogens, and other disturbances, as highlighted earlier in this paper. in contrast, high biological diversity has the capacity to decrease risk with genetic diversity within a single crop and through distribution of risk between a variety of products being grown for harvest and sale. these insights should help us think more clearly about what are long-term goals for a truly resilient food system. small-scale, locally-managed farm operations using agroecological techniques such as biointensive agriculture have the adaptive capacity for increasing biological and ecological diversity both on and between farms, increasing resilience through the ability to rapidly respond to changing environmental and market conditions. highly managed, low acreage production systems such as the biointensive technique have shown greater yields per unit area than conventional production systems reliant on larger acreage. these highly managed systems also result in more efficient water use, reduced pest/pathogen pressures, and protection of adjacent environments. interspersing small farms with large farms and returning some lands to a non-farmed condition to provide localized ecosystem services has the potential to engender social, economic, and environmental resilience through regionally-enhanced, responsive, and more highly-integrated food networks. development of small, diverse farming operations can help communities respond to chronic economic stress by providing supplemental income for some growers and opportunities to build larger, full-time farm businesses for others. high-yield, low acreage techniques can also make farming accessible to a diverse community of people who had not been involved with agriculture, such as urban residents, minorities, and women. however, one barrier to small farmers is often inconvenient access to markets for sale of their products. to have a resilient food system, you have to make it economically viable to farm. therefore, it is crucial to link the shift in food production systems with the shift in food distribution networks. there is a growing emphasis for the need for new, locally based markets that can be the portal for sale of products by small-scale, locally connected producers. indeed, several regional food hubs and networks have emerged in the usa that aim to close the gap between producers and consumers. regional food network and hub models can increase opportunities for direct consumer purchase, or they can serve as aggregation centers for food to be passed into a centralized distribution network, connecting with large volume sellers such as grocery stores, processing facilities, and wholesale distributors. a food system that is predicated upon supporting and cultivating farmers of all scales, who utilize various sustainable production methods for a diversity of crops, and have a variety of market outlets will inevitably be stronger, more resilient, and more adaptable to change than a system that only responds to one scale or type of farmer or one type of market. using biological and agricultural diversity to expand locally based, sustainable farming systems, foster new farmers and food entrepreneurs, and build distributed aggregation, processing and marketing networks that focus on triple bottom line benefits-environmental, social, and economic-have the potential to strengthen our food security and our communities, providing resilience to both acute and long-term stress. the role of ecological biodiversity in agroecosystems historical perspectives of plant diseases pathogens and insect herbivores drive rainforest plant diversity and composition do tomatoes love basil but hate brussels sprouts? competition and land-use efficiency of popularly recommended and discouraged crop mixtures in biointensive agriculture systems southeastern north carolina food system project: an assessment of market opportunities and limited resource farmers in s.e. north carolina. final report statewide-infrastructure-map.html center for environmental farming systems ( a) nc growing together: connecting local foods to mainstream markets on the role of natural enemies in preventing competitive exclusion in some marine animals and in rain forest trees. dynamics of populations building soil organic matter with organic amendments from farm to fork: a guide to building north carolina's sustainable local food economy, a center for environmental farming systems report the crop yield gap between organic and conventional agriculture biodiversity, ecosystem function, and resilience: ten guiding principles for commodity production landscapes biodiversity and ecosystem function in soil regime shifts, resilience, and biodiversity in ecosystem management resilience thinking: integrating resilience, adaptability and transformability the state of working north carolina inside the root microbiome: bacterial root endophytes and plant growth promotion ecology action, one earth, many gardens ecological resilience-in theory and application suppressive composts: microbial ecology links between abiotic environments and healthy plants opening spaces through relocalization: locating potential resistance in the weaknesses of the global food system the practice and politics of food system localization market diversification and social benefits: motivations of farmers participating in farm to school programs herbivores and the number of tree species in tropical forests the city in the country: growing alternative food networks in metropolitan areas biointensive sustainable mini-farming i: the challenge the implications of scaling approaches for understanding resilience and reorganization in ecosystems a coevolutionary framework for managing disease-suppressive soils the texas cytoplasm of maize: cytoplasmic male sterility and disease susceptibility direct and intermediate marketing of local foods in the united states introduction to the symposium on american food resilience pork quality and the role of market organization deciphering the rhizosphere microbiome for diseasesuppressive bacteria mission : feeding the world. organic industrial agriculture energy efficiency in small-scale biointensive organic onion production in pennsylvania, usa. renewable agric and food syst local multipliers response diversity determines the resilience of ecosystems to environmental change north carolina farm to school program the difference: how the power of diversity creates better groups, firms, schools and societies janzen-connell effects are widespread and strong enough to maintain diversity in grasslands ecological resilience, biodiversity and scale community choices, regional solutions plant diseases: their biology and social impact comparing the yields of organic and conventional agriculture emergence of porcine epidemic diarrhea virus in the united states: clinical signs, lesions and viral genomic se determining the methods for measuring the economic and fiscal impacts associated with organic crop conversion in iowa enemies maintain hyperdiverse tropical forests state of the north carolina workforce: an assessment of the state's labor force demand and supply linking agricultural biodiversity and food security: the valuable role of agrobiodiversity for sustainable agriculture sustaining ecosystem functions in a changing world: a call for an integrated approach department of agriculture, agricultural marketing service, north carolina: population profile, transportation and marketing getting to scale with regional food hubs regulatory definitions of large cafos, medium cafos and small cafos. access may still a time to act: a review of institutional marketing of regionally-grown food planning for a networked produce storage and aggregation system for the piedmont region plant diversity in tropical forests: a review of mechanisms of species coexistence key: cord- -x mhzhw authors: bhavani, r. v.; gopinath, r. title: the covid pandemic crisis and the relevance of a farm-system-for-nutrition approach date: - - journal: food secur doi: . /s - - - sha: doc_id: cord_uid: x mhzhw the covid pandemic should be seen as a wake-up call for humanity, to reflect, rethink and redesign food systems that are safe, healthy, sustainable, and beneficial to all. this crisis has disrupted food supply chains, affecting lives and livelihoods. hunger and malnutrition is expected to increase and the poor and vulnerable will suffer the most. there is urgent need to build resilient food systems. a location specific farm-system-for-nutrition approach, based on sustainable use of natural resources and local agri-food value chains can help improve household diet diversity and address nutrition deficiencies. the food-based approach can improve preparedness and resilience of communities to withstand the challenge posed by crises in general, and covid in particular. a large segment of the population in developing countries of the world across asia, africa and latin america depend on agriculture and associated activities for their sustenance. agriculture covering crops, livestock, aquaculture, fisheries and forests is the world's biggest employer and the main source of food and income for the extreme poor (fao ) . the developing countries of the world are also home to a large population of malnourished people. india is a typical example with more than per cent of its workforce engaged in agriculture, a large majority being small land holders, and prevalence of high levels of child undernutrition and micronutrient deficiency. the last decade has also seen the development of active discourse on leveraging agriculture for nutrition and the need for sustainable food systems in order to achieve the sustainable development goals (sdgs). the covid pandemic that has gripped the world in recent months constitutes a major challenge to food and nutrition security of vulnerable populations. many countries declared generalised lockdowns as a measure to counter the spread of the disease. restrictions on transport and movement following the lockdown led to the breakdown of food supply chains, delaying harvest, damaging perishable produce and causing loss to farmers and fishers. different aspects of the impact on lives and livelihoods of the poor have been documented at global and national levels ipes food ; . it is expected that hunger and malnutrition will increase if necessary measures are not taken urgently (fsin ; un ) . according to un ( ) , "the latest data shows that the food security of million people was categorised as crisis level or worse. that number could nearly double before the end of the year due to the impacts of covid- ". responding to the covid pandemic from a smallholder perspective the extent of impact of the covid pandemic therefore makes it all the more important to build resilience within some of the most affected communities, like the smallholder farmers in developing countries, to withstand such shocks and invest in preparedness. the pandemic is the last addition to the list of disasters and crises caused by adverse weather conditions, natural hazards, economic shocks, and conflicts that can upset the livelihood and food and nutrition security of vulnerable populations. fao has identified four areas or pillars in the framework developed for disaster risk reduction to reduce the impact of disasters on food and nutrition securityenabling environment, early warning and safeguards, prevention and mitigation measures, and preparedness to respond (fao ) . the framework is relevant for addressing the covid crisis, which has exposed the 'fragility of the world's food and land use system' (davey and steer ) . resilient food systems that are based on the sustainable use of natural resources must be promoted as a prevention and mitigation measure against such crises. food systems have been defined as 'the entire range of actors and their interlinked value-adding activities involved in the production, aggregation, processing, distribution, consumption and disposal of food products that originate from agriculture, forestry or fisheries, and parts of the broader economic, societal and natural environments in which they are embedded' (fao ) . these need to be accompanied by an enabling policy environment and response preparedness. this calls for agriculture to break away from the thrust on just production, productivity and short-term profit, and instead to mainstream the nutritional dimension, and to promote the diversity of production, while paying attention to soil health and sustainable land use. farm-system-for-nutrition (fsn) is an example of such a food-based, nutrition-sensitive approach. the fsn approach is defined by m. s. swaminathan as: "the introduction of agricultural remedies to the nutritional maladies prevailing in an area through mainstreaming nutritional criteria in the selection of the components of a farming system involving crops, farm animals and wherever feasible, fish". (nagarajan et al. ) the farm-system-for-nutrition approach fsn is a location-specific, inclusive approach, with a design based on available resource endowments and specific environment, to address the nutritional needs of small holder farm families. awareness of balanced diet, nutrient content in different foods and leveraging agriculture for nutrition is an integral component of the approach. in essence, fsn calls for the promotion of location-specific farm systems that integrate arable farming, horticulture, backyard farming and animal farming, to sustainably improve household availability of nutrition while also mitigating risks and conserving natural resources. in developing the farm system design, feasible agricultural interventions to address nutritional deficiencies of the household / community/ location would have to be incorporated. in the words of m. s. swaminathan, ".....the design of the farming system [can] include specific crop varieties that can address the identified deficiencies. sweet potato might provide vitamin a, drumstick tree (moringa olifera) and amaranthus sp. could address the lack of iron" (rao and swaminathan ) . in addition, the approach recognises the need for other direct interventionsto improve production and market linkages for nutritious crops and indirect interventionsto improve women's empowerment, nutrition, education, water, sanitation and hygiene (wash), and natural resource management, along the pathway from agriculture to nutrition (shetty ) . a fsn study on these lines was conducted in two agroecologically different locations in india from to , covering a population of about households with people . the study population was dependent on rainfed agriculture and high level of undernutrition prevailed. diet survey and survey of food consumption pattern revealed that the diet of people was cereal dominated with consumption of all other food groups being lower than the recommended dietary intake levels (bhaskar et al. ) . the fsn design focused on increasing the availability and access to nutrient-rich foods by promoting: the cultivation of millets and pulses suited to the region; nutrition-oriented gardens of fruits and vegetables that grow locally; access to animal foods through poultry and fishery; and nutrition awareness. the viability of recommended practices in terms of economic return was demonstrated through on-farm trials, demonstrating the potential for adoption by farmers and the sustainability of the intervention (pradhan et al. ). an endline survey in late , three years after the intervention, revealed an increase in availability and consumption of millets, pulses and vegetables by households, an increase in proportion of households consuming more than per cent of recommended allowance of all food groups, and an improvement in household dietary diversity (mssrf ). in addition to being nutrient dense, millets and pulses are also regarded as climate-resilient crops that are suited to rainfed farming conditions. building on the experience, agricultural universities in different states of india are now being engaged with, to set up demonstrations of the fsn approach (bhavani ) . more work is required to address post-harvest handling and processing and develop local agrifood value chains. the crisis created by the covid pandemic brings into focus the relevance of location specific nutrition sensitive agriculture approaches such as fsn that draw on local food diversity. the crisis has also highlighted the importance of decentralized models and of local value chains. in many parts of india for instance, farmers' producer organisations were seen to be playing a proactive role in aggregating produce the study was undertaken by the m s swaminathan research foundation under the research programme on leveraging agriculture for nutrition in south asia (lansa) http:// . . . /content/farming-systemnutrition accessed may from smallholder farmers and facilitating market access (rengalakshmi and rao ) . pingali et al. ( ) draw attention to the need for similar measures, in their recent work on transforming food systems. the report on global food crises dwells on this aspect in the light of the covid crisis, and calls for support to ensure the continuous functioning of local food markets, value chains and agrifood systems in food crisis contexts, including support to food processing, transport, marketing and strengthening of local producers' groups (fsin ). torero ( ) calls for sustainable use of land and water resources to grow essential, nutritious food in a more resilient way and 'better treatment for smallholders and migrant workers, who form the backbone of farming'. swaminathan ( ) draws parallels with the irish famine crisis of the s and emphasizes the need for genetic diversity for resilient agriculture systems and postharvest processing, storage, value addition and marketing mechanisms. the covid pandemic should be seen as a wake-up call for humanity, to reflect, rethink and redesign food systems that are safe, healthy, sustainable, and beneficial to all. a farm-system-for-nutrition approach that is location specific, that promotes production of safe and healthy food, which is based on the sustainable use of natural resources by small farmers, that takes into account the risks posed by climate change, and that promotes development of local value chains, can help build resilience of local communities to crises such as the covid pandemic. conflict of interest the authors declare that they have no conflict of interest open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/ . /. establishing integrated agriculture-nutrition programmes to diversify household food and diets in rural india taking the farming system for nutrition approach to scale after covid : how we can improve the global food security system. blog resilient livelihoods -disaster risk reduction for food and nutrition security framework programme. rome: food and agriculture organisation of the united nations sustainable food systems -concepts and framework. rome: food and agriculture organisation of the united nations anticipating the impacts of covid- in humanitarian and food crisis contexts. rome: food and agriculture organisation of the united nations covid- and the crisis in food systems: symptoms, causes, and potential solutions india impact brief: evidence from farming system for nutrition study on farmers and farming in tamil nadu operationalizing the concept of farming system for nutrition through the promotion of nutrition-sensitive agriculture transforming food systems for a rising india finger millet in tribal farming systems contributes to increased availability of nutritious food at household level: insights from india a farmer-led approach to achieving a malnutrition-free india farmer producer organisations could help small holder farmers overcome the effects of the covid- lockdown from food security to food and nutrition security: role of agriculture and farming system for nutrition covid- and food security: lessons for indian agriculture without food, there can be no exit from the pandemic the impact of covid- on food security and nutrition the covid pandemic crisis and the relevance of a farm-system-for-nutrition approach a p h d i n e c o n o m i c s , r . v . b h a v a n i i s d i r e c t o r , agriculture-nutrition-health p r o g r a m m e a t t h e m s s w a m i n a t h a n r e s e a r c h foundation (mssrf). rural development, food and nutrition and security issues are the focus areas of her work. between and , she was on deputation to the national commission on farmers, government of india, as officer on special duty to the chairman. from to , she was project manager of a multi-country multi-institutional research programme consortium leveraging agriculture for nutrition in south asia (lansa) that was led by mssrf. before joining mssrf, she was an officer in state bank of india for a decade.r. gopinath is currently working as a senior scientist at the m s s w a m i n a t h a n r e s e a r c h foundation (mssrf). he holds a ph.d. in economics. he has wide experience in the area of food and nutrition security, agrarian studies and development studies and regularly writes on these issues. at mssrf, gopinath engages in food and nutrition security related research studies, policy evaluation studies and project monitoring and evaluation. he has earlier worked for united nations development programme, india, and with reliance foundation, the csr wing of reliance group of industries, as programme director for tamil nadu, looking after knowledge dissemination to farmers. key: cord- - am l ms authors: nan title: spr date: - - journal: pediatr radiol doi: . /s - - - sha: doc_id: cord_uid: am l ms nan dear colleagues, i confess i haven't read many "welcome letters" at the beginning of the spr program book over the years. perhaps the only defensible benefit of this is that there is no preconception about the content of this message…or the length. i will be brief. this meeting is about building bridges…bridges from our past to the future and bridges between all of us who believe fundamentally in maintaining or improving the health of our children. the content, which is detailed on subsequent pages, speaks for itself. this material will be presented during the sessions with an appreciative look back at past accomplishments-the legacy of our subspecialty-with a vision to the future of pediatric imaging. we can only measure how broad and deep our successes have been by connecting with these beginnings. looking beyond the titles (and the speakers), i think you will see that the material is not only about techniques and tactics but about ideas, insights, energy, all conspiring in the creative process … an aggregate for excellence in pediatric imaging. the content is also punctuated by a strong presence of our clinical colleagues. again, this builds bridges. how can we maintain and expand these relationships? moreover, the connections between science and clinical practice are evident in the structured blending of scientific papers and topical presentations by both imaging and clinical experts. this blending is also "fraternal" in that there will sometimes be disagreement and critical commentary, but this is essential in the advancement of medicine. support and criticism make a stronger mortar. in the end, this gathering is about fostering a connected community, including technologists, nurses, physicists and other allied health experts including industry experts. finally, the emblem of pediatric radiology has always been embossed by cooperation, passion, commitment, and humanistic care. i believe the program content, the presenters and you, the participants, all embrace this. i hope that you will feel the spirit and the passion of the meeting and all of us will in many ways be better able to care for children because of this-even if you never read this message! donald p. frush the gold medal of the society for pediatric radiology is our most distinguished honor. the spr medal is awarded to pediatric radiologists who have contributed greatly to the spr and our subspecialty of pediatric radiology as a scientist, teacher, personal mentor and leader. marilyn goske has always wanted to make a differenceand what a difference she has made! her role as an educator, and her lifelong commitment to improving training for residents, fellows, faculty, medical staff and radiologic technologists has resulted in many wonderful initiatives that have benefited all in pediatric radiology. the work she is most proud of-the cleveland clinic web based curriculum, working with the leadership of spr's philanthropic campaign for children, launching the image gently campaign and the pediatric research component within the american college of radiology's dose index registry share a common theme: educating others in providing the best care possible for children. born in berea, ohio, marilyn's father, george, was a chemical engineer. her mother, cornelia aka "corky", loved writing as one of the first women journalists for the associated press and later teaching, passions she passed on to her daughter. while marilyn was blessed with a strong female role model in her mother, it was her brother, james, who was her cheerleader, always pushing her to dream big. he encouraged her to follow in his footsteps first at ohio university, then on to the ohio state college of medicine to pursue an md degree during an era when nursing would have been a more conventional goal. marilyn met her husband rick on a double date in college-unfortunately, they were with different dates! luckily, they were able to get together for an actual date with each other months later. they quickly became engaged and married within a year of that first true date. when rick started his residency in internal medicine, marilyn transferred to the university of connecticut school of medicine in farmington. it was here that she met her first pediatric radiologist-and what a giant-mike ozonoff! when rick moved on to a neurology residency in rochester, new york, marilyn followed and met another pediatric radiology giant: beverly wood, at strong memorial hospital. beverly proved to be a wonderful teacher, mentor, co-researcher and lifelong friend. marilyn describes beverly as inspirational and "fearless" in trying new technologies. it was during her time in rochester that marilyn went to her first spr meeting and, not surprisingly, won the caffey award for her work on "experimental neonatal intraventricular hemorrhage: clinical, radiographic and pathologic features." by then marilyn had two young children and moved on to the private sector, practicing part-time for several years first in rochester, then in cleveland, ohio. her years in private practice were particularly helpful in learning the importance of patient oriented service-and paved the way for her intuitive public relations strategies when designing the image gently campaign in later years. dr. goske was asked to join the cleveland clinic in , as the first full-time section head of pediatric radiology. it was here that she built a new section and spearheaded the web based education program for pediatric radiology residents with co-founder janet reid. this important free web site with modules is used widely by over radiology residencies nationally and internationally. her passion for education continued, inspiring her to complete a medical education fellowship focused on professionalism within the cleveland clinic lerner college of medicine. her work towards this fellowship has led to many creative educational initiatives including yearly educational summits at the spr. she was named chair of the professionalism committee of the rsna where she along with her committee have sponsored interactive workshops on this topic dear to her heart. dr. goske's energy and effective leadership skills brought her to become involved in the society for pediatric radiology, first as the coordinator for spr's first video-taped course in . mentors diane babcock and carol rumack proposed her for the nominating committee. this was followed by chair of the membership committee, where she organized the first formal survey of the society, then as a board member, then as secretary, and finally as president and chair of the board of directors, completing years on the spr board. working together with stuart royal, she successfully energized the campaign for children raising funds for the research and education foundation of the spr and expanded the work of prior presidents in further organizing the corporate support committee. marilyn's years as president and chairman of the board of the spr were highly successful with many unique strategic goals. she was instrumental in the founding of the junior spr. she led the wonderful spr national meeting in miami which included the first educational summit to enhance knowledge in adult learning and resident competencies. most people would rest after completing their arduous year as president but as chairman of the board, marilyn was just beginning! she moved to cincinnati children's hospital, joining the radiology department and was named the dr. corning benton endowed chair for radiology education where she got to work with dr. janet strife, another influential mentor and friend. acknowledging spr's long focus on reducing radiation doses in the imaging of children but concerned about the lack of change in practice by a majority of radiologists despite increasing reports of possible side effects, marilyn developed a public relations and awareness campaign. her goal was to inspire all to work towards decreasing radiation exposure to children when possible. with the help of many, she founded the alliance for radiation safety in pediatric imaging and the image gently campaign, initially focusing on ct. her ability to encourage numerous experts and societies to work together and get involved in "child sizing the amount of radiation used" has resulted in a groundswell of research and activity in this area. currently organizations with over , members have joined the alliance including international societies. the web site, www.imagegently.org, has been immensely successful filled with free information pamphlets in over languages, pqi projects, and modules for parents, physicians, and technologists. the image gently campaign has received several awards including the associations advance america honor roll, rt image magazine group with the "most influence in radiology" and the most effective philanthropy program from aunt minnie. image gently has spawned the creation of the adult-focused image wisely campaign. the alliance has been named by the joint commission, u.s. food and drug administration, and the american medical association in their influential statements on radiation dose as providing much needed guidance and information. marilyn's exceptional talent is inspiring and coordinating experts in multiple fields to work together towards common goals. she continues to work hard on the image gently campaign with more safety and quality messages planned for the coming years. she is also proud of her work with the acr dose index registry and quality improvement registry in ct scans in children in working toward developing diagnostic reference levels with a talented consortium of pediatric radiologists, medical physicists and technologists. she has acted as a national and international expert in her work with the international atomic energy agency, the world health organization and the national council on radiation protection in medicine and the fda. dr. goske's multiple committee appointments are taken seriously, and her work is always meticulous, well thought out, and brought to successful completion. she has been an active member of numerous national and international societies including the john caffey honorary society, acr, rsna, espr, aawr, and scorch. it is important to remember that dr. goske is also a successful researcher with numerous grants obtained through the spr ref including the thorne griscom education award and the rsna scholar grant. she has published over peer-reviewed articles, electronic publications, chapters, and presented scientific exhibits as well as given numerous scientific presentations. an articulate and engaging speaker, she has been invited to give over lectures locally, nationally and internationally. while marilyn has been very focused on her work with the spr, she believes that it is her amazing family and their love that really fuels her life. her husband rick is an internationally known neurologist and researcher in multiple sclerosis. her adult children jamie and brian, both in manhattan, remain close, and spending quality time together as a family remains the joy of her life. whether it is relaxing together in florida cooking or fishing, or taking an exotic vacation to india, being with rick, jamie and brian makes her the happiest. marilyn's genius is partly refusing to take "no" as an answer. along the way, at every turn there were those who believed that what she wanted to do couldn't be done. her approach was to draft the nay-sayers to the team and charge ahead with their willing and enthusiastic help. daniel burnham might have been talking about marilyn and not about his plan for the city of chicago when he said: make no little plans; they have no magic to stir men's blood and probably themselves will not be realized. make big plans; aim high in hope and work, remembering that a noble, logical diagram once recorded will not die, but long after we are gone be a living thing, asserting itself with evergrowing insistence. as an amazing change agent, inspirational leader, and wonderful role model, the spr is proud to honor marilyn goske with the gold medal. she made big plans! dorothy i. bulas, md pioneer honorees were first acknowledged in as a means to honor certain physicians who made special contributions to the early development of our specialty. it is time to reevaluate the meaning of the pioneer honoree. the subspecialty of pediatric radiology has been in existence now for more than years. we are beyond "the early development"; we must recognize other pioneering paths and should consider contributions to the subspecialty beyond the bounds of a modality, a technique, an observation or a change in practice. whatever this advancement is, it must be forged with vision, innovative ideas, and the ability to enable and sustain science and application. george s. bisset, iii, m.d. why george bisset? has he been part of the pediatric radiology landscape these last ten years? been part of the dialogue that has been increasingly influential across all of radiology, a conversation steeped in a deep tradition of excellence in diagnosis and treatment, and the safety and welfare of our children? been a leader in science and application? part of the landscape? no. but he has been beyond that and has worked tirelessly within the horizon, surveying…a step before, but guiding us on towards our destiny. a conversant? part of the dialogue? maybe. but he has been defining thought and concept upon which such conversation is born and nurtured. part of the science and application? yes, as much as anyone who promotes, who facilitates and sustains discovery, then here we are. horizons, innovation, and the gift of en-abling…what else is needed to define a true pioneer? how was this done? simply stated, george bisset has devoted at least the last decade to the advancement of our specialty in truly novel ways through his leadership, especially in rsna and the abr. in the rsna, as the scientific program committee chair several years ago he was instrumental in the conception, development and implementation of the integration of scientific papers and refresher course topics. this has been a resounding success, is currently used in other categories during rsna and is a model for other meetings, including the annual meeting for the society for pediatric radiology over the past few years. pediatric radiology was first in this effort. george continued to endorse topics that were marquees for pediatric radiology over the year in his education role on the rsna board of directors. he endorsed and implemented the pediatric campus concept at the rsna. early returns are that this was an extremely successful model to consolidate experts in pediatric radiology (and those interested in this subspecialty), pertinent science, education and administration. george is now the president of rsna, perhaps the most widely respected scientific and educational organization for our profession across the globe…and i would argue, with more promise for our future success in pediatric radiology than has ever existed. and george bisset, who through two terms as the pediatric trustee for the board of trustees for the abr, again, was on the horizon of a critical, sometimes perilous, and complete transformation of our certification examination process, always mindful of his constituency and colleagues, his duty as a physician, and the public and patients. this required delicate diplomacy, forward thinking, professionalism, and enlistment of a cadre of experts from within our subspecialty to assure excellence in pediatric radiology through abr certification. he was also a leader in the development, validation and implementation of the imagerich computer based examination model (the pediatric caq) now the standard for the new abr examinations. with these successes in mind, who better to embody the concept of bridging horizons that is the theme for this entire meeting? if you were looking for more numbers and accolades, i apologize. here are some: more than contributions to medical and scientific literature, advancing care through pediatric body ct and mr imaging research, a litany of presentations and invited lectures, vice chairs, chairs, chiefs, boards of directors, committee member and committee leader, clinical excellence including as a pediatric cardiologist and interventional radiologist, a superb speaker and author.… all are on his cv but i believe serve really as signposts for his gifts, some of those mentioned above, that a cv simply cannot convey. he could have played it safe with all of these successes on his cv. but pioneers don't play it safe. they are on the horizon, too busy defining thought and enabling (our) advancement-building bridges. i believe it is time to reevaluate the meaning of the pioneer honoree and i have the greatest honor and pleasure of introducing george s. bisset, iii for the pioneer award for . linked with past awardees, he continues an exceptional legacy and i don't believe his explorations and discoveries are finished… donald p. frush, md the society bestows presidential recognition awards on members or other individuals whose energy and creativity have made a significant impact on the work of the society and its service to its members. in , david kushner was recognized by the spr with its first presidential recognition award for his vision and foresight in working with both the american college of radiology (acr) and the society for pediatric radiology (spr) in developing an important new relationship and for his service to the spr. in summarizing his considerable efforts for that award, i noted that he "contributed substantively to the increased visibility of the spr within the acr. his tenure as our treasurer placed our organization on a firm financial foundation." with the current award, the society recognizes his indefatigable continuing efforts on our behalf including: his work with the acr: . establishing a pediatric radiology caucus at the annual acr meeting, . convincing the acr of the value of managing specialty societies by making the spr its first successful new model for imaging society management, . advocating tirelessly for pediatrics and children's health within the acr by serving on the council steering committee and then as acr council vice speaker and speaker, . helping establish the first pediatric commission, assuring that pediatric issues will receive support of the college and its resources while serving on the board of chancellors of the acr for the past five years. the spr's "image gently" campaign was a beneficiary of this pediatric commission of the board of chancellors, . continuing to shepherd and contribute to the pediatric component of the acr practice guideline process. his work with the spr: since his earlier award, david has served as: foundation from to , including the launch of the formal fundraising effort, "the campaign for children," . spr president - , organizing and running a very successful meeting in savannah, . chair of the board of directors of the spr from to , including leading a strategic planning process that resulted in a new, more focused division of labor amongst board members and defined board responsibilities. david was born in fargo, north dakota, received a ba from the university of minnesota, and received his medical education at the university of pennsylvania. this was followed by two years of training in pediatrics at children's hospital, boston. he then did a two-year fellowship at the national institute of health in bethesda, performing research in embryology and teratology. he returned to massachusetts general hospital for training in diagnostic radiology. this was followed by a year of residency in pediatric radiology at children's hospital boston, followed by a one-year fellowship. he then became director of the pediatric radiology section at massachusetts general hospital, a position he held from to . from to , david was chief of the division of diagnostic imaging and radiology at children's national medical center in washington, dc attracting a strong faculty, training many fellows and promoting research. during that time, he served as a volunteer radiologist and pediatrician to inner city healthcare systems aiding the indigent and homeless, and developing telemedicine capabilities linking free clinics with radiology experts. in , our man inside the beltway moved a bit outside by accepting the medical directorship of radiology at the children's hospital of the king's daughters in norfolk, virginia, and professor of radiology and pediatrics at the eastern virginia medical school. he assures me that life there is good, being a bit more "laid back" with fishing and sailing just outside the door. he also finds time for italian cooking and practicing jazz on his several guitars. fortunately for all of us in the spr, david is close enough to our central office and the acr that he will be able to continue work on our behalf for many years to come. the society bestows presidential recognition awards on members or other individuals whose energy and creativity have made a significant impact on the work of the society and its service to its members. the spr presidential award is given in recognition of stuart's numerous significant and outstanding contributions to the spr over many years of service. the awardee is selected by the honors committee, a committee comprised of the three most recent past presidents of the society. dr. royal is a proud native of birmingham, alabama. he is a second generation physician who came naturally to his desire to care for children as the son of a pediatrician, arnold royal, who took care of children in the birmingham community until he was years old. dr. royal attended rice university in houston, texas followed by md and ms degrees from the university of alabama at birmingham. he subsequently moved to san francisco, where he completed a pediatric internship followed by a diagnostic radiology residency at the university of california, san francisco. dr. royal credits dr. charles gooding at ucsf for influencing his decision to pursue a career in pediatric radiology. during his internship stuart observed dr. gooding make a plain film diagnosis of tapvr, type on a severely ill and perplexing newborn, and he was immediately hooked into radiology. while at ucsf dr. royal was also appointed as a national institute of health research fellow in the department of radiology. following residency, stuart completed a fellowship in pediatric radiology at the children's hospital medical center in boston. from boston, stuart returned to his roots in birmingham, alabama in , where he was appointed as a pediatric radiologist at the university of alabama and subsequently the children's hospital in birmingham. in recognition of his outstanding leadership skills and accomplishments at the children's hospital, dr. royal was appointed as the radiologist-in-chief in , and subsequently the harry m. burns endowed chair of pediatric radiology. he also holds appointments as clinical professor of radiology and pediatrics at the university of alabama at birmingham and serves on the children's hospital board of trustees. at alabama dr. royal has earned the high esteem of his colleagues, referring physicians, and staff for his outstanding clinical acumen as a diagnostic radiologist and for his undaunting commitment to excellent care of children. colleagues describe stuart as one who fosters a strong work ethic, high commitment to teaching, and sincere compassion for children. in , stuart was the recipient of the children's advocate award by childcare resources for improving the quality of care and access to radiological services for underserved children in birmingham. stuart has been married to the love of his life, barbara royal, for the past years. stuart and barbara are the proud parents of two very accomplished children, jeremy a budding radiologist in training at the university of alabama, and rachael, who has an mba and works as a vice president for moody's in new york. stuart and barbara are also the proud grandparents of three grandchildren. in conversation, stuart is quick to pull out his iphone and share the latest pictures of family members while recounting their latest activities and milestones. throughout his professional career, dr. royal has worked tirelessly to advance the mission of the society for pediatric radiology. he is past president and chairman of the board of the spr and has served on numerous spr committees. he ran a highly successful spr meeting in new orleans in . those in attendance will recall the jubilant parade stuart led through the streets of new orleans to culminate the meeting. as president and then chair of the spr board, stuart played a critical and instrumental role in bringing the spr management contract under the umbrella of the acr. the synergy achieved by the spr-acr relationship has yielded results well beyond a simple management contract. pediatric radiology and spr now have a voice at the "radiology table." stuart has also been a strong advocate for supporting translational research to advance the care of children via imaging. to help achieve this goal, he has worked aggressively to secure increased funding for the society of pediatric radiology research and education foundation. following the launch of the ref's campaign for children in , stuart made it his personal mission to work with the leadership of the society, both past and present, to discuss major gifts to the foundation. through stuart's personal effort, the foundation received pledges for many significant leadership gifts, including from spr pioneers drs. hooshang taybi and ed singleton and from himself and barbara. the spr is highly fortunate to have benefited from stuart's numerous contributions and dedication to the care of children. the society is very proud to bestow the president's award on dr. stuart a. royal. the society extends honorary membership to individuals outside of pediatric radiology who have made outstanding contributions to the care of children. this evening, dr. harvey l. neiman, whose leadership of the american college of radiology is resoundingly praised, is the recipient of the honorary member award. for , as in when his contributions were similarly recognized, dr. neiman's selection by the society for pediatric radiology honors committee was made in appreciation for the strength of his efforts to further the spr's philosophy, goals, and programs for responsible diagnosis and treatment of the young patient as embodied in the acr and spr's "image gently" campaign. image gently has succeeded not only in raising awareness of the great diagnostic benefits we can offer to pediatric patients but also directs us to acknowledge the downside of overzealous diagnostic efforts where excessive radiation becomes a risk. importantly, the "image gently" campaign, an upbeat, positive program rather than a punitive one, a smile rather than a frown, makes pediatric and all radiologists aware that their best practice reflects balanced, educated, up-to-date utilization of state-of-the art technology with exercise of responsible leadership in protecting the pediatric patient. for adults, awareness of the need for patient protection is communicated in image wisely. dr. neiman's vision and successful achievements are evident on every page of his curriculum vitae. a consummate strategist in assembling teams to make forward-looking goals a reality, harvey now stands at the top of our specialty as the first physician executive director of the american college of radiology. at this time in big-business medicine, as we see the physician, leader of the patient care team, being diminished to one of many "providers," it is so important for our patients' well-being for us to recognize the obligations commanded by our training, clinical experience and commitment. dr. neiman's recognition of the need for physicians' leadership in improving the quality of patient services and his development of programs in all areas of the college's activities have been just short of miraculous-image wisely for adults, quality and safety including the performance guidelines and accreditations, education, government relations, economics, imaging metrix, acrin, and the new radiology leadership institute-to name only a few. all have contributed significantly to the care of our patients and the stature of our specialty. dr. neiman was born in detroit and attended mumford high school. from wayne state university, he received his b.s. in and his md in . harvey's postgraduate training was at the university of michigan, where he was a resident in radiology ( - ), chief resident ( , and a - fellow in angiography (cardiovascular radiology), receiving abr certification in and a caq in vascular and interventional radiology in february . dr. neiman often expresses his gratitude to and profound respect for his mentor and beloved chief at the university of michigan, dr. william martel. dr. neiman was chief of cardiovascular radiology at walter reed army hospital and a lecturer in cardiovascular radiology at the afip from - . in , he joined the northwestern radiology faculty, rising to professor in , and for ten years he headed up the section of angiography and sectional imaging, advancing its technology and honing the skills of northwestern's radiology residents. harvey also offered a highly sought-after fellowship in interventional radiology, us, and ct. in , dr. neiman left northwestern to assume the chair in medical imaging at the western pennsylvania in pittsburgh. i was the first woman to have completed his fellowship in us, ct, and interventional radiology at northwestern and accompanied him to pittsburgh. his tenure at west penn attests to his talent in making his visions a reality: the department became a highly respected, successful academic private practice notable in many areas including ultrasound, breast and women's imaging, and interventional radiology. harvey instituted an excellent radiology residency program in as well as fellowship programs in in the areas of excellence noted above. during the years since harvey received his md, he has been awarded honors from many national, international, and specialty societies, has been an invited lecturer over times on ultrasound, interventional radiologic, radiologic educational, management, turf issues, disruptive and new technology topics to name just a few. dr. neiman, who was a founder of the sru (society of radiologists in ultrasound), has to his credit peer-reviewed articles, scientific presentations and exhibits, a text co-authored with dr. james yao, angiography of vascular disease ( ) , and book chapters. he has received many honors including fellowship in the american college of radiology, american institute of ultrasound in medicine, society of radiologists in ultrasound and the society of cardiovascular and interventional radiology (now sir). as part of his strong commitment to the future leaders of radiology, for diagnostic radiology he has served as a member of the residency review committee of the accreditation council for graduate medical education. he has been a member of the american college of radiology and its committees and commissions for many years including the commissions on education, ultrasound, and economics. he also served as chair of the commissions on ultrasound and economics. from to , he was a member on the acr board of chancellors, serving as its chairman - . he was president of the radiology advocacy alliance from to . in , nine years ago, dr. neiman became the acr's executive director. he currently serves in this position, where his excellent business skills, knowledge of health policy and economic issues, and strong administrative background have furthered our specialty. his goal, to ensure that the acr's resources benefit all radiologists and patients across all economic strata, is evident in his actions at the college. harvey has a devoted, wonderful family that often included me and my youngest daughter on many pittsburgh occasions. his beautiful, elegant wife of many years, ellie neiman, is here tonight to celebrate with him the spr's recognition of his many achievements. dr. neiman has two accomplished, lovely daughters, jennifer, extremely successful in her marketing career, and hilary, an attorney. jennie's husband, dr. seth kligerman, one of many young radiologists whom harvey has mentored, is on the radiology staff at the university of maryland. how harvey has had time between, through, and among all of these achievements to have become mentor, colleague, and friend to me and to so many others who have been inspired by his ability to see into the future and to shape it in a positive way is remarkable. now that dr. neiman has taken all of radiology under his wing, not just its component parts, the future of our specialty, one of the best, can be assured but also recognized for its centrality to all of medicine. it is my honor and privilege to introduce to you harvey l. neiman md, facr as this year's society for pediatric radiology honorary member. the singleton-taybi award is given in honor of edward singleton and hooshang taybi, in recognition of their personal commitment to the educational goals of the spr. initiated in , the award is presented annually to a senior member of the spr whose professional lifetime dedication to the education of medical students, residents, fellows, and colleagues has brought honor to him/her and to the discipline of pediatric radiology. it comes as no surprise to those who know him that dr. daneman, "dr. d" as some of us call him, has been named the recipient of the singleton-taybi award in recognition of his many years of dedication to the education of residents, fellows, and colleagues. born in south africa in , he received his medical degree at the university of the witwatersrand, johannesburg, receiving the harwood-nash award for the most successful student in surgery. initially, dr. d thought he would become a pediatric surgeon; but after passing the part i examination offered by the royal australasian college of surgeons, he changed his mind and began his training in diagnostic radiology. he chose a radiology residency at the royal prince alfred hospital, in sydney, australia. this included a year in pediatric radiology at the royal alexandra hospital for children in sydney where his interest and love of pediatric radiology began. dr. d then had the foresight to pursue pediatric radiology fellowship training at the hospital for sick children in toronto, canada. after completing the fellowship, he was immediately offered a position as staff radiologist at "sick kids." he became director of body imaging in and radiologist-in-chief in serving in that capacity for years. his management style was simple but effective. he chose staff that were young, but smart and innovative. he nurtured them and provided them with all the tools they needed to become successful professionals, like him. but contributing to his own department was not enough for him. he also found the time and strength to contribute, teach, train, and help pediatric radiologists in the most remote portions of the globe in every continent, which resulted in recognition from prestigious organizations in places such as south america, israel, europe, taiwan and australia: he is an honorary member of the european society for pediatric radiology and the sociedad latinoamericana de radiologia pediatrica as well as other national societies. dr. d is an "institution" inside the great institution that is sick kids. his teaching is unique and praiseworthy in being enthusiastic, provocative, and fun at the same time. his lectures have been regarded as both instructive and practical by his students and trainees due to his special gift of making the most complicated things look as simple as possible. in sharing his diagnostic knowledge and know-how, he passes his own, innate teaching spirit on to his apprentices. he has earned several awards for this, including the outstanding teacher award granted by the university of toronto fellows at sick kids for the past consecutive years. dr. d receives numerous invitations to present at national and international meetings and symposia and has been invited as a visiting professor to more than a hundred institutions across the globe. he does not only teach us the ins and outs of pediatric radiology, but he makes sure that we learn to love it and understand the importance not only of good practice but also the imperative to pass knowledge on by teaching and publishing. dr. d is someone who inspires us to reach beyond our limits, someone we want to emulate. he shares his knowledge, his wisdom, and his advice freely. he shares with us the most incredible secrets of his own career, so we understand from his personal experience. dr. d never tells you what to do, he suggests to you, in an incredible articulate fashion, what you want to do yourself. dr. d has been and is for many of us, more than an educator, more than a mentor, he is our "coach." well before this concept was introduced into medicine by a. gawande , dr. d intuitively had the vision to "coach" his trainees, trying to get the best out of them, without pressure, but with love and passion, and especially emphasizing the importance of achieving a worklife balance in order to prevent the now so common "stress and burnout" affecting the radiology community . he warned us that many high achievers reach their goals only at the expense of their personal lives, but dr. d has been as successful personally as he is professionally. his wonderful wife of years, louise, his two daughters and his recently newborn granddaughter serve as sources of strength and pride. he is a truthful and generous friend to many, both in and out of radiology. it is not uncommon for many of us, who came through sick kids, to come back and visit and be invited to his house to share a wonderful dinner with other invitees, who may be radiologists from north america or from other parts of the globe visiting sick kids to learn from him. dr. daneman's research has widely influenced the field of pediatric radiology. examples include the work of dr. daneman and his colleagues on intussusception, which has promulgated the use of ultrasound for diagnosis, and the use of air enema for reduction. this approach has been adopted as standard practice at many institutions in north america and across the globe. to share his research with others in the field, dr. daneman has authored or co-authored more than publications, including peer reviewed articles and book chapters on a wide range of topics related to the imaging of children. dr. d is one of those rare people who are irreplaceable. he is a superb teacher, a gifted academician, a capable administrator, and a person called "friend" by so many of us. we are thrilled and proud to present our society's singleton-taybi award to dr alan daneman in recognition of his lifelong accomplishments and personal commitment to the educational goals of the spr. we cannot imagine anyone more deserving of this award than dr. d. thank you "coach"! monica epelman, md and oscar navarro, md john caffey, md - dr. caffey was regarded throughout the world as the father of pediatric radiology. his classic textbook, pediatric x-ray diagnosis, which was first published in , has become the recognized bible and authority in its field. the seventh edition of this book was completed several months before his death in . it has been among the most successful books of its kind in the medical field. dr. caffey was born in castle gate, utah on march , . it is interesting that he was born in the same year that roentgen discovered the x-ray. dr. caffey was graduated from university of michigan medical school in , following which he served an internship in internal medicine at barnes hospital in st. louis. he spent three years in eastern europe with the american red cross and the american relief administration, and returned to the united states for additional training in medicine and in pediatrics at the universities of michigan and columbia, respectively. while in the private practice of pediatrics in new york city at the old babies hospital of columbia university college of physicians and surgeons, he become interested in radiology and was charged with developing a department of pediatric radiology in . he frequently expressed appreciation and admiration for the late ross golden, chairman of radiology at columbia presbyterian hospital, who allowed him to develop a separate department of diagnostic radiology without undue interference, and who was always available to help and advise him. dr. caffey's keen intelligence and inquiring mind quickly established him as the leader in the fields of pediatric x-ray diagnosis, which recognition became worldwide almost instantaneously with the publication of his book in . dr. caffey received many awards in recognition of his achievements. outstanding among these were the mackenzie davidson medical of the british institute of radiology in , the distinguished service award of the columbia presbyterian medical center in , the outstanding achievement award of the university of michigan in , the howland award of the american pediatric society in , the jacobi award of the american medical association in , and the gold medal award of the american college of radiology in . he had been a member of the american journal of roentgenology. he was a counselor of the society for pediatric radiology and was an honorary member of the european society of pediatric radiology. dr. caffey's contributions to the pediatric radiologic literature were many. he was instrumental in directing attention to the fact that a prominent thymic shadow was a sign of good health and not of disease, an observation that literally spelled the end to the practice of thymic irradiation in infancy. infantile cortical hyperostosis was described by him and is called "caffey's disease." dr. caffey in first recognized the telltale radiographic changes that characterize the battered child, and his students helped disseminate his teachings about these findings. it was dr. caffey who first recognized and descried the characteristic bony changes in vitamin a poisoning. he recognized and described the findings associated with prenatal bowing of the skeleton. in , three years after his retirement from babies hospital, he joined the staff of the children's hospital of pittsburgh as associate radiologist and as visiting professor of radiology and pediatrics at the university of pittsburgh school of medicine. although dr. caffey came to children's hospital and the university of pittsburgh in an emeritus position, he worked daily and on weekends throughout the years he was there. in pittsburgh, he made four major new contributions to the medical literature. he described the entity, "idiopathic familial hyperphosphatasemia." he recognized and described the earliest radiological changes in perthes' disease. he called attention to the potentially serious effects of shaking children, and used this as a subject of his jacobi award lecture. he described, with the late dr. kenny, a hitherto unrecognized form of dwarfism that is now known as the caffey-kenny dwarf. the john caffey society, which includes as its members pediatric radiologists who have been intimately associated with dr. caffey, or who have been trained by his students, was established in . this society is now among the most prestigious in the field of radiology. his book and the society named in his honor will live on as important memorials to this great man. his greatness was obvious to all who worked with him. he was warm, kind, stimulating, argumentative, and above all, honest in his approach to medicine and to x-ray diagnoses. his dedication to the truth was expressed in his abiding interest in the limitations of x-ray signs in pediatric diagnosis and in his interest in normal variation in the growing skeleton. he was concerned with the written and spoken word and was a skilled semanticist. his book and his articles are masterpieces of language and construction. he stimulated and was stimulated and loved by all who had the privilege of working with him. radiology and pediatrics have lost a great man, but they shall ever have been enriched by his presence. interstitial lung disease, which is more common in infants than older children, is defined as a rare heterogeneous group of parenchymal lung conditions primarily due to underlying developmental or genetic disorders. affected infants typically present with clinical syndromes characterized by dyspnea, tachypnea, crackles, and hypoxemia. mainly due to a lack of evidence based information regarding underlying pathogenesis, natural history, imaging findings, and histopathologic features of interstitial lung disease, the understanding of interstitial lung disease in infants has been limited in the past. however, in recent years, the understanding of interstitial lung disease in infants has been substantially improved primarily due to: ) advances in imaging technology for better detection; ) improvement of thoracoscopic techniques for lung biopsy; ) established pathologic criteria for consistent diagnosis; and ) development of new classification system based on underlying etiology of the interstitial lung disease. in fact, several forms of interstitial lung disease in infants that exhibit distinct clinical, radiological, and pathological patterns are currently emerging. the overarching goal of this article is to review a new classification system, imaging findings, and pathological correlation of interstitial lung disease in infants. improved understanding of this often challenging disorder can aid in early and accurate diagnosis, which in turn, will result in improved patient care. large airway disease in pediatric patients: impact of advanced post-processing techniques catherine m. owens, bsc mbbs mrcp frcr the introduction of multidetector row computed tomography (mdct) scanners has altered the approach to imaging the pediatric thorax. in an environment where the rapid acquisition of ct data allows general hospitals to image children instead of referring them to specialist pediatric centers, it is vital that general radiologists have access to protocols appropriate for pediatric applications. this lecture will focus on the main principles of volumetric ct imaging that apply generically to all mdct scanners and in particular we describe the reconstruction techniques for imaging the pediatric thorax and the low-dose protocols used in our institution on a -slice dual source ct scanner. examples of important clinical applications with the impact and added value of post processing are also given. neoplasms, by definition, comprise an abnormal uncoordinated proliferation of cells that persists even after the inciting stimulus as ceased. the resulting mass may be benign or malignant and arise from any tissue that is normally found in the location where the mass develops. thus, tumors of the chest may arise from bone, lung, pleura, lymphatics, muscle, etc. whether benign or malignant, chest masses may be incidental findings on imaging obtained for other reasons. this presentation will focus on malignant tumors of the chest, address the imaging characteristics and staging of the most common chest malignancies and discuss characteristics that may aid in distinguishing these lesions from their corresponding benign or infectious counterparts. included in this presentation will be the most common chest wall malignancies (ewing family of tumors and rhabdomyosarcoma), mediastinal malignancies (lymphoma, germ cell tumors, and neurogenic malignancies) and pulmonary primary malignancies (pleuropulmonary blastoma and carcinoid). the changing appearance of selected tumors in patients treated with new targeted therapies will be introduced. lung disease is the most common chronic disease of childhood, but young children cannot perform the breathing maneuvers required for the most commonly used method for assessing lung function, spirometry. ct provides exquisite structure information about the lung but concerns regarding the long-term consequences of the relatively high radiation dose limit its use particularly in the pediatric population. magnetic resonance imaging (mri) has the potential to provide regional information about the lung without the use of ionizing radiation. while conventional proton mri has found widespread clinical application in most organs of the body, mri of the lung lags behind because the lung is intrinsically difficult to image with mri. the strength of the mr signal depends on the physical density of protons in the tissue being imaged and the local environment of the protons. the lung has a low physical density and thus a low proton density so little mr signal is generated by the lung. furthermore, the magnetic susceptibility effects from its many air-tissue interfaces cause what little signal is generated to rapidly decay so that the lung typically appears dark on conventional proton mr images. a variety of strategies have been developed to overcome the inherent difficulties of mri of the lung, resulting in recent substantial improvements in image quality. additionally by administering an inhaled gaseous contrast agent, such as the hyperpolarized noble gases helium- or xenon- , direct visualization of lung airspaces in an mr image is possible. a number of unique strategies for evaluating the structure and function of the human lung using hyperpolarized gas mri have been developed. although the level of structure detail possible with lung mri may never equal that of ct, mri may nonetheless has the potential to provide clinically useful information and be a sensitive, effort independent test of pediatric lung disease. for a matter of time, we will focus in this presentation only on the following: intestinal malrotation a normal visceral situs can be inferred sonographically in relation to the right-sidedness of the superior mesenteric vein, to the retromesenteric location of d and to the right iliac position of the ileocecal valve. conversely, intestinal malrotation is likely when the aforementioned features are reversed. in addition, cdu can display the whirlpool pattern in case of midgut volvulus or internal hernia, alleviating the need for preoperative opacification. the reliability of us in diagnosing intussusception is well documented since the early s. the value of us in predicting the success or failure of pneumatic reduction and/or bowel necrosis is more debatable, based upon a coexisting bowel occlusion, the presence of interloop fluid, bowel wall changes (intramural air, dilated mural vascular channels), absent blood flow at cdu. the continuous down-grading of us in comparison to ct, and the opposite conclusions of various series regarding imaging of pediatric appendicitis are based upon different prerequisites and definitions. historically and in most usa institutions, sonography reports are either negative (entire normal appendix), positive (abnormal inflamed appendix), or equivocal (non-visualization or partial visualization of appendix). the equivocal group is then logically investigated by a subsequent abdominal ct. in europe, some usa centers, and in our practice, us reporting include groups and take into account ancillary findings: . normal appendix (blind-ended, lamellated, compressible, < mm in diameter, without peristalsis; . appendix not depicted, no secondary signs; . appendix not depicted, with one of the following: hyperchoic mesenteric fat, fluid collection, local dilated small bowel loop; . appendix inflamed. group represents most cases of perforated appendicitis, groups and the negative sonogram. ct is then indicated only in obese patients and to assess the feasibility of percutaneous interventions. inflammatory bowel disease in the recent literature, mr enterography is often preferred to ct enterography. small bowel series look prehistoric and us is rarely mentioned. sonography however is very valuable both for screening children presenting with abdominal pain, diarrhea, weight loss, or gi bleeding and for following the course of the disease and searching for complication. hypervascularization has been proved to parallel the disease activity. initially mentioned by dr. rita teele, the interest of us for differentiating high-intermediate/low varieties of imperforated anus has been re-emphasized more recently. a perineal rectal cul de sac distance of mm is quoted as the significant cut-off value. us can also display rectourinary fistulae outlined by air. update on mdct and mri of hepatobiliary disease in children: what's new lisa h. lowe, md a variety of disorders may affect the pediatric liver. recent advances in histopathological knowledge and imaging techniques have led to important changes that radiologists must be aware of in order to allow for an accurate limited differential, and in some cases, specific, diagnosis. this presentation will focus on recent developments that have lead to a better understanding of the embryopathogenesis for fibropolycystic liver diseases (including choledochal cysts and caroli disease), histopathological findings that have led to new classification systems for of pediatric vascular anomalies, technological advances and contrast agents in magnetic resonance imaging that are useful to characterize and limit the differential diagnosis of hepatic masses. diagnostic errors in pediatric abdominal imaging: diagnostic pearls and pitfalls george a. taylor, md this presentation reviews the types of diagnostic errors in abdominal imaging occurring over a -year period in an academic pediatric radiology practice. radiologists engage in two interrelated processes when interpreting imaging studies: perception and analysis. failures in perception (failure to identify an important finding) are a common source of diagnostic error in pediatric imaging, while failures in the analytic portion of the process (over-or faulty interpretation of a finding) are not as common. under-interpretation of findings can be related to a number of perceptual and visual phenomena including visual isolation where attention is selectively focused on a main area of the image while less or no attention is given to secondary areas, and satisfaction of search which occurs when additional lesions remain undetected after detection of an initial lesion. many analytic errors are the result of commonly used heuristics or shortcuts in reasoning. these include the availability heuristic in which likelihoods are based on memory of a similar case, the framing effect in which a different diagnosis is reached based on how the information is presented, and the anchoring heuristic in which the initial impression is difficult to change, despite conflicting new information. another recognized pitfall is blind obedience, in which a diagnostician stops thinking when confronted by authority. this authority can be human or technical (reliance on a laboratory value). finally, diagnostic errors can result from an attitude of overconfidence. examples of these heuristics and strategies to minimize cognitive errors will be discussed. marta hernanz-schulman, md, faap, facr this session will consider abdominal masses that present in the neonatal period, spanning developmental, inflammatory and neoplastic conditions. time constraints do not allow an exhaustive list or description, but the more important or frequent lesions are discussed. the presentation is subdivided by systems. the renal section discusses various conditions presenting with hydronephrosis, such as ureteropelvic junction obstruction and duplication anomalies, followed by autosomal recessive polycystic kidney disease and multicystic dysplastic kidney, cystic entities commonly presenting in the perinatal period. neoplastic renal entities include lesions with benign behavior, such as ossifying renal tumor of infancy, with the discussion extending to entities with very poor prognosis such as clear cell sarcoma and rhabdoid tumor, while discussing the congenital mesoblastic nephroma, its histologic subtypes and the differences in their presentation, imaging findings and clinical behavior. suprarenal lesions include the adrenal hemorrhage, congenital neuroblastoma and subdiaphragmatic sequestration. hepatic lesions include developmental anomalies that present as mass lesions, such as choledochal cysts, vascular lesions such as congenital and infantile hemangiomas, and neoplastic lesions such as the mesenchymal hamartoma and hepatoblastoma. differences in clinical presentation, imaging characteristics and behavior of the lesions are discussed. the section on pancreatic lesions discusses pancreatic cysts and pancreaticoblastoma. gi tract and mesenteric lesions include duplication cysts, lymphangioma, and meconium pseudocyst, and their relationship to bowel obstruction and persistent perforation. ovarian cysts can present as large masses in neonatal girls, and should be high in the differential diagnosis of large masses encountered in female infants; the imaging characteristics of simple and complicated cysts are described, as well as their course and potential complications. pediatric procedures: from imaging to intervention the spectrum of vascular anomalies in pediatric patients: multimodality imaging evaluation and current treatment patricia e. burrows, md vascular anomalies are categorized into two main groups, vascular tumors and vascular malformations. genetic and molecular regulation of vascular genesis of angiogenesis, and mutations responsible for some of the vascular malformations, have been delineated. in order to implement future targeted treatment of vascular lesions, accurate diagnosis is important. imaging modalities that are effective in distinguishing the various types of vascular anomalies and demonstrating the extent include ultrasonography with doppler interrogation, mri and various forms of mr vascular flow imaging, conventional angiography and venography. techniques used to image lymphatic channel anomalies, conventional lymphangiography, lymphoscintigraphy and infrared fluorescent lymphangiography. in this presentation, common forms of vascular anomalies will be described and rare or recently recognized anomalies will be mentioned. current treatment of the different forms of vascular anomalies will also be discussed, including pharmacotherapy using beta blockers, angiogenesis inhibitors and mtor inhibitors. endovascular techniques used in treating vascular malformations, including embolization and sclerotherapy will be presented. pediatric vascular disease is extremely varied, with a wide range of conditions requiring diagnostic or therapeutic intervention. technological improvements in non-invasive imaging modalities such as mri and ct have reduced the need for diagnostic angiography; however, with advances in interventional techniques, arteriography in the pediatric patient is now often performed for therapeutic reasons. pediatric arteriography presents unique issues and challenges. tremendous variability in patient size and physical maturity limits the ability to standardize technical aspects of performing arteriography. in addition, radiation protection, sedation/anesthetic support, monitoring of fluid balance, and maintaining patient warmth must be considered. a regimented protocol for assessment of the pediatric patient must be followed, with review of the indications for the study requested, and review of patient-specific issues such as coagulation profile, concurrent medical disease, patient weight, and anesthetic concerns. appropriate patient monitoring is imperative to ensure patient safety. vascular access can be quite challenging. ultrasound and micropuncture access techniques have tremendously improved successful access while reducing associated complications. the smallest catheter that can accomplish procedure objectives should be used. for most diagnostic cases, french systems can be used for children> kilograms, while french catheters are preferred in those < kg. intraprocedural heparinization ( - iu/kg) is also more often used, especially in children weighing less than - kg. rates and volumes of contrast injected for pediatric arteriography are not standardized, as in adult patients. in general, contrast dose should be limited to - ml/kg, and - ml/kg in premature infants and neonates. all these new technique are less invasive, improve patients' outcomes and reduce morbidity. they are also cost-effective as patients are discharged home earlier and recover faster from the intervention. the future holds promising new technologies such as high-intensity focused ultrasound (non-invasive method of thermal ablation) and nanoparticles for drug delivery. pediatric interventional radiology will continue to be an essential part of these minimally invasive therapies. musculoskeletal imaging: from planning to performance kirsten ecklund, md the purpose of this talk is to review advanced mr imaging techniques currently being used in the evaluation of pediatric musculoskeletal tumors. the goals of these techniques include improved image resolution and quality, lesion tissue characterization, and increased acquisition speed. diffusionweighted (dw) and perfusion imaging will be emphasized; however, whole body, metallic artifact mitigation, and volumetric sequences will also be discussed. dw mri is based upon the brownian motion of water within extra and intra-cellular spaces which depends upon tissue cellularity. dwi can aid in the differentiation of benign from malignant lesions, which generally have restricted diffusion. there is even greater potential for dwi in the assessment of tumor response to therapy. the apparent diffusion coefficient (adc) maps are critical to accurate interpretation of diffusion sequences. adc maps distinguish between restricted diffusion and t effect, both of which appear bright on dwi. both qualitative and quantitative tissue assessments can be made with dwi. challenges for dwi in the pediatric musculoskeleton include susceptibility artifacts from bone, motion vulnerability, and geometric distortion at larger fields of view. our current protocols and parameters for dwi will be presented. contrast-enhanced (dce) mr using one of a variety of vendor specific sequences. qualitative and quantitative assessments of inflow and distribution of contrast have been shown to help differentiate between benign and malignant lesions and to evaluate drug efficacy during therapy. this technique is especially promising in those patients undergoing antivascular and antiangiogenic therapy. tal laor, md congenital abnormalities of the musculoskeletal system can result in alterations of limb size, configuration, and/or segmentation. these disorders often affect both the osteocartilaginous skeleton as well as the surrounding soft tissues and can be localized or diffuse. in this session, we will focus on the imaging features of several congenital abnormalities that result in a small or short limb, in altered configuration of a limb, or in abnormal segmentation. deformities of both upper and lower limbs will be examined. like congenital abnormalities, developmental disorders of the pediatric musculoskeletal system can be limited to a single area or can affect numerous sites within the body. for example, neonatal brachial plexopathy is a localized disorder that produces characteristic musculoskeletal alterations about the shoulder girdle and elbow of affected children. the alterations of morphology and function of the shoulder develop over time with growth of the child and change in response to a variety of therapies. we will review the features of developmental anomalies of the pediatric musculoskeletal system and evaluate the role that imaging plays in the initial evaluation and in the subsequent assessment of these children during treatment. multimodality imaging of skeletal trauma in children: using all of the tools peter j. strouse, md skeletal trauma is a common indication for imaging throughout the pediatric age range. newborns may suffer birth trauma. infants and toddlers may be subject to abusive injury. children of all ages may suffer accidental injury. older children and adolescents are increasing hurt in sporting activity and vehicular accidents. fracture patterns vary with maturation of the child. interference with normal growth is a potential complication. imaging of skeletal trauma begins with radiography. proper anatomic and age specific radiographic technique assures optimal diagnostic yield. radiography suffices in most cases to diagnose fracture or confirm normalcy. "clinical correlation" aids in diagnosis. ultrasound, ct, mri and nuclear medicine may play a role in specific instances where plain radiographs are non-diagnostic or to better delineate certain fractures. arthrography and conventional tomography have occasionally been used in the past and tomosynthesis may prove useful. follow-up radiographs may be useful for diagnosis or confirmation of some fractures. this presentation will focus on the imaging of acute skeletal injury. technique and approach for plain radiography will be emphasized. specific indications and roles for ancillary imaging techniques will be defined and illustrated with representative cases. although classically thought of as a disease of adulthood, stroke is much more common in the pediatric population than was once appreciated. this may be due to many factors, not the least of which is increased awareness due to the presence of subspecialty stroke teams now fairly commonplace in many children's hospitals, and the fairly recent advent of more advanced imaging technique such as diffusion-weighted imaging (dwi) and its routine use in imaging the central nervous system (cns) in the child and adolescent. causes of stroke in children can be protean, and range from idiopathic on one end of the spectrum, to traumatic on the other, with many causes in between, many of which may not be intuitive to the clinician without further research. moyamoya disease and its many causes, such as sickle cell disease (scd), trisomy and neurofibromatosis type i (nf i) can all lead to stroke in children, as can congenital clotting deficiencies such as factor v leiden deficiency and congenital cardiac lesions with their resultant shunting of blood between the left and right cardiac circulations. although usually arterial in nature, strokes may arise from the venous system in clinical scenario of venous thrombosis with resultant venous infarctions. factors contributing to venous thrombosis in children and adolescents can be due to dehydration (especially in the very young), severe iron deficiency anemia, inflammatory bowel disease and exogenous hormone ingestion such as is seen with oral contraceptives (ocp) in young women. advanced imaging techniques for neuroimaging in pediatric patients: where are we now? blaise v. jones, md the past decade has seen a large number of advanced imaging techniques introduced to the clinical armamentarium of the pediatric radiologist. from the development of multidetector ct scanners that can obtain whole head diagnostic studies in less than s to the routine use of t mr imaging, technical advances have dramatically changed our ability to diagnose and manage neurological disorders in children. however, all of these advances are not of equal clinical utility, and it is imperative that the pediatric radiologist be well versed in their judicious and appropriate application. this presentation will discuss the effective use of volume ct scanning, cta, swi, asl, fmr, pmr, and other advanced imaging techniques in the diagnosis of neurological disorders presenting in childhood. at the conclusion of the presentation the attendee will have a better understanding of how to ideally apply these technologies in practice. a spectrum of abnormality in pediatric neck: practical imaging choices and interpretation caroline d. robson, mbchb learning objectives: . become familiar with an optimized imaging approach for head and neck infections . recognize the complications of head and neck infections . recognize the utility and interpretation of imaging for neck masses this talk will cover the imaging approach and interpretation of findings in head and neck infection and neck masses. infection includes acute complicated sinusitis, coalescent mastoiditis, neck infection and local and intracranial complications. optimized imaging protocols and image interpretation for neck masses will also be discussed and illustrated. acute complicated sinusitis is diagnosed when acute sinusitis is accompanied by orbital symptoms (e.g. proptosis) and/or mental status changes, seizures or other neurological findings. coalescent mastoiditis is diagnosed when otomastoiditis is accompanied by tenderness and/or swelling over the mastoid process. ct and mr provide complementary information. ct is obtained with contrast. mr sequences include fatsuppressed t , t , diffusion, and fat-suppressed contrastenhanced t weighted images with mr venography. intracranial complications include epidural abscess, subdural empyema, meningitis, cerebritis, brain abscess, venous thrombosis and venous infarction. the limitations and usefulness of ct in the diagnosis of neck abscess will be illustrated. the imaging approach to masses depends on patient age, and the size and location of the mass. us, ct, mr, and nuclear medicine studies provide complementary information. as for infection, optimized imaging approaches and key imaging features for various masses will be discussed. embryology and diagnostic approach in spinal dysraphism l. santiago medina, md, mph and esperanza pacheco-jacome, md congenital anomalies of the spine are malformations that can be confusing due to the complexity of their embryology, and to the sometimes unclear classifications and terminology. the purpose of this review is to give a clear and basic understanding of the different stages of the embryological development of the spinal cord, starting with the bilaminar disc in the first week of gestation. during the second week, the formation of a trilaminar disc (gastrulation), the notochord, and the formation of the neural tube or neurulation. also, a review of the development of the distal cord: conus medullaris, filum terminale, ventriculus terminalis, by a different mechanism, canalization and retrogressive differentiation. beside the embryological review, a case correlation will be presented using mr imaging to demonstrate these malformations. open spina bifida entities include meningocele and myelomeningicele. closed or occult spinal dysraphism (osd) is characterized by a spinal anomaly covered with skin and hence with no exposed neural tissue. osd spectrum includes dorsal dermal sinus, thickened filum terminale, diastematomyelia, caudal regression syndrome, intradural lipoma, lipomyelocele, lipomyelomeningocele, anterior spinal meningocele and other forms of myelodysplasia. several studies have shown that mri and ultrasound have better overall diagnostic performances (i.e., sensitivity and specificity) than plain radiographs for detection of occult spinal dysraphism. for h n , most patients had mild illness but a small percentage required mechanical ventilation and icu admission. the high risk groups include children < years old and those with chronic medical conditions in particular neurodevelopmental impairment. pediatric mortality was . % of all deaths associated with the pandemic reported in the u.s. in both conditions, the most prominent radiographic and ct features were airspace disease including ground glass opacities (ggo) and consolidation, commonly with multi-focal and bilateral involvement. pleural effusion, adenopathy and cavities were absent. in some patients with viral infection, respiratory symptoms may be mild but are complicated by neurological manifestations. a brief review of mri features in h n related encephalopathy including acute necrotizing encephalopathy (ane) will be given. bernard f. laya, do tuberculosis (tb) is a worldwide major public health problem with one-third of the world's population being infected. it is a leading cause of death and disability from infection worldwide. children are amongst the most vulnerable group because of their immature immune status. a child usually gets tb infection after being exposed to a sputum-positive adult. depending on many factors, the infection can lead to latency or tb disease. it can affect virtually any organ in the body and can be devastating if left untreated. tb in children remains a diagnostic challenge. in addition to history of tb exposure, signs and symptoms, laboratory and microbiologic tests, medical imaging remains a valuable tool in its diagnosis. although findings are nonspecific, the radiograph is the most commonly ordered initial imaging tool for screening and diagnosis of pulmonary and musculoskeletal involvement. computed tomography and magnetic resonance imaging offer more detailed assessment especially in cranial and abdominal involvement. medical imaging is also utilized to follow up patients during or after anti-tb treatment. knowledge of the common imaging patterns, pitfalls and dilemma are very important in establishing the diagnosis of tb in children. the pathophysiology of pediatric tb will be discussed as it correlates with imaging findings. the wide spectrum of imaging manifestations in various modalities will be presented. imaging updates along with pitfalls and dilemma in the interpretation will also be discussed. tb can affect almost every organ system but the author will present cases that are more commonly encountered. and concurrent ct/ pet-ct (k . ) panels. there were more indeterminate nodule predictions by pet-ct (n of ; %) and concurrent ct/pet-ct (n ; %) than by ct alone (n ; %). the overall accuracy of ct alone was %, pet-ct alone % and concurrent review %. worst case sensitivity and specificity were % and % for ct alone, % and % for pet-ct alone, and % and % for concurrent ct/pet-ct. conclusions: pet-ct assessment of pulmonary nodules in children is feasible but limited by non-diagnostic quality ct images and atelectasis caused by sedation. subjective assessment of nodules by pet-ct does not appear to improve the ability to distinguish benign from malignant histology in children with solid malignancies. semi-quantitative nodule assessment using the standardized uptake value may improve the performance of pet-ct in this setting and will be investigated in the future. purpose or case report: nec is the most common lifethreatening medical/surgical emergency of the gastrointestinal (gi) system in neonates, with an incidence up to % in infants weighing < g. with advances in treatment of nec, increased survival rates result in rise in post-nec gi complications such as feeding intolerance. development of post-nec bowel strictures results from healing of involved bowel and can result in bowel obstruction. it has been routine to study the bowel of infants after medical treatment for nec by contrast enema and small bowel follow-through prior to initiating feeding. however, in order to "image gently" we are attempting to decrease the radiation exposure to these patients. we postulate that in patients with no abnormal bowel dilation prior to initiation of feeds, the incidence of colonic stricture would be so low that routine enemas would be unnecessary and could be eliminated from the workup. recorded as present or absent in anatomic abdominal regions defined as: and -from the dome of the diaphragm to top of l to the right and left of midline, respectively; and -from top of l to the iliac crest to the right and left of midline, respectively; -from the iliac crest to the top of the sacrosciatic notch; -below the top of the sacrosciatic notch. we assessed the frequency of findings in each region and how often findings in regions and were associated with findings in regions - . % confidence intervals were calculated. results: the fewest pertinent findings were present in region in . % ( / ) ( % ci: . - . %) of radiographs. findings included: abnormal bowel % (n ), bowel gas paucity . % (n ), pneumatosis . % (n ), inguinal hernia . % (n ) and osseous abnormalities . % (n ). pertinent findings were present in region in . % ( / ) ( % ci: . - . %). findings included: abnormal bowel . % (n ), bowel gas paucity gas . % (n ), pneumatosis . % (n ), free air . % (n ), and abnormal bowel with pneumatosis . % (n ). among patients with an abnormality in region , ( . %) also had an abnormality within at least one of regions through . among the patients with an abnormality in region or , ( . %) also had an abnormality within at least one of regions through . catheter/tube tips were located in region in . % (n ) and region in . % (n ) of radiographs, respectively. pneumatosis was present most frequently in regions ( . %), ( . %), and ( . %). free air was present most frequently in regions ( . %), regions and ( . % each). conclusions: our preliminary data suggest that pertinent findings on neonatal portable abdominal radiographs are rarely isolated to the pelvis, implying that gonadal shielding of regions and should not compromise diagnostic accuracy. purpose or case report: the purpose of this study was to determine the sensitivity, specificity, and positive and negative predictive value of ultrasound in diagnosing appendicitis when the appendix is visualized, using three diagnostic categories: positive, negative, and equivocal. the -category diagnostic accuracies for appendiceal diameter and radiologist impression were compared. methods & materials: a retrospective study was performed evaluating all right lower quadrant ultrasound reports dictated over a -month period. included studies were interpreted as positive, negative, or equivocal for appendicitis. report impressions that did not specify one of these categories and studies where the appendix was not seen were excluded. the pathologic diagnosis of appendicitis was considered the gold standard for a positive diagnosis. because virtually all pediatric surgical cases in the region are referred to our hospital, it was assumed that the patient did not have appendicitis if surgery was not performed. logistic modeling using appendiceal diameter as the independent variable established cutoff diameters of ≤ mm negative, > mm positive, and <x≤ mm equivocal. sensitivity, specificity, and positive and negative predictive values were calculated for both methods. results: of the patients imaged during the study period, ( %) met the inclusion criteria; ( %) reports did not categorize the impression and in ( %) studies the appendix was not seen. surgery was performed on ( %) subjects, of which ( %) had a pathologic diagnosis of acute appendicitis. using the radiologist impression, there were true positives (tp), false positives (fp), false negatives (fn), and true negatives (tn), for a sensitivity of % ( % ci - %), specificity of % (ci - %), ppv of % (ci - %), and npv of % (ci - %). there were ( %) cases reported as equivocal; of these, ( %) had a pathologic diagnosis of appendicitis. using appendiceal diameter, there were tp, fp, fn, and tn, for a sensitivity of % (ci - %), specificity of % (ci - %), ppv of % (ci - %), and npv of % (ci - %). there were ( %) cases categorized as equivocal; of these, ( %) had a pathologic diagnosis of appendicitis. conclusions: the use of diagnostic categories enables high ppv and npv with a relatively low number of equivocal cases. using appendiceal diameter alone results in higher ppv than that of the radiologist impression, but also yields a higher number of equivocal cases. purpose or case report: intussusception is an obstructive condition that a segment of the bowel invaginates into adjacent bowel and is an urgency that needs to be reduced as soon as possible to prevent bowel ischemia or necrosis. when it occurs in the infants and young child, it usually develops idiopathically and reduced by the technique such as air enema under the fluoroscopic guidance or saline enema under the ultrasound guidance. the success rate of the non-surgical reduction has reported over %. the pneumatic reduction is to introduce air into the patients' rectum via a ballooned foley catheter by hand pump. a mercury manometer connecting with the foley catheter calibrates the pressure of insufflation, and the recommended maximum pressure is mmhg. the hydrostatic reduction is to drip saline from a bag at the height of ft that may be different according to the institute's guidelines. until recently, in both techniques, the precise measurement of the intraluminal pressure was not possible. with the purpose of intraluminal pressure monitoring, we introduced a specific digital pressure gauge that can measure both pneumatic and hydrostatic pressure in various units and can give the collected data to our workstation. with the data, we purpose to make the curve of intraluminal pressure during the procedure and to compare the pattern and difference in both techniques of reduction, which permits suggesting the better technique for reducing the intussusception. from february , we performed the intraluminal pressure monitoring in children; cases of pneumatic reduction and cases hydrostatic reduction. the results indicated that the curves were similar in both techniques. however, the hydrostatic reduction tended to need longer time and higher pressure difference than the pneumatic reduction. we assumed that a higher flow rate and more fluctuating introduction of pressure in the pneumatic reduction made the difference between both methods. purpose or case report: anecdotal evidence suggests that some pediatric brain tumors, particularly pilocytic astrocytomas, demonstrate greater enhancement on delayed post-contrast t weighted mr imaging compared to early post-contrast imaging. our goal was to compare immediate post-contrast imaging with delayed post-contrast imaging in pediatric brain tumors. methods & materials: the research protocol was granted exempt status by the institutional review board (comirb# - ). between november and march , all patients for whom an mri of the brain was ordered to follow-up known brain tumor or to evaluate new brain tumor underwent a modified protocol that included both immediate and min delay post-gadolinium images. the modified protocol sequence order was dwi, t mprage, contrast injection, immediate post-contrast t mprage, t , flair, min delayed post-contrast t mprage. this sequence allowed both immediate and delayed post-contrast imaging to be performed without scanner downtime. a total of unique patients met inclusion criteria of an enhancing primary brain tumor with the delayed imaging performed within a window of - min. these studies were evaluated independently by pediatric neuroradiologists (ns and lf) and a radiology resident (jm) to compare the degree of lesion conspicuity and edge discrimination, and to determine an overall preference. in cases of discrepancy between reviewers, final grading was determined by group consensus. results: delayed post-contrast images were preferred in / tumors ( %), immediate post-contrast images were not preferred in any case, and / cases were graded as equivalent ( %). notably, delayed imaging was preferred for / pilocytic astrocytomas ( %). in / cases ( %), the improvement in conspicuity and edge discrimination on delayed imaging was felt to have a potential impact on clinical management, e.g. by extending resectable or treatable tumor margin. conclusions: delayed post-contrast imaging can be performed easily by reordering existing mri protocols, and no scanner downtime is required for this protocol change. our results indicate that pediatric brain tumors (particularly pilocytic astrocytomas) often enhance more conspicuously on delayed imaging, that no diagnostic confidence is lost on delayed imaging, and that clinical management may be more accurately guided. -directions) were retrospectively reviewed, after irb approval. both sporadic (n ) and nf- associated optic gliomas (n ) were included. tumors confined to intraconal optic nerve were excluded due to technical limitation of epi dwi within the bony orbit. apparent diffusion coefficient (adc) of the solid portions of the tumor was measured using the region of interest method both at baseline and on follow-up mri. results: for the patients, required treatment (surgery and/or chemotherapy) for symptomatic tumor progression ( sporadic opg and cases of nf- ). median follow-up interval was . years (range: months to . years, sd . years). there was no difference in adc values between sporadic and nf- associated opg. opg that required therapy had significantly higher baseline mean adc ( x - mm /s, sd . ), whereas opg with low mean adc ( x - mm /s, sd . ) remained clinically asymptomatic or stable (stratified mann-whitney test, p . ). an increase in mean adc of x - mm /s doubled the odds the patient will require treatment (or . , % ci: . - . , p< . ). enhancement patterns did not predict tumor behavior or nf- status (fisher's exact test, p . ). conclusions: significantly higher mean adc was seen in opg that required therapy for tumor progression. mri may be a useful prognostic tool in further defining a subset clinically significant sporadic or nf- associated opg. purpose or case report: fast brain mri imaging has recently been introduced for assessing brain ventricles in patients with ventriculo-peritoneal shunts (vps). however, there is minimal literature on how this method could be beneficial for other indications. compared to ct, this method reduces lifetime cumulative radiation dose and has multiplanar capabilities. it is much faster than full brain mri, reducing exam costs and potentially reducing the need for sedation. however, fast brain mri has lower resolution than a standard brain mri and cannot detect hemorrhage. the goal of our study is to retrospectively assess additional clinical applications for fast brain mri. methods & materials: patients who had undergone fast brain mri were found in xenobase, a database which references deidentified electronic medical records at our institution. xenobase was then used to identify subgroups by diagnosis. one of the most common diagnoses was arachnoid cyst. after irb approval, patients with fast brain mri and arachnoid cyst were identified so that their fast brain mri could be compared to any full brain mri and to clinical outcomes. fast brain mri findings were excluded if there was not a full brain mri within year. agreement with full brain mri, and documented effect on clinical management were coded for statistical review. results: between and , there were arachnoid cyst patients with fast brain mri exams. in members of this group, fast brain mri was used alone or in comparison with a full brain mri in the decision to follow or discharge the patient. exams failed to report a pituitary cyst and mass effect which were reported on prior exams. patients had no complications in the year following their fast brain mri. the most common complication was headache ( cases). conclusions: fast brain mri reduces radiation exposure, time, cost, and the need for sedation in vps patients. these benefits may cautiously be extended to other patient groups also requiring routine imaging, such as those with arachnoid cysts. disclosure: the authors disclose that they will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: susceptibility-weighted imaging (swi) is a new technique that exploits susceptibility differences in different tissues, to provide a different type of tissue contrast. swi is a gradient echo sequence utilizing both phase and magnitude data to achieve exquisite sensitivity to tissue magnetic susceptibility effects. it is extremely sensitive to even minute amounts of paramagnetic substances and therefore for detection of blood products (hemosiderin, ferritin), deoxygenated blood, calcium, iron, and small vein depiction. it is particularly suited for vascular imaging, especially in cerebral ischemia. swi has been shown to be more sensitive in detecting cerebral microbleeds than is conventional t *-weighted gradient-recalled echo imaging (gre) partly because of its inherent sensitivity, increased spatial resolution and the thinner slices acquired. recent studies have shown that swi detected more microbleeds in more patients, irrespective of their location and that swi may be more sensitive in detecting traumatic lesions than ct or mri. methods & materials: between january and october we have performed swi on pediatric patients (from day to yrs old) affected with different pathologies. mri was performed using either a -or . -t magnet (achieva ; philips healthcare, best, the netherlands). among these patients also received a classic gre sequence. results: our experience confirms a greater sensibility of swi than gre in detecting microbleedings and larger bleedings. swi is much more helpful in patients younger than year since it can distinguish hemorrhagic and non hemorrhagic punctuate white matter lesions detected as hyperintensities on t -w images. it is more accurate in distinguishing petechial hemorrhages and ischemic foci in patients with germinal matrix hemorrhages. swi can provide important diagnostic information not only in vascular pathologies but also in tumors showing the altered tumor microvascularity, the degree of intratumoral necrosis and the presence of subtle defects of the bbb within the surrounding parenchymal tissue. the technique also allows the detection of possible bleedings in infectious lesions. conclusions: swi is a valuable technique in the evaluation of a wide variety of intracranial pathologies in the pediatric population and its use is advisable on a routine basis. purpose or case report: a common problem with pediatric mr imaging is motion. diffusion-weighted imaging (dwi) is highly sensitive to the effects of both rigid-body motion and brain pulsation. the resulting motion artifacts can manifest in several ways, and include blurring (motion between volumes), slice 'drop-outs' (motion during the diffusion encoding), and aliasing (motion during the parallel imaging/ghost calibration scan). in order to improve image quality in pediatric dwi and avoid the potential for repeat scans, we have implemented our grappa-accelerated diffusion tensor (dt)-epi sequence on over , pediatric patients at our institution, and have developed tailored reconstruction software to correct for large motion and reduce the need for general anesthesia (ga). methods & materials: grappa-accelerated epi dti data was collected on patients at . t and , patients at t between the ages of month and years old. with these data, we investigate the use of a method to select the best grappa and ghost calibration weights; d rigid-body realignment with importance weighting; a new volume rejection criterion for large motion; together with other procedures to lower image noise and reduce phase artifacts. all image reconstruction was performed using compiled threaded matlab code on the vendor's (ge) multiprocessor reconstruction hardware. results: using the maximum motion detected from the d realignment procedure on the , dti exams, % of patients did not move (either through co-operation or ga, denoted here by < mm of motion); % of patients moved between - mm; % between - mm; % between - mm; and % between - mm. except for patients in total, the motion correction steps employed here were extremely robust in correcting for motion. in addition, the motion correction steps employed here do not blur or negatively affect the data on non-moving patients. conclusions: our proposed integrated reconstruction scheme suggests that correcting for different types of motion at different stages of the dti acquisition is critical to provide scans of diagnostic quality. apart from the very rare instance ( . %) where the patient moved continuously an extensively throughout the scan, our motion correction procedures employed here are extremely robust. using this scheme, we show that highly diagnostic motion-corrected dti data can routinely be read on our patient database within min. . participating sites followed mutually agreed upon vendor-specific dti protocols used for neonates in clinical practice: ss-epi; b ;~ mm voxel; - directions; te~ msec; acquisition; parallel imaging; multi-channel ( - ) head coil. tensor data was analyzed at one site using internally developed software in idl. b and eddy current distortion were assessed by analyzing grid line distortion on acr slice ; deviations from linearity were measured in the phase encoding direction. acr slice was used to assess snr of the center and periphery of the b image, and fractional anisotropy (fa) of the phantom, which should approach . deviations from specified sequence parameters were recorded. results: both siemens scanners had some image degradation due to vibration susequently corrected by the vendor. nonlinear gridline distortion was highest on the ge followed by philips but was corrected with the use of nd order shimming. eddy current distortion was consistently smaller than acquisition voxel size after image registration. te varied from - msec; acquisition bandwidth range was - hz/pixel. the mm slice thickness was problematic on clinical ge scanners resulting in non-isotropic voxels. across vendors, snr was consistently higher in the image periphery than center by a factor of . - . ). the greatest difference was showed in patients with fhc. no association was found between the value of ldl-c and imt. the . % received drug treatment at the time of evaluation. in dbt- a no association was found between the imt and the levels of hba c and lipids. and in the ob group found no association between imt and bmi z score. fhc %, % of dbt- and % of ob showed atherosclerotic plaques and intima irregularities. conclusions: the imt ultrasonography was able to demonstrate that patients with chronic diseases, with increased cardiovascular risk in adulthood, showed early alterations of carotid intima media in children. this allows clinical applications of preventive and therapeutic guidance. a benchmark for precision of flow assessment was determined from differences between aortic and pulmonary arterial flows, which should agree. the precision of flow when utilizing a slow flow structure (vein) and a fast flow structure (artery) was then determined, serving as an indicator of the precision of slow flow measurements. this was done in pairs for the upper body (svc flow vs difference between ascending and descending aortic flow), lower body (ivc flow vs descending aortic flow) & total body (svc flow+ivc flow vs ascending aortic flow). paired t-tests were used to identify significant differences in the respective arterial and venous flow rates. with an f-test, the relative precision of the arterial flow (determined from aortic and pulmonary arterial flow) was compared against the precision of agreement between upper, lower, and total body flows, each of which has a slow flow venous component, thus assessing precision of venous flow measurement. results: arterial & venous flow measurements were strongly correlated for the upper body (r . ), lower body (r . ) and total body flow (r . ); net aortic and net pulmonary trunk flow rates were also tightly correlated (r . ). moreover, there was no significant difference in the precision of arterial & venous flow measurements (t-test, p . ). lower venc ( cm/s or lower) improves the accuracy and precision associated with low velocity venous flow, a finding that tended to but it did not reach statistical significance. conclusions: with -d pc mri, the accuracy and precision of venous flow quantification are comparable to arterial flow quantification, though venc settings may improve venous flow assessment. disclosure: dr. tariq has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. the spatial resolution requirements for imaging tiny target vessels in neonates have so far precluded its use of cemra in this patient population. the purpose of our study, therefore, was to explore the potential of high resolution cemra at . t in neonates with suspected congenital vascular anomalies methods & materials: neonates (mean age . days, range - days; mean weight . kg, range . kg- . kg) underwent cemra at . t. cemra was performed under controlled apnea on a -channel . t system using either a -channel head-neck coil ( pts) or a -channel adult knee coil ( pts). gd contrast delivery was calculated based on a total dose of . mmol /kg. parallel imaging factors of - were used, generating . x . x . mm voxels in an acquisition time of - s. images were scored for quality and the presence of artifacts independently by two observers. the cemra series were evaluated to identify pulmonary arterial and venous anatomy. extra-pulmonary vascular anatomy was divided into sections for image quality assessment on mpr. results: the mra data sets had high mean image quality and low mean artifact grading scores. no significant difference was evident between the two observers for scoring image quality and artifact (p . ), and there was good interobserver agreement (k . , % ci: . - . ). the pulmonary arteries were confidently visualized to at least the nd order branches in all patients, at least the rd order branches in ( %). out of evaluated segments, ( %) were graded as the vessel "very well visualized with excellent definition of vessel" pa abnormalities were diagnosed in patients and pv anomalies in patients. correlation was made with open surgical findings in cases, confirming the cemra diagnoses with no discrepancy between the operative and imaging conclusions. the results of our study suggest that high resolution cemra at . t is extremely promising in neonatal cchd and, in combination with echocardiography, may often provide comprehensive information for treatment planning. with appropriate use of physiological motion compensation, parallel imaging and coil configuration, voxel volumes less than . mm are routinely achievable. purpose or case report: it is not well understood whether transfusion-dependent children (mainly those who have hereditary anemias subject to excessive iron levels from regular blood transfusions) with no or mild cardiac iron overload and without signs of heart failure exhibit early changes in cardiac dysfunction. this study aims to evaluate intramyocardial deformation and subsequent cardiac dysfunction in such patients using the cardiovascular magnetic resonance technique of myocardial tagging as well as assess iron overload by another cardiovascular magnetic resonance technique of t star (t *). we hypothesize that transfusion dependent children undergoing chelation therapy will be at high-risk for cardiomyopathy despite normal or slightly elevated iron levels and no signs of heart failure due to progressive myocardial deformation as assessed by myocardial tagging; that is, we expect abnormal mechanical parameters to exist despite t * values which correspond to normal or slightly elevated myocardial iron levels. methods & materials: patients (mean age yrs) requiring regular blood transfusions for various reasons (e.g. thalassemia, sickle cell disease, other anemias) were investigated using harmonic phase magnetic resonance tagging and t * imaging. various myocardial mechanical parameters were quantified and correlated to cardiac iron levels as measured by t *. results: children with no overt signs of heart failure (as measured by ejection fraction and volume indices) exhibited normal t * iron levels in combination with global circumferential abnormal myocardial strain and children exhibited regional strain. conclusions: this preliminary data suggests that transfusiondependent children without overt signs of heart failure exhibit early signs of cardiac dysfunction (an effect of strain as assessed by myocardial tagging) in direct relation to normal or slightly elevated myocardial iron levels (as measured by t *). a larger sample size of children could support the idea of abnormal myocardial mechanics being a diagnostic imaging marker for the development of myocardial iron overload and eventual iron-mediated cardiomyopathy. the choice of coil and field of view varied according to the age and size of the patient. imaging was performed on a . t magnet (philips mri system). after the cine gradient echo time of flight sequences were acquired, the dynamic keyhole mr angiographic sequence was applied in the coronal orientation. this sequence commenced - s after initiation of the first bolus administration of - ml of undiluted gadopentetate dimeglumine ( . mmol/ml, magnevist) at a rate of - ml/sec followed by - ml of saline at a rate of ml/sec. image acquisition was repeated multiple times without delay for s during shallow breathing. contrast material was administered through a peripheral or central venous line, and sometimes via simultaneous bilateral extremity injections. rarely manual hand injection was performed. the parameters were as follows: centra k-space filling, acquired voxel size - . x - . x - , reconstructed voxel size . - x . - x - . , number of dynamics - , keyhole percentage - %, sense (parallel imaging) factor x - x , dynamic times - . s, and injection rate - cc/second. image analysis was based on original contrast-enhanced data sets, mip and volume rendering. the quality of the mrv was graded by a subjective scale from - ( excellent, no limitations; nondiagnostic). comparison with unenhanced mr venographic sequences and doppler ultrasound were available in all cases. results: d mrv provided diagnostic information on patency of venous segments in all cases, including the presence of venous occlusion or stenosis, the segments involved, and collateral venous pathways. conclusions: d mr venography using the method outlined is a reliable means of estimating central venous thrombosis in children, using short dynamic scan times with high spatial and temporal resolution, creating an effect similar to conventional venography. paper #: pa- analysis of optimal phase interval for prospective ekg-triggered cardiac ct in children prakash masand, md, texas children's hospital, savivek bogale, lorna browne, rajesh krishnamurthy purpose or case report: evaluate high temporal resolution cine mri of the heart in children to determine relationship of heart rate to the optimal motion free interval during the cardiac cycle, and to derive a chart depicting optimal reconstruction intervals across a range of heart rates which could be applied for prospective ekg triggered ct imaging of the heart. methods & materials: pediatric patients who had high temporal resolution cine steady state free precession sequence ( frames acquired across a single cardiac cycle) performed as part of a mri/mra of the heart from - were included. a single reader analyzed the high temporal resolution cine data to determine the location and duration of the motion-free phase interval in systole and diastole for heart rates ranging from - bpm. the following information was collected: age, heart rate, duration of systole and diastole, ekg phase and phase percentage of motion-free interval, and duration of motion-free interval. heart rates were grouped in ranges of ( - , - , - etc.), with at least patients in each group. wilcoxon sum rank test was performed to compare the static durations of systolic and diastolic phases for each heart rate group. two-tailed p-values< . were considered to indicate statistical significance. a chart matching heart rate range to the optimal phase of image acquisition and reconstruction was created. results: optimal reconstruction intervals for motion-free imaging of the heart in systole and diastole, and single best phase for a given heart rate are as follows: (please see table ) mean duration of the motionless phase in systole and diastole for a given heart rate is as follows: (please see table ) conclusions: this is the first time that variability in location of the motion-free interval within the cardiac cycle with respect to heart rate in children has been studied in rigorous fashion. this chart will have immediate application in the so-called 'target scan', which uses prospective ekg triggered acquisition of data in combination with half-scan reconstruction to minimize radiation dose with respect to retrospective ekg gated imaging. results: a total of patients were found to have aberrant pda by ccta. nine patients had a pda emanating from the brachiocephalic artery to the pulmonary arteries and one patient had pda emanating from the carotid or the subclavian artery according to the operative report. all ten patients had echocardiography in addition to ccta. nine of the ten patients underwent surgery. one patient was lost to follow up. comparison between ccta and echocardiography to operative report showed the following: out of the echocardiograms agreed completely with ccta and operative report. out of the echocardiograms did not report aberrant pdas which were seen on ccta and confirmed during surgery. in one patient, the echocardiogram reported a double aortic arch which was found to be an aberrant pda from the left brachiocephalic artery; a finding that changed the surgical management and pre-surgical planning. the results were statistically significant with a p value of < . . conclusions: diagnostic accuracy of ductus arteriosus anatomy is important in pre-surgical planning and management of patients with ductal dependent pulmonary circulation. cardiac ct angiography is more accurate as compared to echocardiography in diagnosis of aberrant patent ductus arteriosus. ) in patients younger than year of age. the prospective ecg-gated protocol scanned % of the cardiac cycle with msec padding in patients with heart rates greater than bpm. two experienced radiologists evaluated the image quality and course of the coronary arteries. image quality was assessed based on the degree of homogeneity of vascular enhancement, presence of stair-step artifacts, image signal and noise as well as the overall subjective image quality based on a point scale. the course of the left and right coronary arteries was also evaluated based on a point scale, focusing on how well the evaluator was able to visually follow the coronary artery from its origin to its termination. radiation dose was recorded and compared. results: the mean score of the homogeneity of vascular enhancement, stair step artifacts, image noise and signal, overall image quality, and score given to visualization of the course of the coronary arteries showed no significant difference (p> . ) in the retrospective and prospective ecg gated groups. the mean estimated effective dose was significantly lower for the prospective ecg gated group compared to the retrospective group, ( . msv vs . msv) respectively (p< . ). conclusions: prospective ecg-gated cardiac mdct provides comparable assessment of coronary anatomy, image quality with significantly less radiation dose when compared to the retrospective ecg-gated mdct. prospective ecg gated cardiac mdct is a powerful adjunct to the treatment and surgical planning of pediatric patients with congenital heart disease less than yr of age with lower radiation dose. methods & materials: pediatric neuroradiology lectures were recorded and made available to radiology residents at a university program through on-line streaming video viewed through an internet link. topics included brain tumors, phakomatosis, and congenital brain malformations. one lecture per week was recommended prior to case conferences that reviewed the same topic. pre-and post-tests and a feedback survey were administered. nonparametric paired sign test and analysis of covariance were used to evaluate changes in test scores overall and according to feedback responses. spearman's partial rank correlation coefficient was used to evaluate the relationship between the number of viewed videos and test scores. results: twenty-nine residents completed the pre-test and the post-test. the means (sd) scores were . % ( . %) and . % ( . %) respectively. there was a significant improvement in test scores (p . ). residents that agreed/strongly agreed that the streaming technology lectures were convenient had greater improvement than those who did not ( . vs. - . %, p . ). similarly, those who agreed/strongly agreed that being able to replay a lecture was helpful had greater improvement than those who did not ( . vs. - . %, p . ). finally, those who agreed/ strongly agreed that the streaming technology lecture format was a better teaching tool had greater improvement than those who did not ( . vs. - . %, p . ). significant positive correlation between number of videos watched postconference and improvement was present (spearman's rho . , p . ). conclusions: on-line streaming video with live case conferences enhances radiology resident learning of pediatric neuroradiology. step (mpps) software provided an accurate measurement of scan time. visual charting made gaps in utilization apparent. technologists and nursing notes correlated to gaps identified barriers and opportunities for improvement. nursing and anesthesiology reduced redundancies. standardized protocols lead to more consistent scan times. appointment access for sedated mri was measured by the third available appointment. results: manually entered data points were time consuming, inconsistent and unreliable. the process improvement was most effective when fewer more reliable data points were used to evaluate the effect of change. the program resulted in a reduction of appointment access for sedated mri from days to days with no change in the hours of operation. magnet utilization was increased from % to %. induction outside the scan room provided the most efficient process tested. we ranked first in utilization in a children's healthcare cooperation of america (chca) survey as measured by exams per scanner. patient preference for a.m. scheduling was shown by survey and corroborated by scheduling data. consistent scan times were achieved by protocol standardization augmented by indication driven decision support. conclusions: a consise definition of mr utilization established a metric that was used in the process cycle of analyze-optimize-measure. anesthesia induction outside the magnet was the most efficient practice but required collaboration between nursing, mr technologists and anesthesiology. protocol standardization were valuable aspects of process improvement essential to optimizing parallel sedation. these adjustments reduced appointment access from days to days, increased utilization from % to % and produced a number one rank in utilization by chca survey. we exploited the synonym option in epic order entry to translate indications into procedures mapped to specific protocols for mri neuroimaging. the order screen allows the provider to enter an indication. that indication is linked through a synonym option to a specific exam and protocol. the recommendation is based upon institutionally created clinical care guidelines, and can be accepted with a single click to complete the order. the requesting provider retains the option to override the recommendation. an step in process development utilized an order queue established within the epic inbasket. a pediatric radiologist monitored the queue and communicated with referring providers to obtain additional history and educate toward best imaging practice. these interactions facilitated development of a robust index of clinical indications used to create the synonym pool. results: mri neuroimaging indications were expanded into a robust data set linked to specific mri exams aligned with specific protocols. the synonym option within epic created the opportunity for the requesting provider to simply enter an indication which drives the procedure and recommended protocol. provider satisfaction has been high and concurrence with recommendations nearly universal. conclusions: indication driven order entry was achieved through the synonym option in order entry within the epic emr. imaging recommendations are based upon institutional clinical care guidelines developed through consensus. a robust compilation of pediatric mri neuroimaging indications has been created and linked to specific exams and protocols. compliance with the indication driven recommendation has been high. modifications of the current system are currently under development for all cross sectional modalities and organ systems. paper #: pa- cost-effectiveness of routine neonatal renal ultrasound in non-syndromic complex congenital heart disease elfrides traipe, tch, extraipe@texaschildrens.org; jill v. hunter, marthe munden purpose or case report: to assess the prevalence of abnormal renal ultrasound in non-syndromic complex congenital heart disease (cchd) and assess the cost-effectiveness of routine renal ultrasound in this population. we restrospectively reviewed the initial neonatal renal ultrasound and any subsequent renal imaging in patients with non-syndromic cchd. etiologies included hypoplastic left heart syndrome (hlhs), transposition of the great vessels (tga), coarctation of the aorta (coa), truncus arteriosos (ta), double outlet right ventricle (dorv) with or without patent ductus arteriosus. patients were recruited consecutively as part of a prospective trial for pre-and post-operative magnetic resonance imaging of the brain. results: the neonatal pre-operative renal ultrasounds were analyzed in female and male patients. only of the patients showed any congenital renal anomaly. this patient was born with hypospadias, that would have routinely stimulated neonatal follow up. conclusions: knowledge of embryology would not lead us to anticipate a high co-incidence of congenital renal and cardiac pathology. based on this statement and our findings, our recommendation to improve cost-effectiveness is not to perform routine neonatal renal ultrasound in non-syndromic cchd, but only if otherwise clinically indicated. purpose or case report: to conduct a meta-analysis of the diagnostic performance of contrast enhanced voiding urosonography (cevus) in comparison to voiding cystourethrography (vcug) or direct radionuclide cystography (drnc). a literature search was conducted for studies published on cevus in the pediatric age group. studies were included if the ultrasound contrast agents (usca) levovist® (bayer-schering pharma, germany) or sonovue® (bracco, italy) were used and enough data was available to extract x tables. if the cevus was compared to both vcug and drnc in the same patients the results for each were analyzed separately. a bivariate hierarchical model that takes into account the heterogeneity in cevus sensitivity and specificity in different studies was used for the assessment of the summary diagnostic metrics. the summary roc curve was derived and presented graphically from the parameters of the model. additionally, the % confidence intervals (ci) and the positive (lr+) and negative (lr-) likelihood ratios were calculated. results: out of publications only comparative studies fulfilled the inclusion criteria. these encompassed cevus studies in comparison with vcug and with drnc with regards to detection of vesicoureteric reflux. in studies the usca levovist® and in sonovue® were used. a total of children with pelvi-ureteral-units (puus) were included in the meta-analysis. cevus compared to vcug and drnc had a sensitivity of % (ci: - ) and a specificity of % (ci: - ) with lr+and lr-of . and . , respectively. the performance of cevus was better when compared to drnc than to vcug (sensitivity %, specificity % versus % and %, respectively. the meta-analysis of the diagnostic performance of cevus regarding the urethra included patients ( boys). excellent imaging of urethral anatomy was reported in over % of the patients. however, currently there is only one comparative study with patients available. in this study % sensitivity and % specificity were reported. conclusions: sufficient evidence is available clearly demonstrating the high diagnostic performance of cevus compared to vcug or drnc regarding the detection or exclusion of vur in children. these findings combined with the absence of radiation should be convincing reasons for promoting the widespread use of cevus in children. disclosure: dr. darge has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: prenatal ultrasound (us) has increased identification of infants with asymptomatic renal pelvic dilatation. society for fetal urology (sfu) grading is used in the sonographic evaluation of pediatric hydronephrosis. based on us findings, a nuclear medicine diuretic renogram may assess renal function, which could result in operative intervention. standardized protocols for diuresis renography, the "welltempered renogram," already exist; however, no current study has assessed effect of intravenous hydration (iv) status with us in the evaluation of childhood hydronephrosis. our study assesses the effect of hydration on sfu grading. in this prospective irb approved study, pediatric patients diagnosed with pelvicaliectasis requiring a diuretic renogram were recruited to undergo pre and post hydration renal us. a urinary catheter was placed followed by renal us pre and post iv hydration ( ml/kg normal saline bolus). imaging was performed by the same sonographer on the same us machine. a well-tempered renogram was then performed. all images were reviewed by two blinded radiologists, one pediatric radiologist who assigned sfu grades to each kidney. results: data were collected from studies, with ages ranging from weeks- years, with an average age of months. there were unique patients. of these, underwent a single renogram, underwent two renograms, and underwent renograms. one patient had a solitary kidney due to mcdk. thus, there were usable paired sonograms ( kidneys) for analysis. sfu grades were compared in the pre-and post-hydration us for each kidney. two-sided statistical tests were done to assess whether sfu grades changed significantly after hydration (sign test). of ( %) kidneys remained the same grade post hydration. when there was a difference, most demonstrated an increase ( of kidneys and p< . ). no change in sfu grade pre-and post-hydration differed by more than . only kidney went from grade to grade . sfu above grade is considered clinically significant. no kidney that was grade - pre-hydration became grade - post-hydration. when sfu is dichotomized grade - vs. - , there was no significant change in grade from pre to post hydration (p ). conclusions: hydration does not appear to have a clinically significant effect on sfu grade. therefore, performance of a "well-tempered" us is unnecessary. disclosure: dr. lee has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. study type was significantly associated with both total and weighted score (both p < . ). rus was better and mag was worse than vcug, rnc, and dmsa, which did not differ from each other. other factors associated with worse total scores included patient age - years (p< . ) and non-white race (p . ). gender, prior testing history, wait time, and parent education were not associated with total scores. in the multivariate model, rus remained the best, mag the worst, and dmsa, vcug, and rnc in the middle (p< . ). compared directly, dmsa and vcug total score did not differ (p . ). conclusions: this study documents significant differences among gui studies with respect to the patient and family experience, but there was no overall difference between dmsa and vcug. these findings may be useful to aid decision-making when considering gui for pediatric patients. we retrospectively reviewed the imaging findings of consecutive patients with histologic diagnosis of cd ( males, females; mean age . years; age range - years) who underwent mre between / / and / / . the mre was performed in a siemens avanto . tesla scanner. standard departmental volume of polyethylene glycol and fluid were administered for bowel distention. the imaging protocol included dwi with eight b values ranging between sec/mm and sec/ mm and gadolinium enhanced dynamic d vibe (volume interpolated breath hold exam) in the coronal plane. the studies were qualitatively evaluated in a blinded fashion by two board certified radiologists. disease activity was defined as bowel wall thickening and enhancement in the gadolinium enhanced images. dwi abnormality was defined as bowel thickening, increase signal on dwi images and decrease signal on adc maps of the ileum. intra voxel incoherent motion (ivim) dwi parameters were used as quantitative biomarkers for the analysis of slow diffusion (d) and fast diffusion fraction (f). results: gadolinium enhanced vibe images identified abnormal thickening and enhancement of the ileum in / ( %) patients. dwi identified abnormal signal in / ( %) patients. the sensitivity and specificity of the qualitative dwi for identifying ileitis, as shown by gadolinium enhanced imaging, were % and %, respectively. quantitative analysis showed statistically significant difference in ivim maximal values for f (fast diffusion fraction) between abnormal (mean . , std . ) and normal (mean . , std . ) ileum segments (p . ). there was statistically significant difference in ivim maximal values for d (slow diffusion) between abnormal (mean . μm /ms, std . μm /ms) and normal (mean . μm /ms, std . μm /ms) ileum segments (p . ). abnormal loops of bowel had decreased slow and fast diffusion parameters. conclusions: diffusion weighted imaging has excellent sensitivity and specificity for the detection of active ileitis in pediatric cd. furthermore, quantitative ivim model parameters provide effective biomarkers for this condition. ivim dwi has the potential to assess bowel inflammation without intravenous contrast enhancement and further increase our understanding of cd. methods & materials: forty pediatric patients (median age . years, range . - . ) with suspected (n ) or confirmed ibd (n ) were included and underwent gastroileocolonoscopy with biopsies followed by mre (median interval days, range - ). the mre results were compared with macroscopic and microscopic assessment of the ileum. the clinical importance of the mre results was registered. results: crohn disease (cd) was diagnosed in cases, ulcerative colitis (uc) in , and ibd unclassified (ibdu) in three. macroscopic ileitis was detected in / ( %) of cd cases and in / ( %) of uc (backwash ileitis). microscopic inflammation was found in another four cd cases and one ibdu patient. in total, discrepancy between macroscopic and microscopic inflammation was found in cd, uc and one ibdu patients. the sensitivity of mri was % (against macroscopy and/or microscopy) to % (against macroscopy alone), while the specificity was % and %, respectivley. mre findings was decisive for diagnosis in / ( %) and led to treatment adjustments in / ( %) in the following six months. conclusions: mre is a reliable method for imaging of intestinal inflammation in pediatric ibd, and can be supportive or essential for clinical treatment decisions. results: of children with ec, had ct imaging of the abdomen and pelvis. these children ranged in age from months to years (mean . years +/− . ) with a male predominance (n , %). the most common presenting symptoms were abdominal pain (n ), bloody diarrhea (n ), and rectal bleeding (n ). ec was characterized as a dense and predominant eosinophilic inflammatory infiltrate in the lamina propria and/or epithelium without granulomas. ct scans were abnormal in ( %). no colonic luminal contrast was present in patients, and in one of these, the colon appeared normal. abnormal ct findings included cecal wall thickening (n , %), mucosal enhancement without colonic wall thickening, (n , %), mesenteric lymph node enlargement (n , %), terminal ileal thickening (n , %), jejunal and ileal thickening (n , %), and pneumatosis (n , %). of the patients with cecal involvement, primarily involved the cecum with less severe or no ileal or downstream colonic involvement. pneumatosis extended along the length of the colon with rectal predominance. conclusions: the predominant ct finding in our ec series was wall thickening, most severe in the cecum with variable extent downstream with mild or no involvement of the terminal ileum. although there is overlap, these findings are different from the most common patterns encountered with ulcerative colitis or crohn disease and should raise the possibility of ec in children presenting with abdominal pain and bloody diarrhea. purpose or case report: timely identification of childhood arterial ischemic stroke (ais) is critical to development of acute treatment strategies. we present our experience prior to and following development of a pediatric stroke alert system (sas). through multi-disciplinary collaboration in a tertiary care setting, a pediatric sas was established in . we describe the system, imaging protocol evolution, and impact upon the time between admission and mri initiation (time-to-mri) in patients with childhood ais. of patients in our stroke database (comirb # - ), % met inclusion criteria for stroke alert initiation (acute focal neurological deficit within h). eleven pre- and nine post- patients met criteria. we compared the time-to-mri between these two groups, utilizing a two-tailed t-test. results: the pediatric sas has two phases: i-neurological evaluation and ii-imaging and treatment consideration. phase i stroke alert is initiated when a child presents with an acute focal neurologic deficit. if neurology confirms stroke symptoms and ct head is negative for an alternative etiology, a stroke alert is called prompting an emergent brain mri. if mri confirms an acute stroke, hyperacute therapies are considered. initial mri protocol included dwi, t , flair, d tof cow mra, d tof neck mra and fat saturated t neck imaging. after internal quality review, t mprage brain and contrast enhanced d neck mra were added. the sequence order was also altered so diagnostic sequences were scanned first (dwi and cow mra). there was a trend towards decreased time-to-mri in the post- group (mean min, sd +/− ) as compared to the pre- group (mean min, sd +/− ; p . ). conclusions: institution of a pediatric sas improved urgent neurologic evaluation and demonstrated a trend towards shorter time-to-mri. ongoing quality review has enhanced imaging quality and decreased time-to-mri. continued refinement of pediatric sas's will be critical to the success of recently funded phase i clinical trials in the evaluation of hyperacute therapies. results: there were female and male infants. the mean post-gestational age at presentation was days (range - days), while the corrected age was less than days for all patients. patients presented with seizures and signs of infection; presented with lethargy and later proved to have protein c deficiency. mri was performed - days from presentation in these patients. another patient with known protein c deficiency underwent mri at d for followup of screening us abnormalities. there were a total of deep cerebral white matter lesions: frontal, parietal, temporal lobe. lesions were fluid signal cavities with restricted diffusion. larger lesions had dependent debris. all lesions had associated hemorrhage and most lesions had evidence of adjacent small vessel venous thrombosis. lesions imaged after gad showed peripheral enhancement. three lesions were seen to increase in size on follow-up imaging. three patients, with meningitis confirmed via microbiology and with presumed meningitis by csf counts, underwent surgical aspiration of a total of lesions. all specimens were sent for pathology and culture and were negative for microorganisms. conclusions: recognizing the mr appearance of necrosis and liquefaction after deep white matter cerebral venous infarction in neonates can distinguish this entity from cerebral abscess and potentially avoid an unnecessary neurosurgical aspiration procedure. all four children were initially treated with aspirin but experienced recurrent events on therapy. all four were subsequently anticoagulated. two children have remained on warfarin for - years without recurrent events, while the other two had recurrent events despite adequate anticoagulation. these two children underwent uncomplicated coil embolization of the affected vertebral artery segment, and they have remained symptom-free for five and months since then. conclusions: dava was diagnosed by ca in / patients. all four children with dava in our series suffered recurrent strokes despite aspirin therapy. two of the four experienced further strokes on anticoagulation, necessitating endovascular therapy. these findings suggest that dava in children may require ca to diagnose, and that it may be refractory to standard adult therapies. ongoing multicenter efforts in childhood ais should further evaluate the diagnostic approach and recurrence risk of childhood dava. ) and cerebral gray matter abnormalities were present in ( %). posterior fossa lesions were seen on us in . % , but mastoid views were included in only % of the centrally read us. conclusions: in the largest extreme preterm cohort to date with near-term mri and serial us, % had mod-severe wma on brain mri, similar to previous reports. cerebellar abnormalities were detected more frequently by mri than by us. neurodevelopmental outcomes at - months and school age will assess the relative and combined values of mri and us as outcome predictors. , an analysis technique based on task-free resting state fmri recording, can be useful in assessing disruption of connectivity in certain disease states, including epilepsy. in healthy control subjects, functional connectivity reveals strong bilateral interhemispheric connectivity in such system as sensory-motor, visual, auditory as well as dorsal attention and default mode networks. in patients with epilepsy associated with unilateral diffuse hemispheric disease such data is limited. differences in the pattern of activation would suggest alteration in connectivity in these entities. this finding would impact the typical interpretation of this data that is becoming routinely collected for epilepsy pre-surgical evaluation. methods & materials: siemens (erlangen, germany) system, -tesla (trio) scanner was used for imaging (epibold sequence, te ms, flip angle °). resting state fmri scan were performed in both awake and anesthetized patient. awake patients were instructed to relax and rest while keeping their eyes open. analysis was performed using functional connectomes project scripts based on afni and fsl software packages. resting state data were analyzed for connectivity with the following seeds: somatomotor, visual, auditory, and default mode (posterior cingulated cortex (pcc)). results: we applied this technique to evaluate patients with hemispheric seizure disorders, including rasmussen's, neonatal infarct and migration disorders. all the subjects demonstrated some deviation from typical interhemispheric connectivity with a spectrum of findings. the figure below shows connectivity patterns in a patient with cortical dysplasia. while some interhemispheric connectivity remained in somatomotor (sm) and auditory (a ) systems, it was disrupted in visual (v ) and default mode (pcc) networks. variable patterns were found across the cases that corresponded to lesion side, supportive of disruption in interhemispheric connectivity as measured by fmri. conclusions: resting state functional connectivity patterns are well documented in healthy subjects. these results suggest that interhemispheric connectivity disruption is a typical feature of unilateral diffuse hemispheric disease though variable in presentation, either being limited to select systems or demonstrating broad disconnect between the two hemispheres. these results should be carefully considered when evaluating data for pre-surgical epilepsy evaluation. purpose or case report: premature birth is associated with white matter injury leading to a wide ventricular system. however,normative standards for ventricular size are lacking for this particular group.aims: we aimed to, in a controlled, population based norwegian cohort of ex-prematures without major handicaps, and for men and women separately,to ) create standards for radiological indices of ventricular dilatation, )investigate associations of these measurements with subjectively assessed ventricular size, ) examine differences in ventricular size between ex-prematures and healthy controls methods & materials: the initial birth cohort included neonates, birth weight below g (low birth weight)born within hordaland county, norway, between april st and august th . of eligible survivors (without major handicaps)underwent mr examination during the period january to may . of these were expremature (born before gestational age weeks) and were included in this sub-study. based on t weighted images, the ventricular size was subjectively judged as being normal, mildly, moderately or severely dilated by an experienced paediatric neuroradiologist, while objective measurements were performed in a blinded fashion, by a second observer (sma) using an imaging software program (nordic ice®). results: the normative standards for the ventricular system in ex-premature young adults showed wide variations, in particular for the occipital horns. the agreement between subjective and objective assessment of ventricular size was good. ex-prematures had smaller heads than those born term (control group). there was no difference in ventricular size between the two groups, even after adjusting for head size. ex-premature males had larger ventricles than females; however, the difference disappeared after adjusting for head size. conclusions: young adults born prematurely with a birth weight below g do not have larger lateral ventricles than healthy controls born term, even after correcting for a smaller head size. paper #: pa- best practice for reproducibility when measuring t *: implications for liver and cardiac iron assessment mark ferguson, md, radiology, seattle children's hospital, markferg@uw.edu; randolph otto, seth d. friedman purpose or case report: patients with red blood cell transfusion-dependent conditions receive high amounts of iron that can lead to abnormal iron accumulation in tissues resulting in organ damage. while the liver is the dominant excess iron storage organ, iron related cardiotoxicity is a leading cause of morbidity and mortality in patients with transfusion-dependent thalassemia. therefore, accurate determination and tracking of tissue iron levels in both the liver and the myocardium is important for patient prognostication as well as monitoring treatment changes. while multi-echo gradient echo mri (t *) is widely used and validated method employed for iron assessment, less attention has been given to derived metrics. specifically, the literature almost exclusively reports and uses the mean value for t * from a pixel-wise (pw) map. infrequently used is the median. the median is a potentially superior metric than the mean because it is insensitive to outliers. outliers will always occur in data because of either noise or imperfect vessel exclusion. to compare mean versus median on reproducibility of t * measurement, subjects who had paired heart/liver measurements were examined. the entire liver (excluding vessels) and the interventricular septum myocardium were traced on representative images from each series. mean and median t * values were generated from the pixel maps. r * ( / t *) and coefficient of variation (cv) were computed on a patient-by-patient basis. these measures were then summarized for the group. results: markedly higher r * values were observed in both heart and liver using median summary measures (liver: t − . , p . , heart: t − . , p . ). these findings were accompanied by lower cv's (better reproducibility) for the median approach (liver: t . , p . ; heart: t . , p . ). conclusions: the consistent difference in derived t * values between the methods (median>mean) should be considered when comparing derived r * values to established normal ranges. cv data support that using the median as the final summary metric will always outperform mean metrics for measuring change in r *. this finding has immediate implications for the scientific literature and for guiding therapeutic management over time. results: twelve children (age mo- yo; m:f : ) with gsds ( abca mutations, sp-c mutations, undefined mutation) and children (age wk- yo; m:f : ) with other dlds (including pulmonary interstitial glycogenosis, neuroendocrine cell hyperplasia of infancy, lymphocytic interstitial pneumonia, lipoid pneumonia, diffuse alveolar damage, granulomatous infection, capillaritis and other pulmonary hemorrhage syndromes) were identified. ct findings with highest sensitivity for gsds were ground glass attenuation ( %), parenchymal cysts ( %), and interstitial thickening ( %). parenchymal cysts, honeycombing, and pectus excavatum were more specific for gsds compared to other dlds (p< . ). the combination of either parenchymal cysts and honeycombing or ground glass attenuation and pectus excavatum provided the highest specificity ( %) but low sensitivity ( %). the combination of parenchymal cysts and ground glass attenuation provided good specificity ( %) and modest sensitivity ( %). no combination of findings provided both high sensitivity and specificity. conclusions: ground glass attenuation is the most sensitive finding for gsds, while parenchymal cysts, honeycombing, and pectus excavatum are more specific findings for gsds than other chronic dlds of childhood. however, no single finding or combination of findings on chest ct is both highly sensitive and specific for gsds, and chest ct cannot substitute for genetic testing or lung biopsy for the differentiation of gsds from other dlds. pes were observed in scans of patients without a history of congenital heart disease (chd), and pes in scans of patients with a history of chd. z-axis scan lengths for the chest ct exams ranged from . - . cm. a z-axis scan length of cm centered . cm below the carina captured all pes in all patients, and a length of cm centered . - cm below the carina in patients with chd. a z-axis scan length of cm centered cm below the carina was sufficient to capture at least one pe in all patients, and a length of cm centered - cm below the carina in patients with chd. the radiation effective dose of the chest ctpa exams ranged from - msv. limiting the z-axis scan length on ctpa exams to cm or cm would have resulted in a % or % decrease in z-axis coverage, respectively, and estimated radiation effective dose reduction of - % due to less radiation exposure to the intrathoracic structures, thyroid gland and upper abdominal viscera. conclusions: limiting the z-axis scan length coverage for ctpa exams based on a model of the typical anatomic distribution of pes relative to the reference level of the carina permits a substantial reduction of radiation dose in children without reducing the sensitivity for detection of pulmonary emboli. purpose or case report: to determine whether the addition of multiplanar reformation mdct images affects reader performance parameters and provides added diagnostic value compared to the use of axial ct mdct images alone for diagnosing pe in children. this was an institutional review board-approved retrospective study of consecutive pediatric patients who underwent ctpa for clinically suspected pe. two faculty pediatric radiologists and two radiology residents independently reviewed each study initially using only axial mdct images and later using mpr mdct images in any x-, y-, or z-axis for detecting pe. diagnostic accuracy, confidence level, and interpretation time of mpr mdct images were compared to axial mdct images using mcnemar's test and paired t-tests. the kappa coefficient was calculated to assess interobserver agreement. diagnostic accuracy was compared between faculty pediatric radiologists and radiology residents by logistic regression whereas confidence level, interpretation time, and added diagnostic value were evaluated with analysis of variance (anova). results: the final study cohort consisted of ctpa studies from children ( m/ f; mean age . years). nine ( %) of ctpa studies were found to have pe. diagnostic accuracy in correctly detecting pe ranged from . to % (mean . %), with no significant differences between the use of axial and mpr mdct images. logistic regression indicated no significant difference in diagnostic accuracy of detecting pe between faculty pediatric radiologists and radiology residents for axial mdct images (p . ) or mpr mdct images (p . ). confidence level and interobserver agreement were significantly higher and average interpretation time was longer in evaluating pe with mpr mdct images compared to axial mdct images for all reviewers (p<. ). compared to faculty pediatric radiologists, significantly greater increases in confidence level, interobserver agreement, interpretation time, and added diagnostic value using mpr mdct images compared to axial mdct images to diagnose pe were found for radiology residents (p< . ). conclusions: use of mpr mdct images in diagnosing pe on ctpa in children significantly increases confidence, interobserver agreement, and interpretation time among faculty pediatric radiologists and radiology residents. because mpr mdct images provide significantly greater improvements in reading parameters for residents than for faculty members, their routine use should be encouraged for trainees. paper #: pa- chest ct in children, anesthesia and atelectasis beverley newman, md, radiology, stanford university, bev.newman@stanford.edu; elliot krane, terry e. robinson purpose or case report: in spite of advances in ct equipment and speed, sedation/ anesthesia is required in many young children for optimal quality ct for detailed parenchymal evaluation; resultant atelectasis is a common and important quality issue. our purpose was to evaluate the safety and effectiveness of a standardized lung recruitment technique. methods & materials: with irb approval and parental informed consent, controlled ventilation, low dose, chest ct's (cooperative effort between anesthesia, pulmonology and radiology) were performed in children ( had - cts) ( f, m; ages . - . yrs, mean . yrs). indications included cystic fibrosis ; ciliary dyskinesia ; chronic or interstitial lung disease ; evaluate pulmonary metastases . ct parameters were - kvp, - mas, iv contrast . various prior methods employed by the pediatric anesthesiologists to maintain lung inflation had unpredictable results (a brief survey showed / nonintubated anesthetized cases had problematic atelectasis). a standardized intubation technique was therefore adopted: .use of a tight fitting face mask during induction and iv placement, inspiratory pressures of - and peep of . . introduction as early as possible using an appropriately sized cuffed endotracheal tube. . alveolar recruitment maneuvers- - s breaths to cm h o/ ( - in st cases). . three breaths at / , inspiratory breathold followed by - cm on th breath for scout and inspiratory scan, and complete ventilator disconnection for expiratory scan. recruitment breaths repeated before each scan. two experienced readers reviewed and scored the images on a point scale for overall quality and atelectasis. results: all studies were completed safely with no procedural complications. one child had propofol-related postoperative emergence delirium. all ct scans were diagnostically good to excellent with small subsegmental atelectasis in ( / were the initial cases with lower recruitment pressures) and segmental atelectasis in . cases had prior cts, without this technique, that were suboptimal due to moderate procedural atelectasis, in spite of tracheal intubation in the majority of cases. conclusions: an intubation lung recruitment technique can be performed safely and consistently by different individuals using a standardized protocol. procedural atelectasis that affects quality is reliably absent and repeat sequences are not needed. obtaining a high-quality dynamic airway imaging study is critical for accurate interpretation and subsequent medical decision-making. the ideal mri sleep study is one that allows successful completion while maintaining spontaneous breathing without artificial airway, which can be an anesthesia challenge. dexmedetomidine has been shown to have sedative properties paralleling natural sleep with minimal respiratory depression. we hypothesized that dexmedetomidine compared to propofol would have less effect on upper airway tone and airway collapsibility and provide favorable conditions with less airway interventions required during dynamic mri airway imaging in children with osa. in this prospective study, we examined the requirement for airway intervention for propofol ( - mcg/kg/m) and dexmedetomidine( - mcg/kg/h) in children and adolescents with osa. severity of osa was analyzed by overnight polysomnography. for children with history of mild osa there was no intervention unless oxygen saturation decreases below %; while for children with history of moderate/severe osa, an artificial airway was placed when oxygen saturation decreased below %. results: demographics and osa severity by polysomnography were comparable. requirement for artificial airway by severity of osa as documented by polysomnography will be shown. mri sleep studies required airway intervention in / ( %) children in the dexmedetomidine group versus / ( %) children in the propofol group. mri sleep studies were successfully completed without the use of artificial airways in children ( %) in the dexmedetomidine group versus children ( %) in the propofol group. conclusions: safe and effective anesthetic management is a key factor in obtaining good quality mr images of the airway. although there was no statistical significant difference in the need for airway intervention between drugs, dexmedetomidine provided acceptable sedation for mri sleep studies with less airway intervention in children with osa. dexmedetomidine may be the preferred agent for sedation during mri sleep studies in children, and may offer benefits to children with sleep disordered breathing requiring anesthesia or sedation for other diagnostic imaging studies. an open mouth and administration of cpap resulted in smaller ap diameter of the retroglossal airway compared to images without cpap due to cpap pressure pushing the tongue posteriorly. in patient volume of oral cavity anterior to the tongue increased from . ml to . ml. meanwhile, the ap diameter of the retroglossal airway decreased from . to . mm ( % decrease). in patient the mouth was initially closed but parted when the pressure of cpap was added with the oral volume increasing from . ml to . ml. the ap measure of the retroglossal airway decreased from . mm to . mm ( % decrease). in patient the mouth was then closed and cpap reapplied resulting in an ap measurement of . mm ( % increase). the ap diameter difference between cpap and no cpap were tested with paired t-test, but were not statistically significant (p . ). conclusions: positive airway pressure on a patient by full facemask and an open mouth can have an adverse effect on the retroglossal airway. this adverse effect is an important consideration in the use of positive airway pressure to support airways for osa, or during emergency resuscitation when a full facemask is used. paper #: pa- the purpose or case report: a nanoparticle blood pool iodinated contrast agent (nctx) has been designed and tested in preclinical animal models. we report data in animal models exemplifying its advantages over conventional contrast in the setting of ct pulmonary angiography methods & materials: nctx blood pool nanoparticles of nm diameter with an encapsulated total iodine concentration of~ mgi/ml were administered by intravenous injection to mice, rabbits, dogs, pigs and sheep. (these studies were actually conducted for other purposes and a review of the data revealed the similarities that motivated this paper.) total injected volumes were~ ml/kg in large animals, and as high as ml/kg in small animals to provide satisfactory vessel enhancement. iohexol or iopamidol was administered for comparative studies with conventional contrast. in a subset of pigs, iatrogenic pulmonary arterial emboli were introduced prior to contrast administration. toxicity studies were conducted in mice and monkeys. results: the visualization of pulmonary vessels using nctx blood pool nanoparticles was generally at least equivalent to using conventional contrast, and superior in several cases, particularly in small veins and when bolus timing of the conventional contrast was suboptimal. in all cases, satisfactory vessel enhancement was achieved for a duration of several hours following a single infusion of nctx blood pool nanoparticles. there was no evidence of renal toxicity, and only transient elevation of hepatic enzymes at relevant dose levels. conclusions: nctx nanoparticle blood pool agents demonstrate several advantages over conventional glomerularfiltered iodinated contrast agents for ct pulmonary angiography in animal models, including no nephrotoxicity, no dependence on bolus injection technique, superior depiction of small veins, and capability of re-imaging for follow-up studies without needing contrast re-injection. potential applications in human pediatric subjects include the diagnostic and post-therapeutic evaluation of cardiopulmonary anomalies and pulmonary embolism, especially in patients with renal insufficiency or tenuous vascular access. disclosure: dr. annapragada has indicated that he is a stock holder and consultant for marval biosciences inc. paper #: pa- cardiovascular image quality using a nanoparticle ct contrast agent: preliminary studies in a pig model rajesh krishnamurthy, radiology, texas children's hospital, rxkrishn@texaschildrens.org; ketan ghaghada, prakash masand, abhay divekar, eric hoffman, ananth annapragada purpose or case report: image quality in a separate study using a long circulating, liposomal-based nanoscale blood pool iodinated contrast agent (nctx) suggests clinical utility in pediatrics, potentially reducing difficulties in contrast-ct of children with congenital heart disease (chd) including the size of intravenous cannula, need for accurate timing, inability to simultaneously opacify multiple targets of interest (requiring repeated contrast administration and/or repeated imaging). methods & materials: six pigs (average weight kg) were imaged after slow intravenous infusion of nctx ( mg i/ml) at an iodine dose of approximately mg i/ kg ( . ml/kg). retrospective ekg gated ct imaging was performed h later using a -slice dual-source ct scanner at and kvp. two radiologists analyzed and graded (on a -point scale with : unreadable, : excellent) images aimed at anatomic structures relevant to chd. quality of images obtained at and kvp were compared. uniformity of contrast opacification was measured using a roi-based ctnumber method at various intracardiac and extracardiac sites and mean non-uniformity was calculated. results: there was excellent agreement between the two readers on all counts at kvp. kvp images received lower scores for coronary morphology ( / ), and aortic valve visualization ( . / ), but were comparable in other aspects. pulmonary artery and pulmonary vein branch visualization extended up to the th generation in all cases. visualization of coronary artery branches was possible up to the second generation, with good arteriovenous separation. subtle morphologic features including crista terminalis, thebesian valve, foramen ovale, membranous septum, and chordae of the mitral valve were demonstrated in all cases. automated functional analysis and myocardial mass quantitation was feasible in all cases. there was no significant difference in blood pool attenuation between the atria, ventricles, and extracardiac vasculature on quantitative assessment. no image artifacts were visible on the reconstructed images. conclusions: these findings suggest that nctx promises to be superior to conventional contrast agents for ct imaging of complex congenital heart disease, due to the absence of nephrotoxicity, avoidance of repeated contrast administration, and reduced number of scans performed. avoiding the need for accurately timed scans precludes the need for large bore intravenous access. these attributes make it a promising agent that warrants further studies. disclosure: dr. annapragada has indicated that he is a stock holder and consultant for marval biosciences inc. paper #: pa- theoretical cost and x-ray dose reduction in pediatric congenital heart disease imaging by the use of a nanoparticle contrast agent robert bell, the university of texas-houston; rajesh krishnamurthy, gabriela espinosa, christopher petit, ananth annapragada purpose or case report: the purpose of this study is to determine the effective, population averaged reduction in costs and radiation dose that can be achieved in the diagnosis of congenital heart disease by use of a nanoparticle long circulating blood pool contrast agent. methods & materials: a markov model of the decision tree followed at the texas children's hospital in the image based diagnosis of congenital heart disease was constructed in treeage software. the model included ct angiography, mr angiography, cardiac catheterization, and echocardiography diagnostic modalities. patient records, accumulated between and were examined to inform the model. the radiation dose and cost for each step were encoded as penalty functions. markov simulations were run for two decision trees: ( ) utilizing ct angiography and ( ) replacing conventional ct angiography with blood-pool agent based ct angiography. the overall population x-ray dose and accrued cost was calculated for each pass through the model. results: x-ray dose distributions for the example populations showed substantial reductions per ct study, as much as %. averaged over the population, since a sizeable fraction of patients are diagnosed without ever being exposed to any x-ray based modality, reductions were more modest, but still substantial. costs per ct study were slightly higher when the blood pool contrast agent was used. when the diagnostic probability using the blood pool agent increased, it led to an automatic overall cost reduction. conversely when the diagnostic probability remained unchanged, costs rose, commensurate with the increased cost of the contrast agent. conclusions: the use of a blood pool contrast agent for ct angiography leads to substantial reduction in radiation dose in the setting of congenital heart disease. cost reductions are more modest, and are driven almost completely by the reduction in the number of mr and invasive angiography procedures resulting from increased diagnostic success using blood pool based ct angiography. the model as constructed does not account for potential workflow changes that might result from the use of a new contrast agent. actual reductions realized may therefore be higher. disclosure: dr. annapragada has indicated that he is a stock holder and consultant for marval biosciences inc. paper #: pa- frequencies and patterns of situs discordance in chest and abdomen justin boe, stanford, justinj.boe@gmail.com; beverley newman, shreyas vasanawala, frandics chan purpose or case report: incidence of situs anomalies, including heterotaxy and situs inversus, is estimated at . % of population. as the first step in the segmental analysis of structural heart disease, the determination situs position is of fundamental importance. abdominal situs, as defined by splenic position and morphology, and cardiac situs, as defined by atrial morphology, are usually but not always in agreement. echocardiographers also employ the relative position of the great arteries and vein at the hiatus to determine cardiac situs. we evaluate the frequencies of discordances among abdominal, hiatal and cardiac situses. methods & materials: with retrospective irb approval, imaging records from to were reviewed for the diagnosis of cardiac situs inversus and heterotaxy. patients who had cardiac ct or mri were included. images were evaluated on a d-processing station by a cardiac radiologist. cardiac situs was determined by the morphology of the atrial appendages. when an atrial appendage was not adequately visualized, cardiac situs was assessed by the relative position of the main pulmonary artery and bronchi. hiatal situs was determined by the relative position of the aorta and the systemic venous return, and abdominal situs by the position and morphology of the spleen. results: thirty-five cases were identified, with cardiac ct and mri. patients' age ranged from day to years old. in the abdomen, the numbers of situs inversus, asplenia, and polysplenia were ( %), ( %), and ( %). for the heart, the numbers of situs solitus, inversus, rightisomerism, and left-isomerism were ( %), ( %), ( %) and ( %). the abdominal and cardiac situses were discordant in ( %) cases. polysplenia had the highest number of discordance with the heart. hiatal situs was discordant with the abdomen in cases ( %) and with the heart in ( %) cases. conclusions: situs disagreement between the abdomen and the heart is not uncommon and they should be documented separately in radiology reports. hiatal situs, as used by echocardiographer, disagrees with the cardiac situs in a quarter of the cases. it should be used with caution in the segmental analysis. paper #: pa- diminished asl intracranial perfusion in children with neurofibromatosis type kristen yeom, md, stanford university, kyeom@stanford. edu; cynthia campen, patrick barnes purpose or case report: neurofibromatosis type (nf ), a neuro-cutaneous syndrome affecting / children is associated with moyamoya syndrome (mms). however, no comparisons of cerebral perfusion in patients with nf and nf -associated mms to healthy controls exist. we hypothesize cerebral blood flow (cbf), as measured by magnetic resonance imaging (mri) arterial-spin-labeled (asl), is diminished in children with nf compared to healthy controls, with the lowest levels seen in patients with nf -associated mms. methods & materials: twenty children aged - years with nf , four with mms, and age-matched controls underwent asl cbf on a t magnet. pseudocontinuousspin-echo-asl technique was used. measurements were taken bilaterally in cerebral cortical-subcortical regions, and the deep gray nuclei. trends in measurements as a function of disease severity were tested with the jonckheere-terpstra test for ordered alternatives. a bonferroni-adjusted p-value less than . was considered significant. results: we identified / areas with significantly diminished asl cbf (ml/ g/min) in patients with nf (midrange), and nf -associated mms (lowest) compared to healthy controls (highest). these included the: thalami (left: p . , right: p . ); superior/middle temporal lobes (left: p . , right: p . ); temporooccipital lobes (left: p . , right: p . ); occipital poles (left: p . , right: p . ); centrum semiovale (left: p . , right: p . ); and left parietal lobe (p . ). conclusions: cerebral perfusion diminishes in a graded fashion in children with nf and nf -associated mms, particularly in the posterior circulation and the mca-pca posterior watershed zones. future studies may demonstrate an important role for asl in the presymptomatic diagnosis of cerebral vasculopathy, and the definition of nf -related vasculopathy patterns. paper #: pa- cingulate gyrus mri sign in pediatric nf patients: a novel imaging marker nadja kadom, md, radiology, children's national medical center, nkadom@childrensnational.org; nabila hai, rhea udyavar , amir noor, gilbert l. vezina, maria t. acosta purpose or case report: we observed a magnetic resonance imaging (mri) signal abnormality in the anterior cingulate gyrus of pediatric patients with neurofibromatosis type (nf ). the cingulate gyrus could play a role in cognitive deficits of nf patients. the first objective here is to document inter-rater reliability scores for visual detection of this sign. the second objective is comparing adc values of the cingulate gyrus in areas of visually abnormal mri signal in nf patients to matched normal mris to confirm a pathophysiological basis of the visual mri sign. methods & materials: retrospective analysis, irb approved, nf patients and matched controls. in the visual assessment part, two blinded neuroradiologists rated presence or absence of mri signal abnormality in the cingulate gyrus in three different age groups of nf patients mixed with normal controls. cohen's kappa inter-rater reliability coefficients were calculated. the same blinded neuroradiologists evaluated the cohort one year later, this time by agreement at the workstation. in the adc measurements part, two researchers, one blinded, manually placed roi's in the anterior and posterior cingulate regions of nf patients and their matched controls, and student t-test was used to assess for significance of differences in measured values. results: cohen's kappa for the three age groups showed very good agreement (kappa coefficients were either . or . ). rater agreement at the workstation was %. all subjects with a positive finding also had nf and the sign was not seen in any of the normal controls. the prevalence of the sign was %. adc measurements showed significantly higher adc values in the anterior cingulate gyrus of nf patients when compared to normal controls and also when compared to the posterior cingulate gyrus in nf patients. conclusions: our results show that visual t /flair mri abnormalities in the anterior cingulate gyrus are present in % of patients with nf from ages to years. adc measurements confirm a pathophysiological basis for this finding. future correlation with clinical manifestations, such as learning and behavioral manifestations in patients with nf , are under way to further evaluate the clinical importance of this finding. tract-based spatial statistical analysis of diffusion tensor imaging in pediatric patients with mitochondrial disease seth friedman, phd, seattle children's, seth.friedman@ seattlechildrens.org; andrew v. poliakov, sandra l. poliachik, dennis w. shaw purpose or case report: often diagnosed at birth or in early childhood, mitochondrial disease presents with a variety of clinical symptoms, particularly in organs and tissues that require high energetic demand such as brain, heart, liver, and skeletal muscles. in a group of pediatric patients identified to have complex i or i/iii deficits, but with white matter tissue appearing qualitatively normal for age, we hypothesized that quantitative dti analyses might unmask deficits in microstructural integrity. methods & materials: dti and structural mr brain imaging data were collected in pediatric patients with confirmed mitochondrial disease and clinical control subjects matched for age, gender, scanning parameters, and date of exam. paired tract-based spatial statistics (tbss) were performed to evaluate differences in fractional anisotropy (fa) and mean diffusivity (md). results: in patients with mitochondrial disease, significant widespread reductions in fa values were shown in white matter tracts. md values were significantly increased in patients, having a sparser distribution of affected regions compared to fa. results of tbss statistical analysis will be shown. to be shown in green is the mean fa skeleton which represents the centers of main white matter tracts. all results p<. . red and yellow represent a significant increase, blue and light blue represent a significant decrease. conclusions: despite qualitatively normal appearing white matter tissues, patients with confirmed mitochondrial disease have widespread microstructural changes measurable with quantitative dti. this supports the evaluation of such metrics in other populations where gross imaging features may be normal. to extend our studies to patients with other plp mutations, we analyzed the brains of male pmd patients (ranging in age from to ) and female carriers for whom the plp genotype had been determined and analyzed by mri. for each patient we measured, white matter volume (wmv) and the intercaudate distance (icd). the mri data were correlated with functional disability scores (fds) using a system we developed for clinical evaluation of pmd patients and which was validated by assessments of pmd patients. brain volume and segmentation were measured using nih image . . the average number of coronal slices analyzed from each patients mri was slices. when graywhite contrast was not adequate, then the intercaudate distance (icd) and intercaudate ratio were measured as described in caon et. al., ( ) . results: comparison of the mr measurements and the fds demonstrated that white matter volume inversely correlates with functional disability, suggesting that the initial disability does correlate with the extent of myelination. the intercaudate distance also correlated with the fds, and may usefully substitute when gray-white matter segmentation is not possible. conclusions: pmd is a clinically and genetically heterogeneous disease caused by mutations in the gene encoding the major cns myelin protein, proteolipid protein (plp). myelin is a major target of disease pathogenesis in most cases of pmd, but how the various mutations cause clinical disability is not fully understood. our data demonstrate that the extent of brain white matter atrophy, measured directly by volumetric fractionation, or indirectly by analyzing the intercaudate ratio, is significantly correlated with the patient's functional disability. white matter atrophy is thus the main cause of clinical disability in patients with pmd of all ages and mutation type. paper #: pa- maturational effects on language localization in children demonstrated by fmri susan palasis, md, children's healthcare of atlanta at scottish rite, spalasis@yahoo.com; binjian sun, laura l. hayes, richard a. jones purpose or case report: language localization is of paramount importance when contemplating surgery in children with intractable epilepsy or brain tumors. the potential risk of injury to language centers in the developing pediatric brain needs to be weighed against the potential benefits of surgery. in the past, language localization was crudely and invasively determined using the wada test. most institutions are now transitioning to non invasive localization using functional mri (fmri). the purpose of our study was to analyze language localization relative to age in children using age appropriate language paradigms and fmri. methods & materials: forty three healthy, english speaking, right handed children underwent fmri evaluation for language localization. the studies were performed on a t system. three novel age appropriate language block paradigms were utilized, targeted both to expressive and receptive language processing. these paradigms were the auditory category decision task (audcat), the auditory description decision task (addt), and the listening task. the spatial statistical maps generated by the fmri data were fused to the d anatomical mri dataset. language areas were localized and statistical analysis was performed with age as the variable in a general linear model. results: our results demonstrate a distinct trend in language localization and lateralization with brain maturation. in the young age groups (less than years) the localization tended to be less focused and bilateral in the frontal and temporal regions of the brain. in the older age groups (greater than years), language became more localized and lateralized to the expected left sided pattern. the findings were more robustly demonstrated with the addt task and were statistically significant (p< . ). conclusions: our study clearly demonstrates the plasticity of language centers in the maturing pediatric brain. this observation is significant for neurosurgical planning and rehabilitation in the pediatric population. ( ) no slc a mutations were found in , and subjects, respectively. significantly higher association with slc a mutations was found in bilateral eva+v/c dysplasia ( / ). double mutations of slc a is more often associated with combined eva+ v/c dysplasia, while a single mutation with eva only. cochlear aplasia without eva ( / ) and snhl with normal imaging ( / ) are less likely associated with slc a mutation. conclusions: slc a mutation is highly associated with eva and v/c dysplasia. once eva with or without v/c dysplasia are found at imaging, genetic investigation is recommended for slc a mutation because of possible thyroid involvement. moderate-severe hie who were randomized to cooling ( . °c for h). there were in the hypothermia group and in the control group. all mris were reviewed by a cental reader masked to the clinical findings, groupings, and outcomes. the mri findings were scored according to pattern and extent of injury, including involvement of the cerebral hemispheres, basal ganglia, thalami, internal capsules, and other structures. brain injury scores were correlated with death or disability at months postnatal age. results: no mri abnormalities were observed in of infants ( %) in the hypothermia group and in of infants ( %) in the control group (p . ). infants in the hypothermia group had fewer areas of injury ( %) as compared with the control group ( %, p . ). there were of the infants with death or disability at months. the brain injury score correlated with outcome of death or disability (p . ) and disability among survivors (p . ). conclusions: fewer areas of brain injury on mri were observed following whole-body hypothermia. the mri brain injury score is a marker of death or disability at months following hypothermia for term hie. . presence or absence of the "red dot" on fa color maps was correlated to clinical (ataxia, oculomotor abnormalities etc.) and morphological data, and to fa and md measurements. results: the "red dot" was absent in js and hgpps (genetic cross wiring impairment diseases) and present in coma and wvs (no reported gene abnormalities so far) as in normal controls. js and coma presented on mri molar tooth appearance. hgpps presented "split pons" appearance. js and coma patients presented oculomotor apraxia, wvs and hgpps palsy of the horizontal gaze. mirror movements were found in js and in wvs. ipsilateral responses are present in hgpps. wvs presented multiple cranial nerves impairment. in js, fa and md values of scp, pt and pc were significantly lower than in normal controls (p > . ). in hgpps high fa and low md were found in pc and pt (p > . ) and normal in scp. conclusions: the "red dot" absence is unrelated to morphological or clinical abnormalities. absence of the "red dot" is associated to abnormal measurements of fa and md in pc and pt( low in js and high in hgpps). these findings indicate a pivotal role for the pc in the physiopathology of these diseases. the "red dot" absence seems to be a marker of genetic cross wiring diseases. in this view, coma and wvs should not be considered as part of these diseases. sonographic predictors of intermittant testicular torsion in the pediatric patient jennifer williams, md, pediatric radiology, texas children's hospital, jlwilli @texaschildrens.org; marthe munden purpose or case report: intermittent testicular torsion (itt), defined as sudden onset unilateral scrotal pain with spontaneous resolution, is difficult to confirm both clinically and sonographically. the purpose of this study was to determine if sonographic predictors exist for diagnosing itt in the pediatric patient. methods & materials: a search of the pacs data system for patients presenting with suspected intermittent testicular torsion was performed. fifteen patients with a total of episodes presenting over a year period were found. a retrospective review of the medical records for clinical presentation, surgical outcome, and comorbidities was performed. scrotal ultrasound images and reports were reviewed for testicular size and echotexture, testicular flow, epididymal appearance, vascular bundle appearance, and presence of hydrocele. results: an abnormal appearance of the vascular bundle was found in % of episodes ( / ). initial absence of testicular flow followed by reperfusion during the scan was seen in % of episodes ( / ); % had increased flow ( / ), % had decreased flow ( / ), and % had normal flow ( / ) . nine of the patients had surgery; of these were found to have evidence of itt and was found to have acute testicular torsion. of patients with itt, % ( / ) had an abnormal vascular bundle. testicular flow was not initially visualized but returned during the exam in % of patients ( / ), was increased in % of patients ( / ) and was decreased in % patients ( / ). conclusions: itt is a difficult diagnosis. the most reliable sonographic indicator is an abnormal spermatic cord, found in % of episodes and % of surgically proven itt. dedicated views of the spermatic cord must be obtained in order to differentiate an abnormal epididymis from an engorged vascular bundle (the so-called pseudomass). attention to testicular flow is of particular importance. while visualization of a transition from no or decreased testicular flow to normal flow during the sonogram is certainly diagnostic of itt, increased testicular flow should not lead to false reassurance. purpose or case report: testicular torsion is a common acute condition in boys requiring prompt and accurate diagnosis. the objective was to evaluate ultrasound accuracy and findings, and clinical predictors in testicular torsion in boys presenting to the stollery pediatric emergency department (ed) with acute scrotal pain. methods & materials: retrospective review of us, surgical and ed records for boys aged month to years, presenting with acute scrotum from to , was performed. age, demographics, clinical symptoms, physical findings, us and surgical techniques, findings and diagnoses were recorded. surgical results and follow-up were used as the gold standard as all pediatric urology in our region is performed at our centre. results: patients presented to ed with acute scrotum with the following diagnoses: testicular torsion, possible torsion-detorsion, torsion of appendix testes, epididymo-orchitis, and other. of us performed, boys had torsion confirmed by surgery. there were inconclusive us reports, none of which had torsion at surgery or follow-up. the false positive rate of us was . % ( patients), and there were no false negatives. six torsion patients had no us. median time from ed to us and surgery for torsion patients was and min. six patients had non-salvageable testes. diagnostic accuracy of us compared to surgery was % for torsion and % for other. sonographic heterogeneity was seen in % of patients with testes that the surgeon felt were non-viable at surgery and % of patients with viable testes (p . ). sudden-onset scrotal pain ( %), abnormal position ( %) and absent cremasteric reflex ( %,) were most prevalent in torsion patients. conclusions: color doppler us is accurate and sensitive for diagnosis of torsion in the setting of acute scrotum. despite heterogeneity on pre-operative us, many testes were felt to be salvageable at surgery. rate of salvage of torsion was high. common symptoms and findings of torsion were sudden onset of pain, abnormal testicular position and absent cremasteric reflex. paper #: pa- diagnostic twists of tubal torsion srikala narayanan, md, children's national medical center, snarayan@childrensnational.org; anjum n. bandarkar, dorothy bulas purpose or case report: fallopian tube torsion is a rare cause of acute pelvic pain in a young female and requires prompt diagnosis for immediate surgical intervention. our purpose is to review varied imaging findings of surgically proven cases of tubal torsion. methods & materials: retrospective review of our data base from to revealed cases of surgically proven fallopian tube torsion. ages ranged from to years of age. all had pelvic ultrasound performed, cases had additional ct performed for acute pelvic pain. results: us findings included thickened dilated tubular hypoechoic structure ( ), cystic mass ( ); adnexal ( ), midline ( ). five cases had normal ovaries bilaterally ( with paratubal cysts). ct imaging findings include dilated, fluid filled, thickwalled tube with internal hyperdensity ( hu) likely debris/ hemorrhage in case. additional findings included cystic adnexal mass ( cases), beak sign ( case) and increased vascularity ( case). secondary signs included free fluid ( ), peritubular fat stranding ( ), vascular congestion and thickening of the broad ligament ( ) and enlarged draining vein ( ). laparoscopic salphingectomy was performed in cases (including cases with isolated tubal torsion). laparoscopic detorsion was performed in a total of cases. in addition, laparoscopic cyst drainage was performed in out of these cases. detorsion with paratubal cystectomy and hemorrhagic ovarian cystectomy was performed in of the cases. conclusions: imaging diagnosis of tubal torsion can be difficult. it can occur in isolation with a dilated thickened tubular structure adjacent to a normal ovary or potentially mimic appendicitis, pyosalpinx, complex adnexal cyst or cystic adnexal neoplasm. presence of normal ovaries, beaked tapered tubular structure with intratubal fluid level and hemorrhage may help in making the diagnosis. it is important to recognize this entity in a patient with acute pelvic pain to facilitate prompt tubal sparing surgery. paper #: pa- adjusted renal length in pediatric bone marrow transplant recipients nicholas bodmer, md, university of washington, nbodmer@gmail.com; teresa chapman, sangeeta hingorani, marguerite parisi purpose or case report: bilateral nephromegaly has been observed in the bone marrow transplant (bmt) patients at our institution. this study aims to quantify this observation, thereby providing radiologists with an adjusted baseline agedetermined renal growth curve for bmt patients. methods & materials: a retrospective clinical chart and imaging review was performed on patients who underwent bmt between and and who had abdominal imaging including the kidneys. ultrasound, ct, and mri exams were used for renal length measurement. renal lengths were assessed for each age group, first as an average length of all the patients within that age group overall, and subsequently as an average renal length by age group divided into the following time frames after transplantation: - days, - days, - days, and + days. clinic chart information collected included bun, creatinine, weight, and medication use. results: renal length was measured using imaging cases, distributed across each age group as follows: - months, n ; months- . years, n ; . - . years, n ; . - . years, n ; . - . years, n ; . years and higher, n . renal lengths were greater, on average, within every age group, compared with previously established normative age-related renal lengths (rosenbaum et al.) . the augmented renal lengths universally were observed in the - day post-transplantation timeframe. return to normal renal lengths typically occurred by months post transplant. clinic chart review revealed that the majority ( %) of patients received nephrotoxic medication within two weeks of imaging. conclusions: pediatric bmt patients have larger kidneys in the absence of known renal disease than age-matched peers. a revised, age-based renal length chart for post-bmt patients has been generated which should help prevent the misdiagnosis of nephromegaly in this population, eliminating unnecessary diagnostic evaluations. multiple etiologies to explain renal enlargement in these patients are possible, including fluid overload, nephrotoxic medication, or direct effect of the transplant. purpose or case report: mr urography can be a comprehensive exam for anatomical and functional pediatric renal evaluation. quantification of renal function may benefit when dynamic contrast enhanced images can be obtained at high spatiotemporal resolution and with minimal respiratory motion artifacts. though respiratory triggering may decrease motion artifacts, it results in loss of temporal resolution by a factor of about three. a two-echo gradient echo sequence with segmented outer k-space sampling and view-sharing/dixon image reconstruction (disco, differential subsampling with cartesian ordering) was chosen as a starting point due to its high temporal resolution. it was then modified to enable respiratory triggering while maintaining temporal resolution of one temporal frame every one to two respirations, with segments of k-space only acquired in the expiratory phase of respiration. imaging parameters were: °flip angle, ± khz bandwidth, tr~ . , matrix x , fov - cm, slice thickness mm, and x spatial acceleration. with irb approval and informed patient consent consecutive patients referred for mri renal function evaluation were recruited (age range; . to . years, mean±sd: . ± . years; males % females %), and scanned on a ge t mr using a -channel torso array with the respiratory-triggered high spatiotemporal resolution technique to extract regional gfr maps. two readers by consensus assessed image qualitative snr, motion artifacts and volumetric fat-water suppression performance. results: data acquisition was obtained to completion in all subjects without triggering failure. temporal resolution was approximately s for two respiratory cycles. no case had major fat suppression failure, whereas minor fat suppression failure was seen in % ( % c.i. to %). all cases had diagnostically acceptable snr. no motion artifacts were noted in / cases, while some artifacts with ghosting in / cases. regional gfr maps could be successfully extracted for each patient without the need for image registration. attached figure shows image quality. conclusions: view-sharing offsets loss of temporal resolution from respiratory triggering. thus, high spatiotemporal resolution renal dynamic contrast enhanced respiratory triggered images can be obtained with minimal motion artifacts in a pediatric clinical setting to evaluate renal function. disclosure: dr. chowdhury has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. methods & materials: the study cohort was selected from the irb approved children's oncology group aren b study. cases are evaluated for pre-operative wt rupture based on central review of surgical/pathology findings. wt cases with rupture were matched to wt controls by age and tumor weight (within months and g). ct scans were independently reviewed by blinded radiologists, for presence/absence of rupture and the following ct signs: poorly circumscribed mass, perinephric fat stranding, peritumoral fat planes obscured, retroperitoneal fluid, ascites beyond cul-de-sac, peritoneal implants, ipsilateral pleural effusion, intratumor hemorrhage. sensitivity, specificity of ct for assessing pre-operative wt rupture was determined. the relationship between ct signs and rupture was assessed by mcnemar's test, and the most predictive ct signs determined by backward selection multivariate logistic regression. results: sensitivity, specificity for detecting wt rupture were: reviewer - . %, . %, reviewer - . %, . %. kappa coefficient for interobserver agreement was substantial: . (p< . ). all ct signs tested, except peritoneal implants and intratumoral hemorrhage, had significant association with tumor rupture (p< . ). for reviewer , ascites and fat stranding around tumor were most predictive (odds ratio . and . , p< . ). for reviewer , ascites and retroperitoneal fluid were most predictive (or . and . , p< . ). conclusions: ct has high specificity but relatively low sensitivity for detecting preoperative wt rupture. the presence of ascites beyond cul-de-sac is the best indicator of preoperative rupture, followed by fat stranding and retroperitoneal fluid. paper #: pa- the failed pyeloplasty: evaluation with mr urography damien grattan-smith, children's healthcare of atlanta, damien.grattansmith@mac.com; ricahrd jones, stephen little, wolfgang cerwinka, hal scherz, andrew kirsch purpose or case report: to identify imaging characteristics associated with failed pyeloplasty seen with mr urography. we have performed mr urography in children following pyeloplasty. from this group, children had follow-up surgical intervention with repeat pyeloplasty or balloon dilatation of the upj. imaging features reviewed included degree of hydronephrosis, calyceal transit times, renal transit times, signal intensity versus time curves, as well as functional analysis based on volumetric and patlak differential function and change in the asymmetry index. results: all children who underwent a second surgical procedure had delayed calyceal transit times. the degree of hydronephrosis and renal transit times were either stable or worse when compared to pre-operative evaluation. functional derangement could show stability, slight improvement or deterioration. the asymmetry index estimated the severity of the obstruction. conclusions: mr urography is valuable in the evaluation of children who have undergone pyeloplasty. the calyceal transit time appears to be the most reliable discriminator when comparing successful and failed pyeloplasty. calyceal transit times may be prolonged before the hydronephrosis becomes progressive. disclosure: dr. grattan-smith has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: initial attempts at interpreting functional mr urography (fmru) can be challenging. a time intensive navigation through a multitude of both subjective and objective functional results is necessary to render a useful interpretation. this is a guided review of fmru, noting the important functional findings in high-grade unilateral pelvicalyceal dilatation (pcd), in the absence of ureterectasis, with a contralateral normal kidney allowing for an optimal functional comparison. methods & materials: a retrospective functional evaluation of cases with unilateral pelvicalyceal dilatation (pcd), without prior pyeloplasty, was conducted. the fmru studies were carried out according to a standard protocol and post-processing using the chop-fmru software. this included iv hydration, bladder catheterization and iv furosemide administration. fifteen minutes after diuretic administration, a dynamic coronal d fat saturated t sequence was performed in a supine position over min. a sagittal d t and delayed single coronal t , both fat saturated, followed in a supine and/or prone position. the following functional features were evaluated: visualization of the ureter, the presence of a contrast-urine level and swirling of contrast in the dilated renal pelvis. the functional results included in the analysis were calyceal transit time (ctt), renal transit time (rtt), time-to-peak (ttp), parenchymal volume (pv), differential renal functions (volumetric-vdrf, patlak-pdrf and volumetric patlak-vpdrf) and the difference between vdrf and pdrf. results: patients were comprised of males and females with an age range of . - . years (median . yrs). of the kidneys with pcd, the ureter was visualized in , during the dynamic sequence, / during supine delay and / only in prone position. a contrast-urine level was present in of the dilated systems, and swirling in . the ureter was visualized during dynamic sequence in all contralateral normal kidneys and at no time was swirling or a contrast-urine level identified. the average functional parameters are seen in table . a statistically significant (p< . ) difference between the normal and dilated pelvicalyceal systems was achieved in ttp, pdrf and vpdrf for this small sample size. conclusions: awareness of multiple functional features and the range of calculated results may aid in subsequent combined interpretation of the fmru with the morphologic analysis. disclosure: dr. lecompte has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. and . demographics, clinical presentation , diagnostic studies and treatment outcomes were evaluated. post-procedure imaging was evaluated for clot burden reduction (patency) and residual venous stenosis by two-reader consensus. results: ten patients ( male; female, mean age years, range - ) presenting with acute upper extremity swelling and pre-procedure imaging revealing % occlusion of the axillary and subclavian veins received successful endovascular therapy. all patients underwent infusion catheter placement for thrombolysis with tissue plasminogen activator or urokinase. patients received additional pharmacomechanical treatment. angioplasty was also performed in all patients. the mean treatment duration was h (range - ). post-procedural imaging revealed that of patients achieved - % patency (clot burden reduction) and patient achieved - % patency. the residual venous stenosis was graded: patients had - % stenosis, patients had - % stenosis and patients had - % stenosis. all patients were discharged on full anticoagulation therapy with low molecular weight heparin. patients had surgical rib resection postthrombolysis with an average length of time from thrombolytic therapy to surgery being days (range - ). patients had re-thrombosis events during the follow-up period (mean months; range - ), with one re-thrombosis event occurring within one week of thrombolytic therapy, prior to surgery and the other two occurring - weeks post-rib resection. there were no procedure related complications. one patient was lost to follow-up after initial successful catheter directed therapy. conclusions: percutaneous endovascular techniques such as pharmacomechanical thrombolysis and angioplasty appear to be feasible and safe options for paget schroetter syndrome in otherwise healthy adolescent patients. in attempt to prevent rethrombosis and chronic symptoms, we refer all patients for adjunctive surgical decompression. future larger studies are needed to address optimal strategies for these patients. combined d fluoroscopy image guided percutaneous intervention with real-time optical sensing at the tip of a needle for tissue characterization rami nachabe, philips, rami.nachabe@philips.com; john m. racadio, drazenko babic, ross schierling, jasmine hales, benno hendriks purpose or case report: to investigate the feasibility and potential of real-time tissue characterization at the tip of a needle with diffuse optical spectroscopy (dos) sensing capabilities during d fluoroscopy guidance using cone beam ct and dedicated needle path planning software. methods & materials: a c-arm x-ray system that combines fluoroscopy and d imaging from a cone beam ct was used to image a woodchuck with hepatocellular carcinoma (hcc). the imaging system enabled needle path planning, which was used to perform insertion and navigation of a needle toward the liver tumor. the needle was integrated with optical fibers for real-time tissue spectral sensing at its tip. optical spectra measurements were obtained continuously as the needle passed through healthy liver tissue and then into the tumor. from the diffuse optical spectra measurements, the following clinical parameters were extracted for tissue characterization: blood volume fraction, blood oxygenation, lipid volume fraction and tissue light scattering (related to tissue density). the tissue parameters were compared for healthy liver and tumor using the kruskal-wallis test. results: the tissue density of the healthy liver was lower than that of the tumor. higher blood and lipid volume fractions as well as oxygenation levels were observed in the healthy liver as compared to the tumor. all differences were statistically significant (p< . ). additionally, a much wider heterogeneity in tissue density was observed in the tumor as opposed to the healthy liver. conclusions: differences in tissue properties between tumor and healthy liver enable discrimination between these two types of tissues. adding real-time optical sensing at the tip of a needle to d fluoroscopy image guidance is a feasible technique that complements the imaging information with relevant physiological parameters; it facilitates more precise definition of tumor boundaries despite any target motion during needle insertion. disclosure: dr. racadio has disclosed that he is a consultant for philips healthcare and receives travel reimbursement. rami nachabe, drazenko babic and benno hendriks are employees of philips healthcare. methods & materials: two children aged months and months were treated at this institution for liver failure resulting from urea cycle disorders, with a hepatocyte transplant procedure. the recipient liver was irradiated prior to transplant to facilitate engraftment. the procedure involves the injection of prepared hepatocytes from a suitably screened, compatible donor, via a main portal vein branch into the recipient liver. in both procedures access to the umbilical vein was achieved by the surgery service and a french arterial sheath was placed. a french angled catheter was used for diagnostic runs and to access the right and left main portal vein. a french fogarty catheter (edwards lifesciences, irvine, ca) was placed to isolate each portal vein branch in turn and hepatocytes injected using hand injections. pressures in the main, right and left portal veins were measured and hand injections of contrast made at regular intervals. careful attention must be paid for evidence of pruning of portal branches, indicating occlusion of small portal branches, or portal to hepatic vein shunting. if shunting is seen, infusion must be stopped as embolism of hepatocytes into pulmonary arteries may result with serious clinical sequelae results: in both patients, the desired number of hepatocytes were successfully delivered into the recipient liver. in both cases, mild pruning of the portal vein branches was evident at the end of the procedure. portal vein presssures remained steady. there was no venographic or clinical evidence of pulmonary arterial embolization. conclusions: the interventional radiologist plays a central role in the hepatocyte transplant procedure. familiarity with catheterizing portal branches from an umbilical vein approach, measuring venous pressures, using small occlusion catheters and recognizing venographic end points such as portal vein pruning and portal to hepatic vein shunting are necessary to the safe and successful completion of this new technique. purpose or case report: the aim of the study was to evaluate the trends in term of type of tube placed, number of procedures per year, number and age of the patients as well as the number of procedures per patient and the interval of time between two placements, and finally the irradiation burden borne by the patients. methods & materials: after reb approval the radiologic files of the patients who underwent naso-duodenal-jejunal (ndj) or gastro-jejunal (gj) or jejunal (j) tube placement under fluoroscopy over the past five years ( to ) were extracted from the ris and reviewed. the results were tabulated as a single batch and stratified by year. results: eighty-nine patients representing procedures ( ndj, , gj, j) were included. only patients underwent a single procedure. the average number of procedures per patient was . with a maximum of during the study period. the average patient's age was . months (sd . , median . ). the average fluoro time per procedure was . min (sd . , median . ). the average interval between two procedures was days (sd , , median ). the average fluoroscopy time per patient combining those having a single procedure and those having multiple ones, was . min (range . to . , sd . , median . ). conclusions: fluoroscopic placement of enteric tubes delivers a significant amount of irradiation. our data led to two interventions with respect to insertion and management of the tubes. on one hand, when the attempt pursued by a radiologist is not successful after min of fluoroscopy other strategies should be considered including another operator or an alternative technique for tube positioning. on the other hand, information will be distributed toward the clinicians and nurses in order to improve the management of these tubes and avoid fortuitous displacement which was responsible of a significant amount of repeated procedures leading to undue irradiation. purpose or case report: to evaluate drug elution pharmacodynamics of doxycycline in an albumin-based solution, as used in percutaneous imaging-directed therapy of aneurysmal bone cyst (abc) and microcystic lymphatic malformation (lm) methods & materials: doxycycline mixed with % human serum albumin (hsa), and doxycycline mixed with saline solution (both mg/ml) were evaluated using a fluid diffusion chamber system over h, recording ph and doxycycline concentration. static ph and doxycycline concentrations were recorded every min for the first min, then every min for a total of h, averaged over trials in each of the hsa and saline systems. statistical analysis evaluated standard deviation and rate of change for the trials in each system. drug elution dynamics data were correlated with clinical experience in the doxycycline/albumin treatment of patients ( treatments) with aneurysmal bone cyst (abc) and patients with lymphatic malformation microcysts. results: drug elution was linear in both the hsa and saline systems, with statistically significant (p<. ) slower elution drug release from the albumin system as compared with the doxycycline and saline solution, both over and h. purpose or case report: to describe a successful interventional radiologic approach to the management of paget schroetter syndrome presenting as acute arm swelling in adolecent athletes. methods & materials: institutional review board approval was obtained for this retrospective study. five patients aged to years (mean . years) were treated at this institution over a year period all presenting with acute arm swelling (july -july ). ultrasound confirmed subclavian vein thrombosis in all cases. all were treated with placement of an infusion catheter (ev , plymouth, mn), infusion of tissue plasminogen activator (tpa) at a rate of mg/hour overnight and aspiration of remaining clot with a "trellis" (bacchus vascular, santa clara, ca, usa) thrombectomy device. results: clot was successfully removed in all five patients. complete clearance of clot was confirmed by contrarst venography in all cases. in four patients balloon angioplasty of a narrrowing at the junction of the subclavian and brachiocephalic veins was carried out. in one, the thrombus recurred within h. the patient was retreated the next day with aspiration of clot using the "trellis" device and an infusion catheter placed with low dose ( . mgs/hour) tpa commenced until surgical review; this patient was operated on within h of final thrombolysis. all patients were seen by a vascular surgeon with an interest in this condition. all underwent surgical decompression; at end of the study period all patients were asymptomatic. conclusions: interventional radiologic management of acute axillo-subclavian thrombosis due to paget schroetter syndrome is safe and highly successful in the adolescent population. early recurrence of thrombus is not uncommon and prompt surgical consultation with a view to early surgical decompression is recommended. purpose or case report: diagnostic reference levels (drl) or target radiation dose ranges for pediatric ct scans are needed in the u.s. the first u.s. pediatric ct dose index registry (quircc) within the american college of radiology recorded estimates of patient radiation dose using a new method (ssde) based on body width(bw) for the purpose of developing diagnostic reference levels (drl). in addition to developing drl at the th percentile, the purpose of this study was to determine the ssdes associated with the lower range of acceptable image quality through subjective image quality evaluation. methods & materials: six children's hospitals participated in a retrospective review of abdominal ct with iv contrast on patients < yrs of age. from exams, each site submitted de-identified images for selected cases based on ssde and patient width. a total of cases were selected from the lowest, first quartile and median ssde. six investigators reviewed images from each case under identical viewing conditions and rated them for subjective quality according to a score sheet and reference scale of images with known quantum mottle. cases were considered non-diagnostic if at least of reviewers ranked them as such. results: first, second, and third quartile ssde and ctdi-vol values from sites for each bw will be shown. / cases were ranked non-diagnostic by the reviewers. / non-diagnostic cases were below the th percentile based on ssde. / of "non-diagnostic" cases had ssde less than the th percentile. the unacceptable case with ssde above the th percentile ( cm, ssde . mgy) was due to subcutaneous metal implant with artifact. the quircc th percentile using ctdivol for a yr old is . mgy which is % lower than the acr ct accreditation data's published th percentile. conclusions: this consortium developed target dose ranges (drls) for ct of the abdomen with iv contrast for routine exam indications based on evaluation of image quality that establish lower and upper ranges ( - percentile) of patient dose(using ssde) associated with clinically acceptable images. this study demonstrates that pediatric radiologists in this consortium are comfortable interpreting images at or above the percentile ssde and judged all but one image within this target range as diagnostically acceptable. table ). with the exception of neonate chest, most used age-based techniques; only two centers reported using thickness. no survey used grids for wrist images, while / of the surveys used grids for chest and abdomen exams in -year-olds. at the most common sid there was up to a kvp variation ( year-old chest ap) and up to -fold variation in mas ( year old scoli lat). only two surveys used equipment that displayed the new iec exposure index. conclusions: participants report variability in the techniques and methods used to acquire common radiographic studies, reflecting differences between detector types and users. radiologists, technologists, medical physicists, manufacturers, and the fda have an opportunity to work together to standardize the techniques based on detector type to optimize radiation exposure for pediatric radiographic exams. disclosure: dr. don has indicated that he performs contract research for carestream and that he is on the speaker's bureau for siemens and receives an honoraria. purpose or case report: this study assesses community adoption of ct radiation dose guidelines after a -year international initiative to reduce medical radiation exposure in children. size-specific dose estimates (ssde) from community pediatric body ct scans are compared to ssde from matched scans obtained at a children's hospital that adheres to image gently campaign principles. we reviewed pediatric ct scans ( chest (c), abdomen/pelvis (ap), chest/abdomen/ pelvis (cap)) transferred from community imaging centers to our university children's hospital between july and february . community scans were acquired with variable parameters and reconstructed with traditional filtered back projection (fbp). comparison was made to children's hospital ct scans, performed in accordance with principles of the image gently campaign. because iterative reconstruction (ir) software was added to our scanner during the study, enabling us to reduce ctdivol by %, children's hospital scans were divided into two groups: a) scans obtained with standard weightbased pediatric protocols and fbp (october -october ; c, ap, cap) and b) scans obtained with reduced-dose weight-based pediatric protocols and blended ir/ fbp (october -april ; c, ap, cap). ctdivol and greatest lateral dimension were recorded from each scan and were used to calculate ssde. mean ssde from community scans was compared to mean ssde from children's hospital groups a and b. statistical analysis was performed with student's t-test. results: patient age range was - years in both community and children's hospital groups. mean ssde for community c, ap, and cap scans was . , . , and . times higher than mean ssde for matched scans in control group a (p< . ) and . , . , and . times higher than mean ssde for matched scans in control group b (p< . ). conclusions: ssde was significantly higher for community pediatric body ct scans than for matched scans performed at a children's hospital that adheres to image gently campaign principles. results suggest that more community outreach and education are required in implementation of low-dose ct protocols outside of children's hospitals. concurrent use of ir provides a means of achieving even greater ssde reduction than is possible with fbp alone and should be encouraged. paper #: pa- optimization of tube voltage and current in size-based pediatric ct imaging: a phantom study boaz karmazyn, md, radiology, riley hospital for children, bkarmazy@iupui.edu; yun liang, keith kaser, peter johnson, mervyn cohen purpose or case report: determine the change in ct dose index (ctdivol) required to maintain the same quantum mottle noise when using lower tube voltages ( and kvp) relative to kvp in different sized cylinder water phantoms (cwp) representing a wide range of pediatric body sizes. we performed mdct scans of , , , and cm cwp. thirty scans were performed for each phantom. the tube currents ranged from to mas with increments of mas, and the tube voltage levels were , , and kvp. the noise (standard deviation in hu) was measured using center region of interest (roi) that was % of phantom's area. two other rois (each % of the area) were placed at the center and periphery of the phantom images to measure noise gradient. results: in the smallest ( cm) cwp, approximately the same noise level was maintained with all three tube voltages without a significant change in ctdivol. for the , , and cm phantoms, the average ctdivol needed to be increased by %, %, and %, respectively, to maintain same noise level when the voltage was decreased from to kvp. the average ctdivol needed to be increased by %, % and % to maintain the same noise level in the , , and cm cwp when the tube voltage was decreased from to kvp. the difference between central and peripheral noise increased on average by . %, . %, . %, and . % in the cwp of , , , and cm, respectively. in each cwp, the central to peripheral noise difference was more pronounced (up to . % more) with decrease in kvp from to or . conclusions: noise measurements in the water phantom model indicate that tube voltage could be decreased from to in cwp of cm without significant change in ctdivol. it is also possible to decrease the voltage from to kvp with a minimal (< average %) increase in dose in cwps of , , and cm. the noise gradient increases with larger cwp and smaller kvp. paper #: pa- comparison of radiation dose estimates, image noise, and scan duration in pediatric body imaging using -row and -row ct jennifer johnston, md, radiology, cincinnati children's hospital medical center, jhtai@yahoo.com; daniel j. podberesky, erin angels, terry t. yoshizumi, greta toncheva, donald p. frush purpose or case report: to compare effective dose (ed) estimates, image noise, and scan duration for pediatric chest, abdomen and pelvis protocols using -row and -row ct scanners in various acquisition modes. methods & materials: organ doses were measured using mosfet dosimeters. dose, scan duration, and noise measurements were made in a -year-old anthropomorphic phantom for conventional helical, -detector helical and volume acquisition modes for chest, abdomen and pelvis protocols on a -row ct, and for helical mode on a row ct (aquilion one and aquilion , toshiba medical systems, otawara, japan) using similar scan parameters representing currently used clinical protocols. mean organ doses from three runs for each protocol, in combination with icrp tissue weighting factors, were used to obtain ed for each protocol. noise was measured as the standard deviation of hounsfield units in equivalent locations at levels for each protocol with an roi tool. ed and noise were compared with a paired t-test or sign test. results: compared to helical acquisitions on the -row ct, ed of all tested acquisition modes on the -row volume ct were significantly lower for chest, abdomen/pelvis (ap) and chest/abdomen/pelvis (cap) protocols (table) . scan durations were lower across the board on the -row volume ct. compared to acquisitions on the -row ct, noise was in general similar to those on -row ct protocols, but some acquisition protocols on the -row ct produced greater noise (table) , specifically volume acquisition for chest ct and -detector helical and volume modes for ap and cap protocols. conclusions: dose savings can be achieved for chest, ap and cap ct examinations on a -row ct scanner compared to helical acquisition on a -row ct, with shorter scan durations. image noise was in general comparable between protocols. although noise differences between some modes did reach statistical significance, the impact on overall image quality will need to be studied further. paper #: pa- the observed to expected total fetal lung volume as a predictor of short-and long-term morbidity in surviving infants with congenital diaphragmatic hernia emily stenhouse, the royal hospital for sick children, emilysten@doctors.org.uk; neil patel, judith simpson, watt andrew, gregor walker, carl davis purpose or case report: observed-to-expected total fetal lung volume (o:e tflv) is a validated mr measure which we have previously demonstrated to be significantly reduced in non-surviving infants with congenital diaphragmatic hernia (cdh). our aim was to investigate the relationship between o:e tflv and short-and long-term morbidity outcomes in surviving infants with cdh. methods & materials: a retrospective analysis of cases of isolated left-side cdh referred to our institution for fetal mr evaluation between - weeks. mr imaging studies were performed on a . t philips system using a phased array body coil. the observed tflv was calculated by multiplying the summed area of the region of interest by the section thickness. the expected tflv was calculated with a formula previously described in the literature using the gestational age of the fetus. the observed tflv was expressed as a percentage of the expected tflv at a given gestation. morbidity outcome data was obtained from the case records of all surviving infants. specific measures of illness severity relating to short-term intensive care management and long-term outpatient management were recorded. differences in o:e tflv between outcome groups were assessed by t-test. results: liveborn infants with isolated left-side cdh and antenatal mr scans were identified. scans were performed at - weeks gestation. infants survived to discharge; gestation . ( . - ) weeks, birth weight . ( . - . ) kg. median length of admission was ( - ) days, median duration of follow-up was . ( . - . ) years. o:e tflv was significantly lower in non-surviving infants; vs. %, p . . o:e tflv was significantly lower in infants who received high frequency oscillation ventilation (hfov) versus those who were conventionally ventilated ( % vs %, p . ). o:e tflv was also significantly lower in those infants who had a length of admission greater than the median of days ( % vs. %, p . ). o:e tflv trended lower with other measures of increased morbidity; inhaled nitric oxide use, patch repair of diaphragm, rehospitalisation within year, supplemental feeding at discharge, gastro-oesophageal reflux, and developmental delay. conclusions: as well as predicting survival, lung volume measurement by o:e tflv is a promising predictor of outcome and morbidity in surviving infants with cdh. further studies in larger populations are required to provide quantitative predictive risk data. characterization of the inherent acoustic noise of a dedicated nicu mri system jean tkach, phd, cincinnati children's hospital medical center, jean.tkach@cchmc.org; yu li, ron g. pratt, christopher villa, beth m. kline-fath, charles dumoulin purpose or case report: we have developed a small foot print . t mri scanner specifically for neonatal imaging that can be easily installed in a neonatal intensive care unit (nicu). the scanner has a maximum patient bore diameter of . cm (without rf coil), and roughly twice the gradient performance of the best conventional adult whole-body . t mr systems. it is known that sensory stimulation such as acoustic noise can elicit autonomic instability in both term and preterm neonates. the inherent noise properties of the nicu mri system were measured as part of the initial safety evaluation of the system and compared against that of a conventional . t mri system. to evaluate the inherent acoustic noise characteristics of the nicu mri scanner, sound pressure level (spl) measurements were performed on it and on a conventional adult sized whole body . t hdx ge mri system (ge healthcare, waukesha, wi). a brüel & kjaer model sound level meter (brüel & kjaer sound & vibration measurement a/s, denmark) was used to perform the spl measurements for several different mr acquisitions (spin echo, gradient echo, fast rf spoiled gradient echo, fully balanced steady state free precession, gradient echo echo planar, and diffusion weighted) using acquisition parameters consistent with clinical protocols. the mr sequences, acquisition parameters, noise measurement equipment and methodology were identical for the two mr systems. the maximum spl in units of a weighted decibels (dba) was recorded for each of the mr acquisition/mr system combinations evaluated. results: the maximum spl values measured during each of the mr acquisitions were lower for all sequences (average . dba (range - dba)) for the nicu mri unit as compared to the conventional mri scanner ( table ). the average measured maximum spl value, reported in dba, across all acquisitions was . ± . for the nicu scanner, and . ± . for the conventional mri scanner. the highest spl values were measured for the diffusion-weighted sequence: and dba, for the nicu and conventional mri scanner respectively. conclusions: because of the smaller dimensions of the gradient coils in the nicu mri system, acoustic noise is less than that of conventional mri scanners despite the superior gradient performance of the smaller coils. the lower inherent acoustic noise level of the nicu system provides improved safety for the neonate, and facilitates siting of the unit in the nicu. disclosure: dr. tkach has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. paper #: pa- late neurologic events in extremely premature infants carlos guevara, md, radiology, duke university, cjg @duke.edu; brett bartz, caroline l. hollingsworth, caroline w. carrico, michael c. cotten, charles m. maxfield purpose or case report: germinal matrix hemorrhage (gmh) is a major complication of prematurity. persistence of germinal matrix and immature neurovascular autonomic regulation in the premature neonate is thought to predispose to gmh. most gmh in premature population occurs during the first days of life, and yet the persistence of the germinal matrix to weeks gestation may allow for post-natal gmh outside of the immediate perinatal period. to our knowledge, this is the first systematic review of late gmh (after the first week of life) in a large population of extremely preterm neonates (less than weeks of gestation). this irb approved retrospective review included patients weighing less than g or born at less than weeks of gestation from through . the study population included infants who had a head ultrasound (hus) within the first week of life and at least one follow hus after the first week of life. all hus were reviewed by three experienced pediatric radiologists for the presence and grade of ich or late developing hemorrhagelike lesions (hll). infants with and without hll were evaluated for several clinical variables, including neurodevelopmental outcomes (bayley scales). results: average gestational age of study population was . weeks. the incidence of gmh in the first week of life was % grade , . % grade , . % grade / , and . % posterior fossa. new echogenic foci (hll) at the caudothalamic groove were seen in . % after the first week of life. % of these lesions were bilateral. a four-fold increase in incidence of hll was seen in infants < g compared to those> g. higher grade hemorrhages were not seen in this patient population, although % of infants had late posterior fossa hemorrhages. the clinical course of infants with hll trended towards a higher incidence of stressors, but this was not statistically significant. the psychomotor development index scores were lower than those infants without hemorrhage. conclusions: small hll at the caudothalamic groove are common in extremely preterm infants after the first week of life. higher grade ( - ) hemorrhages were not seen. there were no cases of intraventricular extension and no direct complications. if isolated, this finding necessitates no follow-up imaging, but may be associated with poor neurodevelopmental outcome. disclosure: dr. guevara has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: tof/apv is a rare congenital heart lesion in which pulmonary arteries may become aneurysmally dilated and compress adjacent airways. pulmonary arterioplasty is often required to relieve tracheobronchial compression in addition to intracardiac repair. the purpose of this study was to review pre and postnatal imaging findings and their impact on patient management and clinical course. methods & materials: a retrospective database search identified infants with tof/apv between - ( fetal diagnosed cases and diagnosed postnatally). for fdc, prenatal ultrasound (us) and fetal mri were correlated with postnatal ct for the size of the central pulmonary arteries, airway compression, and presence / distribution of air trapping/atelectasis. for all cases postnatal ct findings (between - days of age) were correlated with clinical management and outcome. results: prenatal diagnosis of tof/apv was suggested sonographically, based on dilated central pas, between - weeks gestational age (ga). fetal mri, performed between - weeks ga confirmed the diagnosis and aneurysmal central pas and demonstrated air trapping &/or atelectasis in / with normal appearing lungs in fetus. size of the pas ( / ) and presence and distribution of lung abnormality ( / ) correlated closely between fetal mri and postnatal ct, although detailed visualization of the central airway/ vascular relationships were better defined on ct. fetal mri identified an unexpected diaphragmatic hernia (dh) not seen on us. for the pnd cases, ct showed aneurysmal pas and airway compression with air trapping &/or atelectasis in / infants. seven infants with airway obstruction on ct required pulmonary arterioplasty; infant with no air trapping did not have arterioplasty. / operative patients survived, one with concomitant dh died at age days due to hemorrhagic shock. one fdc was inoperable due to poor cardiac function and died at age days. conclusions: prenatal mri correlates well with postnatal ct for assessing pulmonary artery size and location and severity of lung abnormality in patients with tof/apv, this allows for appropriate management planning and may negate the need for an immediate postnatal ct. ct accurately depicts the location and extent of airway compression and resultant air trapping or atelectasis, serving to guide the need for and extent of the arterioplasty procedure. paper #: pa- craniosynostosis syndromes: prenatal findings by us and mri eva rubio, md, cnmc, rubioeva@yahoo.com; anna blask, alexia egloff, dorothy bulas purpose or case report: craniosynostosis with associated malformations is a feature of several related syndromes resulting from a fgfr or twist genetic mutation. syndromes include apert, crouzon, pfeiffer, and carpenter syndromes. our purpose was to review imaging findings which aid in suggesting the diagnosis prenatally. we retrospectively reviewed prenatal us and mri findings in cases with prenatal ( with postnatal/molecular) diagnosis of a craniosynostosis syndrome: cases of apert, case of carpenter, and cases of pfeiffer syndrome. results: / cases were correctly diagnosed prenatally. in the second trimester findings may be subtle, with mild calvarial changes; digit abnormalities, in particular, may elude the imager in unsuspected cases. although the diagnosis could be made with either modality, the full spectrum of abnormalities was best appreciated using a combined imaging approach of mri and us. by us many salient features were depicted: turribrachycephaly/trigonocephaly/cloverleaf ( / ); syndactyly ( / ); polydactyly ( / ). agenesis of the corpus callosum was identified by us in ( / ) cases. conversely, mri, performed in all cases, contributed additional observations not well seen by us: the fetal airway was well delineated in all cases ( / ); a low lying spinal cord was noted ( / ), midface hypoplasia ( / ) and migrational/sulcation abnormality ( / ). additional findings of absent ductus venosus with biliary atresia ( / ), abdominal wall defect ( / ) and renal anomalies ( / ) were seen with both modalities. reimaging in later pregnancy depicted important changes ( / ), including worsening hydrocephalus and resolution of suspected airway occlusion. conclusions: us and mri are complementary modalities in evaluating fetuses with craniosynostosis. airway patency, midface hypoplasia, spinal cord abnormalities and intracranial abnormalities are often better seen with mri. fetal activity, digits, bone detail, and cardiac anomalies are better appreciated by us. findings may be subtle in the second trimester. repeat imaging in later pregnancy may reveal specific information affecting delivery planning. paper #: pa- pcpra best paper hyperpolarized carbon- mrsi for pediatric disease john mackenzie, md, department of radiology and biomedical imaging, ucsf, john.mackenzie@ucsf.edu; yi-fen yen, linda nguyen, jeffrey gu, john kurhanewicz purpose or case report: to study the potential of carbon- mr spectroscopic imaging ( c-mrsi)-a radiation free molecular imaging strategy-for the detection and treatment monitoring of pediatric disease. methods & materials: the potential of c-mrsi to detect pediatric disease was tested in rodent models of pediatric arthritis. animals were induced with arthritis and subsequently given intravenous hyperpolarized c-pyruvate, and imaged. the amount of c-lactate produced from pyruvate in normal and arthritic joints was measured both at single points in time and dynamically at either or tesla. the c-mrsi data were compared with clinical measures of arthritis, cell stimulation studies, and joint changes on conventional anatomic mri and histology. results: alterations in lactate production as measured by c-mrsi appear to depict sites of arthritis and correlate with other more established but potentially less reliable or more invasive measures of disease status. imaging robust mouse models of pediatric disease may be feasible at telsa. this method may also be translated from high-field to clinical equipment with reasonable hardware and software modifications that allow detection of hyperpolarized c compounds. c-mrsi depicts increased lactate production at specific regions of inflammation within arthritic joints and is confirmed by histological inspection and anatomic mri. on average, lactate production is increased by % in areas affected by inflammation. conclusions: the intravenous injection of hyperpolarized carbon- compounds and subsequent imaging with c-mrsi provides a unique molecular imaging strategy to noninvasively monitor pediatric disease. this non-invasive imaging strategy may eventually provide clinical utility for several pediatric diseases involving inflammation, infection and tumor. disclosure: dr. mackenzie has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. methods & materials: using the hemangioma-vascular malformation clinic registry at cincinnati children's hospital, we searched for patients diagnosed with khe whose evaluation included mri. twenty such patients were found, although three of the patients had no pre-therapy mris. the imaging studies were reviewed by the authors with assessment of the following characteristics: location, margin definition, soft tissue involvement, and pre and post contrast signal intensity. results: location: lesion location was as follows: trunk ( ), extremity ( ), extremity plus trunk ( ), and head/neck ( ). signal: all lesions were dark on t weighted sequences with diffuse enhancement after contrast administration. the majority of the lesions were bright on t weighted sequences, but there were cases that had heterogenous to low t signal (with all involving the retroperitoneum). of the cases, only one had both high arterial and venous flow by mri. margin definition: four of the lesions had well defined borders (greater than % well circumscribed) with minimal to no adjacent infiltration/edema. two of those four cases were exophytic masses. the remaining cases were poorly defined lesions with adjacent infiltrative fluid signal intensity and enhancement. tissue/organ involvement: tissue/organ involvement was counted if abnormal fluid-signal intensity or enhancement was identified at that site. review of these cases showed fifteen patients with muscular involvement. dermal and subcutaneous involvement was observed in all but cases, with the uninvolved lesions being isolated and deep. additional sites of suspected involvement included bone ( ), pleura ( ), penis ( ), and pancreas ( ). conclusions: khe is a rare neoplasm of infancy with a spectrum of features by mri. poorly defined lesions are much more frequent than well-circumscribed masses. however, pathologic correlation of such infiltrative margins is usually not available as treatments after biopsy are primarily medical rather than surgical. common additional mri features include predominant involvement of muscle, subcutaneous fat, and skin over viscera and bone with lesions generally showing increased t signal and enhancement. is dedicated chest ct needed in addition to pet ct for evaluation of pediatric oncology patients? ibrahim tuna, montefiore medical center, dristuna@yahoo. com; jeffrey levsky, jeremy rosenblum, rosanna ricafort, benjamin taragin purpose or case report: to evaluate the diagnostic accuracy of low dose ct performed during pet-ct as compared to dedicated chest ct in the assessment of pulmonary findings in children with malignancy. the institutional review board approved this hipaa compliant research. pediatric oncology patients, ages between - , with known solid malignant tumors who were referred to pet-ct and standard chest ct within days for staging or assessment of treatment response between - and - were eligible for this retrospective study. radiology reports were reviewed for potential discrepancies. two radiologists re-evaluated the standard chest ct and low dose chest ct portion of the pet ct of the discordant cases, while comparing with the most recent prior studies. studies were scored for pulmonary nodules, bony metastasis, adenopathy, and pleural effusions. true discrepancies were assessed by a panel of pediatric oncologists to judge whether the differences in reports might lead to a significant change in management. results: ( female, male) patients were identified. radiologic reports of different patients ( female, male) had potential discrepancies based on review of the reports. the primary tumors were rhabdomyosarcoma (n ), hodgkin's lymphoma (n ) and others (n ). reevaluation of the original images showed true discrepancies in . % ( / total ). in studies, the discrepancy had no clinical significance. in studies, a pulmonary nodule was identified on standard chest ct which was not described on the pet-ct. both of these patients had rhabdomyosarcoma. one of these patients had findings that pediatric oncologists considered significant enough to alter patient management. conclusions: we found a low false negative rate for clinically significant findings on the low dose portion of pet-ct as compared to standard chest ct. in the future, improvements in acquisition technique and post processing of the ct portion of the pet-ct may further improve its diagnostic utility, obviating the need for a routine separate diagnostic ct, thereby minimizing radiation exposure in these young patients. methods & materials: low-dose cta examinations were performed in pediatric patients over a three year period to evaluate suspected vascular traumatic injury with some patients receiving scans of more than one area of the body. areas scanned in this include the head and/or neck (n ), chest (n ), abdomen and/or pelvis (n ), upper extremity (n ) and lower extremity (n ). in of these patients, suspected vascular injury was due to a history of either blunt (n ) or penetrating (n ) trauma. patients were referred directly from the emergency department, while were inpatients and the remaining were referred from an outpatient setting. patients ( f: m) ranged in age from to years old (mean age ). studies were performed on a -channel mdct scanner with or kv, to mas, . to . mm section thickness, reconstructed with % overlap, and . to . pitch. contrast medium was power-injected using weight-based protocols to optimize iodine delivery. exams were interpreted on a workstation using advanced imaging techniques. patient radiation dose was calculated in all cases. clinical outcome was assessed through a month follow-up when possible. results: all studies were technically adequate. . % (n ) of studies revealed no vascular injury, while . % (n ) revealed acute vascular pathology. vascular injuries included vascular occlusion (n ), vasospasm (n ), narrowing/dissection (n ), pseudoaneurysm (n ), and transection (n ). extravascular traumatic findings were demonstrated in . % (n ), including fractures, lung injury, soft tissue hematomas, and a ruptured baker's cyst. of the patients with acute vascular findings, . % (n ) underwent surgical management (including for vascular injury), while . % (n ) were managed conservatively. one patient with active extravasation was managed with angiographically-guided embolization. in no case was catheter angiography required to confirm cta findings. conclusions: low dose cta is a reliable means to screen pediatric patients emergently for acute vascular injury. vascular and non-vascular pathology can be diagnosed noninvasively for efficient patient management. paper #: pa- elasticity measurement by acoustic radiation force impulse (arfi) technique of normal liver, kidney and spleen in healthy children mi-jung lee, radiology, severance children's hospital, mjl @yumc.yonsei.ac.kr; myung-joon kim purpose or case report: there are many previous studies about using acoustic radiation foce impulse (arfi) value to measure the elasticity of tissue, mainly the liver in adult patients. however, there was limited study about arfi measurement in the children. the purpose of this study is to evaluate the arfi value in the normal liver, kidney and spleen in healthy children and to evaluate the effect of sex, age, and body mass index (bmi). the study prospectively enrolled healthy pediatric volunteers who are under years old, and underwent abdominal ultrasonography and arfi between july and august . arfi velocity measuring was performed by - mhz linear probe for children under years old and - mhz convex probe for older children. arfi velocity was measured three times at each organ. however this measurement was stopped if the child cannot tolerate. results: two hundred two children (m:f : ; mean age, ± . years) were enrolled. and arfi measurement was performed only two time for some organs in three children. the mean arfi value was . ± . m/s in liver, . ± . m/s in right kidney, . ± . m/s in left kidney, and . ± . m/s in spleen. arfi velocity was not different between boys and girls. however, arfi velocity was different between right and left kidneys (p . ). the arfi value of right kidney, left kidney and spleen was correlated with age, height, weight and bmi (p< . ). however, the arfi value of liver was not correlated with these parameters. conclusions: arfi measurement is feasible in children with only three times acquisition for each abdominal organ. the mean arfi velocity was increased according to the age, height, weight and bmi in kidney and spleen, but it was constant in liver. disclosure: dr. lee has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: diagnostic image quality can be achieved over a wide range of radiation exposure in digital radiography. "exposure factor creep" or "dose creep'" in which technologists tend to increase dose to avoid the appearance of noise has been well described. using the alara principle, acceptable images can be achieved while minimizing dose. at our institution "dose creep" has been observed in bedside pediatric chest radiography. to address this we coupled a data mining tool with a continuous quality improvement (cqi) initiative which educates individual technologists on appropriate technique. methods & materials: radiation dose in digital radiography is estimated from an exposure index, a proprietary format that varies among manufacturers. our institution uses a fuji computed radiography system which calculates an s, or sensitivity value, that provides an approximation of the radiation dose to the imaging plate, using an inverse scale. overexposed bedside chest radiographs were defined by a s value less than . a data-mining program was developed to extract from the dicom header the s value and other relevant information, on a monthly basis. these data were used to provide training and feedback on a one-on-one-basis. results: with ad hoc feedback and group training initiatives prior to implementation of this new system, approximately . % ( / ) of bedside chest radiographs were overexposed over a four month period. after one-on-one intervention with the technologists, preliminary findings reveal a trend towards fewer overexposed radiographs with approximately . % ( / ) with s< . conclusions: our tool provides a simple method for systematically identifying overexposed radiographs and the corresponding responsible technologists. we anticipate that this personalized educational program will continue to reduce the proportion of overexposed radiographs and thus the radiation dose to our pediatric patients. purpose or case report: ensuring radiation protection for children undergoing ct scans is challenging due to rapidly changing technology, differences in ct equipment and potential lack of understanding of unique aspects of scanning children. the joint commission has named technologists' training as an "action" item. we developed online training modules to fill potential gaps in ct technologists' education. methods & materials: four modules were created by pediatric radiologists, radiologic technologists and medical physicists; were developed by education/training experts from major ct vendors (ge, philips, toshiba, siemens) through the medical imaging technology alliance. modules were created as microsoft word documents containing de-identified images and edited by education specialists at the american society of radiologic technologists and the alliance for radiation safety in pediatric imaging. they were converted to audio/video format using question/answer narration. vendor modules were created in microsoft powerpoint format and edited. all modules were converted into adobe captivate learning program to achieve uniformity of appearance. modules are hosted on the asrt server and linked to the image gently website. a certificate may be printed as documentation of completion. results: all modules are available at www.imagegently.org. two introductory modules discuss basics of ct equipment and medical physics related to radiation dose in children. the third and fourth modules discuss dose-saving strategies for neu-roct and body ct. four vendor-produced modules address unique aspects of equipment design such as automatic exposure control and dose saving strategies for children. conclusions: through collaborative efforts with medical imaging professionals and vendors, we have developed free online modules addressing radiation protection for children. ct technologist training in specific dose saving strategies for children is variable and limited. these modules have the potential to improve ct technologists' understanding of equipment. end confusion which focused attention on improving communication with patients and families. there is little research regarding health literacy (hl) in radiology. the purpose of our study was to determine if an educational intervention (brochure) improves hl for parents whose child will undergo a fluoroscopic study. methods & materials: an education exemption was obtained from the irb. a multidisciplinary team developed brochures for fluoroscopic procedures. participants were randomly selected and asked to complete a survey to assess their knowledge of the procedure and use of radiation both before and after reading a brochure. a final survey to rate and gain feedback about the brochure was completed. results: median age of children whose parents participated (n ) was years. vcug was most commonly performed ( %). prior to the brochure, % of participants knew the name of the test their child was having. after the brochure, % knew the name (p < . ). prior to the brochure, % felt informed about the test, whereas % felt informed after (p<. ). test scores showed an improvement in parent knowledge about the procedure with a median increase of points after the brochure (scale of - ; p<. ). even after reading the brochure, % of parents wanted more information. prior to the brochure, % of parents knew the test involved radiation compared to % afterwards (p<. ). parents improved their understanding of the relative amount of radiation compared to background from % before to % after the brochure (p<. ). overall, % rated the brochure > on a -point scale with % rating the brochure (p<. ). written feedback was uniformly excellent. conclusions: improving hl for parents is part of the mission of radiology medical professionals. our study demonstrates that there is room for improvement in communicating with parents about fluoroscopy. straightforward information for parents provided as a brochure improves their understanding of radiologic fluoroscopic procedures. paper #: pa- compendium of resources for radiation safety in medical imaging anum minhas, duke university, anum.minhas@duke.edu; donald frush purpose or case report: diagnostic imaging, including ionizing radiation modalities, maintains a foremost role in evaluation of medical disorders. there is increasing awareness and need for information across varied sectors about low level radiation and potential risks. many medical/scientific organizations have resources discussing radiation risk and management. however, there is no one resource compiling the same available information. methods & materials: websites, including those of national and international medical organizations (e.g., acr, "image gently" alliance, iaea) were reviewed for information on radiation dose, risk, justification, optimization, guidelines (which included general information about improvement in quality and dose reduction without specific mention of optimization techniques), appropriateness criteria, and general principles of radiation safety for radiography, fluoroscopy/angiography, and ct. this information was divided by modalities and separated into adult and pediatric populations. information from organizations that were not arbitrarily considered to be national (e.g., subspecialty society, regional organization, individual institution/practice) was not reviewed. the resources were then organized into tables, organized by modality. websites with training modules were noted as well. results: websites were explored. overall, less information is available about medical radiation safety in children compared to adults. across both, most information is available on ct, then fluoroscopy, and finally radiography. across all groups and modalities, there is no information available for patients/parents on optimization, appropriateness, or guidelines, with the exception of adult radiography where there were some guidelines. conclusions: this compendium on medical imaging radiation serves as a collective resource for communities including the public and regulatory organizations. additionally, the compendium can be used to determine redundant or deficient areas, providing opportunities for more comprehensive and efficient efforts in medical radiation protection for patients. inappropriate and cloned histories in children: how big a problem is it? leann linam, md, radiology, uams/ach, llinam@uams. edu; chetan c. shah, s bruce greenberg purpose or case report: acr standards require appropriate clinical history for obtaining imaging examinations. cloning clinical histories is a federal violation. our purpose is to determine the frequency of inappropriate histories (ih) and/or cloning histories (ch) at a tertiary children's hospital. methods & materials: three pediatric moc radiologists reviewed clinical histories for radiographs obtained at a tertiary children's hospital on randomly selected dates ( weekdays and weekend day) for appropriateness and cloning. appropriate histories have associated icd- codes. cloning is defined by identical clinical histories occurring on consecutive days and could be clinically appropriate or inappropriate. only the first patient radiograph on a day was included. χ testing was performed to determine significant differences. results: % ( / ) of exams had ih. ih were significantly more common in inpatients than outpatients (p< . ). nicu examinations accounted for % of all ih and were significantly more frequent than other inpatient locations (p . ). the cvicu examinations accounted for % of all ih and was the second most common patient location for ih, but not significantly different from other inpatient locations (p . ). the increased frequency in ih on the weekend reflects a change in patient mix with fewer outpatient examinations performed than on weekdays and was not significant (p . ). the most common ih included: evaluate ett or evaluate lungs ( each). cloning only occurs in inpatients and was combined with ih in % of patients with ch. the nicu accounted % of ch which was significantly greater than other inpatient locations (p . ). conclusions: in radiographs had ih which can lead to misdiagnoses or nonpayment by insurance companies. inpatients, especially the nicu were the most common patient locations. cloning was also a common problem and was frequently combined with ih. identifying the extent of ih allows for corrective educational measures to be instituted which should improve compliance with existing medical and legal standards for ordering radiographs. paper #: in vivo validation of size-specific dose estimates (ssde) through breast entrance skin dosimetry (esd) during pediatric chest ct angiography sjirk westra, md, radiology, massachusetts general hospital, swestra@partners.org; xinhua li, mannudeep kalra, bob liu, suhny abbara purpose or case report: ssde is a new ct dose measure that corrects scanner console ct dose index (ctdi) for cross-sectional body diameter, being a better estimate of absorbed dose in individual patients of varying body size. ssde has been developed through phantom studies and computer simulations of ct dose, but has not yet been validated in vivo. the purpose of our study was to determine correlation between ssde and measured breast entrance skin dose (esd) for pediatric chest cta across a variety of scanning techniques, scanner models and patient sizes. methods & materials: our study was irb-approved, with waiver of written informed consent. during consecutive chest cta exams done on different scanners over a period of years, we measured mid-sternal esd as an approximation of breast dose with skin dosimeters, which was also expressed as mammogram equivalents. for each scan, we recorded patient age, weight, effective ma, kvp, console ctdivol- cm and dlp- cm (from which we calculated age-adjusted effective dose (ed)). we measured effective chest diameter Ø to convert ctdi to ssde, and we correlated ssde with measured breast esd, using linear regression. we evaluated image quality with regard to answering the clinical question. (table) , due to systematic introduction of automatic exposure control, low kv and high pitch scanning techniques. all studies were of diagnostic image quality to address the clinical question. conclusions: ssde is a valid measure of ct dose in pediatric patients undergoing chest cta over a wide range of scanner platforms, techniques, and patient sizes, and may be used to model breast and other organ dose, and to document results of dose reduction strategies over time. purpose or case report: the purpose of this project was to create an automated system capable of quantifying slice-byslice ct image quality and radiation dose data based on patient size. the information generated from this system should enable size-specific optimization of ct scan parameters in order to obtain images of diagnostic quality at the lowest possible radiation doses. methods & materials: a mathematical model was developed to predict ct image noise based on kvp, effective mas, and water-equivalent diameter of the patient. a conical water phantom was used to calibrate the model on multiple scanners and accounting for different operational modes and scan parameters, including tube voltage (kvp), tube current (effective mas), bowtie filter, and focal spot size. a software application was created to process image data from the scout topogram and incorporate dicom metadata from the axial images. a database and data viewing application were developed to display individual and aggregate study data. all of these systems were integrated and automated to enable real-time monitoring of image quality and radiation dose as a function of patient size. results: since the completion of the automated system, ct exams have been processed. a search application allows the user to find an individual study or a collection of studies based on parameters such as body part imaged or study protocol. the viewing application displays slice-by-slice patient diameter, radiation dose, and image quality for each study. radiation dose estimates are adjusted for patient size, yielding size-specific dose estimates. the application also graphs individual study data compared to those of comparative studies that are included in the search. conclusions: we have successfully developed an automated system that monitors ct image quality and radiation dose data based on patient size. the system enables simultaneous real-time monitoring of all studies performed on all ct scanners at our institution. specifically, the system enables size-specific radiation dose estimates at every scan level. this system will be used to guide protocol adjustments in order to optimize ct image quality and thus optimize radiation dose. disclosure: dr. larson has disclosed that he has a patent application in process through cchmc for ct radiation dose reduction. purpose or case report: at many institutions, ct scan parameters for children are determined by patient age or weight. aapm task group recommends cross sectional body dimension, such as patient width to determine size specific dose estimates. the purpose of our study was to develop prediction models of body width based on patient age and weight and compare these models with actual measured body widths for children undergoing body ct. methods & materials: children's hospitals participated in a -month retrospective review of abdominal ct scans on patients < years of age after local irb approval. recorded values included patient width(cm) from an axial image at the level of the splenic vein, patient age (yrs) and patient weight (lbs). a regression model for predicting patient width as a function of age and weight was determined. results: exams, had all measurements. both age and weight were significant predictors of patient width (p<. ). there was also a significant interaction between weight and age (p<. ), indicating that the relationship between patient width and weight depended on the age of the patient. the r for the regression model for predicting patient width from age and weight individually were . and . respectively. the r for the model including both age and weight and their interaction was . leaving % of the variation unexplained. the regression equation for this model is: patient width . + . x age(yrs)+ . x weight(lbs)- . x age x weight. despite the r of . for the model using both age and weight, the average error (rmse) for predicting patient width compared to a direct measurement of width was . cm. the plot of observed minus predicted values (residuals) versus predicted values indicates that the best model (combination of weight and age) results in measurable errors of predicted patient width relative to direct measurement. conclusions: a combination of both patient age and weight results in a more accurate patient width prediction than using age or weight alone. while age and weight can be used to predict body width, this is not sufficiently accurate for generating ct protocols. therefore, direct measurement of body width form either physical measurement on the patient or from the scout view or an axial image is preferred to select appropriate scan parameters for pediatric abdominal ct. paper #: pa- automated size-adjusted dose monitoring for pediatric ct dosimetry olav christianson, clinical imaging physics group, olav. christianson@duke.edu; ehsan samei, donald frush purpose or case report: the potential health risks associated with low levels of ionizing radiation have created a movement in the radiology community to minimize radiation dose during ct imaging; this is especially important for pediatric patients due to their increased sensitivity to radiation. it is thus essential to accurately assess the risks to pediatric patients undergoing ct imaging. current efforts to monitor radiation dose, however, are limited because they do not account for differences in risk from ionizing radiation due to variability in patient size, age, and gender. in this context, we developed an automated size-adjusted dose monitoring program capable of performing patient-specific risk estimation to facilitate protocol optimization. methods & materials: dicom routing software was used to send dose reports and scout images to an image repository on a dosimetry server. optical character recognition was used to extract dose-relevant data from dose reports; patient size was determined from corresponding scout images. based on anatomical location, risk estimation conversion coefficients (qfactors) were determined for each series in the dose reports. the q-factors were adjusted according to patient size, age, and gender and then multiplied by the dlp to estimate the risk to each patient. this process was applied to the cohort of pediatric patients undergoing ct examination at our institution. to evaluate the impact of including patient size, age, and gender, risk estimates were obtained excluding and including the dependencies on size, age, and gender. the results were computed in units of cancer incidence per cases exposed (cpt). results: the average patient-generic risk estimate for a pilot group of patients undergoing body ct was . ± . cpt. by including patient size, the risk estimate was increased to . cpt± . cpt. by including patient age and gender, the average risk estimate was further increased to . cpt± . cpt. conclusions: we developed a new size-adjusted dose monitoring program for pediatric ct dosimetry. comparisons between patient-generic and our new patient-specific risk estimates show that failure to consider patient size, age, and gender resulted in risk estimates that were too low by a factor of seven. additionally, the increase in standard deviation we observed demonstrates that our method of including patient size, age, and gender is sensitive to the inherent variability in the patient population. disclosure: dr. christianson has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: treatment of prenatally diagnosed lung masses is controversial, with many specialists recommending elective surgical removal in the first year of life because of a reported or perceived increased risk of infection and malignancy, while other centers recommend a conservative approach to management. the natural history of unresected lung masses is not clear. in our center, our standard recommendation is prophylactic resection of asymptomatic lesions, although not all families choose this option. we asked whether respiratory morbidity increased during the time prior to elective resection of prenatally diagnosed lung masses. methods & materials: ninety-eight pregnant women carrying fetuses with chest masses were imaged by ultrasound (us) and magnetic resonance imaging (mri). medical records of the liveborn infants were retrospectively reviewed. results: fetal diagnosis of a lung mass was made at a mean of weeks gestation (range - wks). intrauterine fetal demise was documented in pregnancies. there was one elective termination of pregnancy. three infants were lost to follow up. thus, outcomes were available for children ( % m, % f) with prenatally diagnosed lung masses. significant respiratory morbidity (rm) was defined as the occurrence of pneumonia, asthma, chronic coughing or wheezing, or respiratory symptoms severe enough to require an emergency room visit or hospitalization. of the children who had surgical removal of their lung mass, ( %) had rm prior to surgery. fifteen out of children did not have surgery but have been followed expectantly, and of ( %) developed some form of rm. fifteen of ( %) infants had immediate and significant rm (tachypnea, grunting, increased work of breathing, increased oxygen requirements or need for intubation) in the newborn period leading to urgent surgery (range of age at surgery: - d; mean . d). of the initially asymptomatic infants, ( %) developed rm prior to elective removal of the mass (range - weeks, mean weeks). of the lesions removed, histology revealed: cystic adenomatoid malformation (ccam) %, ccam + sequestration %, sequestration %, congenital lobar emphysema (cle) %, ccam+cle %, other %. conclusions: the risk of respiratory morbidity appears to be increased during the time prior to elective resection of prenatally diagnosed lung masses, which may be important for parents and pediatric specialists to consider when deciding whether to remove an initially asymptomatic lung mass. purpose or case report: it is now accepted that fetal mri with its superior tissue resolution can be very helpful in clarifying anomalies detected during obstetrical ultrasound. this is particularly the case with intracranial abnormalities, although indications are expanding. the current english medical literature, though, appears to be focused on evolving mri techniques and how mri compares to ultrasound with regards to image quality and detection of additional findings which may alter the diagnosis. however, we found no study specifically evaluating the clinical relevance and impact of the information obtained by fetal mri to the specialists who counsel and treat these patients. a "satisfaction and clinical impact" survey was created and sent to all the members of our fetal diagnosis and treatment group, asking specifically how the clinicians rated their satisfaction with this type of imaging, its influence on their counseling and on various clinical decisions, both prenatal and postnatal. results: we received responses from specialists in different clinical disciplines. the greatest number of respondents came from our obstetricians ( %), many of whom perform their own ultrasounds, and from members of our medical geneticists/genetic counselors ( %), although % of respondents were from various other clinical disciplines, both medical and surgical. there was a surprisingly high degree of satisfaction overall with the quality of the images and with the type and amount of information provided. most respondents indicated they felt fetal mri was "moderately" or "extremely" useful for their particular clinical decisions, and most respondents agreed that fetal mri impacted "moderately" or "significantly" on counseling and management of these pregnancies. impact appeared greatest on the counseling of the parents and their decision to terminate/pursue the pregnancy, and the least impact was on issues around delivery. conclusions: fetal mri, in addition to providing images of better quality, particularly in certain conditions, has clinical value in that it directly impacts on the counseling of parents and on clinical decisions. - . ultrasound reports were reviewed to determine sonographic diagnoses. selected patients from this cohort underwent mri using ge . tesla magnet without contrast (sequences included ssfse, fiesta, fgre or dual echo in planes). the images were reviewed and multiple characteristics were assessed for specifiying the area of obstruction. the features included: presence of normal fluid-filled bowel, small rectum for gestational age, signal of meconium in the rectum, and meconium filled dilated bowel. results: cases of sonographically suspected bowel obstruction were identified during the study period; of these underwent fetal mri. of these cases, had normal mri and postnatal outcomes, cases did not have postnatal findings available, and had postnatal meconium peritonitis but no obstruction. one case of congenital chloride diarrhea was diagnosed by fetal mri. a variety of bowel abnormalities were observed amongst the remaining cases. proximal obstruction was diagnosed in cases: jejunal atresia (n ) and multiple atresia (n ). distal obstruction was diagnosed in cases: ileal atresia (n ), meconium plugging (n ), closed gastroschisis (n ), enteral duplication cyst (n ), and imperforate anus (n ). characteristic patterns of features were identified amongst these cases that specified the location of obstruction. these patterns of findings allowed accurate localization of the level of obstruction in all cases when compared to postnatal findings. distal obstruction was characterized by normal fluid-filled small bowel and high t signal in distended loops. jejunal atresia was characterized by multiple loops of dilated bowel with high t signal primarily in the left upper quadrant. small rectum for gestational age was not consistently associated with proximal or distal atresia. conclusions: evaluation of fetal mri with attention to specific features allows localization of bowel obstruction. this may aid in counseling and postnatal management, including the need and type of postnatal imaging study. early diagnosis and treatment of ph may prevent clinical deterioration. pvt may produce a spectrum of imaging appearances, which has not been fully recorded in the literature. the goal of this paper is to review the spectrum of imaging appearances of neonates and survivors of neonatal pvt with special emphasis on the role of us and to correlate these findings with the clinical findings including outcome. methods & materials: a retrospective review of consecutive neonates admitted between - and diagnosed with pvt was conducted. diagnosis was established by us at a mean age of days (range: - ). health records, initial and follow-up (f/u) imaging were reviewed. findings were classified as non occlusive, single branch, pvt (grade ); occlusive pvt (grade ) and pvt with extensive parenchymal ischemia (grade ). results: pvt was diagnosed in patients, of whom were followed up to for years or longer. twelve patients were excluded due to liver disease, expired and were lost to f/u. of the in whom f/u was available, at the time of initial diagnosis, grade pvt was present in , all were on the left. grade pvt was diagnosed in and grade pvt in . on f/u physical exam, findings were unremarkable in / patients. liver function tests (lft) and thrombophilia assessment were available in children, mild lft abnormalities were noted in and children had evidence of thrombophilia. us exams were available in / children. among the survivors of neonatal pvt, us was regarded as normal in only children; showed left lobar atrophy (lla), had slowly progressive splenomegaly without other signs of ph, and developed clinically significant ph requiring shunting. conclusions: pvt has a wide spectrum of imaging appearances, it is possibly underdiagnosed and clinically unsuspected. varying degrees of lla are likely a sequela of clinically silent left pvt. us is a sensitive method for the detection of disease and assessment of progression. paper #: pa- fetal mri in arthrogryposis hedieh eslamy, md, radiology, lucile packard children's hospital, hkeslamy@gmail.com; erika rubesova, louanne hudgins, britton rink, richard a. barth purpose or case report: to present the fetal mri findings in fetuses with a prenatal diagnosis of arthrogryposis and correlate with postnatal outcome or autopsy results. arthrogryposis refers to contractures involving more than one joint which often represent deformational changes secondary to decreased or absent fetal movement. prognosis varies widely dependent on diagnosis, ranging from isolated contractures in amyoplasia to lethality in some cases. we hypothesized that fetal mri may demonstrate central nervous system (cns) pathology and muscle abnormalities which are important for predicting postnatal outcome. methods & materials: we identified fetuses with a diagnosis of arthrogryposis between january and october . all had fetal mri which was performed on a ge . tesla magnet, with ssfse, fiesta and fgre sequences in planes. the fetal mri's were evaluated for cns and muscle abnormalities. the extremities were evaluated for: muscle mass, increase in subcutaneous fat (indicative of muscle atrophy), and extremity joint positioning. these findings were subsequently correlated with the clinical exam of the neonates, pathology in the abortus and karyotype when available. results: results of fetal us, amniocentesis, fetal mri and post-natal or post-termination outcomes will be summarized. five fetuses had ≥ limb joint contractures. a sixth case had neck hyperextension and lateral flexion associated with akinesia and hydrops. on mri, no structural brain or spine abnormalities were identified. the abnormalities detected in the extremities were: severe decrease in muscle mass associated with increased subcutaneous fat ( cases); normal muscle mass ( cases); moderate decreased muscle mass associated with increased subcutaneous fat ( case). in the cases that delivered, the diagnoses were amyoplasia ( ) and distal arthrogryposis ( ). in a fourth case that underwent elective termination, autopsy was consistent with amyoplasia. two cases are pending delivery. conclusions: while fetal mri can be useful to rule out cns anomalies, it may also provide important information on decreased muscle mass as an important prognostic sign in a fetus with arthrogryposis. in our series, severely decreased muscle mass was predictive of amyoplasia, and joint contractures limited to hands and feet with preserved proximal muscle mass was predictive of distal arthrogryposis. both diagnoses are associated with relatively good prognosis and usually normal intelligence. purpose or case report: the purpose of this study is to assess the effects of iterative reconstruction technique (irt) on image quality metrics measured in child-sized anthropomorphic phantoms as kvp is changed. methods & materials: ct scans were performed on anthropomorphic phantoms with sizes of , & years (atom phantoms, cirs, norfolk virginia) using low dose pediatric chest protocols ( . , & msv) to determine baseline noise and dose levels. subsequently three voltage levels ( , & kvp) were used while adjusting mas to maintain baseline ctdivol and without mas adjustment which allowed varied ctdivol. images were reconstructed using % filtered back projection (fbp) and blends fbp: ir ( : , : , & : ) . parameters including ctdivol, dose length product, scan length, kvp, and mas, were recorded for each scan. image noise, contrast:noise (cnr), and signal:noise (snr) data were recorded from rois in phantoms and dilute iodine contrast filled syringes ( , , . %). results: as kv is lowered from to , image noise is doubled if mas is not increased to maintain ctdivol, and cnr is increased but snr is decreased due to the increased image noise. as kvp is lowered from to , image noise is increased nominally ( - %) if mas is increased to maintain ctdivol; therefore the increase in cnr and decrease in snr is negligible. ctdivol is reduced > % in all phantom scans as kv is reduced from to . irt reduces image noise by up to % [range - %] in all phantom sizes and in clinical images. as ctdivol is maintained in patient scans, image noise, cnr, and snr are reduced in patients (p< . ), resulting in improved image quality. conclusions: when lowering kvp, compensation with increases in mas is necessary to maintain ctdivol. however, lower target ctdivol can be achieved when adding irt as image noise can be decreased. for these phantoms, cnr and snr improved using all [selected] levels of ir, even when kv was reduced, resulting in lower ctdivol in phantoms. at all kvp settings when irt is applied, image noise is reduced, resulting in improved cnr and snr for all phantoms. disclosure: dr. bardo has indicated she is in the speaker's bureau and receives an honorarium from koninklijke philips. paper #: pa- adaptive iterative dose reduction in evaluation of the pediatric abdomen with ultra-helical -channel mdct jeffrey hellinger, md, stony brook university, jeffrey. hellinger@yahoo.com; bernice hoppel, richard mather, monica epelman purpose or case report: radiation reduction is paramount for pediatric patients. ultra-helical -channel mdct allows for rapid acquisitions at low dose. we evaluated the ability of a new adaptive iterative dose reduction algorithm (aidr) to reduce noise in low-dose ultra-helical pediatric abdominal ct scans. aidr is an iterative algorithm that adaptively reduces noise in the raw and image domains while preserving image structure. the raw data from consecutive low-dose pediatric abdomen exams was gathered. a dose simulation tool which adds noise to raw projection data was employed to simulate tube current at / of baseline ma. data were reconstructed with both standard filtered back projection and with aidr. regions of interest were drawn in the liver and lumbar musculature to determine the signalto-noise (snr), contrast-to-noise (cnr) and overall diagnostic quality of each data set. statistical significance was determined using a student's t-test. subjective image quality was evaluated by two reader blind review using a five point scale ( excellent, unacceptable). results: the snr and cnr were significantly lower for the % dose reduction datasets compared to the original filtered back projection reconstructions (snr: . vs . , p< . ; cnr: . vs . , p . ). when aidr was applied to the % dose reduction data, the snr and cnr improved to be superior to the native case (snr: . vs . , p< . ; cnr: . vs . , p . ). the average image quality score for the low dose datasets with aidr was . compared to . with standard filtered back projection at the baseline ma conclusions: aidr significantly improves the image quality of pediatric abdominal ct images. with a simulated % reduction in dose, aidr produces images with significantly greater snr and cnr. the subjective image quality scores for aidr showed dramatic improvement over standard filtered back projection. aidr processing algorithms with ultra-helical mdct will allow % reduction in radiation exposure while achieving the same diagnostic quality as compared to routine pediatric abdomen mdct radiation protocols with filtered back projection processing algorithms. purpose or case report: to explore incorporating asir into pediatric head ct protocols, to reduce patient radiation dose while maintaining image quality. methods & materials: an alderson rando head phantom was estimated to approximate the size of a -year-old child's head, and was scanned at decreasing % ma intervals ( to %, to ma) relative to this institution's age-based head ct protocols. each of these studies was then was reconstructed at % asir intervals ( % to %), and a mm roi was obtained in a consistent location behind the frontal bone to estimate noise (sd). using this phantom data, our ventriculoperitoneal (vp) shunt follow-up ct protocol was modified, and patients were scanned at % asir with approximately % ma reductions relative to our normal age-based mas. these asir studies were then anonymously compared to older non-asir head ct studies from the same patients (with identical kvp/slice thickness) by two blinded attending pediatric neuroradiologists. all studies were evaluated subjectively for diagnostic utility ( - ), sharpness ( - ), noise ( - ), and artifacts ( - ). - mm rois were drawn in consistent locations to estimate noise in air, bone, csf, and white matter (wm). results: the phantom study suggested similar same noise levels at % ma/ % asir ( . ) and % ma/ % asir ( . ). patients (average , range to years) were then scanned at approximately % ma reductions, with an average of days (range to days) between the asir study and prior non-asir study. the average ctdivol and dlp values of the % asir studies were . mgy and . mgy-cm, and for the non-asir studies were . mgy and . mgy-cm, representing statistically significant decreases in the ctdivol ( . %, p . ) and dlp ( . %, p . ) values. there were no significant differences between the asir studies and non-asir studies in respect to diagnostic acceptability (p . ), sharpness (p . ), or noise (p . ). there was a non-significant trend that the asir studies had a lower artifact score ( . vs . , p . ). there was good to perfect (kappa . to . ) agreement. the asir studies had statistically significant decreased csf noise ( . vs . , p . ), but no noise differences were seen in air (p . ), bone (p . ), or wm (p . ). conclusions: our findings suggest that asir can provide dose reductions in pediatric head ct without affecting image quality. purpose or case report: to validate the t map as a noninvasive quantitative biomarker of fatty infiltration of muscles and to determine whether the t map can differentiate between boys with dmd and healthy boys. methods & materials: two groups of boys with similar ages (range - years) were evaluated: boys with dmd (mean age . years) and healthy boys (mean age . years). mr images were performed at t. fatty infiltration of the pelvic and thigh muscles on t -weighted images (wi) was graded from to . on t maps with and without fat suppression, the muscle with the greatest fatty infiltration on t -wi was selected, and a region of interest was placed to obtain t values. t values from t maps with fat suppression were subtracted from values of t maps without fat suppression and designated as the "t fat value." t fat values were obtained from the same muscles in all boys. comparison was made between the t fat values of the two groups. the upper reference limit of the reference interval (ri) of t fat values was obtained from the control group to establish the normal range and applied to both groups to determine the accuracy of the t map. results: the gluteus maximus muscle had the greatest fatty infiltration on t -wi. median t fat value was . msec for dmd ( % ri . , range . - . ) and . msec for the control group ( % ri . , range . - . ). when applied to the two groups, the upper reference limit of the ri for control patients yielded % sensitivity, % specificity, % positive predictive value, and % negative predictive value. conclusions: utilization of t maps for the quantitative measurement of fatty infiltration of muscles can clearly differentiate between dmd and normal control boys with a high degree of accuracy and precision. this advanced noninvasive technique may potentially replace invasive muscle biopsies currently used for diagnosis. purpose or case report: prior work has shown that the gluteus maximus muscle has the greatest t relaxation time on mr imaging using t mapping in boys with duchenne muscular dystrophy (dmd). however, an increased t value on t relaxation time mapping may reflect both fatty infiltration and inflammation of the muscle. fatty infiltration characteristically follows inflammation in this disease process. therefore, the purpose of this study was to determine the contribution of each component (fat and inflammation) within gluteus maximus muscles and to correlate each component to clinical assessments. methods & materials: forty-six boys with dmd (ages: - years) were recruited. mr imaging of the pelvis using t maps with and without fat suppression were performed. the t map "fat values" (t value calculated from the t map without fat suppression [fs] minus t map with fs) and the t map "inflammation value" (t value from the t map with fs) were obtained. clinical assessments typically used to evaluate dmd patients (including clinical functional score, ft run, gower score, and step-up time) were also performed. spearman correlation coefficients between fat and inflammation values and the clinical assessments were calculated. results: there was a statistically significant correlation between the fat value of the gluteus maximus muscle and each clinical assessment test (p< . ). however, the inflammation value of the gluteus maximus muscle did not correlate with any clinical assessment. conclusions: in dmd, the amount of fatty infiltration of the gluteus maximus muscle has excellent correlation with clinical assessment. the amount of inflammation of the gluteus maximus muscle, however, does not correlate with clinical function. therefore, further study is needed to determine whether components (fatty infiltration or muscle inflammation) of the single most involved muscle reflect the components of all the muscles of the pelvis and thighs and whether the cumulative muscle involvement of each component represents clinical disease severity. utility of contrast-enhanced mr imaging in children with osteonecrosis: does gadolinium help? lamya atweh, md, radiology, texas children's hospital, laatweh@texaschildrens.org; robert c. orth, wei zhang, r. paul guillerman, herman kan purpose or case report: at our institution, gadolinium contrast-enhanced mr sequences are often obtained to assess epiphyseal and non-epiphyseal osteonecrosis in children. several studies have shown that dynamic contrast-enhanced sequences may provide prognostic information about long-term complications and healing of osteonecrosis. to our knowledge, no studies have determined the added value of routine post-contrast mr imaging in assessing acute complications related to chronic osteonecrosis. the purpose of this study was to evaluate the utility of intravenous gadolinium contrast in the mri identification of complications in children with an established diagnosis of osteonecrosis. methods & materials: patients were restrospectively identified (age range: . years to . year; m:f : ) with an imaging diagnosis of chronic osteonecrosis who underwent contrast-enhanced mr studies between / and / . the pre-and post-contrast mr images were consensus reviewed by two caq pediatric radiologists. pre-and post-contrast images were reviewed at separate times. the pre-contrast images were available during the review of post contrast images. studies were assessed for: osteonecrosis location (epiphyseal, non-epiphyseal osteonecrosis, or both), joint effusion, marrow edema, and epiphyseal collapse. % confidence interval (ci) and cohen's kappa coefficient(κ) was calculated to assess observed agreement. results: the diagnosis of osteonecrosis without complicating features was made in . % (ci: . - . %) ( / ) of pre-contrast studies and . % (ci: . %- . %) ( / ) of post-contrast studies. when chronic osteonecrosis with complicating features was identified,pre-and postcontrast images idenfied joint effusion in . % ( / ) and . % ( / ) (κ . , p< . ); marrow edema in . % ( / ) and . % ( / ) (κ . , p< . ); and epiphyseal collapse in . % ( / ) and . % ( / ) (κ . , p< . ), respectively. myositis or muscle strain was incidentally diagnosed in . % ( / ) pre-contrast and . % ( / ) post-contrast (κ . , p < . ) studies. conclusions: the high observed agreement between the pre-and post-contrast mr images shows that the addition of intravenous gadolinium may not be necessary in the majority of children with chronic osteonecrosis. paper #: pa- systematic protocol for assessment of the validity of bold mri in a rabbit model of inflammatory arthritis at . tesla michael chan, bhsc, university of toronto, mw.chan@ utoronto.ca; afsaneh amirabadi, anguo zhong, antonella kis, rahim moineddin, andrea s. doria purpose or case report: blood oxygen level-dependent (bold) mri has the potential to identify regions of early hypoxic and vascular joint changes in inflammatory arthritis. at this point, there is no standard protocol for data analysis of bold mri measurements in musculoskeletal disorders. standardization of the technique is paramount to compare results between studies and assess the validity of this technique in tissues outside the blood-brain barrier. our objective is to optimize bold mri reading parameters in a rabbit model of inflammatory arthritis by determining the diagnostic accuracy of ( ) statistical threshold values (r> . vs r> . ), ( ) summary measures of bold mri contrast [ the mean of the % bold signal differences within the region of interest (roi) (diff_on_off) and the percentage of suprathreshold voxels within the roi (pt%)], and ( ) voxel activation algorithm (positive, negative, and positive_negative). methods & materials: using bold mri protocols with a carbogen stimulus on a . t magnet, we imaged injected and contralateral knee joints of juvenile rabbits at baseline, and days , and after a unilateral intra-articular injection of carrageenin. nine non-injected rabbits served as controls. receiver operating characteristic (roc) curves were plotted to determine the diagnostic accuracy of the reading parameters. the bold measures from [(injected knee-control knees)/control knees] were counted as positive cases, while the bold measures from [(contralateral knees-control knees)/control knees] were regarded as negative cases. areas under the curve (aucs) were calculated to determine the most accurate parameters. results: using diff_on_off and positive_negative activations as constants, r> . was found to be more accurate than r> . (p . at day ). comparison of diff_on_off and pt% yielded no statistically significant difference (p> . ). finally, positive_negative activations for diff_on_off and negative activations for pt% using r> . were the most diagnostically accurate (auc . , p< . at day , and auc . , p< . ). conclusions: from the results of this study, the most diagnostically accurate and clinically relevant reading parameters included the use of a more lenient threshold of r> . , a diff_on_off measure of bold contrast, and a positive_negative voxel activation algorithm. pt% may used as an ancillary measure of bold contrast. quantitative versus semi-quantitative mr imaging of cartilage in blood-induced arthritic ankles andrea doria, md, phd, diagnostic imaging, the hospital for sick children, andrea.doria@sickkids.ca; ningning zhang, carina man, pamela hilliard, ann marie stain, victor blanchette purpose or case report: to cross-sectionally compare the ability of a scoring system (semi-quantitative method) with a manual segmentation technique (quantitative method) to evaluate the status of the articular cartilage of growing ankles of children with blood-induced arthritis. methods & materials: boys, with hemophilia (a, n ; b, n ) and with von willebrand disease, median age (range, - ) underwent a high resolution mri protocol at . tesla, x-rays, and physical examination using the hemophilia joint health score (hjhs) system. two blinded radiologists scored the mri examinations for cartilage items (horizontal component: surface erosions, scores - and vertical component: cartilage degradation, scores - ) according to the semiquantitative method (international prophylaxis study group mri scale). an experienced operator applied a validated quantitative d-mri method (horizontal components: ac, vc, vctab, thctab; vertical component: thccab) to corresponding high resolution mr images of ankles. results: internal correlation of the semi-quantitative method components was substantial (r . , p< . , tibia) to high (r . , p< . , talus) in any site of investigation, but it was site-specific with the quantitative method, being significant only in the talar trochlea (r . , p< . ). external correlation of corresponding components of the semiquantitative and quantitative methods was moderate (r . , p . ) to poor (r . , p . ) for horizontal components, and non-existent for vertical components. components of the semi-quantitative method highly correlated with lifetime number of previous ankle bleeds (r . - . , p< . ), pettersson x-ray (r . - . , p< . ), and hjhs scores (r . , p< . ). this correlation was poor (r . , p . ) to moderate (r − . , p . ) for horizontal components of the quantitative method. conclusions: the biologic concepts of the semi-quantitative and quantitative mri methods are distinct for assessment of ankles. the semi-quantitative method is valid for assessing cartilage changes in cross-sectional studies of blood-induced arthropathy, however the quantitative method is suboptimal or less powerful for this purpose. paper #: pa- shoulder mr arthrography in skeletally immature patients nancy chauvin, md, department of radiology, the children's hospital of philadelphia, chauvinn@email. chop.edu; camilo jaimes, victor ho-fung, diego jaramillo purpose or case report: there has been a well documented increase in sports participation in children which has lead to an increase in sports-related injuries. to date, there are no studies describing the value of shoulder mr arthrography compared with the gold standard, arthroscopy. we retrospectively reviewed mr shoulder arthrograms obtained in pediatric patients between and who underwent subsequent shoulder arthroscopy. interpretation of the images was performed by three pediatric radiologists who were blinded to the arthroscopy findings. images were evaluated in consensus and independently. assessment included evaluation of the osseous structures, labral-ligamentous complex, joint space and the rotator cuff interval. the mr results were compared with reported surgical findings. sensitivity and specificity were calculated. results: nine patients were excluded due to technical reasons. of the remaining patients, were boys ( . - . years, mean . years) and were girls ( . - . years, mean . years). at arthroscopy, patients ( %) had injury to the anterior inferior glenoid labrum. mr sensitivity was % for depiction of bankart-type injuries with a specificity of %. patients ( %) had hill sach lesions and mr had sensitivity of % with specificity of %. superior labrum anterior posterior (slap) tears ( %) were identified at arthroscopy with mr sensitivity of % and specificity of %. overall, mr arthrography had a positive predictive value of % for identification of a surgical lesion. agreement between the observers was high. interobserver reliability was calculated with an intraclass correlation coefficient (icc)of . with a cronbach's alpha of . . conclusions: mr shoulder arthrography can accurately depict labral and osseous injury and provides pertinent preoperative information. a novel multi-channel mr coil for improved pediatric elbow coil imaging suraj serai, phd, cchmc, suraj.serai@cchmc.org; randy giaquinto, kathleen emery, charles dumoulin purpose or case report: single flex coils or adult size coils are currently used for imaging the pediatric elbow. this frequently results in uncomfortable patient positioning, motion, poor fat suppression, low snr and there is currently lack of a dedicated pediatric elbow coil in the commercial market. our goal was to explore the usefulness of a new coil array dedicated for pediatric elbow imaging and to compare quantitative & qualitative imaging findings to commercially available coils. methods & materials: an eight channel elbow coil was designed. the coil frame was designed to be rigid and lightweight. seven identical loop coils were built into a polycarbonate frame and an eighth coil built into a paddle that fits into the top frame. the coil elements were constructed with heavy copper to provide a high q-factor and increased snr. the complete coil including electronics & covering, weighs only . kg. mr imaging under irb approval was performed on a ge . t scanner using a routine clinical elbow protocol including t w, pdw, t w, fat-sat, non-fat-sat, d & d sequences. subjects were positioned feet-first with the elbow on the side & were subjectively assessed for comfort level. images obtained from the new coil & from the current commercial coils were compared for snr. results: scan positioning was reported to be comfortable. snr was between - % higher as compared to the routine coils. fat saturation was uniform, indicating that the magnetic susceptibility of the coil is well-matched to human anatomy. anatomical detail depiction was subjectively better for anatomic features such as trochlea. detection & diagnostic confidence of elbow disorders were improved with the new coil & greatly decreased motion artifacts were observed. conclusions: the new pediatric elbow coil provided excellent image quality, patient acceptance and clinical performance improvements over existing coils. the open coil design also allows for imaging of the elbow in a partially flexed position or in a cast. the advantages provided by the new coil are expected to include shortened image acquisition times (via parallel imaging) & increased snr. disclosure: dr. serai has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. incremental value of knee radiography in the interpretation of pediatric knee mri yen-ying wu, texas children's hospital, yxwu@ texaschildrens.org; robert c. orth, wei zhang, r. p. guillerman, herman kan purpose or case report: the acr appropriateness criteria recommendation for the imaging work-up of knee pain is radiography followed by mri. in many cases, mri is performed prior to review of radiographs or the referring subspecialist does not feel radiographs add value, particularly when ligamentous injury is suspected. the purpose of this study is to determine if radiography adds incremental value in the interpretation of knee mr studies electively referred by pediatric sports medicine and orthopedic subspecialists. knee mri studies referred from pediatric sports medicine physicians or pediatric orthopedic surgeons between / and / (n , ages - years, m:f : ) with accompanying radiographs were identified. patients were separated into groups based on mri findings: normal, ligamentous injury, or osteochondral injury (osteochondral lesions, bone contusions/fracture, and avulsion injury). knee radiographs were consensus reviewed by two caq pediatric radiologists blinded to mri findings and categorized into the same groups. radiograph and mri findings were compared and categorized into groups: neutral if radiograph and mri findings were the same, misleading if findings were discordant, or helpful if radiographs improved mr interpretation. the latter group was analyzed for impact on mr diagnosis. results: for knee radiographs, were normal, showed ligamentous injuries, and showed osteochondral injuries. when radiographs were interpreted as normal (n ), by mr % were normal, % had ligamentous injury, % had osteochondral injury, and % had both ligamentous and osteochondral injury. when radiographs were interpreted as ligamentous injury (n ), by mr % were normal and % had ligamentous injury. when radiographs were interpreted as osteochondral injuries, by mr % had ligamentous injury, % had osteochondral injury, and % had both ligamentous and osteochondral injury. subset analysis of true positive radiographs (n ) found % to be helpful and % to be neutral in mr diagnosis. for radiographs considered helpful, % resulted in a change in mr diagnosis. in regards to the influence of radiographs on mr interpretation, % ( / ) were misleading, % ( / ) were neutral, and % ( / ) were helpful. conclusions: a minority of pediatric knee radiographs aided mr diagnosis, and none resulted in a change in diagnosis. pediatric knee mri and interpretation should not be predicated on radiologist review of knee radiographs in this subset of patients. paper #: pa- sonographic evaluation of pediatric skeletal lesions: is it worthwhile? henrietta rosenberg, md, radiology, the mt. sinai medical school, henrietta.rosenberg@mountsinai.org; amish patel, neil lester purpose or case report: the purpose of this paper is to demonstrate how ultrasound(us) may serve as a readily available, cost-effective, non-invasive, non-ionizing, practical tool for the evaluation of a variety of skeletal abnormalities in the pediatric age range. we reviewed the clinical and imaging findings in patients seen during the past years in whom us demonstrated abnormalities related to the skeletal system, excluding patients with hip joint effusions or ddh. results: us proved useful in the following situations: evaluation hard superficial immobile mass (osteoma shin) ( ), absent medial end clavicle on x-ray in region of neck mass (us showed abc medial end clavicle)( ), to determine if soft tissue mass involves adjacent bone nodular fasciitis surrounding clavicular head ( ), for diagnosis and followup fracture (displaced/non-displaced) in infants ( ), diagnosis osteomyelitis in patients with cellulitis ( ), question of fracture underlying cephalohematoma or subgaleal hematoma ( ), rib mass (osteochondroma) ( ) or mass costochondral junctions (contour deformities costochondral cartilage) ( ), firm posterior knee mass (baker's cyst) ( ), firm anterior knee mass (septated cystic mass suprapatella region due to rheumatoid disease) ( ), immobile hard scalp mass due to epidermoid cranial vault ( ), painful mass occipital bone with soft tissue components extending through the skull externally and internally due to langerhan's histiocytosis ( ), indeterminate mass clavicle clinically thought to be post-traumatic sequellae, resolved on follow-up ( ), assessment craniosynostosis ( ), for differentiation of pathological entity from normal anatomic structure (lump on back of slender baby proved to be normal posterior spinous process) ( ). conclusions: us is worthwhile for evaluation of wide range of pediatric skeletal abnormalities and helps to determine if the a lesion is one that is "touch" or "don't touch". to maximize diagnostic accuracy, the imager should have thorough knowledge of the clinical history, physical findings, laboratory and other imaging findings. in equivocal cases or in those patients in whom the field of view (fov) is insufficient for complete visualization of an obvious lesion or if malignancy is suspected, us serves to triage those patients in whom further imaging is necessary. high incidence of vertebral fractures in children with acute lymphoblastic leukemia months after the initiation of therapy mary ann matzinger, md frcp(c), university of ottawa, matzinger@cheo.on.ca; nazih shenouda , brian lentle, josée dubois, helen r. nadel purpose or case report: vertebral fractures due to osteoporosis are a potential complication of childhood acute lymphoblastic leukemia (all). to date, the incidence of vertebral fractures during all treatment has not been reported methods & materials: we prospectively evaluated children with all during the first months of leukemia therapy. lateral thoracolumbar spine radiographs were obtained at diagnosis and months. vertebral bodies were assessed for incident vertebral fractures using the genant semi-quantitative method, and relevant clinical indices such as spine bone mineral density (bmd), back pain and the presence of vertebral fractures at diagnosis were analyzed for association with incident vertebral fractures. results: of the children, ( %, % confidence interval [ci] % to %) had a total of incident vertebral fractures, of which ( %) were moderate or severe. thirteen of the children with incident vertebral fractures ( %) also had fractures at the time of diagnosis. vertebral fractures at diagnosis increased the odds of an incident fracture at months by an odds ratio of . ( % ci . to . , p . ). in addition, for every . standard deviation reduction in spine bmd z-score at diagnosis, there was . -fold increased odds for incident vertebral fracture at months ( % ci . to . %, p . ). conclusions: children with all have a high incidence of vertebral fractures months after diagnosis, and the presence of vertebral fractures and reductions in spine bmd zscores at diagnosis are highly associated clinical features. purpose or case report: to provide objective measures of acetabular morphology utilizing volume-rendered ct and to better characterize normal acetabular development in adolescents. implications for the diagnosis of femoroacetabular impingement (fai) will be discussed. methods & materials: hips in consecutive patients ( female, male; ages - years) who underwent abdominal and pelvic ct for non-hip related complaints were retrospectively examined. examinations were performed for a variety of complaints, including abdominal pain, nephrolithiasis, vomiting etc. patients with obvious hip pathology were excluded. pelvic rotation was eliminated, and pelvic inclination was measured and corrected to °u tilizing a volume rendered ct model. measurements of femoral head diameter (fhd), anterior femoral head coverage (fhca), and posterior femoral head coverage (fhcp) were obtained. femoral head area (fha) was defined as π(fhd/ ) . percent anterior femoral head coverage (%fhca) was defined as (fhca/fha)* . percent posterior femoral head coverage (%fhcp) was defined as (fhcp/fha)* . acetabular version by volume-rendered ct (avvr) was defined as (fhcp/fhca). results: average pelvic inclination angle (sd) was . ( . ) for females and . ( . ) for males. average (sd) %fhca was . ( . ) for males and . ( . ) for females. average (sd) avvr was . ( . ) for males and . ( . ) for females. among males, average avvr decreased with subject age. on the other hand, there was little change in average avvr with age among females. conclusions: average avvr is greater for females than males, and this difference becomes more striking with increasing subject age. this represents an unexpected finding given the reported increased incidence of "pincer" type fai among females. characterization of acetabular morphology among adolescents with clinical fai should consider subject age and gender. in this regard, volumerendered ct is capable of providing an objective measure of acetabular morphology. mistakes in musculoskeletal plain film interpretation james crowe, pediatric radiology, texas children's hospital, jecrowe@texaschildrens.org; george s. bisset purpose or case report: to evaluate the mistakes made by trained pediatric radiologists when interpreting radiographs of the extremities obtained for the evaluation of outpatient acute pain (mostly post-traumatic). we retrospectively evaluated all radiographs and associated interpretations obtained during a month period from april , , to october , , of the elbows, wrists, knees and ankles in pediatric outpatients who presented with acute pain in the affected area. all radiographs were previously interpreted by a caq-certified pediatric radiologist varying in experience from year to years. abnormals were identified, including elbows, wrists, knees and ankles. all radiographs were determined to be "as dictated", missed significant finding, or overcall. attention was focused on the missed findings and overcalls. results: findings were as follows: elbow radiographs- missed findings and overcalls, wrist radiographs- missed findings and overcalls, knee radiographs- missed findings and overcalls, ankle radiographs- missed findings and overcalls. this resulted in a total of missed findings ( . % of abnormals) and overcalls ( . % of abnormals). of the misses, % were fractures. the highest mistake percentage occured in the ankles where the combined misses and overcalls approached %. this was also the location where we found the highest percentage of missed fractures ( . %) conclusions: when just abnormal cases were considered, fully trained pediatric radiologists have a mistake rate of approximately . %, if misses and overcalls are included. from a quality improvement perspective, we will review all of the types of misses and overcalls to expose common themes. longitudinal assessment of osteoporosis in a blood-induced hemophilia rabbit model using quantitative ultrasound kuan-chieh wang, university of toronto, kc.wang@ utoronto.ca; afsaneh amirabadi, anguo zhong, christopher tomlinson, andrea s. doria purpose or case report: the reduction of physical activities in hemophilic patients may lead to bone demineralization and consequent osteoporosis. quantitative ultrasound (qus) is free of ionizing-radiation, relatively inexpensive, and easy to use that making this technique suitable for follow-up of hemophilic children with clinical suspicion of osteoporosis. to our knowledge, no previous study has investigated the value of qus for longitudinal assessment of growing bones in an animal model which is paramount for clinical translation of the technique once change in measurements could relate to either the baseline pathology or physiologic bone growth variability. the objective of this study is to investigate the intra-and inter-operator reliability of qus over time, and its ability to discriminate bone loss in pathologic vs control knees of a rabbit model of blood induced arthritis. methods & materials: sixteen juvenile white new zealand rabbits distributed into two groups: received intraarticular blood injections over weeks (n pathologic and contralateral knees), and noninjected rabbits were used as controls (n knees). midshaft tibia speed-of-sound (sos) was measured at baseline, and weeks and of the experiment. two operators scanned each site twice at each time point. qus measurements were compared to microct (reference standard) on week to validate the study results. results: the sos measured in the control group increased significantly (p< . ) over the week period. there was not such an increase in the arthritis sos value (p> . ). in both groups the overall intra-operator coefficient of variation of sos measurements was % at baseline and decreased to % at week likely due to increased tibia size. the inter-operator reliability was % at baseline and % at week . with regard to the effect of bone growth on qus measurements for the control group (n ), sos values increased by . m/s, whereas for the pathologic group (n ), they only increased by m/s. statistically significant differences in ratios of sos between final/baseline results were noted (p . ) between the pathologic and control groups. conclusions: the longitudinal use of qus has an acceptable intra-and inter-operator reliability. even accounting for the significant impact that bone growth has on qus measurements over time, qus can differentiate pathologic from control knees in the proposed animal model and holds potential for clinical use in the assessment of osteoporosis in hemophilic children. methods & materials: the study was approved by the institutional review board. pediatric patients with abdominal tumors ( malignant and benign lesions) underwent diffusion-weighted mr imaging (dwi) on clinical . t (n ) and t (n ) mri scanners. adc maps were generated from b dwi and adc values were retrospectively and independently measured by two radiologists. adc values of benign and malignant tumors were compared with the welch two sample t-test. a p value of . was considered to indicate statistical significant differences. in addition, a receiver operating curve analysis (roc) was performed to determine the optimal cut-off adc value for differentiating benign and malignant tumors. results: the mean adc value (mm /sec) of benign tumors was . x - for the first reader and . x - for the second reader. the mean adc value (mm /sec) of malignant abdominal tumors was . x - for the first reader and . x - for the second reader. the differences between benign and malignant tumors were statistically significant (p< . for both readers). roc analysis revealed an optimal cut-off adc value for differentiating malignant and solid tumors as . x - mm /sec. conclusions: diffusion-weighted imaging with adc maps can be used to differentiate between benign and malignant pediatric abdominal tumors. creation of a database to evaluate imaging findings in long-term survivors of pediatric malignancy alexander towbin, md, radiology, cincinnati children's hospital medical center, alexander.towbin@cchmc.org; seth hall purpose or case report: over the past years, there have been significant improvements in the treatment of pediatric malignancies. improved therapy has led to an increase in the number of long-term survivors. many of these survivors are now experiencing late effects as a result of the original disease process or its treatment. these late effects are frequently identified on imaging. the purpose of this study is to create a database of the imaging findings of long-term survivors of pediatric malignancy in an attempt to begin to classify the findings and identify associations. methods & materials: after irb approval, the institutional cancer registry was searched to identify all patients younger than years of age who were diagnosed with a solid tumor between and . patients were included in the database if they survived for more than years from the date of their initial diagnosis. the electronic medical record system was then used to obtain demographic and treatment information for each included patient. the dictated reports from all cross-sectional imaging studies evaluating the chest, abdomen, or pelvis performed more than two years from the date of diagnosis were then reviewed. each positive imaging finding was classified by the involved organ. results: after querying the institutional cancer registry, patients were identified who met the inclusion criteria for this database. the most common neoplasms were neuroblastoma, wilms tumor, and astrocytoma. of the included subjects, had imaging of the chest, abdomen, or pelvis. overall, reports were evaluated and classified. findings were most commonly identified in the lungs, musculoskeletal system, kidneys, liver, and lymph nodes. conclusions: a database examining the late effects in longterm survivors of pediatric malignancies was created. this database has the potential to help identify the radiologic manifestations of the complications of cancer therapy and thus help guide rationally determined long-term risk-benefit ratios in the treatment of pediatric malignancies. imaging followup of lymphoma in pediatric patients: is pelvic ct necessary? javier lopez bueno, md, children's hospital of eastern ontario, jlopezbueno@cheo.on.ca; nishard abdeen purpose or case report: pelvic ct is often included in the imaging followup of patient with lymphoma before, during and after treatment to assess response to treatment and monitoring for relapses. while such followup is expected to improve detection of relapse, there is little objective evidence of its effectiveness in lymphoma. anecdotally, there are few pelvic relapses in pediatric patients with lymphoma regardless of primary site. we hypothesize that pelvic ct could be avoided as part of the followup without adverse impact on survival or in the detection rate of relapses, and with subsequent significant reduction in the radiation dose, particularly to the gonads. methods & materials: research ethics board approval was obtained. patients diagnosed with lymphoma and with at least one year of followup at our tertiary care pediatric hospital were included. sex, age, type of lymphoma, stage, primary site, site of relapse if any as well as the number of ct scans of the head, neck, chest, abdomen and pelvis were recorded. results: a total of patients met study criteria. there were males and females, with an average age of . years (range - years). eighteen patients had hodgkin disease ( %) and eleven had non-hodgkin lymphoma ( %). mean length of followup was . years (range - years). an average of . pelvic scans per patient were performed for surveillance (range - ). three relapses were detected. of these only one was in the pelvis, in a patient whose initial t cell non-hodgkin lymphoma was extensive and involved the neck, chest, abdomen and pelvis. conclusions: this study suggests a low incidence of pelvic relapse in pediatric patients with lymphoma. the routine use of pelvic ct in surveillance protocols may therefore be of little benefit while imposing a significant radiation burden. our study is limited by small sample size and short length of followup. further large scale studies are required. (esft) is performed by measuring the size of the tumors before and after chemotherapy. the proposed method of measuring tumor size, however, differs amongst recist . (response evaluation criteria in solid tumors), who (world health organization) and cog (children's oncology group) response criteria. in our project, we assessed whether response classification differs between the three different methods. methods & materials: after irb approval, we retrospectively analyzed mri studies of patients with ewing sarcoma who were treated at stanford and ucsf medical centers. tumor size was assessed before and after therapy. tumor measurements were obtained using recist . (longest single diameter), who (longest diameter and perpendicular diameter), and cog criteria (three measurements to calculate tumor volume). tumor response was assessed by the differences in sizes of the tumors before and after treatment using four response categories: progressive disease (pd), stable disease (sd), partial response (pr), and complete response (cr). concordance between the three response classification systems was assessed using cohen's kappa (k) coefficient and percentage of disagreement per response category. results: the k statistic for concordance in cog/who, cog/ recist and recist/who were . , . and . respectively. disagreement rates for recist/who, cog/ who, and cog/recist were . , . , and . % respectively. using tumor volume, twenty-six patients were reclassified: twenty-four cases of stable disease coded by recist were reclassified as progressive disease by cog and two cases of partial response coded by recist were reclassified as complete response by cog. conclusions: this study demonstrates poor agreement between the recist . and cog response criteria in esft. given the degree of discordance between response criteria in esft, evaluation of the prognostic impact of each of these classification systems may guide selection of the optimal system for future use in this disease. imaging recognition of chylous ascites following surgery for abdominal neuroblastoma zeyad metwalli, md, baylor college of medicine, metwalli@bcm.edu; r. p. guillerman, heidi v. russell, eugene s. kim purpose or case report: surgical resection is a standard part of multimodality treatment of neuroblastoma, the most common abdominal malignancy of infancy and early childhood. chylous ascites is a rarely reported complication of surgery for abdominal neuroblastoma, and is likely underrecognized, posing the risk of nutritional deterioration and sepsis. to facilitate early diagnosis and institution of appropriate therapy, we present the salient imaging findings of the largest known series of chylous ascites following surgery for abdominal neuroblastoma. methods & materials: all patients with abdominal neuroblastoma complicated by post-operative chylous ascites over a five-year period at a large children's hospital were identified by a database search. a retrospective review of the imaging studies and clinical charts was conducted. results: chylous ascites developed following surgical resection of abdominal neuroblastoma in of patients, with the diagnosis made between postoperative days and . four cases were high-risk neuroblastoma and one was intermediaterisk neuroblastoma. all cases involved resection of an adrenal mass and dissection around the abdominal great vessels. all cases manifested with abdominal distention on physical exam, and ascites was suspected clinically in cases. computed tomography (ct) in all cases revealed a large volume of ascites of near-water attenuation (range of − to . hounsfield units). the cases imaged with ultrasound (us) showed hypoechoic or anechoic ascites without septations. the chylous ascites resolved after - months of treatment with dietary fat restriction, medium chain triglycerides, intravenous octreotide, or peritoneal catheter drainage. conclusions: chylous ascites is an under-recognized complication of surgical resection for abdominal neuroblastoma, occurring in % of patients in this series. the diagnosis is supported by the demonstration on ct or us of a large volume of ascites causing abdominal distention - weeks post-operatively. the ascites is typically near-water in attenuation rather than fatty in attenuation and should not be misattributed to peritonitis, hemorrhage, bowel leak, or early tumor recurrence. cervical spine injuries in patients with suspected physical abuse nadja kadom, md, radiology, children's national medical center, nkadom@childrensnational.org; zarir p. khademian, tanya hinds, katherine deye, allison m. jackson, eglal shalaby-rana purpose or case report: to evaluate the incidence and nature of cervical spine injuries and relationship to posterior fossa abnormalities in children who underwent brain and cervical spine mri as part of the clinical workup for suspected physical abuse. methods & materials: authors retrospectively analyzed records of eighty-five children less than three years of age who were documented by the child protective services at a level one pediatric trauma center over a period of four years ( ) ( ) ( ) ( ) ( ) . only patients who underwent both mri imaging of the cervical spines (c-spine) in addition to brain imaging as part of the clinical workup were included. cspine and posterior fossa of brain mris were independently reviewed by two pediatric neuroradiologists, both blinded to clinical details. c-spine abnormalities (bone marrow edema, cord edema, intrathecal blood, disc pathology, soft tissue/ ligamentous injury, vascular injury) were documented and correlated with abnormalities seen in the posterior fossa (blood, brainstem edema, cerebellar edema). results: at this time, / patients have been reviewed. twenty patients ( %) had both cervical spine injuries and posterior fossa abnormalities. there were no patients with isolated cervical spine injuries without posterior fossa abnormalities, but there were five patients ( . %) that had posterior fossa abnormalities in the absence of c-spine injuries. fifteen patients ( . %) did not have any spinal or posterior fossa imaging abnormality. none of the patients had bone marrow edema, disc pathology, or intrathecal blood. one patient had vascular neck injury and cord edema. conclusions: our results show that the incidence of cervical spine injury in children under investigation for abusive head trauma is as high as %. our data show further that cervical spine injury predicted posterior fossa injury in all patients, while presence of posterior fossa injury predicted concomitant c-spine injury in only %. the incidence of c-spine trauma we found in these patients is higher than reported elsewhere in the literature and may impact whether or not routine c-spine mri will be included in national imaging guidelines for children under investigation of abusive head trauma. pediatric skull fracture andre loyd, phd, biomedical engineering, duke university, aml @duke.edu purpose or case report: skull fractures are often seen in the setting of non accidental trauma (abuse) abuse, and are usually attributed to falls from heights above m. part of the difficulty in assessing height is due to uncertainties in actual distance. objective: to determine what types of skull fractures can occur in pediatric and adult post-mortem human specimens during controlled impacts on hard surfaces from various heights. methods & materials: skull fracture patterns in postmortem human specimens from a unique bank of pediatric specimens ( -week gestation to -years-old, n ) were subjected to controlled drops from both arbitrarily low heights ( and cm) and high heights ( m) onto an aluminum platen. the specimens were dissected from the neck at the occipital condyles and intracranial were sealed inside the head using pmma. the heads were dropped on to five different impact locations. fractures were identified using palpation and high resolution mdct. results: no specimens between -weeks-gestation and days-old sustained fractures from the - cm drops. three out of four ( %) specimens ages between -and -months old fractured due to the or cm drops. the -and -year-old specimens and all adult specimens survived the - cm drops. all specimens subjected to the m drop fractured. the specimen between -months and -months sustained either a linear fractures or diastatic fractures from the cm and cm drops. the results indicate that some aged infants and young children can sustain skull fractures by being dropped or falling from relatively low heights. drops, as low as cm, can cause linear and diastatic fractures in pediatric skulls. the presences of compliant sutures and fontanelles in neonatal heads allow the head to deform during impact. these data add very important information to mechanisms of skull fractures across ages, including ages in which child abuse is a consideration. evaluation of a new classification system for temporal bone fractures in children aimed at increasing prognostic value badriya al-qassabi, md, mcgill university, albahlania @ yahoo.com; lucia carpineta, rania ywakim, bahar torabi, andrew m. zakhari, lily h p. nguyen purpose or case report: to compare a new classification of temporal bone fractures which specifically evaluates involvement of the otic capsule against the traditional classification system (transverse versus oblique versus longitudinal), to evaluate whether this new classification is able to better identify patients at risk of adverse otologic outcome and neurologic complications in the pediatric population. methods & materials: a retrospective hospital chart review was performed by ent colleagues searching for all patients with temporal bone fractures seen at our center over the past years. this was followed by a blinded review of the ct heads by a resident and a trained pediatric radiologist with neuro expertise. these cts were evaluated for petrous involvement, otic capsule involvement and any associated intracranial lesions. this information was then correlated with clinical outcome measures including post-traumatic hearing deficit, facial nerve palsy, persisting csf leak and global neurologic sequelae. the new classification was compared to the traditional one, and specifically analysed for the ability to better predict the clinical outcomes. results: expectedly, pediatric temporal bone fractures were infrequent and otic involvement even more rare. fractures with involvement of the otic capsule (versus otic sparing) were found more frequently in boys. they were also more likely to be associated with immediate otologic signs and neurologic findings on presentation. these fractures also had the highest association with conductive hearing deficit (> %) and were twice as likely as otic sparing fractures to be associated with immediate facial nerve palsy and with more important concomitant intracranial injuries such as midline shift. conclusions: while our numbers are small, our results suggest a trend that when temporal bone fractures show involvement of the otic capsule, there is higher risk of adverse otologic outcome and neurologic complications even in the pediatric population. absence of a causal relationship between mr detected subdural hematomas (sdh) in neonates with hypoxic-ischemic encephalopathy (hie) deniz altinok, children's hospital of michigan; jay shah, harut haroyan, gulcin altinok, nitin chouthai purpose or case report: the existing controversy regarding subdural hemorrhages noted in patients with hie is an important discussion in the medical, legal and child-welfare realms. it is our goal to provide additional information to this critical debate through mr findings on patients with clinically diagnosed hie. methods & materials: all patients born with clinically diagnosed hie, and treated at children's hospital of michigan in the past years were examined; those with head mri taken within days of life were selected. in total, patients fit the criteria, this included: males and females, and an age range of - days at scan (average age of days at scan). all traumatic births, coagulopathies, and other pertinent clinical findings were noted. mr imaging was reviewed and reported by a blinded pediatric neuroradiologist, these reports were then compared to the "original read". results: all patients were confirmed radiologically to have hie. the causes of hie in all cases examined were either intrauterine/delivery asphyxia, aspiration, or congenital disease. of these cases, the findings were: sdh, parenchymal hemorrhages, intraventricular hemorrhages, cephalohematomas, subarachnoids, large subcutaneous hemorrhage and instance of mca stroke. all patients with mr detectable sdh had or more confounding factors ( meningitis, coagulopathies, chest compressions, cardiac malformation, pph, severe pulmonary hemorrhage requiring transfusion of plasma and prbc). conclusions: it has been hypothesized that sdh is often found incidentally in children diagnosed with hie, this is however a dubious conclusion considering our results. in fact, the presence of sdh and hie concomitantly is low even when including a population with traumatic births such as ours. sports-related concussion in children: an mri and mrs study kim cecil, phd, cincinnati children's hospital medical center, kim.cecil@cchmc.org; todd a. maugans, james l. leach, mekibib altaye purpose or case report: the pathophysiology of sportsrelated concussion (src) is poorly understood, especially for children. following src and mild traumatic brain injury in adults, a few mri and proton mrs studies have identified axonal injury with declines in the neurometabolite n-acetyl aspartate (naa). we wanted to examine a src adolescent population with proton mrs, diffusion tensor imaging (dti) and other mri methods within h of concussion and with short term followup to determine if there were differences in imaging metrics with age and sex matched healthy control participants. methods & materials: twelve children, ages - years, who experienced src were evaluated with impact neurocognitive testing, t -weighted mri, susceptibility weighted imaging (swi), dti, proton mrs, and phase contrast angiography (pca) at less than h, days and days or greater post-concussion. healthy, age and sex matched controls for each src participant were recruited and evaluated at a single time point. quantitative imaging metrics included fractional anisotropy, metabolite concentrations, and global cerebral blood flow (cbf). group comparisons were examined by paired t-test or wilcoxon signed rank test. correlational data employed spearman rank correlation. results: impact results revealed significant differences in initial total symptom score (tss), and reaction time (rt) for the src group compared with the control group, with tss resolving by a mean of days and rt at days. no evidence of structural injury was observed qualitatively for either group. analyses between groups or over time within the src group found no decreases in naa or elevation of lactic acid upon mrs, and no changes in fractional anisotropy upon dti. within the src group, significant changes in the global cbf were observed. improvement towards control values occurred by days for % and by days for % of src group participants. conclusions: pediatric src affects global cbf without evidence of structural or metabolic injury. predictive value of high resolution mr imaging of brain and sella in children with clinical optic nerve hypoplasia for hypopituitarism charles glasier, radiology, arkansas childrens hospital, glasiercharlesm@uams.edu; raghu h. ramakrishnaiah, julie shelton, chetan c. shah, paul h. philips purpose or case report: to review the spectrum of cns abnormalities and their incidence in children with optic nerve hypoplasia and to calculate the sensitivity and specificity of magnetic resonance imaging in predicting endocrine abnormalities. methods & materials: this is an irb approved retrospective study of children with clinical optic nerve hypoplasia who underwent mri of the brain and orbits as part of the clinical workup in a tertiary care pediatric hospital. high resolution mri studies were performed on . tesla scanners. mri studies were reviewed for optic nerve hypoplasia, absent or ectopic posterior pituitary, absent pituitary infundibulum, absent septum pellucidum, migration anomalies and hemispheric injury.radiologists were blinded to patients endocrinologic status.all patients had clinical evaluation by a pediatric neuro-ophtalmologist and endocrinologist. a standardized panel of serologic testing that included serum cortisol, acth, tsh, and free t levels were performed on all patients. statistical analysis was performed to determine the sensitivity and specificity of mr findings in predicting endocrinologic deficiency. results: study included children( males and females) who had clinical optic nerve hypoplasia. the mean age of the study population was yr (sd: . yr). children had unilateral and children had bilateral optic nerve hypoplasia by mri. children had absent posterior pituitary bright spot and had ectopic posterior pituitary, had absent infundibulum, had complete callosal agenesis, partial callosal agenesis and had callosal thinning. had absent septum pellucidum. had hypopituitarism. of the patients with hypopituitarism had abnormal abnormal pituitary on mri, had absent septum pellucidum, and child had migration abnormality. none had corpus callosal abnormality. the sensitivity and specificity of mri in predicting hypopituitarism by demonstration of abnormal pituitary is % and % respectively. the positive predictive value and the negative predictive value is % and % respectively. among the patients with normal endocrinologic function, none had pituitary abnormalities on mri. conclusions: pituitary abnormalities are the most common intracranial abnormality in patients with optic nerve hypoplasia followed by absent septum pellucidum. detection of pituitary abnormalities by the mri has high specificity and high negative predictive value for endocrine abnormality. paper #: pa- ct imaging pearls for shunted pediatric brains srikala narayanan, md, children's national medical center, snarayan@childrensnational.org; nadja kadom purpose or case report: shunted pediatric patients frequently present emergently with symptoms that could indicate shunt malfunction, such as headache and vomiting. here, we present imaging pearls on non-contrast head ct in shunted children. methods & materials: illustration of each of the following: . shunt tip and volume averaging-consider location of side holes and use of multiplanar reformatted images. . shunt at burr hole-consider radiolucent shunt parts. . shunt rupture in the neck-remember to investigate the lower extracranial shunt parts. . shunt in cyst/subdural shunt (vs dislocation)-consider primary shunt location in a cyst rather than shunt dislocation. . enlarged temporal horns-look for it. in infants occipital horns may dilate first. . enlarged rd ventricle-look for bulging of lateral walls. . sulcal effacement-use the "three shades of gray" rule. . small cisterns-detecting shape distortion can help. . periventricular edema-easily overlooked because of similar low density compared to ventricular fluid. . slit-ventricle -requires cautious reporting. conclusions: careful evaluation of ct images in shunted pediatric patients can reveal important clues for making an accurate diagnosis, even when prior images are not available. successful treatment of mice with creatine transporter deficiency kim cecil, phd, cincinnati children's hospital medical center, kim.cecil@cchmc.org; diana m. lindquist, matthew r. skelton, gail j. pyne-geithman, joseph f. clark purpose or case report: creatine transporter deficiency (ctd) is an untreatable x-linked mental retardation syndrome with severe cognitive and speech impairment. patients are identified by an absence of creatine in the brain on mr spectroscopy (mrs) and distinguished from two creatine synthesis deficiency syndromes with genetic testing. for ctd, the absence of the transporter (slc a ) prevents creatine from crossing the blood brain barrier and entering brain cells. a brain specific ctd knockout mouse was developed replicating key features of the human disease and establishing an animal model for treatment of ctd. we report the successful treatment of the ctd knockout mouse and present confirmation by mrs. methods & materials: brain specific knockout and littermate control mice were randomly assigned and treated with on one of three supplements: agentx (confidential), creatine or maltodextrine as placebo. h and p mrs data were collected on a t mr system (bruker). mice (n ) were studied with mrs after weeks of supplementation. single voxel h data were acquired on a ul voxel covering the cerebrum using a double spin echo sequence. p data were acquired with an isis sequence from the same voxel. metabolite quantification was performed with jmrui and compared between groups and over time with statistical tests for significance (t-tests, anova). results: creatine and phosphocreatine levels in the brain were all significantly higher after weeks supplementation of agentx in knockout mice, compared to creatine and placebo fed knockout mice (phosphorus mrs [ ul brain voxel] with phosphocreatine (pcr) ( ppm) observed only in agentx treated knockout mice. adenosine triphospate (atp) gamma (− . ppm), alpha (− . ppm) and beta (− ppm) peaks are noted in all three knockouts. conclusions: successful treatment was achieved in a slc a brain specific knockout mouse for the second largest known cause of x-linked mental retardation in humans, ctd. disclosure: dr. cecil has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. prevalence of abusive injuries in siblings and contacts of abused children kenneth feldman, md, general pediatrics/children's protection program, university of washington/seattle children's, kfeldman@u.washington.edu purpose or case report: siblings and children who share a home with a physically abused child are thought to be at high risk for abuse. however, rates of injury in these children are unknown. disagreements between medical and cps professionals are common and screening is highly variable. our objective was to measure the rates of occult abusive injuries detected in contacts of abused children using a common screening protocol. this was a multi-center, observational cohort study of child abuse teams who shared a common screening protocol. data were collected for all children < years undergoing evaluation for physical abuse and their contacts. for contacts of abused children, the protocol recommended physical examination for all children < years, skeletal survey and physical exam for children < months, and physical exam, skeletal survey and neuroimaging for children < months old. results: among , children evaluated for abuse, met criteria as "physically abused" and these had contacts. for each screening modality, screening was completed as recommended by the protocol in approximately % of cases. of contacts who met criteria for skeletal survey, new injuries were identified in ( . %). none of these fractures had associated findings on physical examination. physical examination identified new injuries in . % of eligible, examined contacts. neuroimaging failed to identify new injuries among imaged, eligible contacts less than months old. twins were at significantly increased risk of fracture relative to other non-twin contacts ( . % vs . %, or . ). conclusions: these results support physical examinations and skeletal survey, regardless of physical examination results, for contacts of abused children < months of age. too few children had cranial imaging to change recommendations to image contact children less than months old. even for children where no injuries are identified, these results demonstrate that abuse is common among children who share a home with an abused child. they support including contacts in evaluations and interventions (foster care, safety planning, social support) designed to protect physically abused children. the project was supported by the health resources and services administration/maternal shown that pediatric rib fractures may be a marker for significant intrathoracic injury. this information has been used to suggest that children with rib fractures and no underlying intrathoracic injury may have sustained them due to insufficient bony mineralization and minor trauma rather than inflicted injury. methods & materials: irb approval was obtained for a retrospective review of all children under years of age with imaging diagnosis of rib fracture over a -year period at two university hospitals. children with prior thoracotomy, previously recognized metabolic bone disease, and prematurity < weeks were excluded. medical records were reviewed and children with documented abuse or accidental trauma were evaluated. children with indeterminate injury mechanisms were excluded. sixty-six patients with rib fractures were included in analysis, due to abusive injury and due to accidental trauma. children were analyzed for associated intrathoracic, abdominal or intracranial injury, additional fractures and retinal hemorrhage. results: abused children were younger ( . +/− . months) than accidentally injured children ( . +/− . months, p< . ). children with rib fractures due to accidental trauma had a higher incidence of intrathoracic injury compared to those due to abusive injury ( % vs %,p< . ). there was no difference in the incidence of abdominal or intracranial injury between groups. mortality and icu admission rates were similar. abused children had a higher total number of rib fractures (mean . vs . , p< . ) and were more likely to sustain additional fractures outside of the thoracic cavity ( % vs %, p< . ). conclusions: abuse is a more common cause of rib fractures in young children than accidents. children with rib fractures due to abusive trauma are less likely to have intrathoracic injury compared to those sustaining rib fractures due to accidental trauma. this suggests differences in mechanism of injury between groups. pediatric elbow fractures: a different angle on an old topic shannon zingula, md, pediatric radiology, cincinnati children's hospital medical center; kathleen emery, christopher g. anton purpose or case report: the most common elbow fractures classically reported in pediatric orthopedic texts are supracondylar (sc) ( - %), lateral condylar (lc) ( %), and medial epicondylar (me) fractures ( %) with fractures of the proximal radius (including but not limited to fractures of the radial neck) being relatively uncommon ( - %). our experience at a large children's hospital suggests a different distribution. purpose: ) to describe the frequency of different elbow fracture types in a large pediatric population, and ) to determine the fracture types that were occult on initial radiographs but detected on follow-up. methods & materials: review of medical records identified children, median age years and interquartile range for age of - years (range, . - years) diagnosed with elbow fractures at our institution from october through july . initial and follow-up radiographs were reviewed in blinded fashion independently by two experienced pediatric musculoskeletal radiologists to identify fracture type(s) on initial and follow up radiographs. note was made of fractures identified on follow up only. results: the most common fractures included sc (n , %), radial neck (rn) (n , %), and lc fractures (n , %). as compared to classically referenced incidences, rn fractures were seen significantly more (p< . ) and me fractures (n , %) significantly less (p . ) than would be predicted. in patients without fracture seen on initial films, occult fractures were seen on follow up; sc (n , %) and rn fractures (n , %) were most common. the frequency of rn fractures compared to the overall group ( % vs. %) approached but did not reach statistical significance (p . ). patients with one fracture had additional fractures seen on follow-up not seen initially with olecranon fractures most frequent (n , %.) this was significantly more common than the number identified on initial radiographs (n , %) (p< . ). conclusions: sc fractures are the most frequent elbow fracture seen initially and in follow up followed by rn and lc fractures in a distribution different than classically described. the relatively high frequency of rn and olecranon fractures detected on follow up speaks to their potentially occult nature. careful attention to these areas is warranted in patients with initially normal radiographs. purpose or case report: previous studies have found that fractures involving the spine, hands and feet are rare on skeletal surveys for suspected child abuse, leading some authors to suggest eliminating views of these regions from the initial skeletal survey protocol. the purpose of this study was to assess this recommendation by performing a historical review of these injuries in a population undergoing screen-film based skeletal surveys for suspected abuse. this cross-sectional, retrospective irb approved study reviewed the reports of the initial skeletal surveys of all children < years of age with suspected abuse imaged between april, and december, . infants underwent skeletal surveys according to acr standards acquired on a mammographic type screen-film imaging system with at least line pairs per millimeter resolution. studies in toddlers were performed using a par speed screenfilm system. results: % ( / ) of all skeletal surveys demonstrated positive findings, and % ( / ) had > fracture. . % ( / ) of all studies had fractures involving the spine, hands or feet. of all positive skeletal surveys, . % ( / ) had fractures involving the spine, hands or feet, and . % ( / ) of all patients with > fracture on skeletal survey had fractures involving these regions. conclusions: these data, acquired in the screen-film era, suggest that fractures of the spine, hands and feet may not be rare in infants and toddlers in cases of suspected child abuse. the benefits of eliminating views of these regions from the initial skeletal survey should be carefully weighed against the cost of missing these potentially important injuries in at-risk pediatric populations. purpose or case report: dating fractures is critical in cases of suspected infant abuse, but there are little scientific data to guide radiologists, and dating is generally based on personal experience and conventional wisdom. we previously reported a scientific scheme for dating fractures in infants based on an analysis of subperiosteal new bone and callus formation in birth-related clavicular fractures. we hypothesize that when used as a guide this system can significantly improve the ability of radiologists to accurately date fractures in young infants. methods & materials: radiographs of presumed birthrelated clavicular fractures in infants - months were reviewed by pediatric radiologists with (reader a) and (reader b) years experience in two reading sessions separated by one year. for the first read, no guidelines were provided. training was carried out prior to the second session, and readers were given the dating scheme as a guide during fracture analysis. readers were asked to provide an estimate of the minimum and maximum fracture age in both sessions. the primary outcome was whether or not the reader's estimated range for fracture age included the actual fracture age. a secondary outcome was the width of the estimate of fracture age. these outcomes were compared across the two reading sessions. results: the rate of correct response significantly increased after training for each reader (reader a: % to %, p<. ; reader b: % to %, p . ). the width of estimated fracture age after training was significantly smaller for each reader (reader a: mean width days to days, p<. ; reader b: days to days, p . ). conclusions: our results suggest that the ability of a radiologist to accurately date fractures can improve significantly when provided with a scientifically based system outlining patterns of fracture healing. this scheme can be applied in radiologic practice and may prove particularly useful in cases of suspected abuse, where fracture dating often has forensic implications. purpose or case report: to demonstrate the acute and subacute features of proximal femoral physeal fractures in the abused child. also to demonstrate how to recognize this injury in patients with unossified femoral heads. the database of patients with suspected non-accidental trauma, accumulated over years, was reviewed. out of a total of patients ( %) were proven to be cases of non-accidental trauma, as determined by the child abuse pediatrician. from these patients, the cases of proximal femur growth plate fractures were identified. results: patients with proximal femur growth plate fractures were identified for a prevalence of . %. one patient had bilateral proximal femoral fractures, for a total of fractures in patients. were boys, were girls with ages ranging from . mos to yrs mos. in patients, the fracture was revealed on imaging performed because of refusal to bear weight; in the other patients, the fracture was found during imaging for the skeletal survey. the fracture was on the left side in cases and on the right side in (the patient with bilateral fractures). in all of the fractures, there was lateral displacement of the femoral shaft. in fractures, the femoral head was not yet ossified simulating the appearance of a dislocation. location of the femoral head in the hip joint was verified by ultrasound or ct (ct abdomen had already been done in patient) thus delineating the presence of a physeal fracture. / fractures were salter-harris i and the other were salter-harris ii fractures. the fracture was acute in cases and subacute in cases. in these subacute cases, periosteal reaction and/or calcifying subperiosteal hemorrhage was present in , and irregularity and scalloping of the metaphysis was present in the other . conclusions: proximal femoral growth plate fractures are quite uncommon in non-accidental trauma. the injuries are typically salter-harris i or ii fractures, seen more often in the healing phase. in the presence of an unossified femoral head, the laterally displaced femoral shaft can simulate hip dislocation; this can be clarified with hip sonogram. purpose or case report: in recent years, metal stents have been used to overcome airway obstruction in children for whom no better surgical option is available. these devices are not designed for use in the airway, however, and may cause significant complications. bioabsorbable airway stents may avoid some of the problems associated with metal stents. methods & materials: this is a retrospective review of all endoluminal insertions of bioabsorbable airway stents at a single institution from april to september . custom-made polydioxanone stents of various sizes (ella dv, ella, czech republic) were used. results: twelve stents were inserted in the airways of seven children. indications were: recurrent obstruction after slide tracheoplasty ( ), persistent airway compression after correction of a congenital cardiac lesion ( ), collapse of stem cell supported tracheal homograft, tracheomegaly following fetal balloon insertion, and syndromic tracheobronchomalacia (tbm). eleven stents (diameters to mm) were placed in the trachea and one in the left main bronchus. two stents had to be removed and replaced for technical reasons (one was too long and the other too narrow). the child with syndromic tbm died when treatment was withdrawn because she could not be weaned from the ventilator. the remaining children are alive at a median follow-up of nine months (range to months). the granulation tissue response was similar to that seen after placement of metal stents. the stents were observed to absorb gradually over a period of approximately three months, requiring serial stenting in two children. conclusions: bioabsorbable airway stents are more difficult to insert than metal stents. they cause similar early complications, especially granulation tissue formation, but appear to avoid potential long-term complications of metal stents, including vascular erosion and growth limitation. disclosure: dr. mcclaren has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: renal angiomyolipomas (amls) in tuberous sclerosis complex (tsc) grow at a faster rate, exhibit a wider and more problematic range of symptoms, and hemorrhage more frequently than sporadic amls. we examined the efficacy of prophylactic embolization of renal amls in tsc in decreasing tumor size, alleviating symptoms, and preventing hemorrhage while preserving renal function. we retrospectively reviewed the charts and imaging studies of consecutive patients who underwent transarterial, transcatheter embolization of amls. tumor volume was measured from available ct or mri imaging before and after embolization. pre-and postembolization symptoms and creatinine levels were documented. results: patients had available follow-up imaging at a mean of months post-embolization. the mean preembolization tumor volume was ml and postembolization was ml; median decrease in volume was %. using the schwartz method, the mean glomerular filtration rate before embolization was calculated to be . ml/min/ . m . after embolization the mean value was statistically unchanged at . ml/min/ . m . none of the patients experienced renal hemorrhage or symptom recurrence during the follow-up period. conclusions: selective embolization of renal amls in patients with tsc decreases tumor volume, relieves symptoms and reduces the risk of future hemorrhage while preserving renal function. etoh was injected percutaneously with g needle; transductal ablation performed through a f micropuncture sheath. drug volumes, technical difficulties, percentage reduction in saliva production, family reported clinical significance, and complications were recorded. results: salivary gland ablation (sga) included bilateral smg and slg ablation without parotid gland ablation in cases, and with unilateral parotid gland ablation in cases. one case of bilateral parotid gland ablation following surgical resection of bilateral smgs. mean etoh dose for smg . ml, and . ml for slg. one case of focal skin necrosis was noted; no other complications. patient families reported response to sga in / cases ( %) with mean saliva production of %. greatest health and family impact was reported with elimination of hospitalizations for recurring aspiration pneumonia ( cases), elimination of choking in bed ( cases) , and improved patient sense of self-hygiene in cases. one complication occurred with temporary marginal mandibular nerve paralysis (resolution in months). conclusions: percutaneous and transductal sga is feasible, safe, and effective in this small patient series, offering an alternative to surgical salivary gland resection, or treatment option following failed surgical intervention. paper #: pa- mr-guided procedures in children: initial experience joao amaral, md, diagnostic imaging, the hospital for sick children, joao.amaral@sickkids.ca; michael temple, dimitri parra, philip john, bairbre connolly purpose or case report: the primary purpose of this study was to review our initial experience with mr-guided procedures in children. our secondary objective was to share some aspects on how to start an mr-guided program in a tertiary pediatric center. patients with lesions identified only on magnetic resonance (mr) imaging were selected to undergo an mr-guided procedure. patients' demographic data, primary diagnosis, referring team's clinical suspicion, lesion's anatomical location, tissue adequacy for pathology, final diagnosis and clinical follow up were reviewed. aspects of starting a program of mr-guided procedures, safety concerns, imaging and technical challenges, and mr compatible materials were also addressed. results: to date, procedures ( bone biopsies, soft tissue biopsy and pre-surgical needle localization) were performed in patients during months. there were girls and boys with a mean age of . years ( y mo- yrs). one patient had a nasopharyngeal carcinoma, cardiofacial syndrome, wilm's tumor and had no previous medical issues. the clinical suspicion for procedures in patients was metastatic disease and for procedures in patients was primary malignancy or infection. lesions were located in the tibia ( -metaphysis and diaphysis), femur ( -metaphysis and epiphysis), thigh ( -soft tissues), sacrum ( ) and retroperitoneum ( ). all biopsies provided adequate tissue for diagnosis. needle localization and hook deployment was also accurate. malignancy was excluded in all patients. final diagnosis included chronic recurrent multifocal osteomyelitis (crmo), osteomyelytis, fibrous tissue, osteoid osteoma, and scar tissue. mean follow up was . months. no patient required a second procedure to confirm the diagnosis. conclusions: mr with its unique soft tissue resolution and lack of ionizing radiation is an excellent method to guide interventions in children. one of the greatest advantages of this method is the precise target localization especially in lesions located in the bone marrow or lesions better identified on mr. special safety measures, specific mr compatible material (needles, surgical instruments), dedicated imaging techniques to reduce or increase material/needle artifact and careful technique are paramount. - . m, f; . - months, mean . months, median months, mode months. sonographic approach expanded as our experience grew over months. studies performed by a single pediatric radiologist. bilateral sonography included: interscalene and supraclavicular neck, nerve roots at neural foramina, cervical spinal canal, diaphragm during spontaneous respiration, rhomboid muscle, serratus anterior muscle, posterior shoulder, all performed and interpreted blind to other imaging. results: interscalene and supraclavicular neck evaluated in all patients. all exhibited echogenic interscalene portion of brachial plexus.size and extent of traction neuroma varied. nerve roots at foramina noted in axial and coronal planes. in cases enlarged root(s)noted. cervical spinal canal studied in patients: cord oscillated normally, no syrinx, cord concentric in canal. intracanalicular traction pseudomeningoceles on concurrent ct myelography or mri were not apparent on us. in cases a "clumped" retracted nerve root on the cervical cord was later found to correspond to a pseudo-meningocele on ct myelogram. otherwise, cervical spinal canal us was unremarkable in cases. diaphragm motion was evaluated in patients during spontaneous respiration; no phrenic nerve palsy. rhomboid muscle was evaluated for atrophy in patients; had atrophy. the rhomboids are innervated by the dorsal scapular nerve which arises solely from c , prior to c joining the brachial plexus. intact rhomboid indicates that the central c root is intact. serratus anterior muscle, innervated by the long thoracic nerve (c ,c ,c ), was evaluated for atrophy in patients; had atrophy. dynamic evaluation of the posterior shoulder looking for posterior laxity was evaluated in patients; had laxity. posterior shoulder dislocation or subluxation is a known sequela of brachioplexopathy which sometimes requires muscle transfer when the child is older. conclusions: comprehensive us evaluation of perinatal brachioplexopathy detects: extent of traction neuromafibroma from the interscalene region peripherally toward clavicles (important for neurosurgeon), thick nerve roots, phrenic nerve diaphragm palsy, muscle atrophy from denervation, and posterior shoulder subluxation. us misses: intracanalicular traction pseudomeningoceles. paper #: alt- impact of the image gently campaigns in adult-focused hospitals: a survey of practice leaders brett bartz, duke university medical center; donald frush, kimberly applegate, michael callahan, laura coombs, marilyn goske purpose or case report: the alliance for radiation safety in pediatric imaging is an organization that uses social marketing to promote radiation protection for children and effect change across radiology practices. the impact of the alliance's image gently campaigns on practice patterns in radiology practices has yet to be assessed, especially outside of freestanding children's hospitals. the purpose of this investigation was to assess the impact of the image gently campaigns on academic and private practices/institutions that treat children but primarily serve adults. a web-based survey was emailed to leaders in radiology practices (n ) who do not practice at freestanding children's hospitals utilizing the acr's pred database. the survey consisted of questions designed to measure the recognition and impact of the image gently campaigns, including the impact on practice patterns. results: a total of practice leaders in u.s. states and territories responded for a response rate of . %. the majority ( %) of sites image pediatric patients in their practices. respondents consisted of department chairs ( %), group presidents/ceos ( %), and division chiefs ( %). the majority ( %) of respondents described their practice as a hospital-based private practice without a dedicated pediatric radiology division. the vast majority ( %) of respondents was familiar with the image gently campaigns; % of respondents reported that image gently had effected a change on how they imaged children. specifically, respondents (%) reported that the campaign caused a modification to lower dose protocols for head ct ( %), chest ct ( %), and abdominal/pelvic ct ( %). slightly more than half of respondents ( %), however, estimated that the image gently campaign resulted in no modification of pediatric fluoroscopy exposure. conclusions: to our knowledge, this is the first survey evaluating the impact of the image gently campaigns. there is near universal recognition of the campaigns, which have impacted practice patterns beyond the freestanding children's hospital in ct, but not in fluoroscopy. reliability of shear-wave velocity using different frequencies in acoustic radiation force impulse (arfi) elastography mi-jung lee, radiology, severance children's hospital, mjl @yumc.yonsei.ac.kr; suyon chang, myung-joon kim purpose or case report: although there are many studies about acoustic radiation force impulse (arfi) measurement, standard protocol has not been established. and a new probe with high frequency has been developed which can be applied for pediatric patients. the purpose of this study was to assess the reliability of shear-wave velocity (swv) at various depths using different frequencies to suggest standard measurement in arfi elastography. methods & materials: arfi elastography of both the elasticity phantom and normal liver was performed at different depths ( - cm) with convex ( - mhz) and linear ( - mhz) probes. ten valid swv measurements at each depth were performed. it was repeated ten times with the phantom and it was done in healthy volunteers (m:f : , age - years; mean . ). the mean value and standard deviation of swv were calculated. results: in both the elasticity phantom and the liver, variability of swv was different between the depths in both probes. the depth with lower variability in the phantom was and cm with the convex probe and cm with the linear probe. in the liver, the depth with lower variability was cm with the convex probe and and cm with the linear probe. in comparison of two probes, the linear probe showed lower variability at and cm depth in the phantom and at cm depth in the liver whereas the convex probe showed it at cm depth in both the phantom and the liver. conclusions: in arfi elastography, measurement of depth shows different variability in both low and high frequency probes. to obtain the most reliable measurement of swv, using high frequency probe is recommended for - cm depth and using low frequency probe is recommended for - cm depth. disclosure: dr. lee has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. imaging -year-old fetuses sabah servaes, children's hospital of philadelphia; teresa victoria, ann johnson, sandra kramer, richard markowitz, diego jaramillo purpose or case report: to demonstrate normal anatomy and pathology of medical museum specimens without disturbing the specimens. methods & materials: nine fetal specimens from a medical museum were imaged with ct and mri ( . t and . t) when possible with the specimens in their preserving fluid and containers. results: the fetal specimens are estimated to be approximately years old. one specimen is from the first trimester, seven are from the second trimester, and one is from the third trimester. normal anatomical structures at various stages of development including the brain (and varied sulcation pattern), lungs (lobar anatomy), and skeletal structures (several developmental features such as the ossification centers, perichondrial structures, and marrow cavitation) can be evaluated using imaging without causing harm to the specimens. pathologic entities including anencephaly and sirenomelia are also evaluated demonstrating features of these entities. conclusions: imaging historical fetal specimens provide an opportunity to evaluate normal developmental changes and pathological entities and also to gain a better understanding of the museum pieces without damaging the museum specimens. pediatric ct interpretations: does a tertiary care radiologist make a difference? wendy d. ellis, monroe carell jr. children's hospital at vanderbilt university; sumit pruthi, david johnson, christopher eakins, chang yu, marta hernanz-schulman purpose or case report: to determine whether a substantive difference exists between the pediatric imaging reports of community radiologists and reinterpretations by tertiary care radiologists at a free-standing children's hospital; and how those interpretations were related to the final diagnosis. methods & materials: this retrospective review examined the computed tomography (ct) reports of all pediatric patients referred to our tertiary care children's hospital over a month period ( / / - / / ). the outside reports and the requested second interpretation reports were compared and their content categorized as "agreement" vs. "disagreement: major or minor". a representative sample of major disagreements in which there was reliable followup information was correlated with the final diagnosis to determine if there was added value provided by the reinterpretation. results: ct scans from patients were submitted for reinterpretation. disagreements were found in / cases ( . %); with . % ( / ) classified as major disagreements. among the neurologic cases, major disagreements occurred in patients ( . %) and minor disagreements in patients ( . %). among the body scans, major disagreements occurred in cases ( . %) and minor disagreements in cases ( . %). in the cohort of cases reviewed for final diagnosis, the second read interpretation was more accurate in . % of cases with a p-value of < . (neurologic . %, p < . ; body . %, p < . ). conclusions: in our review, discrepancy rates between community and tertiary care radiologists in interpretation of pediatric ct scans were substantial, with discrepancies occurring in more than % of cases. further review of the cases for final diagnosis, showed that a significant number of the tertiary care interpretations were more accurate. possibilities that may account for this discrepancy include subspecialty training and elapsed time since performance of the study, which might provide additional clinical data in some cases. diagnostic ct scans performed at outside institutions should not be repeated considering added radiation burden to the child and additional expense. our data indicates there is added value to the reinterpretation which impacts the accuracy of the report (as assessed by the final diagnosis), and should be recognized by payors as integral to optimal patient care. ionizing radiation exposure from radiography in the neonatal intensive care unit-per-patient cumulative effective doses amaya basta, radiology and biomedical imaging, ucsf; jesse courtier, john mackenzie purpose or case report: to better understand the levels of exposure to ionizing radiation for infants in the neonatal intensive care unit (nicu). we retrospectively collected the number and types of radiographs performed per infant in our nicu by searching our radiology information system database over a five-year period. we focused on the most common examinations ( % of all radiographs) and assigned each an estimated equivalent dose based on published literature: chest and abdomen . micro sieverts (μsv), one-view chest . μsv, abdomen . μsv, twoview chest . μsv, two-view abdomen μsv. we then calculated a cumulative equivalent dose (ced) for each infant based on the number of each type of examination they received. descriptive statistics were generated to depict the distribution of number of examinations and ced. results: over five years, , infants cared for in our nicu received at least one radiograph of the chest and/or abdomen. the number of examinations obtained on these infants was . , , , (mean, median, minimum, maximum). the st quartile was and the rd quartile was examinations. the cumulative equivalent dose these infants received was . , . , . , , . μsv (mean, median, minimum, maximum) . the st quartile was . and the rd quartile was . μsv. two hundred infants ( . % of the study population) received a ced of over μsv. conclusions: descriptive statistics provide a valuable assessment for the broad range of radiation that infants receive in the nicu. although the distribution is skewed towards a low level of exposure, a subset of patients ( . %) received a ced of over μsv. identification of factors that cause infants to enter this group will be important for future dose reduction strategies. poster #: cr- congenital cardiac fibroma: a case report earic bonner, meharry medical college, ebonner @email. mmc.edu; seth crapp, david parra purpose or case report: a -week-old male presented to his pediatrician with a ii/vi systolic ejection murmur along the left sternal border. he had mild tachypnea without cyanosis. his oral intake was adequate with no evidence of failure to thrive. he was referred to a pediatric cardiologist who performed an ecg and a transthoracic echocardiogram. the ecg showed normal sinus rhythm at beats per minute with no abnormalities. the transthoracic echocardiogram showed a x x mm homogeneous mass originating from the anterior free wall of the right ventricle, and mild dilation of the right ventricle. mild dynamic subpulmonary stenosis and a secundum atrial septal defect were also noted. although the murmur was significantly louder at one month follow-up, a repeat echocardiogram did not reveal any increase in the size of the mass. at months of age, a cardiovascular magnetic resonance imaging (cmri) study under general anesthesia was performed. cmri revealed a x x mm cardiac tumor that was causing narrowing of the right ventricular outflow tract. the tumor was hypointense on t -weighted imaging and hyperintense on t weighted imaging, with positive delayed enhancement. these findings, along with the size and location of the mass, are consistent with a diagnosis of a cardiac fibroma. chest mra, that was also performed, showed normal extracardiac vascular anatomy with no evidence of peripheral branch pulmonary stenosis. cardiac fibromas do not usually increase in size; however, the concern is the child's risk of arrhythmias. frequent holter monitoring was recommended for this patient. considerations were also made for an electrophysiology study in the next - years to determine the risk of ventricular ectopy. at that point, the patient can be assessed for the possibility of resection of the fibroma. purpose or case report: treatment of pulmonary atresia is complex and demands intricate solutions. one solution is the creation of a conduit between the right ventricle and the main pulmonary artery. the lifespan of these conduits is limited by progressive occlusion over time, which can be treated with endovascular stent placement in lieu of surgical re-intervention. however, these stents are at high ( %) risk for fracture, typically at the stent waist. the radiologist should be aware of this complication, as they may be the first to identify it on chest radiograph. the purpose of this electronic poster is to familiarize radiologists with this entity by presenting cases of stent fracture and migration. methods & materials: over a month period, we identified three children with rv-pa stent fractures and associated stent migrations on chest radiography. imaging analysis was focused on the appearances of these fractured stents. patient management and outcomes were reviewed. results: three children, males, female (ages , , and years) were found to have asymptomatic rv-pa conduit stent fractures with fragment migration. one chest xray was performed in the er for fever and cough; one was pre-op for gi surgery; one was done to confirm abnormal findings seen on a routine cardiac echo. the time between stent placement and fracture detection ranged from to months. two patients had stent fractures and embolizations to the right ventricle that required open surgery to remove stent fragments. the third patient had embolization to both pulmonary arteries, but did not require treatment. all patients did well. conclusions: stent fractures and migrations are a relatively common complication of rv-pa conduit stent placement. pediatric radiologists need to be aware of this complication in order to provide value-added interpretations. purpose or case report: we describe the case of a week stillborn fetus with a . cm diameter craniopharyngioma detected by ultrasonography. a g p woman in her third decade had ultrasonographic examination showing hydrocephalus, polyhydramnios and an intracerebral mass. the nature of the mass was uncertain and intracerebral hemorrhage was considered. the pregnancy was terminated at weeks gestation. at postmortem examination the decedent was a g male fetus with a head circumference of . cm and a crown-rump length of . cm. anterior and posterior fontanelles appeared large. no other external abnormality was found. the placenta was unremarkable and cytogenetics on placental tissue showed a normal male karyotype. examination of fetal viscera was remarkable for mildly underweight adrenal glands ( . g, expected . g) and hepatomegaly ( . g, expected . g). intracranial csf was increased in volume. there was a suprasellar . cm diameter somewhat gritty, but smooth-surfaced tumor. the brain and tumor together weighed g. the floor of the cranium and sella turcica were grossly normal. histologic examination of the tumor showed an adamantinomatous type craniopharyngioma with characteristic epithelium, stellate reticulum, focal keratinizing squamous epithelium and calcification. pre-and postnatal mri of caudal regression syndrome claire b. beaumont, md, university of arkansas for medical sciences, cbbeaumont@uams.edu; nafisa k. dajani, leann e. linam purpose or case report: caudal regression syndrome is a rare form of caudal dysplasia characterized by a spectrum of findings including agenesis of the lumbosacral vertebra, multiple orthopedic deformities in the lower limbs, as well as anomalies of the gastrointestinal and genitourinary tracts. the mechansim of caudal regression syndrome is not completely understood but is believed to be secondary to a defect in the induction of caudal elements. mri is a valuable tool for identifying the specific anomalies involved with caudal regression syndrome on a case-by-case basis. the following is a case from our institution which includes both pre-and postnatal mri. unsuspecting tuberous sclerosis diagnosed on neonatal cranial ultrasound vikas menghani, md, pediatric radiology, women's and children's hospital, drvikasmenghani@gmail.com; puneet gupta, richard thomas, vaseem iqbal, jan najdzionek. purpose or case report: tuberous sclerosis (ts) is a rare autosomal dominant genetic disorder causing hamartomatous proliferation in number of organ systems. because the classical triad of epilepsy, mental retardation and adenoma sebaceum is not commonly seen on clinical examination, imaging plays a central role in the diagnosis and treatment of tuberous sclerosis. central nervous system features of ts include subependymal nodules, cortical tubers, subependymal giant cell astrocytoma, white matter bands and cysts. in patients with ts, cerebral involvement in the form of subependymal nodules is seen in % to % and white matter abnormalities are noted in % to % of cases. knowledge of expected radiological features is thus important in making the correct diagnosis. recent studies have indicated that earlier appearance of brain lesions indicate a greater risk of mental retardation and a more severe clinical course. we present a case of a -day-old neonate who was referred to us with concerns for hydrocephalus. the cranial ultrasound demonstrated multiple echogenic subependymal nodules of varying sizes and mild asymmetry of the ventricles. the differential diagnosis included ts, torch infections, and x-linked subependymal heterotropia. areas of increased echogenicity were noted within the white matter of the left frontal lobe, which favored ts. subsequently, an mri was performed to validate these findings and assess for additional white matter lesions. the mri showed classic manifestations of ts that included periventricular lesions and streaky, linear, wedge-shaped hyperintensities on flair imaging. a noncontrast ct scan was also performed which revealed classic calcified subependymal nodules. cardiac rhabdomyoma and renal angiomyolipoma are the other recognized manifestations of ts and were respectively excluded by subsequent echocardiogram and renal ultrasound. pyloric atresia with epidermolysis bullosa: fetal mri diagnosis with postnatal correlation arnold c. merrow, md, radiology, cincinnati children's hospital medical center, carl.merrow@cchmc.org; jason s. frischer, anne w. lucky purpose or case report: pyloric atresia (pa) is an uncommon disorder, accounting for % of congenital gastrointestinal atresias. up to % of cases have associated anomalies, the most common of which is epidermolysis bullosa (eb). prenatal findings have been reported sonographically for each of these anomalies, both in isolation and in the rare case of association. a case of isolated pa has been reported by fetal mri. we present the first reported case of pa with eb diagnosed by fetal mri with corroborative postnatal imaging and surgical findings. the mother of this child was initially referred to the fetal care center of cincinnati at weeks gestation for a possible myelomeningocele diagnosed by prenatal ultrasound at an outside facility. these ultrasound images were not available for review at the time of our workup. a fetal mri was the first study to be obtained at our institution. the mri showed no myelomeningocele or brain anomalies. the stomach was moderately enlarged throughout the exam and did not empty. subjective polyhydramnios was also noted. no duodenal dilation was seen, and there was minimal fluid in the distal bowel loops. this constellation of findings raised concern for pyloric atresia, resulting in a careful search for any sign of epidermolysis bullosa due to a known association of these disorders. prominent debris was seen layering dependently in the amniotic fluid and in the dilated fetal stomach, and the external ears were abnormally small and misshapen. the pa-eb association was proposed as the underlying diagnosis based on our mri findings. it was also postulated that skin blistering over the lumbosacral spine at the time of the prior outside ultrasound could have mimicked a myelomeningocele, thus prompting the referral to our center. at delivery, the baby had numerous skin defects, and the ears were malformed. an abdominal radiograph obtained after nasogastric tube placement and air injection showed no gas beyond the stomach. a pyloric ultrasound showed a distended stomach without a patent pyloric channel to the duodenal bulb, consistent with pyloric atresia. a skin biopsy confirmed epidermolysis bullosa, and the patient underwent a resection of the pa with gastroduodenostomy. the baby subsequently expired less than two weeks later, most likely due to sepsis based on wound cultures and autopsy results. our case demonstrates the ability of fetal mri to diagnose this rare condition and highlights the key imaging manifestations of the pa-eb association. disclosure: dr. merrow has indicated that he is an author for amirsys and receives a royalty accordingly. purpose or case report: we demonstrate a case where the changing position of the contrast filled appendix lead to the diagnosis of malrotation, with review of the embriology of intestinal rotation. a newborn preterm female presented with a golf ball sized umbilical mass, that reduced by itself, thought to represent an umbilical hernia vs omphalocele. she was unstable to undergo an upper gi exam under fluoroscopy, therefore a limited contrast study was performed at bedside and was inconclusive for malrotation. subsequent nicu radiographs showed changing position of the appendix filled with residual contrast, visiting all quadrants of the abdomen in a random pattern over a few days period. this confirmed our suspicion for malrotation. it is well know that in malrotation the position of the cecum can be variable, most commonly located in the right upper quadrant or left lower quadrant. to our knowledge it has not been described yet that the changing position of the appendix can lead to the diagnosis of malrotation. through this case we display the embriology of the intestinal rotation and the radiologic signs of malrotation. poster #: cr- mr imaging patters of liver transplant complications in the pediatric population edward richer, md, emory university, richerej@gmail. com; adina alazraki, jonathan loewen purpose or case report: pediatric liver transplantation is a relatively common surgery, with more than transplants in the united status annually. the spectrum of post transplant complications has been previously described, primarily utilizing ultrasound. as mri has become a more widely used technique in pediatric imaging, and ultrasound findings may be non-specific, knowledge of mr imaging patterns is an important adjunct in the post-transplant evaluation. we present a spectrum of complications, including vascular, biliary, hepatic parenchymal, and systemic complications. methods & materials: using an electronic record system, we identified pediatric patients with prior liver transplantation who subsequently underwent abdominal mri at our institution and were found to have a post transplant complication. patient management and outcomes were reviewed. results: our review of a subset of the available patients shows vascular complications to be the most commonly encountered abnormality at our institution, including hepatic artery stenosis/thrombosis, and portal vein stenosis/ thrombosis, cavernous transformation of the portal vein. biliary complications were relatively common, including bilary stenoses and bilomas. hepatic parenchymal and systemic complications, such as ptld, were less common. we demonstrate the mr imaging patterns of these complications. conclusions: pediatric liver transplantation is a relatively common surgery, and the mri appeance of post transplant complications warrants illustration as abdominal mri becomes more widely used in pediatric imaging. we present a pictorial review of common patterns of complication. imaging of progressive familial intrahepatic cholestasis (pfic) matthew d. dobbs, md , radiology, vanderbilt university medical center, matthew.dobbs@vanderbilt.edu; sumit pruthi, stephanie e. spottswood purpose or case report: progressive familial intrahepatic cholestasis (pfic) is a relatively rare pediatric liver disease due to a genetic mutation (abcb gene on chromosome q - ) in a bile salt export protein causing cholestasis leading to chronic inflammation within the biliary system. the diagnosis is made clinically with detection of a low ggt in the face of an elevated bilirubin and alkaline phosphatase. genetic testing confirms the diagnosis. one of the subtypes, type , was shown in to be highly related to the development of hepatocellular carcinoma. the vast majority in children in this study developed hcc at less than years of age. radiological contribution to the management of these chronic liver disease patients is to perform surveillance imaging to detect hcc. due to the rarity of this condition, almost no reports exist in the radiological literature describing the imaging features or management of this condition. our presentation will review the imaging findings in our small population of pfic type patients on us, ct, and mri. we will also review suggested surveillance imaging techniques and imaging algorithms. renal rhabdoid mimics wilms tumor vikas menghani, md, pediatric radiology, women's and children's hospital, drvikasmenghani@gmail.com; paul montgomery, jan najdzionek, vaseem iqbal purpose or case report: in the past most pediatric renal tumors have been classified together under the umbrella of wilms tumor. however, over the last decade with advancement in imaging, several distinctive imaging features specific to renal tumors have been recognized which aid in their classification as being distinct pathologically. we present a case of rhabdoid tumor where in the primary tumor arose from the kidney. it had classical imaging features of wilms tumor. we want to highlight that even with the most sophisticated imaging techniques, specific renal tumors cannot always be diagnosed with preoperative imaging and how this alters the management and prognosis for child with a renal mass. in our case, the postoperative findings, pathology and immunohistochemical techniques confirmed a rhabdoid tumor. differentiation of these two tumors is essential since in patients with rhabdoid tumor survival is poor with -year overall survival rates of % for stages i and ii and % for stages iii, iv, and v. on imaging, there are several features that suggest the diagnosis of rhaboid tumor. these include subcapsular fluid collections, linear calcifications outlining tumor lobules, and vascular invasion. also, a pertinent feature of rhabdoid tumor due to its aggressive nature is the presence of lung metastasis ( %) and synchronous malignant brain lesions ( %). these findings were not present on our case, which led us in formulating a diagnosis of wilms. our patient is unusual in the fact that the local renal findings and absence of metastasis, synchronous malignant lesions, and vascular invasion led us to an incorrect diagnosis of wilms tumor. in conclusion, we would like to stress that diagnosis of rhabdoid tumor of the kidney on imaging presents a challenge because of its imaging similarity to wilms tumor. ectopic ureters in young infants: mru findings shin-lin shih, md, department of radiology, mackay memorial hospital; yi-fang chen, chun-chao huang, fei-shih yang purpose or case report: to localize the terminations of ectopic ureters by mri methods & materials: mr urography (mru) was conducted in four female patients with hydroureter and a suspected ectopic orifice. mr imaging was performed with a t mr scanner (achieva; philips). the imaging protocol mainly consisted of a single-shot t -weighted turbo spin echo sequence with a slice thickness of mm and multiplanar reformations. the ages of the four patients were day, days and months (for two). the latter two patients presented with urinary tract infection. the newborn patients presented with abnormal prenatal examination. the pertinent findings and descriptions of a variety of renal anomalies were described. results: the locations of the ectopic ureters were two in the vagina, one in the uterus and one in the bladder neck. the associated renal anomalies were a right duplex kidney in four, a left duplex kidney in one, a left ectopic dysplastic kidney in one and vesicoureteral reflux in one (confirmed by vcug). conclusions: mru may demonstrate the exact point of termination of an ectopic ureter and also the associated renal anomalies. poster #: cr- acquired polycystic kidneys in neuroblastoma survivors richard bellah, , radiology, the children's hospital of philadelphia, bellah@email.chop.edu; bernard kaplan, camilo jaimes, yael p. mosse, jill p. ginsberg, kevin e. meyers purpose or case report: neuroblastoma (nbl) is the most common extracranial solid malignancy of childhood. with current therapy, the prognosis and long term survival of patients affected by this condition has dramatically improved. nevertheless, the treatment for nbl may account for some complications further in life. in patients with neuroblastoma, acute renal failure can occur usually as a result of a thrombotic microangiopathy associated with bone marrow transplantation. in addition, end-stage renal disease has been reported in long-term survivors of nbl. this exhibit describes and illustrates the first case series of five patients with treated nbl in whom the imaging features of polycystic kidney disease (pkd) developed over time, and in some cases, as progressive renal failure ensued. methods & materials: medical and imaging records were reviewed (irb approved) of patients with treated nbl in whom pkd became apparent during the course of followup imaging. results: five patients displayed findings of pkd on us and/or ct. three of the five patients (where images were available) had normal renal imaging at time of nbl diagnosis. the mean age at nbl diagnosis was . years (range . - . yr). the mean age at time pkd was detected was . years (range - yrs). none of the patients had a family history of pkd, or had previously undergone dialysis. all patients received chemotherapy and total body irradiation prior to bone marrow transplantation. four patients survived nbl therapy but eventually developed end-stage renal disease. conclusions: an association between acquired pkd and nbl has not been previously reported. the etiology of this observation is still unclear, but a toxic insult is likely to account for the renal changes. further research is needed to establish the epidemiology, prognosis, and etiology of this association. abnormal migration of the retention anchor suture in a case following gastrostomy tube insertion surendra narayanam, mbbs, dmrd, dnb, division of image guided therapy, department of diagnostic imaging, the hospital for sick children, nrssbabu@gmail.com; joao amaral, luke toh, bairbre connolly, vicente deoliveira, dimitri parra purpose or case report: during percutaneous gastrostomy tube placement, retention anchor suture(s) are deployed into the stomach to tack the anterior gastric wall to the abdominal wall. in our practice the thread of the retention anchor suture is cut at days and the metallic portion passes pre rectum. we report an interesting and very rare migration of the metallic portion of the retention anchor suture in post-primary gastrostomy tube insertion. an -month-old girl, with a mitochondrial disease and severe hypotonia underwent percutaneous gastrostomy placement. during the procedure the retention anchor suture thread snapped and the metallic portion of the suture remained within the stomach. day post procedure, the child became uncomfortable, so a gastrostomy tube check was performed. the suture was not visible in the abdomen on abdominal x-ray or fluoroscopically. on close review of the images, the suture was found projected over the distal esophagus. initial impression was the anchor suture had refluxed into the esopahgeal lumen. careful attempts were made to remove it along with the nasogastric tube, from above under fluoroscopic control. however on withdrawal of the nastogastric tube, the retention anchor suture moved enbloc with the nasogastric tube. once removed the retention anchor suture was confirmed to be within the nasogastric tube. this case illustrates the importance of examining the chest x-ray carefully before assuming a retention anchor suture has passed. to understand the appropriate post procedural radiographic workup and its technique for timely diagnosis. . to learn the potential complications of delayed diagnosis. pediatric retroperitoneal synovial sarcoma ahmad aouthmany, university of toledo medical center, ahmad.aouthmany@utoledo.edu; asif abdullah purpose or case report: pediatric synovial sarcoma most commonly affects the extremities, especially the lower thigh and knee region; other primary sites such as the retroperitoneum have been only infrequently reported. we report an extremely rare case of a retroperitoneal synovial sarcoma masquerading as retroperitoneal hematoma in a -year-old white female with non-traumatic back pain and non-contrast enhanced ct findings of right quadratus lumborum and psoas region presumed hematoma. coagulation studies revealed factor xi deficiency also known as hemophilia c. however, on follow-up imaging, the presumed retroperitoneal bleed persisted and a subsequent mr examination revealed a solid enhancing mass. ct, mr, and fdg-pet findings as well as a brief histopathology are discussed. our case is rare in the regards that the tumor occurred in an uncommon retroperitoneal location in a pediatric patient and was mimicking a retroperitoneal hematoma which posed a significant diagnostic challenge. despite a rare entity, synovial sarcoma among other sarcomatous lesions maybe considered in the differential consideration of a spontaneous retroperitoneal hematoma even in hemophiliac patients. longitudinal bracket epiphysis michael jubang, geisinger, mjjubang@geisinger.edu; farzad sedaghat, william j. malone, george wu, william mirenda purpose or case report: longitudinal bracket epiphysis is a rare anomaly with multiple synonyms such as delta bone, triangular bone, and congenital angular deformity. the purpose of this case report poster is to discuss an -month-old male born with an adducted right great toe with a broad nail and a notch in the center of the distal phalanx. the review will discuss radiographic findings, the natural progression of the disease, the treatment options, the mri findings used for pre-surgical planning, and associated pathology. whole body mri in pediatric non oncologic diseases: pictorial review ramy el jalbout, md, radiology, chu sainte justine, ramy.jalbout@yahoo.com; vijay moorjani purpose or case report: with the advances in scanning techniques and the scanning sequences, the role of wbmri is expanding. mri has a great role in the pediatric population owing to its inherent advantages namely lack of radiation, high tissue specificity, and high diagnostic yield at the level of the entire body under a single sedation. unlike the application of wbmri in the assessment of metastasis and bone marrow involvement in leukemia, its role in systemic diseases is yet to be further investigated. certain diseases such as crmo are very often multifocal. the extent of osteonecrosis in patients on steroids, dermatomyositis and the lesions related to child abuse are very often wide spread in the skeleton. we intend to present some of the findings of these pediatric systemic and multifocal diseases on wbmri. chronic relapsing multifocal osteomyelitis (crmo): crmo can be acute or chronic and is multifocal. the abnormality manifests as high signal intensity. wbmri can guide for the best site for biopsy and provides monitoring for response to treatment. osteonecrosis: only few small studies evaluated the usefulness of wbmri in the diagnosis of both the symptomatic and asymptomatic sites of osteonecrosis in all patients on steroid therapy. wbmri is more sensitive than conventional radiographs. the abnormalities are typically geographical areas of high stir signal intensity. myopathies: wbmri has also the role of detecting the extent of idiopathic inflammatory myopathies such as dermatomyositis in the entire skeleton. child abuse: wbmri has a low sensitivity for the highly specific fractures that are pathognomonic for child abuse. conclusions: wbmri is a useful examination in the pediatric patient that is radiation free, quick and allows imaging of the entire body. it is an adjunct to dedicated mris to look for multifocality and extent of systemic diseases such as crmo, osteonecrosis in patients on steroids and dermatomyositis. it has a great potential as a screening examination but at the same time can detect both the symptomatic and the asymptomatic lesions in the bone marrow and muscles that are otherwise not seen on conventional radiography. it also allows guidance for biopsy and monitors response to treatment. mobile "cerebroliths" in hemihydranencephaly: a case report usha d. nagaraj, md, the ohio state university medial center, usha.nagaraj@osumc.edu; brent adler purpose or case report: hydranencephaly is a congenital central nervous system disorder manifested by the replacement of the cerebral hemispheres with a thin membranous sac filled with cerebrospinal fluid and necrotic debris. hemihydranencephaly is an extremely rare brain condition in which the vascular anomaly is unilateral, with fewer than cases previously reported in the literature. this is a case of a -month-old male who presented to the ophthalmologist for evaluation of possible leukocoria of the right eye. the patient had a history of a difficult vaginal delivery that required forceps delivery with possible associated trauma to the right eye. dilated fundoscopic exam revealed retinal calcifications. this caused a clinical concern for retinoblastoma and ct and mri of the orbits were obtained. ct demonstrated profound dilatation of the left lateral ventricle with only a thin rim of cortex surrounding it. there was some midline shift to the right with mild dilatation of the right lateral ventricle. the thalami and brainstem were spared. there were multiple soft tissue bodies that layered in the dependent portion of the left lateral ventricle, which were isodense to grey matter. mri revealed similar findings consistent with hemihydranencephaly involving the left cerebral hemisphere. there were multiple round soft tissue masses that measured up to cm in size that layered posteriorly in the left lateral ventricle. these masses were isointense to grey matter on t and hyperintense on t . when the patient was placed with his head turned to the left, these masses moved to the dependent portion of the left lateral ventricle. the orbits were normal on both ct and mr. these soft tissue collections are presumed to be mobile collections of infarcted brain tissue. this unusual appearance has not been described in the radiology literature. we review the ct and mr findings and review the relevant literature. purpose or case report: citrullinemia type i is a rare inborn error of urea cycle metabolism resulting in hyperammonemia. in the classic form, the newborn presents with poor feeding, vomiting, progressive lethargy and signs of increasing intracranial pressure - days after birth, rapidly progressing to apnea, coma and death if left untreated. we present a case of a term infant who presented to the hospital on the th day of life with a typical history of poor feeding and profound hypotonia. upon admission he had multiple episodes of apnea and hemodynamic instability prompting intubation and intensive support. laboratory evaluation revealed multiple abnormalities, most notably, hyperammonemia ( umol/l) and elevated citrulline (> umol/l). mri of the brain performed on the th day of life showed findings consistent with term hypoxic ischemic encephalopathy with restricted diffusion in bilateral rolandic cortex and subcortical white matter, bilateral caudate heads and lenticular nuclei, bilateral insular cortex, and bilateral cerebral peduncles. the genu of the corpus callosum, bilateral deep frontal white matter, and the left parietal white matter also demonstrated restricted diffusion suggesting infarction secondary to thrombosis of deep intramedullary veins. an area of restricted diffusion in the right parietal cortex was suspicious for superficial venous infarct. review of the literature reveals that this case of neonatal citrillunemia has unique mri findings. while our patient had diffusion changes with some shared similarities to the previous two cases in the literature, there are also findings consistent with deep intramedullary venous thrombosis and infarction. poster #: cr- duplicated internal auditory canal: a rare anomaly of the temporal bone ahmad aouthmany, university of toledo medical center, ahmad.aouthmany@utoledo.edu; asif abdullah purpose or case report: duplicated internal auditory canal (iac) is a rare anomaly of the temporal bone, which is usually associated with sensorineural hearing loss. only a few cases have been previously described in literature. we describe an extremely rare case of duplicated right internal auditory canal in a six month-old patient with a history of down syndrome. a six month-old male with trisomy presented with profound bilateral sensorineural hearing loss. the patient failed the newborn hearing screening tests. past medical history was unremarkable for recurrent ear infections. on focused physical examination, the auricles were normal appearing. external auditory canals were patent bilaterally revealing clear and translucent tympanic membranes. patient did not reveal a facial palsy. subsequently, a high resolution computed tomography (hrct) of the temporal bone was performed. duplicated appearance of the right internal auditory canal with separation of facial and vestibulocochlear segments was noted. the facial nerve canal demonstrated normal caliber while there was significant narrowing of the cochlear canal near the fundus. significant stenosis of the vestibulocochlear segment of the duplicated iac was identified at the porus acousticus. dehiscent right posterior semicircular canal was also seen. an enlarged right vestibule was also noted. a single iac was identified on the contralateral side with significant stenosis at the porus acousticus. high-resolution magnetic resonance imaging of iac was recommended which revealed normal appearance of the bilateral cochlear and vestibular nerves. duplication of the iac is an extremely rare anomaly involving a redundant osseous canal extending from the cerebellopontine angle through the otic capsule bone toward the labyrinth or cochlea. a duplicated iac may or may not be associated with congenital sensorineural hearing loss secondary to aplasia or hypoplasia of the vestibulocochlear nerve. to evaluate for structural abnormalities that may preclude cochlear implantation, it is important to evaluate pediatric patients with sensorineural hearing loss radiologically. although hrct is the best imaging modality for evaluation of osseous iac, the iac contents are best viewed on mri in oblique sagittal planes of the iac using a -d volumetric steady state sequence. neuroimaging in hemiplegic migraine: cases and review of the literature nicholas v. stence, md, children's hospital colorado-radiology, nicholas.stence@childrenscolorado.org; sita kedia, john a. maloney, jennifer armstrong-wells, timothy bernard purpose or case report: hemiplegic migraine (hm) is a rare variant of migraine with aura. it is characterized by a motor deficit lasting up to h that is fully reversible. little neuroimaging data for hm exists in the literature. we report our experience with two pediatric cases of hemiplegic migraine. we also review published cases of pediatric hm with abnormal findings on neuroimaging. methods & materials: cases and presented to our institution with severe headache (ha), acute right-side weakness, aphasia, and altered mental status (ams), which did not resolve after h. magnetic resonance imaging (mri) and genetic testing are reviewed for these cases. the literature was reviewed for pediatric cases with neuroimaging changes during hm attacks. results: initial mri, including diffusion-weighted imaging (dwi), was negative in both patients within h of onset. repeat mris at h (case ) and h (case ) were both positive for mild hyperintensity on trace diffusion images, and corresponding reduced diffusion on adc maps, involving regions of the cortex and juxtacortical white matter in left middle cerebral artery distributions. these findings completely resolved at months in both cases. mr angiograms (mra) were negative in both cases. case had a family history of migraines and was found to have an unreported mutation in atp a gene at a highly conserved location in vertebrates. case had a family history of hm and was found to have an indeterminant mutation in the cacna a gene. infectious, metabolic and hypercoagubility work up was negative. case required inpatient rehabilitation and at year follow up was requiring speech therapy. case resolved completely. in the literature, cases of hemiplegic migraine with neuroimaging changes were reported. all cases had prolonged hemiplegic migraines (symptoms> h) and showed cerebral edema with or without restricted diffusion. conclusions: all eight hm cases in the literature with abnormal findings on neuroimaging had prolonged attacks. mris for our two cases and two cases reported in the literature were initially normal at admission. mild swelling and restricted diffusion developed in our two cases after h, and resolved on follow up mris. subtle findings on diffusion and t imaging may lag behind the clinical picture in hm, therefore serial neuroimaging may be useful in individuals with prolonged symptoms. most cases eventually show resolution clinically and on mri. correlation of neurosonographic anatomy with matching mr scan planes denise castro, hospital for sick children, denisecastro @ gmail.com; pam rasalingham, omar islam, don soboleski purpose or case report: new high-resolution mr sequences have allowed for exquisive anatomic detail and enables reconstruction of images in any scan plane desired. this ability allows for precise matching of mr image planes with the standard oblique coronal, sagittal and axial images obtained during routine neurosonography. the purpose of this poster is to correlate the morphology demonstrated on neurosonography with the mr image, utilizing this ability in order to enhance our understanding of the neuroanatomy distinguishable on sonographic imaging. we believe this will allow a better appreciation of the subtle differences in echotexture of neuroanatomic structures which are often ignored or overlooked on neurosonography and help improve our detection of subtle sonographic abnormalies. ectopic cerebellum in the posterior cranial fossa: report of a case and review of the literature usha d. nagaraj, md, the ohio state university medical center, usha.nagaraj@osumc.edu; daniel boue, lisa martin purpose or case report: cerebellar heterotopia is a common congenital anomaly frequently encountered in the form of cell rests around the fourth ventricle. however, isolated well-differentiated cerebellar ectopia is extremely rare. of the previously reported cases in the literature, only have presented as a discrete, extraaxial mass and none have been described in the posterior cranial fossa. we present a case of a -year-old male who initially presented with persistent daily headaches. physical exam including a detailed neurologic exam was within normal limits. non-contrast computed tomography (ct) of the brain was initially performed, demonstrating no abnormalities. further work-up with magnetic resonance imaging (mri) was performed, which revealed a well-defined, extra-axial mass superior to the cerebellum and inferior to the tentorium, immediately beneath the vein of galen. the mass was isointense to grey matter on t and t sequences and there was no significant enhancement on post-contrast images. there was mass effect on the vermis and the cerebellar tonsils were displaced mm below the foramen magnum. neurosurgery was consulted and the mass was removed for diagnosis and treatment of the patient's symptoms. the mass was easily identified intra-operatively and gross total resection was accomplished successfully. pathologic analysis of the mass revealed well-formed cerebellar tissue without evidence of neoplasia. to the best of our knowledge this is the only case of ectopic cerebellum presenting as a discrete extra-axial mass in the posterior cranial fossa. our case shows that an extra-axial mass that parallels grey matter on all sequences can be a presentation of ectopic cerebellum. we describe the ct and mri findings, surgical and histopatholgical results and review the relevant literature. pediatric isodense acute subdural hemorrhage jeffrey s. kao, md, msee, university of kansas-wichita, run boston@gmail.com; debbie desilet-dobbs purpose or case report: the density (attenuation coefficient) of subdural hemorrhage (sdh) in computed tomography (ct) is important in assessing the acuity of sdhs. an acute sdh is traditionally described as hyperdense and then becoming isodense in approximately weeks when entering the subacute phase. in this report, we document the case of a pediatric patient with the new appearance of an acute sdh within h of the prior ct that was isodense. greater than % of the collection was isodense, with a small focus of hyperdensity. acute sdhs are known to be isodense to gray matter in patients with anemia (wp smith, am j neurorad ). however, the hemoglobin and hematocrit was within normal limits. in addition, acute sdhs that are only a few hours old can have a mixed hyperdense and hypodense appearance because of uncoagulated blood before clotting takes place (j provenzale, ajr ) . thus, an acute sdh can have an isodense appearance in a non-anemic patient. radiologists should consider the possibility of an acute sdh with an isodense appearance, especially in case of possible non-accidental trauma where timing of an injury is important. undifferentiated sarcoma of the esophagus in an year-old male: case report and radiologic/pathologic correlation michael e. daniel, md, ut southwestern / children's medical center dallas, michael.daniel@utsouthwestern. edu; lisa sutton, sandy cope-yokoyama, neil j. fernandes purpose or case report: mesenchymal neoplasms of the gastrointestinal (gi) tract occur infrequently in the adult and are extremely rare in the pediatric population. the occurrence of these lesions in the esophagus is limited to a collection of case reports in the available literature. most esophageal mesenchymal tumors in the pediatric gi tract are benign leiomyomas. the vast majority of malignant mesenchymal tumors in children are categorized as either sarcomas or gastrointestinal stromal tumors (gist). we report a case of a high grade undifferentiated sarcoma of the distal esophagus in an year-old male. while this tumor most closely resembles a gist, the immunohistochemical profile of the lesion is not typical of any distinct mesenchymal neoplasm. a review of the literature demonstrates a single case report of a likely benign undifferentiated mesenchymal neoplasm of the distal esophagus in an adolescent. to our knowledge, this is the first reported case of an undifferentiated esophageal sarcoma in a pediatric patient. we provide radiologic and pathologic features of the above lesion, and review the typical imaging and pathologic characteristics of mesenchymal gi neoplasms. potential airway management issues in sedated children kimberly fagen, md, ms, children's national medical center, kfagen@childrensnational.org; nadja kadom, ira cohen purpose or case report: many pediatric imaging studies require sedation. it has been shown that a variety of health care professionals other than anethesiologists may provide sedation, including advanced practice registered nurses, nurse practitioners, physician assistants, fellow level trainees, emergency medicine physicians, intensivists, pediatricians and, last but not least, radiologists. moderate sedation, also called "conscious sedation", does generally not require an anesthesiologist as there is usually adequate spontaneous ventilation and no airway intervention required. however, in case of a complication during the imaging study intubation may become necessary. for patients with certain congenital or acquired conditions emergent intubation may be very difficult and should be brought to the attention of an anesthesiologist prior to inducing moderate sedation. the four "d's" is a quick way to assess potentially difficult airways that necessitate consultation with anesthesia prior to moderate sedation: dentition (incisor/tooth size, dental alignment, and macroglossia), distortion (swelling from infection, tumor, or trauma), disproportion (hyoid-chin ratio, such as with micrognathia), and dysmobility (jaw or cervical spine movement issues, i.e. trauma or atlanto-occipital instability). presence of some of these features may be an indication to consider general anesthesia for sedation; at the very least, anesthesiologist's awareness of a potentially difficult intubation adds to patient safety during moderate sedation. purpose or case report: lymphangiomatosis describes the presence of multiple lymphangiomas often with multiorgan involvement; typically bones, spleen, mediastinum and lungs. although lymphangiomatosis has been described in patients ranging from birth up to years, it most frequently presents in childhood. the lesions can occur in any tissue in which lymphatics are normally found, with a predilection for neck and chest involvement. the clinical presentation is variable including pleural or pericardial effusion, hemoptysis, protein wasting enteropathy, peripheral edema, hemihypertrophy and disseminated intravascular coagulopathy. the coexistence of lytic bone lesions and chylothorax serves as an important diagnostic clue. we describe typical radiographic, ct and mri findings in the appropritate clinical setting that narrow the differential diagnosis and raise concern for this rare entity as the etiology for the patient's symptoms. we report a -year-old girl and year-old boy with pulmonary lymphangiomatosis with typical presentation and imaging findings. results: bilateral interstitial infiltrates, pericardial and pleural effusions are evident on chest radiograph. sampling of the pleural fluid demonstrates chylous effusion. ct scans of the thorax reveal diffuse smooth thickening of interlobular septa and bronchovascular bundles with extensive infiltrative involvement of mediastinal fat. osseous and splenic lesions are demonstrated both on ct and mr. differential diagnosis includes interstitial edema, lymphoma and sarcoidosis. conclusions: the natural history of pulmonary lymphangiomatosis is characterized by progressive growth and compression of adjacent structures. therapy should aim to decrease the compressive effects, to control chylous effusions, and to maintain cosmesis. the success of surgical resection is limited by inability to separate lymph collections from normal structures. characteristic clinical and radiographic presentation, chylothorax, and extrathoracic lymphatic dysfunction should prompt a consideration of lymphangiomatosis and prevent delay in diagnosis. aortic arch congenital anomalies: what the radiologist needs to know luana stanescu, radiology, seattle children's hospital, stanescu@u.washington.edu; stephen done purpose or case report: . review classic imaging findings in congenital aortic arch anomalies which can improve detection on radiographs and barium esophagogram . describe pertinent embryologic basis of the radiologic findings . describe correlative imaging findings on ct and/or mri in dedicated cases . describe common diagnostic pitfalls methods & materials: after obtaining institutional irb approval we reviewed various patients presentations with this condition and analyzed images to characterize this particular entity and it's manifestations for better definition of diagnostic criteria. results: radiographs and barium esophagogram: algorithmic approach in reviewing chest radiographs in order to improve detection of aortic arch anomalies; classic findings and common pitfalls. cross-sectional imaging (ct and mri): what the surgeons need to know before surgical repair; detection of associated cardiac anomalies. sample cases: double aortic arch, double aortic arch with complete or partial atresia of one of the arches. conclusions: major teaching points of this exhibit are: . review of classic features of congenital aortic anomalies on radiographs, esophagogram, ct and mri with pertinent embryologic basis . describe the utility of various imaging modalities in congenital aortic anomalies, emphasizing common pitfalls. cardiovascular and mediastinal imaging in children with unexpected clinical presentation shunsuke nosaka, md, radiology, national center for child health and development, nosaka-s@ncchd.go.jp purpose or case report: children with cardiovascular and mediastinal diseases can be congenital or acquired in etiology. they usually present with straightforward clinical course. in certain situation, however, some of the children show unexpected clinical presentation predominantly with those of neighboring organs such as respiratory tract, hepatobiliary system, and gastrointestinal tract. these unexpected presentations can be the cause of delay in proper diagnosis and treatment. the purpose of this exhibit is demonstrate a variety of imaging findings of cardiovascular and mediastinal diseases in children with unexpected clinical presentation. this exhibit is case based presentation of cardiovascular and mediastinal imaging in children including tips, pitfalls and lessons learned among patients presented with unexpected clinical presentation. diagnostic imaging modalities for cardiovascular disease usually consist of various combinations of plain radiography, ultrasound, ct, mr imaging, fluoroscopy, nuclear medicine, and angiography. the general concept of alara-as low as reasonably achievable-should always be utilized when radiation-producing modalities are indicated in children. the diseases included will be double aortic arch found during workup for the cause of aspiration pneumonia, unilateral pulmonary vein atresia presented with recurrent episodes of pneumonia, severe mitral regurgitation secondary to chordal rupture mimicking fluminant hepatic failure, myocarditis initially present as acute abdomen, cardiomyopathy as unusual initial presentation of neuroblastoma, and thymolipoma mimicking gradual development of cardiomegaly. conclusions: it is important for radiologist to be familiar with imaging findings of cardiovascular and mediastinal diseases in children with unexpected clinical presentation. cardiac embryology made easy: a novel teaching approach using claymation andrew phelps, children's hospital boston, aphelpsmd@ gmail.com; purpose or case report: congenital heart disease can be an intimidating subject for radiology residents, and cardiac embryology is key to its understanding. however, this can be an equally intimidating topic to teach! various diagrams and animations are available in textbooks and online, but much like advanced origami, many of these resources suffer from being visually too complex for the first-time learner. to overcome this teaching obstacle, i created my own cardiac embryology animations using modeling clay and incorporated them into a comprehensive didactic lecture on congenital heart disease. methods & materials: cardiac embryology animations were created using modeling clay, a digital camera, and microsoft powerpoint. surface and cross-sectional views were generated, depicting the key events in cardiac embryology: heart tube formation, cardiac looping, chamber division, truncus arteriosus division, and pulmonary venous connection. example models are shown in figure . results: in this lecture, the animations are presented alongside actual embryonic heart photographs. the lecture then uses the embryology knowledge as a basis to explain the common congenital heart diseases and their mri appearances. examples of septal defects, ventricular hypoplasia, and transposition of the great arteries are presented, among others. conclusions: understanding cardiac embryology is required in order to approach congenital heart disease in a logical fashion. modeling clay animations are a cheap and easy way to simplify this complex topic. arterial tortuosity syndrome: an introduction to the clinical and radiologic manifestations in the pediatric population neal desai, umkc som, neal @gmail.com; suchit patel, ayushi gupta, marius hubbel, doug rivard purpose or case report: . to describe the clinical findings of arterial tortuosity syndrome and give a brief discussion of the disease process. . to describe the radiologic manifestations of arterial tortuosity syndrome. . to give a brief discussion of loeys-dietz syndrome-a disease with similar arterial findings, but with unique molecular characteristics from arterial tortuosity syndrome. . to use this knowledge to help establish the diagnosis and reduce mortality. methods & materials: arterial tortuosity syndrome overview • epidemiology • molecular basis • pathophysiology • review of signs, symptoms and presentation • brief discussion of treatment differential diagnosis of arterial tortuosity syndrome • loeys-dietz syndrome-similarities and differences radiologic findings and discussion • chest radiograph • computed tomographic angiography • magnetic resonance angiography-neck • magnetic resonance angiography-head • conventional angiography making a diagnosis • sample case report • review questions conclusions: arterial tortuosity syndrome is a rare disease whose chief manifestation is severe cardiovascular connective tissue defects. due to the nature of these defects and the significance of rapid intervention, it is important to be aware of and recognize the radiologic manifestations associated with arterial tortuosity syndrome in the presence of appropriate clinical history to help offer a better prognosis to the patient. dynamic pulmonary computed tomography for evaluation of cardiopulmonary disease shilpa v. hegde, md, arkansas childrens hospital, university of arkansas, shilpavhegde@gmail.com; s. bruce greenberg purpose or case report: dynamic pulmonary computed tomography (dpct) is a wide-detector ct technique that allows for continuous chest imaging during respiration. when combined with intravenous contrast, the technique is a unique tool for evaluation of cardiopulmonary abnormalities in children with cardiopulmonary abnormalities. the purpose of this poster is to illustrate the technique of dpct for evaluation of cardiopulmonary disease in children with congenital heart disease and persistent respiratory distress. methods & materials: methods and materials: dpct exams with intravenous contrast were performed on infants with a history of congenital heart disease and palliative surgery. four continuous msec gantry rotations were obtained with respiratory rates set at /minute. the imaging was accomplished during the time of a single respiratory cycle. kvp and low ma resulted in effective dose of≈ . msv. eight respiratory phases were reconstructed to create d and mpr cine loops for evaluation of cardiopulmonary abnormalities. results: cardiopulmonary abnormalities were detected in all patients. patency of sano shunt, blalock tausig shunt or patent ductus arteriosus stent was established. intimal thickening was identified in one sano shunt. hypoplastic branch pulmonary arteries were present in infants and pulmonary vein thrombosis in infant. left bronchomalacia was identified in four of five infants and best or only identified on the expiratory phase of respiration. left lung air trapping was present in two patients. conclusions: dpct with intravenous contrast is the ideal study for evaluation of the post-operative infant with congenital heart disease and persistent respiratory distress. the role of low-dose ct angiography in the evaluation of renovascular hypertension in children jessica kurian, md, chop, kurianj@email.chop.edu; monica epelman, kassa darge, els nijs, jeffrey hellinger purpose or case report: historically, the evaluation of renovascular hypertension has been accomplished via us and conventional angiography. based on the reported adult experience we introduced renal ct angiography (cta) for the evaluation of renovascular hypertension in mid- . our institution has a robust, well-established protocol, which results in reproducible, high quality images. we aim to present our imaging strategies for the evaluation of these patients and to discuss and illustrate the role of low-dose cta with -d imaging as a noninvasive alternative in the evaluation of pediatric renovascular hypertension. methods & materials: we used our department information system to identify pediatric patients (< years of age) who had documented renovascular hypertension confirmed either by conventional angiography and/or surgery during a -year period. we present our protocol and discuss the indications, limitations and benefits of renal cta. ct thin slice data, obtained employing dose reduction strategies, was reviewed and reconstructed in d and d renderings. pertinent us and mr studies as well as demographic and clinical data were reviewed and recorded. several causes for renovascular hypertension were documented and relevant ct angiographic findings were selected for presentation. results: radiation dose ranged . - msv. fibromuscular dysplasia was the most common diagnosis followed by neurofibromatosis type . vascular pathology included stenoses, beading, occlusions, and aneurysms. disease was noted in the extraparenchymal renal arteries in approximately % of the cases. the choice of the imaging modality for the investigation of renovascular hypertension in pediatric patients remains controversial. in the authors' experience, cta with -d imaging is a valuable, non-invasive diagnostic tool for the evaluation of pediatric renovascular hypertension. low dose protocols can reduce the radiation exposure associated with ct. this method can spare patients the complications associated with conventional angiography. fetal mri: brain, head and neck malformations-a pictorial essay sumit singh, md, children's hospital of wisconsin, sumitsingh @yahoo.com; mohit maheshwari, teresa c. gross kelly, tushar chandra, ibrahim s. tuna, craig johnson purpose or case report: the purpose of the exhibit is to illustrate various brain, head and neck massses/vascular anomalies on fetal mri. we will also briefly discuss the normal fetal brain anatomy as seen on fetal mri. methods & materials: major indications for fetal mri include evaluation of inconclusive sonographic findings in cases of cns malformations. in our institute patients are scanned on . t mr scanner. a body surface six channel phased array coil is used to maximize signal to noise. all the scans are checked by a neuroradiologist to make sure adequate plane imaging of the brain or other lesion in question were performed. plane scanning of the fetal body is also performed for the laterality determination of the lesion and also screen for other congenital anomalies. results: prenatal usg is frequently inconclusive for evaluation of complex fetal brain and head and neck anomalies. most studies suggest that mri after first trimester is safe. in addition, advent of rapid mri sequences like single shot fast spin echo (ssfse) have helped in reducing scan time and motion artifacts leading to availability of diagnostic quality images. these have led to increasing use of mri as supplemental tool to further investigate inconclusive fetal sonographic findings. mri provides better anatomical delineation of these complex abnormalities. it helps in making appropriate diagnosis with high confidence and aids in appropriate obstetric and prenatal/neonatal surgical planning or intervention. this educational exhibit will illustrate few common fetal anomalies. these will include agenesis of corpus callosum, malformation of cortical development, posterior fossa malformations, ventriculomegaly, in-utero stroke, orbital abnormalities and some fetal neck masses/ vascular malformation. correlation and confirmation with the postnatal mri will also be provided for some cases. conclusions: technical and therapeutic advances have driven the development of fetal mri. it is an important adjunctive tool for prenatal imaging in those instances in which a complex anomaly is suspected by sonography, when fetal surgery is contemplated, or when a definitive diagnosis cannot be determined. it has prognostic implications and may help in optimal and timely obstetric and neonatal management. purpose or case report: this educational report will provide a review of the imaging appearance of intradiaphragmatic and subdiaphragmatic pulmonary sequestrations on fetal mri. the proposed pathophysiology, review of sequestration subtypes, and surgical management options will also be described. case examples will be provided to illustrate the fetal mr imaging findings of these variants of pulmonary sequestration that help support the diagnosis. specifically a "triangle sign" of t hyperintense tissue directed toward the diaphragm will be demonstrated. illustrative case examples will be placed in the context of a differential diagnosis for subdiaphragmatic masses seen on prenatal imaging. imaging signs that help make a diagnosis of these pulmonary sequestration variants and separate this entity from other lesions will be emphasized. poster #: edu- mri of the fetal head and neck masses alok jaju, md, mallinckrodt institute of radiology, alokjaju@gmail.com; joshua shimony, per amundson purpose or case report: fetal magnetic resonance imaging (mri) is a useful problem solving tool for abnormalities detected by prenatal ultrasound (us). masses of the head and neck region can vary from benign incidental lesions to devastating neurological lesions and life threatening tumors. we share our experience in characterizing these lesions by prenatal mri, that can have a bearing on follow up imaging, perinatal management and overall prognosis. we did a retrospective review of all fetal mri studies performed at our tertiary care children's hospital between / and / , to identify fetuses with head and neck masses. we reviewed the maternal demographic and clinical data, prenatal ultrasound, fetal outcomes and post natal imaging (when available). results: out of the fetal mri studies, had dominant head and neck masses. majority were encephaloceles ( occipital, parietal). the remaining included variety of masses such as nasal glioma, teratoma ( ), epidermoid cyst, hemangioma and lymphatic malformation ( ) . mri played a useful role in distinguishing encephaloceles from other masses based on underlying bone defect and intracranial extension. it also helped in characterizing other masses based on location and signal characteristics. the presence and degree of airway compromise was determined. intracranial anomalies associated with encephaloceles including callosal dysgenesis, cerebral and cerebellar hypoplasias, migrational disorders and spinal anomalies were also correctly identified. conclusions: we present the prenatal mr imaging findings of a spectrum of head and neck lesions, correlating with prenatal ultrasound, postnatal imaging and clinical or pathological outcomes. purpose or case report: the immaturity of the cns in neonatal infants makes neurologic assessment difficult. neuroimaging plays an essential role in the assessment of brain injury by helping to indentify the injury and expected neurologic outcome. cranial ultrasound (us) is usually the first neuroimaging modality used since the technique is portable, does not involve radiation and can be used sequentially. magnetic resonance imaging (mri), however, is the most sensitive imaging modality for the detection of hypoxic brain injury. the goal of this presentation is to compare the us and mri performed within a -hour interval, and evaluate these findings to improve the interpretation of the us which is usually the first methodology used to evaluated these patients. we performed a retrospective review of the neonatal imaging studies with us and mri performed within -hour interval on preterm and term newborns with clinical history of hypoxia-ischemia. the imaging findings of the two modalities, mri and us, were correlated with the pattern and severity of the injury and brain maturity. results: diffuse white matter abnormalities were observed in % of the patients by us or mri. the ultrasound identified diffuse increased echogenicity which did not show correlation with mri in % of patients. focal white matter abnormalities were better identified by mri on non-cavitary leukomalacia which is the most common pvl observed in premature neonates with low birth weight and the most difficult to identified using us. cavitary leukomalacia showed strong agreement in both methodologies. the mri identified % more cases of intraventricular hemorrhage, however, the corresponding increase in hemorrhage was of minimal clinical significance. in most cases extra axial hemorrhage was better identified by mri. conclusions: after viewing this exhibit, the viewer will gain a better appreciation and understanding of the neuroimaging characteristics of hypoxia-ischemia in us and mri, and thus improving the interpretation of the us which is usually the first imaging modality used to evaluate this patient population. purpose or case report: the most common thoracic lesions found on prenatal imaging, congenital pulmonary airway malformation (cpam), bronchopulmonary sequestration (bps), and congenital diaphragmatic hernia (cdh), usually have characteristic imaging findings previously described in detail. however, common entities presenting with atypical findings and rarer thoracic entities do occur and can be characterized by fetal magnetic resonance (mr) imaging. the purpose of this educational exhibit is to show examples of atypical presentations of common thoracic lesions and more unusual thoracic entities on fetal mr. when applicable, prenatal mr is compared with prenatal ultrasound, postnatal imaging, operative findings, or pathology. methods & materials: using a radiology information system database, the reports of all fetal mr exams at our institution from january through january were reviewed. when unusual thoracic findings were described in the report, all prenatal and postnatal images (when available) were evaluated. in the cases selected, medical charts were reviewed for operative findings and pathologic reports. results: the cases to be described, both pulmonary and extrapulmonary in location, include: hybrid lesion in a horseshoe lung, cpam extending across the midline, bilateral bps, bps located within the mediastinum, bps located within the leaves of the diaphragm, ectopia cordis and cdh as components in pentalogy of cantrell, cdh with herniation of liver into the pericardium, elongated esophageal duplication cyst, chest wall lymphatic malformation, and tight double aortic arch causing congenital high airway obstruction syndrome (chaos). conclusions: after studying this educational exhibit, the reader will be acquainted with a variety of unusual fetal pulmonary and extrapulmonary lesions, with emphasis on fetal mr. prenatal and postnatal imaging findings in megacystis-microcolon-intestinal hypoperistalsis syndrome (mmihs) mary kitazono, chop, mkitazono@gmail.com; richard bellah purpose or case report: to review the classic constellation of findings seen in prenatal and postnatal imaging of megacystis-microcolon-intestinal-hypoperistalsis syndrome (mmihs), as well as to illustrate additional imaging features that are variably seen in this syndrome. the imaging database at our children's hospital was searched for all cases of mmihs diagnosed since . all available prenatal and postnatal imaging studies were reviewed in patients with a diagnosis of mmihs, and representative images are provided with a description of the findings. results: since , patients ( girls, boy) have been diagnosed with mmihs at our institution, including on prenatal mri and us. the characteristic prenatal imaging findings include marked urinary bladder distension, bilateral pelvicaliectasis, and dilated, tortuous ureters, as well as a diminutive colon containing no or minimal t w-hyperintense meconium on mri. postnatal imaging studies also characteristically demonstrate a massively distended urinary bladder (with no apparent mechanical cause of obstruction) as well as a small, unused colon with dilated, hypoperistaltic small bowel seen proximal to the microcolon. additional findings which are variably seen include intestinal malrotation, stomach and esophageal hypoperistalsis or aperistalsis, gastroesophageal reflux, and biliary stasis. conclusions: although a rare syndrome, the constellation of imaging findings in mmihs is pathognomonic, and recognition of the classic pattern of findings can allow the radiologist to make a diagnosis of mmihs in both the in-utero and postnatal setting. early diagnosis is essential for allowing prenatal counseling regarding this generally fatal disorder, as well as to optimize early management options. purpose or case report: gastric mass lesion are uncommon. this presentation is an educational review of pediatric gastric mass lesions including gastro-intestinal stromal tumor (gist), inflammatory myofibroblastic tumor (pseudotumor). burkitt's lymphoma, squamous cell carcinoma, gastric teratoma, gastric varices, gastric hamartoma, gastric polyp and hypertrophic pyloric stenosis (hps). clinical presentation is varied with upper gi bleeding, feeding intolerance, pain, weight loss and fatigue manifesting. the imaging work-up might initially have been endoscopy or ultrasound. cross section imaging (ct mr) can be invaluable. the role and impact of fdg pet on the management, staging and follow up of the oncologic pathology will be emphasized. imaging findings in megacystic microcolon intestinal hypoperistalsis syndrome, a rare disease kiery braithwaite, pediatric radiology, emory-egleston, kieryb@yahoo.com; kiery braithwaite, paula dickson, marianne m. ballisty purpose or case report: megacystis microcolon intestinal hypoperistalsis (mmih) syndrome is a rare congenital form of severe functional intestinal obstruction which is more commonly found in females. the presenting clinical and imaging features of this disease can often mimic other causes of proximal bowel obstruction in the neonate. in combination with its common association with intestinal malrotation, the clinical picture of mmih syndrome may be confusing at times. awareness of additional imaging features characteristic of mmih syndrome may help the radiologist suggest this diagnosis. the purpose of this study is to enhance the ability of the pediatric radiologist to suggest this rare diagnosis by recognizing this unusual constellation of imaging features. we retrospectively reviewed the clinical data and imaging studies of four patients with mmih syndrome at our institution. imaging studies included plain radiography, ultrasonography, fluoroscopy, and cross sectional imaging. the initial presentation and clinical outcome was also reviewed. results: the clinical presentations of our patients, who were all female, were somewhat varied but typically included symptoms of intestinal obstruction. the diagnosis of mmih syndrome was made in our patients from the first few weeks of life through early childhood. the four patients demonstrated imaging features characteristic of this disease including a very large dilated bladder, severe bilateral hydroureteronephrosis, gaseous distention of the stomach and proximal small bowel, intestinal hypoperistalsis, and a very small colon. the clinical course of these patients that we observed was also quite variable, with some patients dying in neonatal period while another patient continues to do reasonably well at years old after a multi-organ transplant. conclusions: mmih syndrome is a rare and frequently lethal disease. the ability of the pediatric radiologist to recognize this constellation of imaging findings can help the clinical team arrive at a diagnosis of mmih syndrome. more prompt diagnosis can aid in the development of a long term management plan for the patient and in counseling the family regarding the prognostic implications of this disorder. pathologies of omphalomesenteric duct remnant: radiologic-surgical correlation swapnil bagade, md, pediatric radiology, mallinckrodt institute of radiology, bagades@mir.wustl.edu; geetika khanna, rebecca hulett purpose or case report: . to facilitate understanding of embryology of the omphalomesenteric(vitelline) duct and normal anatomy of the umbilicus. . review the spectrum of omphalomesenteric duct malformations and diversity of clinical presentations of these remnants. . illustrate the imaging findings of omphalomesenteric remnants, from the common such as meckel's diverticulum to the uncommon such as the omphalomesenteric duct cyst, with surgical correlation. methods & materials: cases with complications of persistent omphalomesenteric duct were collected from the joint surgery/radiology conferences at a tertiary level children's hospital. imaging features were correlated with intraoperative findings. conclusions: preoperative diagnosis of complications related to the omphalomesenteric duct remnants can be challenging because clinical and imaging features overlap with other etiologies of acute abdomen. knowledge of the embryologic, clinical, radiologic, and surgical characteristics of omphalomesenteric duct remnants will aid in early and accurate diagnosis. neonatal bowel obstruction-a pictorial essay tanmay patel, university of kentucky; harigovinda challa purpose or case report: bowel obstruction is the most common abdominal emergency in the newborn period and in most cases is secondary to a congenital anomaly requiring early surgical intervention. however not every case of abdominal distension or dilated bowel is secondary to mechanical bowel obstruction or underlying surgical condition. radiologic imaging forms a central role in the work up of newborns with suspected intestinal obstruction. the role of the radiologist is to identify whether or not mechanical obstruction is present; if obstruction is identified on initial radiographs, to determine the level of obstruction, and finally to identify the etiology of obstruction. initial plain radiographic evaluation also helps to determine the subsequent diagnostic or therapeutic approach. methods & materials: a retrospective review of multiple radiographic and fluroscopic examinations in patients with diagnosis of neonatal bowel obstruction was performed at kentucky children's hospital. multiple examples of classical imaging findings were compiled and placed into a pictorial review. results: neonatal intestinal obstruction generally presents with nonspecific symptoms such as abdominal distention, vomiting, or failure to pass meconium depending on the level of obstruction and time of occurrence of underlying congenital lesion/atresia in the intrauterine life. initial plain radiographs of the abdomen reveal dilated bowel loops when obstruction is present. high intestinal obstruction is suspected when only few dilated loops are identified, while multiple dilated bowel loops are seen in low obstruction. most cases of high obstruction may not need another diagnostic imaging test. all cases of distal intestinal obstruction require water soluble enema to identify the etiology of obstruction. in conditions like functional immaturity of the colon, and meconium ileus water soluble enema is therapeutic and thus surgery can be avoided in most cases. the objective of this presentation is to present an educational exhibit of classical imaging findings of various types of neonatal bowel obstructions, and how to differentiate between them. conclusions: bowel obstruction is the most common abdominal emergency in the new born period. most cases are secondary to a congenital surgical condition and early diagnosis and treatment significantly reduces mortality and morbidity. radiographic evaluation plays a central role in the diagnosis and treatment of these conditions. poster #: edu- d t -weighted mrcp in the pediatric population-a pictorial review nathan egbert, mbbs mph, university of michigan, nathaneg@med.umich.edu; jonathan r. dillman, peter j. strouse purpose or case report: to demonstrate the utility of d t -weighted magnetic resonance cholangiopancreatography (mrcp) in the pediatric population, and to illustrate the mrcp findings of various conditions affecting in the pediatric pancreaticobiliary system. we identified all mrcp exams performed on pediatric patients (< years of age) from january , through august , by searching institutional electronic medical records. we then identified representative d t -weighted mrcp images of various conditions affecting the pediatric pancreaticobiliary system. results: representative d t -weighted mrcp images (including source, maximum intensity projection, and volume rendered images) from the following conditions will be presented: abnormal biliary narrowing/stricture (including sclerosing cholangitis, anastomotic strictures following kasai procedure & liver transplantation, and "pseudostricture"), biliary atresia, choledochal cyst (including various subtypes, based on todani classification), choledocholithiasis & cholelithiasis, congenital anomalies of the pancreaticobiliary system (including pancreas divisum and anomalous pancreaticobiliary junction), pancreatobiliary system trauma (including main pancreatic duct transection), and other rare conditions affecting the pancreaticobiliary system (including rhabdomyosarcoma of the biliary tree). conclusions: d t -weighted mrcp has become an extremely useful tool in the evaluation of children with suspected disorders of the pancreaticobiliary system. since mrcp has distinct advantages over alternative diagnostic techniques, such as endoscopic retrograde cholangiopancreatography (ercp) or percutaneous cholangiography, including lack of ionizing radiation and noninvasiveness, mrcp is a much preferred initial study for pediatric pancreaticobiliary imaging. this pictorial review is intended to highlight the d t weighted mrcp appearances of various pancreaticobiliary conditions occurring in the pediatric population. purpose or case report: magnetic resonance enterography (mre) is rapidly emerging as an important imaging tool for the diagnosis and follow-up of inflammatory bowel disease (ibd). its lack of ionizing radiation makes this imaging modality especially vital to the pediatric population. using a casebased approach, we will demonstrate the usefulness of diffusion-weighted imaging (dwi) as part of a comprehensive mre protocol for the assessment of ibd in children. the basics of dwi will be discussed with particular attention to abdominopelvic techniques. the role of mre dwi for the evaluation of pediatric crohn disease (cd) and ulcerative colitis (uc) will be reviewed using a case-based approach. key images from pertinent imaging studies will be identified by searching institutional electronic medical records and presented with relevant clinical data. results: a review of pediatric mre examinations suggests dwi can be used to detect the following: ) small and large bowel segments affected by ibd (both cd and uc) ) abdominopelvic abscesses (including within the mesentery, body wall, iliopsoas muscle, and liver) ) abnormal lymph nodes ) sacroiliitis ) perianal disease (including abscesses and other penetrating complications). conclusions: dwi has the potential to play a very important role in the diagnosis and follow-up of pediatric ibd. this mre technique is particularly useful for detecting a variety of disease-related complications. as the exact meaning of bowel wall restricted diffusion is poorly understood to date, continued investigation will be necessary to determine the clinical and histologic significance of this finding. cases of cf involving the gi tract were collected from clinical workflow encounters of the authors and from the main hospital medical records database. relevant imaging studies were reviewed for known gi manifestations of cf. these imaging studies were correlated with clinical histories and available intraoperative and pathologic findings. results: cf involvement of the gi tract presents over a wide range of ages, organs involved, and associated symptoms. these manifestations can generally be divided anatomically into those involving the alimentary tract, hepatobiliary system, and pancreas. alimentary tract manifestations consist of meconium ileus in uncomplicated and complicated forms (with the latter including secondary intestinal atresia, volvulus, and perforation with meconium peritonitisdistal intestinal obstruction syndrome, constipation, rectal prolapse, duodenal fold thickening, and appendiceal dilation. hepatobiliary disorders secondary to cf include microgallbladder, cholelithiasis, biliary ductal abnormalities, neonatal hepatitis, and cirrhosis (including complications such as portal vein thrombosis and ascites). pancreatic expressions of cf include fatty infiltration, calcifications, and cysts/ cystosis, frequently in the setting of malnutrition and/or stooling abnormalities. this exhibit will demonstrate the spectrum of clinical and radiologic gi findings in this disease from the fetal and neonatal period through adolescence across a range of imaging modalities. conclusions: gastrointestinal manifestations of cystic fibrosis occur frequently in the pediatric population and may be the earliest clinical expression of the disease. familiarity with the variety of gastrointestinal imaging findings of cystic fibrosis can expedite appropriate diagnosis and therapy, particularly in those children in whom the primary disease is not clinically suspected. beyond acute appendicitis: imaging of additional pathologies of the pediatric appendix kelly dietz, md, cincinnati children's hospital; arnold c. merrow, daniel j. podberesky, alexander j. towbin purpose or case report: primary acute appendicitis (or appendiceal inflammation caused by a superimposed bacterial infection in the setting of appendiceal obstruction) is by far the most common pathology of the appendix, and imaging evaluations to exclude this diagnosis occur daily in the pediatric radiology setting. the clinical and imaging differential diagnosis in a patient with right lower quadrant pain and suspected appendicitis is a broad but well-recognized list that predominantly involves structures adjacent to the appendix including the ovaries, small and large bowel, and ureters. there are, however, less common pathologies primarily involving the appendix which can create an imaging diagnostic dilemma in the setting of right lower quadrant symptoms. our goal is to review the imaging and clinical manifestations of these less commonly encountered appendiceal abnormalities. methods & materials: cases of appendices that were abnormal by imaging but ultimately determined not to be due to primary acute appendicitis were collected from clinical encounters by the authors as well as through a search of the radiology and pathology report databases. clinical course, surgical findings, and pathology reports (if available) were subsequently reviewed through the main hospital medical records system. results: the collected cases demonstrate a wide range of additional pathologies of the appendix outside of primary acute appendicitis. a variety of imaging modalities were employed in the workup of these cases. examples reviewed in this exhibit include crohn's disease, ulcerative colitis, cystic fibrosis, carcinoid tumor, inguinal hernia with incarceration, retained foreign body, pinworm infestation, and ileocolic intussusception. conclusions: despite the frequency of primary acute appendicitis, there is a differential diagnosis when an abnormal appendix is found by imaging. familiarity with these alternative diagnoses may be particularly helpful in guiding management of the patient whose clinical presentation is not typical for primary acute appendicitis. methods & materials: a hospital pacs database search from the past years for patients with bws. selected cases, with multimodality imaging, were cross-referenced with pathology reports from patient records database. results: intricate abdominal pathologies are depicted utilizing multimodality imaging, such as plain films, us, ct, mri and pet/ct, and with pathologic correlation. cases with highlight the following: liver: hepatoblastoma, nonspecific hepatobiliary cysts, multiple hemangiomas mimicking metastatic disease; adrenal: dysplastic organomegaly mimicking neoplasm; pancreas: diffuse and focal hyperplasia in the setting of hyperinsulinism, organomegaly; renal: neprocalcinosis, including medullary sponge kidney, nephroblastomatosis, organomegaly; adnexal: ectopic paraovarian adrenal tissue mimicking metastatic lymph node; urinary bladder: benign fibro-uroepithelial polyp. conclusions: diagnosis of bws can be difficult when the classic clinical and radiological findings are not present. these few cases highlight the unusual abdominal pathologies, so when detected, a radiologist can aid in the appropriate diagnosis and help guide therapy for these young patients. this poster will discuss pharmaceuticals the fda considers investigational for their intended use. disclosure: dr. lecompte has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. radiologic-pathologic review of pancreatic masses encountered at a tertiary pediatric hospital over a -year period no kwak, md, radiology, long island jewish medical center, kwak_nb@yahoo.com; karen naar, jeanne choi-rosen, lee collins, sukhjinder singh, anna thomas purpose or case report: review of pathologically proven pancreatic masses in pediatric patients encountered at a tertiary pediatric hospital over a -year period. describe the key morphologic features and other pertinent findings using various imaging modalities. correlate pathologic and radiologic findings. methods & materials: illustrate the various imaging characteristics of pathologically proven pancreatic masses including pseudocyst, pancreatoblastoma, solid pseudopapillary tumor, acinar cell carcinoma, ductal adenocarcinoma, lymphoma, pancreatic neuroblastoma, and inflammatory myofibroblastic tumor. correlate pathologic and radiologic findings. identify the key imaging features that allow narrower differential diagnosis. results: pancreatoblastoma and solid pseudopapillary tumor are the more commonly encountered pediatric primary pancreatic tumors. both are bulky and heterogeneously enhancing tumors with solid and cystic elements. pancreatoblastoma occurs more commonly in young children. internal hemorrhage and fibrous capsule favor solid pseudopapillary tumor which more commonly occurs in adolescent girls. ductal adenocarcinoma, acinar cell carcinoma and an inflammatory myofibroblastic tumor, which were pathologically proven in our pediatric patients, are exceedingly rare entities. the imaging findings of these cases and their pathology when available will be presented, as well as a quick literature review of these rare tumors. illustration and correlation of the pathologic and radiologic findings. conclusions: pancreatic masses in children are rare but in general have a better prognosis than in adults. salient imaging findings for the various tumors encountered at a tertiary care center with pathologic and radiologic correlation. evaluation of hepatoblastoma with gadoxetate disodium-typical, atypical, pre and post treatment evaluation arthur b. meyers, radiology, cincinnati children's hospital, arthurbmeyers@yahoo.com; alexander j. towbin, daniel j. podberesky purpose or case report: gadoxetate disodium (gd-eob-dtpa) is a hepatobilliary mri contrast agent that is widely used in adults for characterization of liver tumors and is being increasingly used in pediatric patients. hepatoblastoma is the most common primary hepatic malignancy of childhood. the purpose of this presentation is to describe our experience with the use of this agent in the mri evaluation both before and after initiating therapy in patients with hepatoblastoma. methods & materials: the radiology report system at our institution was queried for all patients with pathology proven hepatoblastomas who underwent a liver mr with administration of gadoxetate disodium between / / and / / . the mr imaging characteristics of the patient's primary hepatoblastoma pre-and post-therapy (when available) and post treatment findings (when available) were reviewed. results: mri studies in different patients were reviewed. the patients ranged in age from months to years. patients had pre and post treatment evaluation with gd-eob-dtpa enhanced mri, patient had only pretreatment evaluation and patients had only post treatment evaluation. of the hepatoblastomas did not take up gd-eob-dtpa during the hepatocyte phase and were therefore low signal intensity during the hepatocyte phase of imaging. this was useful in the pretreatment evaluation of hepatoblastoma, particularly in defining the relationship of the tumor to hepatic and portal veins. post treatment gd-eob-dtpa imaging allowed characterization of the biliary anatomy and demonstrated the communication of a postoperative fluid collection with the biliary tree, consistent with biloma. atypical hepatoblastoma showed uptake of gd-eob-dtpa on hepatocyte phase imaging, similar to what has been described in adults with atypical hepatocellular carcinoma. conclusions: gadoxetate disodium enhanced mri is useful in the imaging evaluation of hepatoblastoma, particularly in defining the relationship of tumor to vascular and biliary anatomy and in characterizing post-treatment complications. disclosure: dr. meyers has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. imaging of the gallbladder and biliary tree in pediatric age group ihsan mamoun, md, cleveland clinic, ihsanmamoun@ yahoo.com; s. pinar karakas, unni udayasankar, neil vachhani, ellen park purpose or case report: interactive educational exhibit to illustrate the embryology, anatomical variants as well as congenital and acquired diseases of the bile ducts and gallbladder in pediatric patients. methods & materials: a)the embryology of the gallbladder and biliary tree will be demonstrated with diagrams. b) imaging techniques for gallbladder and biliary tree including us, ct, mri, ercp and intraoperative cholangiogram will be discussed. c)imaging findings of various lesions with special emphasis on key findings that can lead to accurate diagnosis will be discussed. d)an appropriate list of differential diagnosis will be provided. e)an algorithm for the assessment of suspected biliary pathology will be presented. f)the exhibit will be interactive and the reader will answer questions about the discussed entity, related imaging algorithm and management. results: a)discuss congenital anomalies including duplicated and septated gallbladder, choledochal cyst, caroli disease, situs abnormalities and biliary atresia. b)discuss infectious and inflammatory conditions including cholecystitis, kawasaki's disease, sclerosing cholangitis and hepatitis. c)discuss iatrogenic complications including post transplant biliary stricture and leak. d)discuss benign and malignant neoplasms invoving the gallbladder including polyps, ptld and rhabdomyosarcoma. conclusions: this exhibit will demonstrate a logical approach to imaging of the congenital and acquired diseases of the gallbladder and biliary tree based on the embryology and underlying pathology. postnatal work up of congenital uronephropathies-a pictorial essay harigovinda r. challa, radiology, university of kentucky, hch @uky.edu purpose or case report: the use of obstetric ultrasound routinely in the prenatal care has lead to the discovery of many fetal anomalies. uronephropathies in the newborn represent one of the largest groups of anomalies amenable to neonatal management. since these uropathies are detected mostly in asymptomatic patients the treatment is mainly preventive. the pediatric radiologist has a key role in the post natal work up and management of these patients with prenatally diagnosed neprhouropathies and familiarity with the congenital urinary tract abnormalities is necessary. methods & materials: a retrospective review of multiple radiographic, sonographic and fluroscopic examinations performed in the newborn babies and infants with prenatal diagnosis of urinary tract abnormalities was performed at kentucky children's hospital. multiple examples of classical imaging findings were compiled and placed into a pictorial review. results: numerous anomalies can be detected in utero, including anomalies of renal number, position, morphology, collecting system dilation and bladder, urethral abnormalities. of these postnatal work of congenital hydronephrosis is the most common routinely encountered clinical entity. renal ultrasound is the initial examination in the evaluation in all cases of prenatal hydronephrosis, which is best performed around postnatal day . if collecting system dilatation persists on postnatal ultrasound, further imaging work up with vcug, radionuclide imaging may be required depending on degree of dilatation. conclusions: uroneprhopathies are increasingly detected in the prenatal life with increasing use of obstetric ultrasound. the objective of this presentation is to demonstrate in a pictorial essay of different neprhouropathies and their workup in newborns. isolated fallopian tubal torsion: causes, imaging findings, and how to suggest the diagnosis jesse courtier, md, ucsf dept of radiology, jesse. courtier@ucsf.edu; amaya m. basta, rebecca maine, pierre-alain cohen, shinjiro hirose, john d. mackenzie purpose or case report: the purpose of this educational report is to describe the rare entity of isolated fallopian tubal torsion in the pediatric population and depict the cross sectional imaging findings that help make a diagnosis and guide management. the proposed pathophysiology, predisposing factors, and surgical management will be described. an illustrative case example of -year-old female patient will be provided with surgical correlation. the exhibit will review imaging findings on us, ct and mri that help support the diagnosis including, dilated tubular structure in the pelvis, normal ovaries, and corkscrewing and beaking of the proximal fallopian tube. isolated fallopian tubal torsion will be placed in the context of a differential diagnosis for girls presenting with pelvic pain and the imaging signs that help make a diagnosis of isolated tubal torsion and separate this entity from other causes of pediatric pelvic pain will be emphasized. multimodality imaging characteristics of genitourinary rhabdomyosarcoma rhea udyavar, md, george washington university medical center, rudyavar@gwmail.gwu.edu; amir noor, pranav k. vyas purpose or case report: in this pictorial essay, we will demonstrate salient imaging features of mr, us, and ct modalities for the diagnosis of genitourinary rhabdomyosarcoma in male (n ) and female (n ) children ages - years, evaluated at our institution over the past years. background information, including tumor biology, staging, and treatment will also be discussed. the swollen scrotum: ultrasound technique and differential diagnosis kelli r. schmitz, md, oregon health & science university, schmitzk@ohsu.edu; roya sohaey purpose or case report: to review the ultrasound protocol for the performance of scrotal ultrasound and illustrate the ultrasound appearance of conditions resulting in scrotal swelling in pediatric patients. a retrospective review of the imaging database at a tertiary pediatric referral center was performed to identify pediatric patients who presented with scrotal swelling and underwent diagnostic ultrasound. when available, surgical/pathologic correlation was obtained. results: a variety of pathologic processes result in scrotal swelling. causes illustrated include: testicular torsion, epididymitis/orchitis, hydrocele, varicocele, inguinal hernia, trauma, adrenal rest, and testicular or paratesticular neoplasm. conclusions: the causes of scrotal swelling are myriad, including infectious/inflammatory, developmental, traumatic, and neoplastic etiologies. in children, the clinical presentation of a swollen scrotum is nonspecific, and ultrasound plays a key role in making the correct diagnosis. experiences of starting a functional mr urography program at a university hospital: trials and tribulations steven l. blumer, bsc, montefiore medical center/albert einstein college of medicine, sblumer@montefiore.org; ibrahim tuna, amanda north, benjamin taragin, netta blitman, terry l. levin purpose or case report: starting a functional mru program can be challenging as there are numerous potential hurdles to overcome. this presentation describes the process of starting a functional mr urography (fmru) program at a university hospital and discusses the difficulties encountered starting such a program. selecting a sufficient patient referral base, resolving common and uncommon technological issues, and education of clinicians, patients and technical staff are some of the challenges that will be discussed. conclusions: awareness of the common pitfalls in fmru imaging and close partnering with referring physicians can make establishing a functional mru program easier. despite many potential obstacles, the benefit of exquisite anatomical and functional information provided by fmru in children, without exposure to ionizing radiation, greatly outweighs any challenges. disclosure: dr. blumer has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. pictorial review of ultrasound findings in boys presenting to emergency department/urology with acute scrotum teresa liang, faculty of medicine, university of british columbia, teresaliang @gmail.com; peter metcalfe, william sevcik, michelle noga purpose or case report: testicular torsion is a common acute condition in adolescent boys. rapid and accurate diagnosis is critical. diagnosis is currently based on history, physical findings, and ultrasound (u/s) with doppler. the objective of this poster is to demonstrate ultrasound findings from a retrospective review of acute scrotum over years, and to demonstrate some pitfalls of the technique with regard to testicular torsion diagnosis. we reviewed the u/s, surgical and ed records at the stollery children's hospital for boys aged month to years, presenting with acute scrotum from july , to . age, demographics, clinical symptoms, and physical findings, u/s and surgical techniques, findings, diagnoses and follow-up were also recorded. results: patients presented to uah stollery ed with acute scrotum: were diagnosed with testicular torsion ( inguinal torsion), were suspected of a torsion-detorsion, torsion of appendix testes, epididymitis/orchitis, and other diagnoses including hydroceles, varicoceles, epididymal cysts, abscesses, cellulitis and hematomas. for the patients who had ultrasound, % sensitivity and % specificity for testicular torsion. the ultrasound findings including size, vascularity and echogenicity associated with both salvageable and necrotic testicles including use of color and pulse doppler will be reviewed. the sonographic findings and pictorial examples associated with the more common acute scrotum etiologies will be presented. sonographic findings from problematic cases (those with inconclusive ultrasound reports or false positive reports) will also be addressed. conclusions: ultrasound imaging problem case examples and characteristic findings of common acute scrotum presentations at stollery hospital at the university of alberta are reviewed in this poster. primary and secondary amenorrhea in pediatric patients: from the beginning to the end cesar cortes, md, miami children's hospital, n c @ hotmail.com; yanerys ramos, ricardo restrepo, alejandro diaz, lorena sequeira, edward lee purpose or case report: to describe the role of imaging in evaluating patients with primary and secondary amenorrhea and to illustrate the normal imaging findings of the reproductive organs in the pediatric population as well as the imaging findings of the different etiologies causing amenorrhea. a search of the literature is done to determine the different etiologies of amenorrhea and the role of imaging in their evaluation. first, we will focus on the normal physiologic hormonal influence and changes of the girl's reproductive organs since birth until adolescence on ultrasound and mri. images of the normal appearance of the female reproductive organs as well as imaging findings of the different common and uncommon etiologies of amenorrhea will be shown. then, specific reference will be made to crucial related concepts such as minipuberty of infancy, latest criteria for polycystic ovarian disease and ovarian failure syndrome among others. finally, the treatment, either medical or surgical will be briefly discussed. results: causes of amenorrhea in children range from disorders affecting the hypothalamus, pituitary gland, adrenal glands, and ovaries, as well as uterine and vaginal structural abnormalities. even though history and clinical exam are essential in evaluating a patient with amenorrhea, the pediatric radiologist plays a pivotal role helping guide the area to be imaged and thus the modality that should be used. mri and ultrasound are the main modalities in the evaluation of amenorrhea. conclusions: ultrasound and mri are the main imaging modalities used in the evaluation of amenorrhea in children and are usually part of the work up. amenorrhea in children can have implications in girl's fertility allowing pediatric radiologists to play an important role in helping not only the patient but also their offspring. imaging of mullerian duct anomalies in children kelly k. horst, md, radiology, university of michigan, khorst@med.umich.edu; maryam ghadimi mahani, deepa pai, jonathan r. dillman, peter j. strouse purpose or case report: the purpose of this educational exhibit is to provide an up-to-date appraisal of mullerian duct anomalies presenting in the pediatric population. the appearances of anatomic variants on ultrasound and mri will be used to illustrate the strengths and potential pitfalls of these imaging modalities. methods & materials: patients who have previously undergone ultrasound and/or mri in the course of their clinical workup within the university of michigan health system (umhs) were identified using electronic medical records. imaging reports were reviewed by a single author in order to identify relevant imaging findings (interesting anatomic variations, associated anomalies, etc.). pertinent images from these imaging examinations were de-identified and saved to a secure hard drive. the medical record was accessed by a single researcher to obtain relevant information regarding the patients' clinical presentations. in cases of corrective surgery, pathology reports were reviewed, if available, for correlation with the imaging findings. results: cases of mullerian duct anomalies were reviewed within the pediatric population. clinical manifestations were correlated with imaging appearances. conclusions: mullerian duct anomalies represent a range of developmental variants. although functioning ovaries and age-appropriate external genitalia are characteristic, there may be anomalies ranging from uterine and vaginal agenesis, to duplication of the uterus and vagina, to minor uterine cavity abnormalities. müllerian malformations are frequently associated with abnormalities of the renal and axial skeletal systems, and pediatric patients in particular may present with these associated anomalies. menstrual abnormalities may represent a more typical presentation in the adolescent age group. this is in contrast to the adult population, which may be more likely to present with infertility. the variation in clinical presentations make mullerian duct anomalies difficult to diagnose and, because surgical techniques for correction and treatment depend on the underlying anatomy, understanding these variants in the context of imaging studies is important to their diagnosis and management. patient had radiographs which showed an irregular left humeral metaphysis with an associated fracture. patient had a phase bone scan that showed slightly increased uptake on the angiographic and blood pool phases and increased activity on the delayed phase in the right femur. radiographs showed a moth eaten appearance of the right femur with soft tissue swelling. patient had radiographs that showed periosteal reaction in the right tibia with an associated fracture. patient , in addition to radiographs, had an mri that showed osteomyelitis of the left humerus and scapula with an associated subperiosteal abscess. patient had multi focal osteomyelitis that was demonstrated on radiographs by irregular cortices and periosteal reaction involving the upper and lower extremities. conclusions: neonatal osteomyelitis is an uncommon entity that can have severe complications if not diagnosis and treated promptly. it is important to review cases and to review the appearance of neonatal osteomyelitis on multiple modalities. radiographs will usually demonstrate periosteal reaction and possibly soft tissue swelling. additional studies may be obtained to evaluate for complications, such as abscesses or involvement of the joint space. purpose or case report: review the epidemiology of ddh. describe the critical diagnostic imaging findings of ddh. understand the role of imaging accompanying treatment. methods & materials: images including radiographs, ultrasound, ct and mri will be used to demonstrate the current and historical role of imaging in caring for patients with ddh. discussion of the importance of reducing radiation exposure when choosing imaging studies will be included. results: radiographs and ultrasound are used primarily in making the diagnosis of ddh. ultrasound and mri are most often used during the course of treatment to assess its effectiveness. mri is increasingly utilized without sedation for patients in spica cast. conclusions: imaging is critical in the care of patients with ddh. pediatric musculoskeletal ultrasound of the proximal lower extremity (pelvis to thigh) julia rissmiller, md, dept of radiology, children's hospital boston, julia.rissmiller@childrens.harvard.edu; howard christianson, michael j. callahan purpose or case report: to review indications for ultrasound of the proximal lower extremity (pelvis, hip and thigh), and to illustrate the practical use of ultrasound in evaluation of the proximal lower extremity, emphasizing the sonographic appearance of various musculoskeletal disorders. ultrasound is a well-established modality for the evaluation of painful hip, developmental hip dysplasia, soft tissue infection, palpable masses, and foreign bodies in children. in general, ultrasound has a more limited role for the primary evaluation of other pediatric musculoskeletal disorders including trauma, articular and periarticular diseases and tumors or tumor-like processes. advantages of ultrasound, a relatively non-invasive technique, include excellent spatial resolution, low cost, lack of ionizing radiation, lack of need for sedation, and the ability to image the patient in real-time. the major disadvantage of ultrasound is operator dependency, which is particularly evident in musculoskeletal applications. we present ultrasound examples of pathology involving the proximal lower extremity (pelvis, hip and thigh). cases include developmental hip dysplasia, hip effusion, osseous metastasis to the iliac bone, osteomyelitis of the hip, femoral acetabular impingement, rectus femoris hernia, vascular malformation, ewing's sarcoma and myositis ossificans. results: a range of images from pediatric diagnostic ultrasounds performed of the proximal lower extremity (pelvis to thigh) will be presented emphasizing the sonographic appearance of various musculoskeletal disorders. conclusions: ultrasound is an excellent modality for evaluating the proximal lower extremity in children, beyond the current indications of painful hip, developmental hip dysplasia, soft tissue infection, palpable masses, and foreign bodies in children. a multi-modality pictorial review of lesions of the epiphysis in infants and children ernesto i. blanco, md, st. christopher's hospital for children, eiblanco @gmail.com; jacqueline urbine, evan geller, peter pizzutillo purpose or case report: to review the imaging spectrum of epiphyseal lesions in infants and children. a retrospective review of our imaging database was performed to identify studies with either primary lesions of the epiphysis or processes that affect the epiphysis. results: multiple epiphyseal lesions were elucidated primarily by radiography, with cross-sectional imaging included where clinically necessary. congenital lesions include the epiphyseal dysplasias represented here by chondrodysplasia punctata. epiphyseal infarction may due to multiple etiologies including slipped capitol femoral epiphysis, developmental dysplasia of the hip, sickle cell disease, or idiopathic reasons. neoplasms may occur in the epiphysis, including chondroblastoma and histiocytosis. traumatic lesions include fracture and avulsion. osteomyelitis can occur in the epiphysis as well. pseudolesions that mimic pathology will also be reviewed. other pathologies that can affect the epiphysis include juvenile idiopathic arthritis and hemophilia. conclusions: a wide spectrum of congenital and acquired pathologies may affect the epiphysis in the infant and child. plain radiography, computed tomography, and magnetic resonance imaging all contribute to the diagnosis of these varied lesions. purpose or case report: we aim to present the spectrum of common and uncommon hip disorders in pediatric population. we will formulate a systematic approach and present a flowchart to workup and characterize hip diseases. methods & materials: relevant imaging appearances of normal as well as pathological hip will be presented. normal hip anatomy will be discussed through anatomic drawings and radiological images (plain radiographs, ct, usg, and mri). we will illustrate the various anatomic landmarks, measurements and lines on plain radiographs and ultrasound of hip. results: evaluation of limp and hip pain in the pediatric population has undergone rapid evolution. surgical treatment for these disorders continues to be refined, and our ability to identify patients along the spectrum of disease continues to improve. yet, despite our advances, obtaining an accurate diagnosis can remain challenging, especially in the setting of mild structural abnormalities. many imaging studies can be used to evaluate the bones and soft tissues, but conventional radiography is the primary imaging modality for most clinical conditions. plain radiographs usually are obtained first because they are sensitive and specific for a wide range of bone pathology. more sophisticated imaging modalities including radionuclide scintigraphy (bone scan), ultrasonography (usg), computed tomography (ct) and magnetic resonance imaging (mri) are reserved for specific clinical situations. each of these imaging modalities has specific advantages and disadvantages. it is the aim of this review to guide in selecting and interpreting the appropriate imaging modality for a variety of common disorders. this exhibit will illustrate imaging features of developmental dysplasia of hip, perthes disease, slipped capital femoral epiphyses, hip malformations in syndromes, femoral acetabural impingement, labral disorders, septic arthrits and other disorders. the role of various imaging modalities in evaluation of these disorders will be discussed, along with common imaging pearls and pitfalls. conclusions: a systematic approach is necessary for evaluation of pediatric hip disorders. familiarity with normal appearances, pitfalls and specific imaging of these entities is essential for proper diagnosis and management. osteoid osteomas: a pain in the "night" diagnosis nancy k. laurence, md, the children's hospital of philadelphia, nkang @gmail.com; monica epelman, richard markowitz, camilo jaimes, diego jaramillo, nancy chauvin purpose or case report: a common benign bone-forming lesion, osteoid osteoma comprises approximately % of all benign bone tumors. the tumor is composed of a nidus of vascular osteoid tissue and woven bone lined by osteoblasts, frequently with considerable surrounding inflammation. the radiolucent nidus surrounded by variable degrees of reactive sclerosis usually leads to a straightforward diagnosis; however, sometimes the diagnosis of osteoid osteoma can be challenging, as it may have a non-specific and misleading appearance on different imaging modalities, particularly on mri. the purpose of this exhibit is to review the typical and atypical features of osteoid osteomas on different imaging modalities. we present diagnostic dilemmas of osteoid osteomas from our institution and how imaging characteristics can aid in diagnosis. we performed a retrospective review of our imaging database to identify cases of typical and atypical osteoid osteomas, with special emphasis on cases which posed a diagnostic dilemma on imaging. results: when osteoid osteomas occur in atypical locations the diagnosis can be elusive. when located in the intraarticular space there is often minimal or absent cortical thickening and there may be a joint effusion with synovial hypertrophy. phalangeal lesions may cause extensive bone marrow edema and surrounding soft tissue swelling. both of these types of osteoid osteomas can be mistaken for infection. the recently described "ct vessel" or "vascular groove" sign, a low density vascular groove adjacent to the nidus, is highly specific for osteoid osteoma. in the authors' experience, a rim of sclerosis surrounding the nidus may aid in diagnosis on mri and can be identified as an outer hypointense halo on all sequences. we illustrate the findings in cases of atypical osteoid osteomas which may be difficult to diagnose including intraarticular, phalangeal, and vertebral osteoid osteomas. we also show examples of the newly described sign which has high specificity for osteoid osteoma. conclusions: imaging findings in osteoid osteomas can be misleading and cause misdiagnosis, especially in atypical cases. knowledge of their appearance in atypical locations and specific findings can aid in the correct diagnosis. ultrasound of normal entheses in the growing skeleton nancy chauvin, md, department of radiology, the children's hospital of philadelphia, chauvinn@email.chop. edu; pamela f. weiss, monica epelman, diego jaramillo purpose or case report: ultrasound is an underutilized modality in the evaluation of the pediatric musculoskeletal system. evaluation of tendon insertions about the elbow, knee and foot can be easily performed with ultrasonography. a good knowledge of the age dependent normal ultrasound appearance of the entheses is crucial in order to evaluate for pathology, such as trauma or ethesitis-related arthritis. this exhibit will serve to provide the reader with a practical approach to imaging when assessing tendon insertions. optimal patient positioning and transducer selection will be discussed. in addition, important anatomic landmarks will be described to allow for reproducibility and avoiding pitfalls. methods & materials: transverse and longitudinal ultrasound images of entheseal insertion sites were performed on healthy girls and boys between the ages of and years. ultrasound of the elbow was performed while in full extension and the insertions of the common flexor and common extensor tendons were evaluated. the quadriceps and patellar insertions were imaged with patients in the supine position, with the knees flexed at degrees. the achilles tendon and plantar fascia insertion were evaluated with the patient prone, with the feet hanging off the edge of the table. results: tendons demonstrated the expected fibrillar pattern with parallel echogenic lines. the appearance of the entheses changed as the insertion matured from sonolucent cartilage to echogenic bone. conclusions: using a systematic approach and knowledge of the normal anatomy, sonography of the tendons of the elbow, knee and foot can easily be performed in children. pediatric musculoskeletal ultrasound of the distal lower extremity (knee to ankle) howard christianson, md, radiology, children's hospital boston, howard.christianson@childrens.harvard.edu; julia rissmiller, michael j. callahan purpose or case report: ultrasound is a well-established technique in children for evaluation of the painful hip, developmental dysplasia of the hip, soft tissue infection, palpable masses and foreign bodies. in general, ultrasound has a somewhat more limited role for the primary evaluation of several other pediatric musculoskeletal disorders in the setting of trauma, articular and periarticular diseases and tumors and tumor-like conditions. inherent advantages of ultrasound include excellent spatial resolution, a lack of ionizing radiation, a relatively non-invasive technique and lack of a need for sedation. real-time imaging allows problem solving not available with other modalities which is well suited for musculoskeletal applications, particularly in the setting of trauma. the major disadvantage of ultrasound is operator dependency, which is particularly evident in musculoskeletal applications. the purpose of this study is to illustrate the practical use of ultrasound in the evaluation of the distal lower extremity (knee to ankle) emphasizing the sonographic appearance of various musculoskeletal disorders. examples include: ) cystic lesions around the joints: baker's cyst, synovial cyst, ganglion cyst and suprapatellar bursitis; ) infectious processes: pretibial, subperiosteal and intramuscular abscess; ) tumor and tumor like lesions: nerve sheath tumor, tumoral calcinosis; ) trauma related injuries: sinding larsen johansson, tibialis anterior muscle herniation, hematoma. methods & materials: cases selected for presentation from a series of diagnostic musculoskeletal ultrasounds performed at our institution. results: a range of images from diagnostic ultrasounds performed of the distal lower extremity (knee to ankle) will be presented emphasizing the sonographic appearance of various musculoskeletal disorders. conclusions: selected musculoskeletal ultrasounds of the distal lower extremity are presented to familiarize the audience with the sonographic appearance of various musculoskeletal disorders and to highlight the tremendous potential of ultrasound in evaluating musculoskeletal disease in children and adolescents. role of conventional and dynamic contrast enhanced magnetic resonance imaging in diagnosis of hemihypertrophy syndromes in children shrey k. thawait, md, phd , radiology, yale university-bridgeport hospital, sthawai @jhmi.edu; gaurav k. thawait, sally e. mitchell, laura m. fayad, john a. carrino, kate puttgen purpose or case report: hemihypertrophy syndromes in children are complex and there is some overlap among these conditions. hence, establishing a diagnosis can be challenging. identification of the correct vascular anomaly associated with these overgrowth disorders helps to correctly classify the disease into one of the several syndromes, which in turn guides management. in this educational poster, we will review the definition, clinical presentation, conventional magnetic resonance imaging (mri) and contrast enhanced magnetic resonance angiography and venography (mra / mrv) features of hemihypertrophy syndromes in children. methods & materials: . learn the diagnostic criteria for overgrowth syndromes in children such as klippel-trenaunay syndrome (kts) and parkes weber syndrome (pws) with special emphasis on associated vascular anomalies. . gain knowledge of high resolution mri technique for evaluation of vascular anomalies associated with the hemihypertrophy syndromes. . understand the additional value of dynamic contrast enhanced mra / mrv in the differentiation of the hemihypertrophy syndromes in the pediatric age group. results: . mri technique for a dedicated "vascular anomaly protocol" consisting of fat saturated t weighted, pre contrast axial t weighted, and post contrast triplanar t weighted fat saturated imaging will be described. . special emphasis will be provided on dynamic contrast enhanced mra/mrv. . conventional and dynamic mri features of clinically proven cases of hemihypertrophy syndromes will be demonstrated. conclusions: systematic mri interpretation utilizing a dedicated vascular anomaly protocol enables the radiologist to correctly identify the hemihypertrophy syndrome, and provide detailed extent of disease. correlative ultrasound, mri imaging and physical examination of elbows in hemophilic children andrea s. doria, md, the hospital for sick children-diagnostic imaging, andrea.doria@sickkids.ca; frederico xavier, arun mohanta, carina man, ningning zhang, pamela hilliard purpose or case report: .to report a systematic ultrasound (us) protocol for assessment of hemophilic elbows. . to discuss advantages and disadvantages of us and mri for evaluating hemophilic elbows in comparison with physical examination. .to illustrate us and mri findings and associated pitfalls in hemophilic joints. background: the value of physical examination for assessment of early arthropathic changes in hemophilic joints is unknown. us does not require sedation in young children, but involves operator training and standardized technique. mri is the reference standard imaging modality for assessment of pathology in hemophilic joints. standardization of a systematic protocol for data acquisition and interpretation of us findings and understanding of the correlation of findings between physical examination, us and mri in hemophilic elbows is essential for the use us as an outcome measure both in clinical practice and research. so far such information is not available for growing elbow joints. methods & materials: eight hemophilic boys (age range/ median, - / years) with a history of prior elbow bleeds underwent us and mr imaging, and physical examination on the same day. corresponding images on us and mri were highlighted to illustrate abnormalities and pitfalls. soft tissues (effusion/hemarthrosis,synovial hypertrophy,hemosiderin deposition) changes were characterized as small, moderate, or large. erosions, cartilage and subchondral abnormalities were graded based on depth or extent of articular changes. results: . us is helpful for discriminating synovial hypertrophy, joint effusion/hemarthrosis, and large hemosiderin deposition which otherwise generates susceptibility artifacts on gradient-echo mri obscuring adjacent tissues. . us can visualize erosions, cartilage and subchondral abnormalities at the joint periphery. however,differentiation between subchondral cysts and erosions is usually unfeasible by us. . prior knowledge of the degree of joint maturation is essential for an accurate evaluation of cartilage loss by us. . physical examination has limitations for assessment of early joint changes in contrast to us. conclusions: us can be useful for assessing hemophilic elbows, with advantages over mri in the evaluation of soft tissues. further development of an us-mri atlas on normal cartilage in growing joints is needed for definition of the value of us in the assessment of minimal osteochondral abnormalities. digital atlas of skeletal surveys of common skeletal dysplasias shawn parnell, mbbs, md, dnb, radiology, seattle children's hospital, shawn.parnell@seattlechildrens.org; corey wall, edward weinberger purpose or case report: skeletal dysplasias are conditions of abnormal bone and cartilage growth which result in short stature. developing expertise in the radiographic evaluation of skeletal dysplasias can be difficult, as more than dysplasias exist. exhaustive description of individual dysplasias can be found in hard copy textbooks, without the ability to compare individual dysplasias side by side. by providing radiographic images and descriptive text of thirteen common skeletal dysplasias and two comparative normal skeletal surveys, we aim to facilitate understanding of the terminology and highlight the differences in imaging appearances one may commonly encounter in interpreting skeletal dysplasias. methods & materials: initial skeletal surveys and/or follow up radiographs obtained for evaluation of skeletal dysplasias at our institution from to were compiled and reviewed for best quality images. selected images for each case were labeled according to body part and view, to include ap and lateral views of the spine and skull and ap views of the extremities and pelvis. for neonates, ap and lateral babygram images were used. the software program used for viewing the atlas, written in c#, may be freely downloaded. it permits linked scrolling and resizing of the images, and simultaneous comparison of different cases is available. cases may be viewed as unknowns or in a selfteaching mode. results: radiographic images for thirteen common skeletal dysplasias and two comparative normal skeletons (neonate and child) are provided within an interactive digital atlas. cases include achondroplasia, pseudoachondroplasia, cleidocranial dysplasia, thanatophoric dysplasia, diaphyseal dysplasia, multiple epiphyseal dysplasia, osteopetrosis, osteogenesis imperfecta, multiple hereditary exostoses, dysostosis multiplex, fibrous dysplasia, asphyxiating thoracic dysplasia (jeune syndrome), and spondyloepiphyseal dysplasia. conclusions: by displaying radiographic images of several common skeletal dysplasias in an interactive and comparative format with descriptive text, understanding of basic radiographic terminology and appearances will be facilitated. purpose or case report: . to classify various pediatric msk soft tissue masses . to describe pathogenesis, imaging appearances and differential diagnosis of these lesions methods & materials: radiology and clinical medical records were reviewed and pediatric patients with musculoskeletal soft tissue masses were identified. representative images were collected as examples of each lesion. the lesions were then classified into different groups based on the similar pathology and etiology. brief discussion is done for each of these masses with their multimodality imaging appearances. results: the search yielded pediatric soft tissue masses of multiple different etiologies, including post-traumatic (hematoma, fat necrosis, fibromatosis coli, myositis ossificans), inflammatory or infectious (cellulitis, abscess, granuloma annulare, retained foreign bodies), pseudotumors (synovial cysts, ganglion cysts, vascular malformations) and neoplastic lesions (fatty, vascular, neural, fibrous, muscular). multiple different imaging modalities were used to evaluate these masses, including ultrasound, ct and mri. representative examples of different lesions and their appearances on different imaging modalities will be presented and an organized approach to the diagnosis of these lesions will be discussed. conclusions: musculoskeletal soft tissue masses are relatively common in children. majority of these are benign; however, up to % of these lesions can be malignant "sarcomas". multiple different imaging modalities often provide complimentary information in the work-up of these lesions. despite multimodality imaging approach, tissue diagnosis or short interval follow-up is still often required when the mass does not show typical features of a benign etiology. pediatric radiologists should be familiar with various pediatric msk soft tissue masses and their imaging appearances, and should be able to guide appropriate management. results: elbow mri examinations were reviewed on children aged months to years with ( %) of these investigating clinical instability in children. mechanism of injuries included congenital dislocation ( %), traumatic dislocation ( %), fracture or avulsion ( %) and other injuries ( %). the patient's with congenital elbow dislocations most commonly presented with radial head dislocation and associated dysplasia or flattening, effusion and less frequently dysplasia of the olecranon or capitellum. patient's with traumatic dislocations were frequently associated with ligamentous or capsular disruption, bone oedema and epicondylar avulsion with effusion, loose osseous bodies and fractures less often. the epicondylar avulsions and ligamentous or tendon injuries occurred equally often in those few patients with unspecified injury mechanism. conclusions: a number of the bony, ligamentous, articular and developmental anomalies evident on elbow mri have been illustrated highlighting the importance of careful and systematic review of all elbow structures when presented with a child with elbow instability. accurate identification of these abnormalities is vital to facilitate their appropriate management. methods & materials: from our computerized radiology information system, we retrieved all patients that have foot ultrasound for evaluation of vertical or oblique talus deformities in the last years ( / - / ). the us was performed by a pediatric radiologist using a high resolution linear and tight convex curve probes with foot in neutral, plantar flexion and dorsiflexion. all medical charts, ultrasound scans and foot radiographs were reviewed by a pediatric radiologist. results: we identified nine patients' with foot deformities who were suspected of vertical or oblique talus and were evaluated by ultrasound. seven patients are male; two of them had initial foot radiographs that were not diagnostic. two female patients had unilateral oblique talus deformity. there were patients with vertical talus deformity; three of them had bilateral deformities. conclusions: us can directly visualize the unossified navicular, the talar cartilage and their alignment. dynamic us can. ultrasound evaluation of costal chrondral pathologies in children presented as anterior chest wall mass or pain nucharin supakul, md, radiology, riley hospital for children, tanyasupakul@yahoo.com; boaz karmazyn purpose or case report: to summarize our experience with the use of ultrasonography (us) for evaluation of costal cartilage pathology presented as anterior chest wall mass. methods & materials: from our computerized radiology information system, we retrieved all patients that have chest wall ultrasound for evaluation of a mass in the last . years ( / - / ) . the us was performed by a pediatric radiologist using a localized scan with high resolution linear probe. all medical charts, pathology results, ultrasound scans and other imaging studies were reviewed by a pediatric radiologist. results: ten patients were found with costal chrondral pathologies. nine patients presented with anterior chest wall mass and one with chest wall pain. eight patients had angular deformity of a single costal cartilage and one patient had biopsy proven osteochrondroma, presented with anterior chest wall mass. one patient had a non-union fracture after motor vehicle accident, presented with anterior chest wall pain. in patients with rib deformity, the mass was non-tender. nine patients had prior imaging study including chest x-rays (n ), ct scan (n ), breast mr (n ). all these studies were negative. conclusions: us optimally demonstrated costal cartilage abnormities. chest radiographs and cross sectional studies were negative. we therefore recommend using high resolution chest wall us in children with negative chest radiograph and anterior hard chest wall mass. challenges in pediatric marrow imaging-boning up on current mr techniques srikala narayanan, md, division of radiology, children's national medical center, snarayan@childrensnational.org; neha kwatra, nabile safdar purpose or case report: a wide range of pathologies demonstrate similar findings when imaged using conventional mr sequences. however, pediatric musculoskeletal imagers are increasingly leveraging newer techniques to add specificity to their diagnoses when abnormal marrow signal is detected. the purpose of this educational exhibit is to review the application of current mr techniques to pediatric marrow imaging across the spectrum of normal, variant, and pathologic processes. methods & materials: cases with potentially overlapping imaging appearances on conventional mr sequences, including hematopoetic marrow, sickle cell disease, osteomyelitis, chronic recurrent multifocal osteomyelitis, and infiltrative neoplasms, will be presented. the basis of various mr techniques including chemical shift imaging, "whole body" marrow imaging, diffusion weighted imaging, and fat-water separation techniques such as dixon or ideal (ge) will be reviewed. the strengths and weaknesses of such techniques in differentiating between infection, neoplasm, and normal variation will be emphasized through the case examples. challenges and pitfalls in the imaging of these pathologies using such techniques will be discussed. results: current mr imaging techniques add specificity to diagnoses of marrow pathology which are otherwise difficult to differentiate using traditional sequences alone. the use of opposed phase imaging can be helpful in differentiate hematopoietic marrow or infection from infiltrative and neoplastic conditions. "whole body" marrow imaging may serve as an alternative to other modalities which involve significant radiation exposure. the use of diffusion weighted imaging is a promising, but developing, technique being applied to marrow pathology. conclusions: pediatric bone marrow mr imaging is a challenging area for a vast majority of the radiologists. understanding normal developmental bone marrow changes and being aware of the pitfalls is crucial to render accurate diagnosis. current techniques such as ideal, chemical shift imaging, and "whole body" mri have a potentially important role in further characterization of marrow abnormalities. radiologists beware: unusual imaging manifestations in child abuse eglal shalaby-rana, mbbs (hons), children's national medical center, erana@childrensnational.org; allison m. jackson, tanya hinds, katherine deye purpose or case report: to present less common imaging manifestations of injuries in child abuse that may not be readily recognized as possibly abusive injury. methods & materials: through bi-monthly review of cases with the child protection team over a period of years, the imaging studies of patients with suspected non-accidental trauma were recorded. of the pts with suspected nonaccidental trauma, outcomes were available in patients. the child protection team concluded ( %) were cases of non-accidental trauma with reasonable medical certainty. this data base was reviewed for less common injuries that were found in these medically confirmed cases of child abuse. results: less common manifestations of abuse identified by radiographs included salter-harris injuries in the proximal humerus, and proximal femur. pelvic fractures were rare and when present were associated with sexual abuse. severe chest wall injury, with associated rib fractures, causing complete or near-complete white-out of the chest was occasionally encountered. soft tissue injures, such as hematomas were found in various locations in the body including the buttocks and anterior abdominal wall, were imaged on ultrasound and ct. paraor prevertebral injuries, with or without associated bone injury were identified; one infant presented with retropharyngeal soft tissue swelling. mri identified cervical spine injuries which included ligamentous injury and intrathecal hematomas. conclusions: while classic metaphyseal lesions and rib fractures are the most common, specific injuries documented by radiologic work up of suspected non-accidental trauma, less common injuries to the soft tissue and skeletal system may occur as a result of child abuse. the ability of the radiologist to recognize these uncommon manifestations of demonstrated in axial, coronal, and sagittal planes. the ligament of interest will be denoted by arrows. at the conclusion of the anatomy section, there will be a self assessment exam. the participants then will be asked to identify the ligament. if answered correctly, a summary slide will be displayed and, if common, images of the relevant pathology will be demonstrated. if an incorrect answer is indicated, a slide will appear denoting the incorrect answer with explanation. conclusions: hopefully, with review of this educational exhibit, the participant will have a better understanding of the relevant ligamentous anatomy of the ankle and hindfoot. purpose or case report: the purpose of this educational exhibit is to demonstrate the pathologic sonographic findings, one might encounter in the pediatric ankle. a systematic methodological approach including patient positioning, transducer orientation and sonographic technique are vital for ideal sonographic assessment of the pediatric ankle. using a data search program from a large academic institution, pediatric ankle ultrasounds performed in the last years were reviewed. pathologies include trauma, inflammation/infection, masses and congenital abnormalities. examples of normal anatomy will be included particularly when demonstrating ligament and tendon pathology. the normal side was often assessed for comparison purposes. results: ankle sonography is a useful modality to evaluate commonly encountered pathologies in the pediatric ankle. radiographically occult fractures may be discovered. ligament and tendon pathology, such as tears of the anterior talofibular ligament, high ankle sprain and peroneus longus tendon tears, can be easily detected. signs of infection that can be radiographically occult such as subtle periosteal reaction or fluid collections can be identified. finally, "lumps and bumps" can be characterized. for example, one of the most commonly encountered masses in the pediatric ankle is a ganglion cyst which can be well characterized sonographically. awareness of imaging pitfalls is also critical to avoid misdiagnosis and to guide appropriate management. conclusions: with basic ultrasound skills and knowledge of normal anatomy, sonography of the pediatric ankle is a useful modality to evaluate soft tissue structures and other pathologies. it is comparable to mri and allows for dynamic evaluation without need for anesthesia. resonance angiography (mra) using time resolved imaging is a relatively new technique that has become increasingly utilized in the diagnosis of vascular anomalies. we will describe the technique used at our institution, time resolved imaging of contrast kinetics (tricks, ge healthcare, milwaukee, wi), and the parameters that can be adjusted to optimize the exam. we will review key imaging features of hemangiomas and vascular malformations in various modalities, with a special emphasis on the tricks appearance. we performed a retrospective review of all the tricks studies performed at our institution for suspected vascular anomalies. in addition to the mr imaging features, we specifically analyzed the t weighted with fat saturation post tricks enhancement and the temporal tricks enhancement pattern. we reviewed all additional imaging including plain film, ultrasound, and ct and correlated the radiographic imaging with the available clinical and histopathologic features. results: we present illustrative cases of hemangiomas, kaposiform hemangioendothelioma, venous malformations, arteriovenous malformations, lymphatic malformations, and other pitfall lesions. we propose a diagnostic algorithm that relies heavily on the post contrast t weighted with fat saturation post tricks enhancement pattern and the temporal tricks enhancement pattern. conclusions: time resolved contrast-enhanced mra has become an increasingly important adjunct in the diagnosis of vascular anomalies. optimization of the exam technique and familiarity of the tricks imaging appearance is essential and can often assist in accurate lesion characterization. purpose or case report: vertical expandable prosthetic titanium rib (veptr) is increasingly used in the treatment of thoracic insufficiency, scoliosis, and chest wall defects in children. in contrast to spinal fusion surgery, veptr allows for growth while stabilizing the deformity. we review the indications, pre-operative imaging, normal radiographic appearance, and complications of this device. methods & materials: on review of the literature, the indications for veptr have expanded in the past several years to include thoracic insufficiency, idiopathic and neuromuscular scoliosis, and chest wall defects. we illustrate the normal radiographic appearance of the three common configurations of veptr (cradle-to-cradle assembly, cradle with lumbar extension assembly; cradle-to-ala hook assembly). we discuss the potential complications of veptr, including infection, rib fracture, dislodged hardware, and neurological injury, with an emphasis on imaging diagnosis. results: there is a relatively high rate of reported complications with veptr in the literature. therefore, awareness of the growing number of indications, as well as the expected and unexpected appearance of this device, aids in radiographic diagnosis of complications. conclusions: vertical expandable prosthetic titanium rib (veptr) is gaining acceptance in the treatment of thoracic insufficiency, scoliosis, and chest wall defects in children. recognition of the indications, normal radiographic appearance, and complications of this device will facilitate timely and accurate diagnosis. disclosure: dr. philips has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. spectrum of pediatric spinal neoplasms: an interactive tutorial benjamin t. haverkamp, md, radiology, university of missouri-kansas city, haverkampbt@umkc.edu; salvador f. iloreta, maha jarmakani, lisa lowe, seth gibson purpose or case report: the objective of this educational electronic exhibit is to provide the radiologist with an approach to pediatric spinal neoplasms. emphasis will be placed on narrowing the differential diagnosis using a combination of lesion location, characteristic imaging findings, relevant history, and associations. the exhibit format will include a casebased review of various pediatric spinal neoplasms, radiologicpathologic correlation, and a brief discussion of imaging findings useful in guiding surgical management. an interactive selfassessment exam will be presented at the end of the exhibit. results: a review of the specific etiologies will be presented with classification as intra-and extra-medullary and extradural lesions. radiologic images will be related to gross and microscopic pathology. conclusions: after viewing this exhibit, the learner will be able to: . recognize the clinical, imaging, and pathologic characteristics of pediatric spinal neoplasms. . understand relevant imaging findings useful in surgical management. . test their understanding of the presented material through an interactive exam. poster #: edu- craniosynostosis jason tsai, mbchb, children's hospital boston, jason. tsai@childrens.harvard.edu; diana p. rodriguez purpose or case report: to review the normal developmental appearance of the cranial sutures with computed tomography (ct) and to describe ct findings of the various forms of craniosynostoses. in this irb-approved retrospective study we reviewed ct images of subjects diagnosed with craniosynostosis between and september . we included patients with single-suture synostosis, isolated bilateral coronal synostosis, pansynostosis, and combined craniosynotoses. additionally, we identified individuals with normal appearing sutures from to years of age imaged with head ct to describe the pattern of normal development of the cranial sutures. results: a description of the normal developmental ct appearance of the cranial sutures using computed tomography has been provided. of the group of patients with craniosynostosis the following variables were recorded: age at presentation, the pattern of sutural fusion, skull shape, presence of hydrocephalus, genetic testing, and types of surgical correction. conclusions: we have demonstrated the normal developmental ct appearance of the cranial sutures and the ct patterns of the various forms of craniosynostoses, with clinical, genetic and surgical correlation. posterior fossa tumours: a pictorial review sam byott, md, manchester children's hospital, sambyott@ hotmail.com; neville wright, vivian tang, abdu shabani, stavros stivaros purpose or case report: posterior fossa tumours account for - % of childhood brain tumours. the most common differentials include pilocytic astrocytoma, medulloblastoma and ependymoma. mr imaging is crucial to diagnosis, staging and identification of complications such as hydrocephalus and haemorrhage. soft tissue characteristics alongside tumour location, invasion and clinical history facilitate radiological discrimination prior to surgery. however, there is significant clinical equipoise with regards to the imaging appearances in a significant proportion of cases making definite diagnosis difficult. the aim of this study is to evaluate the radiological findings and correlate with histological data. this will allow identification of the key morphological features that discriminate different tumours. these can then be presented to educate fellow radiologists. methods & materials: radiology pacs and patient notes were used to collate radiological, histological and clinical data. results: there were patients presenting at our institution with posterior fossa tumours. had pilocytic astrocytomas, had medulloblastomas and had ependymomas. one patient had an atypical teratoid rhabdoid tumour (atrt). traditional features alongside more advanced mr characteristics were correlated with histology, and the features allowing for discrimination of tumour types are presented in this pictorial review. conclusions: posterior fossa tumours have a highly variable radiological appearance. we present a range of appearances and describe the important morphological features that allow radiological discrimination of tumour type. poster #: edu- dt imaging of the pediatric spine teresa c. gross kelly, children's hospital of wisconsin, tkelly@chw.org; ibrahim s. tuna, mia s. kelly, tushar chandra, sumit singh, mohit maheshwari, hervey d. segall purpose or case report: some abnormalities of the pediatric spine can be challenging. we have discovered that in many such cases, diagnosis of spinal lesions can be faciliated by using the dt weighted sequence. the purpose of this educational poster is to demonstrate the remarkable usefulness of dt weighted images for delineating pathology of the pediatric spine. methods & materials: lesions of the spine that will be reivewed in this educational exhibit will be categorized as: ( ) vascular ( ) due to infection/inflammation ( ) neoplastic/ neurogenic ( ) congenital ( ) traumatic/iatrogenic ( ) endocrine/metabolic. the imaging characteristics of lesions found in the pediatric spine will be described and the utility of d t -weighted mr sequences for the evaluation of these lesions will be discussed. finally the role of imaging in the treatment planning of abnormalities of the pediatric spine will be addressed. results: this educational exhibit will provide numerous examples of how d t -weighted imaging can elucidate diagnosis of lesions involving the spine. examples include enhancement of the cauda equina in guillain barre syndrome, lipomatous malformations, spondylolysis in children with low back pain, thecal cysts, filar cysts, metastasis, hydromyelia and ventriculus terminalis. conclusions: d t -weighted images of the spine performed in the sagittal plane with coronal and axial reformations, as well sagittal oblique reformations (scotty dog reformations) for evaluation of spondylolysis, can facilitate the evaluation of lesions involving the pediatric spine. the normal pediatric spine: a pictorial review of mr anatomy and development in the infant, child and adolescent ibrahim s. tuna, md, radiology, children's hospital of wisconsin, dristuna@yahoo.com; teresa c. gross kelly, tushar chandra, mohit maheshwari, sumit singh, hervey d. segall purpose or case report: radiological evaluation of the pediatric spine can be more challenging in child than in the adult patient due to the wide range of normal anatomic variants and synchondroses, combined with the unique effects of trauma in children. mri is an excellent imaging modality for the evaluation of the pediatric spine. however, in order to provide an accurate interpretation of acute posttraumatic changes in the pediatric spine, particularly in the setting of abusive head trauma, a fundamental knowledge of normal anatomy, variants and pathology of the pediatric spine is required. the aim of this educational exhibit is to illustrate normal mri anatomy of the spine in the infant, child and adolescent. methods & materials: this exhibit will first describe basic spinal embryology and development of the vertebra and spinal cord, followed by mri depiction of the developmental anatomy of the spine from infancy through adolescence. the changing appearance of the spinal canal, spinal cord and vertebral bodies with age will be illustrated using normal cases from the radiology database. sagittal and transverse diameter of vertebral bodies, thickness of the dural thecal sac, dimensions of the spinal canal, normal bone marrow signal changes, vertebral body heights, level of conus medullaris, prevertebral and paraspinous soft tissues and epidural fat thickness will be described and changes according to age will be pointed out. results: in early life, the spinal cord extends to the inferior aspect of the bony spinal column. because the vertebral bodies grow longitudinally faster than the spinal cord does, the conus medullaris may change. ossification of the vertebral bodies and posterior elements is nearly complete by age , with a resultant decrease in the spinal canal diameter. the nucleus pulposus becomes smaller after years and spans approximately half the disk space in the sagittal plane. the spinal cord is elliptical in cross section in the cervical spine and demonstrates a difference in signal between the normal gray and white matter of the spinal cord which should not be mistaken for intramedullary pathology. conclusions: a solid understanding of normal spine anatomy and embryological development is essential in evaluation of pediatric spine, mainly in the setting of trauma. familiarity with normal anatomic variants is essential to provide an accurate interpretation of pathology in the pediatric spine. spectrum of intracranial cystic lesions in infants and children ernesto i. blanco, md, st. christopher's hospital for children, eiblanco @gmail.com; eric faerber purpose or case report: to review the imaging spectrum of intracranial cystic lesions in the pediatric population. methods & materials: a retrospective review of our imaging database was performed to identify studies obtained in which the findings included intracranial cystic lesions. results: multiple cystic lesions were elucidated primarily by computed tomography or magnetic resonance imaging. these lesions can be divided into nonneoplastic and nonneoplastic tumor-associated cysts. the nonneoplastic cysts, which is the largest group, include: cavum septi pellucidi and cavum veli interpositi, choroid plexus cyst, enlarged peri-vascular spaces, pineal cyst, the large spectrum of arachnoid cysts, colloid cyst, epidermoid cyst, rathke cleft cyst, and porencephalic cyst. nonneoplastic tumor-associated cysts include: craniopharyngioma, optic glioma, pilocytic astrocytoma, hemangioblastoma, and ganglioglioma. conclusions: intracranial cystic lesions are relatively common entities in the pediatric population. a wide spectrum of nonneoplastic and nonneoplastic tumor associated pathologies are presented using both computed tomography and magnetic resonance imaging. kelly, sumit singh, ibrahim s. tuna, hervey d. segall purpose or case report: the aim of this educational exhibit is to provide a comprehensive review of imaging features, classification and management of pediatric spinal cord tumors. we also aim to elicit the differences between pediatric spinal cord tumors and their adult counterparts. we will summarize the differences between the individual tumors based on histological cell types and the pertinent implications on management and outcome methods & materials: this exhibit will provide an overview of the common as well as uncommon tumors of the pediatric spinal cord. various classification systems for these tumors-anatomical as well as histological will be discussed. we will illustrate the relevant imaging findings that can help in differentiating these tumors. results: pediatric spinal cord tumors account for % to % of all pediatric central nervous system tumors. mri is the mainstay for the initial diagnosis as well as the post surgical evaluation and surveillance of these tumors. pediatric and adult spinal cord tumours differ both in terms of anatomical location as well as histology. the disease and treatment related morbidities are also different in children as compared to adults. astrocytomas, ependymomas, glioneural tumors and csf metastasis represent the vast majority of cord neoplasms in the pediatric age group. some of cord tumors may also be associated with inherited syndromes (like neurofibromatosis type ) or may have genetic predisposition. these would also be discussed. we will also illustrate and discuss common non neoplastic spinal masses that may mimic tumors. conclusions: pediatric spinal cord tumors have varied clinical presentations, imaging appearance and outcome. this review would improve the understanding of these tumors thereby helping in diagnosis, management and follow up of these uncommon neoplasms. multi-modality imaging of pediatric head and neck lesions jason au, md, oklahoma university health sciences center, jasonmau@gmail.com; anthony alleman, mahmoud elkaissi, roy jacob purpose or case report: the purpose of this study is to present a side by side comparison of the multi-modality imaging features of pediatric masses. using cases that have been imaged with multiple modalities, the exhibit will delineate the sonographic, mr, and ct appearance of congenital, infectious, and neoplastic head and neck lesions in the pediatric population. methods & materials: a restrospective search of pacs was performed on studies completed at the oklahoma university medical center on the oklahoma university health science center campus from january to the present. ultrasound, ct, and mr examinations were selected that depicted relevant pediatric head and neck pathology. all studies were de-identified prior to image export. results: over twenty representative cases of pediatric infections, fibrous tumors, cystic neoplasms, vascular malformation, bony tumors, developmental anomalies, and other neoplasms were selected for inclusion. results: pictorial review of cases including the following representative cases: myelonmeningocele associated with arnold chiari malformation, lipomyelomeningocele, tethered cord with spinal lipoma/fibrofatty filum, tethered cord and dermal sinus tract, and chiari i with syringohydromyelia. several unique cases including the following will be presented as well: thoracic meningocele with arnold chiari malformation, terminal myelocystocele, diastematomyelia, and myelomeningocele without arnold chiari malformation. while mri demonstrates the cranio-cervical junction and the cervicothoracic spinal cord better than ultrasound, ultrasound often allows for improved resolution of the distal spinal cord, lumbosacral spinal canal, and spinal dysraphism structures near the skin surface in the neonate. conclusions: congenital spinal malformations are complex and variable in imaging appearance. it is important to understand the classification in order to determine the appropriate management and prognosis. in the neonatal period imaging should be performed with ultrasound and mri studies, as they may provide different and complementary information. conclusions: hypoxic ischemic injury is a common condition resulting in a wide spectrum of severe neurological defects. while in the past treatment only consisted of supportive care for hii, recent advances have yielded promising treatment options if initiated within a limited time window. thus due to the severity of the disease and the need for rapid intervention, it is important to recognize radiological manifestations of hii along with its clinical signs and symptoms to offer a better prognosis to the patient. craniosynostosis: looking beyond the sutures tushar chandra, md, children's hospital of wisconsin, drtusharchandra@gmail.com; teresa c. gross kelly, mohit maheshwari, sumit singh, ibrahim s. tuna, hervey d. segall purpose or case report: the aim of this educational exhibit is to provide a framework upon which the diagnosis of the various types of craniosynostosis can be facilitated. our goal is to provide an efficient way to evaluate craniosynostosis for the radiologist in clinical practice. we plan to accomplish this goal by providing a succinct review of the sutures, an overview of the various classification schemes for craniosynostosis and potential complications associated with premature sutural closure. the role of imaging in the evaluation of craniosynostosis will be described and the features of craniosynostosis that are most important to the craniofacial surgeon will be elucidated. finally, surgical strategies for the repair of craniosynostosis and postoperative findings will be described. results: some of the forms of craniosynostosis may have a genetic basis, but many are spontaneous in nature. untreated progressive craniosynostosis can lead to inhibition of brain growth, and an increase in intracranial pressure. mdct with mip and d surface reformations is the preferred modality for diagnostic evaluation of craniosynostosis. it is also a robust modality for post operative assessment and long-term follow up. mri is a useful adjunct for assessment of associated intracranial anomalies and complications. timely and appropriate imaging is essential to assess for potential complications of craniosynostosis which may include intracranial hypertension, anomalies of external and middle ear, hydrocephalus, chronic tonsillar herniation, cranial base deformity, impaired venous drainage, enlarged emissary foramina and veins and optic atrophy. on the other hand, positional plagiocephaly should not be misinterpreted as craniosynostosis. surgical management is typical for nonsyndromic craniosynostosis, which involves correction of craniosynostosis between three to six months of age. conservative management is the mainstay for syndromic craniosynostosis. postoperative follow up imaging for surveillance for ventricular size and signs of raised intracranial pressure are necessary. conclusions: craniosynostosis is a challenging area of pediatric neuroimaging. knowledge of the sutural anatomy, an understanding of the potential intracranial complications caused by premature sutural closure, as well as the role that imaging plays in presurgical planning, can provide a practical way for the radiologist to evaluate craniosynostosis in a fast-paced clinical setting. poster #: edu- the perinatal brain and spinal cord-imaging across a life border: a case-based approach anand dorai raju, md, radiology university of tennessee, araju@uthsc.edu; harris l. cohen, matthew whitehead, asim choudhri purpose or case report: to review normal and abnormal perinatal ultrasound (us) and magnetic resonance (mr) imaging findings and note their significance for the analysis of the fetal and neonatal brain as well as spinal cord and vertebral column using a case based approach. to highlight us and mr capabilities in allowing correct perinatal diagnosis of congenital and acquired central nervous system abnormalities. methods & materials: cases will be shown of normal and abnormal anatomic findings in fetal and neonatal brain and spinal cord imaging. key teaching points necessary for the diagnosis of such brain abnormalities as ventriculomegaly, chiari malformations, holoprosencephaly, and agenesis of the corpus callosum as well as dandy walker malformations and avms will be discussed. intraventricular hemorrhage, periventricular leukomalacia, anoxic injuries and infectious abnormalities will be reviewed. abnormal anatomic findings in fetal and neonatal spine evaluations for congenital and acquired abnormalities and key teaching points necessary for the accurate diagnosis of tethered cord, myelomeninocele, caudal regression syndrome, hydromyelia, diastomatomyelia and sacrococcygeal teratoma will be reviewed. some diagnostic difficulties and controversies will be addressed. conclusions: ultrasound aided by mri can provide ready diagnosis to many central nervous system abnormalities involving fetuses and neonates. ever improving perinatal imaging experience and technique allow for better prenatal as well as postnatal diagnosis. cases showing such imaging and key points helping such imaging diagnoses will be reviewed. overview of imaging of pediatric extraocular orbital tumors srikala narayanan, md, division of radiology, children's national medical center, snarayan@childrensnational.org; nadja kadom, gilbert l. vezina purpose or case report: to show the spectrum of benign and malignant extraocular orbital tumors in children. methods & materials: we reviewed the cross-sectional imaging of orbit (ct and mr) done in the last years. specific imaging signs of extraocular tumors including benign and malignant tumors such as hemangiomas, lymphangiomas, optic nerve glioma, optic nerve sheath meningioma, pseudotumors, rhabdomyosarcoma, orbital myofibroma, eosinophilic granuloma and neuroblastoma metastases will be shown. important imaging features that should be considered when formulating a differential diagnosis will be described. conclusions: the spectrum of diseases affecting pediatric orbit is substantially different from what we see in the adults. it is not easy always to differentiate between different tumors. important imaging characteristics will help us towards better differential diagnosis. in this exhibit, we will illustrate ultrasound anatomy of the neonatal spinal cord. discussion of the normal anatomic variants and pathological conditions of the spinal cord will be provided. representative images of a variety of common and uncommon pathological conditions of the spine will be presented to illustrate teaching points. in abnormal cases, follow up mri images will also be illustrated for comparison. results: ultrasound is a robust screening modality for evaluation of the lumbosacral spine in neonates. it is cheaper, readily available, safer first line imaging modality in neonates suspected to have spinal malformations. under able and well trained operator, diagnostic accuracy of spinal ultrasound approaches mri. however, mri remains the gold standard for imaging evaluation of spine. normal variants that simulate disease processes like ventriculus terminalis, prominent filum terminale and central echo complex will be presented. congenital malformations of the cord such as tethered cord, hydromyelia, lipoma, diastematomyelia, myelomeningocele, lateral meningocele and presacral masses will also be discussed. conclusions: ultrasound is a very useful screening technique for evaluation of pathological conditions of lumbosacral spine in neonates. this review would improve the understanding of utility and limitations of ultrasound in evaluation of neonatal spinal malformations. purpose or case report: although mri is the standard for detecting epilepsy and brain tumor abnormalities, pet-ct is performed to ascertain metabolism related to epileptogenic regions or characterize tumor metabolic activity. asymmetric metabolism often correlates to structural abnormalities like cortical dysplasia. metabolic activity often correlates with tumor aggressiveness or grade. fdg pet is commonly used to assess seizure and tumor metabolism. the lesser utilized amino acid pet tracers (c methionine, fdopa) show increasing value with lower grade tumors due to high tumor to normal tissue contrast. literature is accumulating regarding c methionine (cmet) in the detection of lesions like cortical dysplasia and its ability to delineate low grade seizure related tumor lesions. despite the established fdg and accumulating cmet literature, little information exists about the imaging seen with both in pediatrics. as these studies are increasingly viewed as part of fusion mri images, there is more scrutiny of focal metabolism correlating with mri findings and less interpretative reliance on abnormality based solely on asymmetry. methods & materials: review of patients who underwent cmet and fdg brain pet-ct was performed. each was imaged on a philips scanner and had prior mri. studies demonstrating a variety of tumors, postoperative findings of residual or recurrent tumor, and pseudoprogression were selected. epilepsy cases with structural cortical abnormalities or seizure-associated tumors were also selected. cmet and fdg studies were analyzed by pediatric neuroradiologists and the imaging findings correlated with prior mri and any pathology or follow-up imaging. pictorial galleries of the cmet and fdg imaging patterns were created. results: pathologically proven low-grade glial tumors showed increased cmet uptake and no hypermetabolism on fdg. high-grade tumors showed increased uptake on cmet and hypermetabolism on fdg. patients with residual or recurrent tumors showed uptake similar to their original tumor. granulation tissue and pseudoprogression changes showed increased uptake on cmet and no hypermetabolism on fdg. epilepsy surgery patients with cortical dysplasia or low grade glial tumors showed increased uptake on cmet and fdg hypometabolism. conclusions: this study illustrates the variety of findings on cmet and fdg pet-ct in pediatric patients clinically evaluated for brain tumor and epilepsy. this atlas provides readers with a guide to the appearance of these findings on an emerging imaging technique. pediatric head and neck neoplasms: a multimodality pictorial review alok jaju, md, mallinckrodt institute of radiology, alokjaju@gmail.com; marilyn j. siegel purpose or case report: neck masses are common in children and most occur in the suprahyoid region. knowledge of the fascial spaces involved in conjunction with imaging features can help in diagnosis. in this pictorial review, we present a multimodality imaging approach based on anatomy of the suprahyoid fascial spaces for evaluation of pediatric neck tumors. methods & materials: radiology information system (ris) at our tertiary care children's hospital was queried to identify patients with suprahyoid neck masses who had imaging performed between july and present. a variety of conditions having congenital, inflammatory, neoplastic, or vascular origin were identified and the anatomic location in the neck as well as imaging and clinical findings were retrospectively reviewed. results: the imaging evaluation included ultrasound, ct and mri. lesions arose within the following fascial spaces of the suprahyoid neck: superficial, carotid, masticator, submandibular, sublingual, parotid, parapharyngeal, visceral, retropharyngeal and prevertebral. key imaging features important in diagnosis included lesion vascularity, calcification, necrosis and bone invasion. we discuss and illustrate these imaging findings and relate them to specific suprahyoid fascial spaces. specific lesions include vascular and lymphatic malformations, teratoma, nerve sheath tumors, thyroglossal duct and branchial cleft cysts, pleomorphic adenoma, dermoid cyst, ranula, lymphadenopathy, abscess, lymphoma, rhabdomyosarcoma, neuroblastoma and nasopharyngeal carcinoma. conclusions: knowledge of fascial spaces of the suprahyoid compartment and key imaging features on multiple modalities can aid in the diagnosis of pediatric neck masses. pediatric sinusitis: spectrum of imaging findings with clinicopathologic correlation roy jacob, md, university of oklahoma, drjacobr@gmail. com; paul digoy, robert s. glade, anthony alleman purpose or case report: the clinical spectrum of sinusitis in children can range from uncomplicated bacterial sinusitis to invasive fungal sinusitis. most cases respond favorably to medical management. however, complications occasionally occur due to the spread to adjacent structures. imaging plays an important role in characterizing the disease and guiding the clinical and surgical planning and treatment. this electronic presentation outlines the following- . review radiologic anatomy and unique characteristics of pediatric sinuses. . review the clinical features, pathophysiology, and microbiology of sinusitis. . review of ct and mri imaging characteristics of sinusitis with representative cases such as complicated sinusitis and invasive fungal sinusitis. . review the treatment approaches of sinusitis. methods & materials: a retrospective search of pacs was performed on studies completed at the ou children's hospital in oklahoma city for the last three years. ct and mr examinations were selected that depicted relevant disease processes. corresponding nasal endoscopic pictures were obtained from cases which required surgical management. all studies were de-identified prior to image export. results: over fifteen representative cases of the clinical spectrum of sinusitis and its complications were selected for inclusion. conclusions: this educational exhibit provides a concise review of imaging, clinical features, and treatment of pediatric sinusitis. findings will be richly illustrated with radiological and clinical images. microcephaly or hydrocephalus. knowing the embryology of the cerebellum and th ventricle is important to perceive the development of posterior fossa malformations and to further understand the imaging findings. several classifications schemes have been proposed from a pure embryologic to an imaging-based approach using some essential findings such as the size of the posterior fossa, the presence of csf collection or expansion of csf space, and the size and morphology of the cerebellum. mr is the gold-standard for adequately access and characterize the posterior fossa structures. this pictorial essay will review the mr findings of some of the most common posterior fossa malformations including dandy-walker malformation, persistent blakes pouch, mega cisterna magna, arachnoid cyst, paleocerebellar hypoplasia, cerebellar agenesis, cerebellar and pontocerebellar hypoplasia, cerebelar cortical malformations, isolated brainstem hypoplasia/dysplasia and chiari malformations. we will provide a practical approach to the mr findings of posterior fossa malformations in children. conclusions: mr plays a crucial role in identifying and characterizing malformations of the posterior fossa structures. it should give a logical approach to these complex malformations thus guiding the refereeing physician into the clinical approach and in determining further investigations. results: neuroimaging features of abnormal thalami as encountered in the pediatric population were detailed, and wherever applicable, the relevance of additional mr imaging sequences and techniques to determine etiology was described. while there was considerable overlap in imaging appearances, making a precise diagnosis was found to be challenging in difficult cases, and by and large, a stepwise approach was successfully formulated and used to: . diagnose the more emergent conditions and to . devise a management algorithm for the less acute abnormalities. conclusions: bilateral thalamic lesions are occasionally encountered in pediatric neuroimaging and have a limited differential; a good knowledge base and adequate technique are imperative to tease out the precise diagnosis and institute appropriate management. cortical developmental abnormalities in pediatric seizure patients ibrahim s. tuna, md, radiology, children's hospital of wisconsin, dristuna@yahoo.com; mohit maheshwari, teresa c. gross kelly, sumit singh, tushar chandra, hervey d. segall purpose or case report: to describe various cortical malformations with illustrative examples. we will also briefly discuss the embryology, genetic basis, classification schemes and characteristic imaging findings . methods & materials: this exhibit will illustrate three main categories of cortical malformations: neuronal proliferation, migration and organization. understanding of this complex topic would be facilitated by brief discussion on the embryological basis and proposed genetic causes of some of these cortical malformations. classification schemes on embryology and imaging will be discussed. characteristic imaging findings of these malformations will be discussed and examples from the authors database will be shown. results: neuroimaging in pediatric seizures is challenging. mri is considered the imaging modality of choice because of superior soft tissue contrast and better ability to characterize the pathologic process. we will also discuss the dedicated seizure protocol which is used in our institute. pet-ct imaging can also provides additional information in cases where mri is negative, inconclusive or does not correlate with eeg/clinical findings. brief discussion on advanced imaging techniques will also be presented. malformations are frequently detected in infancy. however, if the initial mri scan performed in infancy is negative, a repeat scan after years of age may be helpful. conclusions: evaluation of cortical malformation in seizure patients still remains a challenging area of pediatric neuroimaging. reviewing of the embryological basis, classification schemes and characteristic imaging findings would improve the understanding the cortical malformations and interpreting the images. poster #: edu- sprs best poster cystic neonatal lesions associated with the spinal cord: discussion and differential diagnosis for these uncommon lesions jacob pirkle, md, jpirkle@mc.utmck.edu, james boyd, brian dupree purpose or case report: to review intradural cystic neonatal spine lesions and discuss the various causes and appearance of these lesions. this poster presentation provides a brief review of neonatal cystic spine lesions, including their etiologies, and presents the targeted audience (radiology resdients, fellows, and practicing radiologists) a helpful differential diagnosis of these lesions based upon their imaging appearance. methods & materials: a brief overview of neonatal cystic spine lesions, their etiology, and imaging appearance is presented in poster format utilizing both literature search and printed reference material. images from several cases of cystic neonatal spine lesions are presented. results: a brief overview of neonatal cystic spine lesions, their etiology, and imaging appearance is presented in poster format utilizing both literature search and printed reference material. images from several cases of cystic neonatal spine lesions are presented. conclusions: neonatal spine ultrasound is often performed to evaluate for abnormalities related to the presence of sacral dimples, cutaneous stigmata, skin tags, hairy tufts, during the evaluation of other congenital anomalies, or when prenatal ultrasound/mri demonstrates an abnormality warranting postnatal follow-up. the identification of cystic spinal cord lesions is relatively rare in the neonate. however, the etiology of these lesions can often be deduced or surmised based upon the location and the imaging appearance of the lesion. the most common cause of a cystic intramedullary spinal lesion is ventriculus terminalis, with a reported incidence of . %. additional lesions include transient dilatation of the central canal, filar cyst, syringohydromyelia, intramedullary arachnoid cyst, and myelomalacia related to in utero/birth trauma. extremely rare etiologies in the neonate include epidermoid/dermoid, cavernous malformation, intranatal cystic infections etiologies, neuroepithelial cysts, and cystic neoplasms. mimics include diastematamyelia, spinal lipomas, and intramedullary hematomas. numerous imaging examples of these lesions are provided in the accompanying poster. brain mri in peroxisomal disorders: a pictorial essay bruno p. soares, md, radiology and biomedical imaging, university of california at san francisco, bruno.soares@ucsf. edu; leonardo vedolin, guido gonzalez purpose or case report: our presentation aims to illustrate the brain mri patterns in peroxisomal disorders. peroxisomes are intracellular organelles involved in important cellular processes including beta-oxidation of very-longchain fatty acids and plasmalogen production. peroxisomal disorders can be categorized into disorders of peroxisomal biogenesis, in which the peroxisomes are abnormally formed and several peroxisomal functions are deficient, and in defects involving a single peroxisomal function, in which the structure of the peroxisome is intact. disorders of peroxisomal biogenesis include zellweger syndrome, neonatal adrenoleukodystrophy, infantile refsum disease and rhizomelic chondrodysplasia punctata. numerous disorders are caused by loss of a single peroxisomal function including x-linked adrenoleukodystrophy and acyl-coa oxidase deficiency. clinical findings in peroxisomal disorders include dysmorphic features, hepatic dysfunction, neurodevelopmental delay, retinopathy and hearing impairment. methods & materials: pictorial essay illustrating brain mri patterns in peroxisomal disorders, including disorders of peroxisomal biogenesis and disorders with loss of a single peroxisomal function. results: brain abnormalities in peroxisomal disorders have a wide spectrum of patterns. neuronal migration disorders with abnormal myelination are typically seen in zellweger disease and neonatal adrenoleukodystrophy. specifically, the association of abnormal myelination with germinolytic cysts is suggestive of zellweger syndrome. classic x-linked adrenoleukodystrophy typically shows posterior central white matter involvement and symmetric demyelination also involving the corticospinal tracts and corpus callosum. a similar pattern of white matter involvement is seen in acyl-coa oxidase deficiency and infantile refsum disease. conclusions: brain mri helps narrow the differential diagnosis and guides subsequent evaluation in infants presenting with clinical features concerning for peroxisomal disorders. therefore, knowledge of the brain mri patterns in peroxisomal disorders is important for the radiologist interpreting neuroimaging studies. clots in tots: role of imaging in diagnosis of acute stroke and its causes in children asif abdullah, c.s. mott children's hospital of the university of michigan, asifa@med.umich.edu; ellen hoeffner, augusto elias purpose or case report: stroke is a major cause of morbidity and mortality in children. long-term neurologic deficits occur in % to % of infants and children after arterial ischemic stroke. limited awareness regarding pediatric stroke among physicians and in general community is a major concern. imaging plays crucial role in the diagnosis of pediatric stroke. the goal of this presentation is to provide awareness to the reader about the role of imaging in childhood stroke and its myriad causes in children. we will provide a case based approach to imaging diagnosis of acute pediatric stroke based on three categories: ( ) arterial ischemic stroke, ( ) cerebral venous thrombosis, and ( ) hemorrhagic. arterial ischemic stroke (ais) is classified according to the pediatric stroke classification (psc). psc includes eight subtypes of ais: ( ) sickle cell disease, ( ) cardioembolic disease, ( ) moyamoya syndrome, ( ) cervical arterial dissection, ( ) stenoocclusive cerebral arteriopathy, ( ) other determined etiology, ( ) multiple probable etiologies, and ( ) undetermined etiology. we will describe the role of computed tomography (ct) and magnetic resonance imaging including angiography (mri/mra) in identifying these causes in relation to available clinical data. the etiologies of cerebral venous thrombosis related infarction would be discussed from an imaging perspective with a case-based approach with emphasis on mrv and swi techniques. finally, we will focus on hemorrhagic causes of childhood stroke such as vascular malformation, aneurysm, neurocutaneous disorders, coagulopathy, and a variety of other causes from an imaging standpoint. perfusion imaging in pediatric stroke demonstrates flow within the brain and can detect areas that are at risk of ischemia; however, further studies in the pediatric population need to be validated for the role of this technique in pediatric stroke. results: the most important factors in the diagnosis of childhood stroke are causal investigation, appropriate laboratory tests, and imaging studies. imaging is frequently the first step in the evaluation of an acutely ill child. conclusions: pediatric stroke is a debilitating disease that requires urgent multidisciplinary approach for diagnosis and treatment. in cases of both ischemic and hemorrhagic origin, the radiological approach to be obtained in emergency setting leads to the initial screening and the first therapeutic possibility. methods & materials: this exhibit will illustrate the characteristic imaging findings of vascular anomalies in the head and neck region. vascular anomalies are divided into vascular tumors and vascular malformations which include slow flow malformations (capillary malformations, venous malformations, lymphatic malformations and their combinations) and high flow malformations (arteriovenous fistula and arteriovenous malformations). complex malformations are also seen in several syndromes including klippel-trenaunay syndrome, phace syndrome, etc. cases from author's database will be used for illustration. results: a review of clinical manifestations, characteristic imaging findings and interventional treatment strategies in cases of head and neck vascular anomalies will be presented with pre and post treatment imaging features. ultrasonography and mri are the mainstay in diagnosis of these malformations. ct scan and catheter angiography may occasionally be needed for diagnosis and treatment planning. various imaging findings and main treatment options will be listed. conclusions: head and neck vascular malformations are common in pediatric population. understanding the characteristic imaging findings and clinical presentation is essential in evaluating the vascular malformations. interventional procedures are generally the preferred treatment modality, either alone or in association with surgery in majority of these cases. isolated cortical diffusion restriction in pediatric brain mri ihsan mamoun, md, cleveland clinic, ihsanmamoun@ yahoo.com; sarah stock, s. pinar karakas, unni udayasankar, janet r. reid purpose or case report: diffusion-weighted imaging continues to emerge as a powerful neuroimaging tool. isolated cortical restricted diffusion is a particularly striking pattern with specific differential in the pediatric population. we aim to review this specific imaging pattern supplemented by case examples and key physiologic and imaging concepts. methods & materials: review the concept of diffusion restriction a) pathophysiology b) specific imaging appearances pictorial review of pediatric conditions that lead to cortical restricted diffusion: a) post ictal change b) infection-i. meningoencephaliitis ii. herpes c) hypoxic ischemic injury d) infarct: venous and arterial e) posterior reversible leukoencephalopathy f) mitrochondrial cytopathy g) metabolic: hypoglycemia. discuss certain artifacts. summary table and differential clues conclusions: the pattern of isolated cortical restricted diffusion has specific differential diagnosis in the pediatric population. the radiologist should be aware of this as use of dwi continues to grow. this exhibit with familiarize the reader with common conditions that specifically affect the cortex and produces true restricted diffusion. methods & materials: high resolution ct scan and mri are mainstay of diagnosis and assessment in patients with sensorineural hearing loss. in this exhibit we will present a pictorial review of ct scan and mri images of various causes of sensorineural hearing loss (snhl) that are seen on imaging. reviewing the embryologic basis of these anomalies would enable better understanding of this complex subject. results: the new system classifies these malformations according to descending order of severity into complete labyrinthine aplasia, cochlear aplasia, common cavity, cystic cochleovestibular malformation or incomplete partition-i (ip-i), cochleovestibular hypoplasia, and incomplete partition-ii (ip-ii). there is a lot of confusion in literature pertaining to mondini deformity. the new classification divides incomplete partition into ip-i representing cystic cochleovestibular malformation and ip-ii representing the classic mondini deformity with three components (cystic cochlear apex, dilated vestibule, and large vestibular aqeduct). recently a subclassification of ip-i and ip-ii has been proposed (subdividing into typical and atypical subtypes)[ ]. this will be discussed briefly. isolated large vestibular aqueduct without associated cochlear abnormalities will also be discussed. we will discuss the relevant embryology with correlations of malformations to the timing of embryologic insult. conclusions: the new classification system provides precision in description of inner ear malformation. this also helps in providing a uniform scale for comparison of effectiveness of cochlear implant for different malformations. purpose or case report: congenital cranial nerve anomalies often present as sensory and/or motor deficits of unknown etiology in the pediatric age group. the early recognition of a definitive cranial nerve abnormality using high-resolution imaging can focus further clinical investigation and shorten the time to diagnosis. methods & materials: to promote appropriate recognition of cranial nerve anomalies, we present the imaging findings of the most commonly affected cranial nerves and provide correlation with clinical presentation. all studies were performed on a . t magnet with dedicated high resolution imaging of cranial nerve exit zones. results: ours is a tertiary care pediatric hospital with an extensive neuroimaging database. we intend to review all known cases of cranial nerve anomalies from the prior years and present interesting and representative images including optic nerve hypoplasia as part of septo-optic dysplasia, kallman syndrome, duane retraction syndrome, and mobius syndrome. conclusions: congenital cranial nerve anomalies present with varied symptomatology including anosmia, impaired vision, occulomotor deficits, and hearing loss. additionally, clinical manifestations of cranial nerve anomalies can be difficult to recognize in the pediatric age group. effective imaging and prompt diagnosis is crucial to initiate appropriate clinical management. purpose or case report: mr is the standard for evaluation of tumors or epilepsy. pet-ct imaging is often performed to ascertain metabolic asymmetries related to epileptogenic regions or to better characterize the metabolic activity of tumors. a baseline for normals with pet-ct fdg- and c methionine does not exist. methods & materials: retrospective review was performed of the pediatric patients who underwent pet-ct with c methionine and fdg. representative studies were selected for patients imaged during infancy (< yr), early childhood ( - ), childhood ( - ), late childhood ( - ), teenage ( - ). c methionine and fdg studies were analyzed for normal patterns of uptake and any trends identified across the stratified age groups. representative pictorial image galleries of the c methionine and fdg imaging patterns through development were created. results: the pattern of radiotracer uptake on c methionine differed from that of fdg. the c uptake remained low level throughout development compared to fdg uptake, which was robust in much of the cortex. the cortical fdg uptake within the frontal lobes progressively increased with age. the c uptake within the brainstem and thalamus was equal to cortex throughout development. the fdg uptake within the basal ganglia was equal to cortex while the brainstem and thalamic uptake was generally less than cortex. several anatomic structures showed robust c uptake not seen on fdg. these included the lacrimal, submandibular and parotid glands. incidentally, the pituitary gland and hippocampus consistently showed c uptake equal to cortex contrary to their appearance on fdg. our institutional protocol regarding the performance of combination c methionine and fdg brain pet-ct studies is presented. conclusions: this study illustrated the normal appearance of brain pet-ct imaging performed with c methionine and fdg in a representative cohort of the pediatric patients through development. normal variance imaging patterns and developmental trends seen with each radiotracer was demonstrated. the pediatric cerebellum: a pictorial review of normal anatomy using mri and diffusion tensor imaging ibrahim s. tuna, md, radiology, children's hospital of wisconsin, dristuna@yahoo.com; sumit singh, teresa c. gross kelly, mohit maheshwari, tushar chandra, hervey d. segall purpose or case report: the aim of this educational exhibit is to illustrate normal anatomical and functional anatomy of the cerebellum in the pediatric patient. the cerebellum receives sensory input from the brain and spinal cord and integrates this information to coordinate motor control. in addition, the cerebellum also plays a role in some cognitive functions such as attention and language. the first step toward understanding how cerebellar abnormalities can lead to neurological dysfunction, is to provide a solid understanding of the neuroanatomy and functional pathways of the cerebellum. we will describe basic cerebellar embryology, the various cell types and gross anatomy using mr images as well as dti fiber tractography. methods & materials: this exhibit will describe the microstructure, gross anatomy and functional pathways of the cerebellum through illustrations, mr images, diffusion tensor imaging (dti) and pathological correlation. first embryology of the cerebellum will be described, followed by mri depiction of the developmental anatomy of the cerebellum from infancy through adolescence. finally dti tractography images will be used to delineate functional pathways to and from, as well as within, the cerebellum. pathological specimens will be photographed to further illustrate gross anatomy. results: afferent white matter pathways travel mainly via the inferior and middle cerebellar peduncles. the main efferent cerebellar white matter pathway is through the superior cerebellar peduncle. transverse fiber tracts are present in the vermis. there are mainly two main systems of cerebellar white matter fibers which are easily visualized with dti color mapping; however more anterior components of dti tracts are intermixed with afferent white matter projections following the middle cerebellar peduncle. conclusions: knowledge of the precise neuroanatomy and white matter tracts of cerebellum may elucidate our ability to comprehend the clinical manifestations of cerebellar diseases in children. a solid understanding of normal cerebellar anatomy, development and functional fiber tracts in the pediatric patient can provide a baseline that may help predict the clinical outcome of various diseases or interventional procedures. gastroesophageal reflux scintigraphy: a low radiation alternative to gerd evaluation in children vikas menghani, md, pediatric radiology, women's and children's hospital, drvikasmenghani@gmail.com; feraas jabi, jan najdzionek, vaseem iqbal purpose or case report: gastroesophageal reflux disease (gerd) is among the common causes for failure to thrive, recurrent cough and aspiration in children. early diagnosis of gerd is essential in avoiding long-term sequelae such as growth delay, chronic lung disease, esophageal stricture, and esophagitis. gastroesophageal reflux scintigraphy, a noninvasive imaging modality, has been applied for detection of gerd and gastric emptying in children over the past few decades. the radiation burden is considerably small given that a very low dose of radioactivity via a short half-life radioisotope like technetium- m tagged to oral sulfur colloid is administered to a patient. this feature makes reflux scintigraphy especially attractive as the patient can be scanned for prolonged and delayed periods without increasing radiation dose permitting not only identification but also assessment of severity of gerd. characterizing gerd severity is essential in determining how aggressive the pediatrician should be with therapy. gastroesophageal reflux scintigraphy also allows a child to be fed their regular meal tagged to radiopharmaceutical without altering food taste. qualitative and quantitative parameters like gastrointestinal transit and gastric emptying time can be measured, respectively. scintigraphy is highly sensitive to low grade reflux making it very desirable for monitoring response to therapy. while scintigraphy like all other imaging modalities,has limitations, it continues to be an excellent technique for gerd identification and characterization as well as in monitoring response to gerd therapy. the pediatric kidney-a review of common and uncommon renal anomalies ruby lukse, staten island university hospital, drjosemorey@gmail.com; josé morey, jeremy neuman, arnold brenner, oren herman, adam bernheim purpose or case report: renal parenchymal imaging in nuclear medicine has long been performed with mtcdimercaptosuccinic acid (dmsa) due to its sufficient binding to the renal tubules to permit renal cortical imaging. dmsa is of particular value when high-resolution images of the renal cortex are needed. this poster will be a pictorial review of common and uncommon congenital anomalies evaluated on dmsa imaging, such as horseshoe kidney, pelvic kidney, sshaped kidney and crossed-fused ectopia. the poster will also correlate planar imaging findingss with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), fluoroscopic imaging and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). purpose or case report: in this poster we will review the differential diagnoses of congenital anomalies that give the appearance of hydronephrosis on renal imaging of the pediatric patient. we will show a pictorial review of both common and uncommon congenital anomalies such as congenital megaureter, ureterocele, uretero-pelvic junction (upj) obstruction, uretero-vesicular junction (uvj) obstruction and posterior urethral valves (puv). we will also review common mimickers of hydronephrosis such as multicystic dysplastic kidney (mcdk) and pseudo-obstruction secondary to bladder overdistention. the poster will also correlate planar imaging finds with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), fluoroscopic imaging and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). the pediatric bone scan-a review of neoplastic pathology shrita smith, staten island university hospital, drjosemorey @gmail.com; josé morey, jeremy neuman, arnold brenner, daniel klein, purpose or case report: bone imaging continues to be the second greatest-volume of nuclear imaging procedure performed today, offering the advantage of total body examination, low cost, and high sensitivity. the diagnostic utility, sensitivity, specificity and predictive value of m-tc bone imaging of malignant conditions have long been established. in fact, more than , , bone scans were performed in the united states in . in this poster we will review the current indications for planar bone imaging for the evaluation of malignant and benign neoplasms in the pediatric population, such as osteoid osteoma, langerhan cell histiocytosis (lch), osteoblastoma, ewing's sarcoma, lymphoma, osteosarcoma and osseous/hepatic metastatic disease from neuroblastoma. the poster will also correlate planar and single-photon emission computed tomography (spect) imaging findings with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), positron emission tomography (pet), and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). the many faces of duplex kidneys on dmsa scans-a pictorial essay neha kwatra, children's national medical center, nskwatra@childrensnational.org; massoud majd purpose or case report: renal duplication is the most common malformation of the urinary tract and is often seen in children with urinary tract infections (uti). the purpose of this study is to learn to recognize duplex kidneys on dimercaptosuccinic acid (dmsa) scintigraphy, review their entire spectrum of findings and correlate with other imaging modalities. methods & materials: dmsa scintigraphy is routinely performed in the nuclear medicine department with a single-head gamma camera (siemens e.cam, schaumberg, illinois). about . h after injection of dmsa, posterior and posterior oblique images are obtained using parallel and pin hole collimators. differential renal function is also calculated. dmsa scan reports containing the words "duplex" or "duplicated" from - were populated using a radiology search engine (montage health care solutions inc.). the images were then reviewed in pacs and representative examples were selected for the poster. the scans were evaluated for renal position, size, contour, any evidence of duplication and parenchymal damage. results: patterns of duplication included non complicated duplex kidney recognized by asymmetric renal size and a prominent cortical bar separating the two moieties, complicated duplex systems with hydronephrosis, scarring or pyelonephritis of one or both moieties. a small nonfunctioning upper moiety was sometimes evidenced by just an indentation along the superomedial aspect of the larger lower moiety. cases with bilateral duplex kidneys were also seen. illustrative examples of each will be provided. correlating findings on other imaging modalities will also be included. conclusions: establishing the diagnosis of duplex kidney on a dmsa scan requires a careful systematic review of the images. the findings can be subtle and it is important for the radiologist to recognize them. correlation with other modalities such as ultrasound or voiding cystogram can be complementary. the assessment of parenchymal function of the upper and lower moieties separately on dmsa scintigraphy can be of immense value in patient management and in choosing surgical options. poster #: edu- f-fdg pet/ct imaging of pediatric brain tumors, neurofibromatosis (nf ) and non-lymphomatous head and neck tumors. lisa states, md, radiology, chop, states@email.chop.edu; purpose or case report: this educational poster will review the current literature and summarize the value of f-fdg pet/ct in standard clinical practice in the evaluation of pediatric brain tumors, nf plexiform neurofibromas and malignant peripheral nerve sheath tumors, and nonlymphomatous head and neck tumors. normal variants and pitfalls will be reviewed. comparison with other pet tracers will be briefly discussed. case examples will be used to illustrate the value of f-fdg pet/ct in grading, staging, assessment of therapeutic response and detection of residual or recurrent disease in various pathologic entities. results: examples of cases will include: benign brain tumor, residual brain tumor in the post-operative bed, brain metastasis, malignant peripheral nerve sheath tumor in nf , head and neck rhabdomyosarcoma, mandibular osteosarcoma, and infection. conclusions: an understanding of the value of pet molecular imaging is essential to the success of the next phase of hybrid imaging with pet/mri which has the potential to play an important role in the development of new diagnostic and therapeutic approaches for the treatment of pediatric brain tumors, nf , and pediatric head and neck tumors. disclosure: dr. states has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. the pediatric bone scan-a review of non-malignant pathology josé morey, staten island university hospital, drjosemorey@ gmail.com; jeremy neuman, arnold brenner, vinh phan, cheryl lin purpose or case report: bone imaging continues to be the second most performed nuclear imaging procedure, offering the advantage of total body examination, low cost, and high sensitivity. the diagnostic utility, sensitivity, specificity and predictive value of m-tc bone imaging of benign conditions have long been established. in fact, more than , , bone scans were performed in the united states in . in this poster we will review the current indications for planar bone imaging for the evaluation of non-malignant diseases in the pediatric population, such as acute osteomyelitis secondary to salmonella enterobacteriaceae and tubercle bacillus (tb), chronic osteomyelitis, reflex sympathetic dystrophy, spondylolysis, bone infarcts in the setting of sickle cell disease, fractures (occult/stress), ankylosing spondylitis, dermatomyositis and non-accidental trauma. the poster will also correlate planar and single-photon emission computed tomography (spect) imaging findings with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), positron emission tomography (pet), and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). purpose or case report: we review the radiologic features of pathologic conditions linked to diesel exposure. the hydraulic fracturing ("fracking") technique is increasingly used in many areas of the country to extract natural gas from rock formations. diesel fuel, or fluids containing diesel, are one component of fracking fluid and create a potential for ground water contamination and risk to air quality. the toxic effects of diesel exhaust are described in the literature, and include asthma, hydrocarbon pneumonitis, and leukemia. there are no scientific data currently available on the effects of chronic diesel ingestion. methods & materials: multi-modality examples of pathology were obtained from a radiology database at a tertiary care pediatric hospital. the specific cases displayed are not known to have diesel exposure, but are intended to serve as representative examples of the type of pathology that may be encountered in the setting of chronic diesel exposure. results: imaging findings of asthma include hyperexpansion, atelectasis, peribronchial thickening, and air-trapping. hydrocarbon pneumonitis may demonstrate low attenuation consolidation and subsequent pneumoatocoeles with ct. leukemia may present on plain radiographs with lucent metaphyseal bands and with marrow infiltration on mri. conclusions: in conjunction with other symptoms not necessarily evaluated in the radiology department, including rhinitis, laryngitis, acute coronary syndrome, and dementia, the radiologist may suggest the diagnosis of diesel toxicity, particularly in populations that may be at high risk of exposure. pediatric radiology in the philadelphia region: a historical review* richard markowitz, md, children's hospital of philadelphia, markowitz@email.chop.edu purpose or case report: the specialty of pediatric radiology in the philadelphia region has grown and evolved over the past eight decades originating from early "visiting" radiologists to drs. hope and kirkpatrick, the "giants" of the s and ' s, to over fifty practicing pediatric radiologists today. clinical excellence, commitment to teaching, and advancement of knowledge through research remain the goals and ideals, much as they were many years ago. philadelphia has been a fertile home and environment for this evolution, mostly because of outstanding leaders and role models who have trained and influenced generations of pediatric radiologists. developments and leadership at the children's hospital of philadelphia, st. christopher's hospital for children, and a.i. dupont institute are highlighted. the purpose of this poster is to tell the story of the growth and development of pediatric radiology in this area and to explore the intellectual origins, professional "genealogy," and legacies left by those who created and those who have carried on this tradition. *note: this material is based on a previously published article: pediatric radiology ( ) : - and "addendum" (pediatric radiology : - ), but never presented at spr. superficial lumps and bumps henrietta k. rosenberg, md, radiology, the mt. sinai medical school, henrietta.rosenberg@mountsinai.org; diane belvin, neil lester purpose or case report: superficial soft tissue masses in the pediatric age range can be quite challenging to the pediatrician and the imager. the purpose of this presentation is to demonstrate the efficacy of duplex/color doppler ultrasound for the diagnosis and follow up of a large gamut of superficial lumps and bumps. methods & materials: we reviewed our experience during the past years using ultrasound to evaluate superficial soft tissue masses that had been encountered in many parts of the body, from the skull to the soles of the feet, in a large group of patients ranging in age from newborn to years. all sonograms were performed after obtaining pertinent clinical information as well information regarding the clinical characteristics of each of the masses, e.g. location, consistency (firm [solid], compressible [cystic]), fixed or easily movable, smooth or irregular surface, tenderness. the masses were palpated by the imaging team and duplex/color doppler ultrasound was performed. comparison sonographic views of the opposite side were obtained as needed. clinical followup and surgical/pathological correlation was obtained in most of the patients. results: most of the masses were benign and included a wide variety of etiologies. most often, us was sufficient for assessment of soft tissue masses if the entire mass was included in the field of view. if the lesion was too large for the field of view or malignancy was suspected, ct/mri were required preoperatively. nuclear medicine studies are reserved for midline masses likely due to ectopic thyroid and pet was used for more complete evaluation of a lesion that was likely malignant. conclusions: duplex/color doppler ultrasound (us) is the modality of choice for evaluation of superficial lumps and bumps! this modality allows for rapid acquisition of information without the use of ionizing radiation, intravenous contrast material, or sedation/anesthesia. reliable information can be rapidly acquired regarding the size, shape, borders, location, internal consistency, vascularity, vascular encasement/displacement. correlation of the ultrasound and clinical findings helps narrow differential diagnosis. sonography helps to determine what is the next best step: watchful waiting (clinical observation, follow-up us), surgical resection, or us guided interventional procedure. present day imaging of down syndrome rupa radhakrishnan, md, radiology, university of cincinnati college of medicine, radhakrp@ucmail.uc.edu; alexander j. towbin purpose or case report: down syndrome is a common genetic condition characterized by unique physical traits and multisystem anomalies. the purpose of this exhibit is to portray the imaging findings of down syndrome and discuss with illustrative examples, the use of imaging in multidisciplinary management. methods & materials: published literature was reviewed to identify the multisystem imaging findings in down syndrome. the electronic medical record system was then searched to find illustrative case examples from our institution. results: in patients with down syndrome, abnormalities can be found in the musculoskeletal, cardiovascular, respiratory, gastrointestinal, and central nervous systems. abnormalities can range from emergent, life threatening conditions such as malrotation with midgut volvulus to chronic conditions such as scoliosis. examples of abnormalities from each organ system and the modalities used for diagnosis and management are described. cardiovascular system: echocardiogram and cardiac mri and ct are useful in evaluating congenital heart disease associated with down syndrome. respiratory system: micrognathia with macroglossia and hypotonia predisposes patients to sleep apnea which can be evaluated with dynamic mri. chest ct demonstrates subpleural cysts which are characteristic of this syndrome. gastrointestinal system: fluoroscopy and/or radiographs are the mainstay in diagnosing many gastrointestinal disorders including duodenal atresia, malrotation, annular pancreas, imperforate anus, and hirschsprung disease. central nervous system: choroid plexus cysts may be identified on prenatal ultrasound in a fetus with down syndrome. imaging is used in the evaluation of epilepsy, hearing loss and alzheimer disease that is more common in these individuals. musculoskeletal system: multiple skeletal anomalies can be present in patients with down syndrome. radiographs are often used as the method of identifying and, if needed, following the anomalies. prenatal imaging: increased nuchal translucency is the earliest imaging finding. other features of down syndrome can be identified on prenatal ultrasound or mri. prenatal imaging is helpful in determining the prognosis of the fetus and in guiding management. conclusions: modern day multidisciplinary management has improved quality of life and survival in individuals with down syndrome. imaging plays a critical role in guiding management in these individuals. imaging the spectrum of lymphatic malformations in the pediatric patient andrew schapiro, md, radiology, university of wisconsin, aschapiro@uwhealth.org; kara gill, bradley maxfield purpose or case report: lymphatic malformations (lm) occur as a result of abnormal development of the lymphatic system during embryogenesis. as % of lm present by years of age, these lesions represent an important pediatric entity. lm can often be suspected clinically in an infant with the classic presentation of an asymptomatic, soft mass in the head, neck, or axilla. however, myriad presentations are possible as lm occur in numerous other anatomic locations, can be multiple, and can be a component of mixed vascular malformations. in addition, the true extent of lm is often not apparent clinically. given these considerations and the implications for proper management, imaging plays an important role in the assessment of lm. the purpose of this exhibit is to review the spectrum of radiographic, ct, sonographic, and mr imaging findings of a variety of lm presentations. methods & materials: cases of lymphatic malformation in pediatric patients identified at a single institution over the past ten years with available imaging were reviewed utilizing pacs. results: images of lm involving the head and neck, chest, abdomen, retroperitoneum, extremities, and skeletal system were identified. in addition, cases of lymphangiomatosis and mixed venolymphatic malformation were identified. various imaging modalities including radiography, ct, sonography, and mr were represented. conclusions: adequate knowledge of the imaging characteristics of lm across multiple modalities enables proper diagnosis, assessment of disease extent, and guidance of appropriate therapy in pediatric patients. results: ct and mr imaging findings in nine cases will be presented. they include ) congenital absence of the inferior vena cava with thrombosis of the external iliac vein secondary to venous stasis ) pyelophlebitis complicating ruptured appendicitis ) left iliac vein thrombosis in a patient with may-thurner syndrome ) splenic vein thrombosis complicating pancreatitis ) splenic vein thrombosis following splenectomy ) renal vein thrombosis in an infant of a diabetic mother ) adrenal vein thrombosis as the presenting sign of antiphospholipid syndrome ) budd-chiari syndrome associated with underlying myeloproliferative disease ) iliac vein thrombosis as a manifestation of behcet's syndrome (hughes-stovin syndrome, a variant of behcet's syndrome, which presents with systemic venous thrombosis and pulmonary artery aneurysms will also be discussed). conclusions: thrombosis of large abdominal and pelvic veins in children and adolescents is uncommon. certain conditions, both congenital and acquired, predispose to the development of venous thrombosis. ct/mr imaging defines the extent of thrombosis, and demonstrates additional findings that may elucidate the nature of the underlying condition leading to clot formation. purpose or case report: because abnormal gait in a young child has a wide range of causes, imaging plays a critical role in establishing the definitive diagnosis. the purpose of this exhibit is to review the clinical clues (age, duration, laboratory markers) and imaging findings of the causes of abnormal gait in a toddler and to assess the strengths and limitations of radiographs, ultrasound, magnetic resonance imaging (mri), and computed tomography (ct). methods & materials: cases, from a single institution experience with various causes for abnormal gait in a toddler, are reviewed and categorized into congenital, traumatic, inflammatory, neoplastic, or neuromuscular etiologies. results: there are various causes of abnormal gait in a toddler. the congenital causes include spinal dysraphism, proximal and distal skeletal deformities and dysplasias. the traumatic causes include non-accidental trauma, toddler's fracture, foreign body, and soft tissue injuries. the inflammatory causes include juvenile idiopathic arthritis, transient synovitis, and infection, including osteomyelitis, septic arthritis, discitis, cellulitis, and abscess. the neoplastic causes include various neurogenic, bone, and soft tissue tumors. the neuromuscular causes include cerebral palsy and spinal bifida. the combination of clinical presentation, supporting laboratory findings, and classic imaging findings help to distinguish the possibilities and often allows confident diagnosis. conclusions: knowledge of imaging findings and clinical factors can demystify the diagnosis of abnormal gait in a toddler. familiarity with the clinical presentation can ensure the performance of the appropriate diagnostic studies, timely diagnosis, and effective treatment. nonaccidental causes should never be overlooked. ultrasonography has become an important tool in the radiologist's armamentarium, augmenting radiography, mri, and ct. approximately different contrast agents for mri and ct are now commercially available for use. although most of them are fda approved in adults, information on usage and safety in children is not readily available. the most important reason is lack of controlled studies in children, especially for the age of - years. however, the lack of fda approval has not limited the use of these promising agents in children. in fact, there is widespread off-label use of these agents in most major pediatric hospitals in the country. based on a review of relevant literature in children, and based on a survey of radiology faculty at major pediatric hospitals, this poster will address the gap between approved use and reality in the setting of pediatrics. results: using a tabular format, this poster will provide a list of mr and ct contrast agents that are available for clinical use, their relevant clinical properties (ionic or nonionic, viscosity, linear or macrocyclic, degree of relaxivity for mri, iodine concentration for ct, cost, dosage, halftime, incidence of allergic reactions, nephrogenic systemic fibrosis and other adverse reactions), fda approval status (for ages - days, days- years, and - years), common pediatric applications, and contrast injection protocols for common applications. conclusions: to enlighten imaging personnel about usage and safety of contrast agents in children. disclosure: dr. krishnamurthy has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. a pictorial essay and literature review of the spleen in sickle cell disease david hindson, md, boston medical center, david. hindson@bmc.org; heather imsande, philippa sprinz, ilse castro-aragon purpose or case report: the morbidity and mortality of sickle cell disease (scd) results from acute and chronic infarction events that affect almost every organ. repeated infarction has some of its greatest visual and physiologic impact within the spleen. continuous hemolysis, sequestration and vaso-occlusion within the spleen result in loss of splenic function early in life and frequently autosplenectomy thereafter. by years of age, approximately % of children with hemoglobin ss disease will have diminished splenic function, putting them at increased risk for infections. treatments for scd have evolved over the last years, and among others include penicillin prophylaxis and immunizations, hydroxyurea and transfusion therapy (or hypertransfusion program). imaging findings are a reflection of the different treatments and their efficacy. methods & materials: our institution cares for a large group of patients with sickle cell disease, from birth to adulthood. this offers an unprecedented opportunity to document the imaging findings of the spleen with different treatment regimens, and over many years. the splenic size and morphology can be followed, by ultrasound, in a very straightforward way. we have compiled a pictorial essay of the various imaging characteristics of spleens from infants to adults. we also performed a literature review to compare and supplement the findings of our images. results: there is a spectrum of imaging findings in the spleen of patients with scd that changes from birth to childhood. the findings range from the normal appearance of a spleen to a calcified spleen, and include regenerative nodules, fibrosis, altered parenchymal echotexture, increased echogenicity, and changes in size, including enlargement secondary to sequestration. the ultrasound characteristics not only change with advancing age, but also appear to depend on whether or not the patient has received specific treatments, and at what age treatment was initiated. conclusions: the ultrasound appearance of the spleen in patients with scd is variable. treatments such as blood transfusions and hydroxyurea, patient compliance with therapy and type and severity of the disease are some of the factors that affect imaging characteristics. cystic fibrosis: not just for children cindy miller, md, radiology, yale-new haven hospital, cindy.miller@yale.edu purpose or case report: cystic fibrosis has been recognized for hundreds of years with the first descriptions of it including such anecdotes as mothers licking the foreheads of their children and knowing that if it tasted salty, an early death could be predicted. it was not until that the disease was first named by dr. dorothy andersen, and for the following years, treatment was largely supportive, and imaging was essentially done with plain films alone. in with the elucidation of the cftr gene, there was an explosion of knowledge which included the range of increased awareness and understanding of the suspected etiology, imaging findings and significance of the ductus bump. the contribution of d imaging for evaluation of the pediatric central airways jessica kurian, md, the children's hospital of philadelphia, kurianj@email.chop.edu; monica epelman, david a. mong purpose or case report: evaluation of the central airways in children has historically been accomplished by flexible bronchoscopy, an invasive technique associated with inherent risks and complications. multidetector ct (mdct) with volume rendering offers a noninvasive alternative for airway evaluation. in this educational exhibit, we will review imaging techniques and clinical applications of mdct for the assessment of large airway maladies in children. methods & materials: mdct imaging in children with a variety of tracheobronchial disorders is reviewed. for each entity, the characteristic clinical features are described, and key imaging features are illustrated. emphasis is placed on the contribution of d techniques for characterizing complex airway anomalies. dose reduction strategies are also highlighted. results: the entities reviewed in this exhibit include, but are not limited to, congenital anomalies of tracheobronchial branching, airway malformations associated with situs, and congenital or acquired airway compression and/or obstruction. conclusions: mdct with volume visualization is a useful adjunct for evaluation of the pediatric central airways in a variety of pathologies. as a noninvasive technique, it avoids sedation risks and spare patients from complications associated with conventional flexible bronchoscopy. low dose protocols should be used to minimize radiation exposure. bronchopulmonary foregut malformation that result from abnormal budding of the primitive foregut. currently, many such anomalies are initially detected by prenatal ultrasound and are further delineated by fetal magnetic resonance imaging (mri), while others may be incidentally detected on postnatal radiologic examinations or later in life in the setting recurrent pulmonary infection. imaging plays a very important role in the diagnosis and characterization of these lesions and assists surgical planning. the purpose of our educational exhibit is to illustrate the common and uncommon radiologic appearances of cpams using various imaging modalities, including radiography, computed tomography, prenatal and postnatal ultrasound, and prenatal and postnatal mri. methods & materials: all pediatric and adult cpam (including both sequestration and ccam) patients were identified using electronic medical records. pertinent imaging reports (including radiography, prenatal and postnatal ultrasound, ct, and prenatal and postnatal mri) were reviewed by a single author in order to identify relevant imaging findings. relevant images from these imaging examinations were de-identified and saved to a secure hard drive. medical records were accessed by a single researcher to obtain relevant demographic information as well as data regarding the patients' clinical presentations. in cases of corrective surgery, operative and pathology reports were reviewed, if available, for correlation with the imaging findings. results: cases of pediatric and adult cpam were identified and presented in a variety of clinical contexts. their appearances were reviewed through multiple imaging modalities. conclusions: congenital pulmonary airway malformations are varied in their clinical presentation and imaging appearance. the purpose of this pictorial essay is to enhance understanding of their diagnosis and to use a multidisciplinary approach in order to highlight imaging aspects that may alter clinical management. disclosure: dr. horst has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. the imaging evaluation of cystic lung disease in children: an evidence-based approach jordan caplan, md, pediatric radiology, lucile packard children's hospital, stanford university, caplan@stanford. edu; beverley newman purpose or case report: the goal of the poster is to provide a framework for use when confronted with cystic lung disease in a child. methods & materials: the differential diagnosis for the types and causes of cystic lung disease in children will be presented using an evidence-based, age appropriate approach. categories of disease discussed and illustrated with case examples will include: a. congenital cystic bronchopulmonary malformations b. infectious cysts c. autoimmune/inflammatory/vasculitic disease with cavitating lesions d. neoplastic conditions e. collagen/soft tissue abnormalities f. mimics of cystic lung disease results: the pathophysiology, imaging appearance, and demographics of the above entities will be reviewed with attention to relevant recent literature. important educational points include the differentiation of bronchopulmonary malformations from neoplasm, notably pleuropulmonary blastoma (ppb), the relationship between lung cysts and ppb, and the management and surveillance of lung cysts in children. conclusions: an evidence-based approach to the broad spectrum of causes of cystic lung disease in children is a useful starting point in forming a concise and pertinent differential diagnosis. an understanding of the pathophysiology, imaging appearance, and demographics of these entities is essential in guiding patient management. pediatric interstitial lung disease (ild): a pictorial review with radiologic and pathologic correlation hollie west, md, diagnostic radiology, vanderbilt university, hollie.c.west@vanderbilt.edu; melissa a. hilmes, sudha p. singh, jennifer soares, lisa young purpose or case report: while adult interstitial lung disease is a well-described and fairly well understood group of disease processes, pediatric interstitial lung disease (ild) remains a subject of uncertainty and misunderstanding for many clinicians and radiologists. confusion surrounding the phenomenon of pediatric ild stems not only from the rarity of the disease, but also from the extensive list of disease entities that can produce ild, the existence of certain patterns that are restricted to infants and children and the fact that patterns of ild manifest differently in a child's developing lung than in an already developed adult lung. imaging plays an important role in diagnostic work-up of this disease and can guide lung biopsy in specific patient populations. methods & materials: the irb approved retrospective study will show patients at our institution over a year period diagnosed with various types of ild, including pulmonary insterstitial glycogenolysis (pig), diffuse neuroendocrine cell hyperplasia (nehi), surfactant deficiency diseases, and lung diseases associated with other systemic processes such as downs syndrome and inflammatory bowel disease. we will include patients with biopsy proven ild and will provide examples of the major ilds, including clinical, radiologic and pathologic correlation. our pictorial review will describe the radiologic patterns associated with the different forms of ild, emphasizing what the radiologist needs to know and how to be helpful to a multidisciplinary team in the diagnosis and treatment of these diseases. results: the study will report the frequency of ild at our institution, including a breakdown of the various subtypes of ild. we will show examples of the subtypes with correlative chest radiography, computed tomography, and pathology. we plan to highlight specific differentiating factors between the different diseases and demonstrate how a radiologist can be helpful in collborating with clinicians in diagnosing and treating these diseases. conclusions: pediatric ild can be a confusing topic for radiologists. increasing knowledge and awareness of these diseases, their clinincal presentation, work up, and treatment is important for pediatric radiologists who work as part of of a multidiciplinary team. poster #: sci- ct radiation dose delivered by community hospitals and imaging centers stephen little, children's healthcare of atlanta, stephen. little@choa.org; damien grattan-smith, bonnie johnson purpose or case report: to evaluate and compare ct radiation dose for pediatric abdominal and cranial ct examinations performed by community hospitals and imaging centers. methods & materials: consecutive ct examinations ( cranial, abdominal) from community hospitals and imaging centers were reviewed following transfer of care. the examinations were performed between january and july . consecutive ct examinations ( cranial, abdominal) performed at our own institution were also reviewed. ctdivol and dlp were obtained from the dose report for each examination ( cm-phantom for abdominal exams, cm-phantom for cranial exams). patient age and weight were obtained from the medical record. results: average ctdivol for abdominal ct performed by local community hospitals and imaging centers was . mgy, while average ctdivol was . mgy for abdominal ct performed at choa. there was a wide variation in ct radiation dose delivered. while some sites delivered a ct radiation dose comparable to our own, others delivered a substantially greater dose. in fact, % of pediatric abdominal ct exams performed by local community hospitals and imaging centers exceeded the notification value recommended by the aapm ( mgy using the cm phantom). low kvp technique for imaging small children was infrequent. multi-phase examinations were more often performed, resulting in additional elevation in ct radiation dose when dlp is considered. average ctdivol delivered by local community hospitals and imaging centers for cranial ct was mgy compared to a ctdivol of mgy for cranial ct performed at choa. % of pediatric cranial ct exams performed by local community hospitals and imaging centers exceeded the notification value recommended by the aapm ( mgy for - years, mgy for > years). conclusions: despite ongoing efforts at education, there is wide variation in ct radiation dose delivered for pediatric abdominal and cranial ct examinations performed by local community hospitals and imaging centers. appropriate use of dose check software on newer scanners may help reduce the number of children subjected to excessive ct radiation dose. ultimately, each site performing pediatric ct must take responsibility for minimizing radiation dose while producing diagnostic quality exams. the impact of adaptive statistical iterative reconstruction on ct image quality parameters -a phantom study karen thomas, md, radiology, hospital for sick children, karen.thomas@sickkids.ca; nancy ford, angjelina protik, paul babyn purpose or case report: to quantify the effect of adaptive statistical iterative reconstruction (asir) on ct image quality parameters. methods & materials: phantom (catphan ) studies were performed on a ge hd -slice scanner to investigate the impact of a) % asir compared to routine filtered back projection using variable kvp ( - ) and mas ( - ), and b) incremental asir % ( , , , , %), scanning at mas and variable kvp ( - ). pitch, acquisition fov and detector width were kept constant. image noise, spatial and contrast resolution, contrast noise ratio (cnr) and wiener spectrum analysis were performed on . mm ax, mm ax mpr and mm cor mpr series. results: % asir resulted in a mean decrease in noise of % ( . mm ax), % (ax mpr) and % (cor mpr) and improvement in cnr of - %. incremental advantage was seen with stepwise increase in asir %. however, application of asir was associated with a small reduction in spatial resolution ( - % at % asir). low contrast detectability (lcd) improved except at the smallest target lesion size. image quality effects at very low mas and at high asir % will be presented. conclusions: image noise reduction and improvements in cnr and lcd with asir hold considerable potential for dose reduction in pediatric ct. this study provides quantitative data that may be used to design asir-enhanced protocols with consideration of diagnostic task, balancing image quality benefits and potential pitfalls. pictorial essay on cardiac mr for congenital heart disease on t mr scanner with rf multi-transmit technology (tx) taylor chung, md, diagnostic imaging, children's hospital & research center oakland, taylorchung @gmail.com purpose or case report: this is a pictorial essay (e-poster) to show artifacts on cine ssfp images pre-tx and post-tx upgrade on congenital heart disease cardiac mr; to illustrate methods prior to tx-upgrade to minimize artifacts. disclosure: dr. chung has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. revisiting the relationship between anthropometric parameters and left ventricular mass abdullahi adamu, md, phd, ahmadu bello university, scorpion kd@yahoo.com purpose or case report: the purpose of this study was to find the correlation between anthropometric parameters and left ventricular mass in normal adolescents and young adults. methods & materials: healthy individuals in the age range to years ( males and females) were included in this study. anthropometry was performed with standard anthropometry kit and measurements of height, weight, body surface area (bsa), upper arm circumference and upper hip circumference were taken. echocardiography was performed and the american society of echocardiography (ase)-recommended method was employed for calculation of left ventricular mass (lvm). statistical analysis was performed using statistica . (stat soft, usa). results: the mean value of lvm for all our subjects was found to be . ± . g. there was significant correlation between lvm and height (r . , p< . ), weight (r . , p< . ) and bsa (r . , p< . ). correlation with upper arm circumference was moderate (r . , p< . ), while it was found to be weak with upper hip circumference (r . , p< . ). diagnostic. both field strengths can be used successfully for cardiac and vascular imaging. the decision as to which to use is weighted by local availability and the relative requirement for detailed vascular vs intra-cardiac imaging. disclosure: dr. nguyen has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. poster #: sci- color coded d cardiac cta of congenital heart disease: a five year experience nhi huynh, md, radiology, st. joseph hospital and medical center, e.nhihuynh@gmail.com; randy richardson purpose or case report: post-processing of cardiac computed tomography angiograms can be performed on a commercially available workstation to create color coded d volume rendered images of the segmented heart and great vessel anatomy in patients with congenital heart disease. these studies optimally demonstrate complex anatomy, streamlining communication between members of the healthcare team and providing a tool for communicating complex anatomy and treatment options with families. these studies have been ordered with more frequency over the past five years. we retrospectively reviewed the types of congenital heart disease demonstrated by cardiac d cta over the past five years at a congenital heart center. methods & materials: color coded cardiac cta postprocessing was performed from ecg gated prospective and retrospective cta data on a commercially available workstation for / patients over the past three years. the anatomy was initially segmented and colored into individual parts of the anatomy of the heart and great vessels as follows rv purple, lv light red, aorta red, pulmonary arteries blue, systemic veins and right atrium aqua, pulmonary veins and left atrium pink, pda or collaterals green, airway yellow, coronary arteries neutral. the anatomy was then reassembled and images obtained every °in a °rotation for display. results: d color coded cta images were used in the treatment and care of congenital heart patients for the following types of congenital heart diseases: cases of complex anatomy (tga, truncus arteriosus, hlhs, tricuspid atresia, tof…), coronary artery anomalies, cases of pulmonary atresia or stenosis, cases of systemic and venous anomalies, cases of coarctation or interruption of the aortic arch, and tracheobronchial tree anomalies. conclusions: color coded cardiac cta post-processing is an effective and viable method for demonstrating anatomy in complex congenital heart patients. it is an excellent tool for demonstrating anatomy which is difficult to see by echocardiography such as: coronary artery anomalies, pulmonic atresia, aortic arch coarctation or interruption, and tracheobronchial anomalies and/or stenosis. neuroimaging in the evaluation of hie in term neonates post hypothermia therapy julio m. araque, md, radiology, medical college of georgia, jaraque@georgiahealth.edu; jatinder bhatia, leann vanlandingham purpose or case report: to illustrate and review the potential utility of brain mri, ct and ultrasound in hypoxic ischemic encephalopathy in newborns treated with hypothermia. neuroimaging studies including brain ultrasound, ct and mri of fifteen term newborns treated in our institution with therapeutic hypothermia, since april were evaluated retrospectively. more relevant lesions are depicted and the diagnostic and prognostic value of the findings is discussed and compared with a review of the literature. results: recent studies showed that patients treated with cooling had a more favorable prognosis than was suggested by the clinical grade of encephalopathy compared with infants treated with standard care. our institutional protocol includes the performance of mri, and ultrasound. ct is performed when is a clinical impossibility of perform mri. brain ultrasound was performed in all the patients. mri scans were obtained in neonates. ct was obtained in patients. all mri studies included dwi. the utility of dwi and adc maps as an aid in diagnosis of non-ischemic lesions is becoming increasingly established. mri evidence of brain injury was visible on basal ganglia in cases with negative ultrasound. abnormal signal intensity in the posterior limb of the internal capsule coexists with lesions in the basal ganglia and thalami have been associated with abnormal motor outcome. the remaining newborns did not develop significant mri evidence of brain injury. it has been suggested that the ability of mri to predict subsequent neurological impairment is unaltered by therapeutic hypothermia. further research is needed for defining the relation between mri findings and cooling. it is possible that imaging findings might be delayed in cooled infants. conclusions: mri offers the highest sensitivity in detecting anoxic injury of the neonatal brain. mr biomarkers in combination with clinical markers may identify patients with adverse outcome with therapeutic implications. disclosure: dr. araque has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: to correlate bowel wall diffusionweighted imaging (dwi) apparent diffusion coefficient (adc) values with multiple mr enterography (mre) and clinical findings in pediatric small bowel crohn disease. methods & materials: pediatric crohn disease patients with mre exams containing diffusion-weighted imaging and demonstrating terminal ileitis were identified. minimum bowel wall adc values were tested for correlation/association with other mri findings and clinical parameters (including laboratory values). results: there is negative correlation between adc value and degree of bowel wall thickening (r (−) . ; p . ). lower adc values were significantly associated with striated pattern of arterial phase postcontrast enhancement (p . ), greater degree of arterial phase postcontrast enhancement (p . ), and presence of stricture (p . ). adc values were not associated with diseased bowel length, degree/pattern of delayed postcontrast enhancement, degree of mesenteric inflammation or fibrofatty proliferation, or clinical markers of inflammation. conclusions: restricted diffusion in pediatric small bowel crohn disease is associated with other mri findings of that are suggestive of active disease, including degree of bowel wall thickening and degree and pattern of arterial phase postcontrast enhancement. our data also suggests that dwi may be useful when attempting to characterize small bowel strictures as either predominantly inflammatory or fibrotic, although further investigation is needed. quantification of blood flow into and out of the liver with d phase contrast mri in the pediatric patient binh huynh, md, radiology, stanford, bhuynh@stanford. edu; shreyas vasanawala, albert hsiao purpose or case report: the ability to probe blood flow dynamics in the liver may aid management of children with liver disease, including shunt fractions in portal hypertension and arterial flow fraction in diffuse liver disease. the purpose of this study is to evaluate the ability to measure blood flow into and out of the liver with time resolved volumetric ( d) phase contrast mri in the pediatric patient. methods & materials: nineteen consecutive patients were retrospectively identified who underwent d flow imaging through the level of the hepatic vessels on . t and t magnets. a software enabling d flow program was utilized to first assess for the feasibility of measurement of flow in the hepatic artery (ha), portal vein (pv), splenic vein (spv), superior mesenteric vein (smv), supra (sivc) and infrahepatic (iivc) inferior vena cava. if measurable, calculations were performed to evaluate for internal consistency by comparing the sum of smv and spv flow to pv flow. calculations were then performed to compare hepatic inflow (pv+ha) to hepatic outflow (sivc-iivc) and for the percentage of pv and ha contribution to hepatic inflow. results: of the nineteen patients, all of the above mentioned six vessels were visualized and measurable in two patients, both of which were imaged on the . t magnet. in the remaining patients, flow measurements were limited by respiratory motion artifacts obscuring the smaller vessels, and severe eddy currents, particularly in patients imaged with the t magnet. the evaluation for internal consistency demonstrated an average of . % ( . % & - . %) difference between smv+spv and pv flow. hepatic inflow was found to closely match the measured hepatic outflow with an average difference of . % ( . % & . %). the portal vein was found to contribute . % and . % to hepatic inflow, while the hepatic artery contributed . % and . %. conclusions: measurement of hepatic flow with phase contrast mri is more challenging than assessment of thoracic flow. when respiratory artifacts are minimal, vessels can be identified and measurements have internal consistency and good agreement between hepatic inflow and outflow at . t. conversely, flow measurements were limited at t by eddy currents. thus, ongoing efforts are aimed at mitigating respiratory motion artifacts at . t. poster #: sci- mri findings in post-fontan hepatopathy adina alazraki, md, radiology, emory university/children's healthcare of atlanta, adina.alazraki@choa.org; pinar bulut, kiery braithwaite, miriam vos, rene romero, nitika a. gupta purpose or case report: as advances in congenital heart disease continue to improve both mortality and quality of life, associated complications are becoming more prevalent. amongst patients who have had fontan repair for hypoplastic left heart syndrome, tricuspic atresia, or other right heart dysfunction, it is well known that liver disease is a complication. we describe the mri findings in post-fontan patients and propose mri as a useful tool to the hepatologist's evaluation of these patients. methods & materials: irb approval was obtained for a retrospective review of patients who underwent fontan repair and were subsequently referred for hepatology evaluation between - . all but one patient was scanned on a siemenstriotrim t magnet; one patient was scanned on a ge twinspeed . t magnet with an equivalent protocol due to orthodontics. a standardized departmental protocol was utilized. mri findings were correlated with age at surgery and years since surgery. mr images were reviewed independently by pediatric radiologists and compared with the dictated report in the patients record. results: patients underwent mri of the abdomen. patients had mri incompatible hardware and patients were not scanned secondary to insurance denial. patients were divided into groups based on elapsed time since surgery: less than years, - years, - years, and greater than years.(table ) mr images were evaluated for the presence of fibrosis, congestion and any other hepatic abnormalities. fibrosis was determined based on a specific pattern of delayed reticular enhancement in combination with liver morphology. congestion was deemed present if there was increased t signal in the liver parenchyma or periportal regions in combination with cloud-like enhancement on dynamic post-contrast images. all patients demonstrated morphologic changes in the liver with varying degrees of hepatic fibrosis and hepatic congestion. fibrotic changes were often non-uniform, and thus could be underdiagnosed by biopsy. interestingly, patients, %, had focal arterially enhancing lesions speculated to represent vascular proliferative lesions, however, none warranted biopsy. conclusions: it is established that patients who undergo fontan develop hepatic abnormalities. mri is a reliable, non invasive technique that accurately demonstrates these findings. mri may be a more sensitive method to evaluate the etiology and full extent of hepatic disease. poster #: sci- complications within the interventional radiology division of a tertiary care children's hospital: initiatives for ongoing quality and practice improvement brian dillon, children's hospital boston, brian. dillon@childrens.harvard.edu; pamela sanborn, yolanda milliman-richard, darren orbach, stephan voss purpose or case report: between and , procedure-related complications occurring within the division of interventional radiology at our institution were recorded and classified according to level of severity. the goals of this study were to determine rates of procedurebased complications based on severity, to establish thresholds for complications, and to determine whether measurable trends in complications over time were evident. methods & materials: between and , , interventional procedures were performed within the division of interventional radiology at our institution. adverse events were characterized both according to level of severity (using an institutional point severity scale), and with brief descriptions of individual events. adverse events were reviewed monthly at the division's morbidity and mortality conference, with respect to procedure type and operator. based on review of our interventional radiology data and benchmarks rates used for diagnostic errors, threshold complication rates were established by consensus between the department quality improvement committee and the division of interventional radiology. for severe events (level and ) there is no allowable threshold; all such events were subjected to both internal and institutional review. results: the overall complication rate was less than % for all procedures performed. the complication rates for the respective severity levels were: level ( . ), level ( . ), level ( . ), level ( . ), and level ( . ). the severity of a given complication was not associated with procedural complexity. no operator-specific trends were identified. conclusions: since , the society of interventional radiology has offered guidelines and strategies for improving safety and quality in interventional radiology. however, no specific benchmark data or procedural recommendations are available for pediatric interventional procedures. our results demonstrate rates of complications well below published overall complication rates for interventional radiologic procedures. this database of procedure-based complications serves as a foundation for a quality improvement program that allows review of complications with respect to specific procedure types, individual operators, and procedural complexity, in an effort to institute an ongoing and continuous process of quality improvement within interventional radiology. purpose or case report: dysosteosclerosis (dss), an extremely rare dense bone disease, features short stature and fractures and sometimes optic atrophy, cranial nerve palsy, developmental delay, and failure of tooth eruption in infancy or early childhood consistent with osteopetrosis (opt). bone histology during childhood shows unresorbed primary spongiosa from deficient osteoclast action. additionally, there is remarkable progressive flattening of all vertebrae mimic ppi blocking mineralization. during ehdp treatment for gaci, in our patient prolonged high dose ehdp resulted in severe skeletal deformity resembling hypophosphatasia which was reversable with drug stoppage. methods & materials: a -year-old boy with gaci referred for profound, acquired, progressive skeletal deformity. he was receiving mg/day of ehdp and was wheelchair bound. we studied him and his response to stopping ehdp. results: skeletal radiographic findings resembled pediatric hypophosphatasia with pancranial synostosis, widened physes with metaphyseal osteosclerosis, "tongues" of radiolucency, along with cupping and fraying, and long-bone bowing. in addition there were large intra and extraarticular calcifications. radiographic features of bp-induced opt included femoral erlenmeyer flask deformity and osteosclerosis (lumbar sine dxa z-score + . ). biochemical parameters of mineral homeostasis were essentially normal although serum osteocalcin was low and he had markedly elevated serum levels of creatine kinase and trap- b consistent with osteopetrosis (opt). after stopping ehdp, he improved quickly with remarkable healing of his rachitic appearing skeleton and decreased joint calcifications. conclusions: our patient with gaci had profound skeletal deformities from high-dose ehdp therapy that significatly improved with drug stoppage. magnetic resonance imaging in the evaluation of infants with hypoxic ischemic encephalopathy julio m. araque, md, radiology, medical college of georgia, jaraque@georgiahealth.edu purpose or case report: to illustrate and review a spectrum of brain abnormalities of infants with hie. defining the most useful approaches and mri sequences, to facilitate identification and early diagnosis of lesions with the potential to predict outcome and abnormal neurodevelopment. methods & materials: reviewed available evidence on mri strategies for evaluating infants with hypoxic ischemic encephalopathy. different cases illustrating lesions are presented and discussed for proper diagnosis correlating physiopathology and imaging appearance. more relevant findings are depicted with didactic illustrations. identifying studies where new techniques such as dwi, adc, dti, swi, or mrs adds significant diagnostic value to the overall interpretation. results: mri is routinely performed as a very sensitive method for detection of hie lesions. advanced mr techniques, such as dti, dwi, adc, mrs, swi offer the possibility of detecting injuries at a time when intervention is theoretically possible. the understanding of the physiopathology allows for prediction of the location and extent of lesions, facilitating identification and appropriate classification. the identification of infants with potentially abnormal neurodevelopment, offers the opportunity to provide therapeutic neurodevelopmental interventions in early childhood. mrs is the best mr biomarker to predict neurodevelopmental outcome in asphyxiated full-term neonates. brain metabolite ratios and regional adc values may vary between mr systems and coils. development of normal values for each institution is required, and support of physicists is mandatory. conclusions: mri continues to evolve as a valuable adjunctive tool routinely obtained in nearly all cases of hie. advanced mri techniques increase sensitivity of conventional t and t -w images and outperform computer tomography and ultrasound for confirming the diagnosis of hypoxic-ischemic brain injury or providing prognostic information for the care of patient with hie. disclosure: dr. araque has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. posterior fossa abnormalities in children amit gupta, mbbs, radiodiagnosis, r.n.t. medical college, udaipur, rajasthan, india, amitsensation@yahoo.co.in purpose or case report: the aim of this exhibit is to demonstrate various conditions involving the posterior fossa in children with emphasis on importance of embryologic development of cerebellum in reaching a correct diagnosis. methods & materials: this pictographic presentation displays the imaging features of cases encountered in our clinical practice on . tesla magnetic resonance (mr) imaging. results: with the advent of mr imaging, there has been a revolution in identification and characterization of malformations of the brain this is especially true in posterior fossa, where the sensitivity and specificity of mr imaging with its multidimensional imaging capability are far superior to those of computed tomography (ct) in the detection of subtle morphologic abnormalities. however, there is still a great deal of confusion regarding their classification, terminology, and spectrum of expression and this is where neuroembryology is of great help. this exhibit demonstrates : ) review of embryology and normal anatomy of cerebellum. ) mr appearance of spectrum of conditions involving posterior fossa in children which includes developmental abnormalities (dandy-walker complex, arnold chiari malformations, cerebellar dysplasia/ hypoplasia, joubert's syndrome, etc.), cysts (arachnoid cyst, giant cisterna magna etc.), tumours (medulloblastoma, ependymoma, hemangioblastoma etc.) and miscellaneous conditions. significantly reduces dose ( / of other gadolinium based contrast agents), and doesn't require trigger imaging. conventional mri provides important information regarding the anatomical extent, size, and relation to critical anatomical structures thus when combined with twist, mri provides the best information without use of radiation in children. functional connectivity mri in pediatric brain tumor patients with and without epilepsy andrew v. poliakov, phd, radiology, seattle children's hospital; david bauer, edward novotny, seth d. friedman, dennis shaw, jeff ojemann purpose or case report: functional connectivity mri (fcmri) is a way to evaluate cortical networks across different modalities such as motor, sensory, vision, and the default mode network using functional magnetic resonance imaging. fcmri relies on correlation in fmri image intensity that occurs between functionally connected regions. this effect can be seen in awake as well as anesthetized patients. we evaluated these pathways in pediatric patients with brain tumors. methods & materials: patients were randomly selected from our tumor database. inclusion criteria included age less than , history of brain tumor resection, and complete fcmri data. imaging was performed on a t siemens trio system. functional mri data were acquired as part of a clinical imaging protocol over . - min using a gradient echo, echo-planar sequence. preprocessing of fmri data followed by independent component analysis (ica) was performed using fsl software. functional connectivity analysis was performed using software provided by functional connectomes project, based on afni and fsl software packages. correlation maps were produced by extracting the bold time course from a seed region, computing the correlation coefficient between that time course and the time course from all other brain voxels, correcting for multiple sampling and degrees of freedom and thresholded at a z value of . . results: fourteen patients were included in the study, eight female and six male. tumor types include ganglioglioma ( ), pleomorphic xanthoastrocytoma ( ), juvenile pilocytic astrocytoma ( ), ependymoma ( ), anaplastic astrocytoma ( ), glioblastoma multiforme ( ), and primitive neuroectodermal tumor ( ). seven patients had tumor-associated epilepsy, and seven patients did not. the figure shows connectivity patterns in the motor network in patients without (a) and with (b) epilepsy. in the patients without epilepsy, functional connectivity was often displaced but not decreased or absent. in the patients with epilepsy, we observed decreased or absent functional connectivity. similar results were found for default mode network: connectivity was diminished or absent in the patients affected by epilepsy. conclusions: fcmri is a novel technique that may prove useful for evaluation and presurgical planning by giving us insight into how tumors disrupt function. functional connectivity was often displaced but relatively preserved in the patients without epilepsy. it was disrupted or absent in the patients with epilepsy. poster #: sci- corpus callosum dti measurements in neurofibromatosis type and normal controls nadja kadom, md, radiology, children's national medical center, nkadom@childrensnational.org; amir noor, rhea udyavar, marine bouyssi-kobar, iordanis evangelou, maria t. acosta purpose or case report: many patients with neurofibromatosis type (nf ) have corpus callosum enlargement; pathogenesis and underlying pathophysiology are unclear. the goal of our study is to investigate the pathophysiological basis of corpus callosum enlargement in nf patients through mri diffusion tensor (dti) measurements. methods & materials: retrospective study, irb approved. patients consecutively selected from institutional data base; inclusion criteria: established diagnosis of nf , brain imaging with dti sequence, abnormally high corpus callosum to skull ratio; excluded were patients with complications of nf that could affect size of the corpus callosum. age and gender matched normal controls were randomly selected from the radiology data base. roi were placed manually over the corpus callosum for dti measurements using dti-studio by two independent researchers, one blinded to diagnosis. results: fifteen nf patients and matched controls were analyzed. the corpus callosum to skull ratio was found to be significantly different between the experimental and control group (p . ). for nf patients we found: a trend to lower apparent diffusion coefficient (adc, p . ), significantly higher radial diffusivity (p . ), significantly lower axial diffusivity (p . ), and significantly lower fractional anisotropy (fa, p . ). conclusions: the significantly lower axial diffusivity in nf can indicate that there are more crossing fibers in the corpus callosum of nf patients than in normal controls. further studies using comparative dti tractography may be helpful in further investigating this stipulation. the significant increase in radial diffusivity can be explained by a variety of factors, including thinner myelin sheaths, increased interstitial fluid, smaller axons, or a combination thereof. the trend of lower adc may indicate low axonal diameter, as adc has been shown to more strongly correlate with axonal diameter without the myelin sheath. in future studies we will correlate abnormal corpus callosum dti markers with cognitive functions in nf patients to see if relationships exist that can be used as predictors of cognitive deficits in nf patients. screening for vitamin d deficiency in children with suspected non-accidental fracture conor kain, md, tripler army medical center; veronica rooks, laura keller, jordan pinsker, allyson cordoni, sarah frioux purpose or case report: determine if routine screening of vitamin d levels after suspected non-accidental fracture detects vitamin d deficiency and changes clinical outcomes. methods & materials: after irb approval we reviewed all skeletal surveys performed at tripler army medical center (tamc) in the last years and selected the children who were evaluated for suspected non-accidental fracture. we determined if -hydroxyvitamin d [ (oh)d] level was requested for these patients and characterized the provider's clinical suspicion of vitamin d deficiency as high or low. per the institute of medicine report and endocrine society guidelines we defined vitamin d deficiency as a (oh)d level of less than ng/ml. we calculated the prevalence of children with low (oh)d levels whose providers had low clinical suspicion for vitamin d deficiency. results: skeletal surveys were done at tamc from november to july . were performed after identifying a suspected non-accidental fracture. of these patients children from ages to months had (oh)d levels requested. for children whose providers had a low pre-test suspicion for vitamin d deficiency, the prevalence of vitamin d deficiency was . % ( % binomial ci . - . , of cases. these results indicate that at least one out of every three hundred children evaluated for nonaccidental fracture could have vitamin d deficiency despite a low clinical suspicion by their provider, although the actual rate is likely much higher given that we found one in eight cases. the child we identified with a low vitamin d level whose provider had no suspicion for rickets was treated with ergocalciferol and continued to be evaluated for abuse. conclusions: routine vitamin d level screening after nonaccidental fracture may detect vitamin d deficiency in children for whom there is low clinical suspicion. as our population resides at a low latitude and receives greater than average sun exposure, the rate of deficiency in children with suspected non-accidental fracture may be much greater in other areas. comet tails and dirty shadows: the secrets behind artifacts in pediatric ultrasound adam edelstein, pediatric radiology, massachusetts general hospital; anuradha shenoy-bhangle, katherine nimkin purpose or case report: to review common ultrasonographic artifacts, explain what causes them, and show how they can be used to aid in diagnosis in a variety of pediatric conditions, including less common entities. methods & materials: ultrasonographic images in patients less than years of age were reviewed. cases were selected that showed classic artifacts which helped with the diagnosis of a variety of entities. results: ultrasound artifacts include comet tail, reverberation, ring down and "dirty" shadowing. these can be used to help characterize a variety of pediatric conditions including gossypiboma, bezoar, subcutaneous foreign body, complications of nec, and staghorn calculus. artifacts can also be used to confirm the presence of stool or bowel gas. conclusions: familiarity with ultrasonographic artifacts is critical for tissue characterization and can help narrow the differential diagnosis in difficult pediatric cases. cardiac cta: non-vascular ring tracheobronchial compression secondary to enlarged patent ductus arteriosus in infants with congenital heart disease. nhi huynh, md, radiology, st. joseph hospital and medical center, e.nhihuynh@gmail.com; todd chapman, randy richardson purpose or case report: tracheobronchial compression or narrowing secondary to a vascular ring has been well documented. the purpose of this study is to describe the frequency of airway compression secondary to an enlarged patent ductus arteriosus detected by ccta without the presence of a vascular ring. methods & materials: a retrospective study of ccta exams in infants was performed over the period between / / and / / . ccta was performed with a -slice mdct, with ekg gating, followed by three-dimensional reformations. results: of the congenital heart disease infant patients, there are patients with tracheobronchial compression or narrowing. of these patients, patients reported to have patent ductus arteriosus as the primary cause of tracheobronchial compression or narrowing. approximately % of patients with airway compression in patients with congenital heart disease are secondary to an enlarged and/or tortuous patent ductus arteriosus. none of these cases were due to a vascular ring. of these patients, , , and patients demonstrated to have mild, moderate, and severe airway compression respectively. conclusions: tracheobronchial compression or narrowing secondary to vascular ring with a patent ductus arteriosus has been well documented. in this study, we demonstrate that a significant percentage of airway compression in patients with congenital heart disease without a vascular ring is due to a tortuous enlarged patent ductus arteriosus. cardiac cta is uniquely equipped to evaluate airway compression due to an enlarged patent ductus arteriosus and can help improve patient care in congenital heart disease patients with respiratory symptomatology. pediatric liver mr elastography: a primer suraj serai, phd, cchmc, suraj.serai@cchmc.org; daniel j. podberesky, alexander j. towbin purpose or case report: a wide variety of pediatric liver disorders may be complicated by the development of liver fibrosis and ultimately cirrhosis. with early interventions, the progression to hepatic fibrosis can be slowed, halted, and in some cases reversed. liver biopsy has long been considered the gold standard for assessing the presence and degree of liver fibrosis. however, liver biopsy has disadvantages, due to its potential sampling error, risk of complications, relatively high cost, intra-and inter-observer variability, and, in general, poor acceptance by pediatric patients and their parents. mr elastography (mre) is a relatively new, non-invasive technique that provides a safe, rapid and cost-effective method for objectively evaluating of a wide variety of hepatic diseases by quantitative stiffness evaluation of the liver-parenchyma. the purpose of this exhibit is to review our clinical experience with this technique and illustrate the application of liver mre in the pediatric population at our medical center. methods & materials: a review of pathogenesis and staging of liver fibrosis in children and current methods available for assessing liver fibrosis will be provided. a review of mre physics and technique, including the specific liver mre protocol used at our institution will be illustrated. we will review widely-used and emerging clinical indications for liver mre, as well as benefits and limitations to the technique, supported by brief literature review. results: in addition to sharing our liver mre technique, we will illustrate clinical case examples from our institution of a variety of liver disorders including non-alcoholic fatty liver disease, non-alcoholic steatohepatitis, storage disorders, cardiac disease, and idiopathic elevated liver enzymes. conclusions: this educational exhibit will review our experience with liver mre, a safe, newly available technique which will play an increasingly important role in the noninvasive evaluation of pediatric liver disease. poster #: sci- spectrum of tuberculosis in children amit gupta, mbbs, radiodiagnosis, r.n.t. medical college, udaipur, rajasthan, india, amitsensation@yahoo.co.in purpose or case report: the aim of this exhibit is to present a spectrum of tuberculosis (tb) in the human body which commonly involves pulmonary, nervous, musculoskeletal, gastrointestinal and genitourinary systems. this pictographic presentation displays the imaging features of tb cases encountered in our clinical practice with reference to plain x-rays, ct and mri as appropriate. results: with the advent of the newer modalities, the utility of the plain skaigram has been largely limited a initial screening tool only. whereas ct scores over mri in pulmonary tb (parenchymal disease, lymphadenopathy, pleural effusion, empyema, miliary disease) and abdominal tb (spectrum from mesenteric lymphadenitis to visceral involvement), the magnetic resonance (mr) imaging is much better in diagnosing cns tb (tuberculoma, abscess, meningitis, subdural empyema and myelitis). in musculoskeletal and genitourinary tb, ct and mr imaging may be preferred based on the stage of disease and the character of the lesion. cardiac involvement (pericarditis) is among the less common affections of tb. conclusions: tuberculosis is a multisystem disease that can affect virtually any part of the body from head to toe. tb demonstrates a variety of clinical and radiologic findings and has a known propensity for dissemination from its primary site and therefore can mimic numerous other disease entities. hence it is imperative for radiologists to understand the typical disease distribution, patterns and imaging manifestations of tb. janet l. strife, md carol m. rumack md ole a. eklof, md clement c. faure, md andres giedion, md denis lallemand, md arnold lassrich md donald r. kirks, md beverly p. wood, md hooshang taybi md marta hernanz-schulman, md, facr m. ines boechat, md, facr neil d. johnson, mbbs dorothy i. bulas, md *deceased singleton-taybi award investigator award this award is given to the author of the best paper presented by a resident or fellow at the spr meeting md ricardo faingold, md andrea doria, md nina m. menezes, phd anthropometric parameters are a strong determinant of lvm in healthy individuals kiyarash mohajer, pierangelo renella, paul j. finn purpose or case report: despite theoretical advantages of higher field strength ssfp cine imaging, time-resolved magnetic resonance angiography (tr-mra), and high resolution contrast-enhanced mra (ce-mra) were performed. two readers independently evaluated the data for image quality, vessel and cardiac chamber definition, and presence of artifacts. snr and cnr were calculated. results: % of ssfp cine images at t were rated as good or excellent quality with % having mild and % having moderate artifacts (k . ) % of arterial and venous phase ce-mra images were considered good or excellent cardiac chamber definition was considered good or excellent in % of arterial and venous phase ce-mra images (k . ). % ce-mra images showed good or excellent definition of the thoraco-abdominal vessels on average, both readers scored cine ssfp images higher at . t and cemra images higher at . t. overall diagnostic performance was high at both field strengths. conclusions: mri of pediatric patients with chd and vascular abnormalities at . t is feasible. relative to . t, snr and cnr are both improved at higher field strength and higher resolution cemra is achievable t are more prevalent, they rarely render cine imaging non-poster # exclusion criteria were lack of correlating us or follow up information. two pediatric radiologists blinded to us findings reviewed the mr images and analyzed the contents of abdominal wall defect, organ location and attachment; spine anomalies; umbilical cord and limb anomalies. results: our search yielded patients. all fetuses had ventral wall defects, small thorax and eviscerated liver and bowel. in two cases kidneys were in extracorporeal location. in / there was no membrane covering extruded organs. in five mr showed organs attached to the placenta or uterine wall (mainly bowel and liver) mahmoud al-hawary and, by adolescence, paradoxical metaphyseal osteopenia with thin cortical bone. reports of consanguinity indicate autosomal recessive inheritance our studies, spanning ages - mo, showed weight %, but length diminishing from~ % to − . sd. head circumference was + sd. she had frontal bossing, blue sclera, normal teeth, genu valgum, and unremarkable joints. radiographs showed orbital and facial sclerosis, basilar thickening, "bone-in-bone" appearance in the pelvis, sclerotic long bone ends, and fractures of ribs and extremities. progressive metaphyseal widening occurred as vertebrae changed from ovoid to flattened and became beaked anteriorly. consistent with opt, serum pth concentrations reflected dietary calcium levels. serum bone alkaline phosphatase, osteocalcin, and trap b were sub-normal. iliac crest contained excessive primary spongiosa and no osteoclasts. splice sites and exons were intact for the genes encoding cholride channel , t-cell immune regulator , opt-associated transmembrane protein the hallmarks include stippled epiphyses, nasal hypoplasia, and hypoplastic distal phalanges and developmental delay. punctate calcifications are seen not only in the epiphyses but also in the paravertebral regions. paravertebral puncta are commonly associated with defective ossifications in the cervical spine. the malformation of the cervical spine causes spinal canal stenosis and instability, which occasionally necessitate surgical intervention none of the cases had brain infarction. conclusions: tortuousity and luminal narrowing of the cervical arteries is a common finding in cdp-bt. this previously unknown malformation is an important factor to discriminate patients at increased risk of cerebral ischemia, particularly in patients undergoing surgical intervention. disclosure: dr. okabe has indicated that she will discuss or describe severe skeletal toxicity from protracted etidronate therapy for generalized arterial calcification of infancy william h. mcalister, md, mallinckrodt institute of radiology campbell sheen purpose or case report: generalized arterial calcification of infancy (gaci) is an autosomal recessive disorder caused by deactivating mutations within the gene for ectonucleotide pyrophosphatase phosphodiesterase- (enpp ). enpp on osteoblasts, chondrocytes, and vascular smooth muscle cells hydrolyzes nucleotide triphosphates to nucleotide monophosphates and inorganic pyrophosphate (ppi) can time-resolved contrast-enhanced mra (twist) classify soft tissue vascular anomalies in the head and neck in children accurately? aylin tekes, md children from - years of age were enrolled. twist and conventional mri was performed (triplanar t -weighted [t -w] imaging with fat saturation, pre-contrast axial t -weighted [t -w] imaging, and post contrast triplanar fat-suppressed t -w imaging). twist was performed in coronal plane using blood-pool mr contrast agent (ablavar-lantheus) to enhance image quality and spatial resolution of mra. two pediatric neuroradiologists evaluated all patients in two different sessions, days apart: one session conventional mri with contrast was evaluated, in the second session twist was evaluated. clinical evaluation and/or percutaneous venogram/lymphogram data were the gold standard. results: our patients had diagnosis of infantile hemangioma (n ), venous malformation (n ), and lymphatic malformation (n ). twist alone could accurately classify / , conventional mri with contrast could accurately classify / . conventional mri with contrast combined with twist could accurately classify all cases. conclusions: twist offers high temporal resolution in the order of seconds, and provides functional data about the dynamics of contrast enhancement comprising the arterial, venous and delayed venous phases kiery cr- , sci- edu- , edu- edu- , edu- , pa- edu- , pa- a- , pa- , pa- , pa- , pa- edu- , edu- , edu- , edu- , edu- , edu- , edu- edu- , edu- , edu- , edu- , edu- , edu- suraj sci- , pa- , pa- edu- pa- , edu- , pa- the society for pediatric radiology gratefully acknowledges the support of the following companies in presenting the th annual meeting and postgraduate course: cme committee reviewers for this activity have disclosed any relevant financial relationships. no conflicts of interest exist.abuse and offer potential mechanisms of injury may help make the diagnosis of child abuse. the pediatric elbow-mri findings with multimodality correlation michael guandalini, md, royal children's hospital; murray bartlett purpose or case report: to describe and illustrate elbow abnormalities identified by mri performed in a cohort of pediatric patients with multimodality correlation. methods & materials: retrospective review of mri elbow studies performed at the royal children's hospital, melbourne between and . the studies were reviewed by a pediatric musculoskeletal radiologist and pediatric radiology fellow with patient demographics, clinical indication, findings and selected images recorded. results: elbow mri examinations were reviewed on children aged months to years ( boys, girls) with equal numbers of left and right sides examined. clinical indications included previous trauma in cases ( %) and nontraumatic conditions in ( %). the most common traumatic indication was suspected or confirmed fractures or avulsions ( %) followed by osteochondral or cartilage injuries ( %), growth arrest ( %), loose bodies ( %) and ligament injuries ( %). hemophilia ( %) was the most frequent nontraumatic indication followed by neoplasm ( %). mild to severe arthropathy, fractures, physeal growth arrest, subluxations, osteochondral lesions and loose bodies were the most frequently demonstrated abnormalities. ligament strains and tears, bone oedema, neuromuscular abnormalities, infections and several neoplasms including lipomas, vascular/lymphatic malformations and bone tumors also featured. conclusions: this pictorial review illustrates the broad range of abnormalities one might expect to encounter on pediatric elbow mri studies, highlighting the major features and corresponding appearances on ct and plain x-ray. spectrum of patellar tendon avulsive injury on mri in children: differentiation between acute and chronic avulsive injuries of the inferior patellar pole and tibial tuberosity zeyad metwalli, md, baylor college of medicine, metwalli@ bcm.edu; herman kan, scott rosenfeld, r. p. guillerman purpose or case report: the extensor mechanism of the knee is an intricate component of the joint and is frequently injured in pediatric athletes. due to the strength of the patella tendon, trauma to the anterior knee is often manifested by avulsive injuries, which may occur on an acute or chronic repetitive basis. purpose: this pictorial review will illustrate differentiating radiographic and mri features of acute and chronic avulsive injuries of the pediatric knee. outline: . anatomy and physiology a. discuss the anatomic differences of the pediatric and adult knee extensor mechanism b. pathophysiology and biomechanical basis for chondro-osseous avulsion injuries versus tendon tears in the skeletally immature. purpose or case report: the purpose of this educational exhibit is to demonstrate the magnetic resonance imaging (mri) appearance of the ankle and hindfoot ligaments using an interactive approach. methods & materials: a tesla siemens mri scanner with a multichannel ankle coil was utilized in the acquisition of images of ankle and hindfoot. three dimensional volume acquisition proton density images will be used to demonstrate the ligamentous anatomy of the ankle and hindfoot in axial, axial oblique, coronal, and sagittal planes. results: the exhibit will begin with an interactive review of the ankle and hindfoot ligamentous anatomy with each ligament poster #: edu- cns imaging findings in hemophagocytic lymphohistiocytic syndrome rupa radhakrishnan, mbbs, md, dnb, radiology, university of cincinnati college of medicine, radhakrp@ucmail. uc.edu; marcia k. kukreja, alexandra filipovich, alexander j. towbin purpose or case report: hemophagocytic lymphohistiocytosis (hlh) is a rare, life threatening condition caused by an uncontrolled proliferation of activated lymphocytes and histiocytes with high levels of inflammatory cytokines. the organs most commonly involved in this disorder include the liver, spleen, lymph nodes, bone marrow and central nervous system (cns). the purpose of this exhibit is to review the cns imaging findings associated with hlh, its complications, and its management. the published literature was reviewed to identify the potential imaging findings hlh. the electronic medical record system was then searched to find illustrative case examples from our institution. cases demonstrating the primary imaging findings as well cases highlighting complications of the disease or its therapy were selected. results: cns involvement is common in hlh with approximately % of patients demonstrating neurological symptoms. ct findings of cns involvement include diffuse parenchymal atrophy, low attenuation lesions in the white matter and calcifications. mr findings include diffuse leptomeningeal and perivascular enhancement, t hyperintense lesions with nodular or rim enhancement as well as confluent white matter lesions, and diffuse parenchymal volume loss of the cerebrum and cerebellum. restricted diffusion has been demonstrated in some lesions. ring enhancing parenchymal lesions have been described representing active demyelination. intracranial hemorrhage may occur as a result of thrombocytopenia and coagulation abnormalities. sepsis with opportunistic organisms can involve the cns and produce intracranial findings such as parenchymal abscesses. cns changes, such as posterior reversible encephalopathy syndrome, are also seen with the commonly used immunomodulatory regimen used in the treatment of hlh. conclusions: this exhibit will aid the viewer in identifying the cns imaging findings of hlh as well as the complications of the disease and its therapy. while the cns imaging findings are not specific, they may help the radiologist formulate a diagnosis in association with the other clinical and imaging findings; furthermore, imaging can help the clinical team in managing the disease and its complications. methods & materials: medical records of our pediatric patients with palpable head masses over the last years, were reviewed and images were collected. correlation of us of these lesions with other imaging modalities and/or pathologic diagnosis was done. results: us appearances of various head masses including congenital/developmental (encephalocele, meningocele, dermoid, occipital protuberance), traumatic (cephalhematoma, subgaleal hematoma, calvarial fracture), inflammatory/infectious (sebaceous cyst, histiocytosis, dermatitis), vascular (malformations, pseudoaneurysm) and neoplastic (benign and malignant lesions including metastases) etiologies, will be illustrated with case based approach. mri and/or ct or tissue diagnosis can be problem solving. role of ultrasound guidance for percutaneous procedures (biopsy, sclerotherapy) will also be described. conclusions: ultrasound can play an important role in the delineation, diagnosis and guiding further management of pediatric palpable head masses. us can differentiate various scalp lesions and suggest the underlying calvarial defect or involvement to some extent, helping to narrow the differential diagnosis for such lesions. color doppler us can be useful to detect vascularity within the lesion or vascular lesions. given that us is often requested for the evaluation of palpable head masses, pediatric radiologists should be familiar with their sonographic features. posterior fossa malformations-a pictorial review rui santos, md, bc children's hospital, ruiradiologia@gmail. com; khalid khashoggi, angela t. byrne purpose or case report: posterior fossa malformations are a group of central nervous system anomalies that may be detected during pregnancy or present early infancy with features that include hypotonia, developmental delay, mutations responsible for the disease and proposals as to mechanism of action of the mutation with respect to disease manifestations. this preceded the development of hypotheses regarding the relationship between genotype and phenotype and the attempt to utilize imaging modalities that could better assess disease activity as it related to functional status. the purpose of this exhibit is to briefly review the history pre- and to focus on the numerous ways in which the understanding has improved since that time. conclusions: . there are over different mutations of the cftr gene responsible for cystic fibrosis with varying prevalence throughout the world. . the class of mutation often dictates its particular mechanism of action. . there is some relationship between genotype and phenotype-particularly with respect to pancreatic involvement. . newer imaging modalities including ct and mri with or without hyperpolarized helium are better predictors of disease severity than is plain film. imaging pulmonary tuberculosis in infants: what are the most useful diagnostic radiological findings? handan cakmakci, pediatric radiology, dokuz eylul university hospital, handancakmakci@gmail.com; nevin uzuner, filiz tetik purpose or case report: early diagnosis and treatment are very important for infants with tuberculosis. infantile pulmonary tuberculosis is more symptomatic, and the risk of severe and life-threatening complications such as tuberculous meningitis or miliary tuberculosis is higher. bacteriologic confirmation of the disease in children is difficult and in younger infants (< months), the tuberculin skin test is frequently negative. therefore, radiological findings play important role in diagnosing tuberculosis in infants. the purposes of this study are to identify chest x-ray and lung ct findings in pulmonary tuberculosis of infants and consider the most useful diagnostic findings of these age group patients.methods & materials: chest radiographs and chest ct images of infants who were diagnosed in our hospital from to were retrospectively reviewed. the study group included boys and girls ranging in age from to months (mean age, months). chest x-ray and computed tomography images were analyzed considering air space consolidation, nodular lesions, cavitating lesions, mediastinal enlargement, hyperinflation, bronchial narrowing, atelectasis pleural effusion on plain radiography and additional mediastinal calcific or caseating lymph nodes on ct images.results: air space consolidation was seen on out of chest x-ray and computed tomography images. nodular lesions were seen out of chest x-ray and computed tomography images. cavitating lesion was seen on out of chest x-ray and computed tomography images. mediastinal enlargement suggesting lymph node was seen out of chest x-ray and computed tomography images. hyperinflation, bronchial narrowing was seen out of chest x-ray and computed tomography images. atelectasis, pleural effusion was seen out of chest x-ray and out of computed tomography images. mediastinal caseating lymph nodes, mediastinal calcific lymph nodes were seen out of computed tomography images. conclusions: frequent and the most useful diagnostic radiological findings of pulmonary tuberculosis in infants are mediastinal or hilar lymphadenopathy with central necrosis and air space consolidations. disseminated nodules including miliary lesions and airway complications are also detected in this age group. ct can show detailed parenchymal lesions and tuberculous lymphnodes especially calcified ones. the ductus bump: radiographic findings of this normal variant and differential diagnoses anusuya mokashi, staten island university hospital, anusuya.mokashi@gmail.com; jeremy neuman, cheryl lin purpose or case report: the ductus bump: review of radiographic findings, differential diagnoses and current controversies. the ductus bump was first described in by berdon et al as a transient physiologic mass in the chest in newborn infants. some controversy remains as to the exact etiology and clinical significance. although initially thought to represent a dilated ductus arteriosus, recently it has been suggested that it actually represents a ductus arteriosus aneurysm that spontaneously resolves. others contend it represents dilation of the infundibulum of the closing ductus. regardless of etiology, the time of discovery, location, and rapid resolution are characteristic of this entity. in this presentation we will review the radiographic and echocardiogram findings of the ductus bump, as well as discuss the differential diagnosis. the frontal radiographic findings are a round mass to the left of the vertebral spine projecting from the mediastinum near the aortic arch. this mass does not indent the esophagus and it cannot be seen on the lateral view. it is classically said to resolve within the first few days of life. the controversy regarding the etiology has also led to some disagreement involving the clinical significance and appropriate follow up, which will also be discussed. after reviewing this educational poster, the reader will have conclusions: abnormalities of the posterior fossa are often difficult to differentiate solely on the basis of their radiologic appearances alone. however, an accurate diagnosis is essential for proper treatment planning and genetic counselling. therefore it is imperative for radiologists to be well versed with the normal anatomy and development of cerebellum so as to correctly diagnose the various posterior fossa abnormalities.poster #: sci- imaging of oculoauriculofrontonasal syndrome with low-dose -dimensional computed tomography paritosh c. khanna, md, radiology, seattle children's hospital, pkhanna@uw.edu; kelly evans, gisele ishak, joseph gruss, michael cunningham, anne hing purpose or case report: oculoauriculofrontonasal syndrome (oafns) combines elements of abnormal morphology of the frontonasal and maxillary processes of the face. the aim of our exhibit is to demonstrate the low-dose computed tomography (ct) features of this syndrome, in seven patients who have been followed at seattle children's hospital (sch) over years. we underscore the imaging features of this condition, and describe additional features including bony nasal abnormalities not previously described in the literature, to improve imaging recognition of this spectrum. we present d ct imaging features of a series of eight patients with oafns. in keeping with the alara (as low as reasonably achievable) concept and the image gently recommendations (www.imagegently. org), ct head and face studies were obtained on six of eight patients at sch, while two had prior exams at outside institutions. using a -slice multidetector ct scanner (ge lightspeed vct, waukesha wi), low-dose ct ( kv, mas or lower depending on age) of the head and face was obtained. planar bone window and d surface rendered images were analyzed. results: our series of patients demonstrated bifid nasal bones, uni-or bilateral mandibular hypoplasia, temporomandibular and zygomatic dysplasia and bony external auditory canal abnormalities. one patient had an interfrontal bone with a frontal bony defect that was contiguous with the metopic suture. we describe additional previously unidentified ct anomalies of the nasal bones, anterior nasal spine and nasal septum. these structures are involved in all patients who had ct imaging available, although unique features are present in each case. conclusions: ct is the mainstay of imaging of craniofacial anomalies in the post-natal period, both pre-and postoperatively. in addition to our low-dose ct imaging findings of oafns, novel nasal bone anomalies identified by our group serve to identify a new subset of patients with this syndrome and may help refine the phenotype of the oafns spectrum. key: cord- - swjzic authors: nan title: scientific opinion on the public health hazards to be covered by inspection of meat from sheep and goats date: - - journal: efsa j doi: . /j.efsa. . sha: doc_id: cord_uid: swjzic a risk ranking process identified toxoplasma gondii and pathogenic verocytotoxin‐producing escherichia coli (vtec) as the most relevant biological hazards for meat inspection of sheep and goats. as these are not detected by traditional meat inspection, a meat safety assurance system using risk‐based interventions was proposed. further studies are required on t. gondii and pathogenic vtec. if new information confirms these hazards as a high risk to public health from meat from sheep or goats, setting targets at carcass level should be considered. other elements of the system are risk‐categorisation of flocks/herds based on improved food chain information (fci), classification of abattoirs according to their capability to reduce faecal contamination, and use of improved process hygiene criteria. it is proposed to omit palpation and incision from post‐mortem inspection in animals subjected to routine slaughter. for chemical hazards, dioxins and dioxin‐like polychlorinated biphenyls were ranked as being of high potential concern. monitoring programmes for chemical hazards should be more flexible and based on the risk of occurrence, taking into account fci, which should be expanded to reflect the extensive production systems used, and the ranking of chemical substances, which should be regularly updated and include new hazards. control programmes across the food chain, national residue control plans, feed control and monitoring of environmental contaminants should be better integrated. meat inspection is a valuable tool for surveillance and monitoring of animal health and welfare conditions. omission of palpation and incision would reduce detection effectiveness for tuberculosis and fasciolosis at animal level. surveillance of tuberculosis at the slaughterhouse in small ruminants should be improved and encouraged, as this is in practice the only surveillance system available. extended use of fci could compensate for some, but not all, the information on animal health and welfare lost if only visual post‐mortem inspection is applied. following a request from the european commission to the european food safety authority (efsa), the panel on biological hazards (biohaz) was asked to deliver a scientific opinion on the public health hazards to be covered by the inspection of meat from sheep and goats. the panel was supported by the efsa panels on contaminants in the food chain (contam) and animal health and welfare (ahaw) in the preparation of this opinion. briefly, the main risks for public health that should be addressed by meat inspection were identified and ranked; the strengths and weaknesses of the current meat inspection system were evaluated; recommendations were made for inspection methods fit for the purpose of meeting the overall objectives of meat inspection for hazards currently not covered by the meat inspection system; and recommendations for adaptations of inspection methods and/or frequencies of inspections that provide an equivalent level of protection were made. in addition, the implications for animal health and animal welfare of any changes proposed to current inspection methods were assessed. sheep and goats were considered together, unless otherwise stated. decision trees were developed and used for priority ranking of biological and chemical hazards present in meat from sheep and goats. for biological hazards the ranking was based on the magnitude of the human health impact, the severity of the disease in humans and the evidence supporting the role of meat from sheep and goats as a risk factor for disease in humans. the assessment was focused on the public health risks that may occur through the handling, preparation for consumption and/or consumption of meat from these species. the term 'priority' was considered more appropriate than 'risk' for categorizing the biological hazards associated with meat from small ruminants, given that a significant amount of data on both the occurrence of the hazards and on the attributable fraction of human cases to meat from small ruminants were not available. risk ranking of chemical hazards into categories of potential concern was based on the outcomes of the national residue control plans (nrcps), as defined in council directive / /ec for the period - , and of other testing programmes, as well as on substance-specific parameters such as the toxicological profile and the likelihood of the occurrence of residues and contaminants in sheep and goats. based on the ranking for biological hazards, toxoplasma gondii and pathogenic verocytotoxinproducing escherichia coli (vtec) were classified as high priority for public health regarding meat inspection of small ruminants. the remaining hazards were classified as low public health relevance, based on available data, and were therefore not considered further. for chemical hazards, dioxins and dioxin-like polychlorinated biphenyls (dl-pcbs) were ranked as being of high potential concern owing to their known bioaccumulation in the food chain, their frequent findings above maximum levels (mls), particularly in sheep liver, and in consideration of their toxicological profile; all other substances were ranked as of medium or lower concern. it should be noted that the ranking into specific-risk categories of hazards is based on current knowledge and available data and therefore ranking should be updated regularly, taking account of new information and data and including 'new hazards'. the main elements of the current meat inspection system include analysis of food chain information (fci), ante-mortem examination of animals and post-mortem examination of carcasses and organs. the assessment of the strengths and weaknesses of the current meat inspection was based on its contribution to the control of the meat-borne human health hazards identified in sheep and goats. a number of strengths and weaknesses of the current inspection system were identified. currently, the use of fci for food safety purposes is limited for small ruminants because the data that it contains is very general and doesn't address specific hazards of public health importance. however, fci could serve as a valuable tool for risk management decisions and could be used for risk categorisation of farms or batches of animals. to achieve this, the system needs further development to include additional information important for food safety, including definition of appropriate and standardized indicators for the main public health hazards identified above. ante-mortem and post-mortem inspections of sheep and goats enable the detection of observable abnormalities and provide a general assessment of animal/herd health, which if compromised may lead to a greater public health risk. visual inspection of live animals and carcasses can detect animals heavily contaminated with faeces, which increase the risk for cross-contamination during slaughter and may constitute a food safety risk if the animals are carrying hazards of public health importance. if such animals or carcasses are dealt with adequately, this risk can be reduced. visual detection of faecal contamination on carcasses can also be an indicator of slaughter hygiene, but other approaches to verify this should be considered. post-mortem inspection can also detect non meat-borne hazards of public health significance, such as echinococcus granulosus, that can be present in carcasses or offal from small ruminants. ante-mortem and post-mortem inspection also have the potential to detect new diseases, which may be of direct public health significance. with regard to chemical hazards, it was noted that current procedures for sampling and testing are, in general, well established and coordinated, including follow-up actions subsequent to the identification of non-compliant samples. the regular sampling and testing for chemical residues and contaminants is an important disincentive for the development of undesirable practices and the prescriptive sampling system allows for equivalence in the control of eu-produced sheep and goat meat. the current combination of animal traceability, ante-mortem inspection and gross tissue examination can support the collection of appropriate samples for residue monitoring. the main weakness of ante-mortem and post-mortem inspection is that they are not able to detect any of the public health hazards identified as the main concerns for food safety. in addition, given that the current post-mortem procedures involve palpation and incision of some organs, the potential for crosscontamination of carcasses exists. for chemical hazards, a major weakness is that, with very few exceptions, presence of chemical hazards cannot be identified by current ante-/post-mortem meat inspection procedures at the slaughterhouse level and there is a lack of sufficient cost-effective and reliable screening methods. in addition, sampling is mostly prescriptive rather than risk or information based. there is limited ongoing adaptation of the sampling and testing programmes to the results of the residue monitoring programmes, with poor integration between the testing of feed materials for undesirable substances and the nrcps and sampling under the nrcps reflecting only a part of testing done by a number of mss, the results of which should be taken into consideration. as neither of the main public health hazards associated with meat from small ruminants can be detected by traditional visual meat inspection, other approaches are necessary to identify and control these microbiological hazards. a comprehensive meat safety assurance system for small ruminants, combining a range of preventive measures and controls applied both on the farm and at the slaughterhouse in a longitudinally integrated way, is the most effective approach to control the main hazards in the context of meat inspection. information on the biological risks associated with the consumption of meat from sheep or goats is sometimes scant and unreliable. in order to facilitate decision making, harmonised surveys are required to establish values for the prevalence of the main hazards t. gondii and pathogenic vtec at flock/herd, live animal and carcass level in individual mss. epidemiological and risk assessment studies are also required to determine the specific risk to public health associated with the consumption of meat from small ruminants. if these studies confirm a high risk to public health through the consumption of meat from sheep or goats, consideration should be given to the setting of clear and measurable eu targets at the carcass level. to meet these targets and criteria, a variety of control options for the main hazards are available, at both farm and abattoir level. flock/herd categorisation according to the risk posed by the main hazards is considered an important element of an integrated meat safety assurance system. this should be based on the use of farm descriptors and historical data in addition to batch-specific information. farm-related data could be provided through farm audits using harmonised epidemiological indicators (heis) to assess the risk and protective factors for the flocks/herds related to the given hazards. in addition, classification of abattoirs according to their capability to prevent or reduce faecal contamination of carcasses can be based on two elements: ( ) the process hygiene as measured by the level of indicator organisms on the carcasses (i.e. process hygiene criteria); and ( ) the use of operational procedures and equipment that reduce faecal contamination, as well as industry led quality systems. there are a variety of husbandry measures that can be used to control t. gondii on sheep and goat farms but at present these are impractical to implement in most farms. a number of post-processing interventions are effective in inactivating t. gondii such as cooking, freezing, curing, high pressure and irradiation treatments, although further research is required to validate these treatments in meat from small ruminants. there are also a variety of husbandry measures that can be used to reduce the levels of vtec on farms, but their efficacy is not clear in small ruminants. there are also a number of challenges that need to be overcome regarding the setting of targets for pathogenic vtec, including the difficulties in identifying husbandry factors that can be used to classify farms according to pathogenic vtec risk, the intermittent nature of shedding, and the problems with the interpretation of monitoring results for pathogenic vtec due to the difficulty to correctly identify pathogenic vtec. the main sources of vtec on sheep and goat carcasses are the fleece/hide and the viscera. to control incoming faecal contamination only clean animals should be accepted for slaughter. there are also a number of measures that can help reducing the spillage or leakage of digestive contents onto the carcass, as well as post-processing interventions to control pathogenic vtec are also available. these include hot water and steam carcass surface treatments. risk categorisation of slaughterhouses should be based on trends of data derived from process hygiene assessments and from hazard analysis critical control point programmes. improvement of slaughter hygiene through technological and managerial interventions should be sought in slaughterhouses with repeatedly unsatisfactory performance. fci can be improved by including information on participation in quality assurance schemes and by greater feedback to the primary producer, as this would likely result in the production of healthier animals. ante-mortem inspection assesses the general health status of the animals and helps to detect animals heavily contaminated with faeces on arrival at the slaughterhouse, so no adaptations for the existing visual ante-mortem inspection are required. routine post-mortem examination cannot detect the meat-borne pathogens of public health importance. palpation of the lungs, the liver, the umbilical region and the joints, and incision of the liver could contribute to the spread of bacterial hazards through cross contamination. for these reasons, palpation and incision should be omitted in animals subjected to routine slaughter. sheep and goat production in the eu is marked by being largely extensive in nature, involving frequent trading of animals and involving nomadic flocks. these differences in husbandry systems and feeding regimes result in different risks for the occurrence of chemical residues and contaminants. extensive periods on pasture or/as nomadic flocks and the use of slaughter collection dealerships may preclude detailed lifetime fci. it is recommended regarding chemical hazards, that fci should be expanded for sheep and goats produced in extensive systems to provide more information on the specific environmental conditions where the animals are produced and that future monitoring programmes should be based on the risk of occurrence of chemical residues and contaminants, taking into account the completeness and quality of the fci supplied, and the ranking of chemical substances into categories of potential concern, which ranking needs to be regularly updated. control programmes for chemical residues and contaminants should be less prescriptive, with sufficient flexibility to adapt to results of testing, should include 'new hazards', and the test results for sheep and goats should be separately presented. 'new' chemical hazards identified are largely persistent organic pollutants that have not been comprehensively covered by the sampling plans of the current meat inspection or which have not been included in such sampling plans. there is a need for an improved integration of sampling, testing and intervention protocols across the food chain, nrcps, feed control and monitoring of environmental contaminants. a series of further recommendations are made in relation to chemical hazards dealing with control measures, testing and analytical techniques and also on data collection and source attribution studies for biological hazards, as well as on methods of detection of viable t. gondii in meat and on assessing the effect of the omission of palpation and incision on the risk posed by non-meat-borne zoonoses. the implications for surveillance of animal health and welfare of the changes proposed to the current meat inspection system were evaluated quantitatively and qualitatively. the proposed changes related to biological hazards included shorter transport and lairage time, improved collection of food chain information, and omission of palpation and incision in animals subjected to routine slaughter at postmortem inspection. recommendations on chemical hazards included the ranking system for chemical substances of potential concern and its updating, the use of food chain information to help facilitate risk based sampling strategies, and the inclusion of 'new hazards' in control programmes for chemical residues and contaminants. from the quantitative assessment, a change to visual only inspection caused a significant reduction of the probability of detection of detectable cases of fasciolosis and tuberculosis in goats. with regard to exotic diseases, clinical surveillance had a greater sensitivity for detecting foot and mouth disease than slaughterhouse surveillance. a change in post-mortem protocol to a visual only system did not significantly reduce the detection of any welfare conditions. following the qualitative analysis, it was concluded that a change to visual inspection (which implies no palpation) would reduce detection effectiveness for tuberculosis. surveillance of tuberculosis at the slaughterhouse in small ruminants should be improved and encouraged, as this is in practice the only surveillance system available in these species. the detection of tuberculosis in small ruminants should be adequately recorded and followed at the farm level. moving to a visual only meat inspection system would decrease the sensitivity of inspection of fasciolosis at animal level, however it would be sensitive enough to identify most if not all affected herds. therefore the consequences of the change would be of low relevance. the feedback to farmers of fasciola hepatica detected at meat inspection should be improved, to allow farmer information to support rational on-farm fluke management programmes. qualitative analysis suggested that the proposal for shortened transport and lairage time would be beneficial to improving the welfare of small ruminants. food chain information should include animal welfare status in order to complement the slaughterhouse surveillance systems (ante-mortem and postmortem inspection) and the latter could be used to identify on farm welfare status. regulation (ec) no / of the european parliament and of the council lays down specific rules for the organisation of official controls on products of animal origin intended for human consumption . inspection tasks within this regulation include: checks and analysis of food chain information animal welfare specified risk material and other by-products laboratory testing the scope of the inspection includes monitoring of zoonotic infections and the detection or confirmation of certain animal diseases without necessarily having consequences for the placing on the market of meat. the purpose of the inspection is to assess if the meat is fit for human consumption in general and to address a number of specific hazards: in particular the following issues: transmissible spongiform encephalopathies (only ruminants), cysticercosis, trichinosis, glanders (only solipeds), tuberculosis, brucellosis, contaminants (e.g. heavy metals), residues of veterinary drugs and unauthorised substances or products. during their meeting on november , chief veterinary officers (cvo) of the member states agreed on conclusions on modernisation of sanitary inspection in slaughterhouses based on the recommendations issued during a seminar organised by the french presidency from to july . the cvo conclusions have been considered in the commission report on the experience gained from the application of the hygiene regulations, adopted on july . council conclusions on the commission report were adopted on november inviting the commission to prepare concrete proposals allowing the effective implementation of modernised sanitary inspection in slaughterhouses while making full use of the principle of the 'risk-based approach'. in accordance with article of regulation (ec) no / , the commission shall consult efsa on certain matters falling within the scope of the regulation whenever necessary. efsa and the commission's former scientific committee on veterinary measures relating to public health have issued in the past a number of opinions on meat inspection considering specific hazards or production systems separately. in order to guarantee a more risk-based approach, an assessment of the risk caused by specific hazards is needed, taking into account the evolving epidemiological situation in member states. in addition, methodologies may need to be reviewed taking into account risks of possible cross-contamination, trends in slaughter techniques and possible new inspection methods. the scope of this mandate is to evaluate meat inspection in order to assess the fitness of the meat for human consumption and to monitor food-borne zoonotic infections (public health) without jeopardising the detection of certain animal diseases nor the verification of compliance with rules on animal welfare at slaughter. if and when the current methodology for this purpose would be considered not to be the most satisfactory to monitor major hazards for public health, additional methods should be recommended as explained in detail under points and of the terms of reference. the objectives of the current legal provisions aimed at carrying out meat inspection on a risk-based analysis should be maintained. in order to ensure a risk-based approach, efsa is requested to provide scientific opinions on meat inspection in slaughterhouses and, if considered appropriate, at any other stages of the production chain, taking into account implications for animal health and animal welfare in its risk analysis. in addition, relevant international guidance should be considered, such as the codex code of hygienic practice for meat (cac/rcp - ) , and chapter . on control of biological hazards of animal health and public health importance through ante-and post-mortem meat inspection, as well as chapter . on slaughter of animals of the terrestrial animal health code of the world organisation for animal health (oie). the following species or groups of species should be considered, taking into account the following order of priority identified in consultation with the member states: domestic swine, poultry, bovine animals over six weeks old, bovine animals under six weeks old, domestic sheep and goats, farmed game and domestic solipeds. in particular, efsa, in consultation with the european centre for disease prevention and control (ecdc), is requested within the scope described above to: . identify and rank the main risks for public health that should be addressed by meat inspection at eu level. general (e.g. sepsis, abscesses) and specific biological risks as well as chemical risks (e.g. residues of veterinary drugs and contaminants) should be considered. differentiation may be made according to production systems and age of animals (e.g. breeding compared to fattening animals). . assess the strengths and weaknesses of the current meat inspection methodology and recommend possible alternative methods (at ante-mortem or post-mortem inspection, or validated laboratory testing within the frame of traditional meat inspection or elsewhere in the production chain) at eu level, providing an equivalent achievement of overall objectives; the implications far animal health and animal welfare of any changes suggested in the light of public health risks to current inspection methods should be considered. . if new hazards currently not covered by the meat inspection system (e.g. salmonella, campylobacter) are identified under tor , then recommend inspection methods fit for the purpose of meeting the overall objectives of meat inspection. when appropriate, food chain information should be taken into account. . recommend adaptations of inspection methods and/or frequencies of inspections that provide an equivalent level of protection within the scope of meat inspection or elsewhere in the production chain that may be used by risk managers in case they consider the current methods disproportionate to the risk, e.g. based on the ranking as an outcome of terms of reference or on data obtained using harmonised epidemiological criteria (see annex ) . when appropriate, food chain information should be taken into account. the scope of the mandate is to evaluate meat inspection in a public health context; animal health and welfare issues are covered with respect to the possible implications of adaptations/alterations to current inspection methods, or the introduction of novel inspection methods proposed by this mandate. issues other than those of public health significance but that still compromise the fitness of the meat for human consumption (regulation (ec) no / , annex i, section ii, chapter v) are outside the scope of the mandate. examples of these include sexual odour or meat decolouration. transmissible spongiform encephalopathies (tses) are also outside the scope of the mandate. the impact of changes to meat inspection procedures on the occupational health of abattoir workers, inspectors, etc. is outside the scope of the mandate. additionally, hazards representing primarily occupational health risks, the controls related to any hazard at any meat chain stage beyond the abattoir, and the implications for environmental protection are not dealt with in this document. in line with article of regulation (ec) no / the european commission has recently submitted a mandate to efsa (m- - ) to cover different aspects of meat inspection. the mandate comprises two requests: one for scientific opinions and one for technical assistance. the european food safety authority (efsa) is requested to issue scientific opinions related to inspection of meat in different species. in addition, technical assistance has been requested on harmonised epidemiological criteria for specific hazards for public health that can be used by risk managers to consider adaptation of the meat inspection methodology. meat inspection is defined by regulation / . the species or groups of species to be considered are: domestic swine, poultry, bovine animals over six weeks old, bovine animals under six weeks old, domestic sheep and goats, farmed game and domestic solipeds. taking into account the complexity of the subject and that consideration has to be given to zoonotic hazards, animal health and welfare issues and chemical hazards (e.g. residues of veterinary drugs and chemical contaminants), the involvement of several efsa units was necessary. more specifically, the mandate was allocated to the biological hazards panel (biohaz), which prepared this scientific opinion with the support of the animal health and welfare (ahaw) and contaminants in the food chain (contam) panels. in addition, the delivery of the technical assistance was allocated to the biological monitoring (biomo), scientific assessment support (sas), and dietary and chemical monitoring (dcm) units of the risk assessment and scientific assistance directorate. this scientific opinion therefore concerns the assessment of meat inspection in sheep and goats, and it includes the answer to the terms of reference proposed by the european commission. owing to the complexity of the mandate, the presentation of the outcome does not follow the usual layout. for ease of reading, main outputs from the three working groups (biohaz, contam and ahaw) are presented at the beginning of the document. the scientific justifications for these outputs are found in the various appendices as endorsed by their respective panels, namely biological hazards (appendix a), chemical hazards (appendix b), and the potential impact that the proposed changes envisaged by these two could have on animal health and welfare (appendix c). differentiation may be made according to production systems and age of animals (e.g. breeding compared to fattening animals). based on the priority ranking, the hazards were classified as follows: -toxoplasma gondii and pathogenic verocytotoxin-producing escherichia coli (vtec) were classified as high priority for sheep/goat meat inspection. -the remaining identified hazards, bacillus anthracis, campylobacter spp. (thermophilic) and salmonella spp. were classified as low priority, based on available data. as new hazards might emerge and/or hazards that presently are not a priority might become more relevant over time or in some regions, both hazard identification and the risk ranking should be revisited regularly to reflect this dynamic epidemiological situation. particular attention should be given to potential emerging hazards of public health importance. a multi-step approach was used for the identification and ranking of chemical hazards. evaluation of the - national residue control plans (nrcps) outcome for sheep and goats indicated that only . % of the total number of results was non-compliant for one or more substances listed in council directive / /ec. potentially higher exposure of consumers to these substances from sheep and goat meat takes place only incidentally, as a result of mistakes or non-compliance with known and regulated procedures. available data however, do not allow for a reliable assessment of consumer exposure. ranking of chemical residues and contaminants in domestic sheep and goats based on predefined criteria, relating to bioaccumulation, toxicological profile and likelihood of occurrence, and taking into account the findings from the nrcps for the period - was as follows: -dioxins and dioxin-like polychlorinated biphenyls (dl-pcbs) were ranked as being of high potential owing to their known bioaccumulation in the food chain, their frequent findings above mls, particularly in sheep liver, and in consideration of their toxicological profile. -stilbenes, thyreostats, gonadal (sex) steroids, resorcylic acid lactones and beta-agonists, especially clenbuterol, chloramphenicol and nitrofurans were ranked as being of medium potential concern, as they have proven toxicity for humans, are effective as antibacterial treatments for sheep/goats and as non-compliant samples are found in most years of the nrcps. -chloramphenicol and nitrofurans were ranked as being of medium potential concern, as they have proven toxicity for humans, they are effective as antibacterial treatments for sheep/goats and as non-compliant samples are found in most years of the nrcps. -non dioxin-like polychlorinated biphenyls (ndl-pcbs) bioaccumulate, and there is a risk of exceeding the mls, but they were ranked in the category of medium potential concern, because they are less toxic than dioxins and dl-pcbs. -the chemical elements cadmium, lead and mercury were allocated to the medium potential concern category taking into account the number of non-compliant results reported under the nrcps and their toxicological profile. -all other substances listed in council directive / /ec were ranked as of low or negligible potential concern owing to the toxicological profile of these substances at residue levels in edible tissues or to the very low or non-occurrence of non-compliant results in the nrcps - , and/or to the natural occurrence in sheep and goats of some of these substances. strengths -ante-mortem and post-mortem inspection of sheep and goats enable the detection of observable abnormalities. in that context, they are an important activity for monitoring animal health and welfare. they provide a general assessment of animal/herd health, which if compromised may lead to a greater public health risk. visual inspection of live animals and carcasses can also detect animals heavily contaminated with faeces. such animals increase the risk for cross-contamination during slaughter and may consequently constitute a food safety risk if carrying hazards of public health importance. if such animals or carcasses are dealt with adequately, this risk can be reduced. visual detection of faecal contamination on carcasses can also be an indicator of slaughter hygiene, but other approaches to verify slaughter hygiene should be considered. -post-mortem inspection can also detect non meat-borne hazards of public health significance that can be present in carcasses or offal from small ruminants. ante-mortem and post-mortem inspection also have the potential to detect new diseases if these have clinical signs, which may be of direct public health significance. weaknesses -currently, the use of food chain information (fci) for food safety purposes is limited for small ruminants, mainly because the data that it contains is very general and doesn't address specific hazards of public health importance. however, fci could serve as a valuable tool for risk management decisions and could be used for risk categorisations of farms or batches of animals. to achieve this, the system needs further development to include additional information important for food safety, including definition of appropriate and standardized indicators for the main public health hazards identified in section of appendix a. -ante-and post-mortem inspection is not able to detect any of the public health hazards identified as the main concerns for food safety. it would therefore be expected that more efficient procedures might be implemented to monitor the occurrence of non-visible hazards. in addition, given that the current post-mortem inspection procedures involve palpation and incision of some organs, the potential for cross-contamination of carcasses exists. strengths of the current meat inspection methodology for chemical hazards are as follows: -the current procedures for sampling and testing are a mature system, in general well established and coordinated including follow-up actions subsequent to the identification of non-compliant samples. -the regular sampling and testing for chemical residues and contaminants in the system is an important disincentive to the development of undesirable practices. -the prescriptive sampling system allows for equivalence in the control of eu-produced sheep and goat meat. any forthcoming measures have to ensure that the control of imports from third countries remains equivalent to the controls within the domestic market. -the current combination of animal traceability, ante-mortem inspection and gross tissue examination can support the collection of appropriate samples for residue monitoring. weaknesses of the current meat inspection methodology for chemical hazards are as follows: -a weakness of the system is that presence of chemical hazards cannot be identified by current ante-/post-mortem meat inspection procedures at the slaughterhouse level, indicating the need for further harmonization of the risk reduction strategies along the entire food chain. -integration between testing of feed materials for undesirable contaminants and the nrcps in terms of communication and follow-up testing strategies or interventions is currently limited. moreover, a routine environmental data flow is not established and keeping habits for sheep and goats provides opportunities for feed coming in without a clear feed chain history. -under the current system, sampling is mostly prescriptive rather than risk-or informationbased. it appears that individual samples taken under the nrcp testing programme may not always be taken as targeted samples, as specified under council directive / / ec, but sometimes may be taken as random samples. -there is a lack of sufficient cost-effective and reliable screening methods and/or the range of substances prescribed/covered by the testing is sometimes limited. -there is limited flexibility to adopt emerging chemical substances into the nrcps and limited ongoing adaptation of the sampling and testing programme to the results of the residue monitoring programmes. in addition, sampling under the nrcps reflects only a part of testing done by a number of mss, the results of which should be taken into consideration. -sheep and goats may not be subject to surveillance over their lifetime at the same level as is the case for other food animal categories such as pigs, poultry and, to a large extent, bovine animals due to the traditional nomadic/outdoor farming systems. as shown in the comisurv assessment, a change to visual only inspection would cause a significant reduction in the probability of detection (i.e. non-overlapping % probability intervals) of detectable cases of fasciolosis and of tuberculosis in goats. small ruminants are usually not subjected to official tuberculosis eradication campaigns, and farm controls are only performed on premises where cattle and goats are kept together, or in flocks/herds that commercialise raw milk. surveillance for small ruminant tuberculosis at present relies on meat inspection of sheep and goats slaughtered for human consumption, or other limited diagnostic surveillance activities. as is the case with tuberculosis in bovines, the contribution of meat inspection surveillance of tuberculosis in small ruminants is to support the detection of flocks/herds with tuberculosis. detection of tuberculosis in individual animals is merely the first step in improving the effectiveness of flock/herd surveillance, and for any given flock/herd, the flock/herd sensitivity will increase with the number of animals slaughtered. in recent years tuberculosis has been reported in small ruminants in several eu countries and most information derives from recognition of tuberculous lesions at the slaughterhouse and from laboratory reports. although small ruminants are not considered to represent a significant reservoir of the disease for the persistence of bovine tuberculosis in cattle, it is still possible that infected sheep and goat herds could act as vectors of infection for other domestic and wild animals. therefore, surveillance and control of tuberculosis in domestic small ruminants does have consequences for the overall surveillance and control of tuberculosis. the feedback to farmers of fasciola hepatica detected at meat inspection is low at present and the real risk to animal health/welfare for this disease, caused by a change to a visual only meat inspection method, is probably low. implementation of welfare assessment protocols using appropriate animal based indicators during clinical and slaughterhouse (ami + pmi) surveillance system would improve the welfare of small ruminants. extended use of food chain information has the potential to compensate for some, but not all, of the information on animal health and welfare that would be lost if visual only post-mortem inspection is applied. food chain information is a potentially effective tool to perform more targeted ante-mortem and post-mortem inspection tasks in the slaughterhouse which may increase the effectiveness of those tasks in detecting conditions of animal health and animal welfare significance. the existing ineffective flow of information from primary production to the slaughterhouses and vice versa reduces the ability of detection of animal diseases and animal welfare conditions at the slaughterhouse and as a result it limits possible improvements on animal health and welfare standards at the farm as farmers will not be aware of the slaughterhouse findings. the conclusions and recommendations on chemical hazards were reviewed by the ahaw working group and none of them were considered to have impact on animal health and welfare surveillance and monitoring. as neither of the main public health hazards associated with meat from small ruminants can be detected by traditional meat inspection, other approaches are necessary to identify and control these microbiological hazards. a comprehensive meat safety assurance system for meat from small ruminants, combining a range of preventive measures and controls applied both on the farm and at the slaughterhouse in a longitudinally integrated way, is the most effective approach to control the main hazards in the context of meat inspection. information on the biological risks associated with the consumption of meat from sheep or goats is sometimes scant and unreliable. in order to facilitate decision making, harmonised surveys are required to establish values for the prevalence of the main hazards t. gondii and pathogenic vtec at flock/herd, live animal and carcass level in individual member states. epidemiological and risk assessment studies are also required to determine the specific risk to public health associated with the consumption of meat from small ruminants. in the event that these studies confirm a high risk to public health through the consumption of meat from sheep or goats, consideration should be given to the setting of clear and measurable eu targets at the carcass level. to meet these targets and criteria, a variety of control options for the main hazards are available, at both farm and abattoir level. flock/herd categorisation according to the risk posed by the main hazards is considered an important element of an integrated meat safety assurance system. this should be based on the use of farm descriptors and historical data in addition to batch-specific information. farmrelated data could be provided through farm audits using harmonised epidemiological indicators (heis) to assess the risk and protective factors for the flocks/herds related to the given hazards. classification of abattoirs according to their capability to prevent or reduce faecal contamination of carcasses can be based on two elements: ( ) the process hygiene as measured by the level of indicator organisms on the carcasses (i.e. process hygiene criteria); and ( ) the use of operational procedures and equipment that reduce faecal contamination, as well as industry-led quality systems. as mentioned in section . of appendix a, further studies are necessary to determine with more certainty the risk of acquiring t. gondii through consumption of meat from small ruminants. in addition, the lack of tests that can easily identify viable cysts in meat is a significant drawback. further, if there is a high prevalence in the animal population, this will hamper the development of systems based on risk categorisation of animals. for these reasons, the setting of targets for t. gondii is not recommended at the moment. there are a variety of animal husbandry measures that can be used to control t. gondii on sheep and goat farms but at present these are impractical to implement in most farms. a number of post-processing interventions might be effective in inactivating t. gondii such as cooking, freezing, curing and high-pressure and -irradiation treatments. however, most of the information available for these treatments originates from research in pigs, so further research is required to validate these treatments in meat from small ruminants. there are also a variety of animal husbandry measures that can be used to reduce the levels of vtec on infected farms, but their efficacy is not clear in small ruminants. in addition, there are a number of challenges that need to be overcome regarding the setting of targets for pathogenic vtec, including the difficulties in identifying husbandry factors that can be used to classify farms according to pathogenic vtec risk, the intermittent nature of shedding, and the problems with the interpretation of monitoring results for pathogenic vtec due to the difficulty to correctly identify pathogenic vtec. the two main sources of vtec on sheep and goat carcasses are the fleece/hide and the viscera. to control faecal contamination from the fleece or hide only clean animals should be accepted for slaughter, as currently required by eu legislation. there are also a number of measures that can help reducing the spillage or leakage of digestive contents onto the carcass, particularly rodding of the oesophagus and bagging of the rectum. post-processing interventions to control vtec are also available. these include hot water and steam pasteurization. risk categorisation of slaughterhouses should be based on trends of data derived from process hygiene assessments and from hazard analysis critical control point programmes. improvement of slaughter hygiene through technological and managerial interventions should be sought in slaughterhouses with repeatedly unsatisfactory performance. dioxins and dl-pcbs which accumulate in food-producing animals have been ranked as being of high potential concern. as these substances have not yet been comprehensively covered by the sampling plans of the current meat inspection (nrcps), they should be considered as 'new' hazards. in addition, for a number of chemical elements used as feed supplements and for organic contaminants that may accumulate in food-producing animals only limited data regarding residues in sheep and goats are available. this is the case, in particular, for brominated flame retardants, including polybrominated diphenylethers (pbdes) and hexabromocyclododecanes (hbcdds) and perfluorinated compounds (pfcs) including (but not limited to) perfluorooctane sulphonate (pfos) and perfluorooctanoic acid (pfoa). fci can be improved by including information on participation in quality assurance schemes and by giving greater feedback to the primary producer, as this would probably result in the production of healthier animals. ante-mortem inspection assesses the general health status of the animals and helps to detect animals heavily contaminated with faeces on arrival at the slaughterhouse. taking these factors into consideration, and given that current methods do not increase the microbiological risk to public health, no adaptations to the existing visual ante-mortem inspection procedure are required. although visual examination contributes by detecting visible faecal contamination, routine post-mortem examination cannot detect the meat-borne pathogens of public health importance. palpation of the lungs, the livers, the umbilical region and the joints and incision of the liver could contribute to the spread of bacterial hazards through cross-contamination. for these reasons, palpation and incision should be omitted in animals subjected to routine slaughter. sheep and goat production in the eu is marked by being largely extensive in nature, involving frequent trading of animals and nomadic flocks. this involves differences in husbandry systems and feeding regimes resulting in different risks for chemical substances and contaminants. extensive periods on pasture or/as nomadic flocks and the use of slaughter collection dealerships may preclude detailed lifetime fci. similarly, in these situations, the level of feedback from the slaughterhouse and authorities to farmers regarding the results of residue testing may be suboptimal. there is less concern about fci from dairy sheep and goats as they are reared under more intensive and controlled conditions. better integration of results from official feed control with residue monitoring seems essential to indicate whether monitoring of residues in slaughter animals needs to be directed to particular substances. therefore, there is a need for an improved integration of sampling, testing and intervention protocols across the food chain, nrcps, feed control and environmental monitoring. to provide a better evidence base for future risk ranking of hazards, initiatives should be instigated to: improve and harmonise data collection of incidence and severity of human diseases caused by relevant hazards; systematically collect data for source attribution; collect data to identify and risk rank emerging hazards that could be transmitted through handling, preparation and consumption of sheep and goat meat. source attribution studies are needed to determine the relative importance of meat and to ascertain the role of the different livestock species as sources of t. gondii and pathogenic vtec for humans. methods should be developed to estimate the amount of viable t. gondii tissue cysts in meat, especially in meat cuts that are commonly consumed. the effect of the omission of palpation and incision on the risk posed by non-meat-borne zoonoses such as echinococcus granulosus and fasciola hepatica should be assessed, particularly in those regions where these hazards are endemic. fci should be expanded for sheep and goats produced in extensive systems to provide more information on the specific environmental conditions where the animals are produced. it is recommended that sampling of sheep and goats should be based on the risk of occurrence of chemical residues and contaminants and on the completeness and quality of the fci supplied. regular updating of the ranking of chemical substances in sheep and goats as well as of the sampling plans should occur taking into account any new information regarding the toxicological profile of chemical residues and contaminants, usage in sheep and goat production, and actual occurrence of individual substances in sheep and goats. control programmes for chemical residues and contaminants should be less prescriptive, with sufficient flexibility to adapt to results of testing, should include 'new hazards', and the test results for sheep and goats should be separately presented. there is a need for an improved integration of sampling, testing and intervention protocols across the food chain, nrcps, feed control and monitoring of environmental contaminants. the development of analytical techniques covering multiple analytes and of new biologically based testing approaches should be encouraged and incorporated into the residue control programmes for prohibited substances, testing should be directed where appropriate towards the farm level and, in the case of substances that might be used illicitly for growth promotion, control measures, including testing, need to be refocused to better identify the extent of abuse in the eu. in addition, control measures for prohibited substances should not rely exclusively on nrcp testing, but should include veterinary inspection during the production phase and the use of biological methods and biomarkers suitable for the identification of abuse of such substances in sheep and goat production in the eu. data collected during clinical and slaughterhouse (ante-mortem and post mortem inspection) surveillance systems should be utilised more effectively to improve animal welfare at farm level. slaughterhouse surveillance of tuberculosis in small ruminants should be improved and encouraged, as this is in practice the only surveillance system available. the detection of tuberculosis in small ruminants should be adequately recorded and notified, followed by control measures at the farm level. lack of feedback of post-mortem inspection results to the farmer prevents instigation of a fluke management programme, which could be detrimental to animal health and welfare. an improvement in this feedback of information is recommended. welfare surveillance systems should become an integral part of the food chain information. an integrated system should be developed whereby food chain information for public health and for animal health and welfare can be used in parallel, more effectively provide farmers with background information on the animal diseases and welfare conditions of key concern that may affect their livestock and why it is important to provide this information to the slaughterhouse through the use of food chain information. following a request from the european commission, the panel on biological hazards (biohaz) was asked to deliver a scientific opinion on the public health hazards to be covered by inspection of meat for several animal species, with the contribution of the panel on contaminants in the food chain (contam) and the panel on animal health and welfare (ahaw). briefly, the main risks for public health that should be addressed by meat inspection were identified and ranked; the strengths and weaknesses of the current meat inspection were evaluated; and recommendations were made for inspection methods capable of meeting the overall objectives of meat inspection for hazards currently not covered by the meat inspection system, as well as recommendations for adaptations of inspection methods and/or frequencies of inspections that provide an equivalent level of protection. in addition, the implications for animal health and animal welfare of any changes proposed to current inspection methods were assessed. this opinion covers the inspection of meat from sheep and goats. the biohaz panel considered sheep and goats together . a decision tree was used for priority ranking of meat-borne hazards present in meat from sheep and goats. the ranking was based on the magnitude of the human health impact, the severity of the disease in humans and the evidence supporting the role of meat from sheep and goats as a risk factor for disease in humans. the assessment was focused on the public health risks that may occur through the handling, preparation and/or consumption of meat from these species. the term 'priority' was considered more appropriate than 'risk' for categorizing the hazards associated with meat from small ruminants, given that a significant amount of data on both the occurrence of the hazards and on the attributable fraction of human cases to meat from small ruminants were not available. based on the priority ranking, the hazards were classified as follows: toxoplasma gondii and pathogenic vtec were classified as high priority for sheep/goat meat inspection. the remaining identified hazards, bacillus anthracis, campylobacter spp. (thermophilic) and salmonella spp., were classified as low priority, based on available data. as new hazards might emerge and/or hazards that presently are not a priority might become more relevant over time or in some regions, both hazard identification and the risk ranking should be revisited regularly to reflect this dynamic epidemiological situation. particular attention should be given to potential emerging hazards of public health importance. the main elements of the current meat inspection system include analysis of fci, ante-mortem examination of animals and post-mortem examination of carcasses and organs. the assessment of the strengths and weaknesses of the current meat inspection was based on its contribution to the control of the meat-borne human health hazards identified in sheep and goats. a number of strengths and weaknesses of the current system were identified. currently, the use of food chain information (fci) for food safety purposes is limited for small ruminants because the data that it contains is very general and doesn't address specific hazards of public health importance. however, fci could serve as a valuable tool for risk management decisions and could be used for risk categorisation of farms or batches of animals. to achieve this, the system needs further development to include additional information important for food safety, including definition of appropriate and standardized indicators for the main public health hazards identified above. ante-mortem and post-mortem inspections of sheep and goats enable the detection of observable abnormalities and provide a general assessment of animal/herd health, which if compromised may lead to a greater public health risk. visual inspection of live animals and carcasses can detect animals heavily contaminated with faeces, which increase the risk for cross-contamination during slaughter and may constitute a food safety risk if the animals are carrying hazards of public health importance. if such animals or carcasses are dealt with adequately, this risk can be reduced. visual detection of faecal contamination on carcasses can also be an indicator of slaughter hygiene, but other approaches to verify this should be considered. post-mortem inspection can also detect non meat-borne hazards of public health significance, such as echinococcus granulosus, that can be present in carcasses or offal from small ruminants. ante-mortem and post-mortem inspection also have the potential to detect new diseases, which may be of direct public health significance. the main weakness of ante-mortem and post-mortem inspection is that they are not able to detect any of the public health hazards identified as the main concerns for food safety. in addition, given that the current post-mortem procedures involve palpation and incision of some organs, the potential for crosscontamination of carcasses exists. as neither of the main public health hazards associated with meat from small ruminants can be detected by traditional visual meat inspection, other approaches are necessary to identify and control these microbiological hazards. a comprehensive meat safety assurance system for small ruminants, combining a range of preventive measures and controls applied both on the farm and at the slaughterhouse in a longitudinally integrated way, is the most effective approach to control the main hazards in the context of meat inspection. information on the biological risks associated with the consumption of meat from sheep or goats is sometimes scant and unreliable. in order to facilitate decision making, harmonised surveys are required to establish values for the prevalence of the main hazards t. gondii and pathogenic vtec at flock/herd, live animal and carcass level in individual mss. epidemiological and risk assessment studies are also required to determine the specific risk to public health associated with the consumption of meat from small ruminants. if these studies confirm a high risk to public health through the consumption of meat from sheep or goats, consideration should be given to the setting of clear and measurable eu targets at the carcass level. to meet these targets and criteria, a variety of control options for the main hazards are available, at both farm and abattoir level. flock/herd categorisation according to the risk posed by the main hazards is considered an important element of an integrated meat safety assurance system. this should be based on the use of farm descriptors and historical data in addition to batch-specific information. farm-related data could be provided through farm audits using harmonised epidemiological indicators (heis) to assess the risk and protective factors for the flocks/herds related to the given hazards. in addition, classification of abattoirs according to their capability to prevent or reduce faecal contamination of carcasses can be based on two elements: ( ) the process hygiene as measured by the level of indicator organisms on the carcasses (i.e. process hygiene criteria); and ( ) the use of operational procedures and equipment that reduce faecal contamination, as well as industry led quality systems. there are a variety of husbandry measures that can be used to control t. gondii on sheep and goat farms but at present these are impractical to implement in most farms. a number of post-processing interventions are effective in inactivating t. gondii such as cooking, freezing, curing, high pressure and irradiation treatments, although further research is required to validate these treatments in meat from small ruminants. there are also a variety of husbandry measures that can be used to reduce the levels of vtec on farms, but their efficacy is not clear in small ruminants. there are also a number of challenges that need to be overcome regarding the setting of targets for pathogenic vtec, including the difficulties in identifying husbandry factors that can be used to classify farms according to pathogenic vtec risk, the intermittent nature of shedding, and the problems with the interpretation of monitoring results for vtec due to the difficulty to correctly identify pathogenic vtec. the main sources of vtec on sheep and goat carcasses are the fleece/hide and the viscera. to control incoming faecal contamination only clean animals should be accepted for slaughter. there are also a number of measures that can help reducing the spillage or leakage of digestive contents onto the carcass, as well as post-processing interventions to control vtec are also available. these include hot water and steam pasteurization. risk categorisation of slaughterhouses should be based on trends of data derived from process hygiene assessments and from hazard analysis critical control point programmes. improvement of slaughter hygiene through technological and managerial interventions should be sought in slaughterhouses with repeatedly unsatisfactory performance. fci can be improved by including information on participation in quality assurance schemes and by greater feedback to the primary producer, as this would likely result in the production of healthier animals. ante-mortem inspection assesses the general health status of the animals and helps to detect animals heavily contaminated with faeces on arrival at the slaughterhouse, so no adaptations for the existing visual ante-mortem inspection are required. routine post-mortem examination cannot detect the meat-borne pathogens of public health importance. palpation of the lungs, the liver, the umbilical region and the joints, and incision of the liver could contribute to the spread of bacterial hazards through cross contamination. for these reasons, palpation and incision should be omitted in animals subjected to routine slaughter. a series of recommendations were made on data collection, source attribution studies, methods of detection of viable t. gondii in meat and on assessing the effect of the omission of palpation and incision on the risk posed by non-meat-borne zoonoses. assessing current meat inspection systems for sheep and goats with the aim of introducing improvements requires a common understanding of the term "meat inspection". however, as discussed previously (efsa, (efsa, , , it seems that there is no precise, universally agreed definition of meat inspection. the term meat inspection is not described specifically in current european union (eu) legislation (regulation (ec) no / ) or in the codex alimentarius's code of hygienic practice for meat (cac/rcp - ) ; rather, there are references to elements of the inspection process for meat such as ante-and post-mortem inspections and food chain information. consequently, the current understanding of the term meat inspection is probably based more on its practical application, and somewhat intuitive, than on a specific, formal definition. the biohaz panel defined the main scope of this scientific opinion as identifying and ranking the most relevant public health risks associated with meat from sheep and goats, assessing the strengths and weaknesses of the current meat inspection system, proposing alternative approaches for addressing current meat safety risks, and outlining a generic framework for inspection, prevention and control for important hazards that are not sufficiently covered by the current system. outside of the scope of the opinion were: microbiological hazards representing only occupational health risks transmissible spongiform encephalopathies (tses) issues other than those of public health significance, but which still compromise fitness of meat for human consumption (for example quality issues such as dark firm and dry (dfd) meat). as the eu regulations do not include different inspection requirements for sheep and goats, both species are considered together, but any important differences between these species are considered when necessary. in this document, the term small ruminant is used to refer to a combination of sheep and goats. in order to evaluate any important differences in meat inspection procedures between countries and/or regions as well as between species, the biohaz panel was supported by input provided during a technical hearing on meat inspection of small ruminants, during which experts from several stakeholder organisations presented information that had previously been requested by means of a questionnaire. following the hearing, an event report was compiled (efsa, ). the conclusions from this report are referred to when relevant. chemical hazards and associated meat safety risks in small ruminants are considered in a separate part of this opinion (see appendix b). although highest priority is given to the public health aims of the improvements of the biological/chemical meat safety system, any implications for animal health and welfare of the proposed changes were assessed (see appendix c). furthermore, issues related to epidemiological indicators and associated sampling/testing methodologies for hazards dealt with in this opinion were addressed by the biological monitoring unit in a separate document (efsa, ). the structure of the eu small ruminants farming industry has already been described in an efsa opinion (efsa, ) . briefly, sheep farming takes place in many areas of europe because sheep are able to live in a wide range of environments, even those hostile for other animals. goats are generally reared in extensive systems, traditionally in less developed areas, such as mountains or arid regions, and are often reared with sheep, especially in southern europe. milk sheep and goats are reared in similar systems, either grazed near the farm or kept housed, with the milk used in most cases for cheese production. meat production in europe reflects the diverse farming systems. lamb meat production originates from sheep milk farms or from farms raising meat breeds. in the mediterranean countries, the lambs from milk farms are slaughtered at approximately one month of age (suckling lambs, the same applies to goat kids). in some of these countries, lambs from meat breeds are generally slaughtered at - days of age and represent the majority of total national lamb meat production. in northern countries, the rearing systems usually produce heavier lambs that may be slaughtered at six or more months of age. the proportion of sheep raised for wool production has steadily decreased over time, but it is still significant in parts of the eu. sheep and goats at the end of their productive life can also be destined for meat production, with the resulting meat usually processed into meat products or exported. although the production and consumption of lambs have decreased in recent years, lamb meat continues to be a traditional product consumed in some countries of the eu such as the united kingdom, ireland and the mediterranean countries (spain, france, greece and italy). these countries have the largest populations of sheep in the eu. in general, the southern countries produce lighter carcasses (about kg) than the northern ones ( - kg). sheep are relatively small animals, with a lower yield of meat per carcass and higher slaughter and processing costs per unit of meat produced. as a result, sheep meat is relatively expensive in the market compared with other protein sources. the co-products (e.g. hides, wool, offal, feet, tails, etc.) have a major effect on the prices received by producers, and the impact on the profitability of the enterprise is profound (byrne et al., ) . eurostat statistics show that sheep meat production in the eu was over tonnes in , with the united kingdom and spain as the greatest producers ( figure ). goat meat production in the eu is concentrated in the southern european countries, especially greece and spain ( there are many forces instigating change in sheep and goat meat production. legislative forces present in the hygiene package and microbiological regulation have increased meat hygiene service costs through structural and food safety requirements as well as mandating the provision of traceability and food chain information (palmer c.m., ) . commercial considerations, such as lower coproduct returns, higher costs of by-product disposal and the sourcing policies of the multiple retailers (using their market power to control margins) have also put pressure on slaughterhouse profitability (palmer, ) . in spite of the eu being only about % self-sufficient in sheep meat, the predictions are that eu sheep numbers are expected to continue to decline over the next years. this problem of falling sheep supplies has led to an overcapacity in the processing sector (byrne et al., ) . the effect of this decline is most acute for large slaughterhouses, which can only be run profitably at certain levels of throughput. given the energy market expectations, greater environmental controls and the pressure on enforcement costs, relief from falling costs looks unlikely (palmer, ) . , ) . these variations, individually and their combinations, lead to between-slaughterhouse differences in process hygiene performance and, consequently, in the hygienic status of the final carcass. at the end of the slaughter line prior to chilling, process hygiene microbiological criteria, as defined in regulation (ec) no / , verify the effectiveness of each plant's food safety management system (which includes ghp and good manufacturing practices (gmp) prerequisite programmes), based on the principles of hazard analysis and critical control points (haccp) systems. generally, smaller slaughterhouses process much smaller quantities of meat for localised markets and operate at a slower line speed. operators in such establishments tend to have a wider skill base than their counterparts in large establishments owing to the many varied roles they perform. however, small slaughterhouses have reduced investment capital for expenditure on premises, equipment and staff food safety management training. disposal of animal by-products and compliance with the microbiological testing regulation (ec) no / places further financial pressure on these lowthroughput businesses. to ameliorate the financial impact of this testing, article in this regulation states that the frequency of this microbiological sampling may be adapted to the nature and size of the food business, based on a standardised risk assessment and authorised by the competent authority. larger slaughterhouses operate more efficiently, with greater separation of duties and better sampling and food safety oversight. these larger units have larger co-product/by-product markets and therefore produce less waste per animal processed. however, the requirement for high-volume throughput with increased slaughter line speed can impinge on operational hygiene and therefore food safety (food standards agency, a; palmer, ) . such differences in structure and operational practices in the varying sized slaughterhouses can determine the effectiveness of the food safety management system (motarjemi, ). hazard identification and risk ranking . . a hazard is defined by the codex alimentarius commission (cac) as a "biological, chemical or physical agent or property of food with the potential to cause an adverse health effect". the first step in the hazard identification carried out in this assessment focused on identifying biological hazards occurring in small ruminants and small ruminant meat that can be transmitted to humans, where they may cause disease. hazards were identified based on evidence found in peer-reviewed literature, textbooks, through reported data (e.g. eu summary reports on zoonoses), previous assessments and efsa opinions, and the biohaz panel's and working group's expert knowledge. from this "long" list of identified hazards, the panel excluded those hazards: for which no causal relationship between human infections and the handling, preparation and consumption of meat from small ruminants could be documented through targeted literature reviews. not presently found in the small ruminant population in the eu. the final "short" list of identified hazards to be included in the priority ranking consisted of hazards occurring in the eu and for which evidence could be found of foodborne transmission through the handling, preparation and/or consumption of sheep and goat meat. in the context of this opinion, when referring to handling and preparation this should be interpreted as handling of sheep and goat meat that occurs immediately prior to consumption, when these activities are carried out by consumers or professional food handlers. based on a review of the scientific literature, a wide range of biological hazards were identified as potential zoonotic hazards related to small ruminants (see table ). from these, the majority were considered not to be small ruminant meat-borne pathogens, as no evidence could be found in the literature to support transmission through handling, preparation or consumption of small ruminant meat (for further information on hazards not included see annex , and section . . in this appendix for those for which evidence for meat-borne transmission was documented). other potential pathogenic microorganisms were found not to be relevant as they are not considered to be currently present in small ruminants in europe (chandipura virus, cryptococcus neoformans var. neoformans and hepatitis e virus), or, if they are, consumption of meat is not considered a significant source of infection. the latter situation applies in particular to linguatula serrata, for which contact with the final host (canids) is the source for the human cases described in europe. for some of these hazards (e.g. extended-spectrum β-lactamase-(esbl-)/ampc-carrying escherichia coli), despite their presence in the animal reservoir, no studies have been conducted to establish whether there is a link between consumption of meat from small ruminants and disease in humans. the presence of mycobacteria has been previously reported in the small ruminant population in the eu (domenis et al., ; malone et al., ; marianelli et al., ; . despite these reports, evidence of meat-borne transmission of these pathogens to humans from small ruminants is lacking, so this potential pathway of infection remains unproven in the context of livestock processed through the eu meat inspection system. a more detailed discussion on the potential for meat-borne transmission of mycobacteria can be found in the scientific opinion dealing with bovines (efsa biohaz panel, ). the remaining hazards were considered eligible for further assessment and risk ranking ( table ). the panel developed a decision tree that was used for the risk ranking of the small ruminant meatborne hazards according to their risk of causing infection in humans following the handling, preparation and/or consumption of sheep or goat meat ( figure ). the cac defines risk as "a function of the probability of an adverse health effect and the severity of that effect, consequential to one or more hazards in a food". in other words, a foodborne risk is a product of the likelihood of occurrence of the hazard and the magnitude and severity of the consequences of the illness it causes on human health. this decision tree was adapted from that presented in the scientific opinion on poultry meat inspection (efsa panel on biological hazards (biohaz), efsa panel on contaminants in the food chain (contam) and efsa panel on animal health and welfare (ahaw), ). however, there are key differences as follows: carcass pathogen prevalence and source attribution are not considered as separate questions, or ranking steps, but these two questions are addressed together in a single step. this modification was considered appropriate as there was insufficient data at eu level for qualifying carcass prevalence and source attribution for the given hazards. furthermore, consumption of meat from small ruminants is both lower and unevenly distributed in the eu relative to that of meat from other animal species such as pigs or poultry. attribution at the population level, as applied in the previous scientific opinions on meat inspection (efsa panel on biological hazards (biohaz), efsa panel on contaminants in the food chain (contam) and efsa panel on animal health and welfare (ahaw), , ), may not provide a sufficiently detailed perspective on the relative risk of different hazards in meat from small ruminants. the risk to consumers of meat from these species, rather than to the population as a whole, was therefore assessed. an added consequence is that the categorisation has been reduced from three to two categories (i.e. the medium category is not used in this opinion). the term "priority" has replaced the term "risk" used in the pork and poultry opinions. risk ranking requires a significant amount of data on both the occurrence of the relevant hazards and the fraction of cases of human disease caused by the different hazard-meat species combinations (i.e. source attribution). while there were sufficient data to perform a risk ranking of the hazards associated with pork and poultry, this was not the case for all potential hazards in small ruminants, for which eu-wide baseline surveys and harmonised monitoring do not exist and relevant studies published in the scientific and technical literature are often limited. the term "priority" was therefore considered more appropriate than "risk" for categorising the hazards associated with meat from small ruminants. based on this, the panel identified the following criteria to be important for determining the final priority category: step : identifying and excluding those hazards that are introduced and/or for which the risk for public health requires microbial growth during steps that take place after carcass chilling. the reasons for excluding such hazards from further assessment were that: ( ) the scope and target of meat inspection are focused on the food safety risks of the carcasses at the end of slaughter when they are chilled but before they are further processed; and ( ) hazards introduced and/or for which the risk relates exclusively to growth during post-chilling processes are better controlled later in the food production chain through, for instance, haccp programmes. step : to assess the magnitude of the human health impact, as measured by the reported incidence (notification rate) or number of cases. where data allowed, the estimated total number of cases was presented, i.e. adjusting for under-reporting. incidence was considered high if the notification rate in humans at eu level, as reported to ecdc, was equal to or higher than cases in population in any given year. step : to assess the severity of the disease in humans based on mortality. if necessary, severity was also evaluated by comparing disease burden estimates, expressed for example in disability-adjusted life-years (dalys) per cases. the daly metric quantifies the impact of disease on the health-related quality of life of acute diseases and sequelae, as well as the impact of premature deaths. severity was considered high if mortality in humans at eu level, as reported to ecdc, was higher or equal to . % in more than one year. step : evidence supporting the role of meat from small ruminants as a risk factor for disease in humans. for this, the following sources of information were considered: . epidemiological link, based on a significant likelihood that the consumption of meat from the given species is a risk factor for human cases, or on outbreak data . carcass prevalence /farm level prevalence (prevalence studies) . comparative considerations for meat from related species . expert opinion that meat consumption is a risk factor. the final outcome of this process involved categorising each hazard as high or low priority, as follows: the priority was characterized as 'high' when a hazard was identified as causing a high incidence and/or severity of illness in humans, and when strong evidence existed for meat from sheep or goats being an important risk factor for human disease. considering the limitations of the data available for the priority ranking, this risk category could be regarded as combining both the medium and high risk categories of the risk ranking carried out in the poultry meat inspection opinion (efsa panel on biological hazards (biohaz), efsa panel on contaminants in the food chain (contam) and efsa panel on animal health and welfare (ahaw), ); the priority was characterized as 'low' when a hazard was identified as not associated with a high incidence and a high severity of human disease or if, despite the hazard causing a high incidence and/or severity in humans, the evidence available did not identify meat from sheep or goats as an important risk factor for human disease; all hazards placed in the low priority category were further evaluated to determine if this was low due to currently controls applied (i.e. any hazard specific control measure implemented at farm and/or slaughter level before chilling of the carcass, including meat inspection procedures). if this was not the case, the hazard was not considered further. however, if this was the case then the hazard was further considered and the effect of any recommendations regarding the removal of specific control measures or meat inspection activities on these hazards was assessed and the categorisation of the hazard was reconsidered. figure : flowchart for priority ranking different public health hazards. risk of infection by handling, preparation or consumption of sheep and/or goat meat. current controls: any hazard-specific control measures implemented at farm and/or slaughterhouse level before chilling of the carcasses. for the hazards shortlisted (table ) , data on the incidence and severity in humans and the prevalence of the pathogens in the carcasses of small ruminants were sought to allow the risk from these microbiological hazards to be ranked, based on the decision tree in figure . see tables , , and for details. the data in table were obtained from the european surveillance system (tessy), covering the years , , and . the data are officially reported to the european centre for disease prevention and control (ecdc) by eu mss; however, some countries do not report on certain diseases; these were specified. the data were supplied as aggregates from all reporting mss. data show notification rates of confirmed human disease cases as per persons, and severity of illness in humans. cases include all reported confirmed occurrences of the disease, regardless of the origin of the infection. in fact, establishing the food-related origin of infection is often not possible and seldom reported. the data on severity include as a proxy the proportion of confirmed human cases that died. this information is usually only available in a small proportion of cases. finally, it has to be kept in mind that the surveillance systems are set up differently in the various eu mss, with different case definitions, national or restricted coverage, voluntary or compulsory reporting, focus, target groups, etc., in addition to the fact that only a small fraction of diseased patients is sampled and the casual organism typed and reported to the respective national health institutes. because of all these caveats, the incidence and severity figures quoted here are only approximate and must be considered with caution. n.a. h a eu population data based on individual ms population sizes reported in eurostat (data extracted: september ). when the given hazard was not reported by a ms to tessy, the population size reported by that ms was also taken out of the calculation of the overall eu population size. b calculated as the percentage of cases with fatal outcome over all cases of disease with known outcome, for a given hazard. c portugal, greece not reporting. d portugal not reporting. for a more detailed review of vtec (including serotype o ) incidence and severity in the eu see the recently published efsa opinion on vtec-seropathotype and scientific criteria regarding pathogenicity assessment (efsa panel on biological hazards, ). e portugal not reporting. f s. enterica subsp. enterica serovar typhi and s. paratyphi serovars not included; netherlands not reporting. g seroprevalence. belgium, denmark, greece, italy, netherlands, portugal and sweden not reporting; spain reporting through the sentinel system and thus not taken into account. france not reported in at the time of extraction of these data. h n.a. = not available. data presented in tables - are related to flock/herd and carcass prevalence of the hazards identified in sheep and goats. they were obtained from monitoring data as reported by the eu mss in the frame of the zoonosis directive ( / /ec), when available. data reported in the period from to were considered. no information was available at carcass level for goats. in these tables, data described as originating from suspect or selective sampling and from clinical investigations were excluded as they do not, in most cases, represent the actual epidemiological situation. food samples described as collected for haccp and own-check purposes were also excluded because the sampling scheme may be biased. samples included are described as originating from control and eradication plans and monitoring and surveillance; consequently they are supposed to represent the occurrence of the zoonotic agent in the reporting country over the years, based on objective sampling. however, it has to be noted that monitoring and surveillance systems for most of zoonotic agents are not fully harmonised between mss. furthermore, data may not necessarily be derived from sampling plans that have a sound statistical design, and may therefore not accurately represent the national situation regarding the true prevalence of zoonoses. data in tables and originate from samples taken from either farms or slaughterhouses, while for table . ( - ) a n.a., no data available. b includes those reported as human pathogenic and non-human pathogenic (i.e. no harmonised scheme to discriminate between both, and data available does not preclude that they are not human pathogenic). c seroprevalence. includes those reported as human pathogenic and non-human pathogenic (i.e. no harmonised scheme to discriminate between both, and data available does not preclude that they are not human pathogenic). c seroprevalence. includes those reported as human pathogenic and non-human pathogenic (i.e. no harmonised scheme to discriminate between both, and data available does not preclude that they are not human pathogenic). c seroprevalence. listeria monocytogenes and toxins of bacillus cereus, clostridium botulinum, clostridium perfringens and staphylococcus aureus were all considered to fall within the category of risk related to growth or introduction post-chilling, for different reasons: b. cereus, c. botulinum and c. perfringens and their spores and s. aureus are considered ubiquitous bacteria, and can be found in a variety of foods. their vegetative forms need temperatures above those used for refrigeration to grow in raw meat to concentration levels of relevance for public health and thus the risk of disease seems not to be correlated with occurrence in raw meat but rather with improper hygiene and storage that allows the production of toxins. illness caused by l. monocytogenes is usually associated with ready-to-eat products, in which contamination has occurred before or during processing followed by growth during storage at refrigeration temperatures. based on incidence and severity in humans (table ) , flock/herd, animal and carcass prevalence (tables , and ) and other epidemiological evidence, the hazards in table were ranked and categorised according to the flowchart in figure , as described in section . . above. a summary of the outcome is provided in table at the end of this section. none of the hazards identified as low priority were found to be such owing to currently applied controls. this organism has a worldwide distribution, persisting in the soil in the form of extremely resistant spores for many years. infection is initiated with the introduction of the spore through a break in the skin or entry through the mucosa. after ingestion by macrophages at the site of entry, germination to the vegetative form occurs, followed by extracellular multiplication and capsule and toxin production. humans can acquire anthrax by exposure to infected animals, animal products or spores in the soil and, depending on the mode of transmission, can develop one of four distinct clinical forms: respiratory, cutaneous, gastrointestinal and oropharyngeal. human cases of pulmonary anthrax have been linked to the large-scale processing of hides and wool in enclosed factory spaces, where aerosolised anthrax spores may be inhaled. humans also acquire the cutaneous form of anthrax from handling contaminated animal products, such as hides, wool and hair. cases of gastrointestinal anthrax have resulted from the ingestion of raw or undercooked meat (spickler, ) and well-cooked beef from infected animals (centers for disease control and prevention, ) . recently, a case of anthrax possibly acquired through handling or consumption of contaminated beef in a household in romania has been reported (popescu et al., ) . consumption of meat (including sheep and goat meat) from carcasses of animals showing clinical signs of anthrax, or animals that have died from the disease, is the most reported common route of foodborne infection resulting in gastrointestinal anthrax. human incidence: based on eu data, low. anthrax has a low human prevalence in the eu (see table for details). between and , the number of anthrax cases reported to the ecdc ranged from two confirmed cases ( ) severity of disease: based on eu data, high. the severity of these infections is considered high, and this is supported by the mortality figures in table . evidence for meat from small ruminants as an important risk factor: no. the organism causes a highly infectious notifiable disease in farmed and wild animals that have grazed on contaminated land or ingested contaminated feed (swartz, ) . the livestock species most susceptible, in descending order, are cattle, sheep, horses, pigs, goats and camels (fasanella et al., a) . the disease is endemic in most countries in africa and asia (thurnbull, ) and in defined regions of other countries. flooding may often concentrate spores of b. anthracis in particular locations. in sheep and goats, the disease is usually peracute, or acute and rapidly fatal, with death occurring in some cases within hours and affected animals showing multiple haemorrhages from natural orifices. although most cases are found dead without showing premonitory signs, pyrexia with temperatures up to c along with depression, congested mucosae and petechiae may be observed ante-mortem. post-mortem findings are characterised by incomplete rigor mortis, widespread ecchymotic haemorrhages and oedema, dark, unclotted blood and blood-stained fluid in body cavities and severe splenomegaly (quinn et al., ) . handling, or direct contact with such animals and carcasses is highly dangerous. anthrax is now rare in livestock in the eu. the major enzootic areas are greece, spain, france and southern italy (fasanella et al., ; fouet et al., ) . a severe outbreak of anthrax occurred in southern italy in (fasanella et al., b . over days, cattle, sheep, goats, horses and deer died. also in italy, an outbreak of anthrax of similar magnitude was reported among cattle, sheep and horses in . given the low number of cases of anthrax in the small ruminant population in the eu, the risk of acquiring this disease through consumption of meat from these species can be considered very low. based on the data presented and on the above discussions, the biohaz panel concluded that b. anthracis was a low priority hazard with regard to meat inspection of small ruminants. this result is not due to current controls (i.e. any hazard-specific control measures implemented at farm and/or slaughter level before chilling of the carcasses, including current meat inspection procedures). human incidence: based on eu data, high. campylobacteriosis is the most frequently reported zoonotic illness in the eu with a reported incidence of . confirmed cases per in (table ) , and it is estimated that there are nine million cases of illness annually in the eu- (efsa panel on biological hazards, ). severity of disease: as the incidence is high, the severity does not need to be considered. campylobacter jejuni is common in the intestines of ruminants of sheep and lambs. the reported prevalence of campylobacter spp. in sheep and goats can be found in tables , and . for sheep and at flock level, the prevalence was . %, while for goats it was . % (at individual animal level there were . % and . %). with regards to carcasses, no data were available for goats. for sheep, the batch prevalence was %, and at individual sample level . %. information from the scientific literature also suggests that campylobacter spp. is often found in small ruminants, with a wide range of prevalences reported. in a study of lambs in the united kingdom campylobacter spp. was isolated from % of the samples taken from the small intestines (stanley et al., ) . on the other hand, sproston et al. ( ) found this bacterium in just % of fresh faecal samples from sheep on a farm in scotland. other studies have reported prevalences somewhere in between these two figures (milnes et al., ; ogden et al., ; oporto et al., ; schilling et al., ) . a seasonal variation in prevalence and the number of campylobacter spp. has also been reported in some studies (milnes et al., ; sproston et al., ) . several studies have investigated the presence of campylobacter spp. in carcasses or meat from small ruminants. garcia et al. ( ) investigated the presence of campylobacter spp. on sheep carcasses, with a resulting prevalence of %. the authors concluded that the prevalence on carcasses reflected the occurrence of campylobacter spp. in both wool and faeces. however, there is a significant reduction in detection following chilling, probably owing to both the low temperature and drying of the carcass (norwegian scientific committee for food safety, ). after swabbing of cm around the circum-anal incision of lamb carcasses before chilling campylobacter spp. was isolated from eight ( . %) of the carcasses. after a relatively slow chilling process (the air temperature was never below °c) campylobacter spp. was recovered from only one carcass ( for contact with sheep as a risk factor for human campylobacteriosis, but consumption of meat from these species was not considered a risk factor. an earlier case-control study in households with primary campylobacter spp. infection in the netherlands also failed to identify consumption of mutton as risk factor (oosterom et al., ) finally, people that had consumed mutton were less likely to become ill with campylobacter spp. infection in a prospective case-control study of campylobacteriosis carried out in norway (kapperud et al., ) . like their sensitive counterparts, antimicrobial-resistant campylobacter spp. involved in human disease are mostly spread through foods, especially poultry meat. as stated in a previous efsa opinion (efsa, ) , "a major source of human exposure to fluoroquinolone resistance via food appears to be poultry, whereas for cephalosporin resistance it is poultry, pork and beef that are important, these food production systems require particular attention to prevent spread of such resistance from these sources". there are no indications that resistant strains behave differently in the food chain compared with their sensitive counterparts, hence there is no need to consider these strains separately in the context of meat inspection. based on the presented data, it is concluded that campylobacter spp. are a low public health priority with regard to meat inspection of small ruminants. this ranking is not the result of current controls. verocytotoxin/shiga toxin (vt/stx)-producing e. coli (vtec/stec) are characterised by the ability to produce potent cytotoxins. pathogenic vtec usually also harbour additional virulence factors that are important for the development of the disease in human (efsa and ecdc, , b) . not all vtec strains have been associated with human disease and there is no single marker or combination of markers that defines a "pathogenic" vtec (efsa panel on biological hazards, ). while stx and eae gene-positive strains are associated with a high risk of more serious illness, other virulence gene combinations and/or serotypes may also be associated with serious disease in humans. for the purposes of this opinion, pathogenic vtec are defined as vtec capable of causing disease in humans. human incidence: based on eu data, low. most reported meat-borne human vtec infections are sporadic cases. in (efsa and ecdc, ), the total number of confirmed vtec cases in the eu was , representing a . % increase compared with , with a fatality rate of . %. table includes data from tessy from to inclusive. in that period the incidence (all vtec serotypes) per population varied between . and . . the data are not easily comparable between eu countries, owing to underlying differences in the national surveillance systems. the concentration of laboratory testing on the o serogroup means that the proportion of non-o strains is largely under-reported (ecdc and efsa, ) . data for have to be interpreted with caution, as vtec o :h caused a major outbreak which resulted in confirmed cases, including cases of vtec infection and of acute renal failure, known as haemolytic-uraemic syndrome (hus), with deaths reported in eu countries, the united states and canada when the epidemic was declared to be over at the end of july (karch et al., ) . it has to be noted, however, that the source of the outbreak was sprouted seeds and not meat. severity of disease: based on eu data, high. pathogenic vtec infections can be severe, and are often associated with bloody diarrhoea, but there is a wide clinical spectrum in the association between specific subtypes of pathogenic vtec and the clinical outcome. bloody diarrhoea has been shown to be associated with an increased risk of developing hus and neurological injury, such as paralysis. hus develops in up to % of patients infected with vtec o and is the leading cause of acute renal failure in young children (efsa and ecdc, ) . this is reflected in the severity figures in table and the corresponding classification in table , which are also supported by high daly (havelaar et al., a) and quality-adjusted lifeyear (qaly) estimates (hoffmann et al., ) published in the literature. evidence for meat from small ruminants as an important risk factor: yes. pathogenic vtec can be found in the gut of numerous animal species, but ruminants have been identified as a major reservoir of vtec that are highly virulent to humans, in particular vtec o . although cattle are considered to be the most important source of human infections caused by vtec o , they have also been isolated from the intestinal contents of sheep and goats. food of small ruminant origin has been reported as a source for human vtec infections (kosmider et al., ; schimmer et al., ; werber et al., ) . transmission occurs through consumption of undercooked meat, unpasteurised dairy products, or water and vegetables contaminated by faeces of carriers. person-to-person transmission has also been documented (rey et al., ) . data reported in the frame of the zoonoses directive ( / /ec) from to can be found in tables - . for all vtec serotypes, the reported prevalence was . % and . % for sheep at flock and individual animal level, respectively. for goats, the figures were . % and . %. prevalences for vtec o were much lower across the board. isolation of e. coli o from goats has been reported in studies from several countries, with isolation rates ranging between % and % (cortes et al., ; keen et al., ; orden et al., ; orden et al., ; schilling et al., ) . vtec strains have also been detected in sheep, with a similarly wide range of prevalence figures (milnes et al., ; oporto et al., ; prendergast et al., ; pritchard et al., ; schilling et al., ; sekse et al., ) . thus it is clear that small ruminants can play an important role by shedding these pathogens in the faeces (blanco et al., ; la ragione et al., ) . the prevalence can be influenced by the sampling and testing methodology, but these studies nevertheless clearly indicate that pathogenic vtec is present in the small ruminant population in the eu. table includes data from official monitoring of sheep carcasses. the reported prevalence was % at batch level and . % at individual carcass level ( . % for vtec o ). the scientific literature also indicates that sheep and goat carcasses or meat can be contaminated with vtec, albeit generally at lower levels compared with those in the animal reservoir. at the higher end of the range, barlow et al. ( ) in australia and zweifel et al. ( ) in switzerland reported prevalences around % in carcasses and lamb cuts. brooks et al. ( ) reported a prevalence of % in lamb cuts in new zealand and other, less recent, studies reported much lower prevalence-between % and % (doyle and schoeni, ; heuvelink et al., ; pierard et al., ; samadpour et al., ) . it has to be noted that this variation in prevalence could be a result of the different testing methodologies used (e.g. use of polymerase chain reaction (pcr) testing), and the fact that not all these vtec isolates would necessarily be pathogenic to humans. a case-control study on risk factors for human vtec in germany identified lamb as an important risk factor for human infection (werber et al., ) . consumption of dry cured sausages made with sheep meat was identified as the cause of an outbreak of vtec o :h infection in humans (schimmer et al., ; sekse et al., ). in the latter study, bacteria with the same properties, including identical dna profiles, were found in five dry cured sausage products and sheep meat used as raw material in sausage production and were identical to the isolates from patients. e. coli with the same virulence genes, serotypes, biochemical characteristics and dna profiles as those found in patients from the e. coli o :h outbreak, were detected in sheep from of farms in norway (brandal et al., ) . more recent research in norway and spain comparing virulence characteristics between strains isolated from humans and sheep has suggested that the latter can be an important reservoir for pathogenic vtec (brandal et al., ; sanchez et al., ) . the evidence arising from epidemiological or source attribution studies points to a minor role for meat from small ruminants as a source of human cases of vtec, although the model used in this study was found to underestimate the observed prevalence of vtec in lamb, so this attribution estimate should be interpreted with caution (kosmider et al., ) . based on the data (see table ) and the assessment presented above, the biohaz panel concluded that pathogenic vtec can be considered to be of high priority for meat inspection of small ruminants given the relatively high prevalence of this hazard in the small ruminant population, the epidemiological links to outbreaks in humans and the severity of the disease in humans. human incidence: based on eu data, high. in the eu, s. enterica subsp. enterica serovar enteritidis and s. typhimurium are the serovars most frequently associated with human illness, although the number of reported cases of s. enteritidis has more than halved since . human s. enteritidis cases are most commonly associated with the consumption of contaminated eggs and poultry meat, while s. typhimurium cases are mostly associated with the consumption of contaminated pig, poultry and bovine meat. human salmonellosis is the second-ranking foodborne disease reported in the eu and most european countries, exceeded only by campylobacteriosis (efsa, ; efsa and ecdc, b) . a total of confirmed cases were reported from eu mss in through tessy, corresponding to a notification rate of . confirmed cases per (table , which also includes data on the severity of human disease). accounting for under-reporting, it is estimated that there are six million cases of this illness annually in the eu- (efsa, ; havelaar et al., b) . severity of disease: as the incidence is high, the severity does not need to be considered. evidence for meat from small ruminants as an important risk factor: no. the common reservoir of salmonella spp. is the intestinal tract of a wide range of domestic and wild animals, which results in a variety of foodstuffs, of both animal and plant origin, as sources of human infections. the organism may be transmitted through direct contact with infected animals or between humans or from faecally contaminated environments. in animals, subclinical infections are common. the organism may easily spread between animals in a herd or flock without detection, and animals may become intermittent or persistent carriers. the variant, s. enterica subsp. diarizonae iiib .k: , , ( ), which might be referred to as "the sheep variant" owing to its adaption to sheep, is endemic in sheep in several regions of the world such as the united kingdom (hall and rowe, ) and norway (norwegian scientific committee for food safety, ) in europe and canada (greenfield et al., ; pritchard, ) and the united states (weiss et al., ). however, the overall conclusion is that s. enterica subsp. diarizonae iiib .k: , , ( ) is very rarely demonstrated as a cause of human infections, including in those areas in which the endemic prevalence in sheep is high such as the united kingdom and norway ((norwegian scientific committee for food safety, ). another salmonella spp. variant well adapted to sheep, causing abortion and death of ewes, is s. brandenburg, which is endemic in the south island of new zealand (sabirovic, ) , but its human health relevance seems to be limited. eu monitoring data for sheep and goats are presented in tables - , which contain data collected by mss from to . the prevalence reported in both herds and individual animals is . % and . %, respectively, for sheep and . % and . % for goats. although salmonella spp. is commonly found in live sheep or goats at variable prevalence levels (bonke et al., ; duffy et al., ; duffy et al., ; hjartardottir et al., ; moriarty et al., ; zweifel et al., ) , there is a more limited number of studies looking at the occurrence of salmonella spp. in sheep and goats carcasses. a prevalence of . % was reported in individual sheep carcasses in the eu monitoring (see table ). some outbreaks linked to meat from small ruminants can be found in the scientific literature (evans et al., ; hess et al., ; synnott et al., ) . these involved unusual consumption patterns (e.g. raw lamb liver) or cross-contamination of raw food ingredients (e.g. yoghurt relish contaminated with carcass blood), therefore it is unclear how significant these events are when assessing the role of sheep or goat meat as a source of salmonella spp. infection. data from epidemiological or source attribution studies suggest that the role of meat from small ruminants as a vehicle for salmonella spp. the occurrence of antimicrobial resistance among zoonotic salmonella spp. is an increasing problem. antimicrobial-resistant salmonella spp. involved in human disease are, like salmonella spp. in general, mostly spread through foods, predominantly poultry meat, eggs, pork and beef (hald et al., ) . as there are no indications that resistant strains behave differently from their sensitive counterparts in the food chain, there is no need to consider these strains separately in the context of meat inspection. fluoroquinolone and cephalosporin resistance are currently considered to be those of most public health concern. meat, particularly poultry meat and pork, is recognised as an important source of human exposure to fluoroquinolone-resistant salmonella spp., and high levels of esbl-/ampc-producing salmonella spp. have also been reported in poultry in some eu mss (efsa and ecdc, a). such resistant strains may or may not be associated with a significant level of human infection, depending on the pathogenicity of the strains involved and the opportunity for them to contaminate the food chain (butaye et al., ; de jong et al., ; efsa panel on biological hazards, c; rodriguez et al., ) . the control of antimicrobial-resistant bacteria in food including poultry meat is further complicated by the fact that resistance mechanisms can be located on mobile genetic elements such as plasmids and thereby be transferred between different bacterial species, for instance between generally apathogenic e. coli and salmonella spp. based on the data (see table ) and the assessment presented above, the biohaz panel concluded that the risk arising from consumption of meat from small ruminants with regards to salmonella spp. is of low priority for meat inspection of small ruminants. this ranking is not the result of current controls. human incidence: based on eu data on congenital toxoplasmosis, low. toxoplasmosis can be contracted by the oral ingestion of oocysts present in cat faeces and the environment, or tissue cysts present in the meat of infected animals (tenter et al., ) . in pregnant women, the parasite can cause congenital infections (abortion, stillbirth, mortality and hydrocephalus in newborns or retinochoroidal lesions leading to chronic ocular disease) and complications (lymphadenopathy, retinitis or encephalitis) in immunocompromised individuals such as organ graft recipients and individuals with acquired immune deficiency syndrome (aids) or cancer (efsa, b) . in immune-competent individuals, - % of cases of toxoplasma gondii infection are asymptomatic, and the majority of the remainder have only mild, self-limiting symptoms. thus, reports of acute symptomatic t. gondii infection (toxoplasmosis) do not provide a reliable basis for assessing overall disease incidence. given these limitations, the incidence of human disease caused by toxoplasmosis is rare ( table ). the prevalence of antibodies to t. gondii in the general population provides an alternative for estimating the number of cases and disease burden (food standards agency, ). t. gondii seroprevalence is known to vary geographically and with age (montoya and liesenfeld, ). although antibodies are found in - % of adults in the united kingdom, seroprevalence is higher in central europe, and similar or lower in scandinavia ( - %). climate and consumption of raw meat, meat from animals farmed outdoors or frozen meat may be factors that contribute to these variations (kijlstra and jongert, ) . seropositivity also varies within countries, being highest in those from rural or small town backgrounds and lowest in those from urban or suburban areas (food standards agency, ). data showing the variation in seropositivity with age are available from a number of countries. for example, in the netherlands, it was found to range from % at years of age to % at years (efsa, b; hofhuis et al., ) . there is evidence of a sharp decrease in seroprevalence over the last years in many populations. for example, in there was a reported seroprevalence of % in france, falling to % in (afssa, ) . this decrease is in part attributable to a decrease in infection in childhood, probably associated with increased standards of living, and has also been linked to changes in meat husbandry and consumption. severity of disease: based on eu data for congenital toxoplasmosis, high. owing to the lifelong impact of symptoms related to toxoplasmosis, the burden of disease is high. mead et al. ( ) showed that t. gondii ranked fourth in hospitalisations and third concerning deaths when compared with other foodborne pathogens. more recent research ranked t. gondii among the highest in population burden estimates (daly or qaly) among foodborne pathogens from both an individual and a population perspective (havelaar et al., a; hoffmann et al., ) . evidence for meat from small ruminants as an important risk factor: yes. the relative role of t. gondii oocysts in the environment versus tissues cysts in meat and meat products as a source of infection for humans could not be determined by laboratory tests until recently. hill et al. ( ) have developed a test to identify a sporozite specific antigen which will be a useful tool in providing information on the relative importance of oocysts as the agent of infection. until this recent development, source attribution information came from epidemiological studies. in europe, three large case-control studies have pinpointed uncooked meat as the most important risk factor for pregnant women (baril et al., ; cook et al., ; kapperud et al., ) . with regard to the prevalence in the animal population, despite t. gondii infection being a major cause of abortion and stillbirth in sheep and goats in the eu, most infections exist subclinically in flocks/herds (dumetre et al., ) . in response to natural infection, seropositive sheep have been shown to harbour infectious parasites as tissue cysts (dubey et al., ; kijlstra and jongert, ; opsteegh et al., ) . antibodies to t. gondii and tissue cysts persist in infected sheep (dubey, ). this implies that serological tests can be used to estimate the number of animals carrying t. gondii tissue cysts in the meat and thereby indicate the risk for public health (opsteegh et al., b) . seroprevalence increases with increasing age (dubey, ; halos et al., ) , and sheep and goats are identified as the main source of infected meat in southern european countries (berger et al., ; dumetre et al., ) . seroprevalence of t. gondii in sheep can range from % to % in certain european countries (efsa, b) . limited data available in slaughtered sheep report seropositive rates of - % in europe (dumetre et al., ; tenter et al., ) . seroprevalence in farmed goats in europe ranges from % to % (efsa, b) . no data have been published about seroprevalence in slaughtered goats in europe, but findings in goats in non-european countries range from % to % (efsa, b; tenter et al., ) . data reported by eu member states under the zoonoses directive ( / /ec), showing a relatively high seroprevalence for this hazard in flocks/herds and individual animals, can be found in tables - . notwithstanding this, significant uncertainty remains regarding this hazard. the prevalence of toxoplasmosis in humans and its importance in terms of overall disease burden still requires research. despite the development of recent laboratory procedures, the proportion of human toxoplasmosis attributable to the consumption of sheep meat is unknown. furthermore, the relationship between seropositivity in sheep and the number of viable tissue cysts in edible tissue has yet to be established (food standards agency, ). these uncertainties hinder the development of control procedures for this hazard. with regard to the role of meat from small ruminants as a risk factor for human toxoplasmosis, a prospective case-control study designed to identify preventable risk factors for t. gondii infection in pregnancy, conducted in norway (kapperud et al., ) found eating raw or undercooked mutton to be independently associated with an increased risk of maternal infection (or = . , p = . ). in the case-control study carried out by baril et al. ( ) , an odds ratio of . was estimated for the consumption of undercooked or raw mutton/lamb. the same odds ratio was obtained for the consumption of undercooked or raw mutton/lamb in the study carried out in (cook et al.) . in addition, raw or undercooked lamb meat is considered a delicacy in certain countries, such as france, and is therefore considered an important source of infection in that country (afssa, ) . this has been recently corroborated by a report of an outbreak of toxoplasmosis linked to the consumption of undercooked lamb (ginsbourger et al., ) . given its high seroprevalence in sheep and goat meat and the correlation of human infection to animal incidence, t. gondii in sheep and goat meat was considered by the panel to be of high priority for meat inspection of small ruminants within the eu (see table ). based on the priority ranking, the hazards were classified as follows: t. gondii and pathogenic vtec were classified as high priority for sheep/goat meat inspection. the remaining identified hazards, b. anthracis, campylobacter spp. (thermophilic) and salmonella spp., were classified as low priority, based on the available data. as new hazards might emerge and/or hazards that presently are not a priority might become more relevant over time or in some regions, both hazard identification and the risk ranking should be revisited regularly to reflect this dynamic epidemiological situation. particular attention should be given to potential emerging hazards of public health importance that arise only in small ruminants. to provide a better evidence base for future risk ranking of hazards, initiatives should be instigated to: improve and harmonise data collection of incidence and severity of human diseases caused by relevant hazards. systematically collect data for source attribution. collect data to identify and risk rank emerging hazards that could be transmitted through handling, preparation and consumption of sheep and goat meat. protection of public health is the top priority objective of meat inspection. the origin of western european meat inspection goes back to the end of the th century, when it became obvious that meat could play a role in the transmission of disease, particularly tuberculosis, and that the trade in animals, meat and meat products needed some sort of safety and quality assurance (johnson, ; theves, ; von ostertag, ) . the first meat inspection act was drawn up in by professor ostertag at the university of berlin. there is no doubt that the meat inspection procedures were highly risk based at that time. ever since, an ante-mortem and post-mortem inspection has been carried out at individual animal level in cattle and it has been extended to other species. the ante-mortem inspection is a simple clinical examination aimed at identifying sick or abnormal animals, as well as assessing the level of cleanliness of the animals entering the slaughtering process. the post-mortem inspection is a pathological-anatomical examination aiming at detecting and eliminating macroscopic abnormalities that could affect the fitness of meat for human consumption. it is based on visual inspection, palpation, incision and, when required, laboratory examination. postmortem inspection is laborious and expensive. the previous situation of slaughtering a few animals originating from a farm has evolved into large numbers of uniform, relatively young and healthy animals presented for slaughter, which have a common genetic background and prior history. at the same time, it is common to find mixed batches of animals arriving at the slaughterhouse, having been assembled at markets and where several farms have each contributed a few animals. transport can also increase the level and/or duration of shedding of pathogens, as well as the surface contamination of animals with pathogens via animal-animal or animal environment-animal contacts in the vehicle, at the market or in the lairage. therefore, it can be assumed that the food/meat safety risks increase as the number/frequency of movements of animals between farm and slaughter increases (scientific committee on veterinary measures relating to public health (scvmph), ). the current state of meat inspection in the eu and six selected exporting countries outside the eu has been reviewed and summarised recently in an external report. for further, more detailed information on the current eu meat inspection system, the reader is referred to that report. still, irrespective of the meat inspection procedures in place, it is well recognised that small ruminants presented at slaughter can be carriers of zoonotic microorganisms (see section . . above), which cannot be detected during ante-and post-mortem inspections. in the following section, an assessment of the strength and weaknesses of the current practices for protection of public health will be given. the food chain information (fci) principle includes a flow of information from farm to slaughterhouse in order to help classify the batch of animals according to its expected food safety risk, so that slaughter procedures and/or decisions on fitness for consumption can be adapted to the health status and food safety risk presented by the batch of sheep or goats. regulation (ec) no / also requires the feedback of information from slaughterhouse to farmers, describing also the information that has to be provided (appendix to annex i of the regulation). fci is recorded at the flock/batch level and its minimum content is described in regulation (ec) no / . fci related to primary production of flocks or herds is based on a farmer's declaration. most mss have made available a standardised fci declaration form to farmers (e.g. ireland, the united kingdom, italy, france). fci must be checked for completeness and content as part of antemortem inspection. in theory, fci may be used to adapt ante-and/or post-mortem inspections. fci serves as a channel of communication between the primary producer and the inspectors at the slaughterhouse. this, theoretically, facilitates the process of evaluating the health of incoming batches and prevents sick or abnormal animals entering the slaughterhouse, by providing early data on probable disease conditions that may be present in the flock or herd. this is based on information related to the on-farm health status of the animals (occurrence of disease, veterinary treatments, specific laboratory testing). the main benefit of the food chain information is that it may create an awareness among primary producers of the need for high standards of animal health and welfare, proper identification of animals and appropriate use of medicines. by contributing to the overall health of the animals sent to slaughter, such a system should have a positive impact on public health by ensuring that the animals are less likely to carry hazards of public health importance. in practice, ante-or post-mortem inspections of sheep and goats are rarely adapted to take account of fci. the main reason that current fci is insufficiently utilised is because of the lack of adequate and harmonised indicators that could help in classifying the animals according to the risk to public health they may pose. the food safety relevance of fci is often limited because the data that it contains is very general and does not address specific hazards of public health importance. also, farmers might not be in a position to properly assess the presence of relevant hazards. feedback of the results of the meat inspection process to farmers is not implemented in all mss to the full extent foreseen in the legislation. the flow of information back to the farm is not straightforward in the absence of a fast and reliable animal movement tracing system, e.g. through the use of electronic individual animal identification linked to a database containing information on the movements of animals (e.g. change of farm, last farm). for example, in ireland between % and % of small ruminants come to the slaughterhouse from assembly centres or markets (efsa, ) . in this case, it is difficult to consider a batch of small ruminants as an epidemiological unit. good feedback to farmers also requires harmonisation of the reasons for condemnation and the systematic use of the same terminology for each reason for condemnation. the ante-mortem clinical examination is carried out to evaluate the health and welfare of the animals, and to prevent sick or abnormal animals entering the slaughterhouse. this is a visual-only inspection, consisting of the identification of clinical signs of a disease and an assessment of the cleanliness of the incoming animals. it is performed at the individual level in sheep and goats. the public health-related strengths of ante-mortem inspection include inspection of individual animals for signs of disease and animal identification. ante-mortem inspection also helps in identifying dirty animals, as required by current legislation. regulation (ec) no / , annex i requires primary producers to ensure the cleanliness of animals going to slaughter. regulation (ec) no / annex ii, section ii states that food business operators, operating slaughterhouses, must have haccp-based intake procedures to guarantee that each animal or, where appropriate, each lot of animals accepted on to the slaughterhouse premises are clean. regulation (ec) no / , annex i, section ii, chapter iii states that animals with hides, skins or fleeces posing an unacceptable risk of contamination to meat during slaughter cannot be slaughtered for human consumption unless they are cleaned beforehand. adjustments can be made to the slaughter process depending on how dirty the batch of sheep or goats is. current pre-slaughter control procedures include: rejection of dirty lots, washing of animals, fleece/hide trimming or clipping (at the farm or at the slaughterhouse, either pre-or post-slaughter), and slaughter of dirty animals at the end of the day (byrne et al., ) . dirty animals that are presented for slaughter are rejected at ante-mortem inspection until their fleece/hide condition improves. suppliers are sometimes penalised financially through reduced price and the cost imposed by remedial actions required to improve fleece/hide condition. certain countries have adopted such measures as part of a "clean livestock policy". these policies were adopted to meet the requirements of the hygiene package and have proved to be effective in reducing the risk posed by dirty sheep (see section . . below). from a public health perspective, ante-mortem examination is of no value in the detection of toxoplasmosis in small ruminants, as animals infected with this previously identified hazard do not show clinical signs. despite the haccp-based intake procedures guaranteeing the health, welfare and cleanliness of animals going for slaughter, it is difficult to identify animals infected with pathogenic vtec and other enteric pathogens. supplying clean animals reduces, but does not prevent, the possibility of introducing this invisible hazard as infected animals are asymptomatic transient shedders (duffy, ) . post-mortem inspection of carcasses is designed to detect and withdraw from the food chain any carcass or part thereof that has grossly identifiable abnormalities that could affect its meat safety or wholesomeness. the meat inspector examines external and internal surfaces of the carcass and internal organs after evisceration for disease conditions and contamination that could make all or part of the carcass unfit for human consumption. generally, inspection procedures include mainly visual examination of the carcass and offal. these procedures are described in annex i, section iv, chapter ii of regulation (ec) no / . palpation is compulsory for liver, lungs and their lymph nodes. in addition, palpation is mandatory for the umbilical region and joints in young animals. incision is currently required only for the gastric surface of the liver. this procedure can be reduced to a visual-only inspection for sheep less than a year old or goats less than six months of age, if certain conditions are met, as stated in regulation (ec) no / , amending regulation (ec) no / , in the spirit of a risk-based inspection. it is unclear to what extent this derogation is currently used as intended. a more thorough examination, involving palpation and incision of other organs, is performed if abnormalities are detected during visual inspection. table in annex summarises these requirements for post-mortem inspection. ultimately, the production of safe food is the responsibility of the food business operator (fbo) as defined by regulation ( post-mortem inspection enables, to a certain extent, detection of lesions related to animal health and welfare, which are not dealt with in this part of the document (see appendix c). for food safety concerns, post-mortem examination can detect visibly contaminated carcasses and offal, which might present an increased food safety risk and is an indication of a hygienically inefficient slaughter process. post-mortem inspection allows for an assessment of the general health status of the animal to be carried out, which could influence the likelihood of important meat-borne hazards to be present in the carcass. classic zoonotic diseases, such as tuberculosis, which can be detected by post-mortem examination, are now controlled in many areas where modern systems of animal husbandry, disease control and animal health care were introduced. hence, the ability of current post-mortem inspection to detect lesions caused by mycobacteria is only relevant in regions where they are present. post-mortem inspection can also detect other non meat-borne hazards of public health significance that can be present in carcasses or offal from small ruminants. examples of these hazards are echinococcus granulosus and trematode parasites such as fasciola hepatica. acquisition of these parasites by humans occurs when subjects inadvertently swallow eggs or cysts attached to tainted vegetation or by drinking contaminated water containing free-floating eggs (e. granulosus) or cysts (f. hepatica) (fried and abruzzi, ) . from the public health standpoint, only e. granulosus is still relatively important in some mss (efsa and ecdc, b), while trematode parasites are less commonly reported in humans in the eu. meat inspection contributes to the monitoring of these parasites as they are routinely detected during post-mortem examination of sheep and goats. this also allows for appropriate disposal of infected organs, thus breaking the life cycle of the parasites. the extent to which meat inspection contributes to reducing the risk to human health posed by these parasites, compared with control measures elsewhere (e.g. anti-parasitic treatments of the final hosts) is not known, so it is difficult to assess the relative importance or effectiveness of this activity in protecting public health. nevertheless, the importance of meat inspection as a monitoring tool has been stressed previously (efsa, ). the slaughter of sheep involves greater challenges than the slaughter of cattle and pigs since the animal is relatively small and has a wool fleece increasing the risk of surface contamination at dehiding (buncic, ) . as mentioned in section . of this appendix, many challenges are posed by the processing procedure at the slaughterhouse, which has a direct effect on the final microbial disposition of the carcass (e.g. line speed, operational hygiene, equipment and training) (hansson, ; palmer, ) . in this context, the mandatory bacteriological analysis of carcasses to evaluate slaughter process hygiene is important. the maximum acceptable microbiological values are set in the phc for the indicators mentioned in regulation (ec) no / . some risks determined at postmortem examination are under the direct influence of the processor and can be ameliorated by corrective action procedures. in the case of the identified hazard, pathogenic vtec, post-mortem corrective actions may include clipping after stunning and bleeding, adjustments to operational hygiene practices, slowing the slaughter line down and/or adding extra personnel at certain carcass dressing stations, with feedback to producers (see section . . below). the competent authority also verifies the fbo's responsibility to produce safe food, as mandated by regulation (ec) no / , through audit and inspection of the slaughterhouse's food safety management system. in terms of the slaughter process, phc are end-product criteria. compliance with these criteria, in regulation (ec) no / , is one aspect of system compliance verification carried out by the competent authority. more details about phc can be found in section . . . . potential threats to public health associated with slaughtered sheep or goats including agents such as pathogenic vtec and t. gondii are carried by animals without signs or lesions. current meat inspection is not designed to detect or eliminate these agents. sometimes, cysts of t. gondii can be macroscopically visible but it is impossible to distinguish them from sarcocystis cysts, except cysts of s. ovifelis. visible meat quality-related abnormalities are detectable at post-mortem inspection, but these are not important for human health (see table ). sometimes, septicaemia and conditions associated with foci of infection in tissue such as arthritis, bronchopneumonia, mastitis, pleuritis or abscesses can be detectable at post-mortem inspection. some of these are caused by pathogens that might have zoonotic implications (e.g. erysipelothrix rhusiopathiae, s. aureus), but, as explained in section of this appendix, the risk to public health arising from these hazards is not considered to be important and is mostly related to occupational exposure or the way the meat is handled after it leaves the slaughterhouse. other conditions that result in condemnation of offal or carcasses are parasitic lesions. these parasites (c. tenuicollis, sarcocystis, fasciola, dicrocoelium, etc.) are not transmissible via meat consumption. in cases where these abnormalities are observed, the meat must be removed as unfit for human consumption on aesthetic or meat quality grounds. the potential for cross-contamination of carcasses exists whenever palpation and/or incision methods are used in the inspection process. palpation of the liver, the lungs, the umbilical region and the joints, and the incision of the gastric surface of the liver during the post-mortem examination of sheep and goats could contribute to the spread of the bacterial hazards of public health importance in small ruminants through cross-contamination. the importance of cross-contamination is not clear in small ruminants, although it has been considered important in other species (walker et al., ) . however, it should be borne in mind that incision is compulsory only for the liver, whereas in cattle and pigs incision of muscle is also required, so the level of contamination is likely to be smaller in small ruminants than in these species. current legislation foresees more detailed palpation and incision if abnormalities are detected during visual inspection. this could also facilitate cross-contamination of normal carcasses with microbiological hazards of public health importance. judgement of the fitness of meat for human consumption in current post-mortem inspection is based on the identification of "conditions making meat unfit for human consumption" but does not make a clear foodborne risk distinction between different subcategories i.e. between non-zoonotic conditions making meat unfit (inedible) on aesthetic/meat quality grounds (e.g. repulsive/unpleasant appearance or odour), non-zoonotic conditions making meat unfit in order to prevent spreading of animal diseases (e.g. foot and mouth disease), zoonotic conditions making meat unfit due to transmissibility to humans via the foodborne route (e.g. toxoplasmosis) and zoonotic conditions making meat unfit due to transmissibility via routes other than meat borne (e.g. brucellosis). the legislation on official controls on fresh meat from (regulation (ec) / , annex i) has a more horizontal approach than the former one (council directive no / , amended by council directives no / and no / and has also in theory a risk-based approach. however, the main experiences are that alternative control regimes, such as visual control of young animals (sheep of less than a year old and goats less than six months old) are not implemented due to the fact that the gains are limited due to: the threshold in terms of implementation of quality assurance systems and extra procedures at herd level is too high logistical challenges connected to the post-mortem meat inspection procedures as some flocks/herds are certified for visual control while others are not due to the fact that alternative control methods are not accepted by some importing countries outside the eu. ante-mortem and post-mortem inspections of sheep and goats enable the detection of observable abnormalities. in that context, they are an important activity for monitoring animal health and welfare. they provide a general assessment of animal/herd health, which if compromised may lead to a greater public health risk. visual inspection of live animals and carcasses can also detect animals heavily contaminated with faeces. such animals increase the risk for cross-contamination during slaughter and may consequently constitute a food safety risk if carrying hazards of public health importance. if such animals or carcasses are dealt with adequately, this risk can be reduced. visual detection of faecal contamination on carcasses can also be an indicator of slaughter hygiene, but other approaches to verify slaughter hygiene should be considered. post-mortem inspection can also detect non meat-borne hazards of public health significance that can be present in carcasses or offal from small ruminants. ante-mortem and post-mortem inspection also have the potential to detect new diseases if these have clinical signs, which may be of direct public health significance. currently, the use of food chain information for food safety purposes is limited for small ruminants, mainly because the data that it contains is very general and doesn't address specific hazards of public health importance. however, fci could serve as a valuable tool for risk management decisions and could be used for risk categorisation of farms or batches of animals. to achieve this, the system needs further development to include additional information important for food safety, including definition of appropriate and standardised indicators for the main public health hazards identified above (section of this appendix). ante-and post-mortem inspection is not able to detect any of the public health hazards identified as the main concerns for food safety. it would therefore be expected that more efficient procedures might be implemented to monitor the occurrence of non-visible hazards. in addition, given that the current postmortem procedures involve palpation and incision of some organs, there is potential for crosscontamination of carcasses. as identified by priority ranking earlier in this opinion, the principal biological hazards associated with meat from small ruminants are t. gondii and pathogenic vtec. the ranking presented in section of this appendix classified all other hazards in the low-risk category. this ranking is provisional because of the limited information available for some of the hazards. neither of the principal hazards identified can be detected by traditional meat inspection, which is focused on identification of visible abnormalities and issues relating to the health and welfare of the animals on the farm, in transit and at the slaughterhouse before slaughter. detection and quantification of those hazards in/on sheep or goats and their carcasses is possible only through laboratory testing. the occurrence and levels of t. gondii and pathogenic vtec on carcasses are highly variable depending on various factors, including particularly: (i) their occurrence in the sheep and goat population before slaughter and the application and the effectiveness of related pre-slaughter controls strategies; (ii) the extent of direct and/or indirect faecal cross-contamination during slaughter line operation (this does not apply to t. gondii); and (iii) the application and the effectiveness of possible interventions to eliminate/reduce them on carcasses (e.g. decontamination). therefore, as far as the presence of these pathogens in/on carcass meat is concerned, the risk reduction strategies, and related controls, are focused on these three aspects. changes are therefore necessary to identify and control microbiological hazards, and this can be most readily achieved by improved use of fci and interventions based on risk. control measures for pathogenic vtec at the slaughterhouse are also likely to be effective against other enteric pathogens, as they would all be controlled by addressing faecal contamination of carcasses. a comprehensive meat safety assurance system for meat from small ruminants, combining a range of preventive measures and controls applied both on the farm and at the slaughterhouse in a longitudinally integrated way, is the most effective approach to control the main hazards in the context of meat inspection. the main responsibility for such a system should be allocated to fbos, whereby compliance is to be verified by the competent authority. the setting up of such a comprehensive meat safety assurance system at eu level is dependent on the availability of reliable information on the biological risks associated with the consumption of meat from these species. as indicated in the priority ranking section of this opinion (section of this appendix), information on the biological risks associated with the consumption of meat from sheep or goats is sometimes scant and unreliable. consequently, in order to facilitate decision making, harmonised surveys are required to establish values for the prevalence of the main hazards t. gondii and pathogenic vtec at flock/herd, live animal and carcass level in individual mss. epidemiological and risk assessment studies are also required to determine the specific risk to public health associated with the consumption of meat from small ruminants. in the event that these studies confirm a high risk to public health through the consumption of meat from sheep or goats, consideration should be given to the setting of clear and measurable eu targets at the carcass level. eu targets to be reached at the national level are already in place for salmonella spp. in breeding flocks of gallus gallus and turkeys and production flocks of broilers, turkeys and laying hens. similar targets in primary production could also be considered for the main hazards of other species, including small ruminants. the use of specific hazard-based targets (i.e. pathogenic vtec or t. gondii related) for chilled carcasses provides: . measurable and transparent focus for the abattoir meat safety assurance system. ) on what has to be achieved at earlier steps in the food production chain. . information for the purpose of consumer exposure assessment for each hazard. . measurable aim for the meat industry in the context of global pathogen reduction programmes. for all these reasons, the chilled carcass targets have to be specific hazard based. this, however, may not be always practical (e.g. in very low hazard prevalence situations). therefore, proper functioning of meat safety quality assurance systems may not rely exclusively on hazard-based testing of the final carcass but on the general hygiene of the slaughter process. this issue is discussed further in the following sections. ). in addition, information on harmonised epidemiological indicators (heis) and related methodologies for the main hazards that can be used in studies to establish prevalence of the main pathogens to establish targets for carcasses and performance criteria for slaughterhouses, as well as targets for incoming small ruminant animals, is provided in the efsa report (efsa, ) . therefore, this opinion should be used in combination with that report. at farm level, the primary goal is reduction of risk for the main hazards, which can be achieved through preventive measures such as flock/herd health programmes, including biosecurity and good farming practices (gfps) that specifically address the hazards identified in section of this appendix. husbandry practices will vary considerably for small ruminants, particularly, the intensity of the rearing system. so, although it is not possible to detect any of the main foodborne zoonotic infections visually at the farm, there are known risk factors that are likely to increase the risk of infection with the main hazards. an important element of an integrated meat safety assurance system is considered to be risk categorisation of flocks or herds based on the use of farm descriptors and data on clinical disease and use of antimicrobials, in addition to data provided by ongoing monitoring of high-risk hazards that constitute the fci. such data could be provided through farm audits using heis to assess the risk and preventive factors for the flocks or herds related to each of the prioritised microbiological hazards (see efsa report, ( )). ongoing monitoring could be put in place for particular pathogens at eu level if, following the completion of the prevalence studies described earlier, these pathogens are identified as presenting a high risk. an assessment of the historical data over a time period could also be used for adjusting the sampling frequency of the main hazards in order to focus control efforts where the risk is highest. a structured approach to gathering more detailed farm information should become an additional farmrelated element of the fci that, in combination with the monitoring results for the main hazards, should form the basis for the risk categorisation of the farms. the frequency of monitoring in higher risk farms could be adapted in a cost-effective manner, e.g. there would be no need to sample every batch of animals to be slaughtered if the result is very likely to be "high risk" or "very low risk". thus, animals from higher risk farms could be systematically directed to, for example, logistic slaughter, or specific treatments such as decontamination at the slaughterhouse, until these high-risk farms demonstrated a decreased risk following the implementation of adequate on-farm measures. this system could act as an incentive for the primary producer to improve farm standards by means of reduced monitoring costs associated with low-risk status. at slaughterhouse level, the primary goal is risk reduction for the main hazards that can be achieved through integrated programmes based on gmp, ghp and haccp, including the use of phc: logistic slaughter based on the risk categorisation of the slaughtered batches; this could be slaughter of higher risk animals at the end of the day. hygienic practices and technology-based measures aimed at avoiding direct and indirect cross-contamination with the main hazards. interventions such as the scheduling of higher risk animals for carcass decontamination or for risk-reducing processes such as heat treatment to reduce pathogenic microorganisms or freezing-based treatments to eliminate parasites such as t. gondii. enteric pathogens are carried in the gastrointestinal tract and/or on the fleece of sheep and goats presented for slaughter, and carcass meat becomes contaminated as a result of direct or indirect crosscontamination that is highly dependent on slaughterhouse technology and the skills of the operators. technical aspects of individual steps of the slaughter process for small ruminants may vary considerably. the order of the processing steps at the slaughterhouse is generally as follows: transport/lairaging-stunning-bleeding-skinning-evisceration-chilling. each of these steps contributes differently to the final microbial load of the carcass. crosscontamination between animals can occur from transport and lairaging and during the slaughter process. contamination occurs particularly during skinning and evisceration. the slaughter of sheep involves greater challenges than the slaughter of cattle and pigs since the animal is relatively small and has wool. "during sheep de-pelting, it is difficult to achieve the low contamination rates capable of being achieved during cattle de-hiding, as the animal is smaller, the fleece is longer and there is a much greater chance of fleece inrolling and contacting the carcass. therefore, overall, de-skinning is a 'dirtier' procedure in small ruminants than in larger ones" (buncic, ) . chilling can help to control the numbers of pathogenic and spoilage microorganisms on carcasses. decontamination treatments for carcasses might be used to reduce the levels of enteric pathogens and can be divided into physical and chemical treatments. physical interventions include water-based treatments, irradiation, ultrasound or freezing. hot water, steam and irradiation effectively reduce the bacterial load. chemical interventions such as treatments with acetic and lactic acid reduce the bacterial load, as observed in poultry (loretz et al., ) . some combinations of treatments further enhance the reductions (loretz et al., ) . freezing and -irradiation can also be effective in eliminating t. gondii in carcasses. however, some of these methods are limited by their practicability, regulatory requirements or acceptability to consumers (acmsf, ) . thus, the best way to achieve reductions in carcass contamination is likely to come either from physical decontamination treatments or from technological developments in the process that are designed to improve hygiene, as long as they are acceptable to the industry and the consumer. each slaughterhouse can be viewed as unique, owing to differences in species slaughtered, logistics, processing practices, plant layout, equipment design and performance, standardised and documented procedures, personnel motivation and management, and other factors. these variations individually and in combination lead to between-slaughterhouse differences in risk-reduction capacity and, consequently, in the microbiological status of the final carcass. hansson ( ) indicated that there was a significantly greater amount of aerobic bacteria in ruminant carcasses slaughtered at lowcapacity slaughterhouses than in high-capacity slaughterhouses. this difference in carcass microbiological status can be accounted for by better separation of low-and high-risk areas, less variation in evisceration techniques, uniformity of the animals slaughtered, increased specialisation of labour and equipment, and improved measures taken to prevent contamination through effective operational hygiene practices in high-volume slaughter establishments (hogue et al., ; rahkio and korkeala, ) . consequently, a risk categorisation of slaughterhouses is also possible, based on the assessment of individual hygiene process performance. for that, a standardised methodology and criteria for the assessment of process hygiene is a prerequisite. in respect to process hygiene, differentiation of abattoirs in current eu regulation is based on the use of process hygiene criteria providing two categories: "acceptably" and "unacceptably" performing abattoirs. however, this differentiation is based solely on carcass testing, and so does not differentiate the abattoirs in terms of the processes but only the end products. more in-depth differentiation, even within each of the two global categories of abattoirs, would have been possible if improved process hygiene assessment methodology and indicators were used. the main guiding principle (koutsoumanis and sofos, ) in abattoir process hygiene differentiation is that abattoir phc need to address the initial level of a hazard and the reduction of that hazard during the production process. in the process of creating phc for abattoirs, the possibilities that need to be considered are whether they should be linked to individual stages of the process (e.g. reduction of occurrence/level of indicator organisms or hazards at a selected one or more specific steps along the slaughter line) or only related to the starting and the end point of the process (e.g. reduction of the occurrence/level in/on the final carcass meat compared with that in/on incoming animals). establishing the frequency of the official controls on the basis of pre-defined and objective criteria. carrying out the official controls using homogeneous criteria for plants with a comparable risk profile. these criteria take six parameters into account: food safety management systems can combine official control and supervision based on compulsory requirements prescribed by law (haccp, traceability, fci, etc.) , and private quality assurance schemes. besides those aspects included in the legislation, abattoirs can voluntarily implement their own quality requirements in the form of certification schemes. certification of production processes is based on the auditing and approval by accredited third-party organisations on an accredited standard. these schemes include official requirements but also pay attention to additional, more stringent, quality and safety aspects of the processes and products. at the slaughterhouse, standards are implemented for animal welfare and hygiene, slaughtering, dressing and evisceration, hygiene control, carcass quality and grading, storage conditions, carcass cutting and processing, etc. the adherence to certification schemes reassures stakeholders (suppliers, clients), government and consumers of the quality and safety of their products, with a view to meeting market demands and consumer satisfaction. retailers and manufacturers are increasingly demanding that their suppliers hold an approved certification. in this sense slaughterhouses are becoming increasingly important throughout supply chains in integrated food safety management systems. some examples of quality assurance schemes are the international standards organisation (iso) , food safety system certification (fssc) , international food standard (ifs), british retail consortium (brc) and globalgap. in summary, classification of abattoirs according to their capability to prevent or reduce faecal contamination of carcasses can be based on two elements: (i) the process hygiene as measured by the level of indicator organisms on the carcasses (i.e. process hygiene criteria); and (ii) the use of operational procedures and equipment that reduce faecal contamination (as described in section . . . above), as well as industry-led quality systems. information about the risk categorisation of slaughterhouses could be then considered with the fci when assessing the risk arising from incoming animals. herbivorous animals most likely contract t. gondii infection via ingestion of pasture, hay, forage, feed or surface water contaminated with oocysts shed by infected cats (skjerve et al., ; tenter et al., ) . oocysts are very resistant and can survive a range of temperatures in the environment. a continuous input of sporulated oocysts, originating from young infected cats, must be present to sustain the oocyst reservoir in the environment (kijlstra and jongert, ). the risk of environmental oocyst contamination can be addressed by using sterilised feed and bedding, and not allowing sheep and goats outdoor access; however, such husbandry practices are not economically viable in most eu commercial sheep and goat enterprises (kijlstra and jongert, ). removing cats from the farm surroundings, or vaccinating cats, could theoretically lead to a reduction of the oocyst load in the neighbourhood of the farm. in reality, most of these measures would not be practical to implement in most situations at the moment. (dubey, ; kijlstra and jongert, ) . moreover, the vaccine may revert to a pathogenic strain and is, therefore, not suitable for human use (hiszczynska-sawicka et al., ). an oral vaccine composed of live bradyzoites from an oocyst-negative mutant strain (t- ) has been effective in preventing oocyst shedding by cats in experimental trials but a vaccine for cats is not yet commercially available (innes et al., ) . while the s strain vaccine remains the only one commercially available, there has been significant progress over the last years in the development of vaccines against toxoplasmosis due to technological advances in molecular biology (kur et al., ) . a cocktail dna vaccine has been shown to prime the immune system of animals against toxoplasmosis with increased immune responses being observed after experimental challenge (hoseinian khosroshahi et al., ) . in principle, an effective recombinant vaccine against both sexual and asexual stages of the parasite should be able to address all three targets listed above, but this is hampered by stage-specific expression of t. gondii proteins (jongert et al., ) . for this reason, the development of vaccines that prevent t. gondii infection in ruminants and/or cats is recommended. surveillance and monitoring of t. gondii in animals preharvest is essential in the control of this parasite, something that is currently not addressed effectively within the eu (efsa, b; opsteegh et al., b) . the most feasible surveillance method is the use of indirect serological tests (e.g. enzyme-linked immunosorbent assay, elisa) on live sheep and goats for the detection of t. gondii antibodies, as seropositivity has been correlated with tissue cyst presence in non-vaccinated animals (buxton, ; conde de felipe et al., ; dubey, ; opsteegh et al., b) . however, a more practical solution is taking a blood sample during bleeding of the animal at the slaughterhouse, or even freezing a piece of meat and collecting the meat juice during thawing. studies have indicated regional differences in seroprevalence in small ruminants which can be accounted for by differences in environmental contamination or by factors that influence the level of exposure of sheep to the environment, such as age and farm management (alvarado-esquivel et al., ; opsteegh et al., b) . monitoring programmes could help in the risk assessment and categorisation of small ruminants with regard to t. gondii at the slaughterhouse as part of the fci provided. for more details on the different options for indicators of the presence of t. gondii we refer the reader to the technical specifications on harmonised epidemiological indicators for biological hazards to be covered by meat inspection of small ruminants (efsa, ). with this background of high t. gondii prevalence in the national flocks and herds of small ruminants, a more realistic approach could be to focus the efforts in setting up a system to identify negative flocks/herds instead. for example, animals raised exclusively indoors and under controlled husbandry conditions (which would need to include for example the exclusion of cats from the farms and the absence of contamination of feed, bedding and water with t. gondii oocysts) would present a much lower risk with regards to t. gondii. when these husbandry conditions are combined with serological testing and the selection of young animals for slaughter, the production of t. gondii-free meat should be a feasible goal. this meat could be then used for either subpopulations at greater risk (e.g. pregnant women or immunocompromised people), or for the elaboration of particular dishes that require little cooking of the meat (e.g. agneau rosé in france). at the moment, this system might be practical to implement only for some intensive farms dedicated to milk or cheese production in some mss. a more detailed explanation about how harmonised epidemiological indicators could help setting up this system is provided in the accompanying report on these indicators mentioned above (efsa, ). there is no way to distinguish t. gondii-infected meat carcasses from uninfected carcasses during meat inspection (dubey et al., ) . similarly, current process hygiene criteria do not address the risk arising from this hazard (or any non-enteric hazard). the presence of t. gondii tissue cysts can be determined only by laboratory methods, particularly by using serological methods. this can be done on farm or at the slaughterhouse. studies on pcr methods to detect and quantify t. gondii in meat samples have shown promise with detection sensitivities comparable to those of bioassay (opsteegh et al., a) . studies using such laboratory techniques allow epidemiological studies to be conducted to determine the seroprevalence of toxoplasmosis in ovine meat and the risks such meat poses to human health (efsa, b; opsteegh et al., b) . additional information on sampling and testing methodologies to detect t. gondii can be found in the efsa report on harmonised epidemiological indicators for sheep and goats ( ). given that t. gondii cannot be horizontally transmitted between ruminants, there is no issue of between-animal cross-contamination with t. gondii at slaughter, and therefore separating sheep and goats from negative and positive flocks or herds during transport, lairage and on the slaughter line would not have any impact on the levels of t. gondii. studies have indicated that t. gondii tissue cysts in meat are susceptible to various physical procedures that can take place at the abattoir or beyond. these include heat treatment, freezing, irradiation, high pressure treatment and curing (addition of salt combined with drying) (table ). heat treatment is the most secure method to inactivate the parasite; however, freezing would probably be the most practical risk management option to control t. gondii for the meat industry (kijlstra and jongert, ). most of the information available for these treatments originates from research in pigs, so further research is required to validate these treatments in meat from small ruminants. these treatments would be particularly appropriate for meat cuts that are intended to be consumed rare. the ranking presented in section of this appendix classified pathogenic vtec as high risk. however, it is important to note that measures aimed at controlling this hazard will also probably be effective in reducing the level of other enteric pathogens such as salmonella spp. or campylobacter spp. control of pathogenic vtec at farm level is complicated by the fact that animals are asymptomatic carriers of these organisms, thus without an active monitoring programme there is no way of knowing which animals are infected and/or shedding at any given time. control activities must therefore be directed at the flock or herd. good management practices such as maintaining stable rearing groups, keeping a closed herd and preventing young animals from having contact with older animals all decrease the spread of vtec on and between farms. a number of studies have reported reductions in bacterial contamination and, in particular, in e. coli o :h levels on carcasses by reducing the level of fleece/hide contamination (hadley et al., ; longstreeth and udall, ) . in this context, the provision of a dry lying area for sheep improves hygiene. in outdoor rearing systems, this is achieved by access to sheltered free-draining land, avoiding access to wet or boggy areas. the housed rearing environment is more easily controlled by the producer. the shelter provided, in addition to the effect of good-quality bedding and the ability to influence access to food/water in the housed system, result in pre-slaughter housing being recommended as a clean fleece policy control measure (food standards agency, b) . other husbandry practices such as internal parasite control, effective mineral supplementation, regular dagging/crutching and the planned pre-slaughter preparation by the producer can have an impact on the on-farm clean sheep policy (food standards agency, b; pugh and baird, ) . although no such information is available for goats, it is probably safe to assume that these principles would also work in this species. controlling diet and feeding before slaughter to minimise digestive upset is essential in ensuring that animals are clean prior to slaughter. the provision of a high-fibre, nutritionally balanced diet, with easily digestible protein, helps develop good faecal consistency (collis et al., ; pugh and baird, ) . lush grass, contaminated water sources, overfertilised grassland, excessive concentrate supplementation and root/forage crop consumption prior to slaughter are dietary causes of fleece contamination (food standards agency, b ). in addition, in a recent review, pointon et al., ( ), considered the impact of pre-slaughter feed curfews of cattle, sheep and goats on food safety and carcass hygiene in australia. the authors examined the ecology of salmonella spp. and e. coli and the efficacy of on-farm withholding of feed, carried out to reduce soiling during transport, in terms of microbial reduction. they suggested that, to minimise carcass contamination with salmonella spp. and generic e. coli, the animals should be fasted before transport only for a period sufficient to complete faecal expulsion, i.e. hours, but not exceeding hours, and they concluded that the implementation of these practices as good agricultural practice is likely to improve the effectiveness in terms of reducing pathogens on the carcasses. good management of animal waste is also essential to prevent spread and cross-infection of other animals. animal waste from animals housed indoors generally accumulates as slurry or farmyard manure. vtec survive for extended periods in faecal, slurry, soil and water environments (besser et al., ; bolton et al., ; bolton et al., ; fremaux et al., ; himathongkham et al., ; hutchison et al., a; hutchison et al., b; islam et al., ; mcgee et al., ; o'neill et al., ) . current control measures to reduce the pathogen risk in animal waste can be applied before, during or after spreading manure. pre-spreading controls include the provision of proper storage facilities for animal waste to prevent leakage of waste into ground water, and keeping animals away from slurry pits or dung heaps. spreading should not take place in conditions where contamination of a water course is more likely to occur. after manure is spread, the land should not be used for grazing for a certain amount of time (at least one month or until all visible signs of animal waste have disappeared in the case of grazing (hutchison et al., ) . despite there being a range of on-farm measures to control vtec at farm level, the efficacy of such measures in reducing the prevalence (or load) of pathogenic vtec in small ruminants is not clear. transport has also been identified as a risk factor for hide cleanliness (animalia, ; byrne et al., ; food standards agency, b) . in compliance with council regulation (ec) no / on the protection of animals during transport and related operations, livestock should be carried in wellventilated, clean vehicles, at the correct stocking density, with the provision of shelter, bedding and access to food and water where appropriate. these measures, particularly relating to vehicle facilities, design and journey distances directly affect fleece/pelt cleanliness. industry standards on stocking densities during transport and lairage also facilitate the requirements of clean livestock policies (anonymous, ; minihan et al., ) . section . . above indicated that categorisation of flocks or herds according to risk can be an important element of an integrated meat safety assurance system. however, for pathogenic vtec there are a number of challenges that need to be overcome for this approach to be feasible, including the difficulties in identifying husbandry factors that can be used to classify farms according to pathogenic vtec risk, the intermittent nature of shedding, and the problems with the interpretation of monitoring results for vtec due to the difficulty of correctly identifying pathogenic vtec. the two main sources of enteric bacteria on sheep and goat carcasses are the fleece/hide and the viscera, but contamination from the former is more common. a number of studies have established a relationship between the dirtiness of sheep at the time of slaughter and the amount of contamination, and therefore the amount of pathogenic bacteria transferred to the carcass during skinning (duffy et al., ; gerrand, ; hauge et al., a; longstreeth and udall, ) . this relationship is addressed by legislation at the production and processing level, within the hygiene package, as previously mentioned in section . . . to meet this requirement for clean fleece/hides, some mss have adopted formalised "clean livestock policies" to categorise livestock including sheep and goats at ante-mortem examination, thereby placing the responsibility of presenting clean animals for slaughter with the producer and the processor (byrne et al., ; hauge et al., a) . pre-slaughter washing of sheep is widely used in new zealand (biss and hathaway, ) , together with routine shearing at high-risk sites. the clean livestock policy adopted by the food standards agency in the united kingdom has had considerable success in meeting the requirements of the hygiene package. it is based on a visual inspection during unloading or lairaging and the categorisation of the animals as acceptable for slaughter, acceptable for slaughter following shearing or clipping (conducted at the primary producers expense), and unsuitable for slaughter. extra time spent in lairage, clipping, subsequent reduction in slaughter line speed, separate processing or excessive trimming and rejection of animals all incur additional costs to producers and processors (food standards agency, b) . similarly, in , the norwegian meat industry also adopted national guidelines for good hygiene slaughter practices regarding the categorisation of fleece cleanliness for sheep (hauge et al., a) . the policy coordinators, in both the united kingdom and norway, communicate the risk of contaminated sheep to the sheep producer, suggesting various husbandry practices, handling methods and pre-slaughter preparation to limit contamination prior to slaughter (animalia, ; food standards agency, b) . as part of the norwegian clean sheep policy, developed by the associations of producers and slaughterers, sheep are shorn in the slaughterhouses. if they do not become visually clean after shearing or they are already shorn on farm and are contaminated after shearing, the carcasses of these animals are processed in a separate line. this separate processing may include heat treatment of meat products and processing into a restricted range of products, with the farmers receiving a lower price (a reduction of - % in the carcass value). hauge et al. ( a) demonstrated that the measures taken as part of the norwegian policy decreased the risks posed by carcasses and thereby validated the use of such clean sheep policies. the influence of animal cleanliness on small ruminant carcass contamination was investigated by several authors in australia, canada, new zealand, ireland and norway (biss and hathaway, a , b , c duffy et al., ; gill, ; hauge et al., a; sumner et al., ) , but there is contradictory evidence on the impact of measures to improve fleece cleanliness on microbiological contamination of lamb carcasses. roberts ( ) and field et al. ( ) found no effect of shearing of sheep on carcass contamination. some more recent studies have reported that shearing of sheep decreased carcass surface bacterial counts (biss and hathaway, a; collis et al., ; schroder and ring, ) . in a study carried out in norway by hauge et al. ( a) a significantly lower level of aerobic plate count (apc) and e. coli was found on carcass surfaces from shorn lambs when compared with unshorn lambs at skinning. at this sampling point, shearing proved to be effective for reducing microbial loads on carcasses. results in this study showed a trend of increasing contamination of carcasses with increasing duration of the time between shearing and slaughter. sheep shorn immediately before slaughter yielded carcasses with the lowest microbial loads with respect to apc. the e. coli results were less definitive, but a similar trend was demonstrated. biss and hathaway ( b), investigating the effect of pre-slaughter washing of lambs on the microbiological and visible contamination of the carcasses at four slaughterhouses in new zealand, showed that total aerobic bacteria and e. coli contamination was greater on carcasses that had been washed before slaughter, irrespective of wool length, and it was generally higher on carcasses derived from woolly lambs than those derived from shorn lambs. other researchers have found that pre-slaughter washing of sheep will only have positive effects if the washed animals are allowed sufficient time to dry before they are slaughtered (newton et al., ; patterson and gibbs, ) . many studies have reported difficulties in making valid microbiological comparisons associated with differences in slaughter hygiene due to individual operators, uneven distribution of microorganisms on carcasses, variations between groups of animals, day-to-day variations, and seasonal variations (biss and hathaway, b; hauge et al., a; ingram and roberts, ) . this may explain the conflicting results obtained in relation to the effect of shearing or washing on carcass contamination in such studies. irrespective of this conflicting evidence about how to best ensure that incoming animals are clean, it seems necessary to continue accepting only clean animals for slaughter as currently required by eu legislation, as it can be assumed that the dirtier the animals are in terms of faecal material, the higher the risk of cross-contamination of the slaughterline environment, including the carcasses. as mentioned above, a second source of enteric bacteria on carcasses are the viscera. during carcass dressing, bacteria are transferred from the gastrointestinal tract to the carcass directly by contact with gut spillage or indirectly via contaminated hands, knives, other equipment and the air. in general, prerequisite gmp and ghp implemented to reduce bacterial contamination will also prevent or reduce carcass contamination with pathogenic vtec, salmonella spp. and other pathogens. during evisceration, the abdominal cavity is opened using a knife and the connective tissue joining the bung and the viscera to the carcass is cut. rodding (sealing the oesophagus with a crocodile clip, plastic ring or starch cone) may be performed to prevent leakage. the spread of faecal material from the rectum can be prevented or reduced by bagging and tying the bung. the current throat sticking practice in halal slaughter (cutting of blood vessels, oesophagus and trachea) limits the effect of rodding as the leakage from the oesophagus occurs before rodding can be applied. if a sticking method such as chest sticking is applied, the effect of rodding will be greater as the oesophagus remains intact, with reduced leakage from the oesophagus until rodding is performed as one of the first steps after bleeding. using this method, contamination from the oesophagus of wool, skinned surfaces and the abdominal and chest cavity, in addition to the operator's hands, equipment, walls and floor, will be avoided to a high degree. the effect of bagging on the level of e. coli on sheep carcasses has been previously investigated (norwegian scientific committee for food safety, ). although the numbers of carcasses were limited, based on relevant -cm sampling sites (circum-anal incision and pelvic duct), it could be concluded that the use of the plastic bag technique during circum-anal incision and removal of the rectum results in a to log reduction in e. coli (figure ). if a plastic bag is not used and the rectum is inserted in the abdomen, the chances of contamination are larger. the hygienic effect of rodding and bagging will depend on the operator's experience at these critical hygienic positions. skinning and evisceration may also be designated as critical control points (ccps) as part of the haccp programme, the critical limit for both being zero visible faecal contamination on the carcasses. monitoring occurs at the trimming stand where every carcass is visually inspected. this inspection may be facilitated using the online monitoring system described by tergney and bolton ( ) . when faeces or faecal stains are detected they are immediately removed by trimming. the cause of the breach in hygiene should also be investigated, and secondary corrective actions require retraining of personnel, replacement of knives, etc. setting and using indicators/criteria for "process hygiene" of slaughterhouses is an integral part of the meat safety assurance system, which targets specifically contamination of the carcasses with enteric pathogens. according to the regulation on microbiological criteria, a microbiological criterion means a criterion defining the acceptability of a product, a batch of foodstuffs or a process, based on the absence, presence or number of microorganisms, and/or on the quantity of their toxins/metabolites, per unit(s) of mass, volume, area or batch. phc included in regulation (ec) no / are defined as criteria indicating the acceptable functioning of the production process. they give guidance on the acceptable implementation of pre-requisite programmes (gmp/ghp) and haccp-based systems to ensure hygienic functioning of slaughterhouse processes and are applicable only to the product at the end of the manufacturing process (final carcass after dressing but before chilling), and not to products placed on the market. in eu countries, phc involve the evaluation of indicators of overall contamination (total viable count of bacteria), indicators of contamination of enteric origin (enterobacteriaceae) and salmonella spp. prevalence. bacteriological analysis of carcasses, as outlined in this regulation, is carried out by the fbo. it involves pooled samples from four risk-assessed sampling sites on each of five sampled carcasses. this must be carried out weekly or, depending on the previous results, once a fortnight. phc set an indicative microbial contamination value above which corrective actions are required by the fbo in order to maintain the hygiene of the process in compliance with eu food law. these corrective actions should include the improvement of slaughter hygiene and the review of process controls. the phc communicate the expected outcome of a process, but they neither characterise nor differentiate between the processes themselves. process compliance must be verified by audits of haccp plans and inspections of processing procedures. the competent authority carries out this role on behalf of the member state as defined by regulation (ec) no / . as phc verifies the hygienic functioning of the process rather than the safety of the product, it does not require validation by independent sampling on behalf of the competent authority. microbiological testing alone may convey a false sense of security due to the statistical limitations of sampling plans, particularly in the cases where the hazard presents an unacceptable risk at low concentrations and/or low and variable prevalences. in addition, for pathogens other than enteric hazards (e.g. t. gondii), phc does not provide any information about risk. sampling and testing, as required by regulation (ec) no / , is only part of the verification process of systems in place. these criteria should not be considered without other aspects of eu food legislation, in particular haccp principles and official controls to fbos' compliance (efsa, c) . with current eu legislation, one element of the phc indicates the maximum acceptable prevalence of salmonella spp. on carcasses at the end of the slaughter line. the inclusion of this pathogen as a process hygiene criterion for carcasses highlights the importance of salmonella spp. as a foodborne pathogen in the eu and the need for good hygiene measures for controlling it in the abattoir. however, the use of this hazard presents some problems, because the salmonella spp. occurrence on carcasses depends not only on process hygiene performance of a given abattoir, but also on the salmonella spp. carriage by incoming animals (or lack of it). hence, when slaughtering batches that are salmonella spp. free or that have a low prevalence, such phc will be satisfied even if the actual process hygiene is inadequate-and vice versa. on the other hand, the current eu salmonella-based process hygiene criterion partly has the nature of a salmonella-related target to be achieved by abattoirs. the important difference is that with the current eu phc the hazard is measured on the carcass before chilling, while with the target-based concept the hazard is measured on the chilled carcass (i.e. just before dispatch onwards to the meat chain). however, the chilled carcass is better suited for assessing consumer exposure, and for the hazard-related target concept, as the prevalence/levels of microbial hazards on the carcass may change during chilling. furthermore, these current salmonella-related eu criteria for chilled carcasses are not clearly linked to other salmonellarelated criteria/targets at preceding and/or consecutive steps of the meat chain. in addition, current eu-legislated phc for abattoirs actually do not provide information on ratios between initial contamination associated with incoming animals versus final contamination associated with carcasses, i.e. on the actual capacity of the process to reduce the incoming contamination, but only on the process outcomes. when the main purpose is to microbiologically characterise the abattoir process itself, which is the subject of this subsection and a prerequisite for related differentiation of abattoirs, this is a significant weakness of the current eu-legislated phc. these shortcomings could be addressed by the setting of specific targets for pathogenic vtec, as described in section . above, instead of using salmonella spp. in phc. in addition, to measure the performance of the slaughter line, phc based on indicator organisms should be implemented, measuring microbial loads in at least two stages of the processing line. this would allow determination of the ratio between indicator organisms on pre-chill carcasses and those found in incoming animals, for a given batch. the phc is considered to be a key component of the proposed meat safety assurance system so, in that context, careful consideration would need to be given to issues such as the number of samples taken per week, the areas where those samples are taken from (both in carcasses and incoming animals) and the need for regulatory auditing of the process hygiene assessment (which may include microbial testing, as well as record verification). this more accurate information based on trends of data derived from process hygiene assessments and from haccp programmes would enable differentiation ("risk categorisation") of abattoirs with respect to pathogenic vtec which, in turn, would enable different risk management options for different risk categories of abattoirs to be used, including: optimisation of balancing pathogenic vtec risk categories of small ruminants with risk categories of abattoirs where they are to be slaughtered. optimisation of the decision whether/where additional pathogenic vtec risk-reducing interventions are to be applied (e.g. carcass decontamination step). more stringent requirements for monitoring/verification/auditing programmes for higher risk abattoirs. more reliable feedback to the farm of origin on the root of problems with pathogenic vtec on carcasses of small ruminants. clearer identification of slaughterhouses where improvement of the slaughtering practices and/or technology is needed. small ruminants represent a reservoir of enteric pathogens. in that context, the slaughtering of sheep involves greater challenges because the animal is relatively small and has a wool fleece, thus increasing the risk of surface contamination at dehiding (buncic, ) , which might result in suboptimal hygiene during slaughtering compared with the slaughtering of cattle. technological and operational shortcomings, such as a too high line speed, no rodding and bagging and the use of seasonal workers not sufficiently trained for the purpose, are reported as additional challenges in some abattoirs (norwegian scientific committee for food safety, ). accordingly, interventions such as surface pasteurisation using hot water might be considered as one of several options to reduce the bacterial contamination on carcasses. hot water at - °c achieves a . to . log reduction in colony-forming units (cfus)/cm in salmonella spp. on beef carcasses (arthur et al., ; cutter and rivera-betancourt, ) . in a study by hauge et al. ( b) lamb carcasses were subjected to hot water pasteurisation at °c for eight seconds. the reduction in e. coli just after pasteurisation was . %, corresponding to . log cfus/cm , and after hours' storage . log cfus/cm . accordingly, surface pasteurisation of sheep carcasses might represent an important and efficient step (ccp) to reduce vtec on the carcasses and the risk of disease among consumers. an automatic surface pasteurisation step is easy to control by measurement of time/temperature, and these results, together with the quality of the process water, might be documented on display and/or on hard copy. the pasteurisation step might be recognised as a ccp in a haccp concept. steam treatment is also allowed in the eu and has been found to reduce bacterial contamination in sheep carcasses by a log cfus/cm , both in enterobacteriaceae (milios et al., ) and aerobic plate counts (james et al., ) . greater reductions of up to . log cfus/cm have been described when using a combination of steam and a hot water wash in sheep carcasses (dorsa et al., ) . similar effects have been observed with salmonella spp. counts in beef carcasses, achieving reductions of < . to . log cfus/cm (phebus et al., ; retzlaff et al., ) . surface pasteurisation can also be achieved by manual steam vacuum technology. however, the use of this technology depends on skilled and responsible operators, and will require close supervision in order to ensure the pasteurisation procedure is correctly applied to the whole carcass. the use of manual steam vacuum was evaluated in a norwegian slaughterhouse, showing a real reduction (median of . log cfus/cm )(hassan, ). surface pasteurisation of ruminant carcasses is an option that allows dealing with carcasses presenting greater risk, such as emergency slaughtered carcasses or unclean carcasses, without the need, for example, to apply a heat treatment on these carcasses. although not permitted in the eu, a range of specific interventions are applied in us slaughter plants targeting enteric pathogens such as pathogenic vtec and salmonella spp. these include the application of organic acids. the application of acetic acid to beef carcasses will reduce e. coli counts by . - . log cfus/cm (sofos and smith, ) . significant reductions achieved with lactic acid have also been described (efsa panel on biological hazards, ). as neither of the main public health hazards associated with meat from small ruminants can be detected by traditional meat inspection, other approaches are necessary to identify and control these microbiological hazards. a comprehensive meat safety assurance system for meat from small ruminants, combining a range of preventive measures and controls applied both on the farm and at the slaughterhouse in a longitudinally integrated way, is the most effective approach to control the main hazards in the context of meat inspection. information on the biological risks associated with the consumption of meat from sheep or goats is sometimes scant and unreliable. in order to facilitate decision making, harmonised surveys are required to establish values for the prevalence of the main hazards t. gondii and pathogenic vtec at flock/herd, live animal and carcass level in individual mss. epidemiological and risk assessment studies are also required to determine the specific risk to public health associated with the consumption of meat from small ruminants. in the event that these studies confirm a high risk to public health through the consumption of meat from sheep or goats, consideration should be given to the setting of clear and measurable eu targets at the carcass level. to meet these targets and criteria, a variety of control options for the main hazards are available, at both farm and abattoir level. flock/herd categorisation according to the risk posed by the main hazards is considered an important element of an integrated meat safety assurance system. this should be based on the use of farm descriptors and historical data in addition to batch-specific information. farm-related data could be provided through farm audits using heis to assess the risk and protective factors for the flocks/herds related to the given hazards. classification of abattoirs according to their capability to prevent or reduce faecal contamination of carcasses can be based on two elements: (i) the process hygiene as measured by the level of indicator organisms on the carcasses (i.e. phc); and (ii) the use of operational procedures and equipment that reduce faecal contamination, as well as industry-led quality assurance systems. as mentioned in section . , further studies are necessary to determine with more certainty the risk of acquiring t. gondii through consumption of meat from small ruminants. in addition, the lack of tests that can easily identify viable cysts in meat is a significant drawback. furthermore, if there is a high prevalence in the animal population, this will hamper the development of systems based on risk categorisation of animals. for these reasons, the setting of targets for t. gondii is not recommended at the moment. there are a variety of animal husbandry measures that can be used to control t. gondii on sheep and goat farms but at present it would not be practical to implement them on most farms. a number of post-processing interventions might be effective in inactivating t. gondii such as cooking, freezing, curing and high-pressure and -irradiation treatments. however, most of the information available for these treatments originates from research in pigs, so further research is required to validate these treatments in meat from small ruminants. there are also a variety of animal husbandry measures that can be used to reduce the levels of vtec on infected farms, but their efficacy is not clear in small ruminants. in addition, there are a number of challenges that need to be overcome regarding the setting of targets for pathogenic vtec, including the difficulties in identifying husbandry factors that can be used to classify farms according to pathogenic vtec risk, the intermittent nature of shedding, and the problems with the interpretation of monitoring results for vtec due to the difficulty of correctly identifying pathogenic vtec. the two main sources of vtec on sheep and goat carcasses are the fleece/hide and the viscera. to control faecal contamination from the fleece or hide only clean animals should be accepted for slaughter, as currently required by eu legislation. there are also a number of measures that can help to reduce the spillage or leakage of digestive contents onto the carcass, particularly rodding of the oesophagus and bagging of the rectum. post-processing interventions to control pathogenic vtec are also available. these include hot water and steam pasteurisation. risk categorisation of slaughterhouses should be based on trends of data derived from process hygiene assessments and from hazard analysis critical control point programmes. improvement of slaughter hygiene through technological and managerial interventions should be sought in slaughterhouses with repeatedly unsatisfactory performance. source attribution studies are needed to determine the relative importance of meat, as well as to ascertain the role of the different livestock species as a source of t. gondii and pathogenic vtec. methods should be developed to estimate the amount of viable t. gondii tissue cysts in meat, especially in meat cuts that are commonly consumed. recommend adaptation of inspection methods that provide an equivalent protection for current hazards the main rationale behind the concept of fci is that animals sent for slaughter can be categorised into different risk groups based on relevant information from the flock/herd of origin. this enables appropriate measures to be put in place during slaughter to deal with the level of risk identified. although regulation (ec) no / mentions the basic requirements for fci, these are very general and as a consequence the information reported in fci is rarely used as described above (section . . of this appendix). there are a number of ways in which fci could be improved. as explained in section . . above, more specific information about the main hazards could be used for assessing the risks associated with batches of animals arriving at the slaughterhouse, resulting in a classification according to these risks. to achieve this, the system needs further development to include additional information important for food safety, including the definition of appropriate and standardised indicators for the main public health hazards identified in section of this appendix. in addition, membership of quality assurance schemes and certification systems can have a positive impact on public health by contributing to the overall health of the animals sent to slaughter. certification procedures at farm level are voluntary tools to ensure compliance with given standards and regulations in the quality assurance system. they are aimed at achieving continuous improvement in production standards by monitoring quality assurance standards or criteria. audits or inspections of farms ensure that the animal (final product) is being raised and handled in accordance with the standards or guidelines, which producers should adhere to. the main areas covered by the standards include usually animal health, welfare and hygiene, identification and traceability, adequate and prudent use of medicines and chemicals at farm level, safety of feed and water, environmental guidelines, hygiene of personnel, processes and infrastructure, and preparation of animals for slaughter. the standards should be regularly updated in line with changes in legislation and with scientific developments. certifications are issued by independent agencies or bodies which confirm that an auditing process has been passed. farmers can also adopt other schemes such as the guides to good farming practices, recommendations of best practice published by international bodies (i.e. world organisation for animal health (oie) and the food and agriculture organization of the united nations (fao)). adherence to such quality schemes and guidelines at farm level has multiple benefits, providing slaughterhouse operators with useful information about animals intended to be slaughtered and could be integrated in the fci. it also increases farmers' responsibilities and has a beneficial influence on meat safety and quality. schemes such as the beef and lamb quality assurance scheme in ireland cover a broad area, relating to animal identification and animal health and welfare, and contribute to ensuring that healthy animals enter the slaughterhouse. farmers should be encouraged to participate in these schemes, and information on whether or not a primary producer is a member should be included in the fci. eu regulations (ec) no / and (ec) no / already require that information gathered during meat inspection is fed back to the primary producer. the main value of such feedback relates to animal health and welfare and production-related diseases, such as liver fluke and pneumonia. however, as mentioned previously, use of this information to produce healthier animals would have indirect benefits for public health. from discussions with stakeholders, it is clear that feedback to the producers is very limited in most mss and that there is considerable room for improvement in that area (see the report from the technical hearing on meat inspection of small ruminants ). ante-mortem inspection assesses the general health status of the animals on arrival at the slaughterhouse. meat for human consumption should be derived from the slaughter of healthy animals. inspection of animals on arrival at the slaughterhouse will help to enforce acceptable standards of transport and handling. this might indirectly contribute to the maintenance of operating standards that minimise the general risk associated with unhygienic and stressful management of food-producing animals. stress has been shown to be an important factor in the excretion of enteric pathogens such as pathogenic vtec, salmonella spp. and campylobacter spp., so inspection procedures that prevent stress are likely to be beneficial (efsa panel on biological hazards, b). measures to keep the transport-lairaging period as short as possible may be beneficial in terms of reducing crosscontamination with these enteric pathogens. the ante-mortem procedure will help to detect animals heavily contaminated with faeces and other material. measures to prevent excessively dirty animals from entering the slaughter line will help to prevent contamination of the carcasses and may reduce the level of enteric pathogens. taking these factors into consideration, and given that current methods do not increase the microbiological risk to public health and have considerable benefits in relation to the monitoring of animal health and welfare, no adaptations for the existing visual ante-mortem inspection are proposed. in the inspection procedure for sheep and goats, as set out in eu regulation (ec) no / , carcasses are subject to visual inspection only. incision is mandatory for the gastric surface of the liver. palpation is mandatory for the lungs, bronchial and mediastinal lymph nodes, the liver and its lymph nodes. in addition, palpation is mandatory for the umbilical region and joints of young animals. palpation of lungs, liver, umbilical region and joints, and incision of the liver could contribute to the spread of bacterial hazards through cross-contamination. although the importance of such crosscontamination has not been studied in small ruminants, it has been considered important in other species ( the pathogens of importance for public health cannot be detected by routine post-mortem examination. consequently, palpation of liver, lungs, the umbilical region and joints and incision of the gastric surface of the liver do not contribute to preventing the risk to public health arising from the meat-borne hazards identified in this opinion. for these reasons, palpation and incision should be omitted in animals subjected to routine slaughter. visual examination contributes by detecting visible faecal contamination and/or spilled intestinal contents, although it is unclear how sensitive the current system is or what contribution this detection makes towards preventing public health risk. the current legislation foresees palpation and incision if abnormalities are detected during visual inspection. it is recommended that these procedures, if necessary, are carried out separately from the routine inspection of carcasses to prevent cross-contamination. elimination of abnormalities on aesthetic/meat quality grounds can be ensured through a meat quality assurance system and not through the official meat safety assurance system including meat inspection. any handling should be performed on a separate line and accompanied by laboratory testing as required. palpation and incision currently assist in the identification of zoonootic pathogens that are not meat borne, such as echinococcus granulosus, fasciola hepatica (although cysts are usually visible before incisions are made) and mycobacterium bovis. the removal of palpation and incision as a requirement in the post-mortem procedure in small ruminants could have a significant effect on monitoring echinococcus, in particular, as meat inspection is the principal method of detection of this pathogen (efsa, ) . in countries where hazards such as echinococcus are present it might be appropriate to conduct a risk assessment to evaluate the benefits to public health of stopping cross-contamination through palpation and incision of viscera with those obtained through monitoring of these non-meatborne zoonotic hazards. fci can be improved by including information on participation in quality assurance schemes and by giving greater feedback to the primary producer, as this would probably result in the production of healthier animals. ante-mortem inspection assesses the general health status of the animals and helps to detect animals heavily contaminated with faeces on arrival at the slaughterhouse. taking these factors into consideration, and given that current methods do not increase the microbiological risk to public health, no adaptations to the existing visual ante-mortem inspection procedure are required. although visual examination contributes by detecting visible faecal contamination, routine postmortem examination cannot detect the meat-borne pathogens of public health importance. palpation of the lungs, the liver, the umbilical region and the joints and incision of the liver could contribute to the spread of bacterial hazards through cross-contamination. for these reasons, palpation and incision should be omitted in animals subjected to routine slaughter. the effect of this omission on the risk posed by non-meat-borne zoonoses such as e. granulosus, f. hepatica and m. bovis should be assessed, particularly in those countries where these hazards are prevalent. conclusions tor identify and rank the main risks for public health that should be addressed by meat inspection at eu level. general (e.g. sepsis, abscesses) and specific biological risks as well as chemical risks (e.g. residues of veterinary drugs and contaminants) should be considered. differentiation may be made according to production system and age of animals (e.g. breeding compared to fattening animals). based on the priority ranking, the hazards were classified as follows: -t. gondii and pathogenic verocytotoxin-producing escherichia coli (vtec) were classified as high priority for sheep/goat meat inspection. -the remaining identified hazards, b. anthracis, campylobacter spp. (thermophilic) and salmonella spp., were classified as low priority, based on the available data. as new hazards might emerge and/or hazards that presently are not a priority might become more relevant over time or in some regions, both hazard identification and the risk ranking should be revisited regularly to reflect this dynamic epidemiological situation. particular attention should be given to potential emerging hazards of public health importance. assess the strengths and weaknesses of the current meat inspection methodology and recommend possible alternative methods (at ante-mortem or post-mortem inspection, or validated laboratory testing within the frame of traditional meat inspection or elsewhere in the production chain) at eu level, providing an equivalent achievement of overall objectives; the implications for animal health and animal welfare of any changes suggested in the light of public health risks to current inspection methods should be considered. ante-mortem and post-mortem inspection of sheep and goats enable the detection of observable abnormalities. in that context, they are an important activity for monitoring animal health and welfare. they provide a general assessment of animal/herd health, which if compromised may lead to a greater public health risk. visual inspection of live animals and carcasses can also detect animals heavily contaminated with faeces. such animals increase the risk for cross-contamination during slaughter and may consequently constitute a food safety risk if carrying hazards of public health importance. if such animals or carcasses are dealt with adequately, this risk can be reduced. visual detection of faecal contamination on carcasses can also be an indicator of slaughter hygiene, but other approaches to verify slaughter hygiene should be considered. post-mortem inspection can also detect non-meat-borne hazards of public health significance that can be present in carcasses or offal from small ruminants. ante-mortem and post-mortem inspection also have the potential to detect new diseases if these have clinical signs, which may be of direct public health significance. currently, the use of food chain information (fci) for food safety purposes is limited for small ruminants, mainly because the data that it contains is very general and doesn't address specific hazards of public health importance. however, fci could serve as a valuable tool for risk management decisions and could be used for risk categorisation of farms or batches of animals. to achieve this, the system needs further development to include additional information important for food safety, including definition of appropriate and standardised indicators for the main public health hazards identified in section of this appendix. ante-and post-mortem inspection is not able to detect any of the public health hazards identified as the main concerns for food safety. it would therefore be expected that more efficient procedures might be implemented to monitor the occurrence of non-visible hazards. in addition, given that the current post-mortem procedures involve palpation and incision of some organs, there is potential for cross-contamination of carcasses. if new hazards currently not covered by the meat inspection system (e.g. salmonella, campylobacter) are identified under tor , then recommend inspection methods fit for the purpose of meeting the overall objectives of meat inspection. when appropriate, food chain information should be taken into account. as neither of the main public health hazards associated with meat from small ruminants can be detected by traditional meat inspection, other approaches are necessary to identify and control these microbiological hazards. a comprehensive meat safety assurance system for meat from small ruminants, combining a range of preventive measures and controls applied both on the farm and at the slaughterhouse in a longitudinally integrated way, is the most effective approach to control the main hazards in the context of meat inspection. information on the biological risks associated with the consumption of meat from sheep or goats is sometimes scant and unreliable. in order to facilitate decision making, harmonised surveys are required to establish values for the prevalence of the main hazards t. gondii and pathogenic vtec at flock/herd, live animal and carcass level in individual member states. epidemiological and risk assessment studies are also required to determine the specific risk to public health associated with the consumption of meat from small ruminants. in the event that these studies confirm a high risk to public health through the consumption of meat from sheep or goats, consideration should be given to the setting of clear and measurable eu targets at the carcass level. to meet these targets and criteria, a variety of control options for the main hazards are available, at both farm and abattoir level. flock/herd categorisation according to the risk posed by the main hazards is considered an important element of an integrated meat safety assurance system. this should be based on the use of farm descriptors and historical data in addition to batch-specific information. farmrelated data could be provided through farm audits using harmonised epidemiological indicators (heis) to assess the risk and protective factors for the flocks/herds related to the given hazards. classification of abattoirs according to their capability to prevent or reduce faecal contamination of carcasses can be based on two elements: (i) the process hygiene as measured by the level of indicator organisms on the carcasses (i.e. process hygiene criteria); and (ii) the use of operational procedures and equipment that reduce faecal contamination, as well as industry-led quality assurance systems. as mentioned in section . of appendix a, further studies are necessary to determine with more certainty the risk of acquiring t. gondii through consumption of meat from small ruminants. in addition, the lack of tests that can easily identify viable cysts in meat is a significant drawback. furthermore, if there is a high prevalence in the animal population, this will hamper the development of systems based on risk categorisation of animals. for these reasons, the setting of targets for t. gondii is not recommended at the moment. there are a variety of animal husbandry measures that can be used to control t. gondii on sheep and goat farms, but at present these would not be practical to implement on most farms. a number of post-processing interventions might be effective in inactivating t. gondii such as cooking, freezing, curing and high-pressure and -irradiation treatments. however, most of the information available for these treatments originates from research in pigs, so further research is required to validate these treatments in meat from small ruminants. there are also a variety of animal husbandry measures that can be used to reduce the levels of vtec on infected farms, but their efficacy is not clear in small ruminants. in addition, there are a number of challenges that need to be overcome regarding the setting of targets for pathogenic vtec, including the difficulties in identifying husbandry factors that can be used to classify farms according to pathogenic vtec risk, the intermittent nature of shedding, and the problems with the interpretation of monitoring results for vtec due to the difficulty of correctly identifying pathogenic vtec. the two main sources of vtec on sheep and goat carcasses are the fleece/hide and the viscera. to control faecal contamination from the fleece or hide only clean animals should be accepted for slaughter, as currently required by eu legislation. there are also a number of measures that can help to reduce the spillage or leakage of digestive contents onto the carcass, particularly rodding of the oesophagus and bagging of the rectum. post-processing interventions to control vtec are also available. these include hot water and steam pasteurisation. risk categorisation of slaughterhouses should be based on trends of data derived from process hygiene assessments and from hazard analysis critical control point programmes. improvement of slaughter hygiene through technological and managerial interventions should be sought in slaughterhouses with repeatedly unsatisfactory performance. tor recommend adaptations of inspection methods and/or frequencies of inspections that provide an equivalent level of protection within the scope of meat inspection or elsewhere in the production chain that may be used by risk managers in case they consider the current methods disproportionate to the risk, e.g. based on the ranking as an outcome of terms of reference or on data obtained using harmonised epidemiological criteria (see annex ). when appropriate, food chain information should be taken into account. fci can be improved by including information on participation in quality assurance schemes and by giving greater feedback to the primary producer, as this would probably result in the production of healthier animals. ante-mortem inspection assesses the general health status of the animals and helps to detect animals heavily contaminated with faeces on arrival at the slaughterhouse. taking these factors into consideration, and given that current methods do not increase the microbiological risk to public health, no adaptations for the existing visual ante-mortem inspection are required. although visual examination contributes by detecting visible faecal contamination, routine post-mortem examination cannot detect the meat-borne pathogens of public health importance. palpation of the lungs, the liver, the umbilical region and the joints, and incision of the liver could contribute to the spread of bacterial hazards through cross-contamination. for these reasons, palpation and incision should be omitted in animals subjected to routine slaughter. to provide a better evidence base for future risk ranking of hazards, initiatives should be instigated to: improve and harmonise data collection of incidence and severity of human diseases caused by relevant hazards systematically collect data for source attribution collect data to identify and risk rank emerging hazards that could be transmitted through handling, preparation and consumption of sheep and goat meat. source attribution studies are needed to determine the relative importance of meat, as well as to ascertain the role of the different livestock species, as a source of t. gondii and pathogenic vtec for humans. methods should be developed to estimate the amount of viable t. gondii tissue cysts in meat, especially in meat cuts that are commonly consumed. assessment of the importance of the hazards in table with regard to their potential as zoonotic agents that can be transmitted via consumption of meat from small ruminants. these bacteria are considered zoonotic, although this characteristic has only been documented in fish. transmission via consumption of meat from small ruminants has not been reported, despite aeromonas being detected in lamb and meat products and having the potential to be a foodborne pathogen (daskalov, ) . these obligate intracellular bacteria are found in sheep, cattle, horses and dogs, as well as deer and rodents in europe (kalinova et al., ), and although they cause human disease, this illness is rare (scharf et al., ) . they are transmitted by ticks of the genus ixodes, therefore they do not present a risk to humans via consumption of sheep meat. arcobacter spp. the genus arcobacter includes species that can be defined as aerotolerant campylobacter-like organisms. they were first isolated from aborted bovine foetuses. information on the real prevalence and clinical importance of arcobacter is limited because of the absence of routine testing protocols and the fact that most laboratories do not use appropriate culture conditions or do not identify isolates to species level. small ruminants have been found to be carriers of these bacteria (de smet et al., ) in europe. recent reports suggest that arcobacters, especially a. butzleri, may be involved in human enteric disease, although the evidence is not conclusive (houf, ). there are no specific epidemiological data establishing a link between arcobacter infection with consumption of meat from small ruminants. in addition, the public health significance of arcobacter remains unclear. borrelia are transmitted by ticks of the genus ixodes, and infect a wide range of hosts including sheep, although their contribution to the maintenance of b. burgdorferi is still not clear (mannelli et al., ) . although present throughout europe, currently there is no evidence that borrelia can be transmitted via consumption of meat. sheep and goat brucellosis is a zoonotic infection. brucellosis is caused by some bacterial species belonging to the genus brucella. of the six species known to cause disease in humans b. melitensis affects goats and sheep, their specific animal reservoir. humans are usually infected from direct contact with infected animals or via contaminated food, typically raw milk, cheese made thereof or other milk products such as cream and ice cream. meat is not considered a source of infection since muscle tissue contains low concentrations of brucella organisms and the survival time in meat seems extremely short. the number of organisms per gram of muscle is small and rapidly decreases as the ph of the meat drops. brucella spp. die off rapidly when incubated at º c in a medium at ph < (icmsf (international commission on microbial specifications for food), ). an exception in survival behaviour seems to be frozen carcasses, in which the organism can survive for years. c. abortus is known to be transmissible from animals to humans, causing significant zoonotic infections. c. abortus causes the enzootic abortion of ewes (ovine enzootic abortion), which has become recognised as a major cause of loss in sheep (and goats) in europe, north america and africa. (pospischil, ) . most cases of c. abortus infection are directly associated with exposure to infected sheep or goats, with transmission most probably occurring by mouth following the handling of an infected ewe or lamb or of contaminated clothing (longbottom and coulter, ) . the role of meat from small ruminants in the epidemiology of human infection with c. abortus is nevertheless unclear. c. difficile is a species of anaerobic, spore-forming gram-positive bacteria that causes severe diarrhoea and other intestinal disease when competing bacteria in the gut flora have been eliminated by antibiotic treatment. there are reports of c. difficile being isolated from small ruminants (hunter et al., ; koene et al., ; rieu-lesme and fonty, ; saif and brazier, ) . however, there is to date no indication of meat-borne transmission to humans. c. pseudotuberculosis is the causative agent of caseous lymphadenitis in small ruminants. these bacteria are commonly found in europe in the ruminant population. cases of human lymphadenitis have been described previously (peel et al., ) , although transmitted via occupational exposure and not through consumption of meat. c. burnetti has been isolated from a large range of animals including farm animals (e.g. cattle, sheep and goats), wildlife and arthropods. it has a near-worldwide distribution. c. burnetti causes q fever in humans, in whom it was traditionally considered an occupational disease in farm and abattoir workers. airborne transmission is also important, and has played a major role in recent outbreaks. the meatborne transmission route has so far not been identified as a possibility (georgiev et al., ) . erysipelothrix rhusiopathiae e. rhusiopathiae is a ubiquitous bacterium which can cause polyarthritis in sheep and lambs. it can also infect humans, in whom it causes either cutaneous (localised or general) or septicaemic disease (wang et al., ) . humans usually acquire the infection through contact with infected animals, i.e. erysipelas is considered an occupational disease. meat from small ruminants has not been identified as a vehicle for human infection. esbls may be defined as plasmid-encoded enzymes found in the enterobacteriaceae that confer resistance to a variety of ß-lactam antibiotics, including penicillins, and second-, third-and fourthgeneration cephalosporins. in contrast, ampc β-lactamases are intrinsic cephalosporinases found on the chromosomal dna of many gram-negative bacteria, which confer resistance to penicillins, second-and third-generation cephalosporins, including β-lactam/inhibitor combinations, and cefamycins (cefoxitin), but usually not to fourth-generation cephalosporins. a growing number of these ampc enzymes are now plasmid-borne (efsa panel on biological hazards, c). a targeted literature search found references that reported the presence of esbl/ampc-gene carrying enterobacteriaceae (geser et al., ; snow et al., ) in small ruminants but none indicated transmission of these enzymes to humans via consumption of meat from sheep or goats. helicobacter pylori h. pylori was previously known as campylobacter pylori (it is taxonomically related to campylobacter spp. and belongs to the family helicobacteraceae). infection of the stomach by h. pylori is associated with several alterations in gastric mucosal cell proliferation, and disorders such as chronic gastritis, gastric ulcers, duodenal ulcers and stomach cancer. colonisation of the stomach by h. pylori is well established and the bacterium is able to withstand digestive enzymes and concentrated hydrochloric acid. h. pylori is believed to be transmitted orally but no food has been as yet identified as a source. no reservoir other than the human gastric mucosa has been identified for h. pylori. plonka et al. ( ) suggest a zoonotic link to sheep, but no evidence of meat-borne transmission is presented. although the isolation of k. pneumoniae from small ruminants' meat has been described (brahmbhatt, ; sharma et al., ) , no evidence for meat-borne transmission of this pathogen to humans could be found. l. spiralis has been reported in the small ruminant population in europe and elsewhere (bisias et al., ; savalia et al., ; seixas melo et al., ) ; however, although it has been considered a potential occupational hazard (heuer et al., ) , there is no current evidence that it can be transmitted to humans via consumption of meat from small ruminants. mycobacterium avium subsp. paratuberculosis m. avium subsp. paratuberculosis (map), which causes chronic enteritis in all ruminants, is the most prevalent mycobacterium found in small ruminants within the m. avium complex (mac). mac includes eight mycobacteria species and several subspecies with different degrees of pathogenicity, a broad host range and environmental distribution in numerous biotopes including the soil, water, aerosols, etc. (alvarez et al., ; biet et al., ) . a link between map and the human chronic enteritis, crohn's disease, has been speculated and supported by several lines of evidence, such as the demonstration of map-specific sequences in crohn's disease-affected tissues. however, at present, there is no agreed consensus on any aetiological role for map in crohn's disease (chiodini, ; waddell et al., ; wagner et al., ) and no evidence that it presents a risk via consumption of meat or meat products. the presence of mycobacteria has been previously reported in the small ruminant population in the eu (domenis et al., ; malone et al., ; marianelli et al., ; . despite these reports, evidence of meat-borne transmission of these pathogens to humans from small ruminants is lacking, so this potential pathway of infection remains unproven in the context of livestock processed through the eu meat inspection system. mrsa has been isolated from most food-producing animals and from most meats, as well as from milk including sheep and lamb meat. where mrsa cc prevalence is high in food-producing animals, people in contact with these live animals (especially farmers and veterinarians, and their families) are at greater risk of colonisation and infection than the general population. food may be contaminated by mrsa (including cc ): eating and handling contaminated food is a potential vehicle for transmission. there is currently no evidence for increased risk of human colonisation or infection following contact or consumption of food contaminated by cc both in the community and in hospital (efsa, ). streptococcus spp. have been isolated in small ruminants, most commonly in milk or mastitis samples (pisoni et al., ; zdragas et al., ) . zoonotic transmission has been described (poulin and boivin, ), but there is no evidence to date that it can cause meat-borne disease in humans. foodborne yersiniosis is caused primarily by yersinia enterocolitica, with y. pseudotuberculosis representing a low fraction of isolates (less than %) from human cases reported (efsa and ecdc, b). the majority of isolates of y. enterocolitica isolated from food and environmental sources are non-pathogenic types, and therefore discrimination between pathogenic and non-pathogenic strains for humans is necessary. no reports of y. pseudotuberculosis have been published of isolates in food items tested during - (efsa and ecdc, , b . pigs are considered to be the primary reservoir for the human pathogenic types of y. enterocolitica, and they can be isolated from the oral cavity, the submaxillary lymph nodes, the intestine and faeces (nesbakken, ) . y. enterocolitica is found in small ruminants, and is considered to be responsible for certain infections in sheep and goats such as enteritis (arnold et al., ; fearnley et al., ; fredriksson-ahomaa et al., ; fukushima et al., ; gourdon et al., ; krogstad, ; mcnally et al., ; milnes et al., ; philbey et al., ; slee and button, ; slee and skilbeck, ; soderqvist et al., ; wojciech et al., ) . mcnally et al. ( ) investigated the relationship between livestock (sheep, cattle and pigs) carriage of y. enterocolitica and human disease with inconclusive results. the majority of the strains isolated from animal reservoirs differ from clinical strains found in humans, biochemically and serologically. so far pigs are the only species pinpointed as being significant reservoirs for pathogenic y. enterocolitica. there is no evidence that sheep and goats are important animal reservoirs for strains involved in human cases, although slee and button ( ) reported the infection of an animal attendant in connection with an outbreak of y. enterocolitica infection in a goat herd in norway. no evidence that yersinia spp. present a risk via consumption of meat or meat products from sheep or goats is currently available. c. albicans is a fungus that is the causal agent of opportunistic oral and genital infections in humans and has also been isolated from sheep and goats, for example in milk samples of goats suffering from mastitis (langoni et al., ) or from sheep droppings (nardoni et al., ) . no evidence to date could indicate transmission of this fungus to humans via consumption of meat. cryptococcosis is a rare disease in animals in europe. a few cases have been described in sheep and goats (lung and mammary gland) in australia. the source of microorganisms is largely environmental. no cases of transmission from animal to animal or from animal to man or from man to man (except corneal transplant) have been described (acha and szyfres, ). c. neoformans is therefore currently considered not relevant in the eu sheep and goat population and not transmissible via meat. species of microsporidia infecting humans have been identified in water sources as well as in wild, domestic, and food-producing farm animals, raising concerns for waterborne, foodborne, and zoonotic transmission (didier, ) . no evidence could be found in the literature of meat-borne transmission of this hazard from small ruminants to humans. enterocytozoon bieneusi e. bieneusi, the species now known to be the most frequent in microsporidial infections of humans, was not discovered until . e. bieneusi has recently been found in the faeces of animals, including pigs, rhesus macaques, cats and cattle. however, the potential reservoirs and the mode of transmission of this pathogen are still unknown (dengjel et al., ) . phylogenetic analysis revealed the lack of a transmission barrier between e. bieneusi from humans and animals (cats, pigs and cattle). thus, e. bieneusi appears to be a zoonotic pathogen." (dengjel et al., ). however, no evidence could be found in the literature for meat-borne transmission of this hazard from small ruminants to humans. parasites of the genus ascaris have very occasionally reported in sheep. however, the transmission of these parasites to humans is via ingestion of eggs that are excreted in faeces of the definite hosts (e.g. in pigs a. sum and in and humans a. lumbricoides), therefore there is currently no evidence of a link between human ascariasis and the consumption of ruminant meat. babesia spp. are vector-mediated parasites, and are transmitted by hard ticks (e.g. ixodes, dermacentor, rhipicephalus and hyaloma spp.). in europe, they are found in cattle and rodents, although they have also been reported in sheep ( (sreter et al., ) . human babesiosis is rare in europe, and only transmitted via tick bites, i.e. there have been no reports of meat-borne transmission to humans from animals. cerebral coenurosis is caused by the metacestode stage of the cestode t. multiceps, which has canids as the final host. both humans and sheep are intermediate hosts in the life cycle of this parasite, which is present in parts of europe (scala and varcasia, ) . infection occurs by ingestion of vegetables or water contaminated with the tapeworm eggs shed by the final host. meat has not been recorded as being involved in transmission of this parasite. cryptosporidiosis in humans is usually linked to consumption of contaminated water or contact with infected animals, mainly cattle but also young sheep and goats. although its presence in meat is considered possible, a quick review of the literature did not reveal any evidence describing the isolation in meat or any outbreaks caused by consumption of meat from small ruminants. c. ovis and c. tenuicollis are the larval stages of taenia ovis and taenia hydatigena respectively, found in the intestines of canids. humans can act as intermediate hosts for these cysticerci, but cases are very rare. consumption of meat is not associated with the transmission of these parasites, but they are targeted during meat inspection because cysticerci are visible and render the meat unfit for human consumption on quality grounds. ) . humans are a dead-end host and may become infected through accidental ingestion of the eggs, shed in the faeces of infected dogs or other canids. this usually occurs via the ingestion of contaminated food (especially vegetables) or water, and also through accidental soil ingestion or by acquiring the eggs directly from the coat of the definitive host. meat, however, has not been identified as a vehicle for transmission of e. granulosus. the trematode fasciola is a parasite of herbivores that can infect humans accidentally, and is commonly found in europe. humans can become infected by ingesting freshwater plants or water containing metacercariae (fried and abruzzi, ). there is currently no evidence of meat-borne transmission of this parasite to humans. g. intestinalis is a ubiquitous protozoan parasite with global distribution, which infects humans as well as a wide range of other mammals. g. intestinalis is excreted in faeces, and it is transmitted to humans via contaminated water or fresh vegetables. no evidence is available for a role for meat from small ruminants in transmitting this parasite to humans. virus of the family astroviridae are associated with gastroenteritis in birds and mammals, including small ruminants and humans. although a potential zoonotic link has been suggested (jonassen et al., ) , information available in the scientific literature does not point at potential transmission of astroviruses to humans via consumption of meat. bdv infections can result in neurological disease that mainly affects horses and sheep in certain areas of germany (bilzer et al., ; durrwald, ; grabner and fischer, ; ludwig et al., ) . the endemic area also includes areas of switzerland, austria and the principality of liechtenstein (caplazi et al., ; weissenbock et al., ) . bdv received worldwide attention when it was reported that sera and/or cerebrospinal fluids from neuropsychiatric patients can contain bdv-specific antibodies. as infected animals produce bdv-specific antibodies only after virus replication, it was assumed that the broad spectrum of bdv-susceptible species also includes man. however, reports describing the presence of other bdv markers, i.e. bdv-rna or bdv-antigen, in peripheral blood leucocytes or brain tissue of neuropsychiatric patients are highly controversial and, therefore, the role of bdv in human neuropsychiatric disorders is questionable (richt and rott, ) . in any case, no evidence of meat-borne transmission has been found. there is a lack of clarity in relation to the taxonomy of bovine enterovirus (bev). while it appears that bev may be zoonootic, based on a serological survey in turkey, and that sheep and goats in europe are infected, it is likely that the main source of infection for humans is contact with infected animals and/or material contaminated with faeces of infected animals. on the basis of the information obtained from the scientific literature, it is proposed that bev should not be considered for risk ranking. chandipura virus, a member of the rhabdoviridae family and vesiculovirus genus, has recently emerged as a human pathogen associated with a number of outbreaks of acute encephalitis in different parts of india (basak et al., ) . the virus closely resembles the vesicular stomatitis virus, and there are reports of antibody detection in small ruminants, also in india (joshi et al., ) . there are no reports of this virus being present in the eu or being able to be transmitted to humans via food. the information available in the scientific literature for this virus in the small ruminant reservoir is very limited. cchf is a tick-borne disease that can also be transmitted to humans through contact with infected tissues or blood from affected (viraemic) livestock, including sheep. cases of cchf have been reported in butchers and abattoir workers (ergonul, ) as well as health care workers, therefore it can be considered an occupational disease. currently, there is no evidence of meat-borne transmission, and it has been reported that "meat itself is not a risk because the virus is inactivated by post slaughter acidification of the tissues and would not survive cooking in any case." (ergonul, ) . hev has been found in both livestock, especially pigs, and humans in europe. the epidemiology of hev is complex, and a foodborne transmission of hev from animal products (e.g. pork and pork products) to humans is an emerging concern. however, only very few systematic studies have been performed so far, therefore the importance of specific food items has not been sufficiently substantiated. although the presence of hev antibodies in sheep has been previously reported in europe (peralta et al., ), there is no evidence that meat from small ruminants has played a role in transmitting the virus to humans (efsa panel on biological hazards, a). the presence of influenza virus has been occasionally reported in small ruminants (abubakar et al., ; shukla and negi, ; zupancic et al., ) . although no information is available for small ruminants, the safety of meat from pigs infected with influenza has been previously assessed, and it was found that these viruses are not known to be transmissible to humans through the consumption of meat (fao/who/oie, ). orf, also known as contagious ecthyma, is caused by a parapoxvirus and is commonly found in the small ruminant population in europe. this virus is transmitted to humans through direct contact with infected animals and thus is considered an occupational disease (uzel et al., ) . meat-borne transmission has not been reported to date. small ruminants are susceptible to infection with rabies virus, which is present in the wild animal reservoir in europe (mainly in bats and wild canids). cases of rabies in sheep and goats have been occasionally reported in europe (maciulskis et al., ; mudura et al., ) , and although experimental oral transmission has been described (bell and moore, ; fischman and ward, ) , transmission of this virus to humans through the consumption of meat from small ruminants has not been reported to date. this rna virus of the family bunyaviridae causes disease in cattle, sheep and goats, and is transmitted to humans by a wide range of mosquitoes, as well as by handling diseased animals (davies and martin, ) . contact with and consumption of meat, as well as other animal products, has been identified as a risk factor for human infection (anyangu et al., ; mohamed et al., ) . the presence of this virus has not been reported in europe so far (efsa panel on animal health and welfare (ahaw), ). rotaviruses are responsible for causing enteritis and diarrhoea in young livestock, including sheep and goats, as well as in humans. some studies that used gene sequencing point to a common evolutionary origin for rotavirus strains found in small ruminants and those found in humans (ghosh et al., ; matthijnssens et al., ). this could suggest that there is potential for zoonotic transmission between livestock and humans, or at least that some exchange of viruses has occurred in the past (nakagomi et al., ) . it is, however, unclear if meat-borne transmission is possible, as there are no data in the literature reporting this possibility. tbe is an infection caused by flavivirus found in both wild and domestic animals in europe, including small ruminants. humans acquire the infection following the bite of an infected tick. transmission via aerosol and direct contact is also possible, as well as by consuming fresh milk from infected animals. however, transmission via consumption of meat has not been described (krauss et al., ) . objective of meat inspection is to ensure that meat is fit for human consumption. historically, meat inspection procedures have been designed to control slaughter animals for the absence of infectious diseases, with special emphasis on zoonoses and notifiable diseases. the mandate that meat needs to be fit for human consumption, however, also includes the control of chemical residues and contaminants that could be potentially harmful for consumers. this aspect is not fully addressed by the current procedures. the efsa panel on contaminants in the food chain (contam panel) was asked to identify and rank undesirable or harmful chemical residues and contaminants in meat from sheep and goats. such substances may occur as residues in edible tissues from the exposure of the animals to contaminants in feed materials as well as following the possible application of non-authorised substances and the application of authorised veterinary medicinal products and feed additives. a multi-step approach was used for the ranking of these substances into categories of potential concern. as a first step, the contam panel considered substances listed in council directive / /ec and evaluated the outcome of the national residue control plans (nrcps) for the period - . the contam panel noted that only . % of the total number of results was non-compliant for one or more substances listed in council directive / /ec. potentially higher exposure of consumers to these substances from sheep and goat meat takes place only incidentally, as a result of mistakes or noncompliance with known and regulated procedures. the available aggregated data indicate a low number of samples that were non-compliant with the current legislation. however, in the absence of substance-and/or species-specific information, such as the tissues used for residue analysis and the actual concentration of a residue or contaminant measured, these data do not allow for a reliable assessment of consumer exposure. independently from the occurrence data as reported from the nrcps, other criteria used for the identification and ranking of chemical substances of potential concern included the identification of substances that are found in other testing programmes and that bio-accumulate in the food chain, substances with a toxicological profile of concern, and the likelihood that a substance under consideration will occur in sheep and goat carcasses. taking into account these criteria, the individual compounds were ranked into four categories denoted as being of high, medium, low and negligible potential concern. dioxins and dioxin-like polychlorinated biphenyls (dl-pcbs) were ranked as being of high potential concern owing to their known bioaccumulation in the food chain, the frequent findings above maximum levels (mls), particularly in sheep liver, and in consideration of their toxicological profile. the following substances were ranked in the category of medium potential concern: stilbenes, thyreostats, gonadal (sex) steroids, resorcylic acid lactones and beta-agonists (especially clenbuterol) because of their toxicity for humans, their efficacy as growth promoters in sheep and goats and the incidence of non-compliant results; chloramphenicol and nitrofurans because they have proven toxicity for humans, are effective as antibacterial treatments for sheep/goats and non-compliant samples are found in most years of the nrcps; non-dioxin-like polychlorinated biphenyls (ndl-pcbs) because, while they bioaccumulate and there is a risk of exceeding the mls, they are less toxic than dioxins and dl-pcbs; and the chemical elements cadmium, lead and mercury because of the number of non-compliant results reported under the nrcps and their toxicological profile. residues originating from other substances listed in council directive / /ec were ranked as of low or negligible potential concern. the contam panel emphasises that this ranking into specific categories of potential concern is based on the current knowledge regarding toxicological profiles, usage in sheep and goat production and occurrence as chemical residues and contaminants. where changes in any of these factors occur, the ranking might need amendment. the contam panel was also asked to assess the main strengths and weaknesses of current meat inspection protocols within the context of chemical hazards. it was noted that current procedures for sampling and testing are, in general, well established and coordinated, including follow-up actions subsequent to the identification of non-compliant samples. the regular sampling and testing for chemical residues and contaminants is an important disincentive for the development of undesirable practices and the prescriptive sampling system allows for equivalence in the control of eu-produced sheep and goat meat. the current combination of animal traceability, ante-mortem inspection and gross tissue examination can support the collection of appropriate samples for residue monitoring. nevertheless, a major weakness is that, with very few exceptions, presence of chemical hazards cannot be identified by current ante-/post-mortem meat inspection procedures at the slaughterhouse level and there is a lack of sufficient cost-effective and reliable screening methods. in addition, sampling is mostly prescriptive rather than risk or information based. there is limited ongoing adaptation of the sampling and testing programmes to the results of the residue monitoring programmes, with poor integration between the testing of feed materials for undesirable substances and the nrcps and sampling under the nrcps reflecting only a part of testing done by a number of mss, the results of which should be taken into consideration. the contam panel was also asked to identify and recommend inspection methods for new hazards. as dioxins and dl-pcbs have not yet been comprehensively covered by the sampling plans of the current meat inspection, they should be considered as 'new' hazards as they have been ranked as being of high potential concern. moreover, for other organic contaminants that may accumulate in foodproducing animals and for a number of chemical elements used as feed supplements, only limited data regarding residues in sheep and goats are available. this is the case, in particular, for brominated flame retardants, including polybrominated diphenylethers (pbdes) and hexabromocyclododecanes (hbcdds) and perfluorinated compounds (pfcs) including (but not limited to) perfluorooctane sulphonate (pfos) and perfluorooctanoic acid (pfoa). the contam panel concludes that sheep and goat production in the eu is marked by being largely extensive in nature, involving frequent trading of animals and nomadic flocks. these differences in husbandry systems and feeding regimes result in different risks for the occurrence of chemical residues and contaminants. extensive periods on pasture or/as nomadic flocks and the use of slaughter collection dealerships may preclude detailed lifetime food chain information (fci). the contam panel recommends that fci should be expanded for sheep and goats produced in extensive systems to provide more information on the specific environmental conditions where the animals are produced and that future monitoring programmes should be based on the risk of occurrence of chemical residues and contaminants, taking into account the completeness and quality of the fci supplied and the ranking of chemical substance into categories of potential concern, which needs to be regularly updated. control programmes for chemical residues and contaminants should be less prescriptive, with sufficient flexibility to adapt to results of testing, should include 'new hazards', and the test results for sheep and goats should be separately presented. there is a need for an improved integration of sampling, testing and intervention protocols across the food chain, nrcps, feed control and monitoring of environmental contaminants. the development of analytical techniques covering multiple analytes and of new biologically based testing approaches should be encouraged too and incorporated into the residue control programmes. for prohibited substances, testing should be directed where appropriate towards the farm level and, in the case of substances that might be used illicitly for growth promotion, control measures, including testing, need to be refocused to better identify the extent of abuse in the eu. meat inspection in the eu is specified in regulation (ec) no / . the main objective of meat inspection is to ensure that meat is fit for human consumption. historically, meat inspection procedures have been designed to control slaughter animals for the absence of infectious diseases, with special emphasis on zoonoses and notifiable diseases. the mandate that meat needs to be fit for human consumption, however, also includes the control of chemical residues and contaminants in meat that could be potentially harmful for consumers. this aspect is not fully addressed by the current procedures. for the purposes of this document 'chemical residues' refer to chemical compounds which result from the intentional administration of legal or illegal pharmacologically active substances while 'chemical contaminants' refer to chemical compounds originating from the environment. this document aims to identify undesirable or harmful chemical residues and contaminants that may occur in meat from sheep and goats taking into account the current legislation and the results from the national residue control plans (nrcps) implemented in line with council directive / /ec. these findings, together with the characteristics of the individual substances and the likelihood that a substance will occur in meat from sheep or goats were used to rank chemical residues and contaminants into categories of potential concern. four categories were established constituting a high, medium, low or negligible potential concern. in the second part, the main strengths and weaknesses of current meat inspection protocols were assessed within the context of chemical hazards. the ultimate aim is an overall evaluation of the current strategies for sampling and analytical testing, resulting in recommendations for possible amendments to the current meat inspection protocols. in this opinion, where reference is made to european legislation (regulations, directives, decisions), the reference should be understood as relating to the most current amendment, unless otherwise stated. sheep (ovis aries) were domesticated from ancestral subspecies of wild mouflon approximately years ago in south-west asia, and by years ago, sheep had been transported throughout europe. today, over sheep breeds are recognised worldwide, and europe supports a greater number of breeds than any other continent. sheep are raised for three main purposes: meat, milk and wool. therefore, a range of different breeds have been developed over centuries to suit the land and weather and husbandry conditions in different areas of the eu. in mountain and arid areas, for example, sheep are bred for hardiness and self-reliance (e.g. scottish blackface). they must be able to survive poor weather and thrive on poor grazing. lowland or grassland breeds, on the other hand (e.g. suffolk and texel), usually do not cope as well with bad weather or poor-quality feed, but produce higher numbers of lambs that are often better suited for meat production. most lambs are born in late winter or spring. many lambs are born outside, particularly those in mountain flocks. indoor lambing is also common, particularly for lowland flocks. good housing facilities and management are important in order to prevent disease and heat stress problems. most meat-breed sheep are slaughtered and presented for meat inspection as younger stock "lambs" from ten weeks up to one year. in accordance with commission regulation (ec) no / , a "young ovine animal" means an ovine animal of either gender, not having any permanent incisor teeth erupted and not older than months. sheep have also been raised for milk production for thousands of years. the east friesian type is one of the most common and productive breeds of dairy sheep. europe's commercial dairy sheep industry is concentrated in the countries on or near the mediterranean sea. most of the sheep milk is used to produce cheese, such as feta, ricotta, manchego and pecorino romano. in france, the lacaune is the breed of choice for making roquefort cheese. dairy sheep kept on small farms are milked seasonally by hand but more modern sheep dairies use sophisticated machinery for milking. ewes are milked once or twice per day. sheep are also widely kept for wool production, particularly in the united kingdom and spain. wool may range from fine or medium fibre diameter to specialised breeds producing wool for carpets. some flocks may be kept for both meat and wool production purposes. meat from older sheep carcasses (mutton), derived from cull adult sheep from the dairy or wool industries, is tougher and is not as widely consumed as fresh meat, but may also be used in sausage production. goats have been associated with man in a symbiotic relationship for up to years. the goat eats little, occupies a small area and each produces enough milk to sustain a family. in europe, goat farming is strongly oriented towards milk production, which is mostly used for cheese production. it has been estimated that the eu has . % of the world's goat population, but it produces . % of goat milk and . % of goat meat generated in the world annually (casey, ) . during the last ten years, the overall eu goat count has diminished. in france, greece and spain, annual goat milk production is , , and million litres, respectively, which comprises % of the total goat milk produced in the eu. france produces a great number of goat's milk cheeses, especially in the loire valley, with examples of french chèvre including bucheron. like sheep, dairy goats kept on small farms are milked seasonally by hand but modern goat dairies use more sophisticated machinery for milking. does are milked once or twice per day. goats produced for fibre are not common in europe, but small local flocks occur in many member states (mss). the fibre taken from an angora goat breed is called mohair. a single goat produces between four and five kilograms of hair per year, shorn twice a year. cashmere is the valuable fine undercoat found to varying degrees and qualities on all goats, except the angora. it grows as a winter down which is shed in early spring, when it is harvested by either shearing or combing. goat meat or chevron is not widely consumed in the eu. specialised larger goat meat breeds such as the boer goat are currently only held in small local herds, but crosses of a boer sire and a cashmeretype breed dam can also be used to provide a suitable carcass. these meat-line goats can grow to slaughter weight ( - kg) in approximately six to nine months on low-quality feeding. again, the meat from older goat carcasses derived from the cull goats from dairy or fibre industries tends to be very tough. meat from older male goats ('billy' goats) can have an offensive odour. the extensive farming practices and generally low economic value of sheep and goats mean that veterinary treatment of individual animals is often limited. sheep and goats are often exposed to parasites, which explain the necessary use of anti-parasitic programmes for the flocks. other veterinary interventions follow normal clinical practice, such as the use of registered mastitis treatments for milking animals, with appropriate withdrawal periods and residue monitoring. it is important to note that, despite recent developments towards large milking goat holdings, sheep and goat production in the eu largely remains extensive in nature, involving frequent trading of animals and nomadic flocks. this involves varied husbandry systems and feeding regimes resulting in different risks for chemical substances and contaminants. sheep and goat populations in the eu as reported by eurostat are presented in table . in accordance with annex i of regulation (ec) no / all animals should be inspected prior to slaughter (ante-mortem inspection) as well as after slaughter and evisceration (post-mortem inspection). there are concerns about slaughter outside licensed premises where animals are not subject to appropriate meat inspection. since january , a mandatory identification of small ruminants has been implemented in the eu by regulation (ec) no / . domestic sheep and goats may be presented for slaughter in small numbers or even as individuals. visual ante-mortem inspection is carried out at the level of the individual animal. extensive periods on pasture or as nomadic flocks, sale at open markets of many sheep and goats, and the presence of slaughter collection dealerships that may combine small numbers of animals purchased from several farmers, means that there is a level of concern that food chain information (fci) shared between farmers and the slaughterhouse (where residue data are managed), may be suboptimal. similarly, in these situations, the level of feedback from the slaughterhouse and authorities to farmers regarding the results of residue testing may be suboptimal. here the individual identification of animals, which has now become mandatory, may contribute to more transparency in the future. there is less concern about fci from dairy sheep and goats as they are reared under more intensive and controlled conditions. fci is the animal's life history data from birth, through all stages of rearing, up to the day of slaughter. in particular, the food business operator (fbo) at the slaughterhouse should receive information related to the veterinary medicinal products (vmps) or other treatments administered to the animals within a relevant period prior to slaughter, together with their administration dates and their withdrawal periods. moreover, any test results for samples taken from the animals within the framework of monitoring and control of residues should also be communicated to the slaughterhouse operators before the arrival of the animals. based on regulation (ec) no / , post-mortem inspection was, and still is, directed primarily at the detection of lesions due to infections, based on observation, palpation, and incision. an exception is the mandatory sampling of adult animals for transmissible spongiform encephalopathies (tses). in contrast to bovine animals, tse testing is not directed at individual animals, but is based on a region and animal stock related monitoring system. visual inspection of the carcass (and offals) may allow, in some cases, for the identification of gross alterations in carcass conformation (e.g. abscesses or deposits) and organ-specific lesions in kidneys, liver, lungs or other organs that might be indicative of recent use of vmps (with the possibility of noncompliance with withdrawal periods) or acute or chronic exposure to toxic substances. in most cases, exposure to chemical compounds does not result in typical organ lesions. hence it needs to be considered that evidence for the presence of chemical residues and contaminants will in most cases not be apparent during the visual inspection of ovine and caprine carcasses. therefore, the meat inspection approach based on "detect and immediately eliminate", used for biotic (microbiological) hazards in slaughterhouses, is generally not applicable to abiotic hazards. while monitoring programmes (council directive / /ec, described in section . ) may provide a gross indication of the prevalence of undesirable chemical residues and contaminants in ovine and caprine carcasses, the sole intervention at abattoir level is the isolation of a suspect carcass as potentially unfit for human consumption, pending results of residue testing. council directive / /ec prescribes the measures to monitor certain substances and residues thereof in live animals and animal products. it requires that mss adopt and implement a national residue monitoring programme, also referred to as the national residue control plan (nrcp, for defined groups of substances. mss must assign the task of coordinating the implementation of the controls to a central public body. this public body is responsible for drawing up the national plan, coordinating the activities of the central and regional bodies responsible for monitoring the various residues, collecting the data and sending the results of the surveys undertaken to the commission each year. the nrcp should be targeted; samples should be taken on-farm and at abattoir level with the aim of detecting illegal treatment or controlling compliance with the maximum residue limits (mrls) for vmps according to commission regulation (eu) no / , with the maximum residue levels (mrls) for pesticides as set out in regulation (ec) no / , or with the maximum levels (mls) for contaminants as laid down in commission regulation (ec) no this means that in the national monitoring plans, the mss should target those groups of animals/gender/age combinations in which the probability of finding residues is highest. this approach differs from random sampling, in which the objective is to gather statistically representative data, for instance to evaluate consumer exposure to a specific substance. the minimum number of animals to be checked for all kind of residues and substances must be at least equal to . % of sheep and goats over three months of age slaughtered the previous year, with the following breakdown (further details on group a and b compounds is presented in section . group a: . % of total samples -each sub-group a must be checked each year using a minimum of % of the total number of samples to be collected for group a. the balance is allocated according to the experience and background information of the ms. group b: . % of the total samples - % must be checked for group b substances - % must be checked for group b substances - % must be checked for group b substances. the balance must be allocated according to the situation of the ms. in the case of imports from third countries, chapter vi of council directive / /ec describes the system to be followed to ensure an equivalent level of control on such imports. in particular it specifies (i) that each third country must provide a plan setting out the guarantees which it offers as regards the monitoring of the groups of residues and substances referred to in annex i to the council directive, (ii) that such guarantees must have an effect at least equivalent to those provided for in council directive / /ec, (iii) that compliance with the requirements of and adherence to the guarantees offered by the plans submitted by third countries shall be verified by means of the checks referred to in article of directive / /eec and the checks provided for in directives / /eec and / /eec, and (iv) that mss are required to inform the commission each year of the results of residue checks carried out on animals and animal products imported from third countries, in accordance with directives / /eec and / /eec. in accordance with article of council directive / /ec, the mss are requested, as a follow-up, to provide information on actions taken at regional and national level as a consequence of non-compliant results. the commission sends a questionnaire to the ms to obtain an overview of these actions, for example when residues of non-authorised substances are detected or when the maximum residue limits/maximum levels established in eu legislation are exceeded. in summary, this means that the term 'suspect sample' applies to a sample taken as a consequence of: non-compliant results, and/or suspicion of an illegal treatment, and/or suspicion of non-compliance with the withdrawal periods. non-compliant results for a specific substance or group of substances or a specific food commodity should result in intensified controls for this substance/group or food commodity in the plan for the following year. article it should be noted that targeted sampling as defined by council directive / /ec aims at monitoring certain substances and residues thereof in live animals and animal products across eu mss. in contrast to monitoring, under suspect sampling, a 'suspect' carcass has to be detained at the abattoir until laboratory results confirm or deny conformity with legislative limits for chemical residues. based on the test results, the carcass can be declared fit or unfit for human consumption. in the first scenario, the carcass is released into the human food chain whereas in the second case the carcass is disposed of. in addition to the minimum testing requirements which form part of the nrcps, council directive / /ec also establishes the requisites for self-monitoring and co-responsibility on the part of operators. in accordance with article , chapter iii of council directive / /ec, mss shall ensure that the owners or persons in charge of the establishment of initial processing of primary products of animal origin (slaughterhouses) take all necessary measures, in particular by carrying out their own checks, to: accept only those animals for which the producer is able to guarantee that withdrawal times have been observed satisfy themselves that the farm animals or products brought into the slaughterhouse do not contain residue levels which exceed maximum permitted limits and that they do not contain any trace of prohibited substances or products. farmers and food processors (including slaughterhouses) must place on the market only: animals to which no unauthorised substances or products have been administered or which have not undergone illegal treatment animals for which, where authorised products or substances have been administered, the withdrawal periods prescribed for these products or substances have been observed. tor : identification, classification and ranking of substances of potential concern . . in the current eu legislation, chemical residues and contaminants in live animals and animal products intended for human consumption are addressed in as one of the objectives of this assessment of current meat inspection protocols is the identification of chemical substances of potential concern that may occur as residues or contaminants in sheep and goats, but have not been specifically addressed in council directive / /ec, a more general grouping of chemical substances was chosen, resulting in the following three major groups: substances that are prohibited for use in food-producing animals, corresponding to group a substances in council directive / /ec veterinary drugs, also denoted vmps, corresponding to groups b and b substances in council directive / /ec and contaminants, corresponding to group b substances in council directive / /ec. the first group of chemicals that may occur in edible tissues as residues are those substances prohibited for use in food-producing animals; these substances correspond largely with group a substances in council directive / /ec. there were different rationales for banning these substances for application to animals and the list of group a substances comprises compounds that are of toxicological concern (including vmps for which an acceptable daily intake (adi) could not be established), as well as substances having anabolic effects and pharmacologically active compounds that may alter meat quality and/or affect animal health and welfare. a second group of chemicals that may be a source of residues in animal-derived foods are vmps (including antibiotics, anti-parasitic agents and other pharmacologically active substances) and authorised feed additives used in the health care of domestic animals; these substances correspond largely with group b and b substances in council directive / /ec. these substances have been subjected to assessment and pre-marketing approval by the with regard to antibacterial agents, it is important to state that the ranking of substances of concern in this part of the document considers only toxicological concerns related to the presence of residues. other aspects, such as the emergence of antimicrobial resistance is considered by the efsa panel on biological hazards (biohaz panel) in a separate part of this opinion (see appendix a of the biohaz panel). a third group of chemical substances that may occur in edible tissues of sheep and goats are contaminants that may enter the animal's body mainly via feed, ingested soil, drinking water, inhalation or direct (skin) contact; these substances include the group b substances in council directive / /ec. feed materials can contain a broad variety of undesirable substances comprising persistent environmental pollutants, toxic metals and other elements as well as natural toxins, including toxic secondary plant metabolites and fungal toxins (mycotoxins). feed producers have to act in compliance with commission directive / /ec, listing the undesirable substances in feed and feed materials and presenting maximum content in feed materials or complete feedingstuffs. in a recent re-assessment of these undesirable substances in animal feeds, the contam panel reevaluated the risk related to exposure to these substances for animals. special attention was given to toxic compounds that accumulate or persist in edible tissues, including meat, or that are directly excreted into milk and eggs. . . , pp. - . the term "dioxins" used in this opinion refers to the sum of polychlorinated dibenzo-p-dioxins (pcdds) and polychlorinated dibenzofurans (pcdfs). as an early warning tool, the european commission has set action levels for dioxins and dl-pcbs in food through commission recommendation / /ec. owing to the fact that their sources are generally different, separate action levels for dioxins and dl-pcbs were established. the action levels for meat and meat products of sheep are . pg who-teq/g fat for dioxins and . pg who-teq/g fat for dl-pcbs. in cases where levels of dioxins and/or dl-pcbs in excess of the action levels are found, it is recommended that mss, in cooperation with fbos, initiate investigations to identify the source of contamination, take measures to reduce or eliminate the source of contamination and check for the presence of ndl-pcbs. maximum residue levels for certain elements in sheep and goats are also laid down in regulation (ec) no / of the european parliament and of the council on maximum residue levels of pesticides in or on food and feed of plant and animal origin, related to the use of copper-containing and mercury-containing compounds as pesticides. for copper, the maximum residue levels are each mg/kg for meat and fat and mg/kg each for liver, kidney and edible offal. for mercury compounds (sum of mercury compounds expressed as mercury), the maximum residue levels are . mg/kg each for meat, fat, liver, kidney and edible offal. a multi-step approach was used for ranking the potential concern of the three groups of substances that are presented in sections . and . . the steps are: evaluation of the outcomes of the nrcps indicating the number of results that are noncompliant with the current legislation evaluation of the likelihood that specific residues or contaminants, including 'new hazards', may be present in sheep and goat carcasses consideration of the toxicological profile for chemical substances. data from the nrcps are published annually and these data were considered as the first step for hazard ranking. aggregated data for the outcome of the nrcps for targeted sampling of sheep and goats from to are presented in tables - results from suspect sampling are not included, as these results are considered not to be representative of the actual occurrence of chemical residues and contaminants. as stated above, suspect sampling arises as (i) a follow-up to the occurrence of a non-compliant result, and/or (ii) on suspicion of illegal treatment at any stage of the food chain, and/or (iii) on suspicion of non-compliance with the withdrawal periods for authorised vmps (articles , and of council directive / /ec, respectively). a non-compliant result refers to an analytical result exceeding the permitted limits or, in the case of prohibited substances, any measured level with sufficient statistical certainty that it can be used for legal purposes. it should be noted that information on the number of total analyses performed for an individual substance is only transmitted by those mss that were reporting at least one non-compliant result for that substance. therefore, it is not possible to extract from the data supplied complete information on the individual substances from each sub-group tested or the number of samples tested for an individual substance where no non-compliant result is reported. in addition, in some cases the same samples were analysed for different substance groups/sub-groups and therefore the number of substance groups/sub-groups tested is higher than the total number of samples collected from sheep and goats. it is to be noted that there is a lack of harmonisation regarding details provided on non-compliant results for the nrcps from mss. this hampers the interpretation and the evaluation of these data. moreover, in some cases, no information is available on the nature of the positive samples (i.e. whether this refers to muscle, liver, kidney, skin/fat or other samples) and these results often give no indication of the actual measured concentrations of residues or contaminants. as a result, in the absence of substance-specific information and the actual concentration of a residue or contaminant measured, these data do not allow for an assessment of consumer exposure. in addition, particularly in the case of prohibited substances, much of the testing may be done in matrices such as urine, faeces and hair and so no data on residue levels in edible tissues are available. another problem with interpreting the data provided arises from the failure to clearly identify in all cases (i) the proportion of total samples tested that are of sheep and that are of goat and (ii) whether a particular non-compliant result refers to a sample from a sheep or from a goat. in spite of the limitations highlighted above, an overall assessment of these data indicates that the percentage of non-compliant results is of a low order of magnitude compared with the total number of samples tested. ( ( ) ( ) ( ) antibacterials (unspecified) c published at http://ec.europa.eu/food/food/chemicalsafety/residues/control_en.htm a summary of the data presented in the previous tables (tables [ ] [ ] [ ] shows that of the ( . %) samples analysed in the eu nrcps during the period - were non-compliant for one or more substances listed in annex i of council directive / /ec. further details are presented in table . as mentioned above, one sample can be non-compliant for multiple substances, so that the number of non-compliant results is higher than the number of non-compliant samples. for example, for b substances, there were non-compliant results in non-compliant samples. one sample can be non-compliant for more than one substance. b published at http://ec.europa.eu/food/food/chemicalsafety/residues/control_en.htm c some of the samples were analysed for several substances in different subgroups (e.g. same sample analysed for b a, b b and b c), this total represents the total number of samples analysed for at least one substance in the group. it should be noted that the data in tables - provide the results for sampling and testing carried out by mss under the terms of council directive / /ec within the nrcps. however, there may be other chemical substances of relevance for control in sheep and goats, particularly in the case of contaminants, which are not included in the nrcps at all or which are not systematically covered by the nrcps. some of these substances are addressed further under tor of this opinion ('new hazards'). of the total number of samples taken for analysis during the period - , . % were taken at farm level while the remaining . % were taken at slaughterhouse level. no information on the types of animals sampled is readily available. results indicate that: . % of the total samples were non-compliant for one or more substances, with . %, . % and . % being non-compliant for group a, group b /b and group b substances, respectively. . % of all samples taken at farm level were non-compliant for one or more substances, with . %, . % and . % being non-compliant for group a, group b /b and group b substances, respectively. . % of all samples taken at slaughterhouse level were non-compliant for one or more substances, with . %, . % and . % being non-compliant for group a, group b /b and group b substances, respectively. the highest proportion of non-compliant results overall ( . %) was for group b substances, contaminants, representing largely exceedances of the mls/mrls specified for these substances. the proportions of non-compliant results overall for group a, prohibited substances ( . %), and for group b /b substances, vmps ( . %) represent largely illicit use of prohibited substances and exceedances of the mrls specified for vmps, respectively. an analysis of the results for sampling at farm level compared with slaughterhouse level indicates that for prohibited substances (group a) the rate of non-compliant results determined for sampling at farm level is considerably lower than that for sampling at slaughterhouse level. the majority ( %) of samples found to be non-compliant for prohibited substances relate to those having anabolic effects (thyreostats, steroids, zeranol, beta-agonists) and only a minority ( %) were non-compliant for substances such as chloramphenicol, nitrofurans and nitroimidazoles. while the incidence of noncompliant results from farm level sampling is low, such sampling is an integral component of the system for controlling illicit use of prohibited substances in food-producing animals, particularly in the case of substances having anabolic effects. in the case of vmps (group b /b ) the rate of non-compliant results determined at farm level is markedly higher than for sampling at slaughterhouse level. however, slaughterhouse-level sampling is more appropriate for identifying non-compliant samples for vmps, based on compliance with or exceedance of the specified mrls in edible tissues. in the case of contaminants (group b ) the rate of non-compliant results determined for sampling at slaughterhouse level is almost twofold higher than for sampling at farm level. indeed, sampling for group b substances is more appropriate, generally, at slaughterhouse level where identification of non-compliant results, based on compliance with or exceedance of specified mrls/mls in edible tissues, can be made. it should be noted also that a direct comparison of data from the nrcp over the years is not entirely appropriate as the test methods used and the number of samples tested for an individual residue varied between mss, and the specified mrls/mls for some substances may change over time. in addition, there are ongoing improvements in analytical methods, in terms of method sensitivity, accuracy and scope (i.e. number of substances covered by the method), which affects inter-year and inter-country comparisons. therefore, the cumulative data from the nrcps provide only a broad indication of the prevalence and nature of non-compliant samples. in conclusion, this compilation of data clearly indicates the low prevalence of abiotic hazards (residues and contaminants) in edible tissues of sheep and goats. only . % of the total number of analysed samples was non-compliant for one or more substances listed in annex i of council directive / /ec. based on these results, it can be concluded that potentially higher exposure of consumers to these substances from edible tissues of sheep and goats takes place only incidentally, as a result of mistakes or non-compliance with known and regulated procedures. the available aggregated data indicate the number of samples that were non-compliant with the current legislation. however, in the absence of species-and substance-specific information, such as the tissues used for residue analysis and the actual concentration of a residue or contaminant measured, these data do not allow for a reliable assessment of consumer exposure. while the data from the annual nrcp testing by mss indicate a relatively low incidence of noncompliant results for sheep and goats, there may be human health concerns regarding certain contaminants. for example, an evaluation undertaken by efsa (efsa contam panel, b) on the risk to public health related to the presence of high levels of dioxins and dioxin-like pcbs in liver from sheep (and deer) concluded that regular consumption of sheep liver would result, on average, in an approximate % increase of the median background exposure to dioxins and dioxin-like pcbs (dl-pcbs) for adults. the study also concluded that on individual occasions, consumption of sheep liver could result in high intakes exceeding the tolerable weekly intake (twi), and that the frequent consumption of sheep liver, particularly by women of child-bearing age and children, may be a potential health concern. independent from the occurrence data as reported from the nrcps, each substance or group of chemical substances that may enter the food chain was also evaluated for the likelihood that potentially toxic or undesirable substances might occur in sheep and goat carcasses. for prohibited substances and vmps/feed additives, the following criteria were used: the likelihood of the substance(s) being used in an illicit or non-compliant way in sheep and goats (suitability for sheep and goat production; commercial advantages) the potential availability of the substance(s) for illicit or non-compliant usage in sheep and goat production (allowed usage in third countries; availability in suitable form for use in sheep and goats; non-authorised supply chain availability ('black market'); common or rare usage as a commercial licensed product) the likelihood of the substance(s) occurring as residue(s) in edible tissues of sheep and goats based on the kinetic data (pharmacokinetic and withdrawal period data; persistence characteristics; special residue issues, e.g. bound residues of nitrofurans) toxicological profile and nature of hazard and the relative contribution of residues in sheep and goats to dietary human exposure. for contaminants, the following criteria were considered: the prevalence (where available) of occurrence of the substances in animal feeds/forages and pastures, and of the specific environmental conditions in which the animals are raised the level and duration of exposure, tissue distribution and deposition including accumulation in edible tissues of sheep and goats toxicological profile and nature of hazard and the relative contribution of residues in sheep and goats to dietary human exposure. considering the above mentioned criteria, a flow-chart approach was used for ranking of the chemical residues and contaminants of potential concern. the outcome of the nrcps (indicating the number of non-compliant results), the evaluation of the likelihood that residues of substances of potential concern can occur in sheep and goats and the toxicological profile of the substances were considered in the development of the general flow chart, presented in figure . ml, maximum level; mrl, maximum residue limits; nrcp: national residue control plan. a contaminants from the soil and the environment, associated with feed material, are considered to be part of the total feed for the purposes of this opinion. b potential concern was based on the toxicological profile and nature of hazard for the substances. c the contam panel notes that the ranking of vmps/feed additives was carried out in the general context of authorised usage of these substances in terms of doses, route of treatment, animal species and withdrawal periods. therefore, this ranking is made within the framework of the current regulations and control and within the context of a low rate of exceedances in the nrcps. d see definitions as provided in the next section . . . figure : general flow chart used for the ranking of residues and contaminants of potential concern that can be detected in sheep and goats. outcome of the ranking of residues and contaminants of potential concern that can occur in sheep/goat carcasses four categories were established resulting from the application of the general flow chart: substance irrelevant in sheep/goat production (no known use at any stage of production); no evidence for illicit use or abuse in sheep/goats; not or very seldom associated with exceedances in mrls in nrcps; no evidence of occurrence as a contaminant in feed for sheep/goats. vmps/feed additives which have an application in sheep/goat production, residues above mrls are found in control plans, but substances are of low toxicological concern; contaminants and prohibited substances with a toxicological profile that does not include specific hazards following accidental exposure of consumers and which are generally not found or are not found above mls in sheep/goats. contaminants and prohibited substances to which sheep/goats are known to be exposed and/or with a history of misuse, with a toxicological profile that does not entirely exclude specific hazards following accidental exposure of consumers; evidence for residues of prohibited substances being found in sheep/goats; contaminants generally not found in concentrations above the mrl/mls in edible tissues of sheep/goats. contaminants and prohibited substances to which sheep/goats are known to be exposed and with a history of misuse, with a distinct toxicological profile comprising a potential concern to consumers; evidence for ongoing occurrence of residues of prohibited substances in sheep/goats; evidence for ongoing occurrence and exposure of sheep/goats to feed contaminants. . . . . substances classified in the category of high potential concern . . . . . contaminants: dioxins, dioxin-like polychlorinated biphenyls (dl-pcbs) in the high potential concern category are dioxins and dioxin-like polychlorinated biphenyls (dl-pcbs) as the occurrence data from the monitoring programmes show a number of incidents due to contamination of feed, such as illegal disposal of dioxin-and dl-pcb-containing waste materials into feed components, or open drying of feed components with dioxin-containing fuel materials. dioxins are persistent organochlorine contaminants that are not produced intentionally and have no targeted use, but are formed as unwanted and often unavoidable by-products in a number of thermal and industrial processes. because of their low water solubility and high lipophilic properties, they bioaccumulate in the food chain and are stored in fatty tissues of animals and humans. the major pathway of human dioxin exposure is via consumption of food of animal origin which generally contributes more than % of the total daily dioxin intake (efsa, ) . a number of incidents in the past years were caused by contamination of feed with dioxins. examples are feeding of contaminated citrus pulp pellets, kaolinitic clay containing potato peel or mixing of compound feed with contaminated fatty acids. all these incidents were caused by grossly negligent or criminal actions and led to widespread contamination of feed and subsequently to elevated dioxin levels in the animals and the foodstuffs produced from them. monitoring programmes also demonstrated that certain food commodities, such as sheep liver can have high dioxin levels even when not affected by specific contamination sources. in , the contam panel delivered a scientific opinion on the risk to public health related to the presence of high levels of dioxins and dl-pcbs in liver from sheep and deer (efsa contam panel, b). efsa evaluated, inter alia, the dioxin and pcb results from sheep liver and sheep meat samples submitted by eight european countries. almost all sheep meat samples were below the relevant mls set by regulation (ec) no / . however, the corresponding liver samples from the same sheep in more than half of the cases exceeded the relevant maximum levels considerably. this finding is likely to be associated with differences in the level of biotransformation enzymes in sheep compared with bovine animals. dioxins have a long half-life and are accumulated in various tissues. the findings of elevated levels in food are of public health concern owing to their potential effects on liver, thyroid, immune function, reproduction and neurodevelopment (efsa, a (efsa, , . the available data indicate that a substantial part of the european population is in the range of or already exceeding the twi for dioxins and dl-pcbs. a report on "monitoring of dioxins and pcbs in food and feed" (efsa, ) estimated that between . % and . % of individuals were exposed above the twi of pg teq/kg body weight (b.w.) for the sum of dioxins and dl-pcbs. in addition to milk and dairy products and fish and seafood, meat and meat products also contributed significantly to total exposure. owing to the high toxic potential of dioxins and the incidence of samples of sheep meat and sheep liver exceeding the maximum limits, efforts need to be undertaken to reduce exposure where possible. in summary, based on the high toxicity and the low maximum levels set for meat and fat of sheep (see table ) and considering that food of animal origin contributes significantly (> %) to human exposure, dioxins have been ranked in the category of substances of high potential concern. (b) dioxin-like polychlorinated biphenyls (dl-pcbs) in contrast to dioxins, pcbs had widespread use in numerous industrial applications, generally in the form of complex technical mixtures. due to their physicochemical properties, such as nonflammability, chemical stability, high boiling point, low heat conductivity and high dielectric constants, pcbs were widely used in industrial and commercial closed and open applications. they were produced for over four decades, from onwards until they were banned, with an estimated total world production of . - . million tonnes. according to council directive / /ec, mss were required to take the necessary measures to ensure that used pcbs are disposed off and equipment containing pcbs is decontaminated or disposed of at the latest by the end of . earlier experience has shown that illegal practices of pcb disposal may occur resulting in considerable contamination of animals and foodstuffs of animal origin. on the other hand, monitoring programmes also demonstrated that certain food commodities, such as sheep liver can have high pcb levels even when not affected by specific contamination sources. this was demonstrated by efsa in its scientific opinion on the risk to public health related to the presence of high levels of dioxins and pcbs in liver from sheep and deer (efsa contam panel, b). efsa evaluated, inter alia, the dioxin and pcb results from sheep liver and sheep meat samples submitted by eight european countries. for sheep liver, the mean upper bound concentration for dl-pcbs (expressed as who-teq ) was . (range: . - . ) pg who-teq/g fat. the corresponding levels in sheep meat were considerably lower: . (range: . - . ) pg who-teq/g fat (efsa contam panel, b). based on structural characteristics and toxicological effects, pcbs can be divided into two groups. one group consists of congeners that can easily adopt a coplanar structure and have the ability to bind to the aryl hydrocarbon (ah) receptor, thus showing toxicological properties similar to dioxins (effects on liver, thyroid, immune function, reproduction and neurodevelopment). this group of pcbs is therefore called "dioxin-like pcbs". the other pcbs do not show dioxin-like toxicity but have a different toxicological profile, in particular with respect to effects on the developing nervous system and neurotransmitter function. this group of pcbs is called "non dioxin-like pcbs" (see below). as dl-pcbs, in general, show a comparable lipophilicity, bioaccumulation, toxicity and mode of action as dioxins (efsa, a) , these two groups of environmental contaminants are regulated together in european legislation and are considered together in risk assessments. based on the high toxicity, widespread use and potential for improper disposal practices of technical pcb mixtures, dl-pcbs have been ranked in the category of substances of high potential concern. . . . . substances classified in the category of medium potential concern . . . . . prohibited substances: stilbenes, thyreostats, gonadal (sex) steroids, resorcylic acid lactones, beta-agonists, chloramphenicol and nitrofurans (a) stilbenes the toxicity of stilbenes is well established (for review see waltner-toews and mcewen, ) and this has led to their prohibition for use as growth promoters in animals in most countries, based also on their involvement in the baby food scandal in the late s (loizzo et al., ) . in particular, diethylstilbestrol is a proven human genotoxic carcinogen (group i iarc (international agency for research on cancer)) (iarc, ), while sufficient evidence for hexestrol and limited evidence for dienestrol for carcinogenicity in animals were found (iarc, ) . diethylstilbestrol is associated with cancer of the breast in women who were exposed while pregnant, and also causes adenocarcinoma in the vagina and cervix of women who were exposed in utero; finally, a positive association has been observed between exposure to diethylstilbestrol and cancer of the endometrium, and between in utero exposure to diethylstilbestrol and squamous cell carcinoma of the cervix and cancer of the testis. in , the use of stilbenes in all species of food-producing animals was prohibited in the european community by directive / /eec. diethylstilbestrol, and other stilbenes such as hexestrol and dienestrol, are likely to be available on the black market and, therefore, might be available for illicit use in sheep and goats. no non-compliant results for stilbenes in sheep and goat samples have been reported from the european nrcps - , indicating that abuse of stilbenes in sheep and goat production in the eu is unlikely. considering that stilbenes have proven toxicity for humans, these substances are ranked as of medium potential concern. however, considering that there is no evidence for current use of stilbenes in sheep and goat production and that no non-compliant results have been found over a number of years of nrcp testing, control measures for stilbenes might be focused on identifying any potential future abuse of these substances in sheep and goat production in the eu. thyreostats are a group of substances that inhibit the thyroid function, resulting in decreased production of the thyroid hormones triiodothyronine (t ) and thyroxine (t ). enlargement of the thyroid gland has been proposed as a criterion to identify illicit use of these compounds (vos et al., ; vanden bussche et al., ) . they are used in human and in non-food-producing animal medicine to deal with hyperthyroidism. the use of thyreostats for animal fattening is based on weight gain caused by filling of the gastrointestinal tract and retention of water in muscle tissues (courtheyn et al., ) . synthetic thyreostats include thiouracil, methylthiouracil, propylthiouracil, methimazole, tapazol (methylmercaptoimidazole) and mercaptobenzimidazole (mbi). use of synthetic thyreostats in food-producing animals has been prohibited in the eu since (council directive / /ec). naturally occurring thyreostats include thiocyanates and oxazolidine- -thiones, which are present as glucosinolates in plant material such as in the seeds of cruciferae, like rapeseed (efsa, b; vanden bussche et al., ) . evidence for the occurrence of thiouracil in urine of cattle fed on a cruciferous-based diet has been demonstrated (pinel et al., ) . thyreostats are very widely available on the black market so there is the possibility for illicit use in sheep/goat production. the results from the european nrcps - show that sheep/goat samples were found to be non-compliant for thyreostats ( non-compliant results out of the total samples analysed for thyreostats). however, it has been shown that the source of the generally low levels of thiouracil determined in urine samples may be from exposure of animals through their diet (le bizec et al., ) . some mss reporting the highest numbers of non-compliant samples for thiouracil state that "the presence of thiouracil in low concentrations may be due to the animals eating cruciferous plant material" and "in line with scientific evidence, the competent authority has concluded that the residues resulted from dietary factors". thyreostats have been considered to be carcinogenic and teratogenic. while the in utero exposure to methimazole or propylthiouracil has been associated with aplasia cutis and a number of other congenital defects (löllgen et al., ; rodriguez-garcia et al., ) , an iarc evaluation found inadequate evidence in humans, but limited evidence (in the case of methimazole) and sufficient evidence (in the case of thiouracil, methylthiouracil and propylthiouracil) in experimental animals for carcinogenicity (iarc, ; efsa b) . thyreostats are prohibited substances owing to their potential toxicity to humans and their efficacy as growth promoters in sheep/goats, but considering that the non-compliant results that have been found in most years of nrcp testing have been attributed largely to a dietary source, these substances are ranked as of medium potential concern. control measures for thyreostats might focus on identifying potential abuse of these substances in sheep and goat production in the eu. (c) gonadal (sex) steroids a broad range of steroids derived from oestrogens, androgens and progestagens are available and have been used as growth-promoting agents in food-producing animals. there is an extensive body of animal production research demonstrating the efficacy of anabolic steroids, often in combination treatments of an oestrogen and an androgen (or progestagen), as growth promoters. all use of steroids as growth-promoting agents in food-producing animals is banned according to council directive / /ec, as amended by directives / /ec and / /ec. the latter included βoestradiol in the list of prohibited substances owing to its demonstrated tumour-promoting (epigenetic) and tumour initiating (genotoxic) properties (russo et al., ) . certain uses of β-oestradiol, progesterone and medroxyprogesterone acetate in sheep and/or goats are allowed for therapeutic or zootechnical purposes only (commission regulation (eu) no / ). there is evidence that anabolic steroids are of economic value for farmers as animals respond to their application with increased growth rate and feed conversion efficiency. anabolic steroids are widely available on the black market so there is the possibility for illicit use in sheep and goat production. , . . , p. - . an accurate estimate for the level of abuse of anabolic steroids in european sheep and goat production from these data. there are divergent views on the potential adverse effects for the consumer from residues of anabolic steroids in edible tissues of treated animals. there is concern regarding the carcinogenic effects of oestrogenic substances, and the long-term effects of exposure of prepubescent children to oestrogenic substances. in the scientific committee on veterinary measures relating to public health (scvph) performed an assessment of the potential risks to human health from hormone residues in bovine meat and meat products (scvph, (scvph, , (scvph, , , particularly as regards the three natural hormones ( β-oestradiol, testosterone, progesterone) and the three synthetic analogues (zeranol, trenbolone acetate, melengestrol acetate) that may be legally used as growth promoters in third countries. it was concluded that, taking into account both the hormonal and nonhormonal toxicological effects, the issues of concern include neurobiological, developmental, reproductive and immunological effects, as well as immunotoxicity, genotoxicity and carcinogenicity. in consideration of concerns relating to the lack of understanding of critical developmental periods in human life as well as uncertainties in the estimates of endogenous hormone production rates and metabolic clearance capacity, particularly in prepubertal children, no threshold level and therefore no adi could be established for any of the six hormones. according to iarc, β-oestradiol and steroidal oestrogens are classified as proven human carcinogens (group ), androgenic (anabolic) steroids as probably carcinogenic to humans (group a); for most progestagens, evidence for human carcinogenicity is inadequate while that for animals varies from sufficient to inadequate (iarc, ) . notwithstanding the toxicological profile of gonadal (sex) steroids, owing to the low prevalence of non-compliant samples from confirmed illicit use in the nrcps, these substances are ranked as of medium potential concern. (d) resorcylic acid lactones (rals) in the eu, zeranol was evaluated together with other hormonal growth promoters by the scvph (scvph (scvph , (scvph , . in these scientific opinions it was concluded that, taking into account both the hormonal and non-hormonal toxicological effects, no adi could be established for any of the six hormones, including zeranol. use of zeranol as a growth promoter in cattle production was widespread in some mss prior to its prohibition in europe in . zeranol is widely available as a commercial product and is used extensively in third countries. hence it is readily available on the market and there is the possibility for its illicit use in cattle production in the eu. zeranol is derived from, and can also occur as, a metabolite of the mycotoxin zearalenone, produced by fusarium spp. the results from the european nrcps - show sheep/goat samples non-compliant for resorcylic acid lactones (a total of seven non-compliant results out of the total samples analysed). however, it has been shown that the source of the generally low levels of zeranol and its metabolites determined in these samples may be from exposure of sheep/goats to the mycotoxin zearalenone through their diet (efsa, a) . some mss reporting non-compliant results for zeranol and its metabolites state that "the residue was found to be as a result of feed contamination on the farm" and it was "probably attributable to mycotoxin contamination of feed". rals are prohibited substances owing to their potential toxicity to humans and their efficacy as growth promoters in sheep and goats, but considering that the non-compliant results that have been found in some years of nrcp testing have been attributed largely to a dietary source, these substances are ranked as of medium potential concern. control measures for rals might focus on identifying potential abuse of these substances in sheep and goat production in the eu. (e) beta-agonists beta-agonists, or β-adrenergic agonists, have therapeutic uses as bronchodilatory and tocolytic agents. a wide range of beta-agonists have been developed, such as clenbuterol, salbutamol, cimaterol, terbutaline, ractopamine, etc., and all of these are prohibited for use as growth-promoting agents in food-producing animals in the eu. salbutamol and terbutaline are licensed human medicines indicated for treatment of asthma and bronchospasm conditions and for prevention of premature labour, respectively. one of the beta-agonists, clenbuterol, is licensed for therapeutic use in cattle (as a tocolytic agent) and in the treatment of obstructive airway conditions in horses (commission regulation (eu) no / ). other beta-agonists, such as ractopamine, have been approved for use in food-producing animals in a number of third countries. treatment of sheep with beta-agonists, such as clenbuterol, results in increased muscle mass and increased carcass leanness (baker et al., ) . the commercial benefits of using beta-agonists in sheep and goat production, particularly lambs, combined with the availability of these substances, indicates that illicit use of beta-agonists as growth promoters cannot be excluded. an outbreak of collective food poisoning from the ingestion of lamb meat containing residues of clenbuterol has been reported in portugal; symptoms shown by the intoxicated people may be generally described as gross tremors of the extremities, tachycardia, nausea, headaches and dizziness (barbosa et al., ) . in the light of the known adverse biological effects of beta-agonists in humans, particularly clenbuterol, and the efficacy of such drugs as repartitioning agents in sheep/goats, but considering that no non-compliant results for sheep/goats have not been found in the nrcps since , these substances currently are ranked as of medium potential concern. (f) chloramphenicol chloramphenicol is an antibiotic substance, first used for the treatment of typhoid in the late s. chloramphenicol may produce blood dyscrasias in humans, particularly bone marrow aplasia, or aplastic anaemia, which may be fatal. there is no clear correlation between dose and the development of aplastic anaemia and the mechanism of induction of aplastic anaemia is not fully understood (watson, ) . although the incidence of aplastic anaemia associated with exposure to chloramphenicol is apparently very low, no threshold level could be defined (emea, ). in addition, several studies suggest that chloramphenicol and some of its metabolites are genotoxic (fao/who, emea, ) . considering the available evidence from in vitro experiments and from animal studies, as well as from a case-control study conducted in china, in which there was evidence for the induction of leukaemia in patients receiving a long-term treatment with chloramphenicol, iarc classified chloramphenicol as group a (probably carcinogenic to humans) substance (iarc, ) . based on these evaluations, the use of chloramphenicol in food-producing animals is prohibited within the eu to avoid the exposure of consumers to potential residues in animal tissues, milk and eggs. consequently, chloramphenicol is included in table until its prohibition, chloramphenicol was used on food-producing animals, including sheep and goats, for treatment of salmonella infections and for prevention of secondary bacterial infections. currently, chloramphenicol, which is licensed for use as a broad-spectrum bacteriostatic antibacterial in pets and non-food-producing animals in the eu, is used also in some third countries for foodproducing animals. hence, chloramphenicol may be available on the black market for illicit use in sheep/goat production. however, the availability for use on food-producing animals of related substances with similar antibacterial properties, thiamphenicol and florfenicol (with no toxicological concern), should mitigate the illicit use of chloramphenicol in sheep/goat production as these alternative drugs are available as prescription medicines. non-compliant results for chloramphenicol in sheep/goats have been reported in most years' results from the european nrcps - ( non-compliant results), indicating that abuse of chloramphenicol in sheep/goat production in europe may be a continuing occurrence. chloramphenicol has proven toxicity for humans and is effective as an antibacterial treatment for sheep/goats but, considering that lower numbers of non-compliant results have been found in recent years of the nrcp testing, chloramphenicol currently is ranked as of medium potential concern. (g) nitrofurans nitrofurans, including furazolidone, furaltadone, nitrofurantoin and nitrofurazone, are very effective antimicrobial agents that, prior to their prohibition for use on food-producing animals in the eu in , were widely used on livestock (cattle, sheep/goats, pigs, sheep and goats), in aquaculture and in bees. various nitrofuran antimicrobials are still applied in human medicine particularly for the treatment of urinary tract infections. a characteristic of nitrofurans is the short half-life of the parent compounds and the formation of covalently bound metabolites which, under the acidic conditions of the human stomach, may be released as active agents (hoogenboom et al., ) . these covalently bound metabolites are used as marker residues for detecting the illicit use of nitrofurans in animal production. it should be noted that the metabolite semicarbazide (sem) has been shown not to be an unambiguous marker for abuse of the nitrofuran drug nitrofurazone because the sem molecule may occur from other sources (hoenicke, et al., ; sarnsonova et al., ; bendall, ). nitrofurans are effective in treatment of bacterial and protozoal infections, including coccidiosis, in food-producing animals. although prohibited for use on food-producing animals in many countries, nitrofurans are likely to be available on the black market for illicit use in sheep/goat production. noncompliant results for nitrofurans in sheep/goats have been reported in most years' results from the european nrcps - , indicating that abuse of nitrofurans in sheep/goat production in europe is a continuing occurrence. a metabolite of furazolidone that can be released from covalently bound residues in tissues has been shown to be mutagenic and may be involved in the carcinogenic properties of the parent compound (emea, a). nitrofurans have proven toxicity for humans and are effective as antibacterials for sheep and goats but, considering that non-compliant results, other than for the marker residue sem, are found only sporadically in the nrcp testing, these substances currently are ranked as of medium potential concern. . . . . . contaminants: non dioxin-like pcbs (ndl-pcbs), chemical elements and mycotoxins (a) non dioxin-like pcbs (ndl-pcbs) the non dioxin-like pcbs (ndl-pcbs) show a different toxicological profile to the dl-pcbs. in , the contam panel performed a risk assessment on ndl-pcbs in food (efsa, a) . in the final conclusion, the contam panel stated that no health-based guidance value for humans can be established for ndl-pcbs because simultaneous exposure to dioxin-like compounds hampers the interpretation of the results of the toxicological and epidemiological studies, and the database on effects of individual ndl-pcb congeners is rather limited. there are, however, indications that subtle developmental effects, caused by ndl-pcbs, dl-pcbs, or polychlorinated dibenzo-pdioxins/polychlorinated dibenzofurans alone, or in combination, may occur at maternal body burdens that are only slightly higher than those expected from the average daily intake in european countries. in its risk assessment the contam panel decided to use the sum of the six pcb congeners (- , - , - , - , - and - ) as the basis for their evaluation, because these congeners are appropriate indicators for different pcb patterns in various sample matrices and are most suitable for a potential concern assessment of ndl-pcbs on the basis of the available data. moreover, the panel noted that the sum of these six indicator pcbs represents about % of total ndl-pcbs in food (efsa, a because of their somewhat lower toxicity than that of dl-pcbs, ndl-pcbs are classified in the medium potential concern category. (b) chemical elements (heavy metals: cadmium, mercury and lead) among the chemical elements, heavy metals traditionally have gained attention as contaminants in animal tissues, as they may accumulate in certain organs, particularly in kidneys over the lifespan of an animal. kidney tissue from sheep forms a specific dietary component in many european cultures. exposure of animals is commonly related to contaminated feed materials, despite older reports of accidental intoxication of animals from other sources (paints, batteries). the contam panel has issued within the framework of the re-evaluation of undesirable substances in animal feeds according to directive / /ec several opinions addressing heavy metals and arsenic in feed materials and the transfer of these elements from feed to edible tissues, milk and eggs. cadmium (efsa, a) is a heavy metal found as an environmental contaminant, both through natural occurrence and from industrial and agricultural sources. cadmium accumulates in humans and animals, causing concentration-dependent renal tubular damage. older animals are expected to have higher concentrations of cadmium accumulated in the kidneys. most of the non-compliant results were for kidney samples with some non-compliant results for muscle and liver being reported. mercury (efsa, a , efsa contam panel, a exists in the environment as elemental mercury, inorganic mercury and organic mercury (primarily methylmercury). methylmercury bioaccumulates and biomagnifies along the aquatic food chain. the toxicity and toxicokinetics of mercury in animals and humans depends on its chemical form. elemental mercury is volatile and mainly absorbed through the respiratory tract, whereas its absorption through the gastrointestinal tract is limited ( - %). following absorption, inorganic mercury distributes mainly to the kidneys and, to a lesser extent, to the liver. the critical effect of inorganic mercury is renal damage. in contrast, in animals, as in humans, methylmercury and its salts are readily absorbed in the gastrointestinal tract (> %) and rapidly distributed to all tissues, although the highest concentrations are also found in the kidneys. data from mss indicated the presence of mercury in animal feeds, but the measured concentrations remained below the maximum content for feed materials ( lead (efsa contam panel, ) is an environmental contaminant that occurs naturally and, to a greater extent, from anthropogenic activities such as mining and smelting and battery manufacturing. lead is a metal that occurs in organic and inorganic forms; the latter predominate in the environment. human exposure is associated particularly with the consumption of cereal grains (except rice), cereal and cereal-based products, potatoes, leafy vegetables and tap water. the contribution of sheep and goat meat and offal to human exposure is limited. given the toxicological profile of these elements and the fact that cadmium accumulates in animals and humans, these three elements have been allocated to the group of substances of medium potential health concern. . . . . substances classified in the category of low potential concern . . . . . prohibited substances: nitroimidazoles, chlorpromazine (a) nitroimidazoles the -nitroimidazoles, dimetridazole, metronidazole and ronidazole, are a group of drugs having antibacterial, antiprotozoal and anticoccidial properties. owing to the potential harmful effects of these drugs on human health (emea, b)-carcinogenicity, mutagenicity, genotoxicity and the occurrence of covalent binding to macromolecules of metabolites with an intact imidazole structuretheir use in food-producing animals is prohibited in the eu, united states, china, and other countries. nitroimidazoles had been used as veterinary drugs for the treatment of cattle, pigs and sheep and goats. although prohibited for use on food-producing animals, not only in the eu but also in many third countries, nitroimidazoles are likely to be available on the black market for illicit use in animal production, particularly as drugs such as metronidazole are readily available as human medicines. however, there are no clinical conditions in sheep/goats for which nitroimidazoles are particularly appropriate. non-compliant results (two) for nitroimidazoles in sheep/goats have been reported only in one year and from one ms from the european nrcps - , suggesting that abuse of nitroimidazoles in sheep/goat production in europe is not widespread. considering that nitroimidazoles have proven toxicity for humans and that they may be effective as antibacterial/antiprotozoal treatments for sheep/goats, these substances might be ranked as of medium potential concern. however, as only occasional non-compliant results have been found over a number of years of nrcp testing, nitroimidazoles currently are ranked as of low potential concern. (b) chlorpromazine chlorpromazine is a sedative and is also used against motion sickness and as an anti-emetic in pets. its use is banned in food-producing animals, including sheep/goats. chlorpromazine is likely to be available as a black market substance for illicit use in sheep/goat production. no non-compliant results for chlorpromazine were reported from the nrcp for the period - , indicating that the substance may not be rarely used illicitly in sheep/goat production in the eu. chlorpromazine is used as an antipsychotic drug in human therapy and has long-term persistence in humans and numerous side effects, including the more common ones of agitation, constipation, dizziness, drowsiness, etc. (emea, ) . chlorpromazine may be effective as a tranquilliser for sheep/goats but, since no non-compliant results have been found over a number of years of nrcp testing, chlorapromazine currently is ranked as of low potential concern. . . . . . contaminants: organochlorine pesticides, organophosphorus compounds, and natural toxins (a) organochlorine compounds organochlorine pesticides, such as dichlorodiphenyltrichloroethane (ddt) and its metabolites, hexachlorocyclohexanes (hchs), dieldrin, toxaphene and others have been assigned to the category of contaminants of low potential concern. occurrence of residues of these substances has declined over the years, because of their long-standing ban, and relatively low levels in animal products can be expected, as shown by results from the nrcps - , which indicate that results out of the total of samples tested for the category of organochlorine compounds were non-compliant for organochlorine pesticides. organophosphorus compounds are classified in council directive / /ec as group b b contaminants, although they may be used also as vmps for the therapy of parasitic infestations of sheep and goats. however, their probably infrequent use and short half-life results in these compounds being assigned to the category of low potential concern, or even negligible potential concern where mrls are not exceeded. results from the nrcps from - indicate that results out of the total of samples tested for the category of organophosphorus compounds were non-compliant. (c) natural toxins: mycotoxins and toxic plant secondary metabolites (c. ) mycotoxins mycotoxins comprise a chemically diverse group of secondary metabolites of moulds which may induce intoxication in humans and animals following ingestion of contaminated food or feed materials. mycotoxins evaluated by the contam panel as undesirable contaminants in animal feeds, including aflatoxins (efsa, b ), deoxynivalenol (efsa, c , fumonisins (efsa, b) and zearalenone (efsa, a) , t- toxin (efsa contam panel, c), ergot alkaloids (efsa contam panel, b) may pose a risk for animal health and productivity when present in feed materials that are used for sheep and goat animals over an extended period of time. however, most of the known mycotoxins are efficiently degraded by the rumen microflora and have a short biological half-life. hence, even if residues of mycotoxins are occasionally detected in animal tissues (monogastric animal species) they do not contribute significantly to human exposure, which is mainly related to the consumption of cereal products, nuts and spices. considering that some mycotoxins like aflatoxins have proven toxicity for humans, some of these substances might be ranked as of medium potential concern. however, since non-compliant results have been found incidentally (two out of samples) over a number of years of nrcp testing, these substances currently are ranked as of low potential concern. (c. (efsa, f) . although for several of these substances potential concerns for animal health could be identified following ingestion with feed, none of these natural toxins appeared to accumulate in edible tissues. the limited data on the kinetics of these metabolites does not preclude in all cases a transfer from the feed into animal tissues under certain circumstances of exposure. for example, residues of gossypol in meat of cattle (and sheep) were demonstrated under experimental conditions (feeding of cotton meal as the main feed component), but such residues are not expected under the conditions of european farming, where cotton seeds or cotton seed by-products are infrequently used and only with limited inclusion rates in feed (efsa, e) . other natural substances, such as the fungal metabolite (mycotoxin) zearalenone, are intensively metabolised in the rumen and following absorption in the liver and other animal tissues, and this may explain certain noncompliant analytical results. zearalanol (zeranol) is one of these metabolites and which is used in certain third countries as a growth-promoting agent owing to its oestrogenic activity (see section . . . . (d) ). this applies also to certain thiocyanates and oxazolidinethiones, originating from glucosinolates produced by a broad variety of plants of the brassicaceae family. they target different steps in the synthesis of thyroid hormones, leading eventually to hypothyroidism and enlargement of the thyroid gland (goitre) (efsa, b) . again, these natural products may explain some of the noncompliant results found in nrcp testing where treatment of animals with antithyroid agents (thyreostats) has been suspected. recently, an increasing use of herbal remedies, given as so-called alternatives to antibiotics for animals, has been reported also in ruminants. many of the herbal products contain biologically active substances that are also addressed in the list of undesirable plant metabolites. however, the remedies are given in low concentrations (lower than the larger amount that could be ingested with feed), and for a limited period. although specific data are lacking, it seems unlikely that residues of these compounds may be found in edible tissues of slaughtered animals. such substances, therefore, are placed in the category of low potential concern within the current classification. vmps, such as antimicrobials, anti-coccidials and anti-parasitics, are used commonly on sheep and goats for prophylactic purposes, particularly prior to turning animals out to grazing (anti-parasitic treatments). therapeutic use of vmps, particularly antimicrobials, may occur in response to diagnosis of infection in individual animals or in the flock. in general, vmps, except the substances allocated to annex table of regulation (ec) no / , are categorised as being of low potential concern because they have all been subjected to premarketing approval which specifies adis, and mrls, with the aim of guaranteeing a high level of safety to the consumer. where exceedances of mrls are found in the residue monitoring programmes (i.e. non-compliant results out of the samples analysed for antibacterials, non-compliant results for anthelmintics out of the samples analysed, and eight non-compliant results out of the samples analysed for anti-coccidials), these are typically of an occasional nature that is not likely to constitute a concern to public health. despite only two non-compliant results being reported out of the samples analysed for corticosteroids, there is concern about their potential illicit use, particularly in fattening lambs. in the negligible potential concern category are the dyes and the prohibited substances, colchicine, dapsone, chloroform and aristolochia spp. . . . . . prohibited substances: colchicine, dapsone, chloroform and aristolochia spp. colchicine is a plant alkaloid that has been used in veterinary medicine to treat papillomas and warts in cattle and horses by injection at the affected area. a possible contamination of food with colchicine has been identified through consumption of colchicum autumnale in forage by animals such as cattle or sheep and, in this context, colchicine has been determined in milk of sheep after exposure to c. autumnale (hamscher et al., ) . colchicine is genotoxic and teratogenic and may have toxic effects on reproduction. no non-compliant results for colchicine in sheep/goats have been reported from the european nrcps - ; however, it is probable that testing for this substance may not be included in monitoring programmes in many countries. in the absence of the absence of evidence for use of colchicine in sheep/goats colchicine currently is ranked as of negligible potential concern. (b) dapsone dapsone is a drug used in humans and formerly in veterinary medicine: in human medicine it is used for treatment of leprosy, malaria, tuberculosis and dermatitis; and in veterinary medicine it is used as an intramammary treatment for mastitis, for oral treatment of coccidiosis and for intra-uterine treatment of endometriosis. following scientific assessment by the committee for medicinal products for veterinary use (cvmp), a provisional mrl of µg/kg parent drug was established for muscle, kidney, liver, fat and milk for all food-producing animals (emea, ) . further information on teratogenicity and reproductive effects for dapsone was required but, when this was not provided, the substance was recommended for inclusion in annex iv to council regulation (eec) no / (now annex, table , of commission regulation (ec) no / ). more recently, the cvmp has reviewed the alleged mutagenicity of dapsone in the context of its occurrence as an impurity in vmps containing sulphonamides and concluded that it is not genotoxic (cvmp, ) , and efsa has issued a scientific opinion on the product as a food-packaging material (compound ), proposing an acceptable level of mg/kg food (efsa, c) . in the absence of evidence for use of dapsone in sheep and goats, dapsone currently is ranked as of negligible potential concern. (c) chloroform and aristolochia spp. in the negligible potential concern category are the prohibited substances, chloroform and plant remedies containing aristolochia spp., as these are not relevant to sheep/goat production and there is no evidence for use of these substances in sheep/goat production. vmps used in sheep and goat production but with no evidence for residues above mrls being found in monitoring programmes and vmps irrelevant for sheep and goat production are ranked as of negligible potential concern. (a) carbamates and pyrethroids carbamates and pyrethroids are used in animal houses and occasionally in animals including sheep for control of environmental infections, such as lice eggs in buildings. there are no recent incidents of non-compliant results reported in nrcp testing in sheep and goats during the period - , resulting in these substances being assigned to the category of negligible potential concern. (b) sedatives a range of sedative substances including barbiturates, promazines, xylazine and ketamine, are licensed for use in sheep, goats and other animal species for sedation and analgesia during surgical procedures or for euthanasia. they are rarely used in sheep and goats. no non-compliant results were found in the nrcp testing for the period - . due to their rapid excretion, these substances generally do not have detectable residues in muscle and so do not have mrls registered in the eu. animals euthanised with these substances are not allowed to enter the food chain. however, it should be noted that testing for this category of substances is not required under the provisions of council directive / /ec. there are no indications for use of dyes such as (leuco-)malachite green in sheep and goat animals. testing of sheep and goat animals for this group of substances is not required under council directive / /ec . a summary of the outcome of the ranking is presented in table . dioxins dl-pcbs mrl, maximum residue limit; nrcp, national residue control plan; psm, plant secondary metabolite; vmp, veterinary medicinal product. the ranking into specific categories of potential concern of prohibited substances, vmps and contaminants presented in this section applies exclusively to sheep and goats and is based on current knowledge regarding the toxicological profiles, usage in ovine animal production, and occurrence as residues or contaminants, as demonstrated by the data from the nrcps for the - period. where changes in any of these factors occur, the ranking might need amendment. another element of future aspects is the issue of 'new hazards'. in this context, new hazards are defined as compounds that have been identified as anthropogenic chemicals in food-producing animals and derived products and in humans and for which occurrence data are scarce. it does not imply that there is evidence for an increasing trend in the concentration of these compounds in food or in human samples. examples are brominated flame retardants, such as polybrominated diphenyl ethers (pbde) and hexabromocyclododecanes (hbcdds) or perfluorinated compounds (pfc), such as perfluorooctane sulphonate (pfos) and perfluorooctanoic acid (pfoa). in , efsa performed a risk assessment on polybrominated diphenyl ethers (pbdes) in food (efsa contam panel, e) . pbdes are additive flame retardants which are applied in plastics, textiles, electronic castings and circuitry. pbdes are ubiquitously present in the environment and likewise in biota and in food and feed. eight congeners were considered by the contam panel to be of primary interest: . the highest dietary exposure is to . toxicity studies were carried out with technical pbde mixtures or individual congeners. the main targets were the liver, thyroid hormone homeostasis and the reproductive and nervous system. pbdes are not genotoxic. the contam panel identified effects on neurodevelopment as the critical endpoint, and derived benchmark doses (bmds) and their corresponding lower % confidence limit for a benchmark response of %, the bmdl , for a number of pbde congeners: bde- , μg/kg b.w.; bde- , μg/kg b.w.; bde- , μg/kg b.w.; bde- , μg/kg b.w. owing to the limitations and uncertainties in the current database, the panel concluded that it was inappropriate to use these bmdls to establish health based guidance values, and instead used a margin of exposure (moe) approach for the health risk assessment. as the elimination characteristics of pbde congeners in animals and humans differ considerably, the panel used the body burden as the starting point for the moe approach. the contam panel concluded that for bde- , - and - current dietary exposure in the eu does not raise a health concern. for bde- there is a potential health concern with respect to current dietary exposure. the contribution of ovine meat and ovine-derived products to total human exposure is currently not known. as these compounds bioaccumulate in the food chain, they deserve attention and should be considered for inclusion in the nrcps. in , efsa delivered a risk assessment on hbcdds in food (efsa contam panel, f) . hbcdds are additive flame retardants, primarily used in expanded and extruded polystyrene used as construction and packing materials, and in textiles. technical hbcdd consists predominantly of three stereoisomers (α-, βand γ-hbcdd). also δ-and ε-hbcdd may be present but at very low concentrations. hbcdds are present in the environment and likewise in biota and in food and feed. data from the analysis of hbcdds in food samples were provided to efsa by seven european countries, covering the period from to . the contam panel selected α-, β-and γ-hbcdd as of primary interest. as all toxicity studies were carried out with technical hbcdd, a risk assessment of individual stereoisomers was not possible. main targets were the liver, thyroid hormone homeostasis and the reproductive, nervous and immune systems. hbcdds are not genotoxic. the contam panel identified neurodevelopmental effects on behaviour as the critical endpoint, and derived a bmdl of . mg/kg b.w. owing to the limitations and uncertainties in the current data base, the contam panel concluded that it was inappropriate to use this bmdl to establish a healthbased guidance value, and instead used an moe approach for the health risk assessment of hbcdds. as the elimination characteristics of hbcdds in animals and humans differ, the panel used the body burden as the starting point for the moe approach. the contam panel concluded that current dietary exposure to hbcdds in the eu does not raise a health concern. the occurrence data reported to efsa have shown that hbcdds could be detected in a limited number of meat samples. as the total number of sheep and goat meat samples analysed for hbcdds are sparse and thus the current knowledge about the prevalence and their levels in edible tissues of ovine animals is limited, their inclusion into nrcps even as a temporary measure should be considered. perfluorinated compounds (pfcs), such as pfos, pfoa and others have been widely used in industrial and consumer applications including stain-and water-resistant coatings for fabrics and carpets, oil-resistant coatings for paper products approved for food contact, fire-fighting foams, mining and oil well surfactants, floor polishes, and insecticide formulations. a number of different perfluorinated organic compounds have been widely found in the environment. in , efsa delivered a risk assessment on pfos and pfoa in food (efsa, g) . the contam panel established a tdi for pfos of ng/kg b.w. per day, and a tdi for pfoa of . μg/kg b.w. per day. a few data indicated the occurrence of pfos and pfoa in meat samples. however, owing to the low number of data, it has not been possible to perform an assessment of the relative contribution from different foodstuffs to human exposure to pfos and pfoa. a recent study in which contaminated feed was fed to sheep demonstrated the transfer of pfos, pfoa and various other pfcs with different chain lengths into milk and meat of the sheep (kowalczyk et al., ) . as pfcs have found widespread use and ubiquitous distribution in the environment, but representative data on their occurrence in meat are still limited, an intensified monitoring of these compounds in tissues as well as feed should be considered. besides the heavy metals discussed in section . . . . , attention should be given also to those compounds that may be used as feed supplements (e.g. copper, selenium, zinc). the correct use of these supplements cannot be guaranteed. although supplementary feeding to sheep and goats at pasture with trace elements is practised, supplements for sheep are not permitted to contain copper. however, the risk of copper supplementation cannot be ruled out on mixed livestock farms where supplements containing copper for other livestock, e.g. pigs or calves, may be given in error to sheep, resulting in undesirable residues in animal organs, such as the liver. sheep are particularly susceptible to copper toxicity; goats appear to be able to tolerate higher intakes (underwood and suttle, ) . in the absence of supplementation, the main source of copper is the pasture, the uptake of which is a complex interaction between the copper, molybdenum and sulphate levels in the plants and the grass plants themselves. for example, sheep that consume excess subterranean clover (trifolium spp.) will develop chronic copper accumulation in their tissues as a result of the copper/molybdenum balance in the clover (radostits et al., ) . there are also large differences between breeds in susceptibility to copper toxicity (underwood and suttle, ) . a closer communication of results from official feed control seems essential to decide whether or not analytical monitoring of residues in slaughter animals needs to be directed to these substances that might be overused or mistakenly used in sheep or goat feeds. in light of the existing regulations and the daily practice of the control of residues/chemical substances in sheep/goat carcasses, the strengths and weaknesses of the current meat inspection methodology can be summarised as follows: the strengths of the current meat inspection methodology for chemical hazards are as follows: the current procedures for sampling and testing are a mature system, well established and coordinated, and subject to regular evaluation that is in place across eu mss, with residue testing that is based on common standards for method performance and interpretation of results (commission decision / /ec), laboratory accreditation (iso/iec ) and quality assurance schemes. the residue monitoring programmes are supported by a network of eu and national reference laboratories and by research in the science of residue analysis that serves to provide state-of-the-art testing systems for control of residues (see annex ). there are well-developed systems and follow-up actions subsequent to the identification of non-compliant samples. as indicated in section . , follow-up on non-compliant samples is typically through intensified sampling (suspect sampling), withholding of slaughter and/or of carcasses subject to positive clearance as compliant, and on-farm investigations potentially leading to penalties and/or criminal prosecutions. the regular sampling and testing for chemical residues is a disincentive for the development of bad practices. there is constant development of new approaches in sampling and testing methodologies, particularly in the area of prohibited substances, directed at identifying illicit use of such substances in animal production; for example, use of samples other than edible tissues, such as excreta, eyes, fibre, etc. that demonstrate enhanced residue persistence characteristics, and use of indirect testing procedures, such as genomics, proteomics and metabolomics, to identify treated animals. the prescriptive sampling system allows for equivalence in the control of eu-produced sheep/goat meat. any forthcoming measures have to ensure that the control of imports from third countries remains equivalent to the controls within the domestic market (this issue is addressed further in tor ). the current combination of animal traceability, ante-mortem inspection and gross tissue examination can support the collection of appropriate samples for residue monitoring. however, any indication of misuse or abuse of pharmacologically active substances through visual assessment needs to be confirmed by chemical analysis for potential residues. the weaknesses of the current meat inspection methodology for chemical hazards are as follows: presence of chemical hazards cannot be identified by current ante-/post-mortem meat inspection procedures at the slaughterhouse level, indicating the need for further harmonisation of the risk reduction strategies along the entire food chain. at present, there is poor integration between the testing of feed materials for undesirable contaminants and the nrcps in terms of communication and follow-up testing strategies or interventions. moreover, a routine environmental data flow is not established and keeping habits for sheep and goats provide opportunities for feed coming in without a clear feed chain history. under the current system, sampling is mostly prescriptive rather than risk or information based. it appears that individual samples taken under the nrcp testing programme may not always be taken as targeted samples, as specified under council directive / /ec, but sometimes may be taken as random samples. there is a lack of sufficient cost-effective and reliable screening methods and/or the range of substances prescribed/covered by the testing is sometimes limited. there is limited flexibility to adopt new chemical substances into the nrcps and limited ongoing adaptation of the sampling and testing programme to the results of the residue monitoring programmes. the sampling under the nrcps reflects only a part of testing done by a number of mss and, therefore, data from the nrcps may not provide the most complete information for certain categories of substances. sheep and goats may not be subject to surveillance over their lifetime at the same level as is the case for other food animal categories such as pigs, poultry and, to a large extent, bovine animals owing to their traditional nomadic/outdoor farming systems. current monitoring of residues and contaminants in edible tissues of slaughter sheep/goats is based on council directive / /ec. in turn, risk ranking as presented under tor is also based largely on the chemical substances listed in council directive / /ec. the outcome of the ranking showed that only a small number of compounds are considered to constitute a high potential concern for consumers. however, considering the recent information available from the re-assessment of undesirable substances in the food chain, covered by more recent efsa opinions from the contam panel, additional compounds have been identified that require attention. prominent examples of such substances are and dl-pcbs, which were identified as compounds of high potential concern as they bioaccumulate in the food chain, are likely to be found in sheep/goat carcasses and have a toxicological profile that points towards public health concerns even at low (residue) concentrations. in addition, it has been shown that these substances are found in edible tissues of sheep, particularly in sheep liver. other halogenated substances such as brominated flame retardants, including polybrominated diphenylethers (pbdes) as well as hexabromocyclododecanes (hbcdds) and perfluorinated compounds (pfcs), such as pfos and pfoa have a different toxicological profile. these compounds bioaccumulate in the food chain and deserve attention, as currently the knowledge about the prevalence and level of residues of these compounds in edible tissues of sheep and goats is limited. chemical elements, such as copper, selenium and zinc, given as feed supplements may be mistakenly provided to sheep and goats resulting in undesirable residues in animal organs, such as the liver. inclusion of these various substances in the nrcps (even as a temporary measure) should be considered together with an intensified monitoring of feed materials for the presence of these compounds, to support forthcoming decisions on whether or not these substances require continued monitoring either in feed materials and/or in slaughter animals. due to the nature of the husbandry systems applied, sheep and goats are more likely to be exposed to environmental contaminants than other livestock. therefore, any incident giving rise to contamination of the environment may be noted primarily in animals kept outdoors, i.e. in sheep and goats. it is important to note that sheep and goat production in the eu is marked by being largely extensive in nature, involving frequent trading of animals and nomadic flocks. this involves differences in husbandry systems and feeding regimes resulting in different risks from chemical substances and contaminants. extensive periods on pasture or/as nomadic flocks, sale at open markets of many sheep and goats, and the presence of slaughter collection dealerships that may combine small numbers of animals purchased from several farmers, means that there is a level of concern that fci shared between farmers and the slaughterhouse (where residue data is managed), may be suboptimal. similarly, in these situations, the level of feedback from the slaughterhouse and authorities to farmers regarding the results of residue testing may be suboptimal. here the individual identification of animals, which has now become mandatory, may contribute to more transparency in the future. there is less concern about fci from dairy sheep and goats if they are reared under more intensive and controlled conditions. fci should be expanded for sheep and goats produced in extensive systems to provide more information on the specific environmental conditions where the animals are produced. it is recommended that sampling of sheep and goats should be based on the risk of occurrence of chemical residues and contaminants and on the completeness and quality of the fci supplied. to achieve this, better integration of results from official feed control with residue monitoring seems essential to indicate whether monitoring of residues in slaughter animals needs to be directed to particular substances. it should be noted that for the small ruminant chains more environmental information should be provided. therefore, there is a need for an improved integration of sampling, testing and intervention protocols across the food chain, nrcps, feed control and monitoring of environmental contaminants. moreover, the combination of data from both sheep and goats into one data set is based on the assumption that both food chains are identical. in many cases such an assumption is not justified. a separation of records for both species is recommended. in addition, there is a need to develop new approaches to chemical residues and contaminants testing. recent developments in chemical analytical techniques allow the simultaneous measurement of a broad range of substances. analytical techniques covering multiple analytes should be encouraged too and incorporated into feed quality control and national residue control programmes. application of such validated methods for multi-residue analyses comprising veterinary drugs, pesticides and natural and environmental contaminants should be encouraged. for prohibited substances, testing should be directed towards the farm level. one of the limitations of the currently applied analytical strategies is the generally poor sensitivity of some screening methods, resulting in the potential failure to detect residues in the low µg/kg range and, therefore, to identify non-compliant samples. new approaches including molecular biological techniques for the identification of indirect biomarkers of exposure in animals, as well as the development of reliable in vitro assays based on the biological action(s) of the compounds under analysis, are considered to be of additional value. such approaches may help in detecting molecules of unknown structure or that are not included in the nrcps but share a common mechanism of action, thereby better orienting and rationalising the subsequent chemical analysis. in the case of many of the substances that might be used illicitly for growth-promoting purposes in sheep and goat production, the results of nrcp testing show no non-compliant results (e.g. stilbenes) or indicate that reported non-compliant results may be attributable to dietary sources (e.g. thyreostats, zeranol) or are the result of endogenous production (e.g. gonadal (sex) steroids). therefore, future nrcp testing relating to such substances needs to be reduced and/or refocused, in terms of the range of analytes tested and the appropriateness of samples taken for testing, to better identify the extent of abuse of growth-promoting substances in sheep and goat production in the eu. in addition, control measures for such substances must not rely exclusively on nrcp testing, but should include veterinary inspection/police activities along the food chain directed at identifying abuse of such substances in sheep and goat production in the eu. finally, it should be noted that any measures taken to improve the efficacy of meat inspection protocols also need to address the compliance of imports to the eu with these strategies. where eu meat inspection would move to a risk-based approach, particular attention to the achievement of equivalent standards of food safety for imported food from third countries will be required. currently, within the prescriptive system for meat inspection and residue monitoring applying in the eu, third countries exporting food products of animal origin to the eu need to demonstrate that they have the legal controls and residue monitoring programmes capable of providing equivalent standards of food safety as pertains within the eu. if eu meat inspection moves to a risk-based approach, particular attention will need to be paid to the achievement of equivalent standards of food safety for imported food from third countries. the risk-ranking appropriate within the eu in relation to veterinary drugs and contaminants might not be appropriate in third countries to achieve equivalent standards of food safety. rather than requiring that a risk-based monitoring programme applying within eu mss should be applied similarly in the third country, an individual risk assessment for each animal product(s)/third country situation may be required, which should be updated on a regular basis. this section contains conclusions derived from the material discussed in the document, together with recommendations for improvements to meat inspection with regard to chemical hazards within the eu. tor to identify and rank the main risks for public health that should be addressed by meat inspection at eu level. general (e.g. sepsis, abscesses) and specific biological risks as well as chemical risks (e.g. residues of veterinary drugs and contaminants) should be considered. differentiation may be made according to production systems and age of animals (e.g. breeding compared to fattening animals) as a first step in the identification and ranking of chemical substances of potential concern, the contam panel considered the substances listed in council directive / /ec and evaluated the outcome of the national residue control plans (nrcps) - . the contam panel noted that only . % of the total number of results was non-compliant for one or more substances listed in council directive / /ec. potentially higher exposure of consumers to these substances from sheep and goat meat takes place only incidentally, as a result of mistakes or non-compliance with known and regulated procedures. the available aggregated data indicate a low number of samples that were non-compliant with the current legislation. however, in the absence of substance-and/or species-specific information, such as the tissues used for residue analysis and the actual concentration of a residue or contaminant measured, these data do not allow for a reliable assessment of consumer exposure. other criteria used for the identification and ranking of chemical substances of potential concern included the identification of substances that that are found in other testing programmes and that bioaccumulate in the food chain, substances with a toxicological profile of concern, and the likelihood that a substance under consideration will occur in sheep and goat carcasses. taking into account these criteria the individual compounds were ranked into four categories denoted as being of high, medium, low and negligible potential concern. the highest overall proportion of non-compliant results under the nrcps were for group b substances, contaminants ( . %) representing largely exceedances of the maximum residue limits/maximum levels (mrls/mls) specified for these substances. the proportion of noncompliant results overall for group a substances, prohibited substances ( . %) and for group b /b substances, veterinary medicinal products (vmps) ( . %) represent largely illicit use and exceedances of the mrls, respectively. dioxins and dioxin-like polychlorinated biphenyls (dl-pcbs) were ranked as being of high potential concern owing to their known bioaccumulation in the food chain, their frequent findings above mls, particularly in sheep liver, and in consideration of their toxicological profile. stilbenes, thyreostats, gonadal (sex) steroids, resorcylic acid lactones and beta-agonists, especially clenbuterol, were ranked as being of medium potential concern because of their toxicity for humans, their efficacy as growth promoters in sheep and goats and the incidence of non-compliant results. chloramphenicol and nitrofurans were ranked as being of medium potential concern, as they have proven toxicity for humans, they are effective as antibacterial treatments for sheep/goats and as non-compliant samples are found in most years of the nrcps. non-dioxin-like polychlorinated biphenyls (ndl-pcbs) bioaccumulate, and there is a risk of exceeding of the mls, but they were ranked in the category of medium potential concern, because they are less toxic than dioxins and dl-pcbs. the chemical elements cadmium, lead and mercury were allocated to the medium potential concern category taking into account the number of non-compliant results reported under the nrcps and their toxicological profile. residues originating from other substances listed in council directive / /ec were ranked as of low or negligible potential owing to the toxicological profile of these substances at residue levels in edible tissues or to the very low or non-occurrence of non-compliant results in the nrcps - , and/or to the natural occurrence in sheep and goats of some of these substances. the low potential concern category includes nitroimidazoles chlorpromazine, organochlorine pesticides, organophosphorus compounds, natural toxins, as well as and vmps exceeding mrls. in the negligible potential concern category are the prohibited substances colchicine, dapsone, chloroform and aristolochia spp., the dyes, as well as vmps occurring below mrls. the contam panel emphasises that this ranking into specific categories of potential concern is based on the current knowledge regarding toxicological profiles, usage in sheep and goat production and occurrence as contaminants or chemical residues, as demonstrated by the data from the nrcps for the - period. future monitoring programmes should be based on the system for the ranking of chemical compounds into potential concern categories as presented in this document. regular updating of the ranking of chemical compounds in sheep and goats as well as of the sampling plans should occur, taking into account any new information regarding the toxicological profile of chemical residues and contaminants, usage in sheep and goat production, and actual occurrence of individual substances in sheep and goats. tor to assess the strengths and weaknesses of the current meat inspection methodology and recommend possible alternative methods (at ante-mortem or post-mortem inspection, or validated laboratory testing within the frame of traditional meat inspection or elsewhere in the production chain) at eu level, providing an equivalent achievement of overall objectives; the implications for animal health and animal welfare of any changes suggested in the light of public health risks to current inspection methods should be considered strengths of the current meat inspection methodology for chemical hazards are as follows: the current procedures for sampling and testing are a mature system, in general well established and coordinated including follow-up actions subsequent to the identification of non-compliant samples. the regular sampling and testing for chemical residues and contaminants in the system is an important disincentive to the development of undesirable practices. the prescriptive sampling system allows for equivalence in the control of eu-produced sheep and goat meat. any forthcoming measures have to ensure that the control of imports from third countries remains equivalent to the controls within the domestic market. the current combination of animal traceability, ante-mortem inspection and gross tissue examination can support the collection of appropriate samples for residue monitoring. weaknesses of the current meat inspection methodology for chemical hazards are as follows: a weakness of the system is that presence of chemical hazards cannot be identified by current ante-/post-mortem meat inspection procedures at the slaughterhouse level, indicating the need for further harmonisation of the risk reduction strategies along the entire food chain. integration between testing of feed materials for undesirable contaminants and the nrcps in terms of communication and follow-up testing strategies or interventions is currently limited. moreover, a routine environmental data flow is not established and keeping habits for sheep and goats provides opportunities for feed coming in without a clear feed chain history. under the current system, sampling is mostly prescriptive rather than risk or information based. it appears that individual samples taken under the nrcp testing programme may not always be taken as targeted samples, as specified under council directive / / ec, but sometimes may be taken as random samples. there is a lack of sufficient cost-effective and reliable screening methods and/or the range of substances prescribed/covered by the testing is sometimes limited. there is limited flexibility to adopt emerging chemical substances into the nrcps and limited ongoing adaptation of the sampling and testing programme to the results of the residue monitoring programmes. in addition, sampling under the nrcps reflects only a part of testing done by a number of ms, the results of which should be taken into consideration. sheep and goats may not be subject to surveillance over their lifetime at the same level as is the case for other food animal categories such as pigs, poultry and, to a large extent, bovine animals owing to their traditional nomadic/outdoor farming systems. meat inspection systems for chemical residues and contaminants should be less prescriptive and should be more risk and information based, with sufficient flexibility to adapt the residue monitoring programmes to results of testing. if new hazards currently not covered by the meat inspection system (e.g. salmonella, campylobacter) are identified under tor , then recommend inspection methods fit for the purpose of meeting the overall objectives of meat inspection. when appropriate, food chain information should be taken into account dioxins and dl-pcbs which accumulate in food-producing animals have been ranked as being of high potential concern. as these compounds have not yet been comprehensively covered by the sampling plans of the current meat inspection (nrcps), they should be considered as 'new' hazards. in addition, for a number of chemical elements used as feed supplements and for organic contaminants that may accumulate in food-producing animals only limited data regarding residues in sheep and goats are available. this is the case, in particular, for brominated flame retardants, including polybrominated diphenylethers (pbdes) and hexabromocyclododecanes (hbcdds) and perfluorinated compounds (pfcs) including (but not limited to) pfos and pfoa. control programmes for residues and contaminants should include 'new hazards' and take into account information from environmental monitoring programmes which identify chemical hazards to which animals may be exposed. provide an equivalent level of protection within the scope of meat inspection or elsewhere in the production chain that may be used by risk managers in case they consider the current methods disproportionate to the risk, e.g. based on the ranking as an outcome of tor or on data obtained using harmonised epidemiological criteria. when appropriate, food chain information should be taken into account sheep and goat production in the eu is marked by being largely extensive in nature, involving frequent trading of animals and nomadic flocks. this involves differences in husbandry systems and feeding regimes resulting in different risks for chemical substances and contaminants. extensive periods on pasture or/as nomadic flocks and the use of slaughter collection dealerships may preclude detailed lifetime fci. similarly, in these situations, the level of feedback from the slaughterhouse and authorities to farmers regarding the results of residue testing may be suboptimal. there is less concern about fci from dairy sheep and goats as they are reared under more intensive and controlled conditions. better integration of results from official feed control with residue monitoring seems essential to indicate whether monitoring of residues in slaughter animals needs to be directed to particular substances. therefore, there is a need for an improved integration of sampling, testing and intervention protocols across the food chain, nrcps, feed control and environmental monitoring. fci should be expanded for sheep and goats produced in extensive systems to provide more information on the specific environmental conditions where the animals are produced. it is recommended that sampling of sheep and goats should be based on the risk of occurrence of chemical residues and contaminants and on the completeness and quality of the fci supplied. there is a need for an improved integration of sampling, testing and intervention protocols for domestic sheep and goats across the food chain, nrcps, feed control and environmental monitoring. the development of analytical techniques covering multiple analytes and of new biologically based testing approaches should be encouraged and incorporated into feed quality control and chemical residue/contaminants testing in the nrcps. the combination of data from both sheep and goats into one data set assumes that both food chains are identical, which is not the case. a separation of test records for both species is recommended. for prohibited substances, testing should be directed where appropriate towards the farm level. future nrcp testing relating to substances that might be used illicitly for growth promoting purposes needs to be refocused to better identify the extent of abuse in the eu. in addition, control measures for prohibited substances should not rely exclusively on nrcp testing, but should include veterinary inspection during the production phase and the use of biological methods and biomarkers suitable for the identification of abuse of such substances in sheep and goat production in the eu. commission decision / /ec specifies the performance criteria for methods, including recovery and accuracy, trueness and precision. the decision specifies, also, the validation required to demonstrate that each analytical method is fit for purpose. in the case of screening methods, validation requires determination of the performance characteristics of detection limit, precision, selectivity/specificity and applicability/ruggedness/stability. for confirmatory methods, in addition to determination of those performance characteristics, validation requires, also, determination of decision limit and trueness/recovery. the analytical requirements for the determination of dioxins, dl-pcbs and ndl-pcbs are laid down in commission regulation (ec) no / . following a criteria approach analyses can be performed with any appropriate method, provided the analytical performance criteria are fulfilled. while methods, such as gc-ms and cell-and kit-based bioassays are allowed for screening purposes, the application of gc/high-resolution ms is mandatory for confirmation of positive results. screening methods include a broad range of methods, such as elisa, biosensor methods, receptor assays, bioassays and biomarkers for the presence of residues of concern. these screening methods generally use specific binding of the molecular structure of the residue(s) by antibodies or other receptors to isolate and measure the presence of the residues in biological fluids (urine, plasma) or sample extracts. more recently, biomarkers for the use of prohibited substances such as hormonal growth promoters have been identified as potential screening methods for these substances. physicochemical methods, such as lc or gc with various detectors, may be used, also, as screening methods. in the particular case of antimicrobials, microbiological or inhibitory substance tests are widely used for screening. in such tests, using multiple plates/organisms or kit formats, the sample or sample extract is tested for inhibition of bacterial growth. if, after a specific period of incubation, the sample inhibits the growth of the bacteria, it is considered that an antibacterial substance is present in the sample, but the specific substance is not identified. given that this is a qualitative analytical method, a misinterpretation of the results cannot be ruled out, and some false-positives can occur. microbiological methods are screening methods that allow a high sample throughput but limited information is obtained about the substance identification and its concentration in the sample. when residues are found in a screening test, a confirmatory test may be carried out, which normally involves a more sophisticated testing method providing full or complementary information enabling the substance to be identified precisely and confirming that the maximum residue limit has been exceeded. with the significant developments in liquid chromatography and in mass spectrometry over the last decade, confirmatory methods are largely ms-based, using triple quadrupole, ion trap, and other ms techniques. indeed, with current methodology in a modern residue laboratory with good ms capability, much of the two-step approach of screening followed by confirmatory testing has been replaced by single confirmatory testing. this has been made possible by the greatly-enhanced separation capability of ultra-high-performance liquid chromatography (uplc), coupled with sophisticated ms detection systems. the parallel growth in more efficient sample extraction/clean-up methods is an integral part of these advances in confirmatory methods and such chemistries produce rapid, sometimes (semi)-automated procedures providing multi-residue capability. techniques based on highly efficient sorbent chemistries for solid-phase extraction and techniques such as quechers are examples of these advances. such combinations of uplc-ms/ms methods with appropriate sample extraction/cleanup technologies allows for unequivocal, quantitative determination of a broad spectrum of substances in a single analytical method. particularly in the area of prohibited substances, the power of ms techniques is being applied to identify hitherto unknown compounds and to identify exogenous from endogenous substances. for example, time-of-flight ms provides accurate mass capability and may allow for retrospective analysis capability from the ms data. the technique of gc-combustion-isotope ratio ms has been utilised to study the c/ c ratio of substances in urine samples, where, for example, such c/ c ratio differs significantly between endogenous (or natural) testosterone and exogenous (or synthetic) testosterone. liver examination at slaughter is the most direct, reliable, and cost-effective technique for the diagnosis of fasciolosis. moving to a visual only meat inspection system would decrease the sensitivity of inspection of fasciolosis at the animal level; however, it would be sensitive enough to identify most if not all affected herds. therefore the consequences of the change would be of low relevance. the feedback to farmers of fasciola hepatica detected at meat inspection should be improved, to allow farmer information to support rational on-farm fluke management programmes. quantitative analysis indicated that the proposed changes to the meat inspection system would not affect detection of welfare conditions; however, for leg and foot disorders and sheep scab a combination of the two surveillance components (clinical surveillance and meat inspection) were found to be more effective than either one of the surveillance component on its own. qualitative analysis suggested that the proposal for shortened transport and lairage time would be beneficial to improving the welfare of small ruminants. food chain information should include animal welfare status in order to complement the slaughterhouse surveillance systems (ante-mortem and post-mortem inspection) and the latter could be used to identify on-farm welfare status. other recommendations on biological and chemical hazards would not have a negative impact on surveillance of animal diseases and welfare conditions. in this mandate, the ahaw panel and the ad hoc working group (wg) are focusing on the implications for animal health and welfare of any changes to the current meat inspection (mi) system, as proposed by biological hazards (biohaz) and contaminants in the (contam) panels. "implications for animal health and welfare" relates specifically to monitoring and surveillance of animal diseases and welfare conditions during mi (that is, inspection at the slaughterhouse before and after slaughter, in this document referred to as ante-mortem (ami) and post-mortem (pmi) inspection, respectively). therefore, the objective of this work was to identify possible effects and to assess the possible consequences on surveillance and monitoring of animal diseases and welfare conditions if the proposed changes in the mi system were applied. apart from its contribution to assuring public health, current mi also contributes to surveillance and monitoring of animal diseases and welfare conditions (efsa, ) , and may be an important component of the overall monitoring and surveillance system. further, mi offers the only opportunity for monitoring some diseases and welfare conditions at certain stages of a control and eradication programme. therefore, any change in mi system that could lead to a loss of sensitivity (reduced probability of detection) may compromise the surveillance efficacy. in the case of animal welfare, ami and pmi also play a role in surveillance and monitoring of the welfare of farmed animals, and, moreover, it is the only place to assess poor welfare during the transport of animals to the slaughterhouse. small ruminants are subjected to different periods of feed and water restriction, handling and transport prior to arrival at the slaughterhouse. ami begins with the observation of animals at the time of unloading from the transport vehicle and the purpose is to determine whether animal welfare has been compromised in any way on the farm and during handling and transport. welfare conditions such as fitness to travel, prevalence of injury, lameness and exhaustion, and the cleanliness of the animals are ascertained during ami. certain other welfare conditions such as bruising may not always be detectable during ami, but become visible during routine pmi. welfare conditions related to foot and leg disorders would be detectable only if the animals are observed during walking, e.g. unloading or moving to lairage pens, and are also less likely to be detected by visual examination during pmi. when mi detects apparent defects or abnormalities, incision of the relevant joints, tendons and/or muscles could be necessary to determine the presence as well as the severity of foot and leg disorders. implications for surveillance and monitoring for small ruminant health and welfare of changes to meat inspection as proposed by the biohaz panel the proposed modifications to the mi system that may have implications for animal health and welfare (see biohaz appendix a for full details), include: shorter transport and lairaging, which may be beneficial in terms of reducing crosscontamination of pathogens salmonella spp. and human pathogenic escherichia coli (see biohaz appendix a, section . ). the changes to address prioritised hazards not currently detected by mi will focus on improved collection and use of relevant food chain information (fci), including the use of harmonised epidemiological indicators, to provide information for categorisation of farms, which can be used for, for example, risk-based ami, logistic slaughter and/or decontamination (see biohaz appendix a, sections and . ). omission of palpation and incision in animals subjected to routine slaughter at pmi. if abnormalities are detected during visual inspection, palpation and incision should be carried out separately from the routine inspection of carcasses to prevent cross-contamination) (see biohaz appendix a, section . ). to assess the impact of proposed changes to the current mi on the overall sensitivity for surveillance and control of animal diseases and welfare conditions, a quantitative assessment was performed based on expert opinion and modelling. an external consortium (comisurv), under the provision of an efsa procurement, performed this work. the detailed methodology, as well as results and conclusions, together with assumptions and limitations of the modelling, can be found in the comisurv report for small ruminants mi (hardstaff et al., ) . these limitations include: the parameters for the probability of detection were based on expert opinion and therefore there is uncertainty as to the true range of these values. limited number of experts to cover the different subjects needed for the assessment. variations in the epidemiological situation of the disease and welfare conditions between countries. a brief description of the methodology that was applied is given below. an initial long list of small ruminant diseases and welfare conditions relevant to the eu was established, based on general textbooks, references, and expert opinion. wg experts filtered this list using a decision tree, following previous methodology and criteria developed for previous opinions (efsa biohaz, contam and ahaw panels, , ) . a disease or condition was retained on the list by the wg experts using the following criteria: a high likelihood of detection of a disease or welfare condition at mi, at the age that animals are presented at the slaughterhouse (if likelihood was medium, low, or the condition was undetectable, it was excluded from the list). the disease or welfare condition is considered relevant to the eu (conditions not occurring in eu member states (ms) were omitted). the condition is relevant to animal health and welfare (conditions mainly relevant to public health were not retained, as they should be dealt with by the biohaz panel). the slaughterhouse surveillance component (ami + pmi) provided by mi is significant for the overall surveillance of the disease or welfare condition (if there are other surveillance or detection systems much more effective and highly preferable to mi, the conditions were removed from the list). the final list of conditions established by the wg experts to be assessed by the comisurv consortium is shown in table . a total of twenty conditions (eleven diseases and nine welfare conditions) were included in this list. a stochastic model to quantify the monitoring and surveillance effectiveness of mi in small ruminants was developed. a definition of a typical and a mild case for each of the diseases and welfare conditions listed in table was provided by the comisurv experts. typical cases were by definition detectable cases and express more developed clinical signs than mild cases. typical cases were defined as the clinical signs and/or lesions that are expected to be observed in more than % of affected or infected small ruminants arriving at slaughter. the mild case of a disease or welfare condition is the form that could be seen at the early stages of the disease or at some point between the subclinical (and without pathological lesions that are observable through the meat inspection process) and the fully developed form (i.e. "typical" form). a mild case is neither typical nor non-detectable. the animal will probably present more subtle signs than in the typical case. as an example, a typical case of echinococcosis would show hydatid cysts in the liver and in the lungs, and a mild case would have a low number of small cysts in liver and lungs. the proportion of affected animals presenting as typical or mild cases, as well as the non-detectable fraction was estimated (see comisurv report for details). the most likely detection probability, as well as th and th percentiles (the probability intervals) of the output distribution of ami, pmi, and ami and pmi combined were derived for each of the conditions in table , both prior to and following suggested changes to the mi system as proposed by the biohaz panel. the inspection protocols in the current and visual only systems are compared in table . the probability of detection was calculated for both detectable cases (mild and typical), and for all cases (referred to as stage in the comisurv report). mastitis x a stage -all diseases and welfare conditions listed were evaluated with regards to their probability of being detected at mi. b stage -for selected diseases and welfare conditions, surveillance by mi was to be compared with clinical surveillance. as inspection tasks aimed to detect orf do not change in a visual-only system, orf was not further discussed. in addition, for three of the selected diseases and two welfare conditions, considered to be more adversely affected in terms of probability of detection following the proposed changes to the mi system, further modelling was implemented to quantify the effectiveness of monitoring and surveillance in the overall monitoring and surveillance system, both prior to and following suggested changes to the mi system (referred to as stage in the comisurv report). the objective for exotic diseases (i.e. foot and mouth disease (fmd), was to evaluate the probability of detecting at least one infected case of infected small ruminants by slaughterhouse inspection relative to other surveillance system components (component sensitivity), which for the purpose of this opinion was clinical surveillance. for endemic diseases (fasciolosis, lower respiratory tract infection) and welfare conditions (leg and feet disorders including foot rot, sheep scab) the objective was to calculate the case-finding capacity i.e. the proportion of infected or affected animals detected by the surveillance components (detection fraction) during both slaughterhouse and clinical surveillance. note that the word surveillance as used in this opinion does not imply that any action is taken to capture, or act upon, the information that is collected. it merely points to the potential of these systems to be used for such purposes. the detection probability for each disease and condition using the current mi system and the visual only system is shown in table (detectable cases) and table a of annex (all cases, including subclinical cases not detectable at slaughterhouse). a change to visual only inspection caused a significant reduction in the probability of detection (i.e. non-overlapping % probability intervals, stage ) during mi of detectable cases of fasciolosis (with a % reduction in detection probability) and tuberculosis (tb) in goats ( %) ( table ). when all cases were considered (see annex , table a) , the change to a visual only pmi protocol resulted in a clear reduction in the detection probability of three diseases, tb in goats (with a % reduction in detection fraction), fasciolosis ( %) and pulmonary adenomatosis/maedi-visna ( %)), although none of these reductions was significant when the overlap of probability intervals was considered. values for the probability of detection at ami and for the two proposed pmi scenarios for all cases (detectable and non-detectable cases combined) were also determined for welfare conditions (table and annex , table a , respectively). the probability of detection was significantly higher for ami than pmi for broken bones, diarrhoea, leg and foot disorders, partial prolapses/hernias and sheep scab. a change in pmi protocol to a visual only system did not significantly reduce the detection of any welfare conditions. pmi had a significantly higher probability of detection than ami for mastitis. combined slaughterhouse probabilities of detection were higher for detecting cases of many welfare conditions than when the slaughterhouse inspection components were considered separately (table and annex , table a ). where this was not the case, i.e. the detection probability of the combined mi process yielded equal values as either ami or pmi on its own. this was due to the fact that the experts had agreed that the respective welfare condition could not be detected at all with the one of the two mi steps. therefore the results of the combined mi are solely based on the results of either ami or pmi. for three welfare conditions (arthritis, broken bones and poor body condition), the pmi of detectable cases with visual only protocol also reduced the detection probability, although this was not significant. when considering all cases (annex , table a ), the probability of detection for the combined inspection was lower than for detectable cases. the change in pmi protocols led to a slight reduction in the detection probability of two welfare conditions (arthritis and poor body condition), yet none of these reductions were significant when the overlap of probability intervals was considered. the probability of detection for all detectable cases of diseases and welfare conditions at ami, pmi (two proposed scenarios-current and visual) inspection scenarios with the most likely (ml), th and th percentiles. shaded rows indicate diseases identified as having a significant reduction in detection probability in the visual-only scenario. for the two welfare conditions (leg and foot disorders and sheep scab) included in the overall surveillance analysis (stage ), a combination of the two surveillance components (clinical surveillance and mi) was found to be more effective (detecting a higher fraction of affected animals) than either one of the surveillance component on its own. however, the change in pmi protocol did not greatly affect the detection fraction of these welfare conditions (table ) . with regard to epizootic diseases, clinical surveillance (detection of clinical signs) had a greater sensitivity for detecting fmd than slaughterhouse surveillance, and the sensitivity increased with an increase in population size (table , stage ). a change to a visual only system would not have a negative impact on sensitivity of detection. a qualitative assessment was conducted, based on a literature review and expert opinion from the wg members, for the diseases identified as having a significant reduction in detection probability of detectable cases in the quantitative assessment of the comisurv report (tb in goats and fasciolosis) and welfare conditions. therefore routine inspection, unlike inspection for btb in the bovine, does not differ substantially from the visual only mi being proposed. information regarding the presence of tb is not specifically recorded at pmi. the comisurv report relating to the contribution of meat inspection to animal health surveillance in sheep and goats investigated the probability of detection of specific diseases and welfare conditions for three scenarios: one for inspection tasks as currently required by the legislation; one with visual inspection only; and one in which risk categorisation based on a hypothetical public health risk formed the basis for subsequent inspections. according to the comisurv report, the most likely values for the proportion of non-detectable, mild and typical cases elicited by experts for tb in goats were . , . and . , respectively. the pmi had a significantly higher probability of detection of tb in goats than ami for detectable cases and all cases, and the reduction in the probability of detection of tb in goats was significant for visual only pmi. the probability of detection (most likely values) of tb in goats (table for detectable cases and annex , table a for all cases) for combined ami and pmi was . ( . for all cases) changing to . ( . for all cases) for visual only, which represents a % reduction. as is the case with btb in bovines, the contribution of mi surveillance of tb in small ruminants is to support the detection of flocks/herds with tb, and the detection of individual animals with tb is merely the first step in improving herd surveillance. since more than one sheep or goat per flock/herd is likely to be slaughtered per time period (e.g. per year), the flock/herd probability of detection is a function of the individual animal sensitivity, the number of animals slaughtered from the herd and the within-herd prevalence of tb. for any given flock/herd, the flock/herd sensitivity will increase with the number of animals slaughtered. officially tuberculosis free (otf) status, however, is not available for small ruminants as it is for bovine herds, so the herd status is important in controlling tb in small ruminants, but not in substantiating freedom from tb. for tb in goats, the results from the comisurv report suggest that a change from the current inspection to visual only will reduce the probability of detection for detectable cases. a qualitative risk and benefit assessment for visual only pmi of cattle, sheep, goats and farmed/wild deer, commissioned by the uk food standards agency (fsa) (fsa, a), considered the absolute and relative animal health risk of tb in small ruminants as negligible when moving to a visual only pmi system when compared with the current legal requirements of inspection for sheep and goats (regulation (ec) / ). the main reason to reach this conclusion is that the current legal pmi requirements for small ruminants are mainly visual and do not require the incision of the lungs. incision of lymph nodes are required if in doubt after the initial visual inspection. considering that the majority of positive submissions to government labs in the united kingdom are associated with lesions in the mediastinal and bronchial lymph nodes, it is likely that the most frequent tb-like lesions in small ruminants (as described above) are not detected under the current traditional pmi requirements, which are initially visual, and therefore nor would be by visual only inspection. this lack of sensitivity is aggravated by the current commercial speed of slaughtering lines and the limited time available to carry out the inspection of carcases and offal. in the united kingdom, tb in non-bovine farmed animals is rare. small ruminants are not considered to represent a significant reservoir of the disease for other animals or to be of any significance in the persistence of btb in cattle. although small ruminants are considered as spillover hosts, it is still possible that severely infected sheep and goats could act as vectors of infection for other domestic and wild animals. in these circumstances, on-farm identification of possible sick small ruminants by farmers and a differential diagnosis from other respiratory disease and necropsy examination of lungs and relevant lymph nodes by farm veterinarians are the most effective control activities. fasciolosis (liver fluke) in small ruminants has a world wide distribution and is caused by the trematode parasite, fasciola hepatica. the direct losses due to fasciolosis are mortality, liver condemnation and reduced growth rate. disease results from the migration of large numbers of immature flukes through the liver, from the presence of adult flukes in the bile ducts, or both. liver fluke can infect all grazing animals, but is most pathogenic in sheep (armour, ) . the incidence of liver fluke is inextricably linked to high rainfall and is particularly prevalent in years when summer rainfall is high, which facilitates the survival and proliferation of the snail intermediate host and infective parasite stages present in the environment (ollerenshaw, ) . changes in recent epidemiological patterns, due to climate change, have resulted with increasing prevalence in northern european countries and the survival of fluke on pasture over winter, exposing sheep to infection for long periods (daniel and mitchell, ) . there have been increasing reports of liver fluke disease over the last decade in countries such as the united kingdom and ireland, most likely due to higher than average rainfall and temperatures through the seasons, and greater stock movements (taylor, ) . in southern european regions, for example in spain, the infection of snails could occur throughout the year, with a higher infection rate at the end of summer-autumn and at the end of the winter, and sheep eliminating eggs throughout the year (manga et al., ) . prevalence studies in the north-west of spain have indicated a liver fluke infection rate of approximately % of sheep flocks (ferre et al., ) . regulation (ec) / requires that domestic sheep and goats going for human consumption must have visual inspection of the liver and the hepatic lymph nodes, palpation of the liver and its lymph nodes, and incision of the gastric surface of the liver to examine the bile ducts. liver examination at slaughter is the most direct, reliable, and cost-effective technique for diagnosis of fasciolosis (urquhart et al., ) . reliance upon clinical signs to diagnose fasciolosis may result in low detection rates (rojo-vázquez et al., ) . mi is a convenient means of confirming a suspected herd or flock infestation, assessing the extent of infestation or determining the effectiveness of anthelmintic treatment (kissling and petrey, ) . pmi can confirm acute and sub-acute liver damage with liver enlargement, caused by the presence of immature flukes. animals suffering from chronic fasciolosis show a deterioration of the carcass, cholangitis, biliar occlusion and hepatic fibrosis with adult fluke present in bile ducts. besides the liver, other organs and structures can be found damaged, such as periportal and mesenteric lymph nodes that are enlarged and exhibit a brownish colour (rojo-vázquez et al., ) . mckenzie's study ( ) compared the new zealand inspection procedure (observation and palpation of livers) with the european community procedure (observation and incision through the gastric surface of liver to examine the bile ducts) and found that the new zealand method detected fewer truly infected livers, but misdiagnosis by inspectors gave more false-positives. the gastric surface incision procedure has a specificity of % and sensitivity of . % to . % (kissling and petrey, ) . this underlines their importance in animal disease surveillance and the importance of the present mi technique in liver fluke surveillance. effective disease monitoring systems are essential to the provision of reliable information on diseases to producers, thereby protecting a nation's agricultural system and its potential for production (glosser, ) . information on fluke infestation at herd level allows farmers to develop and implement control programmes that can attempt to reduce risk factors and recommend the use of drugs in a more strategic fashion (fairweather, ) . edwards et al., ( ) demonstrated that one-third of farmers would improve their animal husbandry if informed of the mi findings for their lambs. the comisurv report on the contribution of mi to animal health surveillance determined that there would be a significant difference in detection rates between the current and the visual only mi techniques (a probability of . of all detectable cases by current method compared with . by the visual only method). a reduction in liver fluke surveillance by the use of a less sensitive mi procedure will reduce the quality of information available for producers and thereby directly impact animal health and welfare. the quantitative analysis (see comisurv report) of detection levels for welfare conditions indicated that none of them will be significantly affected by the proposed changes to mi. however, the results also revealed that when both ami and pmi were considered, the probability of detection was high for most welfare conditions. it was also evident that detection of two welfare conditions, i.e. leg and foot disorders (including foot rot) and sheep scab, would be more effective when a combination of clinical and slaughterhouse surveillance systems are used. leg and foot disorders in sheep are caused by either infectious conditions, i.e. interdigital dermatitis (also known as scald), foot rot, contagious ovine digital dermatitis, or non-infectious conditions such as white line disease (shelly hoof), granulomas, foot abscesses, interdigital fibromas, and foreign bodies such as thorns, wire or soil balls (kaler and green, ; conington, et al., a conington, et al., , b fawc, ) . overgrown and misshapen hooves are also attributed to lameness in sheep and erysipelas can cause outbreaks of lameness in lambs. the importance of routine feet examination in sheep health management is well documented (hodgkinson, ) . the farm animal welfare council (fawc) suggested that there is adequate legal protection for sheep suffering from lameness as the european transport regulation ec/ / prohibits the transport of unfit animals, and specifically includes those that are "injured or present physiological weaknesses or pathological processes" and, in particular, are "unable to move independently without pain or to walk unassisted". the fawc also recommended that the surveillance of lameness in sheep should be undertaken by the uk government, in conjunction with farm assurance schemes, to determine trends in lameness over time, which would also apply to other mss where the prevalence of lameness is high (e.g. more than % of flocks being affected at national level). lameness in dairy goats is also a common welfare problem and abnormalities detected in the united kingdom were horn separation, white line lesions, slippering, abscess of the sole, foreign bodies and granulomatous lesions (hill et al., ) . interdigital dermatitis has also been reported to be the cause of lameness in goats kept indoors in greece (christodoulopoulos, ). sheep scab is a skin disease caused by the mite psoroptes ovis and has been widely prevalent in europe. it is a major animal welfare, husbandry and economic problem (bisdorff et al., ; bisdorff and wall, ) . the objectives of the ami in the current hygiene legislation, regulation (ec) / , are to determine: conditions that may might adversely affect human or animal health, paying particular attention to the detection of zoonotic diseases and animal diseases for which animal health rules are laid down in eu legislation, and whether there is any sign that welfare has been compromised. council regulation ( implementation of welfare assessment protocols using appropriate animal based indicators during clinical and slaughterhouse (ami + pmi) surveillance systems would improve the welfare of small ruminants. these welfare surveillance systems should become an integral part of the food chain information (fci). sheep are thought to be tolerant of being transported and deprived of food and water for long periods (knowles et. al., ) . it is a common practice by farmers to withdraw food on the farm for several hours prior to transport of sheep / lambs to auction markets or slaughterhouses, primarily to reduce soiling. however, dehydration can be a welfare problem during long transport distances/times, especially in high ambient temperatures (knowles, ) . recovery from the effects of food and water deprivation is a very slow process and therefore lairage appears to be of very little benefit. in this regard, full recovery from hours of transport has been shown to take up to hours (knowles, ) . owing to these, the biohaz panel's proposal for shortened transport and lairage time would be beneficial to animal welfare. the eu regulation (ec) no / on the hygiene of foodstuffs requires slaughterhouse operators to request fci declarations to ensure animals entering the food chain are safe for human consumption. fci is also a good source of information to facilitate the detection in the slaughterhouse of abnormalities indicative of animal health and welfare conditions. fci is recorded at the flock/herd level, and its minimum content is described in regulation (ec) no / . fci related to primary production of small ruminant herds/flocks is based on a farmer's declaration. most mss have made available to farmers a standardised fci declaration form. a whole-chain approach to food safety, animal health and animal welfare requires slaughterhouse operators to be provided by livestock producers with information about their animals consigned to slaughter. based on the fci provided food business operators (fbos) can assess potential hazards presented by the animals and are required to act upon any information recorded on the fci declaration as part of their hazard analysis and critical control point (haccp) plan. this helps the slaughterhouse operator to organise slaughter operations and to ensure that no animals affected by disease or certain veterinary medicines enter the food chain. quality assurance schemes at primary producer level are voluntary tools operated by independent agencies or bodies to ensure compliance with given standards and regulations. these schemes increase farmers' responsibilities with regard to animal health and welfare and have potential for integration within the fci provided (oie, ) . the fci also assists risk management to determine the required inspection procedures and should be analysed by risk management and used as an integral part of the inspection procedures. the value of the fci in guiding risk management to discriminate between animals subsequently going through different types of inspection procedures should be evaluated. as for any evaluation of (pre-) screening procedures, the sensitivity and specificity of the classification should be estimated. priority should be given to improving test sensitivity, noting that (pre-) screening tests should preferably produce few false negative classifications for the sake of animal disease detection and surveillance. test specificity will largely be an economical parameter, since the subsequent inspection of all "fcipositive" animals or groups should detect any false positives not correctly identified during the fci pre-screening. regulation (ec) no / requires that data from the ami and pmi at the slaughterhouse is delivered back to the farmer/producer when the inspections reveal the presence of any disease or condition that might affect public or animal health, or compromise animal welfare. currently this feedback of information to primary producers is not fully implemented in all mss (efsa biohaz, contam and ahaw panels, concludes that the effective and efficient flow of information provides valuable information to both the farmer and the fbo and allows more targeted and effective inspection procedures in the slaughterhouse and effective interventions on the farm that should contribute to a cycle of continuous improvement with positive implications for animal health and welfare. the effectiveness of this information cycle depends on a reliable animal identification and recording system at the slaughterhouse and an information transfer system to the primary producer. the collection and communication of slaughterhouse inspection results is an opportunity to collect and use data and knowledge applicable to disease control and the effectiveness of interventions, animal production systems, food safety and animal health/welfare (garcia, ) . at national and eu level such data can contribute to disease surveillance (for the detection of exotic diseases, monitoring of endemic diseases and identification of emerging diseases) and targeted animal health and welfare interventions. therefore fci, if consistently and effectively implemented as enshrined within the hygiene package, will form an integral part of a risk-based mi system. extended use of fci has the potential to compensate for some, but not all, of the information on animal health and welfare that would be lost if visual only pmi is applied. for the fci to be effective it should include species-specific indicators for the occurrence of disease and welfare conditions. fci for public health purposes may not have an optimal design for the surveillance and monitoring of disease and welfare conditions; therefore, an integrated system should be developed whereby fci for public health and for animal health and welfare can be used in parallel, more effective. the conclusions and recommendations from the contam panel refer to areas such as the ranking system for chemical substances of potential concern and its updating, the use of fci to help facilitate risk-based sampling strategies; the inclusion of new hazards in control programmes for chemical residues and contaminants (see contam appendix b, for full details). none of these were considered to have an impact on animal health and welfare surveillance and monitoring. as shown in the comisurv assessment, a change to visual only inspection would cause a significant reduction in the probability of detection (i.e. non-overlapping % probability intervals) of detectable cases of fasciolosis and of tuberculosis in goats. clinical surveillance had a greater sensitivity for detecting fmd than slaughterhouse surveillance following the assessment by comisurv, although the sensitivity of meat inspection increased with an increase in population size. a change to a visual only system would not have a negative impact on sensitivity of detection. as shown in the comisurv assessment, the proposed changes to meat inspection would not greatly affect the probability of detection of any of the welfare conditions analysed. from the comisurv assessment, for two welfare conditions (leg and foot disorders and sheep scab), a combination of the two surveillance components (clinical surveillance and meat inspection) were shown to be more effective (detecting a higher fraction of affected animals) than either one of the surveillance components on its own. according to regulation (ec) / , current inspection in small ruminants includes visual inspection and palpation of the lungs and respiratory lymph nodes. a change to visual inspection would imply that palpation is abandoned. small ruminants are usually not subjected to official tuberculosis eradication campaigns, and farm controls are only performed on premises where cattle and goats are kept together, or in flocks/herds that commercialise raw milk. surveillance for small ruminant tuberculosis at present relies on meat inspection of sheep and goats slaughtered for human consumption, or other limited diagnostic surveillance activities. as is the case with tuberculosis in bovines, the contribution of meat inspection surveillance of tuberculosis in small ruminants is to support the detection of flocks/herds with tuberculosis. detection of tuberculosis in individual animals is merely the first step in improving the effectiveness of flock/herd surveillance, and for any given flock/herd, the flock/herd sensitivity will increase with the number of animals slaughtered. results of two recent risk assessments (comisurv report; fsa, a) show that a change from the current inspection to visual only will reduce the probability of detection of tuberculosis in small ruminants. however, the consequences for animal health were considered as negligible in the fsa assessment, due to the fact that current meat inspection does not prescribe routine incision of lymph nodes, and the only inspection task omitted will be palpation of lungs and respiratory lymph nodes. in recent years tuberculosis has been reported in small ruminants in several eu countries and most information derives from recognition of tuberculosus lesions at the slaughterhouse and from laboratory reports. although small ruminants are not considered to represent a significant reservoir of the disease for the persistence of bovine tuberculosis in cattle, it is still possible that infected sheep and goat herds could act as vectors of infection for other domestic and wild animals. therefore, surveillance and control of tuberculosis in domestic small ruminants does have consequences for the overall surveillance and control of tuberculosis. liver examination at slaughter is the most direct, reliable, and cost-effective technique for diagnosis of fasciolosis. moving to a visual only meat inspection system would decrease the sensitivity of inspection at animal level for fasciolosis, however it would be sensitive enough to identify most, if not all, affected herds. therefore the consequences of change are low (charleston et al., ) . the feedback to farmers regarding fasciola hepatica detected at meat inspection is low at present and the real risk to animal health/welfare for this disease, caused by a change to a visual only meat inspection method, is probably low. implementation of welfare assessment protocols using appropriate animal based indicators during clinical and slaughterhouse (ami + pmi) surveillance systems would improve the welfare of small ruminants. extended use of food chain information has the potential to compensate for some, but not all, of the information on animal health and welfare that would be lost if visual only post-mortem inspection is applied. food chain information is a potentially effective tool to perform more targeted ante-mortem and post-mortem inspection tasks in the slaughterhouse which may increase the effectiveness of those tasks in detecting conditions of animal health and animal welfare significance. the existing ineffective flow of information from primary production to the slaughterhouses and vice versa reduces the ability of detection of animal diseases and animal welfare conditions at the slaughterhouse and as a result it limits possible improvements on animal health and welfare standards at the farm as farmers will not be aware of the slaughterhouse findings. the conclusions and recommendations on chemical hazards were reviewed by the ahaw working group and none of them were considered to have impact on animal health and welfare surveillance and monitoring. data collected during clinical and slaughterhouse (ante-mortem and post mortem inspection) surveillance systems should be utilised more effectively to improve animal welfare at farm level. slaughterhouse surveillance of tuberculosis in small ruminants should be improved and encouraged, as this is in practice the only surveillance system available. the detection of tuberculosis in small ruminants should be adequately recorded and notified, followed by control measures at the farm level. lack of feedback of post-mortem inspection results to the farmer prevents instigation of a fluke management programme, which could be detrimental to animal health and welfare. an improvement in this feedback of information is recommended. welfare surveillance systems should become an integral part of the food chain information. an integrated system should be developed whereby food chain information for public health and for animal health and welfare can be used in parallel, more effectively provide farmers with background information on the animal diseases and welfare conditions of key concern that may affect their livestock and why it is important to provide this information to the slaughterhouse through the use of food chain information. all cases: the combination of detectable cases (mild and typical) and non-detectable cases. case-finding capacity: characteristic of a surveillance system for endemic disease, describing the ability of the system to identify infected or affected herds or individuals, so that a control action can (potentially) be taken. the detection fraction is a measure of the case-finding capacity. case type: includes detectable (mild or typical cases) and non-detectable cases. clinical surveillance: surveillance based on clinical observations in the field. combined inspection: taking into account ante-mortem and post-mortem inspection. component sensitivity: the probability that one or more infected animals will be detected by the surveillance component during a specified time period, given that the disease is present at a level defined by the design prevalence. a risk assessment of shiga toxin-producing escherichia coli (stec) in the norwegian meat chain with emphasis on dry-cured sausages. panel on biological hazards, norwegian scientific committee for food safety norwegian scientific committee for food safety konsekvenser for dyr og mennesker norwegian scientific committee for food safety great hygienic effects from more strict requirements for the sheep slaughter campylobacter excreted into the environment by animal sources: prevalence, concentration shed, and host association comparative studies on the survival of verocytotoxigenic escherichia coli and salmonella in different farm environments epidemiological investigations on campylobacter-jejuni in households with a primary infection escherichia coli o : h and non-o shiga toxin-producing e-coli in healthy cattle, sheep and swine herds in northern spain genetic diversity among campylobacter jejuni isolates from healthy livestock and their links to human isolates in spain direct detection and genotyping of toxoplasma gondii in meat samples using magnetic capture and pcr a quantitative microbial risk assessment for meatborne toxoplasma gondii infection in the netherlands evaluation of elisa test characteristics and estimation of toxoplasma gondii seroprevalence in dutch sheep using mixture models a longitudinal study of verotoxinproducing escherichia coli in two dairy goat herds prevalence and characterization of vero cytotoxin-producing escherichia coli isolated from diarrhoeic and healthy sheep and goats liver distomatosis in cattle, sheep and goats of northeastern iran subtilase cytotoxin encoding genes are present in human, sheep and deer intimin-negative, shiga toxin-producing escherichia coli o :h studies on the reservoir status of leptospirosis in gujarat updates on morphobiology, epidemiology and molecular characterization of coenurosis in sheep distinct host species correlate with anaplasma phagocytophilum anka gene clusters sheep and goat medicine zoonotic agents in small ruminants kept on city farms in southern germany outbreak of haemolytic uraemic syndrome in norway caused by stx -positive escherichia coli o :h traced to cured mutton sausages minimising the bacterial count on lamb carcases by means of slaughtering methods scvmph (scientific committee on veterinary measures relating to public health) . opinion on revision of meat inspection in veal calves. european commission, health and consumer protection directorate-general. directorate c-scientific opininos main aspects of leptospira sp infection in sheep an outbreak of escherichia coli o :h -bacteriological investigations and genotyping of isolates from food potentially human-pathogenic escherichia coli o in norwegian sheep flocks tuberculosis in goats on a farm in ireland: epidemiological investigation and control study on prevalence of klebsiella pneumoniae in meat and meat products and its enterotoxigenicity a study of the sero-prevalence of influenze-a viruses in sheep and goats risk factors for the presence of antibodies to toxoplasma gondii in norwegian slaughter lambs enteritis in sheep and goats due to yersinia enterocolitica infection epidemiology of yersinia pseudotuberculosis and y. enterocolitica infections in sheep in australia investigation of the presence of esbl-producing escherichia coli in the north wales and west midlands areas of the uk in to using scanning surveillance yersinia enterocolitica in sheep -a high frequency of biotype a nonacid meat decontamination technologies: model studies and commercial applications temporal variation and host association in the campylobacter population in a longitudinal ruminant farm study babesia microti and anaplasma phagocytophilum: two emerging zoonotic pathogens in europe and hungary seasonal variation of thermophilic campylobacters in lambs at slaughter attribution of campylobacter infections in northeast scotland to specific sources by use of multilocus sequence typing microbial contamination on beef and sheep carcases in south australia current concepts -recognition and management of anthrax -an update an outbreak of salmonella mikawasima associated with doner kebabs diagnosis of human visceral pentastomiasis pathogenicity of yersinia enterocolitica biotype a procedures in the current meat inspection of domestic sheep and goats . . criteria used for the evaluation of the likelihood of the occurrence of residues or contaminants in sheep and goats . weaknesses of the current meat inspection methodology for chemical hazards tor : adaptation of inspection methods use of a β-adrenergic agonist to alter muscle and fat deposition in lambs food poisoning by clenbuterol in portugal semicarbazide is non-specific as a marker metabolite to reveal itrofurazone abuse as it can form under hofmann conditions special issue plenary papers of the th international conference on goats recent developments in the use and abuse of growth promoters regulation (ec) no / for dapsone as an impurity in veterinary medicinal products containing sulphamethoxazole or other sulphonamides scientific opinion of the panel of contaminants in the food chain (contam panel) on request from the european commission related to zearalenone as undesirable substance in animal feed scientific opinion of the panel of contaminants in the food chain (contam panel) on request from the european commission related to aflatoxin b as undesirable substance in animal feed scientific opinion of the panel of contaminants in the food chain (contam panel) on request from the european commission related to deoxynivalenol (don) as undesirable substance in animal feed scientific opinion of the panel of contaminants in the food chain (contam panel) on request from the european commission related to the presence of non dioxin-like polychlorinated biphenyls (pcb) in feed and food scientific opinion of the panel of contaminants in the food chain (contam panel) on request from the european commission related to fumonisins as undesirable substances in animal feed opinion of the scientific panel on food additives, flavourings, processing aids and materials in contact with food (afc) on a request related to a th list of substances for food contact materials scientific opinion of the panel of contaminants in the food chain (contam panel) on request from the european commission related to pyrrolizidine alkaloids as undesirable substaces in animal feed scientific opinion of the panel of contaminants in the food chain (contam panel) on request from the european commission related to cyanogenic compounds as undesirable substances in animal feed mercury as undesirable substance in animals feed-scientific opinion of the panel of contaminants in the food chain glucosinolates as undesirable substances in animal feed-scientific opinion of the panel of contaminants in the food chain scientific opinion of the panel of contaminants in the food chain (contam panel) on request from the european commission on tropane alkaloids (from datura spp.) as undesirable substances in animal feed scientific opinion of the panel of contaminants in the food chain (contam panel) on request from the european commission on theobromine as undesirable substances in animal feed scientific opinion of the panel of contaminants in the food chain (contam panel) on request from the european commission on gossypol as undesirable substances in animal feed scientific opinion of the panel of contaminants in the food chain (contam panel) on request from the european commission on ricin (from ricinus communis) as undesirable substances in animal feed opinion of the scientific panel on contaminants in the food chain (contam panel) on perfluorooctane sulfonate (pfos), perfluorooctanoic acid (pfoa) and their salts cadmium in food -scientific opinion of the panel of contaminants in the food chain (contam panel) scientific opinion of the panel of contaminants in the food chain (contam panel) on request from the european commission on saponins in madhuca longifolia l. as undesirable substances in animal feed results of the monitoring of dioxin levels in food and feed update of the monitoring of dioxins and pcbs levels in food and feed scientific opinion on lead in food efsa panel on contaminants in the food chain (contam), a. statement on tolerable weekly intake for cadmium scientific opinion on the risk to public health related to the presence of high levels of dioxins and dioxin-like pcbs in liver from sheep and deer scientific opinion on the risk for animal and public health related to the presence of t- and ht- toxin in food and feed scientific opinion on pyrrolizidine alkaloids in food and feed scientific opinion on polybrominated diphenyl ethers (pbdes) in food scientific opinion on hexabromocyclododecanes (hbcdds) in food scientific opinion on the risk for public health related to the presence of mercury and methylmercury in food scientific opinion on ergot alkaloids in food and feed emea (the european agency for the evaluation of medicinal products) emea (the european agency for the evaluation of medicinal products), a. committee for veterinary medicinal products emea (the european agency for the evaluation of medicinal products), b. committee for veterinary medicinal products emea (the european agency for the evaluation of medicinal products), . committee for veterinary medicinal products. dapsone ( ) committee for veterinary medicinal products expert committee on food additives. chloramphenicol -toxicological evaluation of certain veterinary drug residues in food evaluaion of certain veterinary drug residues in food agriculture organization of the united nations/world health organization expert committee on food additives), . safety evaluation of certain contaminants in food who food additives series, . who/jecfa monographs , who determination of colchicine residues in sheep serum and milk using high-performance liquid chromatography combined with electrospray ionization ion trap tandem mass spectrometry depletion of protein-bound furazolidone metabolites containing the -amino- -oxazolidinone side-chain from liver, kidney and muscle tissues from pigs formation of semicarbazide (sem) in food by hypochlorite treatment: is sem a specific marker for nitrofurazone abuse? monographs on the evaluation of carcinogenic risks to humans. sex hormones (ii) iarc monographs on the evaluation of carcinogenic risks to humans. pharmaceutical drugs iarc monographs on the evaluation of carcinogenic risks to humans. some thyrotropic agents iarc monographs on the evaluation of carcinogenic risks to humans transfer of perfluoroctanoic acid (pfoa) and perfluoroctane sulfonate (pfos) from contaminated feed into milk and meat of sheep: pilot study towards a criterion for suspect thiouracil administration in animal husbandry italian babyfood containing diethylstilbestrol - years later aplasia cutis congenita in surviving co-twin after propylthiouracil exposure in utero evidence that urinary excretion of thiouracil in adult bovine submitted to a cruciferous diet can give erroneous indications of the possible illegal use of thyreostats in meat production diseases associated with inorganic and farm chemicals aplasia cutis congenita and other anomalies associated with methimazole exposure during pregnancy estrogen and its metabolites are carcinogenic agents in human breast epithelial cells the identification of potential alternative biomarkers of nitrofurazone abuse in animal derived food products opinion on the risk assessment of dioxins and dioxins-like pcbs in food. cs/cntm/dioxin/ final opinion of the scientific committee on veterinary measures relating to public health on assessment of potential risks to human health from hormone residues in bovine meat and meat products, adopted on review of specific documents relating to the scvph opinion on april on the potential risks to human health from hormone residues in bovine meat and meat products opinion of the scientific committee on veterinary measures relating to public health on review of previous scvph opinions of the mineral nutrition of livestock analysis of thyreostats: a history of years the world health organization reevaluation of human and mammalian toxic equivalency factors for dioxins and dioxin-like compounds weight increase of the thyroid gland as a tentative screening parameter to detect the illegal use of thyreostatic compounds in slaughter cattle residues of hormonal substances in foods of animal origin: a risk assessment pesticide, veterinary and other residues in food quantitative assessment of the impact of changes on meat inspection on the effectiveness of the detection of animal diseases and welfare conditions (comisurv report) implications for surveillance and monitoring for small ruminant health and welfare of changes to meat inspection as proposed by the contam panel and has also zoonotic implications. the pathological and histological findings in sheep and goats are similar to those seen in cattle these reports highlight the possible role of domestic goats and sheep as reservoirs of tb, and the need to re-evaluate the evidence for m. bovis (and m. caprae) transmission among cattle and small ruminants described the main pathological lesions in goats in the lungs in the form of abscesses ( - cm in size) with yellowish white, caseous or caseocalcareous lesions. lesions are also seen in the retropharyngeal, mediastinal or mesenteric lymph nodes and in liver, spleen and udder. lesions is sheep are very similar to those in goats, ranging from encapsulated soft, caseous lesions and encapsulated, calcified tubercles are also present in the lungs and liver in general, small ruminants are not subjected to official tb eradication campaigns; however, sheep and goats may undergo a bovine tuberculin skin test for detecting tb infection if located on premises where btb has been confirmed in cattle (subject to findings of a veterinary risk assessment), or if m. bovis infection has been confirmed in the sheep/goat flock/herd itself. if goats are kept together with cows, such goats must be inspected and tested for tb. furthermore, given that milk has it involves a visual inspection of the lungs, trachea and oesophagus, with palpation of the lungs and the bronchial and mediastinal lymph nodes both m. bovis and m. caprae cause tuberculosis in bovines and other species, including humans. further in the text, only m. bovis is mentioned regulation (ec) no / of the european parliament and of the council of april laying down specific hygiene rules for food of animal origin oj l interference of paratuberculosis with the diagnosis of tuberculosis in a goat flock with a natural mixed infection elevation of mycobacterium tuberculosis subsp. caprae aranaz et al. to species rank as mycobacterium caprae comb. nov., sp. nov liver fluke morphopathology of caprine tuberculosis. i. pulmonary tuberculosis. anales de veterinaria de murcia prevalence and regional distribution of scab, lice and blowfly strike in great britain control and management of sheep mange and pediculosis in great britain liver fluke (fasciola hepatica) in slaughtered sheep and cattle in new zealand, - foot lameness in dairy goats contribution of meat inspection to animal health surveillance in sheep and goats characterisation of white line degeneration in sheep and evidence for genetic influences on its occurrence foot health in sheepprevalence of hoof lesions in uk and irish sheep tb in goats caused by mycobacterium bovis fasciolosis in cattle and sheep outbreak of tuberculosis caused by mycobacterium bovis in golden guernsey goats in great britain scientific opinion of the panel on biological hazards (biohaz) on a request from the commission on tuberculosis and control in bovine animals: risks for human health strategies scientific opinion on the public health hazards to be covered by inspection of meat (swine) scientific opinion on the public health hazards to be covered by inspection of meat (poultry) reducing the future threat from (liver) fluke: realistic prospect or quixotic fantasy? veterinary parasitology seroprevalence of fasciola hepatica infection in sheep in northwestern spain a qualitative risk and benefit assessment for visual-only postmortem inspection of cattle, sheep, goats and farmed/wild deer an evaluation of food chain information (fci) and collection and communication of inspection results (ccir) for all species the use of data mining techniques to discover knowledge from animal and food data: examples related to the cattle industry back to the future: the animal health monitoring system -a political necessity being addressed in the united states differentiation by molecular typing of mycobacterium bovis strains causing tuberculosis in cattle and goats lameness and foot lesions in adult british dairy goats the importance of feet examination in sheep health management naming and recognition of six foot lesions of sheep using written and pictorial information: a study of english sheep farmers comparison of new zealand and european community ovine liver inspection procedures a review of the road transport of slaughter sheep effects of stocking density on lambs being transported by road evaluation of the gammainterferon assay for eradicaiton of tuberculosis in a goat herd cost-effective meat inspection: the scientific basis. surveillance kinetics of fasciola hepatica egg passage in the faeces of sheep in the porma basin a case of generalized bovine tuberculosis in a sheep tuberculosis due to mycobacterium bovis and mycobacterium caprae in sheep guide to good farming practices for animal production food safety the ecology of the liver fluke (fasciola hepatica) tuberculosis in goats aranaz a and spanish network on surveillance monitoring of animal tuberculosis, . a database for animal tuberculosis (mycodb.es) within the context of the spanish national programme for eradication of bovine tuberculosis update on trematode infections in sheep tuberculosis in goats on a farm in ireland: epidemiological investigation and control concurrent outbreak of tuberculosis and caseous lymphadenitis in a goat herd emerging parasitic diseases in sheep . fasciolidae. in: veterinary parasitology mycobacterium bovis causing clinical disease in adult sheep meat inspection, comprising both ante-mortem and post-mortem inspection, is recognised as a valuable tool for surveillance and monitoring of animal diseases and welfare conditions, and helps in the recognition of outbreaks of existing or new disorders or disease syndromes, in situations where clinical signs are not detected on-farm. meat inspection represents a practical way to evaluate the welfare of small ruminants on-farm, and the only way to evaluate their welfare during transport and associated handling. changes in the meat inspection system may negatively affect the efficiency of the surveillance and monitoring of animal diseases and welfare conditions. the focus of the animal health and welfare (ahaw) panel was to assess the implications for surveillance of animal health and welfare of the changes proposed to the current small ruminants meat inspection system by the biological hazards (biohaz) and contaminants in the food chain (contam) panels. briefly, the recommendations of the biohaz panel were related to (i) shorter transport and lairaging, (ii) improved collection of food chain information to provide information for categorisation of farms, which can be used for e.g. risk-based ante-mortem inspection, logistic slaughter and/or decontamination, (iii) omission of palpation and incision in animals subjected to routine slaughter at post-mortem inspection (if necessary, detailed inspection with potential use of palpation and incision should be carried out separately). the contam panel recommendations included (i) the ranking system for chemical substances of potential concern and its updating, (ii) the use of fci to help facilitate risk-based sampling strategies, and (iii) the inclusion of new hazards in control programmes for chemical residues and contaminants.to assess the impact of proposed changes to the current meat inspection on the overall sensitivity for surveillance and control of animal diseases and welfare conditions, the results and conclusions of a quantitative assessment, carried out by an external consortium (comisurv) under an efsa procurement, were analysed. this report assessed the impact of a change from the current small ruminant meat inspection to a visual only system in terms of detection efficiency of a list of twenty selected diseases and welfare conditions of sheep and goats. additional information from scientific literature and other recent assessments were also taken into account by experts to assess the impact of proposed changes on the detection probability and overall surveillance of animal diseases and welfare conditions.a change to visual only inspection caused a significant reduction in the probability of detection (i.e. non-overlapping % probability intervals) of detectable cases of fasciolosis and tuberculosis in goats (stage ).with regard to exotic diseases, clinical surveillance (stage ) had a greater sensitivity for detecting foot and mouth disease than slaughterhouse surveillance, and the sensitivity increased with an increase in population size. this indicates that for those countries in europe with a large sheep population, clinical surveillance is highly effective for detecting at least one case of foot and mouth disease in an infected sheep. for countries with high slaughter numbers of sheep, slaughterhouse surveillance would be almost equally efficient in detecting the disease. a change in post-mortem protocol to a visual only system did not significantly reduce the detection of any welfare conditions.in recent years tuberculosis has been reported in small ruminants in several eu countries and most information derives from recognition of tuberculosus lesions at the slaughterhouse and from laboratory reports. according to regulation (ec) / , current inspection in small ruminants aimed at detecting tuberculosis includes visual inspection and palpation of the lungs and respiratory lymph nodes. a change to visual inspection would imply abandoning palpation, which is the reason for this reduced detection. surveillance of tuberculosis at the slaughterhouse for small ruminants should be improved and encouraged, as this is in practice the only surveillance system available. the detection of tuberculosis in small ruminants should be adequately recorded and followed at the farm level. detectable cases: cases that are detectable by routine meat inspection procedures. they will express a range of combinations of clinical and pathological signs. a proportion of detectable cases will fit the definition of the typical case and a proportion will be milder cases.detection effectiveness: the proportion of animals with lesions (i.e. detectable by visual inspection, palpation and/or incision) that are actually detected.detection fraction: the proportion of infected or affected units that are successfully detected by the surveillance system.mild cases: the mild case of a disease or condition is the form that could be seen at the early stages of the disease or at some point between the subclinical and the fully developed (i.e. "typical") form. a mild case is neither typical nor subclinical. the animal will probably present more subtle signs than in a typical case. mild cases fit the mild case definition validated by experts.monitoring: investigating samples or animals in order to obtain information about the frequency of disease or infection as it varies in time and/or space.non-detectable cases: cases that are beyond the detection capacity of current meat inspection protocols. these will often be early cases at a stage where distinct clinical signs have not yet developed, but they can be cases with mild infection that leads to only subclinical conditions, without pathological lesions detectable by meat inspection.non-overlapping probability intervals: indicates that scenarios differ significantly from each other.overall surveillance system: includes several components, such as slaughterhouse surveillance and clinical surveillance. stage : assessment of the probability of detection at meat inspection. the objective of stage modelling was to estimate case type-specific (for typical and mild cases) as well as overall probabilities of detection at meat inspection.stage : assessment of the relative effectiveness of meat inspection within the overall surveillance system by comparing meat inspection with other available surveillance methods.typical cases: cases that are, by definition, detectable cases and express more developed clinical signs than mild cases. they fit the typical case definition provided by the experts, which is defined as signs and/or lesions that are expected to be observed in more than % of affected or infected of animals seen at the slaughterhouse. key: cord- -nclkfw h authors: donno, dario; mellano, maria gabriella; cerutti, alessandro kim; beccaro, gabriele loris title: chapter nutraceuticals in alternative and underutilized fruits as functional food ingredients: ancient species for new health needs date: - - journal: alternative and replacement foods doi: . /b - - - - . - sha: doc_id: cord_uid: nclkfw h abstract a diet containing high levels of fruit has been associated with a lowered risk of chronic diseases as, in addition to their vitamin and mineral content, they also contain various compounds with health-protective effects, in particular antioxidant and antiinflammatory compounds. wild plant species are of interest to the food industry because of their ability to replace synthetic chemicals and nutraceuticals; however, the nutritional, economical, and sociocultural values of some neglected and underutilized natural resources have not yet been fully exploited. some of these less well-known and underutilized fruits, which have the potential to provide novel sources of health-promoting agents, are presented in this chapter (i.e., asimina triloba (l.) dunal, crataegus azarolus l., lycium barbarum l., morus nigra l., and amelanchier canadensis (l.) medicus). underutilized fruits could represent an opportunity for growers to gain access to these special markets where consumers place emphasis on high contents of nutrients that are capable of preventing degenerative diseases. the development of specific horticultural models for nutraceutical fruit production could be an interesting opportunity to obtain a highly standardized raw material for fresh or derived products. the health benefits of different foods or diets. many are unwilling or unable to follow dietary guidelines, which is perhaps not surprising as dietary reference values take little or no account of today's busy lifestyles (hardy, ) . the concepts of nutraceuticals, dietary supplements, functional foods, medical foods, and dietary supplements are confusing and the terms are often used interchangeably. nutraceuticals are described as products extracted, purified, or produced from a plant, animal, or marine source (e.g., antioxidants from blueberries, elk velvet, or fish oils), or produced from dried, powdered, or pressed plant material. they have a demonstrable physiological benefit or provide protection against chronic diseases (prabu et al., ; srivastava et al., ) . dietary supplements have more defined health roles, as vitamins, minerals, herbs, botanicals, amino acids, and other dietary substances are intended to supplement the diet by increasing the total dietary intake of these ingredients (roberfroid, ) . dietary supplements are not intended to treat or cure disease (gibson and makrides, ) whereas nutraceuticals are used in the prevention or treatment of diseases. the concept of functional foods is different from that of nutraceuticals and they can be defined as food products that are used in the standard diet to provide beneficial health effects in addition to the traditional nutritional effects (whitman, ) . it is possible to link the key concepts (i.e., health, technology, and nutrition) with the main players in the functional food research and development process (i.e., food technologists, nutritionists, and specialists) ( fig. . ). the combination of skills possessed by these different players is essential for the development of innovative nutraceutical products. these products must present higher quality standards (and organoleptic properties) compared to corresponding conventional products and aim to maintain well-being (bigliardi and galati, ) . a diet containing high levels of fruits and vegetables has been associated with a lower risk of chronic diseases because, in addition to their high vitamin and mineral content, these foods also contain compounds with health-protective effects, in particular antioxidant and antiinflammatory compounds (donno et al., b) . in plant biochemistry these molecules are secondary metabolites (i.e., chemical compounds produced within the plants that are not directly involved in the normal growth, development, or reproduction of the organism). some are found to defend against diseases, predators, ultraviolet radiation, parasites, and oxidants; some facilitate the reproductive process (e.g., serving as attractive smells and coloring agents); and others are important for interspecies competition (kaur and das, ) . these same metabolites provide beneficial health and wellness effects in humans and animals. evidence from epidemiological, in vitro, in vivo, and clinical studies has consistently demonstrated that a diet rich in plant foods can reduce the risk of some degenerative diseases including diabetes, obesity, inflammatory disorders, cardiovascular complications, and cancer (cheung and mehta, ) . inflammation is a protective measure produced by an organism to eliminate an injurious stimuli. the use of antiinflammatory substances can be an effective tool in the therapeutic treatment of diseases; in this context, medicinal plants and their isolated compounds are used globally in folk medicine to treat different inflammatory conditions (de cassia da silveira et al., ) . in the continuous search for new natural bioactive antiinflammatory molecules, fruits are increasingly being seen as a rich source due to their essential oils and their isolated components, the monoterpenes (dell' agli et al., ) . moreover, polyphenols are the most abundant bioactive compounds reaching values of g/day in the diet, approximately -times higher than vitamin c intake (arts and hollman, ; scalbert et al., ) . the quantity and quality of polyphenols in plant foods may vary significantly according to intrinsic and extrinsic factors such as plant genetics, soil composition, growth conditions, stage of maturity, and postharvest conditions (jeffery et al., ) . the dietary intake of phenolics is greatly affected by the eating habits and preferences of individuals (shahidi and ambigaipalan, ) . simple phenolics (i.e., hydroxycinnamic acid conjugates and flavonoids) are important constituents of fruits, vegetables, and beverages. these compounds show a wide range of antioxidant activities in vitro and are thought to exert protective effects against major diseases such as cancer and cardiovascular disease (rice-evans et al., ) . in the plant kingdom, antioxidant compounds can range from simple molecules (e.g., vitamin c and phenolic acids) to highly polymerized compounds (e.g., tannins). phenolic compounds can be divided into many different classes ( fig. . ); however, bigliardi, b., galati, f., . innovation flavonoids and phenolic acids are the most abundant in plant materials (tabart et al., ; tabart et al., ) . these low molecular weight secondary metabolites exhibit excellent antioxidant properties. moreover, organic acids are also considered as antioxidants with multiple uses in pharmacology (eyduran et al., ) ; however, their specific mechanisms of action can vary depending on both the structure and the chemical environment (komes et al., ) . nutraceuticals on the market today consist of both traditional and nontraditional foods. traditional nutraceuticals are natural whole foods with new information about their potential health qualities. many (if not most) fruits, vegetables, grains, fish, dairy, and meat products contain several natural components that deliver benefits beyond basic nutrition. even tea and chocolate have been noted to contain beneficial-health attributes in some studies. conversely, nontraditional nutraceuticals are foods resulting from agricultural breeding or with added nutrients or ingredients (prabu et al., ) . wild food plants have become very important for the food industry as they can be used to replace synthetic chemicals and nutraceuticals (sadia et al., ) ; however, the nutritional, economic, and sociocultural potential of neglected and underutilized natural food resources have yet to be fully exploited and are suffering from a lack of research interest (beccaro et al., ; donno et al., ) . for example, data on the antioxidant properties of several plant resources, in particular plants not used in nutrition and medicine, are still lacking. therefore studies on these plants may be of interest in the search for novel sources of natural antioxidants, functional foods, and nutraceuticals (donno et al., c) . many alternative and underutilized fruits such as asimina triloba (l.) dunal, crataegus azarolus l., lycium barbarum l., morus nigra l., and amelanchier canadensis (l.) medicus are presented in this chapter as novel sources of health-promoting agents. the pawpaw (a. triloba l. dunal) is a tree fruit native to the temperate woodlands of the appalachian region. it belongs to the annonaceae family, which includes genera and over species. a. triloba is the only temperate species as the rest of the family thrives in tropical or subtropical climates. during the growing season, the pawpaw has a whitish to light-green color that turns yellow-brown at maturity . the ripe fruit is highly aromatic and the banana-like flesh surrounds two rows of large bean-shaped brown seeds. pawpaw fruits were traditionally consumed by native americans, then by european explorers and settlers, and today they are consumed by local populations in rural areas. despite some consumer and professional interest, the high perishability of the fruit has been a major factor in slowing the development of this fruit in a larger market (mclaughlin, ) . pawpaws contain significant levels of phytochemicals and unique compounds that may promote health. the fruits are comparable to apples and oranges since they are rich in polyphenolic compounds, vitamin c ( - mg kg − ), magnesium ( - mg kg − ), iron ( - mg kg − ), copper ( - mg kg − ), and manganese ( - mg kg − ). their antioxidant activity may also be comparable to that of more extensively studied fruit. moreover, pawpaw fruits are also a good source of potassium ( - mg kg − ), essential amino acids (mean value of mg kg − of protein), riboflavin ( . - . mg kg − ), niacin ( - mg kg − ), calcium ( - mg kg − ), phosphorus ( - mg kg − ), and zinc ( - mg kg − ). they are comparable to other important tropical fruits; for example, they contains levels of polyphenols that are similar (caffeic acid and vitamin c) or higher (ellagic acid, ferulic acid, and quercetin) than mango (mangifera indica l.). the levels of antioxidant compounds are also similar to other tropical fruits such as guava, papaya, banana, and ananas (kobayashi et al., ; kral, ) . some alternative food medicines and products that contain extracts of pawpaw (e.g., paw paw cell reg, graviola max, royal graviola, and graviola liquid extract) have been reported to exhibit antitumor efficacy in animal models and in a limited number of clinical studies (coothankandaswamy et al., ) . azarole fruits (c. azarolus l.) have attracted attention in the food, nutraceutical, and medical fields because of their widely reported health benefits (e.g., they reduce the risk of cardiovascular diseases). the systematics of the crataegus genus have been problematic because of hybridization, introgression, polyploidy, and apomixis. considerable revisionary work has led to a substantial reduction in the number of species that can plausibly be recognized as crataegus, with global estimates now suggesting there are - species, which is a much more manageable number to handle in studies of chemical variation within the genus (bahri-sahloul et al., ) . crataegus fruits and flowers are used for medicinal purposes; specifically, the fruits are not only consumed fresh and dried but are also used to produce jams, marmalades, and syrups. the weight of the fruit ranges from to g and they are variable in size (up to mm diameter) and color (yellow to bright red to black). there are - large seeds in the center of each fruit and each contains on average g of total sugar, . mg of total acidity, mg of vitamin c, mg of ca, mg of p, mg of fe, mg of k, mg of mg, . mg of cu, . mg of mn, mg of na, g of protein, and g of carbohydrate per g (bignami et al., ) . crataegus species. their high contents of flavonoids, proanthocyanidins, catechins, phenolic acids, essential oils, and terpenoids explains their use as natural therapeutics in the treatment of neurodegenerative diseases, some types of cancer, disorders of the immunological system, and cardiovascular diseases. extracts from crataegus spp. exert a wide range of pharmaceutical properties, especially on the cardiovascular system, including cardiotonic, antiarrhythmic, hypotensive, hypolipidemic, and antioxidant activities. the use of fruits in the treatment of heart ailments dates back to the late s and numerous laboratory tests and clinical trials have demonstrated their efficacy in the treatment or prevention of cardiovascular diseases (belkhir et al., ) . goji is a solanaceous deciduous shrub native to china, tibet, and other parts of asia, and its bright orange-red ellipsoid berries are - cm long. the two closely related species, l. barbarum l. and lycium chinense miller, have been historically used as food and medicinal plants in china and other asian countries. their highly similar anatomy and tissue structure makes differentiation based on morphological and histological analyses very delicate. the most common name for the goji berry is "wolfberry," and it derives from the character "gou" as it is related to the one that means wolf. the fruits are collected from late summer to autumn, dried in the shade until the skin shrinks, and then exposed to the sun until the outer skin becomes dry and hard and the pulp remains soft (donno et al., a (donno et al., , a . lycium fruits are a rich source of nutrients and phytochemicals including organic acids, sugars and polysaccharides, carotenoids (zeaxanthin), vitamins (i.e., vitamin c, vitamin b complex, and vitamin e), flavonoids, phenolic acids, minerals, trace elements (i.e., zinc, iron, calcium, selenium, germanium, and phosphorus), amino acids (including eight essential amino acids), alkaloids, and fats (amagase and farnsworth, ) . studies indicate that the goji fruit has positive effects on aging, neuroprotection, general well-being, metabolism and energy expenditure (i.e., glucose control in diabetics), glaucoma, immunomodulation, and cytoprotection, as well as having antitumor and antioxidant properties. l. barbarum and l. chinense fruits are widely used in traditional chinese medicine and they can also be sold as dietary supplements or classified as nutraceuticals for prolonged and safe use (donno et al., b) . some authors report that the health-promoting agents in goji fruit might confer beneficial health effects by alleviating oxidative stress and counteracting free radicals (donno et al., b; potterat, ) . lycium spp. fruits are most often incorporated into complex herbal preparations at - g/ g of dried material. if decoction is used then scientific references indicate a dosage of - g/ ml of goji, equivalent to - g of fresh berries. research recommends ml of decoction four times daily ( ml/day), which is equivalent to approximately g of fresh berries. goji has been used as a food and herbal medicine for over years without any toxic effects; however, there have been two case reports of possible interactions between goji fruit tea and warfarin (coumadin) (amagase et al., ; larramendi et al., ) . the mulberry (morus spp., moraceae family) has become domesticated over thousands of years, adapting to tropical, subtropical, and temperate zones in the northern hemisphere, and growing in a wide range of climatic, topographic, and soil conditions. there are species of morus (about known cultivars) including the white mulberry (morus alba l.), black mulberry (m. nigra l.), and red mulberry (morus rubra l.). m. nigra has juicy fruits with a nice color and a unique, slightly acidic flavor (donno et al., c) . mulberries are sweet fruits and they play an important role in the food industry due to their high levels of bioactive compounds (mulberry fruits can vary in terms of their chemical composition and antioxidant properties). for this reason, mulberries can be considered as a good source of nutrients and antioxidant compounds (especially anthocyanins and polyphenols) and they can also provide nutritionally useful amounts of minerals (liang et al., ) . mulberry trees have historically been cultivated for their leaves, which can be used as food for silkworms. mulberry fruits are currently consumed as both fresh and processed products (e.g., juices, fruit salads, and dried fruits) due to their nutritive value. the production and consumption of mulberry fruits is rapidly increasing, largely due to their aromatic taste, nutritional value, and biological activities. one of the most important bioactive constituents of mulberries are the anthocyanins. these pigments have dual value: first, they constitute an integral part of the sensory attributes since their levels and various forms pertain directly to the coloration of the final product; and second, they are thought to possess diverse biological properties and therefore are considered as secondary metabolites with potential nutritional value. several researchers have studied the contents of phenolics (i.e., flavonoids and anthocyanins) and carotenoids in mulberry extracts (sánchez-salcedo et al., ) . mulberry fruits are traditionally used as worming, hypoglycemic, emetic, or laxative agents. in chinese herbal medicine the mulberry fruit has been used as a folk remedy to treat several diseases including oral and dental diseases, diabetes, hypertension, arthritis, and anemia. several studies have confirmed that mulberries may have positive health effects in humans due to their phenolic composition, and this is especially true for people with type diabetes mellitus. similarly, mulberry leaves have also shown promising biological effects (calin-sanchez et al., ). the genus amelanchier (family rosaceae) is subdivided into approximately species (e.g., amelanchier alnifolia, amelanchier arborea, and a. canadensis) and is widespread in north america and in parts of europe and asia. a. canadensis, also known as the shadblow serviceberry, ripens in early june and is widely used in the landscape trade. the serviceberry is native to north america (western and north central united states, alaska, and western canada), but is less well-known and rarely grown in europe (except scandinavian countries) despite its edible fruits, frost resistance, and decorative value (stushnoff, ) . the maroon-purple fruits of a. canadensis are similar to those of a. arborea (i.e., glabrous, wax-coated pomes of - mm diameter). in the last two decades there has been growing interest in using the sweet serviceberry in the food industry in fresh fruits, pies, pastries, preserves, jams, jellies, spreads cereals, and snack foods, in particular in canada and the united states (michigan). the fruits have also been added to cider, wine, beer, and tea (cazares-franco et al., ) . the important health benefits of serviceberries, especially their ability to act as a good source of minerals (e.g., manganese, magnesium, iron, calcium, potassium, and copper) and carotenoids (e.g., lutein), has been emphasized in the literature. moreover, the fruit is also rich in nutraceutical compounds, especially phenolic compounds (e.g., anthocyanins, chlorogenic acid, catechins, and rutin). amelanchier spp. seed oil may serve as a potential dietary source of tocopherols, sterols, and unsaturated fatty acids (juríková et al., ; ozga et al., ) . indigenous north americans used different parts of the serviceberry plant for medicinal purposes; for example, in canada the fruits were used as a juice for treating stomach and intestinal ailments. eye drops and eardrops were also prepared from ripe serviceberries. the boiled bark can be used as a disinfectant while the root infusion can be used to prevent miscarriage after injury. native american communities also prepare a tea from the twigs to administer to women after birth, while a tonic from the bark is given to women after delivery to hasten discharge of the placenta. moreover, several cultivars of amelanchier spp. were found to possess free radical scavenging activity (due to their relatively high anthocyanin content) and antiviral activity against enteric coronavirus. finally, serviceberry fruits show antidiabetic properties (due to their aldose reductase inhibitor activity) and exhibit the ability to regulate lipid metabolism and energy expenditure (bakowska- barczak and kolodziejczyk, ; bakowska-barczak et al., ) . the type of sample determines the sampling protocol and how the samples are handled. the main considerations are the degree of homogeneity of the material and the possible variation in the compound content, not only between different materials but also between different samples of the same material. the cultivar, origin, season, and growth conditions will also affect the bioactive content (nedović et al., ) . it is essential that the sampling protocol and the number of collected samples reflects the composition of the whole sample. the time between sample collection and analysis should be as short as possible and the protocol should minimize any effects that may cause undesirable losses prior to analysis (mitra, ) . therefore identification is an important step in the collection of wild plants, even if it is often overlooked by the nutraceutical companies: in the european market only % of food product plants are collected in germplasm repositories (fowler, ) . moreover, an individual plant species may have different cultivars with different genetic characteristics, chemical compositions, and health effects on the efficacy of the final product and consumer health (kerslake and menary, ) . the fruit harvest period can vary across different sampling sites and years (dvaranauskaitė et al., ; lakusic et al., ) . the development of tree species is also influenced by natural factors (endogenous or exogenous) as well as by human factors. these factors can influence the chemical composition of plant organs and the respective derived products (tibaldi et al., ). food quality is not only dependent on intrinsic characteristics (i.e., genetic factors) but is also closely linked to the pedoclimatic conditions in the collecting area. indeed, plants growing in more suitable areas have greater potential in terms of product quantity and quality (vegvari et al., ) . knowledge of environmental characteristics, such as the best pedoclimatic conditions for plant development, can help identify the best raw material to be used for fresh plant material and derived functional foods (rates, ) . each species has its own requirement in terms of altitude, latitude, mean temperature, average annual rainfall, light availability, and physic-chemical soil properties. climatic conditions have direct effects on the physiological processes and phenology of the plant (e.g., growth, flowering, and fruit ripening) thus they can also affect the availability of essential metabolites for the biosynthesis of active compounds (vegvari et al., ) . a plant can almost completely lose the ability to synthesize specific bioactive molecules outside of its own habitat (vv.aa., ). therefore the use of advanced agrotechniques alongside dedicated genetic improvement allows tree species to fit better with the cultivation site and can also improve the final product quality (capasso et al., ) . assessing the chemical composition of fruit is very important because it allows the functional product to be standardized. each nutraceutical product should have the same qualitative and quantitative chemical composition in every production batch in order to maintain quality, safety, and efficacy (ong, ) . the relationship between these products and the different factors such as their origin, the pedoclimatic conditions (e.g., soil, latitude, altitude, mean temperature, light intensity, and rain frequency), and the agronomic techniques used means that standardization should first extend to the raw materials through the selection of plants with the best bioactive compound content. the subsequent transformation process and the use of standardized methods, together with analytical laboratory controls, contributes to the production of a final product with reproducible and consistent chemical and physical characteristics (i.e., bioactive compounds, appearance, texture, density, and solubility) (khan, ) . considering that food composition is affected by many factors, and that compounds are not uniformly distributed within and between samples of a given food, statistically valid sampling and sample preparation are of utmost importance to obtain representative and homogeneous samples (rodriguez-amaya, ) . the main causes of data inaccuracy are that only a single sample lot is analyzed per food and that errors are not observed between intralaboratory and interlaboratory evaluations in which the same homogenized samples are analyzed. the selection, number, handling, and preparation of samples prior to extraction are important factors that can affect data quality. sample preparation may consist of multiple steps such as drying, homogenization, sieving, extraction, preconcentration, derivatization, and hydrolysis (luthria, ) . qualitative and quantitative studies of bioactive compounds mostly rely on selecting the proper extraction method (smith, ) . extraction is the first step in the study of bioactive compounds and is crucial to the final result. the five main objectives of extraction are: ( ) to extract targeted bioactive compounds from complex samples, ( ) to increase the selectivity of analytical methods, ( ) to increase the sensitivity of bioassays by increasing the concentration of targeted compounds, ( ) to convert the bioactive compounds into a more suitable form for detection and separation, and ( ) to provide a strong and reproducible method that is independent of variations in the sample matrix (nedović et al., ) . therefore extraction should be carefully optimized and performed. the polarities of the different bioactive compounds, which vary significantly due to their conjugation status and their association with the sample matrix, determines the solvents to be used in the extraction (sasidharan et al., ) . when selecting solvents for the extraction of bioactive compounds, the molecular affinity between the solvent and solute, mass transfer, use of a cosolvent, environmental safety, human toxicity, and financial feasibility should also be considered (nedović et al., ) . optimizing the extraction parameters not only increases the extraction efficiency of the analyte of interest but also reduces the solvent consumed and the waste generated during the extraction process, thus making it more environmental friendly (chemat et al., ) . specific pretreatments (e.g., storage under modified atmosphere, microbial and chemical acidification, pasteurization, and utilization of depolymerizing enzymes) are sometimes needed to preserve the raw materials and extract biomolecules; moreover, additional procedures (e.g., rotary shaking, stirring, and sonication) can also be used to improve the extraction (laufenberg et al., ) . during identification and characterization of bioactive substances, the critical point is usually the selection of the correct measuring method. spectroscopic methods usually permit crude identification of the bioactive compounds present in food, but in most cases the specific composition can remain obscure. however, spectrophotometry remains very useful for the evaluation of antioxidant activity (table . ). detailed information about the composition of food requires additional methods, such as chromatography and mass spectrometry, to fully characterize the structures of the molecules in the samples (nedović et al., ) . technological innovation in analytical instruments has allowed increasingly sophisticated qualitative and quantitative assessments of the chemical composition of nutraceutical foods (cordell, ) . chromatographic techniques are mainly used to analyze fresh foods and derived products. chromatography offers a very powerful separation ability, such that the complex chemical components in the extracts can be separated into many relatively simple subfractions. furthermore, the recent approaches of applying hyphenated chromatography and spectrometry such as high-performance liquid chromatography-diode array detection (hplc-dad), gas chromatography-mass spectroscopy (gc-ms), capillary electrophoresis-dad, hplc-ms, and hplc-nuclear magnetic resonance (nmr), can provide additional spectral information. this is very helpful for qualitative analysis and for online structural elucidation (liang et al., ; steinmann and ganzera, ) . more specifically, hplc is currently the most widely used analytical method when combined with different detectors (e.g., diode arrays, mass spectrometry, and fluorescence) (donno et al., ) . it is regarded as the gold standard in the authentication of nutraceuticals, functional foods, pharmaceuticals, and herbal medicines due to its precision, sensitivity, and reproducibility despite its high instrumental cost, relatively long analytical time, and large organic solvent consumption (donno et al., b) . identification and quality control of the food material can be performed using marker compounds: a chemical constituent of a raw material, drug substance, or food product that is used for identification or quality control purposes, especially when the active constituents are not known or identified. the active compounds are responsible for the intended pharmacological activity or synergistic therapeutic effects (ong, ) . it is necessary to determine most of the phytochemical constituents of analyzed products to ensure the reliability and repeatability of pharmacological and clinical research, as well as to understand the bioactivities and possible side effects of active compounds and to enhance quality control (liang et al., ) . chromatography combined with a suitable detection technique offers a powerful tool for separating the individual compounds and developing a characteristic profile of the sample, otherwise known as a fingerprint. combining a chromatographic separation system online with a spectroscopic detector has become the most important approach for identifying or confirming the identity of target and unknown chemical compounds (cuadros-rodríguez et al., ) . if hyphenated chromatography is further combined with chemometric approaches, clear pictures may be developed for chromatographic fingerprints (bertacchini et al., ) . the complexity of fresh foods and derived products means that it is necessary to consider many factors for their fingerprint evaluation. the quality of a functional food is closely related to its chemical constituents and their concentrations and may vary slightly according to differences in the climate, cultivation conditions, harvest time, drying, and storage (hibbert, ) . to analyze the large amount of generated data, a variety of analytical methods have proven to be useful and versatile tools for the extraction, visualization, and interpretation of the information. in particular, pattern recognition methods as a principal component analysis allows better visualization of the information included in the fingerprints. the original variables are transformed into latent variables to summarize the systemic patterns of variation between the samples (ieri et al., ) . exploratory data analysis is easier if represented as a multivariate data table as a low-dimensional plane. sustainability is a broad concept and is considered to be ambiguous because it means different things to different people at different periods of time. as a consequence there are many different definitions of sustainable agriculture; however, most of them are connected to the three pillars of sustainability: society, economy, and environment. for example, reganold et al. ( ) summarized this concept as "to be sustainable, a farm must produce adequate yields of high quality, be profitable, protect the environment, conserve resources, and be socially responsible in the long term." there are a number of indicators that can be used to assess the environmental performance of a production system. many studies claim that indicators that consider many aspects of the environmental impact at the same time are more useful to address the complexity of agricultural systems (bastianoni et al., ) . therefore some of the most important features of an indicator are its ability to summarize, focus, and condense extensive datasets (obtained from complex environmental parameters) to a manageable amount of meaningful information (godfrey and todd, ) . life cycle assessment (lca) is defined by the international organization for standardization (iso : ) as the compilation and evaluation of the inputs, outputs, and potential environmental impacts of a product system throughout its life cycle. the origin of lca can be found in the late s within the context of american industry (hunt et al., ) and numerous studies have been carried out to adapt this method to the agricultural sector (audsley et al., ) . lca is now considered a useful tool for comparing alternative food products, processes, or services, and as the background for environmental product declaration (schau and fet, ) . the results of lcas are commonly presented as impacts in a range of different categories such as global warming, acidification, nitrification, ozone depletion, and toxicity (pennington et al., ) . nevertheless, more importance and consideration is being given to the results in single impact categories. one example is the carbon footprint, which in the lca approach corresponds to the "global warming potential." this category expresses the number of co equivalents (co eq., a collective unit for all molecules with a global warming potential) that are associated, directly and indirectly, with all stages of development of the system under consideration. the term co eq. is intended to express all greenhouse gases, with each being weighted according to their global warming potential. the advent of the carbon footprint has made lca results available to a wider audience (weidema et al., ) . food production systems have their own specific agronomic requirements. even different varieties of the same species may have unique requirements in terms of fertilizers, pesticides, water, plantation strategies, and field management, which may result in different environmental burdens (de gennaro et al., ) . one exemplary case is the growing of ancient cultivars or forgotten fruits with high nutraceutical values (donno et al., (donno et al., , . ancient cultivars are bound to the area they are grown through centuries of slow adaptation to the pedoclimatic conditions, thus resulting in lower agricultural inputs compared to introduced cultivars (bisht et al., ; jarvis et al., ) . a lower agricultural input theoretically produces a lower environmental impact; however, in order to be sure about this it is necessary to apply an environmental impact assessment method. a didactical case study was reported by cerutti et al. ( ) , in which the authors investigated the environmental burden of ancient varieties of apple in north west italy. hundreds of different cultivars of apple (malus domestica borkh.) were grown in italy until the s. after this time the proliferation of commercial cultivars caused the local germplasm to lose importance and be forgotten by growers and consumers. many ancient cultivars were gradually replaced by commercial ones with low phytochemical and nutraceutical traits. the italian fruit-growing scene underwent significant change and golden delicious is now the most cultivated variety (more than % of total orchards); however, the genetic diversity has fortunately been largely preserved thanks to germplasm repositories (donno et al., ) . while golden delicious dominates, the ancient apple germplasm of the piedmont region (northern italy) is actually represented by ∼ cultivars, almost all recently described by their nutraceutical, morphological, and agronomic traits (bounous et al., ) . the commercial appeal of traditional cultivars is related to their unique quality traits and to the claims of their lower environmental impacts due to being grown on the original agricultural land. ancient cultivars usually require fewer treatments and field operations per hectare of cultivation in comparison with foreign cultivars because they are more adapted to the pedoclimatic characteristics of the native region. cerutti et al. ( ) used lca methodology to calculate the environmental performance of grigia di torriana, magnana, and runsé cv., three ancient apple cultivars from torino and cuneo provinces. the environmental impacts of these cultivars were compared to that of golden delicious. the study was performed in accordance with the iso : standard series guidelines and with the cradle-to-gate approach as the basis for the life cycle inventory (lci) (international organization for standardization, ). data regarding orchard structure, agricultural inputs, resource consumption, and orchard management practices were obtained directly from the growers who filled in a questionnaire for the season. in order to consider minor geographical differences, the lci for each cultivar included the average of three orchards spread throughout the two provinces. environmental impacts were calculated according to several functional units. considering the impacts for growing hectare of orchard, the golden delicious cultivar showed the lowest environmental performance emitting . t co eq.; conversely, less emissions were observed in the life cycle of the three ancient cultivars (average . t co eq.). this result confirms that if low-input agricultural systems are managed properly, and are producing high-value products (including high levels of nutraceutical components), they can be more sustainable than high-input systems (cerutti et al., ) . it could be important to apply the same methodology to some underutilized fruit species (i.e., those of nutraceutical value) in order to evaluate the sustainability of their production and consumption. worldwide interest in introducing the cultivation of these tree species to promote the differentiation of the cultivated agrobiodiversity and the consumption of new functional foods with excellent nutraceutical properties could also be encouraged by the specific agronomic traits of these species that could be managed with more environmentally friendly agrotechniques (if compared with the most commonly grown fruit species), and by the possible greater sustainability of their production. research carried out in the field of natural bioactive compounds is increasing our understanding of healthy compounds that are naturally available in food, in particular in fruit. this will permit their increased use in foods (instead of artificial drugs), which will in turn increase their quality and added value. new methodologies for the extraction, purification, identification, and quantification of biomolecules using ecofriendly analytical techniques will need to be developed to improve the extraction yields (chemat et al., ; oroian and escriche, ) . with the advent of high-throughput technologies and their applications in food science, the food and beverage industries have been taking steps to transform their traditional r&d and product development processes. the food and beverage industries are now faced with a situation in which they should quickly adapt to new market demands and regulatory updates and be prepared to make expensive and risky decisions as to whether they should proceed with significant investments in the development of functional products (younesi and ayseli, ) . alternative and underutilized fruits represent an opportunity for local growers to gain access to specialized markets where consumers lay emphasis on exotic character and the presence of nutrients that are capable of preventing degenerative diseases. the creation of specific horticultural models for nutraceutical fruit production could be an interesting opportunity to obtain a highly standardized raw material for fresh or derived products. in addition, phytochemicals from these fruits could have further applications in the food industry, such as increasing the stability and shelf life of food products. studies relating to the toxicological analysis of bioactive extracts; the metabolism of bioactive compounds, their bioavailability, and bioaccessibility; and the sensorial and nutritional traits of food products with added bioactive compounds from underutilized fruits should be undertaken (ayala-zavala et al., ) . the development of new functional products with intended health claims requires concrete scientific criteria. to meet the current stringent regulations for functional products, the food industry must approach this topic using integrative approaches. integration of complex biological knowledge relevant to human health and diseases into the functional product development process could not only increase the capacity of innovative product development, but could also support informed decision making (younesi and ayseli, ) . food science is a blend of many scientific and engineering disciplines, such as chemistry, biology, agricultural science, and chemical engineering, which is applied to provide a better understanding of food and its transformation and to deliver safe and desirable food products to the consumer (smithers, ) . in addition, economic analysis of the extraction processes and marketing of natural bioactive extracts should be contemplated. if food products are to be produced for use in the nutraceutical and pharmaceutical industries, there will be certain criteria that production system must meet: for example, it must clearly be economical, environmentally safe, and not have an impact on the environment (barnes and prasain, ; cerutti et al., ) . a source of bioactive substances should be identified and cultivars of the same species must be considered in order to choose the highest and the most stable concentration of natural compounds (fowler, ; joubert et al., ) . once this source has been identified, a constant and stable supply of plant material should be secured. this means that an agronomic system for biomass production should be developed in order to allow the full expression of the genetic capability of the cultivar (kerslake and menary, ; khan, ) . moreover, climate and soil conditions should fit with the species requirements. the impact of fertilization and irrigation on the biomass production and its chemical constituents should be understood and the economic growth and cultivation of the raw material should generally be explored (lakusic et al., ) . in the future, a plant production of secondary metabolites may be controlled with different growth regulators according to good agricultural practices used in this agronomic production (donno et al., a) . the successful production of biomass should include the development of appropriate harvest techniques and storage processes and mechanization of the harvest process should be addressed in order to maintain an economic system of production (spinelli et al., ) . the integral exploitation of the entire food production supply chain could have economic benefits to producers and a beneficial impact on the environment, leading to a greater diversity of products for human consumption. these products represent a new class of functional foods 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food development key: cord- -uxuff y authors: wolfson, julia a.; leung, cindy w. title: food insecurity and covid- : disparities in early effects for us adults date: - - journal: nutrients doi: . /nu sha: doc_id: cord_uid: uxuff y the covid- pandemic has dramatically increased food insecurity in the united states (us). the objective of this study was to understand the early effects of the covid- pandemic among low-income adults in the us as social distancing measures began to be implemented. on – march we fielded a national, web-based survey ( % response rate) among adults with < % of the federal poverty line in the us (n = ). measures included household food security status and covid- -related basic needs challenges. overall, % of low-income adults in the us were food secure, % had marginal food security, and % were food insecure. less than one in five ( . %) of adults with very low food security reported being able to comply with public health recommendations to purchase two weeks of food at a time. for every basic needs challenge, food-insecure adults were significantly more likely to report facing that challenge, with a clear gradient effect based on severity of food security. the short-term effects of the covid- pandemic are magnifying existing disparities and disproportionately affecting low-income, food-insecure households that already struggle to meet basic needs. a robust, comprehensive policy response is needed to mitigate food insecurity as the pandemic progresses. food insecurity, a condition defined by limited or uncertain access to sufficient, nutritious food for an active, healthy life, disproportionately affects low-income communities and communities of color [ ] . food is a core social determinant of health [ ] and food insecurity is associated with numerous poor health outcomes in both the short and long term [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the unprecedented covid- pandemic, and the associated social and economic response [ ] (e.g., school closures, stay at home orders, business closures, and job losses) have the potential to dramatically increase food insecurity and its related health disparities among already at-risk populations. early evidence suggests that food insecurity is indeed rapidly rising above pre-epidemic levels [ ] [ ] [ ] . household food insecurity has risen from % in to % in march ; in april , % of households with a child aged and under were food insecure [ , ] . households already struggling with food insecurity may find their current situations exacerbated by covid- with fewer resources to comply with social distancing recommendations. food insecure individuals also may have less flexibility in their jobs to allow them to earn income while staying home, or may be at higher risk of losing their jobs completely, thereby decreasing (or eliminating) their incomes. these factors may put food insecure households both at higher risk of contracting covid- and of greater food insecurity due to the economic effects of covid- mitigation efforts. in addition to the long-term health and economic effects of the covid- pandemic, it is important to understand the immediate impact of social distancing measures to fight covid- on vulnerable populations who already struggle to meet their basic needs. to do so, we fielded a national survey of low-income adults in the us on [ ] [ ] [ ] [ ] [ ] [ ] march to understand the immediate effects of how covid- was impacting low-income americans and any disparities in its effects based on food security status. we designed a web-based (qualtrics) survey to measure the initial effects of covid- on low-income adults in the united states (us) in mid-march , just as some states were beginning to implement school closures and "stay at home" orders. the web-based survey was formatted to be accessible when access both via smart phones and on a personal computer or laptop. the survey was fielded using turkprime, an online crowdsourcing platform that is designed to be used for academic research [ ] . turkprime allows researchers to use quotas to recruit a sample that matches their specific needs and has been used in numerous academic studies from a variety of disciplines published in the peer-reviewed literature [ ] [ ] [ ] [ ] [ ] . in the present study, we used a census matched panel of us adults (matched on age, gender, and race/ethnicity to the overall population) and limited the sample to low-income adults with household incomes < % of the federal poverty line (fpl). the fpl is calculated based on both household size and annual household income. for example, % of the fpl for a four-person household is $ , , and % of the fpl for a four-person household is $ , per year. the annual income for a two-person household at % fpl is $ , . the survey was open to participants on - march . we invited eligible panel members to participate and participants completed the survey ( % completion rate). additional exclusions included participants who completed the survey in < min (n = ), indicated they did not live in the us (n = ), and were missing food insecurity data (n = ) resulting in a final analytic sample size of . forty-four percent of participants took the survey on a personal computer or laptop and % took the survey on a smart phone or mobile device. this study was determined to be exempt by the institutional review board at the university of michigan. food security: food security status over the past days was measured using the -item us household food security module [ ] . questions are ordered by severity and include three levels of screening for adults, and an additional level of questions only for households with children. affirmative responses to questions were summed to create a total food security score (out of for adults and out of for households with children). food security categories (high, marginal, low, very low) were assigned according to us department of agriculture scoring guidelines [ ] . the term food insecurity refers to the combined categories of low and very low food security. covid- -related basic needs challenges: we inquired about challenges related to meeting basic needs people may have faced in the early weeks of the us covid- epidemic and response. first, we asked about participants' ability to comply with recommendations to purchase two weeks of food (which was recommended by public health efforts to limit grocery shopping trip and facilitate social distancing). we also asked participants whether they had encountered any of the following challenges due to the coronavirus: the ability to feed their family, availability of household items such as toilet paper, access to healthcare, access to medications, the ability to pay bills, ability to rent or pay mortgages, whether they had been unable to work due to lack of childcare, and whether they had been unable to work due to illness. covid- -related workplace reactions: at the time of data collection, some, but not all, states had begun issuing stay at home orders and mandatory business closures. even in states without stay at home mandates, some businesses were making adjustments to operations due to covid- . we asked working adults (i.e., those with full-or part-time work outside the home) what their employer was doing to adjust to the pandemic. specifically, we asked "workplaces in the us are adjusting to the coronavirus situation in different ways. what is your workplace doing to adjust?" participants were given the following response options: nothing, my workplace is proceeding as normal; all employees are encouraged to work at home; all employees must work at home; essential employees must come in to work but others can work from home; hours are being reduced for hourly employees; my place of employment has temporarily closed due to the coronavirus; my place of employment has closed and i have been laid off; work is busier and employees need to work longer hours; other. expected impact of covid- on employment and income: we asked working adults what they expected would happen at their job if they or someone in their family became ill with covid- . response options focused on whether they would be able to stay home, whether they had vacation or sick days they could use, and what they expected would happen if they missed work due to illness. all analyses were conducted in with stata, version (statacorp lp, college station tx, usa). first, we describe the socio-demographic characteristics of the study sample overall and by food security status using cross tabulations and chi-squared tests of significant differences. next, we examine differences in covid- -related basic needs and workplace challenges (among participants working full or part time), by food security status using cross tabulations. missing data was treated using listwise deletion. significant differences by food security status were assessed using chi-squared tests. all tests were two tailed and significance was considered at p < . . the characteristics of the sample of low-income adults are presented in table . overall, % of this sample was food secure, % had marginal food security, and % were food insecure ( % low food security; % very low food security). individuals with low or very low food security were more likely to be non-hispanic black or hispanic, to have children in the home, and have less than a college education. individuals with very low food insecurity were also more likely to rent their homes, not have health insurance or have medicaid, and were more likely to be receiving snap benefits. the distribution of the sample by state of residence is shown in appendix a. table . demographic characteristics of the study sample overall and by food security status (n = ). food security status p-value high marginal low very low marital status single, never married ( ) ( ) ( ) ( ) figure shows the ability of low-income us adults to comply with public health recommendations to stock up on two weeks of food to avoid excess grocery store trips and facilitate social distancing. nearly / ( %) of food-secure, low-income adults reported being able to comply with that recommendation, compared to less than one in five ( . %) of low-income adults with very low food security. adults with very low food security were more likely to report their local stores were sold out of products, and not being able to afford to purchase an extra two weeks of food at one time. nutrients , , x for peer review of question text: "experts have recommended stocking up on two weeks of food for your household to prepare for the coronavirus. have you been able to do this? [please check all that apply. one respondent was missing data for this question and was excluded from analysis. differences within each response option by food security status are significant at p < . based on chi-squared tests. potential basic needs challenges related to covid- are displayed in figure . for every challenge asked about, food-insecure adults were significantly more likely to report dealing with that challenge, with a clear gradient effect based on severity of food security status. strikingly, . % of adults with very low food security reported not having enough food to feed themselves or their family compared to . % of adults with low food security, . % of adults with marginal food security and . % of adults with high food security. half ( . %) of adults with very low food security did not have enough money to pay their bills compared to . % of those with low food security, . % of those with marginal food security and . % of food secure adults. [please check all that apply. one respondent was missing data for this question and was excluded from analysis. differences within each response option by food security status are significant at p < . based on chi-squared tests. potential basic needs challenges related to covid- are displayed in figure . for every challenge asked about, food-insecure adults were significantly more likely to report dealing with that challenge, with a clear gradient effect based on severity of food security status. strikingly, . % of adults with very low food security reported not having enough food to feed themselves or their family compared to . % of adults with low food security, . % of adults with marginal food security and . % of adults with high food security. half ( . %) of adults with very low food security did not have enough money to pay their bills compared to . % of those with low food security, . % of those with marginal food security and . % of food secure adults. food-secure, low-income adults working full or part time ( . % of the overall sample) were more likely than their food-insecure counterparts to work in jobs that were either proceeding as normal, were busier than usual, or had closed and laid off employees. in contrast, working adults with food insecurity were more likely to have their hours reduced ( table ) . when asked what they thought would happen if they or someone in their family got sick with covid- , working adults with very low food security were less likely than their food-secure counterparts to have sick days or food-secure, low-income adults working full or part time ( . % of the overall sample) were more likely than their food-insecure counterparts to work in jobs that were either proceeding as normal, were busier than usual, or had closed and laid off employees. in contrast, working adults with food insecurity were more likely to have their hours reduced ( table ) . when asked what they thought would happen if they or someone in their family got sick with covid- , working adults with very low food security were less likely than their food-secure counterparts to have sick days or vacation days they could use, and were more likely to say they would lose their job if they missed too many days of work ( % very low food security vs. % high food security, p < . ). table . covid- effects on workplaces among low-income adults working full or part time in the us overall and by food security status as of - march (n = ). this study presents results from a national survey of low-income adults in the us in the days immediately following the first major policy steps to enforce covid- -related social distancing measures on a wide scale in the us. though large-scale school and business closures were only beginning to be implemented [ ] , we find that the effects of the covid- pandemic were already impacting low-income adults, with disproportionately negative effects for low-income adults experiencing food insecurity. this initial evidence from a time period before even greater economic effects and job losses took place demonstrate that the covid- pandemic threatens to greatly exacerbate existing health disparities related to food security status. indeed, evidence from later surveys show that food insecurity in the us has dramatically increased well beyond levels seen during the great recession [ , ] . results from this study illuminate the extent to which, very early in the covid- trajectory in the us, individuals with food insecurity were disproportionately vulnerable to the severe economic and health consequences of the crisis. our findings show that as early as mid-march , food-insecure adults currently working outside the home were at greater risk of losing their income or their jobs if they got sick from covid- . regardless of whether they get sick or their employment status, food-insecure individuals were also more likely to report expecting that they will lose income during the pandemic. for already low-income households, loss of income puts them at high risk of severe food insecurity and an inability to meet other basic needs, both of which can lead to future physical and mental health problems [ ] [ ] [ ] [ ] . compared to low-income, food-secure adults, food-insecure adults were more likely to report that they had already been laid off, and that their income would go down substantially. fifty-four percent of food secure adults reported they expected their income would remain the same compared to % of adults with very low food security (results not shown, but available upon request). subsequent massive job losses [ ] and more extensive social distancing measures [ ] after data collection ended have likely exacerbated the trends we document in our results. across the lifespan, food insecurity is associated with a range of negative health outcomes over the short and long term, including poor mental health outcomes such as depression, stress, and anxiety [ , , ] , poor diet quality [ , ] , high rates of chronic diseases such as diabetes and obesity [ , , ] , and lower overall health status [ , , ] . food insecurity is also associated with higher healthcare expenditures, in part due to the higher burden of chronic health conditions among food-insecure patients and the known tradeoffs between food and medicine [ , ] . as the covid- pandemic and the associated economic fallout progress, it will be critical for policymakers, health systems, and the public health community to proactively and comprehensively address access to food and other basic needs, particularly for populations at risk of, and already experiencing, food insecurity. failure to do so will have long-term implications for population health, health disparities, and the health care system as a whole. food-insecure adults are more likely to be people of color, with lower social standing, who have less flexible and secure jobs, and are more vulnerable to chronic stress and other basic needs insecurities [ ] . in , . % of adults in the us were food insecure; among low-income adults (< % fpl), . % were food insecure [ ] . we find that, as of mid-march, , % of adults with an income < % of the fpl were food insecure in the past days, and these individuals were more likely to be non-hispanic black or hispanic. this disparity in food security status based on race/ethnicity is an additional way in which covid- is disproportionately impacting communities of color in the us. since mid-march, adult and child food insecurity rates in the us have dramatically risen [ , ] . in our study, adults currently experiencing food insecurity were not able to buy food in bulk quantities and therefore are at greater risk of exposure to the virus (due to the need for more frequent food shopping trips) as well as being at greater risk of an acute hunger crisis (due to lack of financial resources to purchase sufficient food). in addition, as individuals already at risk for food insecurity are more vulnerable to losing their jobs, rates of food insecurity will climb higher as the pandemic progresses. direct income support, expanded unemployment benefits, and additional support for federal food assistance programs included in the cares act (passed on march ) and the families first coronavirus response act (passed on march ) are important first steps to supporting low-income families in the us [ , ] . however, longer-term support for individuals, as well as institutions and organizations that provide food, is needed. some communities are already experiencing unprecedented demand in the emergency food system [ ] , and the federal government, states, and cities are scrambling to ensure that families with children who depend on free or reduced price meals at school do not go hungry [ ] . given the scale of the pandemic and the likely duration of social distancing measures and the associated economic impacts, more support is urgently needed to mitigate the toll of covid- on the most vulnerable members of society. in particular, in addition to direct economic support to individuals, financial support for the emergency food system, greater flexibility for school systems to provide food to families, and long-term, expanded food assistance support via the supplemental nutrition assistance program (snap) are all urgently needed. expanded snap benefits were critical for providing needed support for low-income families during the great recession, and were effective at reducing food insecurity [ ] . congress and the trump administration should urgently increase snap benefits and expand eligibility for the program to help low-income families afford food during this extraordinary time. results from this study should be considered in light of some limitations. first, the web-based survey panel does not use probability-based sampling and is not nationally representative. however, the turkprime panel is national in scope, and uses census-matched quotas to achieve a sample that closely aligns with the demographics of the population in the us which mitigates some of this concern. however, because we limited our sample to households < % of the fpl (based on income and household size), and because the survey was only available in english, the demographics of our sample may be more similar to the us population overall and undercount some key demographic groups, particularly non-hispanic blacks and hispanics, non-english speakers, and immigrants. relatedly, this data was collected via a web-based survey which by definition required participants to have internet access via a computer or a smart phone. this method of data collection could also have undercounted some groups (e.g., those with very low income, without high school degrees, and those living in rural areas without broadband internet access) [ ] , likely those especially vulnerable to food insecurity. it is important to note, however, that any bias introduced from these factors would have biased results into the direction of undercounting, rather than overcounting, food insecurity and the other outcomes we document here. second, respondents could choose whether or not to participate in the survey which may introduce some selection bias. third, all measures in the study are self-reported and may be subject to a social-desirability bias. however, the fact that the survey was fielded online and was completely anonymous may mitigate this concern. fourth, this survey is cross-sectional and we cannot make any statements about causal relationship between the coronavirus and our measure of food insecurity in the past days. finally, data were collected very quickly after social distancing measures and business and school closures began to be implemented in some (but not all) states. this is a strength as we were able to capture the immediate, real-time impacts on low-income adults. however, some measures also focused on anticipated effects. it is possible that the respondents did not accurately assess the likely effect of the coronavirus pandemic on their employment and income. however, initial evidence in the weeks after our data were collected show clearly that unemployment and rates of food insecurity have skyrocketed. the longer-term effects on low-income adults in the us, and associated disparities based on food insecurity, may be better or worse than those expected by participants in this survey. it will be imperative for future research to examine the long-term effects of the coronavirus pandemic and associated social distancing measures on food insecurity and associated health outcomes, particularly among vulnerable communities that were already struggling at the start of the pandemic. the strengths of our study include the fact that we were able to collect these data so quickly after a national emergency was declared and states began implementing policies to slow the spread of covid- . our large national sample of low-income adults is another key strength as is our use of the gold standard -question usda food security screener module. the social and economic upheaval caused by the covid- pandemic is magnifying existing disparities and disproportionately affecting low-income, food-insecure households that already struggle to meet basic needs. the early effects documented in the present study are likely to continue to worsen as the pandemic continues unless extensive policy and economic supports are swiftly implemented. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. household food security in the united states err- social determinants of health inequalities food insecurity and health outcomes no food for thought: food insecurity is related to poor mental health and lower academic performance among students in california's public university system food insecurity: a key social 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dietary intake social discomfort moderates the relationship between drinking in response to negative affect and solitary drinking in underage drinkers behavioral therapy preferences in people with migraine guide to measuring household food security definition of food insecurity closures: how is each us state handling coronavirus? perception of unmet basic needs as a predictor of physical functioning among community-dwelling older adults treat or eat: food insecurity, cost-related medication underuse, and unmet needs material need insecurities, control of diabetes mellitus, and use of health care resources: results of the measuring economic insecurity in diabetes study food insecurity and health care expenditures in the united states america is in a depression, the challenge now is to make it short-lived food insecurity and mental illness: disproportionate impacts in the context of perceived stress and social isolation associations between food security status and diet-related outcomes among students at a large, public midwestern university household food insecurity as a determinant of overweight and obesity among low-income hispanic subgroups: data from the - california health interview survey food insecurity is associated with chronic disease among low-income nhanes participants food insecurity and health across the lifespan families first coronavirus response act never seen anything like it': cars line up for miles at food banks united states department of agriculture food and nutrition service. find meals for kids when schools are closed food security improved following the arra increase in snap benefits; err- % of americans don't use the internet. who are they? pew research center key: cord- -tonry ys authors: pavlovich, kathryn; henderson, alison; barling, david title: organizing for thoughtful food: a meshwork approach date: - - journal: agric human values doi: . /s - - - sha: doc_id: cord_uid: tonry ys this paper provides an alternative narrative for organizing food systems. it introduces meshwork as a novel theoretical lens to examine the ontological assumptions underlying the shadow and informal dynamics of organizing food. through a longitudinal qualitative case study, we place relationality and becoming at the centre of organizing food and food systems, demonstrating how entangled relationships can create a complex ontology through the meshwork knots, threads and weave. we show how issues of collective concern come together to form dynamic knots of interactions, how the threads within the meshwork indicate processes of movement, and how the weave suggests degrees of food system resilience—but always in flow. this theoretical approach thus provides a platform for addressing thoughtful concerns about “food matters” including the integrity of our global food system, the negative health and environmental impacts of industrialized food production, and food safety issues. in this paper, we develop the concept of meshwork to examine the informal processes of organizing within food systems. in our globally traded food industry, international and national authorities seek to maintain food security and food safety; yet, there is increasing concern that food standards are compromised and food outcomes are inequitable (blay-palmer et al. ; davey and richards ) . fraudulent production, inadequate safety practices, and negative health and environmental outcomes continue to be associated with industrialized food production and the consumption of highly processed foods (e.g. asfaw ; baker and friel ; neate and moulds ; pollan ; van bommel and spicer ) . this is despite attempts to ensure traceability and address issues of food quality, safety, and provenance through food regulation and labelling (barling et al. ; campbell ; henderson ; hoff et al. ) . nowhere is the fragility of our food supply chains more evident than in the current covid- environment, with increasing concerns regarding both the length of distribution chains and issues accessing immigrant labour. this means that the timing for a new ontological perspective based upon relationality is important as we participate in new forms of meshing local and global. thus, there are increasing calls for a more thoughtful ecological sensibility that recognizes and sustains the integrity and interaction of locally diverse and globally integrated food systems. this would enable ethical production practices, more equitable outcomes for vulnerable agricultural producers, safer distribution processes, and improved health outcomes for consumers (barling ; carolan ; mason and lang ; tansey ) . as consumers and producers respond, locally organized food initiatives (e.g. farmers' markets, food boxes, food rescue, and the slow food movement) increasingly interact with hierarchically organized global food systems in a dialectical transformation that builds horizontal (and local) as well as vertical (and global) links (davies ; gomez and bouty ; mckeon ; stock et al. ) . this move towards an ecological sensibility extends collective and individual opportunities to think about impacts at a planetary level (seyfang ) . despite this growing diversification, and the associated body of literature that documents specific initiatives in "food matters" (e.g. food justice, food sovereignty, and alternative means of production), research examining new ways of organizing within and between food systems lacks appropriate theoretical frameworks to account for a shift away from predominantly hierarchical structures. blay-palmer et al. ( ) discuss how knowledge-sharing networks might foster collective action to transform food systems, but provide less detail about how this might be achieved. we contribute to this debate by further unravelling the organizing dynamic within and between food systems through the concept of meshwork. from a meshwork perspective, food system(s) are not discrete entities with fixed boundaries; rather food production, distribution, and consumption exist as fluid and dynamic connectivities, practices, and interactions that comprise lines of flow that are woven and entangled in various relationalities. we therefore place relational connectivity at the core of the meshwork as a reflexive awareness of the nuanced, interconnected layers of meaning inherent in the paradoxes, tensions, and complexities of the lived experiences of organizing. this builds on the findings of albrecht and smithers ( ) who demonstrated that the reconnection perspective of local food systems is complex and contingent on individual preferences that go beyond normative assumptions. our research question, "how does a meshwork approach contribute to our understanding of the organizing process within and between food systems, and indicate opportunities for positive change?" is considered through a qualitative case study, out of our own back yard (ooooby) in aotearoa new zealand, an organization that delivers food boxes of primarily organic, fresh and artisan foods from local growers. as such, the ooooby case study offers a unique example of an organizing initiative that embraces food producers, food distribution, and food consumers to illustrate the complex organizing and relationality of "food matters". in this case study, we abductively and iteratively move between narrative description of our findings and the emergent theoretical framework. importantly, we contribute to a new understanding of organizing as a potentiality of relational process. from this perspective, organizing is a relational process that always has inherent potential for further reflexive connectivity, and we demonstrate some of the challenges and opportunities inherent in organizing emergent alternative food initiatives. recent research in organization studies has moved away from considering an organization as a static entity, recognizing that the term organization can refer to a continuing process of change as "becoming", as well as an entity grounded in the action of organizing (chia ; chia and tsoukas ; putnam and nicotera ; accard ) . both organization and organizing are therefore considered to be dynamic, emergent processes in which communication plays a significant role (pavlovich and henderson ) . the communicative constitution of organizing thus contributes to sensemaking (weick and sutcliffe ) , may confer authority (nicotera ) , and contribute to inscribing the material and structural conditions for agency (cooren ; gomez and bouty ) . the implications of such perspectives of organization in relation to interactions and organizing in complex networks such as food systems demand that we consider how tensions and dissensus are communicated, managed, and negotiated, recognizing that interactions are dynamic and fluid, and involve the consideration of materiality and non-materiality, as well as human agency. holt and den hond ( , p. ) claim that despite the "proliferation of organization theories", the phenomenon of organizing needs fuller attention and expression, because the ontological assumptions underlying organizing in dynamic systems remain vague. while current theoretical approaches to organizing provide a vocabulary regarding organizing, they do not foreground and privilege the fluidity and dynamic interactions that underpin how relationality enacts organizing (holt and den hond ; wahlin ) . as carolan ( , p. ) states: one of the valuable lessons… is to emphasize food's relational underbelly, which is to say that any ontological claim about "it" cannot stop at its compositional materiality…in sum, food-and how/what we feel about "it" and the feelings of care we attribute to "it|-cannot be divorced from the embodied practices, socio-institutional arraignments, and cultural conventions whence it came. to capture this shadow and informal dynamic of organizing food (the underbelly), we suggest that the concept of meshwork provides an innovative theoretical framework for understanding the weaving together of both self-organizing and hierarchical operating systems (czarniawska ; hamilton ; ingold ) , and moves beyond the consideration of food systems as discrete entities. from this perspective, the connectivity in "food matters" comprises complex relationalities that flex and flow (chia and tsoukas ) . the threads in the overall meshwork represent a complexity with a collective quality that cannot be reduced to any constitutive elements (allen and brown ; pavlovich ) , but can be woven together in different ways, with the knots and threads continuously changing, alongside the introduction of new threads in the weave. for example, wahlin ( ) uses meshwork in relation to a capital of culture initiative in umea, sweden to examine the self-organizing and performative strategizing that developed over the period of the initiative. as wahlin comments, "the meshwork provides an additional layer of interpretation that goes beyond spatio-temporal artefacts and organizational recipes. organizing and strategizing are-from a meshwork perspective-simply a never-finished business whose existence illuminates the multifarious options available in creative processes" (p. ). meshwork therefore allows for complex conceptualization and examination of ambiguities, tensions, and paradoxes, and acknowledges latour's ( ) interest in re-assembling the social world. however, rodon and silva's discussion of meshwork ( ) examines the infrastructure or "architecture" of self-organising within a complex (health) system. similarly, wahlin focuses more on the fluid relationality in the structure of the meshwork, rather than the dynamic processes of becoming and performativity, the entangling and disentangling of knots and threads. wahlin's use of the term "duality", for example, to describe "enabling" and "constraining" seems at odds with the complexity of the meshwork theoretical lens. we would argue that "enabling" and "constraining" are each mutually implicated in the other, in a dynamic dialectical relationship. the strength of meshwork over other organizing theories, such as actor-network-theory (ant) (latour ) and network analysis, is that it places relationality at the very core of the organizing process (chia ; langley et al. ) . the organizing potentiality therefore resides in a process orientation that becomes the very fabric of events and actions that constitute our phenomenological world (morin ) . network analysis has been critiqued for focusing simplistically on the relationships between actors in fields of interconnected points as unidimensional, fixed nodes; closed systems that generate knowledge, dependent on nodal density, centrality and structural configurations. hence, networks do not account for tensions, disruptions and histories, with the nodal dots making "cuts" that interrupt the flow of interconnections rather than following the lines of entanglement (hicks ) . similarly, ant's "flat ontology" has struggled to conceptualize layers such as complex social structures and agency as it ignores social processes, entrenched power relationships, marginality, multiplicity, and other perspectives ( ; munir and jones ) . ant too has been at risk of becoming too rigid, culminating in the application of ruthless semiotics to create a reality that is too simple without "sensitivity to complexity" (gad and jensen , p. ) . krarup and blok ( ) have also contended that ant's tendencies towards radical descriptivism ultimately undercut the uncertainties of social reality, with intangible and ephemeral complexity such as moral codes and social phenomena failing to be acknowledged (cresswell et al. ; krarup and blok ) . further, our meshwork approach has shared objectives with other approaches in terms of addressing some of the social factors and dynamics made invisible in more established social theorisation. bourdieu's theory of habitus takes account of context and experience, attempting to resolve the tensions between structure and agency; however, the focus is on the continuity of stable patterns of behaviour, knowledge, and practice rather than the messy loose ends and entanglements of meshwork. even the diversity of assemblage research, which places the behaviour of actors and the associated relationalities at its core (deleuze and guattari ), focuses less on the properties and behaviour of the whole in its examination of the parts. our focus, then, is on meshwork as a relational ontology that addresses the processes of emergence and becoming. meshwork entanglements are conceptualized as multidimensional knots, taking consideration of the more complex ontology required for a more thoughtful, moral and ecological sensibility. klenk ( , p. ) explains that "life is lived not within the perimeter of the network, but along lines that open even as they get entangled with others". in a meshwork approach, threads within one "system" therefore become intertwined with other threads and knots in other 'systems' to weave a whole world of mutual involvement, continually ravelling (and unravelling) within an overall meshwork to grow or "issue forth" along the interwoven lines of their emergent relationships, histories and future trajectories. in this paper, we examine how a meshwork lens contributes to a deeper understanding of the emergent processes of organizing within and between dynamic "food matters". our inter-disciplinary approach moves beyond a simplistic examination of local food initiatives to consider how they are organized through relationality. we contribute to the literature on food systems in global contexts by extending the concept of meshwork to conceptualize the challenges and opportunities faced by emerging forms of organizing food, adding to insights on knowledge sharing (e.g. blay et al. ) and reconnection by small scale producers (e.g. albrecht and smithers ) . as elsewhere in the western world, aotearoa new zealand has a variety of food initiatives in response to challenges within global food contexts. in this paper, we focus on a single case study (stake ) , out of our own backyards (ooooby) as part of a wider research programme that examines the challenges and opportunities provided by emerging food initiatives. ooooby delivers food boxes of primarily organic, fresh, and artisan foods from local growers to customers in specific regions of aotearoa new zealand (and in sydney, australia; and fresno, california, usa); it intends that profits from each local hub remain in the local region and contribute to the development of a healthy, sustainable food supply. ooooby is one of the emergent food initiatives that uses online software to organize food distribution and is disrupting traditional food distribution systems. critically, it is also one of the few food distributors that has maintained its delivery service during the . week covid- lockdown in new zealand. ooooby collects customers' orders and sources the required produce from growers, packs the boxes, and then delivers them to the customer's door. ooooby puts smallscale farming at the heart of building sustainable ways of organizing food (www.oooob y.org). the aim is to build more integrity for food initiatives within local economies and provide better value for money for the consumer. ooooby supports local jobs with fair returns to producers (with a % return rather than the standard % from supermarkets); provides fresher food, organic where possible; and reduces the environmental footprint-less packaging, less food waste (picking only the produce that is required), and less food miles (sourcing locally). ooooby differentiates itself from a franchise way of operating through being an enabler of local food networks. its purpose is to provide the technology hub, with local communities being empowered to operate their hubs how they see fit. eian (the ooooby software developer) said: people don't buy an ooooby franchise. if they are committed, believe in the mission and they are capable of setting up a hub then the only start-up cost is their own wages. no money comes to us other than the % of revenue administration fee. ooooby began operating from a converted shipping container in october in auckland, new zealand with customers, and has delivered more than , food boxes to , homes (www.oooob y.org). by early , it had grown to include seven hubs: auckland/waiheke island, hamilton, tauranga, taranaki, and christchurch (new zealand), and sydney (australia) and fresno (usa). however, at the time of writing, ooooby has reduced to four hubs: auckland and christchurch (new zealand), sydney (australia) and fresno (usa). our case study thus offers us both longitudinal and context variability data. we chose a qualitative research design to examine the narratives, living interactions, and meanings of actors who (re) create organizing patterns such that relationships become centre-stage (cunliffe ) . this approach involves an examination of the interweaving of relational spaces and connections (ricoeur ) (the threads, knots and "spaces-in-between" in meshwork) and recognizes the "messy" nature of qualitative research (edwards and stamou ) that seeks to rethink the boundaries of theory development and knowledge sharing. we began this research by contacting the founder of ooooby in , and he was enthusiastic to work with us on our research. our data collection comprised a series of semistructured interviews with the directors, software developer, hub developer, hub managers in tauranga and hamilton, and local growers supplying ooooby. we also conducted second interviews with the founder and the managers of the three hubs in tauranga, hamilton and christchurch to document more recent changes in the organizing process and practices. each interview lasted approximately - min and involved a conversation about the aims, values, and vision for ooooby, the challenges and constraints, and the day-to-day policies and practices. we followed ethics protocols approved by the university ethics committee; we have used pseudonyms for participants; each interview was audio recorded and transcribed, and we took additional notes during the interviews. our method of analysis is abductive and iterative. abduction involves "reading and re-reading data, looking for 'surprises'" (cunliffe and eriksen , p. ) . it involves identifying data that is unexpected or paradoxical to develop new theoretical concepts to explain these findings. we began by reading our data for initial themes (braun and clarke ) that acknowledge the historicity of the data, its contextuality, its biographic content, and its socio-political intentionalitythe content-what was, what is, and what might be (fine et al. ) . we engaged with the multiple interpretations and transformative possibilities perceived both by participants and by us as researchers. we then drew on our meshwork theoretical approach to re-consider the data regarding the performance of organizing, the relational sense-making, and the complex materiality of the organizational infrastructures and regulatory regimes. as we worked further with the data we reflected on the intricacy of the meshwork metaphor to understand the relationality of the knots and the "spaces-in-between" that provide the possibility of both constraints and transformative opportunities in this fluid and dynamic food initiative (carolan ) . returning to the data enabled us to gather further insights into how these tensions were played out or resolved (baxter and montgomery ; putnam et al. ) as we reconceptualized the complex web of interactions that comprise the fabric of entanglements of local, national, and global food production and distribution at play. with our purpose being to explain the complexity of organizing food, relational connections are central to our analysis, highlighting the call for a more thoughtful relational ontology; an awareness of how organisms relate to each other and to their environment through lived experience (carolan ; pavlovich ) . analysis of our first interviews revealed relational connectivity that became knots of selforganization in the meshwork weave. we conceptualise these knots as evolving entanglements of threads representing common issues, relationalities, and materialities. the purpose of these knots is that they provide commonalities around which organizing occurs. we describe the first, and most significant knot -an ecological sensibility. eian, (ooooby software developer) summed up his reasons for engaging in an ecological sensibility: i joined ooooby for environmental reasons, using less energy to get food from place to place, so lower food miles and a lower carbon footprint. but as i became more involved, i started to think about fair returns for the farmer. i know i could never be a farmer; i can't get up at am and work so physically hard like they do. but their prices can be unilaterally changed by supermarkets. "this is how much you will get for your broccoli". i would completely understand if they gave up and got a cushy job in the city. but then there would be no food. so that's an even stronger drive for me now. other participants noted similar alignment of values through environmental and social stewardship that contributed to developing this knot. for instance, rob (founder of ooooby) references alignment with an ecological sensibility that includes economic and food quality/safety issues: the fundamental problem with our food system is that it uses too much energy, it's not fair, there are too many leaks in the supply chain, and it's too easy for people to get squeezed without anyone else in the supply chain knowing about it. also, the food is flavourless and it's not good for you because it is pumped with all this stuff. it has lost its humanness. similar thoughts were expressed by mary, a hub manager, "i remember even as a child that i wanted to be part of something that creates a more fair, just, and environmentally conscious world so i've always been involved in community activities". these relationships facilitate the formation of a close entanglement, or knot, that characterizes an ecological sensibility (e.g., fair wages for farmers, environmental stewardship, organic food) that contributes to a more thoughtful approach to production processes. we can see from the above quotes how similar values from different relationalities become interwoven as they tangle and flex into a meshed interdependency. the continuing entanglement of these knots can form a stabilizing relational conduit that characterizes the value alignment of the meshwork, in this case an ecological sensibility. such entanglements demonstrate how these knots act as organizing conduits to bring matters of collective concern together. as carolan ( , p. ) has commented in relation to issues in food studies, "bringing these care relationships into focus is to therefore enact a more enlivened notion of "value", and make problematic those practices that seek to strip caring relationalities from our understanding of the productive world". the emergent nature of these relationalities can enhance the development of new connections that can become new threads and lines within the meshwork, as noted by (donna), a hub manager: we were having discussions with another foodbox when ooooby came to us. when i sat down and evaluated both the systems, the other one was purely business, commercial, and was all about the science of the food, all about the sugar content in the food… they wouldn't touch organics and told me it was rubbish. whereas ooooby was all about local foods, developing local suppliers, and using organics whenever possible. the decision was easy. rob continued in discussing this alignment: our goal is to be able to resource smaller players into organics and then have a channel to market that is easy and accessible for them so that it works for them to sell to the local market. they need to state their intentions by how they're going to market their product and also how they're going to grow the product, what are the inputs. we definitely don't want to be funding people who are going to go throw all these toxins back in the soil and do the same old thing. this "value alignment" explains how threads can be suspended from one knot to another. they are continually "becoming" and can grow in complexity as new threads become part of the entanglement or knot. the thread in this case is access to markets and distribution, and the above quote illustrates how, through relationality, the thread becomes woven into the knot. the above quotes also highlight how an ecological sensibility can seek to transform problematic organizing processes as more thoughtful intentions align with the values within the meshwork. yet, knots may equally comprise complex relationalities with dissimilar agendas and modes of being that are in conflict with each other, sometimes where a single thread becomes dominant and constricts the knot, limiting the relationalities and new connections that can be formed. for example, supermarket chains with preferred supplier contracts often limit the possibility of local food producers gaining access to larger local markets (humphrey ). to some extent, ooooby exists to circumvent the possibility of such constricted knots, seeking to fill the "spaces-in-between" within globalized food systems, creating new lines, threads, and entanglements. seen as a meshwork, the food system is characterised by evolving entanglements, weaving together to form new knots, and the formation of new lines. while our data illustrated knots of collective concerns, they were formed by independent movement through lines of interaction and travel forming threads in the meshwork. we focus briefly on two, much smaller knots-system autonomy and food surplus-to demonstrate relationality as the movement of threads, and lines. one of the aims of ooooby is to facilitate the development of autonomous food initiatives that are adaptive to local contexts for food resilience. being autonomous helps local communities self-organize within their local context. to achieve this, relationalities that focus on specific practices, such as financial transparency, enhance local autonomy while also ensuring equity and consistency among the hubs. rob commented: we want each hub to have as much autonomy as possible, but we need transparency to ensure that we are a collective. we want our growers to be paid %, when the industry average is %; the hubs have to show their financials so everyone can benchmark across each other. everyone's salaries will be available so that some level of equity is apparent. autonomy implies that while each hub is independent, there is movement through and among the threads to ensure consistency of practices. connection among the hubs occurs as knowledge sharing moves from hub to hub through the threads that create the knot of autonomy. to encourage this alignment, ooooby endeavours to make their infrastructure organizing processes-their lines of flow-transparent. for instance, they ensure everyone knows that they charge the hubs % of revenues that comprise of: % for intellectual property (ip) and software development, % finance and management services, and % marketing. eian also spoke about "a self-organizing sort of philosophy", and "working towards our own obsolescence". he commented: what i would love to see is a way where it is much easier for ooooby operations to spring up organically with less input from us, where people could very easily access all of the tools that they need so that it becomes very simple to set up the ooooby hub. this example (system autonomy) demonstrates how knots were linked and tangled through meshwork interactions between, among and through the various threads. the threads enacted movement along lines of flow, and the knot facilitated consistency among the hubs for local autonomy. hence, these relationships were messy trails of becoming rather than restricted movements along static connections. our third example is a small knot (food surplus) created from previously dangling threads; that is, relationships that had not yet formed but held the material possibility. in this case, ooooby often has left over food surpluses that are not sent out in boxes to customers. by creating relationships with charity organizations such as the city mission, kaivolution, and food rescue to give away this surplus food, these dangling threads could form a knot through these new relationships, which again aligned with meshwork values. as mary, a hub manager stated, this new thoughtfulness is "helping people out who need it". this example illustrates how threads can grow into new spaces, ravelling and unravelling in a dynamic process of weaving and knotting. in this way, relationships can be seen as movement, always emerging, as they cluster and strengthen together along lines of flow-rather than being seen as part of a linear infrastructure such as a network. this emerging knot demonstrates how threads can begin to bundle into new spaces, and how the meshwork can continue to evolve by weaving in dangling threads. our analysis of the first series of interviews also examined the interactions influencing the overall meshwork weave, with two "yarners" emerging that impact on weaving the ooooby meshwork. klenk ( ) describes yarning as entanglements that twist the fibre to give it strength and durability, or what we would consider to be meshwork resilience. again, these entanglements are related to the multiple and diverse points in the weaving of threads and lines in which similar knots emerge from common relationalities. the first yarner we identified was variation and redundancy that acts to twist the weave. with its aim to "reverse local organic food from being the icing on the cake, to being the cake itself" (rob, ooooby founder), ooooby relies on many local producers. rob stated, "we [ooooby] may be the common hub in the middle but we expect the players feeding into it will typically be small scale cottage industry. we want to encourage private local food production". local food production will vary in local contexts, because it aims to be responsive to local needs. stemming from this variation in the weave of local producers is the notion of redundancy. rob further explained: as our hub system is replicated, there will be more support and encouragement for someone who's got a problem to go to multiple places for it to be solved rather than some central middle, central repository of information. we have an example of this happening now. in auckland, evelyn is going away on holiday and the sydney guys are going to cover a lot of her work so we've got this redundancy built in. we've also got training happening so we've got auckland training fresno in california. the more hubs we get the more points of support that there are. these practices demonstrate how the multiple and varied meshwork threads self-organize through positive interpretations of redundancy. the flows along the threads replicate information gathering and sharing by running up and down the lines-with the yarner (variation and redundancy) twisting the overall mesh of the weave. bergson ( ) claims that such small-scale heterogeneous connectivity creates difference-in-kind, the source of novelty and differentiation. the scope and depth through diversity of producers can provide support for self-organization and resilience through the complexity and fluidity of threads within the weave. thus, this yarner may strengthen the associated knots and provide resilience in the weave. we compare this with a more formalised hierarchy that follows a productivist ideology (lawrence et al. ) with a central knot and tight systems and connections between them. this tighter weave is characterized by low cost production, little slack and redundancy, and becomes less resilient to change. the mainstream global food system, involving complex regulations, industrialized food production, long-distance distribution infrastructure, and corporate supermarket chains might be said to provide typical examples of such formal hierarchies. such tight weaves with little redundancy and flexibility limit the possibilities for large linear supply chains to be responsive to local needs. the second yarner that impacted on the weave in relation to ooooby was the low level of regulation. because most of the produce handled is fresh and whole food, at the outset there was minimal direct regulatory involvement. rob confirmed: nz's regulatory system is pretty relaxed compared to the states and australia. plus, we don't process any food so we don't need to comply with any food processing regulations. mostly, we just handle raw food and there is no actual license required to do that. we are only audited for safe handling practices. other food, like honey and jam, is packaged and the suppliers have to comply, not us. one of the suppliers commented, "i am not certified to supply a supermarket; but i don't need anything for the markets and foodboxes". nevertheless, a hub manager, mary, stated that she personally visits the local growers every year to ensure that they are organic and/or spray-free, implying a personal code of practice and the enactment of relationships that ensure oversight of supplier practice. the low level of regulation infrastructure is thus a yarner that actually enables the strengthening of the meshwork that the ooooby system is a part of. "i can tell immediately if sprays have been used. we've all got to be honest for the system to thrive", she said. these yarners-variation and redundancy, and simple regulation-emerge from the multiple and varied threads and knots that twist the weave in various ways. we suggest that for ooooby, these yarners create a loose weave with multiple relational entanglements-a flat rather than a hierarchical means of organizing-and they are the source of meshwork resilience. the small-scale heterogeneous connections create overlapping functions that in turn create opportunities for both substitution and renewal. the relationality that emerges from this connectivity enhances the resilience of the loose meshwork weave as it supports the transfer of best practice throughout ooooby through the ongoing movement among meshwork threads. our second set of interviews gives a longitudinal lens on meshwork relationality, demonstrating how the process of organizing is always an impulse to change (accard ; ingold ) , "becoming" something else (chia and tsoukas ) , and temporal (bakker et al. ) . our more recent contact with ooooby participants suggests that ooooby meshwork has changed and become less resilient than expected. the tauranga and hamilton ooooby hubs are now "serviced" from the auckland team and the taranaki hub is no longer operating; although, christchurch is still self-sufficient, as are the hubs in fresno and sydney. a variety of issues has meant that the smaller local hubs were no longer viable for local producers; they have proven difficult to manage and they have not been able to maintain/grow customer numbers. effectively, ooooby has downsized from seven to four hubs, and refocused on hubs in large cities. ooooby is experiencing the tension between needing to be a hierarchy (auckland servicing other hubs) and wanting hubs to be self-organizing, autonomous and locally adaptive (as in christchurch, fresno and sydney). there is a stratification process occurring that characterizes consolidation, acknowledging broken threads and a tighter weave that changes the meshwork texture. this demonstrates a shift in the meshwork weave, some "unknotting" resulting in loose threads, and the reinforcing of key knots-economies of scale-that are more typical of mainstream food supply systems. the original vision of infinitely replicable, autonomous and self-organizing hubs exists in tension with the materiality of managing supply and demand-not evident in -and the changing entanglements and relationalities created partly by changes in various material and relational contexts. changes in the operating context for ooooby have proved challenging as the regulation yarner has twisted the weave in a new way-always becoming. the introduction of the food act , which came into force on march , represents a change in the "weave" of the regulatory environment for the food system in aotearoa new zealand, and demonstrates how the materiality of regulatory demands created mesh-work. mesh-work is seen as the sometimes arduous, but always reflexive process of weaving together new materialities and relationalities through movement among and between threads. for example, the act takes a new approach to managing food safety; it requires even small-scale food producers to register as a business, develop a food control plan, and become "verified" if they do not sell directly to the customer; for example, at the farm gate or farmers' market (see https ://www.mpi.govt.nz/food-safet y/food-act- /). this regulatory change is costly and time consuming, meaning that many small, local suppliers selling through ooooby could not afford to become registered,. the waikato hub manager, donna, confirmed: we could only source stuff from registered producers, and for people (suppliers) who were just selling us their surplus it just wasn't going to work. i think when the food act came in that was like… oh my gosh… okay, what's next? similarly, another hub manager, hannah, commented on how the new regulations created a uniform material context that changed how ooooby was able to manage supply and demand: it [the food act] was a nightmare; we were panicking that we were going to be doing something illegal. if you are an ooooby customer, you are getting a box with different things supplied by different people and because it comes through ooooby, an online retailer basically, we had to comply with the act…. if you were just delivering produce to a place and packing it in a box you are low risk under the food act. but the minute i cut a pumpkin, i go up to risk level three and i have to do one million other things that are very onerous. this challenged one of the original philosophical premises on which ooooby was founded: working with small food producers to be responsive to the needs of local communities: mesh-work then refers to how the processes of organizing-as becoming and relationality-are enacted for meshing to occur. such "work" may be either challenging and frustrating or productive and creative, or both. if these processes are fraught, and the work needed creates too much conflict or is too challenging, then the meshwork weave can break down, or the original lines of knots and entanglements continue to privilege specific threads and thus constrain emerging relationalities. it also became evident that customers used to the continuous availability of globally sourced food expected to be able to customize their weekly food boxes, and hub managers in taranaki, tauranga and hamilton struggled to find sufficient, regular supplies of locally-sourced food that met the individualized demands of their customer base. paradoxically, as one of the ooooby directors, kevin, commented, "in order to grow the local grower base you've got to have a customer base". the knot related to an ecological sensibility shared by ooooby hubs was inconsistent with the complex relationalities introduced by growing the customer base, demonstrating broken threads. rob, confirmed the demise of the taranaki hub, the taranaki region has very little local food from local farmers, and especially since the advent of the food act and the higher regulations farmers were required to comply with. so there was a large increase in freighting charges to supply the food that would often come from hawkes bay and similar regions that have significant horticulture production. another smaller hub manager, hannah, commented: "we couldn't keep the customers". she described customers whose attitude was: we were living the ooooby dream, but to make that work for a customer base that is large enough to get an income, we either need to go to larger suppliers which may still be local and organic, but then it is not so much "out of our own backyard", but more about going to commercial growers. ooooby managers in the smaller hubs also found that the scale of the local hub prevented the financial investment in buildings (for example, cool storage), equipment (for example, delivery vans), and personnel (relying on volunteers to cover the hours required for sorting and packing food boxes). as ingold ( ) comments, in these entanglements of threads and pathways, action emerges from the interplay of forces conducted along the lines of meshwork. ooooby knots are based on shared values; the enactment of those values in the processes of organizing that they established demonstrates the relationality that allowed this meshwork to develop and flourish. this involves complementary roles and materialities that mesh together to form a new weave (of threads, lines and knots) within the context of the existing food system(s). when the ooooby meshwork reached into a "space" to form a new hub, the original intentionality of ooooby began a process of mesh-ing with this new context, and with suppliers, managers, and customers with different histories and expectations, and different relationalities. as the initial weaving of threads begins, and knots are encountered that are less flexible, there are meshwork changes. knots and entanglements can become strengths in meshwork, or can become impenetrable. hence, the relationality of the mesh-ing is challenging, either through material constraints (number of producers, food bill) or because of mismatches in the expectations of customers/ hub managers and volunteers. the ooooby initiative has encountered difficulties in integrating its self-organizing features and sensibilities with the existing food system(s) and the emerging hubs have had difficulties maintaining the local autonomy of meshwork set up by the ooooby initiative. they were not always able to be sufficiently adaptive, or resilient, or locally emergent but relied on the original lines of flow and did not become selfmanaging easily or in a timely manner. this comment from rob, founder of ooooby, demonstrated his own resilience and commitment to his vision, despite the sometimes arduous mesh-work, involved: look, emotionally it has been an absolute rollercoaster because we never knew what was around the next corner. there have been things come up that we have thought are going to really derail us. and we have managed our way through it... there are definitely nights when, like two nights ago, i woke up with a grip in my chest. you know you just have to wait until the morning comes, when the sun comes up. the spaces-in-between mainstream food systems thus provide opportunities for weaving new meshwork lines such as when food box delivery initiatives and farmers' markets emerge, or for elaboration (new threads and knots) of the existing meshwork. organizing and strategizing are thusin a meshwork perspective-always becoming in a multifaceted series of ever-changing entanglements that form new meshwork within the meshwork, weaving an intricate web of potential relationality. this innovative research uses the concept of meshwork to make a unique theoretical contribution to an alternative narrative for food organizing matters. we attend to critiques by holt and den hond ( ) and carolan ( ) to provide research that challenges the ontological assumptions underlying the shadow and informal dynamics of organizing. our use of meshwork furnishes a complex analysis of relationality in our case study of emerging food initiatives in aotearoa new zealand, to consider their interactions at a local level within emerging national contexts. as earlier noted, we are now in a covid- environment, meaning that we need new ontologies that examine how relationalities mesh within potentially fragile food supply chains. thus, we have placed relational connectivity at the core of a meshwork lens as a thoughtful and reflexive awareness of the nuanced, interconnected layers of meaning inherent in the paradoxes, tensions, and complexities of the lived experiences of organizing (wahlin ) . we have identified how meshwork entanglements and knots can be self-organizing, and are constantly ravelling and unravelling. some may emerge as localised variations like patchwork and are replicated throughout the weave; they may also form entanglements that are independent of each other, or they may be hybrids and embroidered in unique ways, and may never form a tight knot that has any stability. we also illustrated how yarners have impacts on the resilience of the weave, always in relationship, and becoming. we extend current theories of organizing food beyond human and political concerns to include a broader understanding of socio-cultural impacts and a closer focus on the performance of organizing; for example, through detailed understandings of mesh-work and meshing and how the relationalities of mesh-ing can contribute to a broader ecological sensibility (seyfang ) . we have also contributed by demonstrating how entangled relationships in food matters can create a complex ontology of organizing through meshwork knots, threads and weave. when issues of collective concern come together to form knots of stabilizing conduits, the meshwork threads indicate processes of movement and reconnection, while the weave suggests degrees of system resilience. this complex ontology explains how messy entanglements are interwoven and enmeshed, rather than travelling predictably along lines, and demonstrates how the process of organizing is always "becoming" (ingold ) . our research offers a contribution regarding how the organizing of food matters occurs through the relational knots of common concern that can become knowledge-sharing processes. as seyfang ( ) found, in her work on sustainable consumption, this can enhance an ecological sensibility and the enactment of ecological citizenship. we also extend current work, with insights from our meshwork approach into how small producers can organize and enact relationships in ways that create new possibilities for connectivity within existing food systems. our research has significant practical implications for aotearoa new zealand, a country heavily dependent on primary food exports. it begins to identify the challenges and opportunities that emerging forms of organizing and regulation face, as multiple and interdependent food initiatives interact. creative engagement with such dynamic organizing and regulatory environments will determine future food policies and the management of specific food production, distribution, and consumption issues. we hope that this research will enable us to map how food initiatives in aotearoa new zealand could deliver healthier options and greater food security. in this particular case study, our findings demonstrate the challenges associated with sourcing sufficient local growers, with managing the boundaries between public and private interests, and with organizing the (crowd, and other) funding and legal entities that underpin each iteration of ooooby in local regions. at the same time, we highlight the significant opportunities created for mentoring new initiatives, and for sharing expertise, while remaining adaptable to local conditions. a limitation of this paper is our focus on a single case study; 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donovan, jason; erenstein, olaf title: agri-nutrition research: revisiting the contribution of maize and wheat to human nutrition and health date: - - journal: food policy doi: . /j.foodpol. . sha: doc_id: cord_uid: jdf nt research linking agriculture and nutrition has evolved since the mid- th century. the current focus is on child-stunting, dietary diversity and ‘nutrient-rich’ foods in recognition of the growing burdens of malnutrition and non-communicable diseases. this article concerns the global dietary and health contribution of major cereals, specifically maize and wheat, which are often considered not to be ‘nutrient-rich’ foods. nevertheless, these cereals are major sources of dietary energy, of essential proteins and micronutrients, and diverse non-nutrient bioactive food components. research on bioactives, and dietary fibre in particular, is somewhat ‘siloed’, with little attention paid by the agri-nutrition research community to the role of cereal bioactives in healthy diets, and the adverse health effects often arising through processing and manufacturing of cereals-based food products. we argue that the research agenda should embrace the whole nutritional contribution of the multiple dietary components of cereals towards addressing the triple burden of undernutrition, micronutrient malnutrition, overweight/obesity and non-communicable diseases. agri-nutrition and development communities need to adopt a multidisciplinary and food systems research approach from farm to metabolism. agriculture researchers should collaborate with other food systems stakeholders on nutrition-related challenges in cereal production, processing and manufacturing, and food waste and losses. cereal and food scientists should also collaborate with social scientists to better understand the impacts on diets of the political economy of the food industry, and the diverse factors which influence local and global dietary transitions, consumer behavioural choices, dietary change, and the assessment and acceptance of novel and nutritious cereal-based products. the sustainable development goals (sdgs) define the international development agenda to (united nations general assembly ). designing effective policies, strategies and programmes for achieving the sdgs is a complex and multidisciplinary process, requiring specialists to escape the substantive sectoral silos which characterise global development (waage et al. ) . because of multiple entry points to the agenda, agriculture should recover its place as the central driver for food and nutrition security, for achieving inclusive and sustainable economic growth, reversing environmental damage, and boosting the resilience and welfare of the most disadvantaged populations (omilola and robele ) . however, there has yet to emerge a cross-sectoral vision on the form that engagement between agriculture and nutrition should take. for the second half of the last century, the agriculture-nutrition interface was concerned, in broad terms, with the availability of and access to calories and protein. now, many countries are increasingly facing the 'triple burden' of malnutrition: i) undernutrition (hunger) and ii) micronutrient deficiencies on the one hand, and iii) overnutrition (overweight and obesity) on the other. the sdgs include the ambitious sdg 'zero hunger' by -which appears unachievable. in the state of food security and nutrition in the world ) fao et al. estimate that almost million people were still hungry in . the data confirm that the trend in the number of people affected by hunger globally has been rising since . preliminary assessments suggest that the current covid- health pandemic may add - million hungry people in . these trends imply that the number of hungry people will likely exceed million by , almost percent of the global population. the prevalence of child stunting has been declining and in was . percent, or million children, but will still fail to meet the sdg target. while we continue to combat undernutrition and micronutrient deficiencies, overnutrition is increasing globally. 'if the prevalence continues to increase by . percent per year, adult obesity will increase by percent by , compared to the level' (fao et al. : ) . obesity is an important element of the triple burden per se, with great significance as a contributory factor to a range of noncommunicable diseases (ncds), which are targeted not in sdg but in sdg 'health and wellbeing'. it is unfortunate that diet-related interlinkages with ill-health are not explicit in sdg , and that ncd targets are separated from sdg , given conclusive evidence from global burden of diseases studies of the interconnections between undernutrition and overnutrition. policies should simultaneously address both dimensions to be effective (the lancet ). traditionally the agricultural sector has responded to food insecurity by increasing the production of cheap, high calorie staple foods. recently, some have argued against 'staple grain fundamentalism' and advocated for more research, inter alia, on 'micronutrientrich' foods such as fruits and vegetables to achieve food and nutrition security (pingali ; krishna bahadur et al. ; pingali and abraham ; sanchez ) . sanchez ( ) recommended a major shift in research priorities 'from non-nutrient-rich' foods, including cereals, to 'nutrient-rich foods ' (p. ) . considering the global extent of micronutrient malnutrition, renewed efforts to combat micronutrient deficiency diseases is necessary. however, such efforts should be in addition and not instead of a continued focus on cereal foods. so far, only some have argued for a balance in research to meet increasing demand for both staple crops and for nutrient-rich foods (zhou and staatz ) . this viewpoint signals the need to nudge the agri-food and nutrition policy paradigm. it aims to add missing dimensions to the efforts of the agri-nutrition community of national and international researchers, funders and implementing organizations who are working towards and beyond the sdgs to tackle the 'triple burden' of malnutrition and also the pandemic of diet-related ncds. we reflect on the shifting nature of concepts and priorities for agriculture and nutrition research and development programming. we suggest that faster progress towards nutrition, food security and diet-related health targets hinges, in part, on embracing a set of challenges beyond micronutrient malnutrition and sdg 'zero hunger' (byerlee and fanzo ; fanzo ) . in particular, there are unexploited opportunities through increasing availability of, and access to, healthy foods derived from cereals, specifically maize and wheat, and through enhanced crop qualities. benefits would include reductions in diet-related ncds such as cardiovascular diseases, cancers, diabetes and chronic respiratory diseases, through assuring intakes of bioactive food components (section . ), in particular dietary fibre (section . ), of which cereals are a rich source. other cereals are important in global diets, including rice and so-called 'minor' grains and 'speciality' grains, but are beyond the scope of this viewpoint. we also suggest further analysis of the interrelationships between public and private food policies and strategies, food processing, and consumer behaviour and preferences that will lead to better manufactured products, and more precise public interventions and health outcomes. these are proper concerns of the national and international agri-nutrition communities. research in agriculture and nutrition has changed over the decades. reviews of agricultural development, food security and nutrition reveal several shifts since the middle of the th century (levinson and mclachlan ; the world bank ; nomura et al. ; gillespie and harris ; harris ) . since the s, agricultural development has maintained a strong orientation towards increasing the supply of staple food crops, reflecting concerns over global population increase and the ability of food production to keep pace (byerlee and fanzo ) . the aim was to expand and secure production of cheap, energydense foods which were acceptable to consumers-as an input for food-and farmers-in terms of their willingness to produce. food research interests and commercial investments have diversified over the years to include sustainable development and climate change adaptation, but the overall public policy orientation has continued to focus on agricultural production as a supply of food to urban areas and a generator of income and export revenues. while investments in staple crop production are generally considered to have been a success, only recently has research addressed nutrition, health and the transformation of food systems. reviewing experience from the s, a report for the world bank ( : ) commented that 'both the fields of agriculture and nutrition have lacked unified zeal for addressing nutrition problems explicitly through food over the past several decades' (p. ). on the disciplinary disjuncture between agriculture and nutrition, hitherto, '… ownership of nutrition issues has been limited in agriculture, and emphasis on food has been low among nutritionists' (the world bank : ). fan et al. ( ) have suggested that in the development of agrinutrition thinking, 'the early s seemed to signal a turning point' (p. ). micronutrient deficiencies are now widely recognised to be as important, if not more important than undernutrition. jonsson ( ) , who traced the 'paradigm shifts' in public health nutrition from , noted that the 'micronutrient paradigm' prevailing at the time of writing began in . ridgway et al. ( ) have referred to the nutrition science, guidance and policy changes since the early th century as 'paradigm shifts' in public health. similarly, rifkin ( ) has critiqued the thinking about primary health care, and highlighted the undue attention given to 'microcosms' (meaning 'a narrow and siloed focus' on health) 'that block the critical importance of viewing improvements in health in the much wider environment of social, political and economic contexts' (p. ). both ridgway et al. and rifkin frame their paradigmatic arguments within kuhn's 'the nature of scientific revolutions' ( ) . over the last two decades, discussions at the intersection of agriculture and human nutrition and health have gathered momentum. in , harvestplus was established within the cgiar to advance research and deployment of biofortification, and work intensified on staple food crops to address common forms of micronutrient malnutrition (nestel et al. ) . the more recent shift towards sustainable food systems acknowledges changing patterns of consumption, variously towards animal-source foods, and towards vegetarianism and veganism, waste reduction, a circular food economy and reducing the environmental footprint. these factors and others are implicated in the search for 'sustainable and healthy diets' (fanzo ; fao and who ) . the 'food systems' paradigm recognises that food and health are fundamental in all ecosystems (a nh ). the definition of desired food system outcomes has been broadened and sharpened: 'nutritional security has now emerged as the central issue in world food production as well as the key link between food security and human health. nutrition security occurs when availability, access and stability not only refer to calories, but also to proteins, fats, fibers and micronutrients' (sanchez : ). the high level panel of experts on food security and nutrition of the committee on world food security (hlpe ) advocates adding two additional elements to the four pillars of food security (availability, access, utilization and stability), being 'agency' (individual and group), and 'sustainability' (economic, social and environmental) . researchers have also advocated incorporating 'nutrition-sensitive' elements-specific nutrition goals and targeted interventions-into agricultural development programming (jaenicke and virchow ) , into agrifood policies (gillespie et al. ) and into value chain development (allen and de brauw ; gelli et al. ). these discussions have downplayed the contribution of cereals in alleviating food and nutrition insecurity among the most vulnerable population groups. the causes of malnutrition are complex, involving multiple disease conditions, inadequate water, sanitation, hygiene, and care practices, and a range of basic causes at the societal level (unicef ) . agrinutrition research on improving diets targets adequate intakes of vitamins and minerals (gillespie and harris ) , and the 'triple burden' of hunger, micronutrient malnutrition and overweight/obesity. according to the global nutrition report (development initiatives ), 'among children under years of age, . million are stunted, . million are wasted and . million are overweight. there are . million obese adults' (p. ). obesity is a global problem, a 'ticking time bomb' with major current and future adverse health and economic impacts, coexisting with hunger/undernutrition and hidden hunger/micronutrient deficiency (popkin et al. ) . based on data in shekar and popkin ( ) , at the time of writing it can be said that probably half the world's adults are overweight or obese, threequarters of whom live in low-and middle-income countries. shekar and popkin outline the range of public health interventions that, based on diverse country experiences, have significant potential for addressing obesity: fiscal and regulatory controls of industry conduct; food systemwide interventions through agricultural research and food production and manufacturing, subsidies, infrastructure and logistics; and education and early child-hood interventions. the global nutrition report also referred to diet-related ncds, but the siloed nature of some agri-nutrition thinking exhibits limited interest beyond energy provision and fortification programmes in the dietary and health contribution of the cereals. nevertheless, cereals form the major part of the actual diets of the urban and rural poor. this implies an incomplete agenda for steadfast advancement towards development goals. the 'triple burden' itself has come under scrutiny by scrinis ( ) who argues that the concept abstracts from a complex phenomenon that has social as well as biological dimensions. it is a fragmented framing of the problems, and results in fragmented research and policy proposals. arguably, the triple burden focuses attention on proximal indicators or objectives (underweight, stunting, wasting, and overweight/obesity). the ultimate objective of good nutrition should be healthy lives and wellbeing, including freedom from physical and mental disease-of which there are multiple and complex causes-and specifically from diet-related ncds-which also have non-diet-related causes. child stunting is a principal indicator of nutrition insecurity and micronutrient malnutrition, attributable to deficient maternal and infant diets, and affecting the poor disproportionately (arimond and ruel ; unicef ; smith and haddad ) . since black et al. ( ) it has been clear that maternal and child malnutrition, evidenced in childhood stunting, contribute significantly to the global disease burden. stunting incurs huge intergenerational health, economic and social costs. many international organisations recognize stunting as the major challenge: the world bank highlights stunting ( ); prominent indicators for the child nutrition programme of usaid are stunting and wasting of under-fives (usaid ); the gates foundation strategy on nutrition acknowledges the importance of 'hidden hunger', or micronutrient malnutrition (bmgf ); the european union action plan on nutrition directly targets stunting (european commission ); the uk global challenges research fund (gcrf) addresses global issues faced by developing countries, among which stunting is a major theme (ukri ). interventions now commonly advocated are micronutrient focused, malnutrition-preventative food-based approaches rather than clinical, curative 'therapeutic' interventions still favoured by some ministries of health (thompson and amoroso ; fao and fcrn ; poole et al. ; gelli et al. ) . the dependence in nutrition metrics on stunting as an indicator is indisputably important, but it is one measure of overall food and nutrition security. for children suffering severe acute malnutrition, other childhood conditions often attributable to (maternal) malnutrition, such as low birthweight, also have long-term consequences for the chronic disease burden (briend and berkley ; lelijveld et al. ). leroy and frongillo ( ) have acknowledged that stunting-or 'linear growth retardation'-has become a widely-used and useful tool. they argued that stunting is associated with, but does not cause, the health correlates of linear growth retardation, except for a causal relationship with difficult births and poor birth outcomes. brown et al. ( ) reviewed empirical studies which examined factors associated with child malnutrition, focusing on the three major indicators of malnutrition, being wasting, stunting and underweight. they noted that stunting was the common indicator, and that wasting was relatively understudied. a danger of emphasising a single indicator such as stunting, and associated targets, is the tendency to reduce the multiple dimensions of complex or 'wicked' problems, like poor nutrition and health, to simple solutions, like more micronutrients. just as the conditions for food security and good health cannot be reduced to good nutrition, good nutrition in turn cannot be reduced to an adequate micronutrient intake. fao et al. (fao et al. ) take a comprehensive view of the nutrition challenges, noting that 'diets of poor quality are a principal contributor to the multiple burdens of malnutrition-stunting, wasting, micronutrient deficiencies, overweight and obesity and both undernutrition early in life and overweight and obesity are significant risk factors for ncds. unhealthy diets are also the leading risk factor for deaths from ncds. in addition, increasing healthcare costs linked to increasing obesity rates are a trend across the world' (fao et al. :xxiii) . however, this misses a potential benefit from clear communication to a concerned wider audience, by referring to sdg only in terms of health costs, and not the critical targeted reductions in ncds. there is an abundant literature which links diverse diets to provision of the vitamins and minerals that prevent 'hidden hunger' and micronutrient deficiency diseases (jones et al. ; pellegrini and tasciotti ; baudron et al. ; dulal et al. ; nithya and bhavani ; komatsu et al. ; rosenberg et al. ) . dietary diversity is a proxy for nutrient adequacy (fao ) and is inferred from estimates of the nutrient content and frequency of consumption of foods from different food groups, elicited through individual and household surveys (zezza et al., ; ruel, a; wfp, ) . we are learning more of the gaps in rural and urban populations in terms of access to more diverse diets, i.e., those richer in fruits and vegetables, and about less-nutritious patterns of consumption of processed foods and beverages (penny et al. ; law et al. ; bren d'amour et al. ) , and the differential distributional impacts of temporal, spatial and socioeconomic dimensions of local food environments (duran et for vulnerable populations, increasing consumption of 'nutrient-rich foods' can be achieved through multiple strategies, including ownfood production among the rural poor, better incomes, and enhanced market availability and access for all consumers. nevertheless, we are also learning more about specific barriers to adoption of better diets, for example, the complexity of linkages between agroecological, economic and social systems and education, and cultural barriers including food taboos on maternal behaviour patterns and infant and young child feeding practices (klassen et al. ; chegere and stage ) . the outcome of dietary diversity assessments is often the food consumption score (fcs) (wiesmann et al. ; arimond et al. ; kennedy et al. ). the fcs is constructed by using weightings based on estimated nutrient content at the food category level. the weightings are crude estimates of the nutritional value of different food groups. revision of the food consumption score nutritional quality analysis guidelines (fcs-n) (wfp ) has introduced a more disaggregated food list which discriminates nutrient-rich foods from other less nutrient-rich items belonging to the same food group. dietary diversity scores have been found to be sensitive, robust, valid and cheap-tomeasure indicators of micronutrient intake adequacy in many contexts (headey and ecker, ; nithya and bhavani, ; ruel, ; zhao et al., ; wiesmann et al., ) loose application of protocols may be partly responsible for varying results of studies investigating the association between indicators of dietary diversity and nutritional status. a systematic review of the use and interpretation of dietary diversity association in studies between and by verger et al. ( ) found wide variation among the study characteristics in respect of the unit of analysis, the location, study design, sample size, choice of indicators and analysis of the dietary diversity data. the results showed inconsistent use of protocols and misleading data interpretation within the sample. they also criticised the lack of comprehensiveness of the food items included in food groups across datasets. overall, we need to revise the conceptualisation of food types in dietary diversity studies for various reasons. two areas are raised here for wider discussion: mis-categorisation and missing nutrients. an aggregation problem is that heterogeneous foods are included within a single category. for example, different meats and other foods based on animal-source products have varying nutritional qualities; vegetables and fruits differ considerably in the micronutrient content; fortified (orange) sweet potatoes are categorised with orange vegetables rich in vitamin a, whereas fortified (yellow rice) is not so distinguished; nor are other bio-or industrially-fortified products so distinguished . in particular the single 'staples' category of cereals and tubers includes numerous diverse foods. they are derived from a wide range of crops which exhibit inherent between-species differences. they also often exhibit different within-varietal nutritional qualities attributable to plant breeding and varying production systems and conditions. from these staples many foods are derived through processing and manufacturing that alter nutritional quality for better-by improving acceptability and digestibility-and for worse-by stripping out valuable nutrients and adding noxious components. through ultra-processing into other forms-such as products high in saturated fats, sugar and salt-they can be nutritionally harmful, obesogenic and contribute to ncds (who, b). another issue with measures of dietary diversity is the categorisation of the macronutrients (fats, carbohydrates and proteins) and micronutrients. the measures do not differentiate among, or include all, essential vitamins and minerals which are epidemiologically significant; nor essential fats-or more precisely, fatty acids; nor essential amino acid content and hence protein types. the fcs-n ignores some nutritional deficiencies including those that are context-specific to national, regional (within country) and even local levels (who, a). zinc, iodine, folic acid and vitamin d deficiencies would be examples. moreover, there is a significant omission of the many components of foods that are 'bioactive substances' and contribute to health (weaver ; perez-gregorio and simal-gandara ; sanchez ). the health-promoting bioactive food components ('biofocs') are not included in the dietary diversity discourse and are largely absent from the agri-nutrition literature, but their significance is recognised in biomedical research, food sciences and within the food industry (section . ). dietary diversity as conceived is an essential but partial approach to combatting food insecurity. there is a particular dilemma when overt hunger due to insufficient food calories is an immediate population and policy concern, and where energy needs are paramount (harris ) . more comprehensive dimensions of food insecurity such as the integrated food security phase classification (ipc) are used in humanitarian contexts. in their deconstruction of the meaning of 'famine', maxwell et al. ( ) critique the ipc which assesses famine in five phases, the indicators for which use data on food consumption (or hunger), changes in livelihoods, prevalence of acute malnutrition, and mortality. they argue, inter alia, that the ipc gives a 'mono-dimensional view' of a phenomenon that is multifactorial. even so, the set of ipc indicators captures a wider range of health drivers and outcomes than does the focus on dietary diversity and stunting. it also links to sdg and targets for reductions in infant and child mortality and ncds (united nations, b). the argument thus far is for agri-nutrition research to open up to a broader perspective on the nexus of agriculture, food, nutrition and health. at the heart of this complexity is acknowledgement that foods contain more than the conventional macro-and micronutrients, and that agri-nutrition research should address the nutrition and health requirements for all the essential biofocs. only relative to other 'nutrient-rich' foodstuffs are cereals 'nutrientpoor'. this terminology reflects the emphasis on micronutrient malnutrition. most cereals provide varying amounts of proteins, fats, minerals and vitamins, in addition to being important sources of dietary energy. wheat contributes some % of the total dietary calories and proteins globally (shiferaw et al. ) , rice contributes % of global calories and contains important minerals, vitamins and bioactive phytochemicals with other essential food components found in rice bran (fukagawa and ziska ) ; maize is a staple of over billion people for whom the grain energy contribution to the diet can exceed %. whole maize grain is rich in anthocyanins with many nutritive properties which can be enhanced by the traditional process of 'nixtamalization' ( qualities of cereals are amenable to improvement through traditional plant breeding, genomic selection, bio-and industrial fortification (mattei et al., ; palacios-rojas et al., ; shewry and hey, ; velu et al., ; yu and tian, ; zhao et al., ) . however, the micronutrient content of cereals-based foods is also often reduced through processing methods (suri and tanumihardjo ) . cereals are the dominant source of carbohydrates in the global diet, providing essential food energy. energy matters universally, but has particular importance when minimal energy needs are not being met. persistent humanitarian situations come to mind due to natural disasters such as famines and floods, and anthropogenic disasters such as conflict. across the rural south and under seasonal conditions of hardship and hunger, cereals provide necessary bulk and energy for the poor and those involved in physical work. carbohydrates are a complex and contested nutrient. several classification systems are used currently (ludwig et al. ) . some adverse health reactions to carbohydrates in cereals are well-documented: for example, specific components of wheat affect people with coeliac disease and wheat allergy (brouns et al. ) . regarding starch, a high glycaemic response is known to have adverse effects on diabetes and obesity. however, a higher amylose content compared with amylopectin decreases digestibility, postprandial glycaemia and insulinaemia, and hence can reduce the glycaemic index of carbohydrate foods. a series of systematic reviews and meta-analyses of prospective studies conducted on carbohydrate quality and human health by reynolds et al. ( ) concluded that higher intakes of df or whole grains were likely causally associated with reductions in the risk of mortality and in the incidence of a wide range of ncds and risk factors. in light of the popular concerns about starchy food intakes, they found less evidence for the potential benefit of a low glycaemic index or low glycaemic load diets. nevertheless, processed 'whole grain foods' may not have the same health benefits as unprocessed whole grains, and some 'whole grain foods' which contain added 'free' sugars probably have adverse implications for health (ludwig et al. ). in addition, there is a popular and simplistic misconception that avoidance of cereals, particularly wheat, reflects a healthy lifestyle (igbinedion et al. ) . it is often difficult to disentangle food science and policy from food populism and marketing, whose concerns 'have generally not been substantiated by detailed scientific review' (shewry : ) . according to the uk sacn ( : ), 'total carbohydrate intake appears to be neither detrimental nor beneficial to cardio-metabolic health, colorectal health and oral health… there are specific components or sources of carbohydrates which are associated with other beneficial or detrimental health effects'. thus, it may be the balance of carbohydrate qualities as well as overall energy intake that determines effects on chronic disease and health outcomes (ludwig et al. ; reynolds et al. ) , although this view is contested. there are other components of foods that, puzzlingly, are not invariably considered to be 'true' nutrients but yet are essential for healthy diets: 'other components of food that are not technically "nutrients" also contribute to nutrition and health, such as fiber, probiotic bacteria, and phytonutrients' (the world bank : ). these collectively are 'bioactive food components' (biofocs): dietary fibre and other biofocs that are not energy, protein, fats, minerals, vitamins and water are handled in many different ways by different authors and authorities: 'non-nutritional, but biologically-active substances [include] toxins and contaminants, such as alkaloids and aflatoxins, which are detrimental to health, as well as constituents, such as phytochemicals, that may be health-promoting' (webster-gandy, ). in , the us offices of disease prevention and health promotion, public health and science, and health and human services solicited comments on a proposed definition of biofocs because: 'foods provide numerous chemical constituents that may influence health and disease prevention, in addition to those usually characterized as essential nutrients. the physiological implications of these food components have been the subject of recent scientific inquiries and publications. widespread scientific, governmental, and consumer attention to these components, referred to here as ''bioactive food components,'' has sparked an interest about how they should be defined and how best to evaluate their significance in promoting health and disease prevention. bioactive food components exist not only in commonly consumed foods but also as ingredients in fortified foods and dietary supplements' (federal register : ) . examples of bioactive compounds include carotenoids, flavonoids, phytosterols, glucosinolates, and polyphenols. since vitamins and minerals elicit pharmacological effects, according to gökmen ( ) they also can be categorized as bioactive compounds. bioactive compounds are found naturally in various foods, and have beneficial antioxidant, anticarcinogenic, anti-inflammatory, and antimicrobial properties. some naturally occurring substances and others introduced during food manufacturing, such as acrylamide in bakery products, may also have adverse effects (gökmen ) . most of the beneficial effects of the consumption of wholegrain cereals on ncds are currently attributed to the bioactive components of dietary fibre and a wide variety of phytochemicals (bach knudsen et al. ). there is much research into the bioavailability and bioaccessibility of such active compounds and nutrients, as well as macronutrients such as carbohydrates, by the food processing industry as well as academic researchers, not least the use of nanoemulsions as vehicles for bioactive compounds to improve the sensory, nutritional and health properties of processed foods (mahfoudhi et al. ; leong et al. ; santos et al. ) . our interest here concerns the mainly naturally-occurring substances in foods that are beneficial or essential to nutrition and health. these biofocs are known to prevent and combat health conditions comprehended by sdg , target . 'to reduce premature mortality from non-communicable diseases' (united nations, b). because biofocs such as fibre and phytochemicals, like proteins, minerals and vitamins, are also found in cereal foods, it is a mistake to classify cereals automatically and universally as 'nutrient-poor'. research on biofocs seems to be largely siloed in biomedical and food science disciplines and discussions of functional foods, in the same way that, it is argued, nutrition is siloed from agri-food sustainability (el bilali ). bio-focs are, however, present in popular health media (brouns et al. ; duyff ) . the literature on biofocs is abundant, the science is complex, and this viewpoint can only summarise the field. here we acknowledge cereal carbohydrates not only as important source of energy, but also as a source of diverse biofocs and in particular, of dietary fibre (df). the dietary and health impacts of carbohydrates are summarised in fig. . simply put, carbohydrates provide energy through digestion of sugars, starch and oligosaccharides in the small intestine. some carbohydrates also create a glycaemic response with adverse effects on, for we thereby differ from the us office of dietary supplements' view which defined bioactive compounds as 'constituents in foods or dietary supplements, other than those needed to meet basic human nutritional needs, which are responsible for changes in health status ' weaver, c.m. ( ) . bioactive foods and ingredients for health. there is now a good understanding of the physiology, biochemistry, and metabolism of most carbohydrates (reynolds et al. ) , and of the importance of df in disease prevention (cummings and engineer ) . stephen et al. ( : ) give an account of df intake, types and dietary sources, and the relationships with numerous ncd risks. these include improvements in all-cause mortality, cardiometabolic health and risk factors including hypertension, hyperlipidaemias, type diabetes, obesity in terms of both energy intake and appetite effects, gastrointestinal health including faecal weight and constipation, diverticular disease, oesophageal disease and a range of cancers. broad guidelines for df intakes exist in national and international nutrition policies but dietary guidance still focuses on topics other than fibre (stephen et al. ) , with the level of detail lagging that for vitamins and minerals (see section . below). in fact there is little in the who fact sheet on the role of df: only '… many people do not eat enough fruit, vegetables and other dietary fibre such as whole grains… eating at least g, or five portions, of fruit and vegetables per day reduces the risk of ncds and helps to ensure an adequate daily intake of dietary fibre' (who ). in a review of european countries, we learn about diversity in df sources, consumption and recommendations: 'grain products provide the largest proportion of fibre in the diet for all countries studied, with bread by far the largest grain source, with smaller contributions from breakfast cereals, pasta and biscuits and pastries. vegetables, potatoes and fruits also contribute substantially, but these vary more widely from country to country, depending on climate and cultural norms. recommendations about types of fibre to consume are therefore difficult as "not one size fits all"' (stephen et al. : ) . processing also affects the nutritional quality of grains, and differences have been identified between the quality of processed grains and of fibre added to manufactured foods compared to naturally occurring df within whole grain foods (slavin ; reynolds et al. ). dietary guidelines are political tools for promoting healthy consumption patterns 'and can also serve as the basis for developing food and agriculture policies' (muka et al. ; fao and fcrn :v) . new research reported by herforth and masters ( ) reviews methodologies, approaches and metrics for estimating the affordability of nutritious diets around the world. a proposal to harmonise nutrient reference values could introduce new rigour to dietary guidelines , and new analytical tools for estimating human nutrient requirements are becoming available (e.g., schneider and herforth ( ) ). dietary advice about the consumption foods such as of whole grains rich in df is not uncommon, but quantitative guidelines are unavailable for many countries, and details are often incomplete (herforth et al. ). in particular, gaps persist on the quality of df essential to meet dietary recommendations (stephen et al. ) . the relative inattention given to df and other biofocs is significant for agricultural sciences research. weaver ( ) has commented that because bioactives are of increasing interest, more research is needed to understand the complex relationships between individual food components, foods, and the biological effects, thus providing better evidence to inform dietary guidelines. a balanced, comprehensive and more thorough understanding of the contribution of carbohydrate-rich cereals to diets in respect of under-nutrition, overnutrition and ncds will likely alter dietary research and guidelines. all evidence hitherto points towards consumption of more fibre and more whole foods, including cereal grains. springmann et al. ( ) found that in all fao-defined geographical regions, with the exception of north america, current intakes of whole grain foods should at least double compared with national dietary guidelines, and in the cases of who and eat-lancet guidelines, increase by % and % n. poole, et al. food policy xxx (xxxx) xxxx respectively. adoption of dietary guidelines would lead to major reductions in the global burden of diet-related ncds through increasing consumption both of cereals rich in df, and necessarily of fruits, vegetables, pulses, nuts and seeds rich in both micronutrients and df. new knowledge is needed specifically of df: '[the uk scientific advisory committee on nutrition] sacn would welcome research to improve the functional categorisation of specific dietary fibres and relevant extracts: building structure-function understanding to link and predict from defined, measurable physical and chemical properties to specific physiological effects. this should include defining physiologically meaningful effect ranges for colonic and faecal ph, short chain fatty acids, and bacterial populations' (sacn : ) . concern about the sustainability of agriculture and diets is not new (reynolds et al. ; tilman and clark ) , and has received new impetus. the eat-lancet commission reference diet was 'based on the best evidence available for healthy diets and sustainable food production' (willett et al. : ) , using food groups plus added fats, sugar, salt, and other dietary constituents. grains were recognised therein as the principal source of energy in global diets, with whole grains and fibre from grains associated with reduced risk of coronary heart disease, type diabetes, and overall mortality. the formulation of model sustainable diets that are affordable by the global poor in different food cultures is still pending (hirvonen et al. ; willett et al. ; drewnowski ) . using data, a leastcost eat-lancet commission healthy diet formulated according to local food preferences and availability has been found to be unaffordable by billion people globally . for india, sharma et al. ( a) have illustrated how diets across local and national geographical dimensions and socio-economic levels deviate significantly from the eat-lancet reference diet. economic modelling suggests that increasing the supply of fruit and vegetables to meet the who's dietary recommendation of g/person per day is for many countries unlikely by the year (mason-d'croz et al. ). therefore, assuring diverse diets incorporating nutrientrich foods is not a trivial matter. this suggests the need for more research into how, in diverse food cultures and seasons, intakes of cereals and other fibre-rich foods such as pulses, can complement 'nutrientrich' foods to meet revised dietary recommendations. fao and who ( ) and the hlpe ( ) have recommended moving towards context-specific 'territorial diets' based on locally available, economically accessible, and culturally acceptable foods, delivered through sustainable systems. cereals, for energy and much more, will be the foundation of such diets. understanding the nutritional requirements for df and other bioactives adds a new dimension to the continuing agenda for optimising plant breeding and production conditions for best nutritional outcomes in uncertain and changing climates. increases in crop productivity are necessary in many countries and challenging contexts. bloom et al. ( ) offer various explanations for their estimation that research productivity generally has fallen during the past years. for agricultural research, they have calculated a negative annual growth rate in agricultural productivity both for the united states and globally. but in summary, the finding is robust that 'ideas are getting harder and harder to find' (p. ) and that considerable increases in research investment are needed to maintain gdp growth rates. a major task is to redress the significant yield gaps in crop productivity between many african countries and other regions. investment by the international community in local capacities to address local conditions is essential. a recent report critical of the agra programme shows that there is no consensus on the merits of a "green revolution" approach to agricultural intensification, and that the evidence of poor impact impels exploration of alternative models of sustainable crop production for food and nutrition security among the poor in africa (bassermann and urhahn ) . moreover, greater collaboration among international and national cereals researchers is necessary, in order for wheat and maize scientists to share lessons learned with the other major cereal sector, rice, and with 'minor' cereals which are also very important regional food crops, with many advantages of local adaptation, resilience and nutritional quality. soil characteristics and production systems affect crop macro-and micronutritional qualities for human consumption (herencia et al., ; kihara et al., ; lovegrove et al., ; shewry, ; shewry and hey, ) . more local knowledge is needed. there is also considerable potential for plant breeding strategies to improve grain composition through exploiting natural variation, genomic selection, mutagenesis and transgenesis, improving cereal cell wall polysaccharides, and specifically improving the starch composition and structure through natural and induced mutations: 'in recent years the manipulation of the amylose-amylopectin ratio in cereals [maize, rice, wheat and barley] has been identified as a major target for the production of starches with novel functional properties and improved health benefits' (lafiandra et al. : ) . programmes of biofortification of seed varieties and industrial fortification of processed products are proven and should be continued, accompanied by efforts to integrate biofortification into public and private policies, programmes, and investments, and to evaluate and enhance consumer uptake (bouis and saltzman ; bouis ) . similarly, programmes of industrial fortification of cereal products should be expanded, considering how to overcome the obstacles to fortification programmes where flour is derived from local milling rather than industrial-scale processing (ansari et al. ; poole et al. ) . the loss of nutritional quality through processing is a major challenge. public sector food policy still allows the food industry to mill away much of the nutritional content of cereals and to create ultraprocessed foods (upfs). these often contain noxious qualities and components, and contribute directly to the huge and increasing global health and economic costs of ncds (monteiro et al. ; vandevijvere et al. ) . agricultural scientists and socioeconomists should collaborate with food scientists in order to enhance the nutritional quality of inputs to the food industry and to assess health claims and assure consumer acceptance of novel or reformulated products. collaboration between cereal scientists and industry food scientists are also needed to improve processing and develop innovative technical approaches to overcome the spoilage of fats in whole grain foods, and achieve the effective substitution of 'free' or added sugars that have adverse health effects. overall, we need a reorientation of food manufacturing towards processes and products that enhance the nutritional contribution of cereal foods rather than over-processing which strips out the nutritional content, adding instead the noxious components. in plant breeding and metabolic studies together, as well as cereal processing and manufacturing, further research is needed to elucidate the relationship between dietary components of cereals and cereal foods, and glycaemia/insulinaemia that underlies some of the critical increase in ncds. new metrics have been proposed to assess the dietary quality of carbohydrate-rich foods in respect of calories and other macro-and micronutrients which should generate enhanced dietary guidelines, promote novel and healthy foods, increase the accuracy of product labelling, and reduce consumer confusion about nutritional qualities (liu et al. ). food safety is one dimension that spans the whole food system and n. poole, et al. food policy xxx (xxxx) xxxx demands diverse but coherent technical, commercial and policy responses. as an example of the food safety challenges to nutrition and health from cereals, mycotoxins are an important agent. for cereal systems, aflatoxicosis is a common health hazard in africa, first identified in the s. aflatoxins in maize can develop in the field, causing ear-rot, and in the absence of field contamination, during post-harvest grain processing and storage (council for agricultural science and technology ). a systems approach to food safety in the maize sector was recently designed and implemented in kenya, funded by the cgiar research program on agriculture for nutrition and health (an h) (paca, no date). results suggested that testing procedures throughout the maize value chain could enhance food safety from aflatoxin poisoning for million kenyans (hoffmann ). recommendations included 'the adoption of coregulation that is a governance option that uses government-backed standards adopted by industry, leading to shared responsibility to manage aflatoxin risk in kenya and elsewhere in the region' (herrman et al. : ) . hence the importance of collaboration with farmers and with private sector firms such as maize millers (fisher et al. ; pretari et al. ) . post-harvest losses are known to account for a major part of global food production. food waste is a serious threat to narrowing the gap between supply and demand (mason-d'croz et al. ). the causes of losses persist throughout the food system and in low-income countries are mainly connected to financial, managerial and technical limitations in harvesting techniques, storage and cooling facilities in difficult climatic conditions, infrastructure, packaging and marketing systems. given that many smallholder farmers in developing countries live on the margins of food insecurity, a reduction in food losses could have an immediate and significant impact on their livelihoods. food systems improvements may not necessarily be costly or technologically advanced. recent research on combatting losses in tanzania, mainly for maize, found that the use of inexpensive kg hermetic storage bags could reduce infestation by, and losses through, insects and other pests and mitigate food insecurity by % in the lean season for smallholder farmers (brander et al. ) . in this case, disentangling the effects of the technology itself from the effects of training on adoption of new storage technology needs further work, and illustrates the multisectorality of the food systems challenges which constrain good nutrition and health. progress in addressing the nutritional drivers of ncds is largely held up by the twin obstacles of commercial interests and lack of political will (horton ) . current nutritional challenges have much to do with the political economy of food through lobbying of the food industry, with advocacy of civil society, and the need for public regulation of and policies for research and investment, sectoral taxation, prices, subsidies and incentives, and food trade and security policies. the cereal industry is centre-stage in food trade, manufacturing and processing as well as consumption. balarajan and reich ( ) have identified six themes in the political economy of nutrition that highlight current challenges: leadership, intersectoral coordination, accountability, issue framing, hierarchy and demonstrating effectiveness of nutrition actions. agri-nutrition scientists and socioeconomists should participate in this agenda and adopt multidisciplinary approaches, particularly through joint ownership of issues, shared prioritisation, industry engagement, and above all by deploying food systems thinking (gillespie and van den bold ; gillespie et al. ) . the global alliance for improved nutrition (gain) is one collaborative vehicle which aims to increase the availability, affordability and consumption of nutritious and safe foods, and change market incentives, rules and regulations to promote nutritious diets. based on experience in south asia, and the growing literature on public-private sector food, nutrition and health linkages, poole et al. ( ) have identified various ways for researchers to engage in enhancing the delivery of nutrient-rich foods, and limiting the consumption of harmful foods. the prevalence of adult obesity has superseded underweight, both globally and in all regions except parts of sub-saharan africa and asia (development initiatives ). two recent research examples among many illustrate the importance of understanding consumer behaviour in the varying contexts of economic and nutrition transition. in india, like many other countries, the nutrition transition towards obesity is marked by increased sales of processed and packaged foods (law et al. ) . analysing data from a representative sample of take-home purchases of packaged food and beverages by urban indian households between and , they found that purchased quantities per capita lagged those in western economies which have advanced further along the transition except for high levels of consumption of foods such as packaged milk, processed wheat or edible oils. income was not a simple determinant of purchasing patterns. similar health and research challenges have been reported by smart et al. ( ) in sub-saharan africa, where undernutrition and increasing overnutrition are prevalent. investigating the changes in food demand in mozambique, they found that urbanization impels consumption of more nutritious foods and more processed foods at the same time, with both positive and negative impacts on diet quality and implications for health. urbanization and increased consumption of processed foods were significantly and strongly associated with deterioration in diet quality. they conclude that 'as urbanization continues and incomes rise, african cities need to consider what mix of policies and programs might counteract the negative effects we see from both these factors on diet quality' (p. ). such findings imply more social science analysis of consumer education and behaviour change, not least in favour of whole grain foods, and more political economy analysis which might reduce the production, distribution and consumption of upfs of which cereals, as noted, are often an ingredient (mattei et al. ) . such analysis should cast a light on why knowledge and dietary guidelines have often had limited influence on public nutrition policy and less on actual public health and consumer education and behaviour change . cereal grains such as maize and wheat are used as an input to livestock feed as well as food, offering an indirect route to better (human) nutrition outcomes. maize grain is an important feed source for monogastric livestock, and poultry in particular-and may imply different feed quality needs as compared to food (krishna et al. ) . cereal crops are also grown for forage and crop residues and are an important by-product widely used as feed in the global south (blümmel et al. ; valbuena et al. ) . as sanchez ( ) notes in response to the eat lancet commission, animal-source foods (specifically red meat, poultry and eggs) are a nutritional necessity for hundreds of millions, '…if not billions, of fertile women and children in low-and middle-income countries who in all likelihood need more that the g/ day indicated in the eat-lancet diet' (p. ). here we avoid contention concerning the sustainability of livestock production in general (adesogan et al. ) , and limit ourselves to reiterating the ongoing importance of cereals as an input to livestock production, in order to meet the nutritional needs of vulnerable populations. it has been argued that agricultural research, by concentrating on staple cereals, has not responded adequately to persistent micronutrient malnutrition and child stunting, and increasing overweight and obesity (pingali ; pingali and abraham ). sanchez ( ) supports n. poole, et al. food policy xxx (xxxx) xxxx work on nutrition-sensitive food systems and nutrition security in terms of availability, access and stability of calories, proteins, fats, fibre and micronutrients. now is also the time to reiterate the contribution of cereals beyond energy, particularly whole grains, to nutrition and health. the challenges enumerated in the previous (section . ) are by no means exhaustive and will require comprehensive and collaborative approaches to maximise the dietary contributions of cereal foods. admittedly, a comprehensive approach and multidisciplinarity exacerbate the operational challenges for many policy and research organisations, national and international, which have struggled hitherto to integrate thinking about nutrition security, rather than just food energy security, into agricultural research. this suggests new research partnerships between agricultural scientists, nutritionists, biomedical and food science researchers and socio-economists, and more support from the international community directed towards under-resourced national agricultural and nutrition research communities. understanding of carbohydrate components of foods from field to plate, and on to digestion, fermentation and metabolism is needed. ludwig et al. ( ) identify a number of 'carbohydrate controversies' that need further research, including those related to the contribution of whole grains and df to diets, health and wellbeing. a focus on stunting and the 'micronutrient malnutrition paradigm' is unduly narrow and siloed. micronutrient malnutrition is, to use rifkin's term, a 'microcosm' ( ), rooted in a constrained definition of 'nutrient' that does not take into account the many other essential food components. it blocks 'the critical importance of viewing improvements in health in the much wider environment of social, political and economic contexts' (p. ). wells et al. ( ) embrace a wider biological approach to nutrition: ''the concept of malnutrition should also incorporate the gut microbiome, representing millions of genes from microorganisms. the microbiome generates a collective metabolic activity that affects and responds to the human host' (p. ). moreover, the 'triple burden' concept implies addressing not just sdg but also the ncds cited in sdg , and it is important to communicate this concern to a wider readership. use of the term 'non-nutrient components of foods' (the world bank ) is a misnomer: should not df be classed as a nutrient? just as there is a case for modernising the definition of protein quality (katz et al. ) , so may there be also a case for redefining nutrients in terms of df and other naturally-occurring food components that takes into account the nuanced and net effects on health of a wide range of bioactive compounds. meanwhile, 'biofocs' will serve the purpose for those substances that are essential to nutrition and health. and that implies new research on cereal foods, carbohydrates and df. we need to build knowledge about production factors affecting df, phytochemicals and other biofocs in major and minor cereals (gołębiewska et al. ) . distinction should be made among naturally-occurring substances and contaminants, industrial supplements and additives, and those which are beneficial or harmful (yasmeen et al. ( ) . to do so is beyond the scope of this viewpoint. agri-food systems thinking provides a robust platform for reshaping the agri-nutrition research agenda and to incorporate multi-disciplinary partnerships. there are ongoing wheat and maize systems research needs, which are to: i) accelerate plant breeding for nutritional quality and biofortified crop varieties, and scale up industrial fortification, both being proven strategies for enhancing the nutrient-intensity of major cereals among other crops (harvestplus ); ii) persist in crop productivity and sustainability research in diverse soil and production conditions and in the context of climate change, especially under the resource-constrained conditions of smallholder farmers (ritzema et al. ; kihara et al. ); iii) enhance practices for processing, manufacturing, storage and distribution of natural, bio-and industrially enriched cereal foods to reduce losses and nutritional harm in terms of both quality and quantity (sharma et al., b) ; iv) understand consumer behaviour at a disaggregated level: livelihood patterns and access to different foods among vulnerable groups, in different cultures, and in different production and marketing systems (haddad ) ; v) identify the inherent contradictions and resolve the trade-offs within cereal food systems concerning environmental sustainability, poverty reduction, profitability for actors and firms throughout the value chain, and improved nutrition and health of vulnerable populations. agri-nutrition and development communities need to embrace a multidisciplinary research agenda that integrates disciplines, goes beyond the nutrition 'microcosm', redefines nutrients and rethinks agrifood cereal systems. this calls for collaboration with other food systems stakeholders to broaden understanding of the nutritional and healthpromoting value of cereals, including preserving and enhancing the nutritional qualities of processed foods, and with consumers, assessing and assuring acceptance of novel and nutritious cereal-based products. research funds are increasingly with foundations and industry rather than traditional publicly-funded bilateral and multilateral donors and development organisations. it is not only because the problems are multidisciplinary and multisectoral that researchers must look for new collaborations: the required level of resources is held by the private sector. hence sdg . it would be pretentious to claim to have identified a kuhnian paradigm shift in agri-food systems for food security, nutrition and health, but we do need a broader and more nuanced understanding of the nutritional and health-promoting value of diverse foods, including cereals. we do not want to question here the merit of researchers and organizations engaged with cereals versus 'nutrient-rich foods'. micronutrients matter but so also do many other food components that contribute to health and wellbeing. we do want future research reprioritization, and the community of researchers, research funders and implementing organizations in agriculture, nutrition and international development to rethink strategies that go beyond vitamins and minerals, specifically to integrate the contribution of dietary carbohydrates and other macronutrients to health and wellbeing. cereals and 'nutrient-rich foods' are complementary in agri-nutrition and require additional research and resources, and increased attention for one should not replace the other. while concentrating on maize and wheat, we acknowledge that many of these considerations apply to rice, the other major cereal crop, and also to so-called 'minor' grains and 'speciality' grains-but detailed discussion is beyond the scope of this viewpoint. in rifkin's words, 'paradigm change depends on people accepting a new interpretation of events and putting in place policies to accommodate this new interpretation' ( : ). as long as the sdgs remain, and beyond, and while food systems drivers are evolving and acute, food security and nutrition research cannot be 'either/or' any of the elements of a comprehensive agri-nutrition agenda. in the covid- pandemic exposes the fragility of global food systems and adds urgency to reshaping the agri-nutrition agenda (development development initiatives, ; global panel ; united nations, a) . among the likely outcomes of the pandemic will be increases in poverty, hunger and malnutrition among the world's most vulnerable populations through reductions in dietary quality, incomes and healthcare provision. the lancet global health considers increasing food insecurity as a result of covid- to be 'an impending natural disaster' (editorial : e ) . with the likelihood that reduced national and international resources will imperil the work of national governments and organisations and the development community, the chances of achieving at least some of the sdgs are retreating beyond . the commitment to food security expressed in the g ministerial statement on covid- highlights the importance of cooperation, efficiency, appropriate support mechanisms and functioning markets 'to help ensure that sufficient, safe, affordable, and nutritious food continues to be available and accessible to all people, including the poorest, the most vulnerable, and displaced people in a timely, safe, and organised manner, consistent with national requirements' (g extraordinary agriculture ministers meeting : no page numbers). the views expressed in this paper are those of the authors and do not necessarily reflect those of any institution. the usual disclaimer applies. nigel poole is currently a visiting fellow, socio-economics program, international maize and wheat improvement center (cimmyt), mexico. jason donovan is senior economist, socio-economics program, cimmyt, mexico. olaf erenstein is director, socio-economics program, cimmyt, mexico. inclusive food system transformations for healthy diets: national experiences with a global challenge animal source foods: 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nutrition sensitivity buy or make? agricultural production diversity, markets and dietary diversity in afghanistan food counts. measuring food consumption and expenditures in household consumption and expenditure surveys (hces). introduction to the special issue improving nutritional quality of rice for human health dietary diversity scores: an indicator of micronutrient inadequacy instead of obesity for chinese children projected demand and supply for various foods in west africa: implications for investments and food policy authors wish to acknowledge the critique and suggestions of reviewers which have helped to shape the final version. we also extend thanks to colleagues who responded to queries about dietary and health effects of carbohydrates and to those who commented on fig. . simplifications, errors and omissions are the responsibility of authors. key: cord- -stod j authors: parekh, niyati; deierlein, andrea l title: health behaviours during the coronavirus disease pandemic: implications for obesity date: - - journal: public health nutrition doi: . /s sha: doc_id: cord_uid: stod j objective: obesity is a risk factor for severe complications and death from the coronavirus disease (covid- ). public health efforts to control the pandemic may alter health behaviors related to weight gain, inflammation, and poor cardiometabolic health, exacerbating the prevalence of obesity, poor immune health, and chronic diseases. design: we reviewed how the pandemic adversely influences many of these behaviors, specifically physical activity, sedentary behaviors, sleep, and dietary intakes, and provided individual level strategies that may be used to mitigate them. results: at the community level and higher, public health and health care professionals need to advocate for intervention strategies and policy changes that address these behaviors, such as increasing nutrition assistance programs and creating designated areas for recreation and active transportation, to reduce disparities among vulnerable populations. conclusions: the long-lasting impact of the pandemic on health behaviors, and the possibility of a second covid- wave, emphasize the need for creative and evolving, multi-level approaches to assist individuals in adapting their health behaviors to prevent both chronic and infectious diseases. obesity is a major public health concern in the usa. there are approximately % of americans with obesity (defined as a bmi > kg/m ), of which % suffer from severe obesity (bmi > kg/m ) ( ) . emerging evidence suggests that obesity is a strong risk factor for severe complications, hospitalisation and death from the coronavirus disease (covid- ) ( ) . in new york city, compared with adults (aged < years) with a bmi < kg/m , those with a bmi - kg/m and those with a bmi > kg/m were · ( % ci · , · ) times and · ( % ci · , · ) times more likely to be admitted to acute and critical care, respectively ( ) . although the specific biological mechanisms continue to be elucidated, inflammation and immune dysregulation are central to the aetiology of covid- , attacking the lungs and vasculature system and progressing to the heart, kidneys and other organs throughout the body ( , ) . individuals with obesity may be particularly susceptible to covid- infection due to the range of comorbidities associated with excess adiposity, including hyperglycaemia, hypertension, inflammation and impaired respiratory function ( ) . while social distancing measures are necessary to control the pandemic, they will also have unintentional consequences that may worsen the obesity epidemic and its related comorbidities in the usa. sheltering-in-place has significantly altered health behaviours and the food environment by limiting opportunities for daily physical activities, encouraging screen time and sedentary behaviours, disturbing sleep and promoting consumption of ultraprocessed foods and alcohol. all of these behaviours may contribute to weight gain and the development of cardiometabolic diseases, such as diabetes, hypertension and cvd. during this time, public health professionals are faced with the dual challenge of continuing to promote obesity prevention strategies, while supporting covid- containment efforts. herein, we discuss modifiable behavioural risk factors for weight gain that have been affected by the pandemic: physical activity, sedentary behaviours, sleep and diet (fig. ) . we provide strategies to improve them, which can be incorporated into public health messaging, interventions and tele-medicine during this period. the majority of american adults do not meet the national recommendations of at least min of moderate physical activity or min of vigorous physical activity (or an equivalent combination) per week ( ) . physical activity is associated with a wide range of meaningful health benefits. individuals who engage in regular physical activity are more likely to have a healthy weight status; reduced risks of cardiometabolic diseases, some cancers and osteoporosis; improved cognition; and shorter periods of depression and anxiety ( ) . physical activity is also critical for improving quality of life among individuals with chronic conditions and disabilities. social distancing and lockdown measures have diminished opportunities to participate in several domains of physical activity, particularly those related to recreation, transportation and work. recreational sources of activity, such as health clubs, gyms, pools, and indoor and outdoor sports facilities (e.g., tennis and basketball courts), have limited access and even after re-opening many individuals may be reluctant to use them. daily activities associated with transportation and work, for example, walking a child to the bus stop, running errands or climbing a flight of stairs at the office, have also been drastically reduced. these short bouts of activity throughout the day are important contributors to daily energy expenditure and weight gain prevention and allow for breaks in sedentary behaviours. during this time, efforts should be made to schedule movement throughout the day, particularly for individuals who do not have a regular exercise routine. walking is an excellent low-impact exercise that can improve cardiovascular fitness and increase energy expenditure, even in short -min increments ( ) . caregiving and household activities, such as playing with children, cleaning and gardening, may also be used to off-set lost daily activities from other domains. additionally, at-home exercise classes and programmes are available for free or low cost on many social media platforms (e.g., instagram, youtube and facebook) for various types of exercises and skill levels. information on these resources and other physical activity strategies can be tailored and distributed to target populations. the average american adult spends · - · h/d engaged in sedentary behaviours, such as sitting while working, higher alcohol intake fig. (colour online) interrelationships of behavioural risk factors for weight gain that have been affected by the covid pandemic; the confluence of these behavioural changes is hypothesised to exacerbate the national prevalence of obesity that is a threat for disease severity and mortality reading, watching television and using computers, smartphones or other devices ( ) . although the overall evidence for an association between sedentary behaviours and obesity in adults is inconsistent, sitting for extended time periods is associated with greater waist circumference and higher blood levels of tag, glucose and insulin, which are biomarkers of poor cardiometabolic health ( ) . the types of sedentary behaviours that individuals engage in are also important. among all of the sedentary behaviours, television watching likely has the greatest influence on weight gain due to the obesogenic behaviours that accompany it ( ) . television watching is an environmental stimulus that increases food intakes, independent of hunger-satiety signals or food palatability; therefore, consumption of meals and energy-dense snack foods in front of the television may result in excess energy, fat and sugar intakes ( ) . television watching also exposes individuals to advertisements for unhealthy foods and beverages, which may further encourage their consumption ( ) . for the majority of individuals, stay-at-home measures have increased sedentary time, especially among apartment dwellers. physical activity breaks throughout sedentary time can reduce sitting-related health risks and are associated with lower bmi and improved cardiometabolic health biomarkers ( ) . individuals can also keep meals and snacking separate from all work-, school-and leisure-related sedentary behaviours to reduce opportunities for overeating and junk food consumption. modern society has resulted in an increased prevalence of deficient sleep health, which encompasses inadequate sleep duration, poor sleep quality and sleep disorders. the average american adult suffers from deficient sleep due to sleeping less than the recommended - h/night, having a job that requires shift work and/or having a sleep disorder (e.g., insomnia, sleep apnoea) ( ) . deficient sleep is associated with increased risks of diabetes, hypertension, cvd and obesity ( ) . experimental studies demonstrate that restricted or impaired sleep reduces glucose tolerance and insulin sensitivity and alters appetite-regulating hormones, resulting in decreased satiety and increased feelings of reward and pleasure in response to food stimuli ( ) . individuals with short or disrupted sleep report greater energy intakes, which may be attributed to more frequent meal occasions, larger portion sizes and preference for energy-dense foods that are high in fat and carbohydrates ( ) . moreover, energy expenditure from physical activities is often reduced among people with inadequate sleep ( ) . the pandemic may disrupt and shorten sleep in several ways, including altering usual bed times (e.g., going to bed later), increasing screen time and intensifying anxiety and stress levels. individuals may be able to overcome some of this disruption by maintaining good sleep hygiene practices, such as setting a consistent sleep/wake routine, extending sleep duration to meet recommended amounts and avoiding or reducing blue light exposure from screen use (using blue light blocking glasses or software) around bedtime, since blue light may interfere with melatonin levels and stimulate brain activity ( ) . limiting late-night snacking and alcohol consumption and achieving recommended amounts of daily physical activity also help to regulate sleep. the external and household food environments are strongly correlated with individual diet quality and health. greater access to and purchases of fruits, vegetables and whole grains are associated with higher nutrient intakes, improved immune function and reduced chronic illness, while greater access to and purchases of ultra-processed foods are associated with nutrient deficiencies and chronic disease development ( ) . ultra-processed foods are defined as industrially manufactured, ready-to-eat or ready-to-heat formulations, which contain little to no whole, fresh foods. prior to the pandemic, ultra-processed foods constituted the majority of energies purchased by us households and were the main source of total and added sugars, na and fats. although some ultra-processed foods may provide vitamins and other essential nutrients (e.g., vitamin c, n- fatty acids and folic acid), the majority of these foods contain preservatives and additives (e.g., na, trans fats, high fructose maize syrup, artificial colourings, nitrites and sulphites), as well as neo-formed contaminants and chemicals ( , ) . these ingredients are hypothesised to influence cardiometabolic disease development through several mechanisms, including dysregulating blood lipid, glucose and hormone concentrations; altering gut microbiota; increasing body fat stores; and generating oxidative stress and inflammation ( , ) . additionally, ultra-processed foods are hypothesised to promote poor dietary habits, such as snacking and overeating, due to their convenience, omnipresence, low cost and large portion sizes ( ) . the pandemic has drastically changed the food environment. record high unemployment rates compounded by interruptions in the food supply chain due to worker shortages, heightened safety inspections and delays in the transportation and delivery of fresh foods have left consumers with no choice but to consume what they can afford and access at their local food stores. lockdown measures have also reduced the frequency of grocery shopping, further decreasing the ability to purchase perishable fresh foods, particularly produce. rates of household food insecurity are mounting and early reports from grocery retail stores demonstrate historically high sales of shelf-stable and ultra-processed foods, such as boxed macaroni and cheese and snack foods, as well as alcohol ( , ) . aside from issues surrounding substance abuse and mental health, alcohol consumption is associated with stimulating appetite, overeating and weight gain. although achieving optimal dietary quality is challenging during this time, individuals can make several efforts to increase their intakes of nutrient-dense foods. grocery store purchases should focus on frozen, canned (low na varieties) or dried plant-based items, like whole grains (e.g., brown rice, whole grain maize meal, whole wheat pasta and oats), pulses (legumes and beans), vegetables and fruits, as well as fresh produce that does not quickly perish, such as apples, pears, cabbage, carrots, squashes, sweet potatoes and beets. gardening, even in window sills and balconies, may further help to encourage consumption of vegetables, fruits and fresh herbs. stay-at-home measures have also increased reliance on cooking and baking, which provides the opportunity to make more healthful versions of storebought processed foods. for example, soups and stews, pizza, breads and cookies may all be home made with whole grains, vegetables and low sugar and salt content. beverage consumption should focus on varieties of water (e.g., plain, seltzer and fruit infused), while avoiding all sugar-sweetened beverages. the us dietary guidelines recommend that if alcohol is consumed then it should be done in moderation, defined as up to one drink for women and two drinks for men per day ( ) . for individuals who consume alcohol, daily drinking should be limited and should not be higher than pre-pandemic intakes, which may suggest that alcohol is being used as a coping mechanism for social isolation, boredom and other stressors. historically, obesity has been of public health concern due to its strong associations with chronic disease morbidity and mortality. the covid- pandemic has highlighted that obesity greatly increases susceptibility to complications and mortality from infectious diseases as well. public health measures to control the pandemic may alter health behaviours related to weight gain, inflammation and poor cardiometabolic health, exacerbating the prevalence of obesity, poor immune health and chronic diseases in the usa and other countries with developed economies. however, for many of these behaviours, specifically physical activity, sedentary behaviours, sleep and dietary intakes, the influence of the pandemic can be mitigated. table summarises individual-level practices related to each behaviour that may be promoted during this time. at the community level and higher, public health and health care professionals need to advocate for intervention strategies and policy changes that address these behaviours. for example, expanding community nutrition services and government food assistance programmes to reduce disparities among vulnerable populations or increasing designated areas for recreation and active transportation, such as green spaces, street traffic closures and protected bike lanes to provide safe spaces for individuals to exercise, walk, run and bike while maintaining social distance, particularly in urban areas. the long-lasting impact of the pandemic on health behaviours and the possibility of a second covid- wave emphasise the need for creative and evolving, multi-level approaches to assist individuals in adapting their health behaviours to improve immune function and prevent both chronic and infectious diseases. during extended periods of screen time • limit late-night snacking and avoid eating in the absence of hunger • limit consumption of packaged salty and sweet foods and sugarsweetened beverages • consume more plant-based foods, specifically whole grains, vegetables, fruits, lean proteins and dairy. substitute with lowsugar, low-salt frozen or canned items if fresh produce is unavailable • cook healthy meals at home • maintain good sleep hygiene practices; aim for at least h of sleep every night, avoid screens, bright lights, and caffeinated and alcoholic drinks before bed • consume alcohol in moderation or do not drink at all • cope with stress by doing breathing exercises, yoga, meditation, engaging in regular activity and ensuring sufficient sleep prevalence of obesity and severe obesity among adults: united states obesity a risk factor for severe covid- infection: multiple potential mechanisms obesity in patients younger than years is a risk factor for covid- hospital admission covid- cytokine storm: the interplay between inflammation and coagulation obesity and impaired metabolic health in patients with covid- physical activity and public health: updated recommendation for adults from the american college of sports medicine and the american heart association physical activity, exercise, and chronic diseases: a brief review the importance of walking to public health screen time, other sedentary behaviours, and obesity risk in adults: a review of reviews sedentary time in adults and the association with diabetes, cardiovascular disease and death: systematic review and meta-analysis non food-related environmental stimuli induce increased meal intake in healthy women: comparison of television viewing versus listening to a recorded story in laboratory settings priming effects of television food advertising on eating behavior meta-analysis of the relationship between breaks in sedentary behavior and cardiometabolic health the epidemiology of sleep and obesity short sleep duration and dietary intake: epidemiologic evidence, mechanisms, and health implications the role of sleep duration in the regulation of energy balance: effects on energy intakes and expenditure dealing with sleep problems during home confinement due to the covid- outbreak: practical recommendations from a task force of the european cbt-i academy characterization of the degree of food processing in relation with its health potential and effects ultraprocessed products are becoming dominant in the global food system the un decade of nutrition, the nova food classification and the trouble with ultra-processing ultra-processed diets cause excess calorie intake and weight gain: an inpatient randomized controlled trial of ad libitum food intake americans drop kale and quinoa to lock down with chips and oreos pandemic drives alcohol sales -and raises concerns about substance abuse dietary guidelines for americans th edition acknowledgements: none. financial support: none. conflict of interest: none. authorship: a.d. and n.p. wrote this work. ethics of human subject participants: not applicable. key: cord- - qk cpzd authors: wilkins, jennifer l. title: challenges and opportunities created by the covid- pandemic date: - - journal: j nutr educ behav doi: . /j.jneb. . . sha: doc_id: cord_uid: qk cpzd nan the covid- pandemic is an unprecedented challenge with immediate impacts on public and economic health. it has radically changed relationships across the globe. our personal relationships have been radically altered as we've learned to socially distance ourselves, wear face masks when walking or shopping, smile more with our eyes, and nod or wave our greetings. we're holding zoom meetings and classes and forming exclusive social "pods" of quarantine buddies and sharing meals virtually. our relationship with food is changing too. in a matter of months, covid- has brought about a change in behavior many nutrition educators view as critical to public health and sustainability: cooking. i dearly hope that the current surge in home cooking spells a long-term reversal in the overall decline home cooking that stretches back to . a recent hunter survey suggests that it may. more than half of the respondents said they were cooking more than before the pandemic. of particular interest to nutrition educators, threequarters of respondents claimed they had become more confident in the kitchen, and % said they will continue to cook more after the crisis ends. as people around the world have adjusted to covid- -driven stay-at-home guidelines, family meals-not just dinner-have become part of the new normal. for some, the shift to family meals may be one of the few good things to come out of the pandemic. not all changes are positive, however. sales of processed and "comfort" foods such as potato chips, cookies, popcorn, pretzels, candy have taken off since early march. scoffing at nutrition standards in the midst of a pandemic is understandable. as nutrition writer bettina elias siegel points out, stress often increases desire of highly palatable, yet unhealthy, food. while crushing stresses of "job insecurity, cramped living spaces, poorer sleep, a dearth of childcare, and lack of assured access to medical care" are new for many americans, for low-income families they were a way of life well before covid- . the opportunity for nutrition education is to advocate for nutrition quality and access to healthy food for all, in the best and worst of times. now is the time ensure our food safety net is adequate for the purchase of healthy food to cook. the pandemic is changing our relationship with food well beyond the kitchen. driven perhaps by increased uncertainty about the food supply, increased reliance on the emergency food system or simply by a need to control something basic to survival, home gardening is on rise at rates not seen since the great recession of . whether on a patch of lawn converted to vegetable beds, in containers on apartment deck, or in window boxes, more of us are growing some of our food. at the time of this writing, local suppliers are reporting seed shortages and consumers are starting their "pandemic gardens." the timing couldn't be better to integrate garden-based learning with nutrition education programming. further, snap-ed practitioners can remind recipients their benefit can be used for vegetable seeds. reports of breakdowns in conventional food supply chains and covid- hotspots among frontline food workers particularly in large industrial meat packing plants have exposed food system vulnerabilities, inequities and ethical breaches. the crisis that unfolded in big meat's supply chain shines light on yet another opportunity for nutrition educators to work at policy, systems and environmental change levels to create change. as the food system policy director at the johns hopkins center for a livable future, bob martin, suggests, "this virus is a warning shot, and it provides us with an opportunity to change our food system in ways that are less susceptible to disruption." as nutrition educators, academics, researchers and advocates we can help bring this change by helping less concentrated, more diverse, locally controlled and resilient food systems emerge and thrive. trends in us home food preparation and consumption: analysis of national nutrition surveys and time use studies from america gets cooking: the impact of covid- on americans' food habits. food study : complete study results cooking during covid- : family meals and fantasies of future dinner parties americans drop kale and quinoa to lock down with chips and oreos. bloomberg news need the comfort': processed foods make a pandemic comeback anxiety baking" say about socioeconomics and poor diet. the lunch tray seed companies can't keep up as more americans turn to growing their own food. cbs news growing youth growing food: how vegetable gardening influences young people's food consciousness and eating habits from farm to factory to table, coronavirus pandemic challenges us food system (commentary). syracuse.com meat-free future? coronavirus exposes america's fragile food system. the guardian key: cord- -ltjurdrq authors: acheson, d.w.k. title: food and waterborne illnesses date: - - journal: encyclopedia of microbiology doi: . /b - - . - sha: doc_id: cord_uid: ltjurdrq there are many different biological, chemical, or radiological agents that when added to food can result in many different types of illness. some may be rapidly fatal; others require long-term exposure to result in illness. some lead to short-term illness and others result in long-term complications. the universe of such agents and situations is enormous. this article summarizes some of the principal foodborne microbiological agents that clinicians and those involved with public health have to deal with. while the range of agents is broad and the list is long there are several basic mechanisms such as ingestion of preformed toxins or toxin production once a microbe is present in the intestine that facilitate sorting these agents into some logical framework. however, at the end of the day it is always key to think about ingested agents as a cause for illness, whether that illness be confined to the intestinal system or more systemic. in principle all foodborne illness is preventable and of the key messages to consumers and health care professionals is to know if you or your patient is at greater risk from foodborne illness. if one is dealing with an ‘at risk’ patient, it is important they be educated on what foods to avoid and what precautions to take to minimize the likelihood of acquiring a foodborne illness. while treating most foodborne illness is straightforward, prevention is clearly the path of choice. the topic under discussion is foodborne illness. while there are many causes of foodborne illness the focus of this text is on microbes. the text approaches the issues by discussing illness due to toxins preformed in foods and toxins made once the microbes have been ingested, illness due to other mechanisms that affect the gastrointestinal tract, and finally foodborne illness that has manifestations other than purely gastrointestinal. a wide variety of the common foodborne pathogens is discussed, with a brief description of what they are, the types of illness they cause, and the kinds of food most frequently associated with them along with some commentary with regard to treatment. food-and waterborne illness typically brings to mind the image of an individual who develops an acute gastrointestinal illness following exposure to contaminated food or water. however, the definition of illness that may be attributed to food or water is broad and encompasses exposure to toxins, carcinogens, metals, prions, allergens, and other factors, in addition to the classic infective pathogens. as reviewing each of these agents in detail is beyond the scope of this article, our focus will be on foodand waterborne infections only; an extensive list of foodborne pathogens is given in table . this article discusses the current epidemiology of foodborne illness, provides an overview of the various toxins and organisms considered to be the more important foodborne agents, and discusses some preventative approaches that can be used to help ensure consumers stay safe with regard to the food they prepare and eat at home. the clinical symptoms, treatment, and long-term consequences of various foodborne infections are also briefly reviewed. foodborne illness typically consists of acute gastrointestinal upset with nausea, vomiting, diarrhea, and abdominal cramps. typically, symptoms resolve without the need for significant medical intervention and without long-term consequence. however, on occasion foodborne infection causes severe illness or death. unfortunately, in the early stages of illness, differentiating between a patient with an inconsequential infection and the patient who may develop life-threatening sequelae can be difficult. some systemic consequences of infection occur several days or weeks after the initial exposure. examples include the hemolytic uremic syndrome (hus) secondary to shiga toxin-producing escherichia coli (stec), the development of guillain-barré syndrome (gbs) after campylobacter infection, and the association of a number of enteric bacterial pathogens with reactive arthritis and postinfectious irritable bowel syndrome. the true burden of foodborne illnesses in the united states and in other parts of the world is largely unknown; however, the number of suspected deaths worldwide from foodborne pathogen exposure is staggering. several million children die each year worldwide from acute diarrheal disease and resulting dehydration, the majority of which is likely due to contaminated food or water. in the united states, until recently, we had very little data on the numbers and outcomes of foodborne infection. the development of the foodborne diseases active surveillance network (foodnet) in by the centers for disease control and prevention (cdc) has provided, for the first time, the opportunity to determine the epidemiology of foodborne disease in the us population. foodnet is the (eip) , and is a collaborative venture with eip program sites, the us department of agriculture (usda), and the food and drug administration (fda). foodnet performs populationbased active surveillance for confirmed cases of campylobacter, e. coli o :h , listeria, salmonella, shigella, vibrio, yersinia, and hus, as well as cryptosporidium and cyclospora infections. in , surveillance occurred within a defined population of . million americans using information from clinical microbiology laboratories in ten states. foodnet monitors only confirmed cases of diarrheal infection, missing cases that never present to medical attention. however, through additional surveys, foodnet has the capacity to determine the frequency of diarrhea and the number of physician visits within the study population. utilizing foodnet and other data, the cdc provides our current best estimate of the true burden of foodborne infections in the united states. mead and his colleagues from the cdc estimate that there are million illnesses, hospitalizations, and deaths annually due to foodborne infections. this means that, on average, somewhere between one in three and one in four americans will have a foodborne infection each year. while these data provide an excellent estimate of disease prevalence in the united states, they also illustrate some major gaps in our knowledge of foodborne infections. specifically, determining attribution can be very difficult. for example, in the context of sporadic infections, the precise food that has caused the illness and the point at which the food was contaminated are usually unknown. or indeed whether the infection was acquired through person-to-person spread or by some other route is difficult to ascertain. also, in million cases, or % of the estimated million infections each year, no specific pathogen is identified. disease due to unidentified agents results in hospitalizations and deaths, which begs the question as to whether these are due to known pathogens or foodborne infections yet to be discovered. our ignorance as to the cause of more than % of the estimated foodborne illness is a daunting problem. however, many new agents have been discovered and linked to foodborne disease in the last years. table offers a list of some recently described food-and waterborne pathogens, some are new pathogens and others are agents previously recognised but infrequently linked to illness or considered nonpathogenic. for example, campylobacter jejuni was once thought to be an unusual cause of bacteremia but is now known to be one of the most frequent bacterial causes of enteritis in the united states. in , the most recent year for which preliminary foodnet data are available, the cdc confirmed laboratory-confirmed cases of infections from the foodnet sites. incidence varied dramatically between the foodnet sites. for example, campylobacter affected . per people in georgia and . per in california. salmonella infections varied from . per in oregon to . per in georgia. though the explanation for these geographic differences is unknown, they seem to suggest true regional variation of foodborne pathogens. another trend observed in foodnet data was the preponderance of cases in the young and elderly. in , foodnet identified cases of hus in children aged below years (rate: . per children); ( %) of these cases occurred in children aged below years (rate: . ). across all age groups, clinical outcomes differed by pathogen. while the total number of listeria monocytogenes and e. coli o :h infections were less than for some of the other pathogens, they were associated with much higher hospitalization rates and death rates than any of the other bacterial pathogens monitored (table ) . table reflects the lack of correlation between the propensity for an organism to cause disease and its propensity to result in the death of the patient. since foodnet began to operate in , the accumulated data have also revealed a seasonal trend, with a spike in infection with the three major pathogens (salmonella, c. jejuni, and e. coli o :h ) during the summer months (figure ) . the summer predominance of bacterial foodborne infections is likely multifactorial. clearly, warmer weather allows for more rapid bacterial growth on food that is improperly refrigerated. consumer habits also change in the warmer months, with more picnics and barbecues, contributing to problems with keeping food refrigerated, increased risk of cross contamination, and so on. foodnet surveillance effectively monitors trends in the rates of infection over time and there have been a number of changes since foodnet surveillance began, with the estimated annual incidence of several infections changing significantly from baseline to (figure decreased significantly ( % ci ¼ - %). in contrast, significant increases in incidence compared with baseline occurred for salmonella enteritidis ( %, ci ¼ - %), salmonella newport ( %, ci ¼ - %), and salmonella. javiana ( %, ci ¼ - %). the estimated incidence of salmonella heidelberg and salmonella montevideo did not change significantly compared with baseline. while foodnet produces excellent data on the epidemiology of foodborne illness overall, it has several important areas of weakness. it does not survey for many of the common foodborne pathogens, including viruses, which are thought to cause the vast majority of foodborne illness. similarly, it does not address the cause of illness in patients who do not have a stool sample sent for analysis: those who either do not seek medical care or do seek care but do not have a stool sample analyzed. in an adjunctive study reported by the cdc, % of residents interviewed through random phone consultations reported an episode of diarrhea during the previous month. this translates to . episodes of diarrhea per person per year, which if multiplied roughly by the population of the united states, represents million diarrheal cases per year. in this study, merely % of those with a diarrheal episode sought medical care, and of those, only % reported submitting a stool sample for culture. thus, our best data on the causes of acute gastrointestinal disturbance from foodnet surveillance are based on cultures of less than % of diarrheal episodes. nonetheless, despite the current limitations of our evaluation of foodborne illness, the endeavors of state, local, and federal authorities have been critical to improving our knowledge of disease frequency, pathogen epidemiology, and the establishment of control systems to limit food contamination. the knowledge gained from foodnet surveillance allows for targeted efforts to improve food safety and education. as noted previously, the diversity of foodborne pathogens listed in table is far too extensive to be discussed completely within the scope of this article. in the following sections therefore, many of these microbial agents will be discussed briefly with a focus on typical modes of transmission, the foods they frequently contaminate, and the specific serious consequences that may ensue from infection. although foodborne agents cause disease by a wide variety of mechanisms, the mode of infection often falls into one of the following three categories: ( ) ingestion of preformed toxins produced by bacteria in food prior to consumption; ( ) infection with pathogens present in food which, following ingestion, produce toxins in the gastrointestinal tract; and ( ) infection with organisms having various virulence factors that permit the microbes to be invasive, cause local damage, or create physiologic perturbations that result in clinical disease. of the three mechanisms, the preformed toxin is the most consistently transmitted via food. as each toxigenic organism requires a specific environment to stimulate toxin production, each has a predilection for certain types of food. as a result, different types of foods confer different risks for toxin ingestion. the major toxins of the common foodborne pathogens are discussed in detail in the next few sections and were reviewed by sears and kaper in . c. botulinum produces one of the best-known and deadly preformed toxins. the organism's natural habitat is soil, and therefore, its spores frequently contaminate fresh fruits and vegetables. commercial food sources have been occasionally implicated, but the majority of outbreaks have been traced to home-canned foods, especially vegetables, fruits, fish, and condiments. recent outbreaks have been attributed to chili, carrot juice, and home-prepared fermented tofu. generally the disease is rare, and in the united kingdom, only cases have been recognized between and . a recent report from the united kingdom provides a brief review of c. botulinum and foodborne botulism as well as descriptions of the six episodes ( cases with three deaths) of this disease that occurred in the united kingdom between and . to prevent botulism, the clostridium spores must be destroyed by heating food to a temperature of c for min, usually with the aid of a pressure cooker. in an anaerobic environment with a ph above . , any surviving spores will germinate and produce their deadly toxins. there are seven antigenically distinct types of botulinum toxin, each of which is designated by a letter, a-g. types a, b, e, f, and g are associated with human disease, with type a accounting for about % of outbreaks and type b %. once ingested, the toxin is absorbed through the proximal small intestine and spreads via the bloodstream to the peripheral cholinergic nerve synapses where it irreversibly blocks acetylcholine release. a flaccid paralysis results, with cranial nerves affected first, followed by respiratory muscle paralysis and death if left untreated. the diagnosis of botulism is clinical and treatment should be initiated prior to confirmation with laboratory data, as the traditional mouse bioassay for toxin detection requires days for final results. samples such as food, vomitus, serum, gastrointestinal washings, and feces are all reasonable specimens to test. newer pcr-and enzyme immunoassay-based detection methods are now being used. early in the course of disease, treatment may include emetics or gastric lavage to remove unabsorbed toxin. a trivalent (a, b, e) horse serum antitoxin decreases the progression and duration of paralysis, but it does not reverse existing paralysis. pentavalent and heptavalent antitoxins are also being investigated. human botulism immune globulin intravenous (big-iv) may also be beneficial. botulism carries a significant mortality rate, of up to %, with type a toxin. of those who survive the acute phase of illness, most recover completely. see later in the article for a discussion of infant botulism, which is a similar condition but not due to preformed toxin. a second well-known group of preformed toxins are those produced by s. aureus. s. aureus produces a variety of enterotoxins, defined by their antigenicity as enterotoxins a-h. staphylococcal enterotoxins a through g are responsible for % of staphylococcal food poisoning outbreaks. on rare occasions, other staphylococcal species, including coagulase negative staphylococci, have been found to produce similar enterotoxins. the toxins are small proteins with similar tertiary structures and biologic activity, including superantigen properties. ingestion of as little of - ng of toxin is considered sufficient to cause disease in humans. compared with botulinum toxin, staphyloccocal toxins are not inactivated by heating or boiling; nor are they susceptible to ph extremes, proteases, or radiation. as a result, once formed in food, these toxins are almost impossible to remove. the mechanism through which the toxin acts is not fully understood, but is suspected to be via stimulation of the autonomic nervous system and gut inflammation. as the toxin is not absorbed systemically, protective immunity is not induced following exposure. typically, patients become symptomatic between and h after ingestion of the food containing staphylococcal enterotoxin, with nausea ( - %), vomiting ( %), and abdominal cramps ( - %). diarrhea occurs in a large proportion of patients ( - %), but fever is rare. treatment of affected individuals is supportive and symptoms usually abate within days. there is no need to treat with antibiotics directed toward s. aureus. s. aureus is present in the mucous membranes and skin of most warm-blooded animals. food is most often contaminated with s. aureus through the fingers or nose of a food worker. the toxin is produced when contaminated food is stored at room temperature for a sufficient length of time to allow the organism to grow and produce toxin. the bacterial population must be greater than organisms per gram of contaminated food before appreciable amounts of toxin will be produced to elicit illness. a number of different foods have been associated with staphylococcal food poisoning, including egg products, cooked meat products, poultry, tuna, mayonnaise, and particularly cream-filled desserts and cakes. this disease is more frequently associated with food from the home or a service establishment rather than commercially prepared food. it has also occasionally occurred in large outbreaks with thousands of affected individuals. a third example of preformed toxins are those of b. cereus, a gram-positive, spore forming aerobe that causes two distinct clinical syndromes: a short-incubation period emetic syndrome and a long-incubation period diarrheal syndrome. the organism is known to produce up to three enterotoxins. cereulide and the tripartite hemolysin bl have been identified specifically as emetic and diarrheal toxins, respectively. nonhemolytic enterotoxin, a homologue of hemolysin bl, has also been associated with the diarrheal syndrome. the toxins associated with the diarrheal illness are not preformed but produced by the organism during the vegetative growth phase in the small intestine. the emetic toxin, named cereulide, is thought to be an enzymatically synthesized peptide produced as the organism grows in food, especially starchy foods such as rice and pasta. like staphylococcal toxin, cereulide is resistant to heat, ph variation, and proteolysis, and is therefore rarely destroyed during food preparation. its exact pathogenic mechanism remains unknown, but it has been shown to stimulate the vagus afferent by binding to the -ht receptor. the emetic syndrome presents much like s. aureus-related foodborne disease, occurring - h after exposure and causing nausea and vomiting. fever is not characteristic of the illness and full recovery usually occurs. diagnosis can be made by finding the organism in the food or vomitus of the patient, or through detection of the emetic toxin through bioassays or the enterotoxins by commercial immunoassays. new approaches include the use of real-time pcr to detect cereulide-producing b. cereus genes in potentially contaminated food. derived from various types of food, a number of naturally occurring toxins may cause human foodborne illness. many are associated with consumption of seafood contaminated by algae. others are due to fungal contamination of food or inherent to certain fruits and vegetables. scombroid poisoning typically occurs after the ingestion of spoiled, dark-fleshed fish, especially tuna and mackerel. the clinical symptoms of poisoning, including flushing, headache, palpitations, dizziness, nausea, vomiting, and diarrhea, are attributable to excess levels of histamine present in temperature-abused fish. histamine is produced by bacterial metabolism of the amino acid histidine in fish muscle. bacterial replication and histamine production occur when fish is not frozen promptly after being caught or is stored at room temperature for several hours. symptoms of intoxication begin within minutes to several hours following ingestion. most resolve fully within hours, but, occasionally, bronchospasm or circulatory collapse may occur. the diagnosis is clinical, and treatment consists of antihistamines. elevated histamine levels in the contaminated fish or the patient's serum may be diagnostic, but few laboratories, other than regulatory laboratories, are equipped to undertake this analysis. ciguatera poisoning is due to the ingestion of neurotoxins from tropical and subtropical marine fin fish, including mackerel, groupers, barracudas, snappers, amberjack, and triggerfish. it affects individuals yearly, mainly in the caribbean and south pacific islands. the toxin is produced in reef algae, the dinoflagellates (e.g., gambierdiscus toxicus). it spreads through the food chain via consumption of smaller organisms and fish by larger predators, accumulating at dangerous levels in the flesh of large fish. two groups of compounds are implicated in ciguatera fish poisoning: the lipid-soluble ciguatoxins, which activate nerve synapse sodium channels, and the water-soluble maitotoxin, which induces neurotransmitter release by binding to calcium channels. in humans, these toxins cause gastrointestinal symptoms - h after ingestion, including nausea, vomiting, and watery diarrhea. neurologic symptoms follow, with weakness, heat-cold temperature reversal, vertigo, ataxia, paresthesias, and dysathesias of the perioral region, palms, and soles. death and serious cardiovascular complications are uncommon. most symptoms resolve within a week, but neurologic symptoms can persist for months. the diagnosis of ciguatera is clinical; however, the toxin can be detected in fish using a mouse bioassay or newer enzyme immunoassays. five main types of shellfish poisoning have been described: paralytic, neurotoxic, diarrheic, amnestic, and azaspiracid. like ciguatera, illness is due to toxins generated by algae, usually dinoflagellates, which accumulate in the shellfish. the paralytic variant of shellfish poisoning is due to saxitoxin, an agent that blocks neuronal sodium channels and prevents propagation of the action potential. clinically, this results in a rapid-onset, life-threatening paralysis. brevitoxin, the agent responsible for neurotoxic shellfish poisoning, also binds sodium channels but does not cause paralysis; instead, it produces a clinical syndrome similar to but less severe than ciguatera. symptoms of nausea, vomiting, and paresthesias occur within hours of exposure and resolve completely within days. diarrheic shellfish poisoning causes gastrointestinal disturbance with nausea, vomiting, and diarrhea. the toxin acts by increasing protein phosphorylation. amnestic shellfish poisoning, also known as toxic encephalopathic poisoning, causes outbreaks of disease in association with consumption of mussels. manifestations include nausea, vomiting, diarrhea, severe headache, and, occasionally, memory loss. the toxin domoic acid is a glutamate receptor agonist that causes excitatory cell death. diagnosis of human illness due to shellfish toxins is clinical based on symptom profile and prompt onset of symptoms after shellfish consumption. the exception to this is amnestic poisoning, which may not cause symptoms until - h after exposure. the toxins can be detected using either mouse bioassays or high-performance liquid chromatography (hplc), but this is done primarily for research purposes or in monitoring. owing to the serious consequence of shellfish poisoning, large-scale surveillance systems for contamination of shellfish populations have been implemented. tetrodotoxin is present in certain organs of the puffer fish and if ingested can cause rapid paralysis and death. symptoms may occur in as little as min or after several hours. the illness progresses from gastrointestinal disturbance to almost total paralysis, cardiac arrhythmias, and death within - h after ingestion of the toxin. the diagnosis is clinical and based on history of exposure. mouse bioassays and hplc have been used to detect tetrodotoxin in food. aflatoxins are produced by certain strains of fungi (e.g., aspergillus flavus and aspergillus parasiticus) that grow in various types of food. most human exposure occurs through mold-contaminated corn or nuts, especially tree nuts (brazil nuts, pecans, pistachio nuts, and walnuts), peanuts, and other oilseeds. because mycotoxins can be produced prior to or after harvest, eliminating them from food is nearly impossible. aflatoxin b is the most common and toxic, but there are several types of toxins (b , g , and g ). they are potent mutagens and carcinogens, with b causing deoxyribonucleic acid (dna) damage in the p tumor suppressor gene. exposure to the aflatoxin predisposes the patient to hepatocellular carcinoma, especially in conjunction with chronic hepatitis b infection. with a high ingested dose of aflatoxin, a condition known as aflatoxicosis may occur, characterized by fever, jaundice, abdominal pain, and vomiting. aflatoxin exposure is common in asia and parts of africa but uncommon in the united states. the diagnosis is clinical, but assays to detect the toxins in food exist. serum and urine markers have also been developed to quantify exposure. vibrios currently, there are over vibrio species, a group of gram-negative marine organisms, most of which are not human pathogens. the most common and severe human illness is caused by vibrio cholerae o , the species responsible for seven cholera pandemics. the previous six were caused by the 'classic' biotype and the seventh pandemic, which began in , was caused by the 'el tor' biotype. in the united states, cholera is mainly acquired through consumption of gulf coast seafood or through foreign travel. a clean water supply is critical to cholera prevention, as the organism is resistant to washing, refrigeration, and freezing of a wide variety of seafood and fresh produce. because stomach acidity does kill many of the organisms, more than v. cholerae are usually required for infection; those with decreased gastric acidity may be infected with lower doses. the incubation period is usually - days, but may be as short as a few hours or as long as days. infection causes voluminous watery diarrhea. hypotension and shock may result within the first h of infection. the primary virulence factor is the cholera toxin, which targets an intestinal g-protein, producing cyclic adenosine monophosphate (camp). the increase in camp produces watery diarrhea by inhibiting intestinal sodium absorption and increasing chloride and bicarbonate secretion. the toxin is transmitted to the organism via a bacteriophage. indeed, in recent years a new pathogen, v. cholerae o , evolved in the indian subcontinent. non-o strains were not previously associated with human epidemics, but this pathogen appears to have acquired the cholera toxin and other virulence factors through horizontal transmission and bacteriophage infection. vibrio parahaemolyticus also inhabits marine environments and is acquired principally through the ingestion of raw shellfish. this vibrio has been a major foodborne pathogen in japan, but is less common in the united states. in recent years there has been global dissemination of v. parahaemolyticus serotype o -k . infection is characterized by diarrhea, abdominal cramps, nausea, and vomiting, with fever and chills present in about % of cases. dysentery occurs in a minority of patients, more often in children than in adults. occasionally, wound infections and septicemia occur. symptoms may appear in as little as h, but are typically present - h after exposure. disease is attributed to a kda protein called thermostable direct hemolysin (tdh). the gastroenteritis is usually self-limiting. patients require fluids, and antibiotics may be useful if intestinal symptoms persist. vibrio vulnificus is another free-living estuarine organism that is frequently isolated from shellfish, most often acquired through raw oyster or clam consumption. it is the most common life-threatening vibrio infection in the united states. individuals with diabetes, immunosuppressive disorders, and liver disease including hemochromatosis and alcoholic liver disease are especially susceptible to infection. in these groups the case fatality ratio may exceed %. infection presents with fevers, chills, nausea, vomiting, and diarrhea. hypotension and sepsis ensue. large hemorrhagic bullae erupt and progress to necrotic ulcers. v. vulnificus is an encapsulated organism, thereby resistant to the bactericidal activity of normal human serum. the pathogenesis of v. vulnificus is not well understood but has been summarized recently by gulig and colleagues. the organisms are sensitive to the amount of transferrin-bound iron in the host, which may explain the increased susceptibility in patients with hemochromatosis. definitive diagnosis may be made from blood, stool, or wound cultures. due to the severity of infection, antibiotics should be initiated promptly. v. vulnificus is susceptible to many antimicrobials, including tetracycline, ciprofloxacin, trimethoprim-sulfamethoxazole, ampicillin, and chloramphenicol. clostridium perfringens is an anaerobic, spore-forming, gram-positive rod associated with two distinct types of foodborne disease. the species has been divided into five distinct types, a-e. type a causes the majority of human infections and is usually linked to the consumption of meat or poultry (typically high-protein foods) that have been stored between and c for more than h. at this temperature, clostridial spores germinate and begin vegetative growth. at an infective dose of vegetative cells, ingested clostridial spores transiently colonize portions of the intestine and produce enterotoxin. ingestion of preformed toxin or nongerminated spores will not usually result in disease. the enterotoxin (cpe) is a heat-labile kda protein encoded by the cpe gene. c. perfringens types a, c, and d all carry this gene, but for unclear reasons only type a is frequently associated with foodborne disease. cpe functions by a complex mechanism, inserting itself into the host cell membrane and altering membrane permeability. clinically, diarrhea and severe abdominal cramps develop - h after exposure; vomiting and fever are less common. diagnosis is complicated by the presence of c. perfringens in the bowel microflora of many asymptomatic individuals. however, a number of tests are able to detect the enterotoxins in stool, including enzyme immunoassays or latex agglutination. c. perfringens type c causes the second distinct foodborne illness, mainly in developing countries. it causes a necrotizing enterocolitis seen in the context of malnutrition. the type c strains produce enterotoxin and type 'a' and 'b' toxins. the b toxin appears to be responsible for the cell necrosis associated with infection. as the b toxin is inactivated by intestinal proteases, illness occurs in patients in whom these enzymes are inadequate (e.g., in malnutrition) or in the presence of trypsin inhibitors found in undercooked pork or sweet potatoes. infant botulism results from the germination of ingested spores of botulinum toxin-producing clostridia that colonize the large intestine. the spores germinate within the intestine and produce botulinum toxin. of the various potential environment sources such as soil, dust, and foods, honey is the one dietary reservoir of c. botulinum spores that has definitively been linked to infant botulism by both laboratory and epidemiological studies. children aged months are very susceptible to developing infant botulism. honey continues to be an important exposure source in young infants and cases continue to occur. jars of honey bear a label advising parents to not feed honey to children less than months old. the two main e. coli species associated with foodborne illness are stec and enterotoxigenic e. coli (etec). the former are relative newcomers to the scene of foodborne pathogens. the first stec to be associated with disease in humans was e. coli o :h following two outbreaks of hemorrhagic colitis in . since then, at least different serotypes of stec have been associated with clinical disease and have become recognized as the most common cause of hus. not all stec have been associated with human illness and the more virulent forms are often referred to as enterohemorrhagic e. coli (ehec) that are characterized by having the ability to attach and efface intestinal epithelium, produce shiga toxins (stx), and carry a specific plasmid. stec bacteria colonize the intestinal tracts of many mammalian species, particularly ruminants (cattle, sheep, and goats). most human illness is due to the ingestion of contaminated bovine products, but an increasing number of reports associate infection with fecally contaminated fresh produce (lettuce, alfalfa sprouts, unpasteurized apple cider, spinach) and water. one of the key virulence factors of stec is bacteriophage-encoded stx. the two main types are stx and stx , but there are at least five subtypes of stx (stx , c, d, e, and f). the infectious dose of some stec (e.g., o :h ) is known to be very low, in the region of - organisms. symptoms typically develop - days after ingestion, but may occur in as little as day or as long as days. nonbloody or bloody diarrhea is the primary acute manifestation. treatment of stec and its major complications is currently largely supportive. controversy exits as to the role of antibiotics, with concern that treatment of pediatric patients with certain antimicrobials (e.g., fluoroquinolones and trimethoprim-sulfamethoxazole) may actually increase the likelihood of serious complications such as hus. several recent reviews relating to foodborne e. coli infections have been written, and the reader is referred to them for more details. a well-described example of a long-term consequence following infection with a foodborne and waterborne pathogen is the hus resulting from stec infection. in the united states, . % of patients will require a renal transplant following hus. in up to % of patients with hus, the pancreas is also damaged, causing some patients to develop permanent diabetes mellitus. etec infection is a common cause of disease in developing countries, and is frequently associated with travelers' diarrhea. etec are transmitted through contaminated water and food and have caused a number of large outbreaks in the united states; however, their importance in sporadic disease is not known. incubation periods range from h to days, and typical symptoms are abdominal discomfort and watery, nonbloody diarrhea without fever. etec have two significant virulence characteristics: the ability to colonize the intestine and the capacity to produce enterotoxins. a variety of colonization factor antigens (cfa) and two different types of toxins, known as heatstable (st) and heat-labile (lt) toxins, have been found in etec. the st group consists of small peptides that effect intracellular concentrations of cyclic guanosine monophosphate (gmp). the lt toxins are structurally and functionally much like the cholera toxin. oral rehydration is the mainstay of treatment and is often life saving for infants. antibiotic therapy is not routinely required. salmonella salmonella are one of the most common causes of foodborne illness in humans. they can be divided into two broad categories: those that cause typhoid and those that do not. the typhoidal salmonella, such as s. typhi and s. paratyphi, colonize humans and are acquired through the consumption of food or water contaminated with human fecal material. the much larger group of nontyphoidal salmonella are found in the intestines of other mammals and, therefore, are transmitted through food or water that has been contaminated with fecal material from a wide variety of animals and poultry. more than serovars of salmonella are differentiated by their somatic (o) antigens and flagellar (h) antigens. in the united states, most typhoid is the result of food contamination by an asymptomatic chronic carrier, or from foreign travel. typhoid fever continues to be a global health problem, but is uncommon in the united states; only outbreaks occurred between and . in contrast, the number of cases of nontyphoidal salmonella increased steadily over the last four decades. s. enteritidis infection due to contamination of hen eggs is a particular problem, with an estimated contamination rate of in eggs. the bacteria penetrate intact eggs lying in fecal material or infect them transovarially before the shell is formed. other common sources of nontyphoidal salmonellosis are inadequately pasteurized milk, foods prepared with raw eggs, meat, poultry, and fecally contaminated fresh produce. the infectious dose of s. typhi is thought to be around organisms. typhoid infection is characterized by high fevers, abdominal discomfort, and a rose-colored macular rash. the infective dose of nontyphoidal salmonella may vary from < to depending on the host, the food vehicle, and the type of salmonella. these species tend to cause bloody or nonbloody diarrhea, fever, nausea, vomiting, and abdominal discomfort. in all types of salmonella the most critical virulence determinant is their ability to cross the intestinal epithelium and cause invasive disease. the most pressing problem regarding salmonella is the emergence of multidrug-resistant strains. for example, s. typhimurium phage type dt is resistant to ampicillin, chloramphenicol, streptomycin, sulfonamides, and tetracycline. in europe quinolone-resistant strains of salmonella have been detected. campylobacter, which was not recognized as a foodborne pathogen until the mid s, is now one of the most common bacterial foodborne infections diagnosed in the united states. campylobacter are gram-negative, spiral, microaerophilic organisms. two species of campylobacter, c. jejuni and c. coli, are responsible for the vast majority of human disease, with c. jejuni causing % of infections and c. coli near %. campylobacter fetus, campylobacter upsaliensis, campylobacter hyointestinalis, and campylobacter lari have occasionally been associated with gastroenteritis. in human studies, infectious doses as low as organisms may result in disease, and one drop of chicken juice may contain infectious organisms. campylobacter are more frequently associated with sporadic disease than with outbreaks, and person-to-person spread does not appear to be common. c. jejuni and c. coli are intestinal commensals in many animals and birds, including domestic pets. the main vehicle for human infection is poultry, but other raw meats, milk, and water have also been implicated. surface water can be contaminated with campylobacter and waterborne outbreaks have been reported. the pathogenicity of campylobacter depends on its motility; in vitro, nonmotile strains are not capable of invading intestinal epithelial cells. typical infection causes diffuse colonic inflammation with marked inflammatory cell infiltration of the lamina propria, which may be mistaken for inflammatory bowel disease. symptoms usually occur within - days after exposure, but may occur as quickly as h or as late as days. high fevers, headache, and myalgias may precede the onset of nausea, vomiting, and diarrhea. the diarrhea may be loose and watery or grossly bloody. abdominal cramps and pain may predominate. interestingly, the disease is sometimes biphasic, with an apparent settling of symptoms after - days followed by a recrudescence. local complications resulting from direct spread of the organisms from the gastrointestinal tract are rare and include cholecystitis, hepatitis, acute appendicitis, and pancreatitis. the case fatality rate is low, approximately . per infections. however, long-term complications may occur including gbs. gbs affects - persons per in the united states each year, or less than person per infected. a recent article by hughes and cornblath address this issue and they point out that about a quarter of patients with gbs have had a recent c. jejuni infection, and that axonal forms of the disease are especially common in these people. the pathogenesis of injury is molecular mimicry, in which the immunologic response to the core oligosaccharides of campylobacter lipopolysaccharide cross-react with a variety of neuronal glycosphingolipids. up to % of individuals affected by gbs require mechanical ventilation, and another % will have permanent neurologic deficits. the overall risk of developing gbs following campylobacter infection is considered to be in . the percent of cases of gbs linked to prior infection with campylobacter is estimated to be - %. at least campylobacter serotypes have been associated with gbs, but serotype o: is thought to be the most common association. the interval between infection and the development of gbs may be as short as week or as long as . those with a rapid onset of gbs are suspected to have had prior exposure to the critical campylobacter serotypes and therefore primed for a rapid immune response. diagnosis of campylobacter is confirmed by stool culture. pcr and enzyme immunoassays are now available and may become useful for species-specific antigen detection. as with salmonella, a growing number of campylobacter are developing antimicrobial resistance. fluoroquinolones are generally very active against campylobacter when they are susceptible, and there was a period when it appeared that these would be the drugs of choice. however, the increasing problems with fluoroquinolone resistance now makes fluoroquinolones much less desirable and not a drug of choice in first-line therapy. in sweden, quinolone resistance in clinical isolates of c. jejuni increased more than fold in the early s; macrolide resistance is also increasing. of the three members of the genus yersinia, y. enterocolitica and y. pseudotuberculosis are considered to be foodborne pathogens, whereas y. pestis is typically not. overall, yersinia cause less foodborne illness than salmonella or campylobacter, and the majority of isolates in food, environmental samples, and human stool are nonpathogenic species. y. enterocolitica is divided into biogroups, with more than 'o' antigens used to designate strains. most human disease is associated with serotypes o , o , o , or o . y. enterocolitica is an invasive organism. all pathogenic strains carry a plasmid pyv, coding for the virulence proteins yersinia outer proteins (yops) and adhesin a (yada), which block phagocytosis, opsonization, and complement activation; and yersinia enterotoxin (yst), invasin (inv), and attachment-invasion proteins (ail), which mediate invasion and serum resistance. a variety of tests, including pcr and dna hybridization, congo red absorption, salicin fermentation, and esculin hydrolysis, can be used to determine if a strain is pathogenic. y. enterocolitica infection results in mesenteric lymphadenitis, enteritis, and diarrhea. most infections are selflimited, but symptoms can be prolonged, lasting several weeks or longer. complications such as ulceration and intestinal perforation may occur. the classic long-term complication following yersiniosis is the development of reactive arthritis, occurring most commonly in patients who are hla-b -positive. although antibiotic therapy is not routinely required, many antimicrobials are effective; ceftriaxone or fluoroquinolones are recommended for serious infection. yersinia infection is most frequently associated with raw or undercooked pork consumption. swine are the major reservoir of these organisms, though pathogenic human strains have been found in sheep, dogs, cats, and wild rodents. milk is a frequently reported source, and since y. enterocolitica can survive and indeed multiply in milk at c, small numbers of organisms can become a significant health threat, even if the milk is refrigerated. six serotypes and four subtypes of y. pseudotuberculosis have been described, but serotype o is associated with about % of human disease. the clinical picture is similar to that of y. enterocolitica. l. monocytogenes is a pathogen of great concern because of the high mortality rate associated with infection. listeriosis is the major concern from exposure to l. monocytogenes and although rare and usually occurring only in high-risk populations ( cases per year estimated to occur in the united states) is associated with high morbidity and mortality rates, with a case fatality rate of over %. of the seven listeria species, only l. monocytogenes is a significant human pathogen. it is common in the environment, present in soil, water, on plants, and in the intestinal tracts of many animals. thirty-seven different types of mammals, at least species of birds, and between and % of humans are carriers of listeria. although the organism is readily killed by heat and cooking, the fact that it is ubiquitous makes recontamination a real risk. of particular concern is that the organism is able to grow and multiply at refrigerator temperatures in certain foods, so even minor contamination of a product may result in high levels of bacteria after extended storage. the infectious dose is not known, with some studies suggesting it may be as high as organisms, and others suggesting that it may be as low as several hundred. the more critical determinant of listeria infection is likely individual susceptibility, with the elderly, pregnant women, the immunocompromised, and newborns having higher rates of infection and higher mortality rates. foods associated with listeriosis include unpasteurized milk, soft cheeses (e.g., feta, camembert, and brie), coleslaw, smoked seafood, luncheon meats, and hot dogs. human infection occurs sporadically and in outbreaks. infected individuals suffer a mild, transient gastroenteritis - days after contaminated food is consumed. most immunocompetent adults have no further symptoms. susceptible individuals may suffer, after a period of days, fevers and mylagias, septicemia, meningitis, or encephalitis. pregnant women have a -fold increased risk of infection, and transplacental transmission may cause spontaneous abortion, premature birth, neonatal sepsis, and meningitis. once the diagnosis is established, l. monocytogenes is readily treated by penicillins or aminoglycosides. l. monocytogenes has also been associated with febrile gastroenteritis and is linked with a variety of food items. generally, such episodes are self-limiting and do not lead to listeriosis. it is unclear how frequently l. monocytogenes causes enteritis since it is not an organism that is routinely looked for in this context. shigellae are unusual in that they are not present in fecal material from animals such as poultry, beef, and pork, and are therefore not transmitted in the same manner as nontyphoid salmonella, campylobacter, or e. coli. instead, these bacteria are highly host adapted, infecting only humans and some nonhuman primates. transmission occurs when a food product is contaminated by human fecal material. there are four different species of shigella (s. dysenteriae, s. flexneri, s. sonnei, and s. boydii) and all cause human disease. in the united states and other developed countries, most infection is due to s. sonnei, though s. flexneri is also common. one of the most striking features of shigellosis is the very small inoculum of organisms required to cause disease: as few as - of the most virulent genus, s. dysenteriae, are sufficient to cause dysentery in healthy adult volunteers. this low infectious dose permits person-to-person spread, with % of persons in a household becoming infected when an index case is identified in a family. given that these organisms are not typically present in food other than through human contamination -either directly during food preparation or indirectly from contamination with human fecal materialall shigellosis could be considered to be due to person-toperson spread. a variety of foods have been implicated in shigellosis including salads (potato, tuna, shrimp, macaroni, and chicken), raw vegetables, dairy products, poultry, and common-source water supplies. shigella often cause bloody diarrhea. some species carry stx and may cause hus like e. coli o :h . treatment with antibiotics shortens the duration of fever, diarrhea, and bacteremia, and reduces the risk of lethal complications. it also shortens the duration of pathogen excretion in stool, thereby limiting the spread of infection. a recent concern, however, is the increasing antibiotic resistance of shigella species. antibiotic resistance occurs quickly in shigella, attributed to horizontal transfer of resistance genes on integrons. multidrug-resistant isolates have been discovered in several developing countries. e. sakazakii is a motile, peritrichous, gram-negative rod that was previously referred to as a 'yellow-pigmented enterobacter cloacae'. e. sakazakii is a recently identified foodborne pathogen that has been implicated most frequently in causing illness in neonates and children from days to years of age. a recent review by bowen and braden of cases indicated that e. sakazakii has a mortality rate of - %. twelve infants had bacteremia, thirty-three had meningitis, and one had urinary tract infection. most newborns with e. sakazakii infections die within days of infection. death is usually attributed to sepsis, meningitis, or necrotizing enterocolitis. the case fatality rates vary from to %. sources of e. sakazakii associated with infant infections have not been identified in many cases; however, epidemiological investigations have implicated rehydrated powdered infant formula as well as equipment and utensils used to prepare rehydrated formula in hospital settings. enteroinvasive e. coli (eiec) is not frequently recognized as a foodborne pathogen, but infection has been linked to water and other foods such as cheese. eiec causes morbidity and mortality in young children in developed countries, but is a more important pathogen in developing countries due to poor hygiene and sanitation. a number of prominent serogroups found to be eiec have been described, including o , o , o , o , o , o , o , and o . clinically, eiec produces disease similar to shigellosis, with watery diarrhea or dysentery. eiec should be considered in those subjects with dysentery and substantial fecal leukocytes, in whom other invasive organisms have been ruled out. enteropathogenic e. coli (epec), like shigella species, is transmitted mainly by the fecal-oral route from one infected individual to another. epec has no known animal reservoir and is transmitted via food and water once contaminated by an infected person. epec is a major cause of infantile diarrhea worldwide, but mostly affects the developing world. the organisms have caused major outbreaks in various developed countries, but their role in sporadic disease is unknown because we lack routine diagnostic testing for these bacteria. clinically, epec infection presents with a watery, nonbloody diarrhea. low-grade fever and vomiting are common. in the developing world, mortality rates may be high, especially among infants. enteroaggregative e. coli (eaec) get their name from the way in which they adhere to epithelial cells in culture, in a 'stacked brick' pattern. these bacteria have been associated with acute or persistent diarrhea among immunocompromised patients and in developing countries. currently, there is no known animal reservoir for eaec, and fecal-oral spread from one person to another is considered to be the usual route of transmission. as with epec, contamination of food and water from infected individuals is probably important. in hiv patients with persistent eaec-associated diarrhea, antibiotic treatment has resulted in clearing of the organisms and in improvement in symptoms, suggesting that these bacteria are true pathogens, but they may be more opportunistic than other foodborne bacteria. aeromonads are gram-negative, facultatively anaerobic, motile, oxidase-positive bacilli that have been associated with foodborne illness. they are present in soil, freshwater, and sewage, and can contaminate fresh produce, meat, and dairy products. the infection rate tends to peak during the summer months. of the various species, aeromonas hydrophila, aeromonas caviae, aeromonas veronii, and aeromonas jandaei are most frequently associated with acute enteritis and foodborne infections. all typically cause persistent watery diarrhea. patients often have abdominal pain and dysenteric-like symptoms can occur, but fecal leukocytes and red cells are usually absent from stool. nausea, vomiting, and fever may occur in up to % of patients. infection is usually self-limiting and full recovery occurs in most healthy individuals without antimicrobial therapy, often making the diagnosis of academic interest only. the exception may be the patient with persistent diarrhea in whom no other cause has been identified. a number of protozoa have been associated with consumption of contaminated food and water. according to a review by karanis and colleagues, at least waterassociated outbreaks of parasitic protozoan disease have been reported. giardia lamblia and cryptosporidium parvum account for the majority of outbreaks ( , . and , . %, respectively), entamoeba histolytica and cyclospora cayetanensis were the etiological agents in nine ( . %) and six ( . %) outbreaks, respectively, while toxoplasma gondii and isospora belli were responsible for three outbreaks each ( . %) and blastocystis hominis for two outbreaks ( . %). balantidium coli, the microsporidia, acanthamoeba, and naegleria fowleri were responsible for one outbreak each ( . %). however, questions remain in the literature as to whether some of these less frequently seen agents are truly the cause of illness or simply 'detected at the time'. c. parvum is an apicomplexan protozoan parasite that causes diarrhea in both immunocompetent and immunocompromised individuals. its pathogenic potential in immunocompromised patients first became evident during the early acquired immunodeficiency syndrome (aids) epidemic. its ability to affect healthy individuals was confirmed in , when more than people in milwaukee developed cryptosporidiosis as a result of contaminated municipal drinking water. cryptosporidia are typically waterborne, but foodborne and person-toperson spread have occurred. the primary reservoirs are bovine and human. symptoms tend to occur days after ingestion of the oocysts. once ingested, the oocysts release four sporozoites, which then attach to and invade intestinal epithelial cells, especially in the jejunum and ileum. as a result, infection may be missed by diagnostic evaluation such as endoscopy. the diagnosis is made by a modified acid-fast or kinyoun stain for oocysts in the stool, or using commercially available immunofluorescence assays. typically, cryptosporidiosis causes watery diarrhea, abdominal cramping, nausea, and vomiting. fever is infrequent. in the immunocompetent, infection is selflimiting and recovery is the rule after a week or two. immunocompromised hosts do not clear the infection, and malabsorption may become a significant and lifethreatening problem. unfortunately, there is no known treatment for c. parvum infection, and current methods of water purification are ineffective for removal of the organism from the public water supply. g. lamblia is probably the most common enteric protozoan worldwide. though it may not cause dramatic enteric disease and has few systemic complications, giardiasis can lead to profound malabsorption and misery. only g. lamblia is known to infect humans. like other enteric protozoa, it is transmitted via the fecal-oral route and is most commonly spread through contaminated water. disease is caused by ingestion of cysts, which excyst in the proximal small intestine and release trophozoites. the trophozoites divide by binary fission and attach intimately to the intestinal epithelium via a ventral disk. the infectious dose is as low - cysts. clinical symptoms vary greatly; infection may be asymptomatic, or at the other extreme, may result in substantial abdominal discomfort, chronic diarrhea, protein-losing enteropathy, and intestinal malabsorption. g. lamblia can be diagnosed by fecal microscopy looking for either cysts or trophozoites. currently, many laboratories use commercially available kits utilizing either fluorescence microscopy with specific antibodies or enzyme immunoassays. metronidazole is the drug of choice for treatment. e. histolytica is the second leading cause of parasitic death in the world, with more than deaths annually. it is spread through fecal contamination of food and water or by person-to-person contact. amebic cysts are the infectious agent. they may survive for weeks in an appropriate environment. following ingestion, they pass unharmed through the stomach, travel to the small intestine, and excyst to form trophozoites. the trophozoites then colonize the large bowel and either multiply or encyst, depending on local conditions. the trophozoites invade the colonic epithelium, resulting in ulceration of the mucosa and amebic dysentery. they may also spread hematogenously to the portal circulation, causing parenchymal liver damage and amebic abscesses. the onset of symptoms in amebic dysentery may be gradual, initially presenting with mucoid stools and constitutional symptoms before progressing to bloody stools, abdominal pain, and fever. amebic abscesses may develop months to years after exposure. there are two types of entamoeba: e. histolytica is pathogenic while e. dispar is a commensal. microscopic examination of the stool has been the standard technique used to diagnose amebic dysentery, but this technique cannot distinguish between the two species. in the patient with classic symptoms of amebic dysentery, this distinction may not be important. however, elisa and stool pcr techniques are now commercially available and allow specific identification of e. histolytica. once the diagnosis is made, in the united states, metronidazole is the only drug available for treatment. in invasive amebic infections metronidazole should be followed by a luminal agent such as paromomycin or iodoquinol to eliminate bowel colonization by cysts. c. cayetanensis has caused a number of outbreaks in north america associated with consumption of imported raspberries in - . cyclospora has also been associated with basil and snow peas, undercooked meat and poultry, and contaminated drinking and swimming water. in immunocompetent patients, cyclospora infection results in self-limiting diarrhea with nausea, vomiting, and abdominal pain. in immunocompromised patients there can be a chronic cycle of diarrhea with anorexia, malaise, nausea, and abdominal discomfort followed by transient remissions. infection is diagnosed through detection of oocysts in stool by direct stool microscopy and oocyst autofluorescence. the infection can be treated successfully with trimethoprim-sulfamethoxazole. t. gondii is an intracellular pathogen that invades the human host from the gastrointestinal tract and causes symptomatic or asymptomatic toxoplasmosis. the vast majority of persons infected with t. gondii are asymptomatic. however, there is a risk of reactivating infection at a later time should the individual become immunocompromised. this is especially a concern in patients with aids. there is a greater risk of this when the cd lymphocyte count falls below cells/ml. primary maternal infection during pregnancy can be transmitted to the fetus and can result in serious sequelae and there are an estimated - cases of congenital toxoplasmosis in the united states each year. felines of all types are the only animals in which t. gondii can complete its reproductive cycle; thus cats are a major source of infection. with regard to foods, humans may become infected from consuming undercooked contaminated meat from an infected animal or from consuming food that has been contaminated in the environment with oocysts in the soil and then not cooked (e.g., fresh produce). according to cdc, viruses account for many more cases of foodborne infection than bacterial causes. viral syndromes range from simple gastroenteritis to life-threatening hepatitis. viruses contaminate both food and water, but they do not reproduce in these media; nor do they produce toxins. several viruses, such as the noroviruses, cause large outbreaks, while others are only associated with sporadic disease. the difficulty in diagnosing viral illness has precluded the acquisition of large amounts of epidemiologic data. however, the advent of rapid tests such as enzyme immunoassays is beginning to change this and will eventually lead to a better understanding of the epidemiology and disease burden caused by the various foodborne viral pathogens. noroviruses (genus norovirus, family caliciviridae) are a group of related, single-stranded rna, nonenveloped viruses that cause acute gastroenteritis in humans. norovirus is the official genus name for the group of viruses provisionally described as 'norwalk-like viruses' (nlv). noroviruses are the principal cause of epidemic, nonbacterial gastroenteritis in the united states. mead and colleagues estimate these viruses cause million infections, hospitalizations, and deaths annually. norwalk virus (now called norovirus) was first described after a large outbreak in . noroviruses have been associated with many large outbreaks in cruise ships, nursing homes, banquet halls, and other institutional settings. the primary source of infection is feces-contaminated drinking water, but the virus may also be spread through food that has been stored or washed in contaminated water or handled by an infected food service worker. noroviruses are highly contagious, with fewer than viral particles sufficient to cause disease, and are resistant to freezing, heating, ph extremes, and disinfection. symptoms tend to occur h after exposure and consist of vomiting and diarrhea. the diarrhea is watery without red cells, leukocytes, or mucus. the disease is usually selflimiting, resolving in - days without long-term sequelae. diagnosis can be made using transmission electron microscopy to find norovirus particles in stool, vomitus, or food. serologic testing, enzyme immunoassays, and pcr techniques also establish the diagnosis. the only treatment required is to prevent dehydration. handwashing will have a significant impact on the spread of the infection. a number of other viruses have also been associated with outbreaks of acute enteritis and are suspected to be spread through the fecal-oral route. table includes a list of potential foodborne viruses: rotavirus, enteric adenovirus, saporo-like viruses, coronaviruses, toroviruses, reoviruses, and the smaller-sized viruses such as caliciviruses, astroviruses, parvoviruses, and picobirnaviruses. all cause a similar acute illness with a self-limiting noninflammatory, watery diarrhea. hepatitis a is an rna virus, belonging to the family picornaviridae, with a worldwide distribution. it is spread via the fecal-oral route through contaminated food and water, and person-to-person spread. in sporadic infections, up to - % of susceptible household contacts of the affected individual are infected with hepatitis a. large outbreaks have been traced to a variety of foods including contaminated water, shellfish, milk, potato salad, and fresh fruits. one of the largest outbreaks in the united states was in from green onions. symptoms develop days after exposure on average, with a range of - days. the lengthy incubation period complicates tracing the source of infection. during the incubation period and the first week of acute illness, hepatitis a virus can usually be detected in stool. therefore, there is a prolonged phase when an individual is asymptomatic, but may transmit the disease to others, a significant concern in relation to food workers and foodborne transmission. an inactivated viral vaccine was licensed in and the cdc and the american academy of pediatrics have been implementing an incremental hepatitis a immunization strategy for children since then. in endemic countries, childhood infection and immunity are almost universal; childhood disease tends to be asymptomatic. in the united states, disease typically occurs after foreign travel to an endemic region. it may present with fever, jaundice, fatigue, abdominal pain, nausea, and diarrhea. diagnosis of the acute infection may be established serologically and treatment is supportive. an immune globulin may also be used for pre-or postexposure prophylaxis. hepatitis e virus was first described in after an epidemic affecting individuals occurred in kashmir, causing cases of fulminant hepatic failure and deaths. it is a small rna virus from the caliciviridae family usually transmitted through contaminated drinking water. hepatitis e is responsible for most of the epidemics of hepatitis in the developing world and is transmitted through contaminated water. it is the major etiological agent for acute hepatitis and acute liver failure in endemic regions. it causes severe liver disease among pregnant females and patients with chronic liver disease. person-to-person spread occurs rarely, with secondary attack rates of . - . % in household contacts of infected individuals. foodborne spread has not yet been documented. hepatitis e is endemic to india, southeast and central asia, parts of africa, and mexico. it has an incubation period of - weeks, although most people develop symptoms around days postexposure. clinically, the disease is similar to hepatitis a, with constitutional symptoms followed by jaundice. most patients recover, but mortality rates of up to % have been reported, with pregnant women at higher risk. the diagnosis is made serologically. hepatitis e vaccines remain experimental. preventing illness in the first place is clearly the most desirable approach when dealing with food safety and foodborne illness and there are many approaches to take with regard to prevention. prevention is particularly important when it comes to individuals who are young, elderly, or have compromised immune systems, and there are a number of steps that can be undertaken to minimize the potential risk. at the outset, it is important to recognize that certain groups are at much greater risk than others. this is well illustrated in the context of listeriosis in which the likelihood of developing illness varies in relation to a variety of underlying conditions ( table ) . for example, there is a times greater risk of a transplant patient becoming sick from listeriosis as compared to an individual under the age of with no underlying medical conditions. according to the council for agricultural science and technology (cast), a majority of foodborne illnesses can be attributed to improper food-handling behaviors (tables and ). leading causal behaviors are failure to ( ) hold and cool foods appropriately, ( ) practice proper personal hygiene, ( ) prevent cross-contamination, ( ) cook to proper internal temperatures, and ( ) procure food from safe sources. information related to the proper handling of food can be found at www.foodsafety.gov. risk assessment of listeria monocytogenes in ready-to-eat foods. technical report (microbiological risk assessment series; no. ), food and agriculture organization of the united nations and the world health organization, . behaviors that % of a national panel of food safety experts (n ¼ ) rated as being of special importance to pregnant women and/or infants and young children, with those rated as important to both groups presented first. table consumer food-handling behaviors of special importance to elderly and immune compromised individuals elderly and immune compromised individuals avoid soft cheeses, cold smoked fish, and cold deli salads l. monocytogenes avoid hot dogs and lunchmeats that have not been reheated to steaming hot or f store eggs and poultry in the refrigerator salmonella enteritidis avoid raw or partially cooked eggs, foods containing raw eggs. cook eggs until both the yolk and white are firm. use a thermometer to make sure that foods containing eggs are cooked to . c ( f) cook shellfish until the shell opens and the flesh is fully cooked; cook fish until flesh is opaque and flakes easily with a fork nlv obtain shellfish from approved sources nlv; vibrio species avoid eating raw or undercooked seafood/shellfish (clams, oysters, scallops, and mussels). cook fish and shellfish until it is opaque; fish should flake easily with a fork. when eating out, order foods that have been thoroughly cooked and make sure they are served piping hot behaviors that % of a national panel of food safety experts (n ¼ ) rated as being of special importance to the elderly and/or immunocompromised individuals, with those rated as important to both groups presented first. emerging infections; enteropathogenic infections; epidemiological concepts and historical examples; global burden of infectious diseases antimicrobial resistance in nontyphoidal salmonella campylobacter jejuni infections: update on emerging issues and trends infections of the gastrointestinal tract invasive enterobacter sakazakii disease in infants food poisoning exotoxins of staphyloccocus aureus guillain-barré syndrome escherichia coli o :h and other shiga toxin producing e. coli strains waterborne transmission of protozoan parasites: a worldwide review of outbreaks and lessons learnt enterohaemorrhagic escherichia coli in human medicine food-related illness and death in the united states diarrheagenic escherichia coli pathogenesis and diagnosis of shiga toxin-producing escherichia coli infections salmonella typhimurium dt : a virulent and drug resistant pathogen bacillus cereus food poisoning and its toxins enteric bacterial toxins: mechanisms of action and linkage to intestinal secretion the enteric toxins of clostridium perfringens fish and shellfish poisoning key: cord- -wp ehemj authors: chen, ray zhuangrui; wong, ming-hung title: integrated wetlands for food production date: - - journal: environmental research doi: . /j.envres. . . sha: doc_id: cord_uid: wp ehemj abstract the widespread use of compound pelleted feeds and chemical fertilizers in modern food production contribute to a vast amount of residual nutrients into the production system and adjacent ecosystem are major factors causing eutrophication. furthermore, the extensive development and application of chemical compounds (such as chemical pesticides, disinfectants and hormones used in enhancing productivity) in food production process are hazardous to the ecosystems, as well as human health. these unsustainable food production patterns cannot sustain human living in the long run. wetlands are perceived as self-decontamination ecosystems with high productivities. this review gives an overview about wetlands which are being integrated with food production processes, focusing on aquaculture. in order to increase production and enhance production efficiency in modernized conventional food production systems including aquaculture, high nutrient input, density breeding and assembly line production are usually adopted; with addition of pesticides, disinfectants, antibiotics, vaccines, immune-stimulants, and vitamins. however, efficient management for protecting the adjacent environment is either lacking or insufficient, while these conventional production systems also exert harmful effects to the environment (bunting, ; wong et al., ) . eutrophication is one of the greatest adverse environmental impact of modern aquaculture due to intensification through increasing use of pelleted feeds and expansion of the aquaculture area (edwards, ) . almost two third of the nutrients found in feeds are not consumed by cultured fish during growth and released into the immediate environment, with only one third is assimilated by the fish (edwards, ) . the residues originated from uneaten feeds, fecal matters and excreta contributed to most of the nutrients that become pollutants stagnated in the environment. both organic and inorganic matters discharged from aquaculture activities, especially nutrients such as, nitrogen and phosphorus have been involved in stimulating phytoplankton production, and in some instances the development of algal blooms (bunting, ; jacobs and harrison, ) , including toxic algal blooms which may in turn lead to anoxic zones, fish kills, and loss of biodiversity (anderson, ; backer and mcgillicuddy, ; hallegraeff, hallegraeff, , imai et al., ) . food production is increasingly being adversely affected by agriculture and aquaculture, and also domestic, industry discharges. pesticide residues have become nonpoint source pollution in waterways which are threatening the drinking water resources and aquatic ecosystems (dwiyana and mendoza, ; krone-davis et al., ; matamoros et al., ; moore et al., ; vymazal and březinová, ) . ammonia and nitrite arising from degradation of protein can be of primary toxic to aquatic organisms (bunting, ; kadlec and zmarthie, ; mook et al., ; tyson, ) . antimicrobial resistance (amr) bacteria detected in consuming animal food products has become an emerging public health concern, for instance, amr of bacteria was detected in oysters and mussels (rees et al., ) , pigs and poultry birds (amaechi et al., ) , fishes and prawns and also the ambient soil and water ways (sengeløv et al., ; silvester et al., ; thiele-bruhn, ; vivekanandhan et al., ; yohanna et al., ) . food safety issue has become increasingly important worldwide (blidariu and grozea, ) . efforts have been made to minimize the negative effects of food production systems on our environment. nevertheless, there seems to be an urgent need to develop sustainable aquaculture and agriculture in the near future. (klinger and naylor, ; stankus, ; turcios and papenbrock, ) . however, the food production patterns of currently mainstream worldwide are defective which are wasteful, pollution-carrying and unsustainable. hence, the food industries are facing great challenges. this article aims at reviewing how wetlands could be integrated with food production processes via ecological approach, along with a dual purpose of pollution control and safe and quality production. it is commonly recognized that food security is the greatest challenge to sustain human standard of living in the st century (un, ) , because of rapid population growth, which the increase in global population has been projected to reach . billion by (national intelligence council, ) . in addition, more than one billion of the present global population of . billion is under-nourished (mustafa, ) . it is envisaged that global food production will have to increase by at least % over the next decades to meet the ever increasing food demand (fao, ) . the way to feed the global population equitably and sustainably is in fact a great challenge in the near future (hill and mustafa, ) . according to the assessment made by the world wildlife fund, overuse of the planet's natural resources has reached an alarming level, with human demands on natural resources doubled in the last years. the wwf's 'living planet report' states that global consumption of resources is % above earth's sustainable ability (wwf, ) . furthermore, major pressures are exerted on the environment, due to continued consumerism in developed countries and growing affluence in a number of emerging economies. these led to an even higher demand of natural resources (rockström and karlberg, ) . therefore, it is rather difficult to ensure sufficient food and water for all to sustain livelihoods for present and future generations (hill and mustafa, ) . climate change also plays a profound role in various food production processes. for example, the impacts of global warming on harmful algal blooms may affect the quality and safety of the aquatic products (hallegraeff, ) . besides, extreme changes in climates are observed more frequently in recent years worldwide and aquaculture and agriculture are seriously affected by these extreme weathers, such as severe storms, tornados, salinity intrusions, droughts and floods (sutradhar et al., ) . rising sea level can affect aquaculture in coastal areas and cause salinity intrusion into deltas which can also affect freshwater aquaculture (edwards, ; sun et al., ) . although efforts (such as alternative to the burning of fossil fuels, targets and agreement on reducing the carbon dioxide) have been made by developing technologies to assist sustainable development, the rate of development is insufficient to ease the immediate threats of climate change (hill and mustafa, ; woolhouse et al., ) . water and soil loss, soil desertification and salinization, water eutrophication and among other factors are threatening agriculture and aquaculture in varying degrees. these environmental pressures are aggravating their effects on food production, and the range of influences has been enlarged by overlapping influences. as a consequence, the normal ecosystem functions and services of our food production systems has been degraded (rockström and karlberg, ) . apart from excessive nutrients such as nitrogen and phosphorus, which can cause eutrophication in water, elevated concentrations of a wide range of persistent toxic substances (pts), including heavy metals (such as mercury (hg), chromium (cr), lead (pb)), persistent organic pollutants (pops such as ddt) and certain emerging chemicals of concern (such as flame retardants) found in soil, water and air worldwide during the past decades, are greatly threatening our food production and food safety. despite of the success of many countries and regions of the world (such as the usa and eu) with relatively successful control and management practices for pts, the lack of efficient control and management in this regard, especially in certain rapidly developing countries, making pts easy to spread into environment. this situation has increased the potential poisons to human body by direct ingestion of contaminated water and consumption of food products grown in contaminated fields, and even through skin exposure and breathing air (jane et al., ) . for instance, the pearl river delta (prd), one of the most developed regions in china, has become the world's factory for various industries, e.g. textiles, and electrical/electronic products, and rather high concentrations of polychlorinated biphenyls (pcbs), cadmium (cd), pb and hg in fish reared in fish ponds around the area have been frequently reported (cheung et al., ; nie et al., ; zhou and wong, ) . li et al. ( ) reported a soil pollution status of pts in a newly developing industrial area around bohai bay, tianjin in northern china that relatively high concentrations of ddt (varied from nd (less than the limit of quantification) to ng/g, with a mean value of . ng/g), hch (varied from nd to , ng/g, with a mean value of ng/g) and pahs (varied from . to , ng/g, with a mean value of ng/g) compared to most of the earlier studies in china hu et al., ; li et al., ; zhang et al., , in and around the industrial area. exposure of pts to the local residents was associated with a higher risk of local residents' health, such as breast cancer (odds ratio: . , % confidence interval: . - . ), stomach cancer (odds ratio: . , % confidence interval: . - . ), dermatitis (odds ratio: . , % confidence interval: . - . ), gastroenteritis (odds ratio: . , % confidence interval: . - . ), and pneumonia (odds ratio: . , % confidence interval: . - . ). most of these pts are non-biodegradable, and could be bioaccumulated and biomagnified in aquatic food chains, which could then subsequently impose health effects on consumers via dietary intake of pts associated with large carnivorous fish (such as swordfish and grouper). it has been observed that trash fish (small fish without high commercial value) used in fish farms as feeds in south china is often contaminated (cheng et al., ; liang et al., liang et al., , zhou and wong, ) . it has been observed that fish meal and oil derived from trash fish served as the major components of feeds for conventional aquaculture are contaminated with ddt, hg, and even dioxins, e.g. in usa and canada (campbell et al., ; damsky et al., ) . to produce products using contaminated feeds or in contaminated fields will ultimately exert human health risks, especially to sensitive members of the population, such as infants and pregnant women. various studies revealed that pts play a crucial role in the pathogenesis of some health effects, such as pops, hg with male subfertility (hauser et al., ; hsu et al., ; mcauliffe et al., ) , autism in children due to metal overload (bjørklund, ; hagmeyer et al., ) ; cancers associated with high loadings of pts in human bodies (cohn et al., ; li et al., ; steinmaus et al., ; vogt et al., ) , etc. sustainable development involves the integration of cultural, economic, political and environmental factors (hoff, ) . however, cultural and political concerns are often given ways to economic development both in the past and at present. there is also a lack of efficient educational and political guidance in developing countries. in addition, unsustainable living and production patterns have also resulted in deterioration of environmental quality for sustainable development. to produce larger quantities of food to satisfy demand of the ever increasing population more effectively, conventional agriculture and aquaculture developed in the last decades focused on intensive production. many food items are produced in monoculture, for cultivating and harvesting crops or animals more easily. high technological farms use compound feeds, chemical fertilizers, pesticides, hormones and confined intensive animal feeding operations, since they are perceived as the most efficient strategies to maximize the output of limited land areas or water bodies. heavy use of antibiotics in confined animal feeding operations contributes to the problem of amr that would extend to affect human health (morrissey et al., ; woolhouse et al., ) . , t of antibiotics were estimated to be produced, used and misused per year (laxminarayan et al., ) , and under the directional selection by antibiotic residues, the host animals contain amr strains of bacteria may serve as a reservoir for amr genes in other food animals (amaechi et al., ; woolhouse et al., ) and drive the evolution of other microorganisms (habets and brockhurst, ; laxminarayan et al., ) . although antimicrobial peptides which have been proposed as a promising new class of antimicrobials and been applied as feed additives (kogut et al., ; yu et al., ) , the new study provided the first evidence that evolved resistance to a therapeutic antimicrobial peptides can provide cross-resistance to a human immunity peptide (habets and brockhurst, ) . amr has become a global environmental problem similar to climate change (woolhouse et al., ) . high fertilizer levels applied to enhance production or exploit the productive potential of crops for continuous production had resulted in an imbalanced soil nutrients and heavy use of pesticides (richter et al., ; ng et al., ) , due to the increased yield is more susceptible to pests, and pesticides are generally used for pest control. on the other hand the natural enemies of pests are also susceptible to pesticides, which in turn, leading to more usage of pesticides. nutrient loss through runoff is also a problem, and it has been reported that non-point source pollution from agriculture accounts for - % of the nutrient loading to rivers and lakes (min and jiao, ) , and high nitrate concentrations in drinking water has been associated with methemoglobinemia and consequential cyanosis in infants (fan and steinberg, ) . the pesticides used for reducing pests and weeds in conventional farms, together with the surplus of chemical fertilizer have led to negative impacts, causing biodiversity loss and eutrophication (chau et al., ; hortle and bush, ; richter et al., ) , and even threats to human health (hu et al., ; jones et al., ; lebov et al., ; rauh et al., ) . there are signs of using less pesticides recently (moore et al., ; o'geen et al., ; vymazal and březinová, ) , but such actions have led to serious crop yield reductions (oerke, ; oerke et al., ) . compound feeds with high protein contents used to accelerate the growth of food animals without efficient methods to treat the residues are known to cause ecological hazards (edwards, ; zhang and fang, ) . approximately . t of nitrogen and . t of phosphorus (per hectare) are released to the environment, from intensive striped catfish farming (bosma et al., ; de silva et al., ; phuong et al., ) . these high-efficient conventional food production patterns which exploit the potential production, without sufficient concern about the negative impacts on the long-term ecological and human health, are unsustainable to our planet. the more production we achieved, the more natural resources are exploited, leading to higher impacts on ecological and human health. fortunately, some sustainable production techniques are becoming popular to ratify the conventional production systems: sustainable agriculture/ aquaculture, organic farming (paull, ) , regenerative agriculture, biodynamics farming and permaculture (koepf, ; nandal and kumari, ; olsen, ; poincelot, ; rhodes, ; paull, ) , all aiming at sustainable production, paying more attention to the balance of nature resources and human activities in food production, utilizing regenerative production resources, and producing safer food with less impacts on the ecosystem. there seems to be an urgent need to produce safe and quality food, which is environmental friendly. to achieve this, it is necessary to explore possibilities by means of technological innovation, and reformation of production patterns, based on the combination of suitable technologies and efficient management methods. in nature, all the materials can be cycled and used. however, over exploitation of resources and the amount and types of waste generated by human beings have disturbed the natural balance. hence, facilitating certain wastes as resources in food production is an essential key to sustainable development. proper treatment and disposal of an ever increasing amount of food wastes generated from densely populated cities such as hong kong is a recent environmental concern. recycling food wastes into feeds to ensure safe and quality fish production seems to be feasible, which could also partially ease disposal pressure and save natural resources (cheng et al., ) . water plays a significant role in food production, especially in aquaculture. however, water is also the major medium for diffusion of pts, introducing pts into fish farms, affecting the culture fish, and also discharging pts from farms and impose negative environmental impacts (amaraneni, ; an et al., ; fatta et al., ; rouff et al., ) . thus, water quality and management of water are major keys linking to safe and quality fish production, which is environmentally friendly. known as "earth's kidneys" for their purification capacity, wetlands are indispensable components of the earth's ecosystem. they are also among the most important natural habitats that support biodiversity and provide subsistence for humans. despite the fact that wetlands occupy only % of the earth's surface, they support approximately % of all living organisms on earth (zhao and song, ) . with the annual production value of - times (product value in terms of dollar value) of farmland ecosystems, wetlands are in fact the most productive ecosystem (zhang, ) . many wetlands are used for food production, for instance, mariculture, pond aquaculture, and plantation of crops. there exists great potential for integrating different food production systems into wetlands, in order to enhance sustainable food production, taking advantage of its ecological multifunction. these functions includes water conservation, runoff regulation (beutel et al., ; lizotte et al., ; ludwig and wright, ) , peat accumulation, carbon sequestration (kleinen et al., ; tuittila et al., ) , pollution purification, toxic substance transformation (paing et al., ; sudarsan et al., ; vymazal and březinová, ) , and disaster prevention for both droughts and floods wassens et al., ) . some wetlands are used for or linkage to different types of food production, based on their unique characteristics. studies show that wetlands integrated with other systems for food production processes are able to achieve more sustainable food production (please refer to cases below for details). . . cases of integrating wetlands for food production . . . integrated wetlands with animals wetlands, like paddy fields and cane shoots (zizania latifolia (griseb)) fields are artificial surface flow systems, generally consisting of water on the surface, with cultivated commercial aquatic crops. higher economic benefits have been achieved through ecological approaches via integrating with appropriate animals in these modified flooded fields. rice-duck (wang et al., ; yang et al., ; zhen et al., ) , rice-fish (cruz et al., ; suloma and ogata, ) , rice-crab (yan et al., ) , and rice-prawn (nair et al., ) farming commonly practiced in asian countries are recognized as sustainable systems using less fertilizer and pesticide. the paddy fields or cane shoot fields provide shades, shelters and organic matters for the animals, which in turn oxygenate the soil and water, consume pests and favor nutrient recycling. these animals, especially the fish and duck are also viewed as a tool within an integrated pest management (ipm) system to make the agricultural activities more sustainable and environmentally friendly. berg ( ) reported that approximately % of pesticides was decreased by the benefit of ipm on rice-fish farms during years, whereas non-ipm farms had increased the amount of pesticides used by %. these farming patterns help the farmers to increase the revenue by limited fields. it is reported that net revenue increased from the rice-fish system over the rice monoculture ranged %- % in west africa (ofori et al., ) , %- % in indonesia (dwiyana and mendoza, ) . rice-fish farming system has been listed by the food and agriculture organization of the united nations (fao) and the united nations educational, scientific and cultural organization (unesco) as one of the globally important agricultural heritage systems (giahs), with qingtian county of zhejiang province of china selected as a pilot conservation site (lu and li, ) . rice-fish farming has been practiced more than years in china and the practices in other countries only began after the mid-nineteenth century (java), mostly in the last century (such as japan, thailand) (little et al., ) , and african countries in recent years (such as egypt, nigeria) (ofori et al., ; suloma and ogata, ) . similar to rice-fish farming, rice-duck, rice-crab, rice-prawn farming makes use of the symbiotic relationship between paddy fields and animals to more effectively utilize nutrients and energy, reduce chemical fertilizer and pesticide inputs, increase food safety and productivity, and also mitigate the pollutants discharge zhang et al., ; zhen et al., ) . besides, it is reported that co-culture animals in wetland fields, especially organic co-culture patterns, could effectively improve quantity and composition of soil carbohydrates (nair et al., ; yan et al., ; yang et al., ) that would conduce to sustainable use of the soil resources. traditional low input rice-animal farming releases less nitrogen into environment, but the yield is limited. thus, some conventional patterns are invoked to boost yield in most of these practices (edwards, ) , such as using chemical fertilizers, pelleted feeds and chemical pesticides. however, increasing feeds or fertilizer use in rice field would also reduce the nitrogen use efficiency. hence, appropriate management of additional input would be necessary. hu et al. ( ) indicated that fish yield can be increased in traditional rice-fish farming system without increasing nitrogen (n) pollution and without decreasing n use efficiency, and rice yields. this could be achieved by managing the ratio of feed-n to fertilizer-n that quantities n input (with a constant input rate of kg/ha). a balance will be reached with % fertilizer-n and % feed-n, while n not used by rice can be used by phytoplankton or other primary producers in the field that are subsequently consumed by the fish. there are well-developed human-livestock-crop-fish production systems in china, based on efficient waste recycling techniques (delmond et al., ; edwards, ). mulberry-dike-fish pond is one of the giahs (altieri and koohafkan, ) and the best known integrated production model. mulberry trees are cultivated on the pond dikes, with leaves fed to silkworms. excreta and pupae of silkworms are added into fishponds serving as fertilizer and fish feeds respectively, and the fertile pond mud consisting of fish excreta, organic matter, and chemical elements is brought up regularly from bottom and applied as fertilizer for the mulberry trees (zhong, ; ruddle and zhong, ; wong et al., ) . these principles of dike-aquaculture have been modified and now widely with many sub-units of ditches and stagnant waters to suit different regional needs (korn, ) . accordingly, assorted dike-pond and canal-dike agroecosystems have emerged throughout asia. the types of crops growing on the dikes are often governed by market demand and requirements of pond input. in early days, mulberry dikes, sugarcane dikes, fruit dikes, and miscellaneous crop dikes (such as soy-bean (glycine max), peanut (arachis hypogea), carrot (duucus curotu) were popular in pearl river delta (prd). the principal commercial crops cultivated were mulberry, sugarcane and various fruits (especially litchi (litchi spp.), longan (dimocarpus spp.), and bananas (musa spp.). a wide variety of vegetable crops are intercropping, inter-planting and rotation on the dikes, based on characteristics of different species, and under continuous cultivation. these vegetable crops and also some grasses are planted on all available spare land, including the dike slopes, roadsides, around the settlements, and along the watercourses. those are the fundamental components of a dike-pond system, providing essential food for domestic use as livestock and fish feeds, and vegetables for home consumption and marketing (ruddle et al., ) . the fish ponds normally raises several different compatible fish species (mainly of the carp family) at the same time. in this polyculture system, each fish species possesses distinct feeding habits, based on their physiology and morphology, occupying a different trophic level within the pond. there are also other aquatic organisms (such as carps and shrimps) thriving in the same water body. within the same pond, different living organisms are in proximity of each other, connected by nutrient and energy transfer through water. this so called "integrated multitrophic aquaculture (imta)" is in fact a diverse and low-cost approach to waste treatment, combined with efficient ecological management of aquaculture (klinger and naylor, ) . the harmonious structure of this system could be achieved through appropriate selection of different fish species and their optimum stocking ratios through the experience gained by fish farmers in the past (turcios and papenbrock, ) . in prd, it is common to co-culture bighead, silver carp, grass carp, black carp, mud carp and common carp in the same pond, with grass carp as the principal species, accounting for % of the fish. grass carp is the main breeding object which is mainly fed with grasses, sugarcane husks, leafy vegetables and macrophytes grown on dikes or adjacent water bodies and those plant material constitutes . % of fish feed, additional feeds made up food consisting of the fermented residues of soy-bean curd, soy-bean cake, peanut cake and rice bran. the bighead and silver carp are fed by naturally grown plankton which favor the nutrient-rich water. the common and mud carp are detritus feeders which consume excrement, unconsumed food, snails and worms (zhong, ) . apart from the typical production model of mulberry-dike-fish pond, there are several secondary production models that coexist with these integrated dike pond systems. different domestic animals, such as rabbits, chickens and goats are reared on the dikes; while ducks on the pond water. furthermore, aquatic plants such as duckweed, water lettuce and water hyacinth are kept in rivulets, canals, and associated bodies of water for feeding fish and pigs. pond mud is used to cultivate mushrooms while the off-season for silkworm in winter and the nutrient-rich mud-bed is also used to fertilize the dike after the final crop of mushrooms have been harvested (zhong, ) . the by-products and manures from pigs and chickens are used to generate biogas; and the biogas residues are used as fish feed and fertilizer (jiang and zhao, ) . these integrated agriculture-aquaculture systems are excellent examples of sustainable aquaculture, where energy is fully utilized and most if not all elements derived from waste materials and byproducts are efficiently recycled. furthermore, all the living organisms are designed to co-exist harmoniously in this artificial ecosystem and kept balance on the resource utilization and the amount of different species. on the contrary, the conventional fish farming methods are less sustainable in terms of resource utilization. large amounts of nutrient-rich wastewater, containing chemical residues such as antibiotics and disinfectants are produced, together with unconsumed fish feeds and excretion, imposing harmful effects on the receiving environment (klemenčič and bulc, ; konnerup et al., ; silvester et al., ; richter et al., ; avant, ; tonguthai, ) . unfortunately, the area dike-ponds has continued to decline in recent years, given way to factories, residential buildings and other facilities gradually, following the economic reforms of south china started in (wong et al., ) . . . . "aquaponic" (aquacultureþ hydroponics) system "aquaponic" system is an approach which integrated intensive aquaculture with innovated agriculture technologies, with crops growing in liquid without soil (hydroponic culture). this is basically derived from the recirculating aquaculture system (ras) which recycle water through filters to remove food and fish residues. the name "aquaponic" refers to the combination of 'aquaculture' and 'hydroponic' (chalmers, ) , focusing on recycling the aquaculture effluent (which is full of nutrients), through recirculating over trickling filters or other suitable substrates (such as gravel, expanded clay and sand) for growing crops (palm et al., ; salam et al., ) . based on the principles commonly adopted in constructed wetlands, this technique enhances the purification capacity of the system. as a matter of fact, most of the designs of 'hydroponic' component of "aquaponic" are similar to artificial treatment wetlands, serving as ras for the purification of wastewater, which is connected to a tank for fish culture. some cash crops including fruits, ornamental flowers, culinary or medicinal herbs and vegetables are grown instead of aquatic plants. the basic components of "aquaponics" system consist of a fish culture tank, a settleable component for suspended solids removal, a biofilter, and a hydroponic component, with the latter three usually combined (rakocy and hargreaves, ; rakocy, ; tyson et al., ) . although "aquaponics" system may involve high capital and operating costs, even higher energy inputs than the conventional pond and cage cultures (edwards, ) , it is an ideal setup to reduce water pollution and eutrophication derived from aquaculture effluent. it has been noted that integrated use of renewable energy such as solar, wind, and biogas energy could reduce the energy cost which is supposed to be the prime operation cost after the construction of aquaponics system (gigliona, ; mohamad et al., ; olafs, ) . increasing the variety of products and overall productivity of "aquaponics" system could ease the cost and enhance the practicability of this technology. it has been suggested to combine algal culture, aquaculture and aquaponics together (chalmers, ; nuttle, ) . in this system, quails produce eggs and meats and their manures are used to supply nutrients needed for algal culture. tilapia are used to consume surplus micro-algae and are supplied as food. manure derived from the cultured fish, effluent and algal water serve as fertilizers for the nearby aquaponic crops, without any disease problems. algae are harvested weekly and manufactured for commercial end users. these new economic possibilities are attractive to inland farms in arid regions and water-limited farms in other regions, since it is basically a water re-use system (diver, ; graber and junge, ; nichols and savidov, ) . "aquaponic" has become a fastgrowing industry in australia (lennard, ) , as the lack of freshwater is a major limit for aquaculture. constructed treatment wetland (ctw) is an artificial wetland which is able to utilize natural functions of vegetation, soil, and microorganisms for treating wastewater, including municipal or domestic sewage, industrial and agriculture wastewater, landfill leachate, and stormwater runoff, which has been proven to be a well-established and cost-effective method (turcios and papenbrock, ; webb et al., ) . it is regarded as a low cost, and a low carbon method for wastewater treatment and has been applied in food production processes. for instances: ctws have been used to treat the wastewater from animal husbandry (hammer et al., ; lee et al., ; niu et al., ) and aquaculture (lin et al., a; schwartz and boyd, ) , and non-point source pollution from agriculture (o'geen et al., ) . it has also been applied to lower heavy metal bioaccumulation (cheng et al., ; guittonny-philippe et al., ; yadav et al., ) , and mitigate the use of hazardous pesticides (kohler et al., ; krone-davis et al., ; vymazal and březinová, ) . a simple integration of ctw into a recirculating hatchery was conducted by buřič et al. (buřič et al., ) in the czech republic that different from traditional rass which generally involve specialized technologies, such as microsieve filtration, ozonization, and uv sterilization (azaizeh et al., ; good et al., ; sharrer et al., ; terjesen et al., ) . this study indicated that ctw integration has the potential to increase production (potential final biomass with cw use was estimated to be % greater than without cw use) of a recirculating hatchery without added operational or environmental costs. for mariculture, webb et al. ( ) demonstrated that ctws planted with salicornia spp. for the treatment of effluents from land-based intensive marine aquaculture farms, and salicornia can be sold as an agricultural crop. however, it requires a relatively extensive area to build ctw systems sufficient for effluent treatment (starkl et al., ) . in order to remove major pollutants from catfish, shrimp and milkfish pond effluents, a ctw with the size of . - . times the pond area for treating the polluted fishpond effluents would be needed (lin et al., a; schwartz and boyd, ) , with the following hydraulic conditions: a low hydraulic loading rate (hlr) ranging . - . m day À (lin et al., a (lin et al., , b , and a long hydraulic retention time (hrt) ranging - . days (sansanayuth et al., ; schwartz and boyd, ) . according to shpigel et al. ( ) , about , m of ctw with salicornia are required to remove nitrogen and total suspended solids produced from kg of % crude protein fish feed ( m kg À of feed) during one year. nevertheless, most of the food production systems lack spared land to build a sufficiently large ctw. hence, to integrate ctws with food production systems more compact designs would be essential, especially turning ctws into food production fields would be more practical than single function of wastewater treatment. different from the ctws that build on land, agriculture in water is implemented on water surface, using it as a culture medium for agriculture. this method called "chinampa" in the early agriculture in mexico while the aztecs cultivated agriculture islands as early as - bc. plants are cultivated on stationary islands (by staking mud, lake sediment, and decaying vegetation out of the shallow lake bed and fencing in the rectangle with wattle) or movable islands (artificial floating islands, also called "floating gardens") in lake shallows. the build-up layers of vegetation are raised cm above the water level, making the chinampas like sponges of organic earth that achieved the effective use of water surround them (ruiz et al., ) . waste materials dredged from canals and surrounding cities were used to irrigate the plants. flood tolerant trees are often planted at the corners to secure the chinampas (turcios and papenbrock, ) . fish are raised in the canals forming islands in proximity, and the sedimentary waste from fish is collected to fertilize the crops planted on the islands. these chinampas produce very high crop yields with four or up to seven harvests a year (tuerenhout, ; turcios and papenbrock, ) . a new floating garden technology is developed in bangladesh (irfanullah et al., ) , to allow farmers who live in areas covered by water during wet season to grow food on flooded land. water hyacinth and bamboos are used to construct rafts as floating bodies, soil and cattle manure are placed on the surface of the rafts, with vegetables planted in the soil. new rafts would need to be built every year, and the old ones can be used as fertilizer during the dry season. gourd (lagenaria spp.), okra (abelmoschus spp.), groundnut (arachis spp.) and leafy vegetables are grown organically in these floating gardens and provided vital food and income for the poor people in developing countries. floating island is a new ecological treatment technique for wastewater enriched with nutrients. it can also be used as floating garden but different in the use of modern floating body and culture medium (such as polystyrene, haycite, roseite, etc.) (dai et al., ) instead of fertility medium like mud and cow dung. this technique has a variety of forms and is also named as "ecological floating bed", "aquatic grassland", and "artificial floating island" . besides water purification, it is also used as habitat for birds and fish for ecological restoration and protection, and for developing agriculture in water for food production sang and li, ) . previous studies showed both terrestrial plants and aquatic plants can be cultured on floating islands as green food or safe feedstuff. these included paddy (oryza sativa, oryza glaberrima), celery (oenanthe javanica), goose grass (eleusine indica), canna (canna indica), barnyard grass (echinochloa crusgali), water spinach (nasturtium officinale), vetiver grass (vetiveria zizanioides), reed (phragmites australis); the yields are generally higher than those cultured on land . it was demonstrated that levels of heavy metals and nitrite contained in crops cultured in an eutrophic lake (shahu lake, wuchang, china) by floating islands were safe for consumption. however, biological concentration of heavy metals and pts would be a public health concern and the quality of products should be strictly controlled. wetlands provide various essential functions to sustain the global ecosystem, and can be integrated into different food production systems mentioned above. there seems to be great potential for producing safe and quality food which is environmentally friendly, by incorporating modern practices with wetlands. this is especially true for enhancing the capabilities of nutrient recycling and water purification of the whole production system, whether it is organic farming or intensive conventional farming. mutual benefits could be achieved by the coexistence of different components and polyculture of different animal species, fully utilizing substances and energy derived from different components. the composition of the whole system is independent of the outside environment. in fact, it is a relatively closed-system, for mitigating the negative effects derived from each of the production system and the environment. the wastes are contained, degraded and utilized, instead of spreading to the outside environment as pollutants (fig. ) . integrating wetlands with aquaculture, or agriculture and animal farming through adopting different appropriate patterns are the foundation of the whole system, depending on various functions of wetlands which support energy transfer, nutrient cycling and production processes. one of the most potential benefits of wetlands for integrating usages would be contribution to saving water resources. being an indispensable medium for living beings, water is also essential during the production processes of both agriculture and aquaculture (zhong, ) . the integration of wetlands with food production systems would greatly enable water storage and would therefore become more self-sustained, with sufficient water supply for production processes. degradation of pollutants in water or wet soil is usually more effective than in dry soil, as microorganisms are more active in wet than dry condition, with a more rapid transfer of nutrients and energy flow. in addition to external interferences, wastes, animal manure and excreta are the main pollutant sources within the production ecosystems, consisting of organic matter, ammonia, nitrite, and pathogenic bacteria. accumulation of these substances is hazardous to both living organisms and the environment, and therefore effective degradation of pollutants in time is vital to prevent negative impacts on the whole ecosystem. the relationship of each component within a well-established and integrated production ecosystem is primarily based on efficient transfers of energy and exchange of substances (zhong, ) , with wastes and by-products from one species recycled to become food or fertilizers for another species. the organic wastes are efficiently degraded by microorganisms, earthworms and mollusks into inorganic matter and nutrients. inorganic compounds in wetlands are able to supply the large amount of nutrients required by algae and higher plants (turcios and papenbrock, ) . nutrients are recycled within food chains and food webs involving a variety of producers, consumers and decomposers which are supported by suitable habitats and conditions. in the integrated dike-pond system, the pond is the heart of this production system that produce the marketable fish. the organic residues settle to the bottom of the pond as nutrient rich pond mud, and the pond mud is excavated and used to repair and fertilize the upper surface of the dike that produce the essential inputs for the pond that demonstrated the main nutrient cycling. in aquaponics, aquaculture effluent generally contains elevated levels of ammonia, nitrate, nitrite, phosphorus, potassium, and other secondary pollutants, and also micro-nutrients applied to produce hydroponic plants (diver, ) . the suitable ratio of farmed animals and plants and their associated components is important to health and stabilization of the ecosystem that determines the efficiency of energy transfer and nutrient cycling which in turn affect productivity. in mulberry-dike-fish pond system, % to % is the best proportion of dike and ponds, yielding the highest economic benefit (ruddle et al., ) . if the dike and pond ratio is not suitable, self-reliance between the needs from fish rearing and dike fertilization could not be achieved, and additional feeds or fertilizer may be needed (zhong, ) . it is known that kg of grass can be transformed into . kg of grass carp and . kg of bighead carp or silver carp; while kg of sugar-cane leaves can be transformed into . kg of grass carp (zhong, ) . these estimation indicated that t of fish product would require t of cattle manure, t of pig manure or t of duck manure, and consequently the dike-pond system will become a major sink for manure and other organic wastes (bunting, , p. ) . in general, there is a lack of effective and feasible governance tools to solve various pressing problems facing food production, especially the environmental pressures. this is especially true for environmental problems due to different pts, threating not only food production, but also human health. large predatory fish such as tuna, swordfish and shark containing rather high levels of mercury, hazardous to human health (especially fetus, infants and pregnant mothers), is a typical example (ko et al., ) . changes have to be made concerning the patterns of living and production. inevitably, sustainable development is highly dependent on usages of clean/green energy which is pollution-free and renewable, and operations of clean/green industries which are non-polluting without waste generation; in addition to clean/green community and individual life styles which are with high concerns and feasible governance on the ecosystem preservation and individual development (hill and mustafa, ) . this can only be achieved by proper and effective management of all input and output, including wastes of individual subsystems such as urban centers, industries and food production fields. therefore, sustainable management of food production is linked to both sustainable agriculture and sustainable aquaculture (hill and mustafa, ) . listed below are four principles involved in achieving sustainable food production, focusing on minimal environmental disturbance and safe food production management (fig. ) . ( ) minimize input of hazardous substances. in view of bioaccumulation and biomagnification of various pts (such as hg, pbdes, and ddts) into the food production systems; the amr problem caused by the directional selection of antibiotic; and other problems caused by the residues of pesticides and hormones, that have been threatening the human and ecosystem health, a better control of these inputs to the food production systems is highly essential. integrated farms using strategies such as polyculture and co-culture are more efficient in using resources, with a higher total commercial income than monocultures (nair et al., ; ofori et al., ; wang et al., ; xi and qin, ). however, serious problems are encountered, if pts are entered into the production systems, and their concentrations are magnified due to bioaccumulation and biomagnification along the aquatic food chains (scholz-starke et al., ; windham-myers et al., ; zaldívar et al., ) . catastrophic loss of crawfish (procambarus clarkii) was reported in an integrated rice-crawfish facility due to the usage of pesticides for the control of rice water weevil (lissorhoptrus oryzophilus) (avault, ) . thus, strict management is needed to control the inputs of pts during food production processes. the use of safe feeds (with low and acceptable levels of pts), and bio-degradable pesticides without persistent toxic effects is also recommended. ( ) minimize negative impacts on the ecosystem. this is important to maintain a healthy environment adjacent to food production systems, by enhancing the capability of pollutant treatment, especially the wastewater pathway which is the main pathway affecting the adjacent ecosystem. this could be achieved by effective waste treatment, e.g. taking advantages of wetland and biogas techniques, by improving the structure and function of the food production systems, enhancing their capability of water purification and waste management. for instance, inclusion of the components of hydroponic, constructed treatment wetland or floating islands into aquaculture could eliminate potential eutrophication problems (dai et al., ; graber and junge, ; shutes, ; yeh et al., ) . ( ) recycle waste as resources. there is a need to recycle all fig. . a concept framework for environmental friendly and safe food production management. wastes (e.g., sediment enriched in nutrients could be used as fertilizer) and byproducts (e.g. food processing byproducts such as bone and head of fish could be used as fish meal) generated as resources in food production systems, as much as possible. minimizing inputs of hazardous substances would therefore ensure safer use of these wastes and byproducts. a good management of waste recycling not only minimizes pollution discharges, but also maximizes nutrient utilization, resulting in enhanced yields and economic benefits. for instance, the mud derived from aquaculture is regarded as a good "slow-release" fertilizer in agriculture with high concentrations of organic matter, nitrogen and phosphorus, which has been used to fertilize the dike and cultured mushrooms in the integrated dike-pond system (bergheim et al., ; westerman et al., ) . ( ) select high quality production sites. the selection of high quality food production site is absolutely vital to ensure safety of food products. currently, many sites for food production, and also water sources for food production are polluted, especially in developing countries, where factories are built in the vicinity of food production farms. thus, insulating food production sites from polluted sites would ensure higher quality production of food items, without entry of different toxic chemicals. for instance, t of red tilapia was killed in the chao phraya river (thailand) in , due to the clandestine and illegal release of untreated factory effluents (pongpao and wipatayotin, ) ." in rapidly developing countries, the main safety risks for a food production system include pathophoresis, raw or improperly treated wastewater for irrigation, entry of pesticide residues, heavy metals and other pts into food production systems, from contaminated soils, water, and air, resulting in accumulation of these substances in the cultured products, imposing subsequent health risks, e.g. autism is linked with body metal overload, with children who have high consumption rates of fish contaminated with mercury (ko et al., ) . unfortunately, the use of trash fish for feeding carnivorous fish species, and even the commercial pellets containing fishmeal (also made of low quality fish processing waste) is also the major sources of pts, entering into the cultured products (liang et al., ) . in addition, the use of food supplements such as hormones and antibiotics for enhancing fish growth should be more strictly regulated and managed (jeong et al., ) , but it is difficult to regulate and manage such behaviors". in addition to adopting safe food production management mentioned above to inhibit entry of pts into the food chains, nonchemical methods should be used for controlling pests and diseases, i.e., biological control (resistant cultivars, predators, antagonistic organisms) or physical control (barriers, traps, manipulation of the environment) (chalmers, ) . in this regard, farming indoor would require fewer pesticides and fertilizers, which could reduce human health risks associated with high exposure to agrochemicals, comparing to open conventional farming (graff, ) . in fact, isolating the production sites from the pollution sources, such as air emission and waste effluent from various industries is absolutely necessary to ensure safe and quality products. for ground-based urban farming, a minimum distance is recommended between production fields and main roads to reduce the contamination of crops by lead and cadmium (säumel et al., ) . suitable buffer zones should be considered as one of the components in these production systems in order to minimize potential harmful effects. there have been public health concerns about the potential risks from integrated animal-animal system recently, due to outbreaks of virulent strains such as h n avian flu, when different kinds of animals are reared in close proximity (bunting, ) . in view of this, potential mutation of virus within one kind of animal into a more virulent strain should not be overlooked, as it will be more readily be transmitted from human to human. therefore, the type of animals to be included in the integrated system should be carefully chosen, and the possible interaction between different types of animals grown together should be carefully monitored. however, pigs and poultry have been raised together on farms in asia and europe for centuries (edwards et al., ) , and there has been no evidence for the transmission of viruses to humans, mediated by such production strategy in the past. however, when compared to the past history, the outbreak of virulent strains has become more frequent. these included h n avian flu, severe acute respiratory syndromes (sars), swine influenza virus (siv) and middle east respiratory syndrome (mers). this is likely caused by the differences in terms of food production patterns between the past and present. rearing livestock in pens, especially under intensive farming, restricts the activity of livestock. continual application of medications and disinfectants to maintain low pathogenic environments may have reduced the immunity of livestock and enhanced the tolerance and infectivity of pathogenic organisms. in addition, a large proportion of human population is having from many types of unhealthy habits (such as eat unhealthily, lack of exercise, irregular schedule of work and rest, live with oversized pressure), resulting a sub-health condition with low resistance, rendering themselves to become more susceptible. there were evidences of correlation between agriculture intensification and biodiversity loss and possible influences on disease emergency (morand et al., ; thongsripong et al., ) . thus, researches should put more focus on the therapeutic thought of increasing the resistance first, instead of extensive application of antibiotics and disinfectors. considering the recycling of waste produced by an animal species to another as resource, especially the excrement which may contain pathogenic bacteria and viruses, it is suggested to use wetlands for minimizing the risks. wetlands can treat wastewater effectively, converting animal waste to plant biomass, which can be used as feeding materials for rearing animals. wetlands are known for their high efficiency in pathogen removal (wu, ) . furthermore, rotating different plant species at certain time intervals is effective on reducing diseases (zhong, ) , and ensuring safety of food products (specht et al., ) . agriculture and aquaculture are the two main food production patterns. organic production pattern is regarded as a more sustainable farming system than conventional pattern, in terms of conserving soil, water, energy and biodiversity (gabriel et al., ; pimentel et al., ) , although it is less sustainable in producing the required food for the growing population in order to satisfy the increasing demand for food, conventional production pattern is still indispensable, but improvements to enhance food safety and environmental protection are essential. urgent solutions are needed to address the issue of pts entering into the production systems, and also waste materials (animal wastes and nutrients) escaping the systems, threatening environmental and human health. in principle, wetlands integrated with food production are able to treat inorganic and organic residues, produce safe and quality food, and increase the variety of production by appropriate polyculture that would enhance the overall income (chau et al., ) . the relatively closed-systems are more efficient in maximizing usage of resources and minimizing adverse environmental impacts. multiple wetland techniques and functions would be contributing to these strategies which would also be contributing to vertical farming. the strategies of integrated wetlands with food production are illustrated in fig. . the organic combination of agriculture, aquaculture and wetland can form an intensive polyculture production ecosystem. a good management practice is required to assemble various adjacent food production systems (such as aquaculture, animal farming and agriculture), for sharing resources more effectively. in general, functional wetlands are mainly used to treat wastewater, converting organic waste into inorganic matter, and provision of available nutrients for enhancing crop growth. the polyculture practice can maximize total production and economic return per unit area of land in limited areas (ruddle et al., ) . the highly polluted conventional production patterns could be integrated with functional wetlands to minimize the adverse environmental impacts, and enhance food production more efficiently. however, hazardous substances for controlling pests should be replaced by less harmful or harmless methods, for instance, pesticides could be replaced by ecological control (such as ipm) or biopesticides, or even some chinese herbs. use prebiotics or probiotics to replace the antimicrobials, as well their mixture, so-called 'synbiotics' (woolhouse et al., ) could contribute to enhance the resistance and well-being of their host, but harmless to the ecosystem (marteau and boutron-ruault, ; patterson and burkholder, ) . although there is a consciousness that we need to produce plentiful food for the growing population (godfray et al., ; pinstrup-andersen, ), the waste of food in most of the developed areas is seriously and still with starvation in some poverty areas (gustavsson et al., ; knight and davis, ; lundie and peters, ) . in fact, how to feed the global population equitably and sustainably is the great challenge in the near future (hill and mustafa, ) . in today, how to eat safety and health is becoming the primary concern for most of the peoples. another hand, how to keep our lives sustainable is becoming a big topic, as our environment has been polluted, the normal functions of our ecosystem have been disturbed, and some of the production resources are depleting, such as the non-renewable phosphate rock may be depleted in - years (cordell et al., ) . thus, how to produce safety food via environmentally friendly patterns would be more vital in the coming future. food production systems with more efficient use of resources such as nutrients, energy, land, and water and less interference from hazardous substances are able to generate safe and quality food, which is environmentally friendly. in a properly integrated food production system, nutrients and energy are continuously recycled and utilized within the system, which is also effective, in reducing pollution emissions to the adjacent environment. integrated wetland techniques (such as hydroponic, constructed treatment wetland or floating island) with food production processes, coupled with polyculture of different fish species or other organisms (such as ducks, crabs, shrimps, and etc.), are able to promote ecosystem health, and achieve sustainability, mainly via its wastewater purification and nutrient recycling capability. the integration of agriculture systems with aquaculture systems is one of the important traditional practices. small-scale integrated agriculture-aquaculture systems are still widespread and of considerable importance for rural farming in some countries such as bangladesh, indonesia and vietnam (edwards, ) . nevertheless, some of these existing integrated agro-ecosystems are not completely in conformity with safe food production management, or considered as environmentally friendly. some may lack of control on waste and effluent or without proper waste and wastewater treatment, resulting in eutrophication of receiving waters. some may lack of quality control on the additional inputs, such as using feeds contaminated with ddt and hg. moreover, some may lack of suitable management to isolate the production systems from the pollution sources, such as using raw and improperly treated wastewater for irrigation, uptake of pesticide residues, heavy metals and other pts derived from contaminated soils, water, and air. hence, smarter plans for operating the holistic production system would be important and meaningful in order to achieve sustainable living and industrial production patterns. future studies are needed to provide a balanced diet to different species for maintaining a local ecological balance, finding cure to diseases using harmless techniques, raising overall production, and preventing disease dissemination among animals, especially in regions of different climatic conditions. furthermore, the government should formulate political guidance to promote the transform of environmentally unfriendly conventional food production systems into environmentally friendly integrated food production systems and also provide the needed technology and knowledge support. furthermore, both the national 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the pearl river delta mercury accumulation in freshwater fish with emphasis on the dietary influence key: cord- -jhejhz d authors: muscogiuri, giovanna; barrea, luigi; savastano, silvia; colao, annamaria title: nutritional recommendations for covid- quarantine date: - - journal: eur j clin nutr doi: . /s - - - sha: doc_id: cord_uid: jhejhz d nan the world is currently experiencing the pandemic of coronavirus (cov). in late , the cov infection began in wuhan, hubei, china. it had been originally called ncov and it has been renamed covid- by the world health organization on february . this epidemic began with animal-to-human infection, and the direct cause of death is generally due to ensuing severe atypical pneumonia. covid- has now been declared a pandemic by the world health organization, and people in all countries are under quarantine in order to reduce the spread of the virus, which then also lessens the impact on medical resources. since quarantine is associated to the interruption of the work routine, this could be result in boredom. boredom has been associated with a greater energy intake, as well as the consumption of higher quantities of fats, carbohydrates, and proteins [ ] . further, during quarantine continuously hearing or reading about the pandemic without a break can be stressful. consequently, the stress pushes people toward overeating, mostly looking for sugary "comfort foods" [ ] . this desire to consume a specific kind of food is defined as "food craving", which is a multidimensional concept including emotional (intense desire to eat), behavioral (seeking food), cognitive (thoughts about food), and physiological (salivation) processes [ ] . of interest, a gender difference has been reported in food craving, with a higher prevalence in women than in men. carbohydrate craving encourages serotonin production that in turn has a positive effect on mood. in a sense, carbohydrate-rich foods can be a way of self-medicating anti stress. the effect of carbohydrate craving on low mood is proportional to the glycemic index of foods. this unhealthy nutritional habit could increase the risk of developing obesity that beyond being a chronic state of inflammation, it is often complicated by heart disease, diabetes, and lung disease that have been demonstrated to increase the risk for more serious complications of covid- [ ] . quarantinerelated stress also results in sleep disturbances that in turn further worsen the stress and increase food intake thus giving rise to a dangerous vicious cycle. therefore, it is important to consume food containing or promoting the synthesis of serotonin and melatonin at dinner. a considerable variety of plant species including roots, leaves, fruits, and seeds such as almonds, bananas, cherries, and oats contain melatonin and/or serotonin. these foods may also contain tryptophan, which is a precursor of serotonin and melatonin. protein foods such as milk and milk products are the main sources of the sleep-inducing amino acid tryptophan. moreover, tryptophan is involved in the regulation of satiety and caloric intake via serotonin that mainly lowers carbohydrate and fat intake, and inhibits neuropeptide y, the most powerful hypothalamic orexigen peptides [ ] . further, beyond sleep-inducing properties, milk products such as yogurt could also augmented natural killer cell activity and reduce the risk of respiratory infections [ ] during quarantine the increased intake of macronutrients could also be accompanied by micronutrients deficiency as occurs in obesity [ ] , which is commonly associated with impaired immune responses, particularly cell-mediated immunity, phagocyte function, cytokine production, secretory antibody response, antibody affinity, and the complement system, thus making more susceptible to viral infections [ ] . thus, during this time it is important to take care of nutritional habits, following a healthy and balanced nutritional pattern containing a high amount of minerals, antioxidants, and vitamins. several studies reported that fruits and vegetables supplying micronutrients can boost immune function. this happens because some of these micronutrients such as vitamin e, vitamin c, and betacarotene are antioxidants. anti-oxidants increase the number of t-cell subsets, enhance lymphocyte response to mitogen, increased interleukin- production, potentiated natural killer cell activity, and increased response to influenza virus vaccine compared with placebo [ ] . beta carotene is most abundant in sweet potatoes, carrots, and green leafy vegetables while sources of vitamins c include red peppers, oranges, strawberries, broccoli, mangoes, lemons, and other fruits and vegetables. the major dietary sources of vitamin e are vegetable oils (soybean, sunflower, corn, wheat germ, and walnut), nuts, seeds, spinach, and broccoli. in addition, quarantine could be associated to a less time spent outdoor, less sun-exposure, and reduced production of vitamin d as a result of lower levels of -dehydrocholesterol in the skin. vitamin d deficiency in winter has been reported to be associated to viral epidemics. indeed, adequate vitamin d status reduces the risk of developing several chronic diseases such as cancers, cardiovascular disease, diabetes mellitus, and hypertension that significantly higher risk of death from respiratory tract infections than otherwise healthy individuals [ ] . further, vitamin d protects respiratory tract preserving tight junctions, killing enveloped viruses through induction of cathelicidin and defensins, and decreasing production of proinflammatory cytokines by the innate immune system, therefore reducing the risk of a cytokine storm leading to pneumonia. since the time spent outdoor and consequently the sun exposure is limited, it is encouraged to get more vitamin d from diet. foods containing vitamin d include fish, liver, egg yolk and foods (e.g., milk, yogurt) with added vitamin d. another essential trace element that is crucial for the maintenance of immune function is zinc. it has been reported that zinc inhibited severe acute respiratory syndrome (sars) coronavirus rna-dependent rna polymerase (rdrp) template binding and elongation in vero-e cells [ ] . although oysters contain the most zinc per serving, the most common food to get zinc are represented from poultry, red meat, nuts, pumpkin seeds, sesame seeds, beans, and lentils. all the above described nutrients are enclosed in mediterranean diet pattern that could represent a healthy nutritional pattern to be followed in quarantine. key ingredients of mediterranean cuisine include olive oil, fresh fruits and vegetables, protein-rich legumes, fish, and whole grains with moderate amounts of wine and red meat. in conclusion, due to the quarantine-related situational stress-eating, nutrition becomes a priority at this time. many people probably have much of what they might need at home, and so there is no reason to rush to buy groceries creating mass gatherings that could contribute to the spread of covid because during quarantine food stores stay open throughout. keeping foods that are good sources of immuno-supportive nutrients, planning times to eat, meals, portions and having a cutoff time for eating but mostly having in mind positive attitudes could be helpful to tackle the negative health effects of quarantine. conflict of interest the authors declare that they have no conflict of interest. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. eaten up by boredom: consuming food to escape awareness of the bored self neuroactive compounds in foods: occurrence, mechanism and potential health effects food craving: new contributions on its assessment, moderators, and consequences risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease pneumonia in wuhan, china diet promotes sleep duration and quality reducing the risk of infection in the elderly by dietary intake of yoghurt fermented with lactobacillus delbrueckii ssp. bulgaricus oll r- impact of micronutrient deficiencies on obesity micronutrients and immune function: some recent developments effect of vitamin and trace-element supplementation on immune responses and infection in elderly subjects vitamin d and chronic diseases: the current state of the art zn( +) inhibits coronavirus and arterivirus rna polymerase activity in vitro and zinc ionophores block the replication of these viruses in cell culture key: cord- -dq t bbd authors: d’souza, anisha a.; kumari, durga; banerjee, rinti title: nanocomposite biosensors for point-of-care—evaluation of food quality and safety date: - - journal: nanobiosensors doi: . /b - - - - . - sha: doc_id: cord_uid: dq t bbd abstract nanosensors have wide applications in the food industry. nanosensors based on quantum dots for heavy metal and organophosphate pesticides detection, and nanocomposites as indicators for shelf life of fish/meat products, have served as important tools for food quality and safety assessment. luminescent labels consisting of nps conjugated to aptamers have been popular for rapid detection of infectious and foodborne pathogens. various detection technologies, including microelectromechanical systems for gas analytes, microarrays for genetically modified foods, and label-free nanosensors using nanowires, microcantilevers, and resonators are being applied extensively in the food industry. an interesting aspect of nanosensors has also been in the development of the electronic nose and electronic tongue for assessing organoleptic qualities, such as, odor and taste of food products. real-time monitoring of food products for rapid screening, counterfeiting, and tracking has boosted ingenious, intelligent, and innovative packaging of food products. this chapter will give an overview of the contribution of nanotechnology-based biosensors in the food industry, ongoing research, technology advancements, regulatory guidelines, future challenges, and industrial outlook. increased outbreaks in foodborne illness and the need to meet the demands of growing populations have been the driving forces for ensuring that food production undergoes quality control for evaluation of its fitness for human consumption (sekhon, ) . food safety is crucial at every step right from its production to its preservation, transportation, and consumption. consumers expect optimal quality, good stability, and a safe food product at a reasonable price. monetary and legal aspects related to food products as a consequence of food contamination are of grievous concern to food producers accompanied with loss of consumer confidence (odumeru, ) . with these concerns, food safety and nutritional quality have always been a priority issue for producers, food safety regulators, the food industry, and consumers (karlsson, ) . foodborne illness could also be as serious as botulism, listeriosis, or hemolytic uremia syndrome, which often need hospitalization. hence, an accurate and quick monitoring of food quality should be feasible during various stages of food production until consumption. conventional analytical methods mandate high numbers of pathogens or analytes for visual or identifiable changes in food. low levels of analytes in food generate low signals with great variations, which are difficult to detect with confidence (rodríguez-lorenzo et al., ) . moreover, many analytical techniques are destructive and affect the seal of the packaged food (duncan, ) . until recently, most of the biosensors developed were marketed for medical applications. moreover, food matrices offer many limitations due to their opacity, coloring matter, light scattering and complexity of food materials. advances in the area of analytical methods and scientific tools, with better detection methods in the complex matrix of foods, thus dictate the need for development of advanced biosensors for the food industry. nanocomposite-based biosensors provide new solutions to tackle critical analytical evaluation and detection problems of contaminants and achieving quality and safety in the food industry. the unique traits of nanoscale composites with improved stability make them outstanding for sensor applications (fig. . ) . their use has enabled improved sensitivity and portability with unparalleled performance and real-time sensing in complex matrices. the current chapter features the various nanocomposites chapter evaluation of food quality and safety employed in improving the conventional analytical and sensing applications in the food industry. additionally, monitoring of food freshness, pathogen contamination and toxins in food products, after being dispatched until they are consumed requires point-ofcare sensing technology. the chapter describes specific demands of nanocomposite-based nanosensors in addressing crucial segments related to food safety and quality, such as determining contamination, pesticide residues, antibiotics, shelf life and organoleptic assessment at point of care. the chapter also discusses the existing and future prospects of nanotechnology-based biosensors along with their commercial potential. as per the international union of pure and applied chemistry, biosensors are devices that contain an amalgamation of receptors with transducers for selective quantification using incorporated biological recognition elements (thévenot et al., ) . the receptor of a biosensor recognizes and interacts with the analyte. receptors could be enzymes, antigens (ag), nucleic acids, or organelles performing an affinity, biochemical, or catalytic reaction. binding or catalysis between receptors and substrate transforms the physical, chemical, or biologic information to some form of energy, such as, electrochemical, optic, fluorescence, mass, or calorimetric signals, which is measured by the transducer. the transducer thus provides quantifiable physicochemical signals proportional to the analyte concentration (thakur and ragavan, ) . biosensors are widely used to determine contamination, raw material and product composition. they also keep tab on quality check. besides government's mandatory regulations, quality check also encompasses nutritive value; degree of food spoilage, especially of meat and fish; degradation during storage; processing, distribution, and presentation fit for human consumption; peak freshness, with minimized opportunity for foodborne diseases; and health hazards on food consumption. monitoring organoleptic characteristics, such as, smell, odor, and taste of food is also an important parameter for determining food quality. rapid, nondestructive detection of foodborne pathogens, pesticide residues and allergens with high analytical sensitivity are the major needs of the food industry (murugaboopathi et al., ) . additionally, on-site monitoring of fermentation, antibiotic residues, and toxins in food is also required in the food industry. noninvasive sensing technology at point-of-care settings may be beneficial for food testing, especially if the analytes can be determined just by visual observation of the product. the demand for quick and specific biosensors for analysis of food has thus been continuously rising and expanding to address the different aspects of food quality and safety. friendly applicability and simplified communication with end users are the ultimate striving goals for assuring quality of food products. nanotechnology is "the understanding and control of matter that involves manipulation of structures at dimensions of - nm" (sargent, ) . application of nanotechnology to sensors or biosensors in the food industry is known as "nanosensors" or "nanobiosensors," respectively. nanosensors are relatively a new concept in the food industry compared to their application in pharmaceuticals. nanocomposites are utilized in several ways to improve the efficiency of nanosensors. they essentially consist of nanoparticles (nps) attached to any of the various recognition labels followed by detection through any of the sensing approaches illustrated in fig. . . nanotechnology in sensing, permits miniaturization of sensors which facilitates their integration with normal food production and packaging machinery and equipment, or can chapter evaluation of food quality and safety be used offline as point-of-care devices (leonard et al., ) . the demand for analyte samples and reagents used in nanosensors is less than that of conventional methods of detection. additionally, the time factor involved for detection is significantly reduced from hours to minutes compared to many traditional laboratory analytical techniques. nanomaterials differ in properties from those of the bulk macroscopic material due to their existence and interaction at the atomic levels. the small size of nanomaterials ( - nm) results in large surface areas with high surface reactivity, high electric conductivity, enhanced magnetic properties and improved quantum confinement effects, such as, luminescence and catalytic properties, making them very sensitive (kaittanis et al., ) with high analyte-capturing efficiencies (duncan, ) . the slightest modification of the nanostructures with respect to their size, self-assembly, surface composition, and shape alters and tunes their electronic, conductive, fluorescence, light-scattering, binding properties and the absorption-emission spectra. they can also permit engineering with different molecules and combinations of individual bioaffinity agents and act as transducers to enable ultrasensitive detection, as well as, multiplex sensing assays for different pathogens and protein-based toxins (tallury et al., ; xu and ying, ) . for instance, in one study, combinations of metallic platinum nanocomposites and single-walled carbon nanotubes coated on glassy carbon provided enhanced sensitivity for detection of hydrogen peroxide and glucose over individual nanocomposites by voltammetry within s. the presence of nanocomposites ensured that the electric contact of the glass electrode and the biosensor loaded with glucose oxidase enzyme was more sensitive than that of an unmodified glass electrode loaded with the same enzyme (hrapovic et al., ) . the unique properties of nanomaterials can thus be easily exploited for improving sensitivity, robustness, and reproducibility of biosensors, diagnosing within a shorter span of time, and at the same time being relatively economical (nath et al., ) . nanoproperties change before and after binding with analytes. a simple example would be illumination with different-colored fluorescence on interaction with different pathogens. they permit real-time and online qualitative and semiquantitative detection. they can be also called "naked eye chemosensors." such online sensors provide greater control over product properties during manufacturing, thus improving product quality and cost reduction (ravindranath et al., ) . incorporation of nanoparticles (nps) into composites also permits intimate contact with analytes like pathogens, as nps often exhibit size similar to biologic species, such as, bacilli and viruses. gold nanoparticles (aunps) exhibit length-dependent absorption properties; permitting simultaneous detection of organisms. hybrid nanocomposites of iron oxide-gold nanorods and iron oxide nanodumbbells have tunable optic and magnetic properties. iron oxide-gold nanorods upon binding with pathogens exhibit different aspect ratios and thus differ in plasmon properties and also facilitate magnetic separation. this functionality was explored for multiplex optic detection (wang and irudayaraj, ) . nanowires conjugated to fluorescent antibodies (ab) can detect pathogenic microorganisms. for instance, if the food contains traces of salmonella, salmonella abs conjugated to fluorescent antibodies are coated on the nanowire. the ab-coated nanowire upon interaction with salmonella would alter the fluorescence of the probes, making them visible (dingman, ) . the nanocomposite-based nanosensors thus permit visual identification of pathogens at point-of-care without significant lag time, and serve as a simple technique for consumers to know the quality and safety of food products. coupling of metallic nps to affinity ligands can lead to sensing of genetic strands, bacteria, or toxins using any of the sensing principles based on change in fluorescence, magnetic, raman scattering, and electrochemical changes, as depicted in fig. . (alivisatos et al., ) . the high sensitivity of nanosensors permits real-time detection and quantitation at molecular and single-cell levels (tallury et al., ) . online real-time analysis has significantly reduced the time for pathogen detection. earlier analytical techniques needed over h for permitting sufficient growth of pathogens to be detected (mahalik and nambiar, ) . nps exhibiting magnetic, fluorescence and conductive materials have been exploited for detection, imaging and tracking through various probes. for instance, quantum dots (qds) permit labeling and visualization, replacing classical fluorophores. metallic nps are conducting in nature and thus wiring of the biologic unit facilitates a rapid transfer of electrons. hence, electrodes are often modified with a monolayer of aunps conjugated to bioelements. in one study, glucose oxidase conjugated to silver/ gold/platinum nps electrodeposited on metal electrodes enhanced transfer of electrons between enzyme and electrode with improved stability (zhu et al., ) . the role of conducting polymer nanowires and semiconductors as nanomaterials in sensor applications has already been reviewed (willner et al., ) . application of nanotechnology in nanosensors is, however, not restricted only to recognition labels but could range from recognition element to transducer or running systems. platforms technology of nanotechnology in microfluidics, microelectromechanical systems, cantilevers, and microarrays have further widened the realm of quality analysis (sozer and kokini, ) (fig. . ) . microfluidic systems based on silicon have been popular as laboratory-on-a-chip technology. they are multifunctional wherein sampling, separation, reaction, and detection can be performed on the same device. nanocantilever-based sensors have been used to detect various molecular interactions, such as, ag-ab, enzymesubstrate-cofactor, chemical interactions, receptor-ligand and nucleic-acid hybridization (hall, ; kumar, ) . bio-finger is a portable nanosensor consisting of nanocantilevers made of piezoresistive material for detection of pathogens, chemicals, and toxins in food based on ligand-receptor interactions. any binding or interaction between an ag and ab induces mechanical stress on the nanocantilever, which is coated with antibodies, and changes the electric resistance of the material. multiple such nanocantilevers can be arranged in an array to form a single chip. the total analytical time for detecting the analyte is - min. the cost of bio-finger is expected to be $ , cheaper than the existing diagnostic techniques. arrays have an upper hand in obtaining sensitive and simultaneous detection of analytes. reference sensors can also be incorporated into the array, minimizing the noise. food contamination caused by pathogens (bacteria, fungi, protozoa, viruses, prions, and worms) and toxins remains a major concern globally. conventional techniques for identification of figure . . schematic representative of (a) simplified microfluidic system (b) mass sensors used in nanocantilever. increase in bacterial growth increases bacterial mass and depletes nutritive layer deflected by nanocantilever due to change in mass. pathogens include microscopic examination, growth patterns of culture upon culturing in differential media, their biochemical tests, and immunoassays (tallury et al., ) . these techniques are laborious, with lag times greater than h for pathogen amplification. the process of sample preparation remains a determinant for specificity and sensitivity of many assays (kaittanis et al., ) . lately, molecular diagnostics, such as, identification of dna segments and proteins of the pathogen's genome and virulent strains using polymerase chain reaction (pcr), ligase chain reaction, and checkerboard hybridization have been employed (tallury et al., ) . however, these methods mandate the need of undamaged microbial dna for detection. identification of circulating abs and specific cell-wall epitopes made of carbohydrate or proteins can also be achieved by immunoassays, phage typing, and flow cytometry; but are limited to homogeneous, purified, and simple matrix samples (kaittanis et al., ) . rubpy dye [tris( , -bipyridyl) dichlororuthenium (ii) hexahydrate] labeled with ab-conjugated silica fluorescent nps ( nm in diameter), which were conjugated to anti-escherichia coli ab, enabled single e. coli o :h detection obtained from processed beef samples within min. the fluorescent signal of the dye varies on the biorecognition of e. coli. sensitivity of the method was similar to that of conventional plate counting but with a shorter readout time. the technique also permits high-throughput quantitation of - bacterial cells using microtiter plate reader (zhao et al., ) (fig. . ) . silicon/gold nanorod nanoarrays functionalized with anti-salmonella abs bearing organic-dye particles become visible in the presence of salmonella. the high aspect ratio of silicon nanorods upon interaction of anti-salmonella abs with salmonella ags shows increased fluorescence intensity of dye molecules (fu et al., ) . electrostatic interactions of aunps functionalized with fluorescent π-conjugated anionic polymers like p-phenylene ethylene results in quenching of fluorescence. however, in cases of bacterial contamination, fluorescence emission increases due to displacement of the anionic polymer with the negative cell surface of bacteria, including e. coli, lactococcus lactis, streptomyces coelicolor, and bacillus subtilis. linear-discriminant analysis generates a characteristic signature plot specific for each microorganism. the method has been successful for detection of × cfu (ie, od = ) (phillips et al., ) . different strains of norovirus, parvovirus, corona virus, adenovirus, simian rotovirus, herpes virus, and sendai virus at a count of particles in food and drinking water have been discriminated using aunps (fan et al., ) . surface-enhanced raman scattering (sers) based on nanostructured gold and silver nanorods as substrates, can detect and differentiate strains of bacillus species and simultaneously screen e. coli, listeria monocytogenes, and salmonella typhimurium within s of collection time chu et al., ) . principal component analysis is used to analyze the raman scatter and classify the data according to the presence of different species, strains, and gram-types. yet another advantage is the differentiation between viable and nonviable cells. nonviable cells have significantly reduced sers (chu et al., ) . surface plasmon resonance (spr) effect of aunps improved the performance and sensitivity -fold compared to conventional methods (chen et al., ) . interaction of magnetic nps with pathogens undergoes spinspin relaxation time (t ) of adjacent water molecules (chemla et al., ) . change in relaxation times (∆t ) can be detected by benchtop-magnetic relaxometer ( mhz, . t ) or superconducting-quantum interference device (squid) or by magnetic resonance imaging ( mhz, . t ) (zheng et al., b) . the higher the relaxivity of iron-oxide nps, the higher is the sensitivity of detection. mycobacterium avium spp. paratuberculosis (map) was quantified in whole milk using spherical iron-oxide nps and dextran-coated iron oxide nanorods (r m/m per s) within - min without any interference (kaittanis et al., ; nath et al., ) . in the presence of map, conjugation of ironoxide nps changed the spin-spin ∆t of water protons. low bacterial concentration caused assembly of nps on bacterial surfaces, and hence high ∆t was observed. while at high bacterial concentrations, ∆t decreased due to the dispersed state of the nps. in the presence of a magnetic field, nps acquire magnetization. on switching off of the magnetic field, free nps relax rapidly by brownian rotation and thus do not contribute to any signals. abs bound to pathogens are immobilized and undergo neel relaxation; that is, the oscillations vary in the presence of a target with slow decay of magnetic flux, dissipating magnetic flux detectable by squid, as opposed to, the change in brownian motion observed in free nps (chemla et al., ) . magnetic nps conjugated to ab and immobilized with squid on amylar film detected l. monocytogenes above a count of × (grossman et al., ) . however, the requirement of high infrastructural costs limits the application of these magnetic np-based sensors for the food industry. nanosensors commonly use immunoassays with ab immobilized on nps coupled with immunocapture for detection (warriner et al., ) . immunomagnetic separation is performed to concentrate the analytes or pathogens above the signal-to-noise ratio. antibodies specific to analyte or pathogen are conjugated to magnetic particles followed by separation with a magnet prior to detection (fig. . b) . l. monocytogenes have been captured by immunomagnetic nps during a h time duration. the immunomagnetic nps consisted of magnetic nps (diameter of nm) functionalized with l. monocytogenes ab via biotin-streptavidin linkages. the separated complex was injected into a microfluidic chip and detected using an impedimetric immunosensor at hz. resistance of complexes dispersed in mannitol solution decreased the impedance. the method was sensitive in simple matrices, such as, buffers with a sensitivity of cfu/ml. the sensitivity decreased in matrices like milk, lettuce-rinse samples, and beef homogenates with a limit of detection of - cfu/ml within h due to interference of high protein/fat content. the method exhibited high specificity in the presence of other foodborne bacteria like e. coli, staphylococcus aureus, and salmonella tyhphimurium (kanayeva et al., ) . aunps conjugated to secondary enzyme-labeled l. monocytogenes ab detected l. monocytogenes with high specificity over other enteric bacteria at log cfu/g in wild-blueberry samples. the nps were immobilized on screen-printed carbon electrodes for amperometric sensing (davis et al., ) . magnetic iron-oxide nps conjugated to vancomycin quantified s. aureus using a magnetic resonance system. vancomycin interacted with the peptidoglycan of the bacterial cell wall. the method could detect almost bacteria present in µl of sample within min. the magnetic nps form clusters upon identification of the analyte and the self-assembled cluster complexes decrease the nuclear spin of surrounding water protons (t ). detection of t was possible by a handheld portable device consisting of a microcoil array for nuclear magnetic-resonance measurements, a microfluidic network for handling sample and mixing with nps, and a permanent magnet to generate a polarizing magnetic field . the combination of gold-microelectrode array in a microfluidic device along with magnetic nps conjugated with ab helps in detection of pathogens, for example, e. coli in ground beef. the bacterial cells were concentrated by immunocapture by a factor of - in a volume of pl; and the metabolism was detected by impedance. detection time was comparatively reduced with bacilli in a dilute sample (gomez-sjoberg et al., ) . e. coli could be detected with nanocantilever coated with agarosenutritive media for bacilli. as the mass of the cantilever array increased, the resonance frequency changed. the cantilever could detect a mass of approximately active e. coli cells within h ( fig. . b). selectivity of the method could be improved by adding antibiotics to the nutritive media (gfeller et al., ) . likewise, magnetic nps conjugated to anti-h n ab aggregated in the presence of avian flu virus. high transition-temperature superconducting quantum interference senses the immunomagnetic reduction of the reagents and allows quantitation of h n in wash-free samples . diagnostic kits containing aunps have been studied for detecting influenza virus in poultry. these diagnostic kits have aunps conjugated with specific protein of the avian influenza virus (emami et al., ) . literature has ample such examples for detection of pathogens (table . ). an immunochromatographic assay for rapid detection of s. aureus has been developed by huang et al. (huang, ; huang et al., ) . on a defined zone of nitrocellulose membrane, igg antiprotein a (cell wall protein of s. aureus) conjugated to aunps was mobilized. two precooked foods naturally contaminated with bacterium and processed foods artificially spiked with s. aureus were allowed to flow past the igg antiprotein by capillary action. a red color was seen for the specific reaction with antiprotein a at chapter evaluation of food quality and safety < cfu/g. the same technique could identify different strains of s. aureus and non-s. aureus strains ( fig. . c ). nanobioluminescence detection spray developed by ag-romicron contains a luminescent protein engineered to detect salmonella and e. coli. the spray is directly applied to food or beverage and the proteins react with the pathogens, producing a visual glow. aunps cause the free electrons in the conduction band to form plasmonic bands. any minor change in the dielectric constant locally either by adsorption or by aggregation shifts the plasmonic bands. interaction between nucleic acid and aunps causes a shift in the peak of spr (sun and xia, ) . for detection of anthrax, aunps are used in probes. hybridization between the target gene and the aunp-based probes alters the dielectric constant and hence diffraction of light. this method is simple, specific, and sensitive with a color-selective nature and was found to detect anthrax lethal factor as low as fm concentration (bailey et al., ) . methicillin-resistant strains of s. aureus possess the meca gene, which can be detected using dna-modified aunps and does not require target or signal amplification (storhoff et al., ) . aunps capped with oligonucleotideprobes (alkanethiol- nucleotide probes) have been studied in detecting the inva gene of salmonella. on amplification of the target gene by pcr, high sensitivity was observed in comparison with agarose gel electrophoresis. detection limit of the probe was . ng/µl (majdinasab et al., ) . aunps assembled via -aminoethanethiol on the surface of gold chip were immobilized with gold-binding polypeptides (gbp)protein a-human igg conjugated to anti-salmonella ab. the surface modification intensified the binding signal intensity threefold and caused a -fold increase in sensitivity in comparison with the bare chip (ko et al., ) . the detection techniques of nucleic acids and those involving spr techniques currently are limited to only clean, isolated samples, and evaluation of the same in mixed matrices of food analyte is warranted. toxins disrupt the phospholipid bilayer of host cell plasma membranes by generating pores within the layer. fungal toxins (mycotoxins), cyanobacterial toxins in freshwater, and marine toxins in shellfish are retained in food samples even after the death of the pathogen (kayal and charbit, ) . regulatory bodies have set maximum permitted levels for mycotoxins in food products (european commission regulation, ) . detecting low levels of mycotoxins is a challenging issue in complex food matrices (berthiller et al., ) . aunps coated with thiolated lactose derivatives mimic the distal portion of gm ganglioside, an extracellular matrix of intestinal epithelial cells, and conjugates with cholera toxins. interaction of toxin and nps occurs within min with a red shift of the plasmonic band and allows a detection limit of nm (schofield et al., ) . similarly, globotriose-coated aunps resemble the globotriaosylceramide present on renal epithelia and intestinal microvilli. the b subunit of shiga-like toxin interacts with this bioartificial substrate and permits visual detection of the interaction (chien et al., ) . in another study, multiplexed sandwich fluoroimmunoassays have been used for simultaneous examination of four toxinscholera, ricin, staphylococcal enterotoxin b, and shiga-like toxin using cadmium-selenide-zinc sulfide (cdse/zns qds) at four different wavelengths after binding to their specific ab (goldman et al., ) . staphylococcal enterotoxin b isolated from food samples by immunomagnetic separation using magnetic nps coated with anti-staphylococcal enterotoxin ab could be quantified by fluorescence nanotransduction (branen et al., ) . fluorescent quantum dots (qds) have also quantitated staphylococcal enterotoxin b, ricin, cholera, and shiga-like toxin. europium quantum dots depicted sensitivity of pg/ml, times more than conventional enzyme-linked immunosorbent assays (tang et al., b) . ab-labeled luminescent qds have also been studied for detecting botulinium toxin serotype a with picomolar sensitivity (warner et al., ) . staphylococcal enterotoxin b reacts with polyclonal ab-coated aunps and then with fixed polyclonal ab on porous nitrocellulose membranes placed in a lateral-flow assay device. toxin-ab reaction reproducibly led to the formation of a red line at the detection zone within min with increased sensitivity up to pg/ml on silver enhancement (rong-hwa et al., ) . likewise, aunps conjugated to igg-rabbit anti-staphylococcal enterotoxin b immobilized on a polycarbonate surface, enabled detection of staphylococcal enterotoxin b. the food analytes were mainly tomatoes, baby foods, and mushrooms spiked with enterotoxin, centrifuged, and passed through a cation exchanger, carboxymethyl cellulose analytical column to remove the interfering food materials. after incubation of these eluted samples with the membrane for min, the membrane was exposed to hrp-conjugated anti-staphylococcal enterotoxin b igg and detected by chemiluminescence. detection limit was . ng/ml (yang et al., ) . aflatoxin (toxins of aspergillus) detection has been studied with aunps bearing aflatoxin ab up to levels of . ng/ml in grains within min. immobilization of these nps on immunochromatography strips facilitated portability with performance comparable to that of high-pressure liquid chromatography (hplc) (shim et al., ) . toxins in milk interact with aflatoxin m ab anchored on iron-oxide nps, isolating the toxins and allowing quantification by enzyme-linked immunosorbent assay (radoi et al., ) . aflatoxin b in artificially contaminated milk up to concentrations of . ng/ml could be detected using piezoelectric immunosensor based on aunps (jin et al., ) . nanoiron-oxide nps core coated with aunps as shell, detected aflatoxin b in nuts when used as labels in a lateral-flow immunodipstick with similar results as obtained by hplc but with a shorter readout time of min. samples for analysis were prepared by extraction of ground peanuts, hazelnuts, pistachios, and almonds with an admixture of methanol and water followed by filtration (tang et al., a) . immunomagnetic nps conjugated to polydopamine-extracted aflatoxin from liquid food samples with % recovery in case of aflatoxin af and % of aflatoxin b in red wine. it thus helps in concentrating the analyte, which can then be analyzed (mccullum et al., ) . antimicrocystin-lr-coated single-walled carbon nanotubes bind to microcystin-lr (toxin released by cyanobacteria) in drinking water up to levels of . nm. the method is an improvement over the sampling time involved in the traditional method of quantitation by enzyme-linked immunosorbent assay (wang et al., a) . recently, antideoxynivalenol conjugated to poly(maleic anhydride-alt- -octadecene)-coated qds were studied for detection of deoxynivalenol (trichothecenemycotoxin) in diluted extracts of maize with detection limit of µg/l (speranskaya et al., food preservatives like benzoates and taste-intensifying additives, such as, glutamates have been checked for their isolation and isotachophoresis zonal electrophoresis detection on a microfluidic poly(methylmethacrylate) chip. the method is very sensitive, with low limits of detection (µm/l) with no interference from food (bodor et al., ) . concentrations of benzoic acid and its salt added as food preservatives are dictated by law, as well as, controlled by regulatory agencies (european union law, ) . nanomaterial made of glassy carbon electrodes can benzoic acid inhibits the biocatalytic activity of tyrosinase and polyphenol oxidase. concentrations of benzoic acid up to . µm could be proportionally detected by catalytic inhibition of tyrosinase entrapped in titania gel modified with multiwalled carbon nanotubes and nafion in nonalcoholic beverages. the results obtained were consistent with those obtained with hplc method but with a better sensitivity of . µa/µm (kochana et al., ) . amperometric quantitation of monosodium glutamate in food seasonings, sauces, and soups using glutamate oxidase anchored to a screen-printed electrode was in the range of - mg/dl detected within min (basu et al., ) . melamine is an adulterant often found in pet foods, raw milk, and infant foods to elevate the protein content. cyanuric acidfunctionalized aunps bind to melamine selectively and cause aggregation of aunps, which change in color from red to blue. limits of detection are . ppb and the results are easily visible to the naked eye (ai et al., ) . based on a similar principle, chemical reductants and crown ether-modified thiols specific to melamine binding have been included in sensing technology, which prevents formation of aunps. this results in a change of color (kuang et al., ) . sers-based detection using patterned gold nanostructures (bluray disc surfaces) have also detected melamine up to levels of ppm from contaminated noodles, wheat gluten, cakes and chicken feed liu and ma, ) . adulteration of urea in milk is an emerging concern. blends of urease enzyme and polyvinyl pyrrolidone electrospun to form beaded nanofibers of dimensions - nm were used for urea biosensing. the implantable patch had been originally used for biosensing urea in kidney failure patients, which can also be extrapolated for urea contamination in milk (gouma, ) . water poisoning with cyanide could be detected up to levels of nm by quenching of fluorescence exhibited by aunps . detection of acrylamide in water is also possible by voltammetry, using single-walled carbon nanotubes coated on glassy carbon electrodes (krajewska et al., ) . perchlorate, a food and water pollutant, has also been detected using -dimethylaminoethanethiol-modified aunps based on the sers principle at . µg/l (gu et al., ) . addition of colorants like ponceau r and sudan i are illegal as they are carcinogenic adulterants (duncan, ) . carbon nanotube-based colorimetric assays have been developed for detection of such food colorants often used in soft drinks and beverages . graphene-modified glassy carbon electrodes detected sudan iv in ketchup and chili powder in the range of × - m- × - m (mo et al., ) . multiwalled carbon nanotubes with ionic liquid nanocomposites containing carbon-ceramic electrodes have been used for electrochemical detection of dyes used in food and beverages, such as, tartrazine and sunset yellow (majidi et al., ) . mercury (hg) in elemental, inorganic, and organic forms is toxic to humans. techniques for removal of mercury, cadmium (cd), silver (ag), and titanium (ti) have been developed using superparamagnetic iron-oxide nps functionalized with dimercaptosuccinic acid from water (yantasee et al., ) . aunps functionalized with hg-specific oligonucleotide consisting of thymine can detect hg (ii) up to concentrations of . nm (zhu et al., ) . monolithic nanostructured cages of cubic fm m (c ) monoliths aid in naked-eye detection of toxic metal ions like hg (ii), lead (ii), and cd (balaji et al., ) . detailed reviews of optic sensors for detecting hg are also reported (el-safty and shenashen, ). ironoxide nps immobilized with alkaline phosphatase measure the amperometric reaction between alkaline phosphatase and ascorbic acid -phosphate on contact with hg, cu, ag, and pb in water or other complex matrices (loh et al., ) . different nanosensors used for detection of heavy metals are listed in table . . organophosphates widely used as pesticides and insecticides are retained in plants, water, and fruits due to their high aqueous solubility. they irreversibly inhibit acetyl cholinesterase enzyme, wang and si ( ) essential for central nervous system functioning. high consumption causes buildup of the neurotransmitter and interferes with muscular responses and acts as a neurotoxin (mulchandani et al., ) . conventionally, they are detected by chromatography, which is time-consuming and needs trained personnel for extensive preparation steps with no real-time detection. organophosphorous pesticides can be selectively determined by ab immobilized on magnetic nps coated with -aminopropyl triethoxysilane based on enzyme-linked immune sorbent assay with high sensitivity . acetyl cholinesterase immobilized on copolymer of polypyrrole and polyaniline followed by doping with multiwalled carbon nanotubes could detect thiocholine up to . ng/ml with good reproducibility. polypyrrole is used as a polymer matrix as it can be easily electropolymerized in neutral ph solutions at lower oxidation potentials conducive for biologic molecules, while carbon nanotubes provide effective wiring and an anionic dopant. copolymer of polypyrrole with aniline provided a porous matrix for entrapment of acetyl cholinesterase (du et al., b) . a disposable screen-printed electrode consisting of multiwalled carbon nanotubes with drosophila melanogaster acetyl cholinesterase and prussian blue detected dichlorvos and carbofuran (organophosphate and carbamate pesticides) up to . µg/l in vegetable and water samples . residues of herbicide , -d up to pg/ml could be detected using cadmium telluride (cdte) qd as label. the qd capped with mercaptopropionic acid was coupled to alkaline phosphatase using edc coupling followed by conjugation to , -d. competitive binding between conjugated , -d-alkaline phosphatase-cdte qd and free , -d anti- , -d-igg ab immobilized in an immunoreactor column enabled fluoroimmunoassay detection . carbon nanotubes and metallic nanomaterial-based electrochemical sensors for detection of pesticide have been reviewed recently . some more examples are cited in table . . crystal violet and malachite green, fungicides, and antimicrobials banned by the us food and drug administration (fda), are common adulterants found in fish grown in contaminated waters. patterned gold nanostructures have been able to detect them up to ∼ . ppb levels based on the ser principle . shelf life of food products refers to the period for which they can be used while maintaining the food quality. extrinsic factors, such chapter evaluation of food quality and safety hu et al. ( ) as, gaseous atmosphere, storage temperature, and relative humidity coupled with intrinsic properties of food determine the shelf stability and perishability of food. shelf-stable foods have lower water activity and/or low ph, whereas perishable foods have the opposite intrinsic properties (mcmeekin and ross, ) . stale food results in unacceptable flavor, odor, accumulation of gases, release of exudates, physicochemical changes in appearance, consistency, and color. stale meat or fish releases gaseous amines like ammonia due to floral growth or any chemical change of the product. biogenic amines are also indicators of food spoilage (ruiz-capillas and moral, ); for example, histamine, putrescine, and tyramine consumption have all been linked to hypertension and migraine (linares et al., ) . xanthines are breakdown products of purines and are used for predicting shelf life of fish and meat (devi et al., ) . xanthine oxidase conjugated to chitosan-zno nps dispersed on a multiwalled carbon nanotube scaffold within matrix of polyaniline was studied as a xanthine sensor. addition of zno nps to carbon nanotubes promotes better and faster transport of electrons between the active sites of biomolecules (ie, xanthine oxidase and electrode with good chemical stability). chitosan permitted formation of bioadhesive films for immobilization of xanthine oxidase. the sensor displayed a detection level of . mm without any interference from matrices (devi et al., ) . conjugation of xanthine oxidase to agnps further enhanced the stability of enzymes on storage for days at room temperature (devi et al., ) . moisture content and gases, especially oxygen in excess, are mainly responsible for food spoilage. zno-and tio nps have been studied for detection of ethanol and oxygen, respectively (robert, ) . photoactivated indicator ink, consisting of tio -or sno nps and redox-active methylene blue dye, detects even trace quantities of oxygen retained during packaging or during leak cases (mills and hazafy, ) . electrospun nanofibers and nanowebs made of carbon, metal-oxide semiconductors, polymers (nylon- , polyacrylic acid, and polyvinyl alcohol), and ceramics have been employed as sensors for detection of ammonia, hydrogen sulfide, nitrogen dioxide, carbon dioxide, carbon monoxide, moisture, formaldehyde, and other volatile organic gases (ding et al., ) . adsorption of gases changes the oxidation-reduction potential of oxide semiconductors and affects the electric conductance (shevade et al., ) . polyacrylic-acid nanofibers coated with qcm (quartz crystal microbalance) exhibit a sensitivity of ppb for the detection of ammonia (ding et al., ) . perylene-based nanofibrils containing fluorophores detect parts-per-trillion level of gaseous amines (che and zang, ) . a tenside (detergent) film dispersed with carbon-coated cunps is also sensitive to humidity. moisture causes the polymer to swell, resulting in separation of nps, and hence absorption and reflection of different colors. on dissipation of moisture, the sensors are reusable (luechinger et al., ) . some more examples are given in table . . a research team at the canadian wheat board center for grain research has developed sensors for conducting polymeric nps made of anilineboronic acid-phosphate complex to monitor the quality of grains (neethirajan et al., ) . the nanosensors particularly used for carbon dioxide detection essentially consist of anilineboronic acid-phosphate complexes between the goldinterdigitated array microelectrodes and indium-doped sno coated glass slides and electrolyte layer, followed by a layer of polytetrafluoroethylene as a selective layer. the conducting polymer responds to any volatile gases, insects, fungi, and analytes; detects the source and type of spoilage; and generates a change in electric resistance in the presence of moisture. the sensors have a low power requirement too, and hence can be placed at pest hideouts (neethirajan et al., ; neethirajan et al., ) . standardization of sensory properties (color, smell, taste, and texture) conventionally relies on sensory analysis of trained expertise and thus is subject to human variation, is nonautomatic, and is expensive. chemical fingerprinting of flavor and aroma is extremely complex and difficult due to the heterogeneity of different compounds, contributing to unique experiences of flavor (smell and taste) (gardner and bartlett, ) . gas chromatography cannot detect volatile compounds below their threshold limits and needs a time run up to min for a single analysis (garcía et al., ) . finally, odors perceived are of isolated peaks and not of integral sensation. electronic nose and electronic tongue are designed similar to the olfactory and taste buds on the tongue and identify variations rather than quantification of any analytes. electronic nose (natural olfactory sensor emulator), also known as e-nose, can detect hydrophobic volatile gases having molecular weights in the range of - da produced from food products (reineccius, ) . e-nose consists of three integrated sections-a sample loading part followed by a sensor and finally a data processing unit. the sample loading part transfers a sample to the sensors. adsorption of volatiles to the sensor arrays changes the resistance of the sensors proportional to presence of the volatiles and senses specific chemical odors. the sensor arrays are composed of metal-oxide semiconductors, piezoelectric crystals conducting organic polymers, or quartz semiconductors. polymers with intrinsic conductance, such as, polypyrroles may also be blended with varying sensitivity to analytes. nonconductive polymers, such as, polyethylene oxide or ethyl cellulose admixed with carbon black may be used (shevade et al., ) . adsorption of volatile gases with high vapor pressure (eg, fatty acids, alcohols formed during bacterial or yeast fermentation) induces oxidation-reduction of oxide semiconductors, changing the dimensions of the composites and affecting electric conductance (shevade et al., ) . the data-processing system processes the signals by intelligent pattern recognition algorithms, including discrimination factorial analysis for recognizing unknown samples, principal component analysis, and partial least squares for quantifying bitterness. alcohols, fatty acids, esters, and ketones yield strong responses, whereas carbon dioxide, water, and nitrogen dioxide have lower responses. the high surface-volume ratio of nanocarriers favors gas adsorption on sensor arrays and hence increased selectivity and sensitivity of sensors, detectable in a short span of time. it also minimizes the device size and power consumption and simplifies device circuitry. for example, electronic noses can easily detect ganoderma boninense, a plant pathogen responsible for basal stem rot on tree trunks and food products (abdullah et al., ; durán and marcato, ) . as described earlier, an electronic nose based on polymeric nps of polyanilineboronic acid has been demonstrated for detecting ongoing spoilage during storage of grains (neethirajan et al., ) , as well as, discriminating strains of species producing mycotoxins and mold from healthy grains (magan and evans, ) . a number of reviews on the same with details can be referred (cabanes et al., ; sahgal et al., ) . cyranose (cyrano sciences, pasadena, ca) is a commercial handheld electronic nose consisting of nanocomposites of conducting polymers, for example, poly(vinyl butyral) and poly(ethylene oxide), with carbon-black nanotubes with advanced pattern recognition algorithms. for identification, the instrument has to be trained to associate and store smell prints of each volatile with distinct responses (gouma and sberveglieri, ) . cyranose detects salmonella, e. coli, and s. aureus in beef and sausages at concentrations from ppb onward (balasubramanian et al., ; abdallah et al., ) . it gives simple results, such as, "accept" or "reject," "mixture identified," or "contaminated." sensitivity and specificity of an electronic nose detecting e. coli o :h and non-o strains ranged between . % and % for nonnormalized data (younts et al., ) . libra nose is also a metalloporphyrin-coated quartz microbalance sensor arraybased electronic nose for detection of alcohols, amines, ketones, and aromatic compounds (di natale et al., ) . metalloporyphyrins mimic the mammalian olfactory receptors, which are also metalloproteins in nature. chemical selectivity and sensitivity of sensors depend on metal and peripheral constituents of the complex (brunink et al., ) . microfabricated beams of silicon (cantilevers) coated with polymer are also nanomechanical sensors for detecting volatile gases. interaction of volatile gases results in swelling of the polymer, and the surface stresses cause bending of the cantilever or change in resonating frequency for cantilevers in static or dynamic mode (gouma and sberveglieri, ) . nano-zno film gas sensors evaluated quality of chinese vinegar. zno nps are sensitive to hydrogen sulfide, nitrogen dioxide, chlorine, ozone, and alcohols at room temperature. this is a unique feature compared to headspace gas chromatography, which requires heating to achieve equilibration of volatile gas in the headspace (zhang et al., ) . few nanosensors can detect gases released from food products that are not suitable for consumption due to spoilage (valdés et al., ; ghasemi-varnamkhasti et al., ; Śliwińska et al., ) . quality of food can also be differentiated using nanosensors (durán and marcato, ). an electronic tongue responds to soluble portions of food using an array of sensors combined with pattern-recognition analysis. the pattern obtained is matched with the existing database of tastes. electronic tongues are composed of layer-by-layer ultrathin films of molecular building lipid/polymer membranes with , -fold increased sensitivity than that of the normal human tongue. molecular assemblies of polyhydroxyl groups and association of sodium ions at particular ph decide the tastes of particular foods. in the presence of analyte, the building block self-assembles and forms receptors (hou et al., ) . the electrode charge density of the lipid/polymer membrane and ion distribution changes and gives a particular membrane electric potential, or spr imaging measures molecules adsorbed by receptors for food. receptors for bitterness have been immobilized on polypyrrolemodified carbon nanotubes. upon binding, polypyrrole reorients, which is recorded as an electric signal. bitterness up to fm could be detected in beverages (song et al., ) . discrimination of degradation products in orange juice has been efficiently detected using microelectrodes of polyanilinenano fibers used as taste sensors (medeiros et al., ). the electronic nose and tongue replace the human sensory test for quality determination, which often fails on routine and repeated analysis. a number of glucose-sensitive sensors have been developed for determining glucose content in commercial beverages (eg, aunps coated with glucose-sensitive enzymes) (ozdemir et al., ) . pseudomonas fluoresens immobilized on carbon nanotubes with epoxy composite could detect . - . mm of glucose and xenobiotics in anaerobic conditions with high sensitivity (kirgoz et al., ) . animals treated with veterinary therapeutic products are exposed to wide range of chemicals legally or illegally. majorly, they include antimicrobials used in treatment of infectious diseases or to enhance growth rates or feed efficiency. residues of these chemicals, especially antibiotics in milk and poultry livestock, including penicillin, tetracycline, macrolides, and β-lactam, pose as toxic hazards, lead to allergic responses, or to the development of antibiotic-resistant strains in the poultry, as well as, in humans consuming them (ferrini et al., ) . chloramphenicol molecularly imprinted poly(ethylene glycol dimethacrylate-nmethacryloyl-l-histidinemethylester) nps attached onto the surface of spr detected ng/kg of chloramphenicol in a honey sample. the method was verified to be selective with thiamphenicol and florphenicol with similar chemical structures (kara et al., ) . anti-penicillin g immobilized on gold electrode modified with a self-assembled nanolayer of thioctic acid detected × - m of penicillin g in milk by impedimetry (thavarungkul et al., ) . tobramycin could be detected by qcm nanosensor of gold surface containing a self-assembled monolayer of mercaptane up to a concentration of . × - m in chicken egg white and milk (yola et al., ) . lysine is used as marker for nutritional damage caused in food products due to heat treatment, for example, ultraheated temperature (uht) treated milk. the estimation of lysine in processed food products, based on advanced "maillard reaction," gives an indication of the protein damage due to food processing. lysine has a free ε-amino group that can easily react with other reducing sugars present in food as ingredients. this reaction gives a specific color and flavor to food when heated to a high temperature, which acts as an indicator (luong et al., ) . a detection system based on biotin-labeled ab, coupled with an enhanced chemiluminescence or fluorescence, detects protein present in analytes (luong et al., ) . a quick, reliable, and sensitive immunodipstick colloidal gold coated with vitamin b -igy ab has been developed for vitamin b measurement in food samples. the visible detection limit of vitamin b is ng/ml. this immunodipstick probe is simple and effective with no requirement of trained operators. vitamin b is essential for normal functioning of the neural system and brain. this is of special note for vegetarians, as plant products are deficit in vitamin b (selva kumar and thakur, ) . certain food products (eg, poultry, meat, cheese, and shrimp) are characterized by high amounts of cholesterol. they can also be quantified using carbon nanotubes. these carbon nanotubes have polymer enzyme coatings. carbon nanotubes increase the electrocatalytic effect due to enhanced surface coverage area for measurement of electrocatalytic response using voltammetry. carbon nanotubes promote electron transfer reactions in redox reactions (yang et al., b; wisitsoraat et al., ). an online database has also reported infusing nanocapsules of plant steroids replacing meat cholesterol (mulvaney, ) . some of the other nanobased systems to determine nutritional content are given in table . . plant growth-promoting agents and steroids are used in food production and livestock reproduction, respectively, to gain maximum profits with minimum investments. however, consumption of these steroidal hormones puts humans at risk, while growthpromoting agents accumulate along the food chain in fatty tissues, and it is difficult to rid consumers' systems of the substances for a prolonged time. for example, tests are conducted to estimate progesterone in milk and other food products originating from farm animals. these diagnostics are primarily immunoassay-based techniques (tothill, ) . improved versions of immunosensors lanzellotto et al. ( ) that are based on nanotechnology are required for on-site and real-time monitoring of food products, which are still in the nascent stage. a detailed explanation of various growth-promoting agents in agricultural crops, such as, pesticides and insecticides is already covered in section . . . nanobiosensors composed of an atomicforce microscopy tip functionalized with acetolactate synthase enzyme detected the herbicide metsulfuron-methyl, an acetolactate synthase inhibitor, through force curves (sekhon, ) . misuse of clenbuterol, used for treatment of asthma, for increasing the fat and protein in pigs has led to development of a florescence-based immunoassay. this assay, consisting of cdse/cds qds and fe o / aunps for ag-ab attachments, can estimate clenbuterol in the linear range of . - , pg/ml in pig urine (wang et al., b) . food allergens are food components that on consumption trigger allergic reactions that could range from minor skin rashes to severe, life-threatening conditions. examples of major potential allergens include peanuts, wheat protein gluten, milk, egg, nuts, shellfish, and soybeans. the european community has identified allergenic food ingredients as food allergens and has fixed regulations for labeling them (pilolli et al., ) . food allergy is described as an immune response that could be genetic or environmentally induced, and is ige mediated or non-ige mediated (cellular), involving oral, gastrointestinal, and respiratory tracts. evaluations of ige-based hypersensitivity due to peanut protein ara h using aunps localized plasmon array have been studied up to a detection limit of nm (olkhov et al., ) . soy protein, a major food allergen of soymilk, soy yogurt, fruit, and soy juice, has been detected by silica nps doped with nile blue (particle size nm). nile blue-doped silica nps prepared by reverse-micelle microemulsion and linked to antisoy protein ab detected soy protein up to . mg/l with an incubation time of h (godoy-navajas et al., ). egg-white protein (ovalbumin) added to whole milk can be detected up to ppm within min by combined technology of immunomagnetic separation of ovalbumin by magnetic microbeads followed by sers using silver dendrites for quantitation . spr-based techniques are coupled with sensors for quantification of α-lactalbumin present in marketed milk and whey protein isolates (indyk, ). adulteration of bovine and caprine milk with colostrum has been reported using an iggbased spr immunosensor with a short analytical real-time monitoring time of within min during milking (pilolli et al., ) . quantitative determination of bovine serum albumin, immunoglobulin g, α-lactalbumin, β-lactoglobulin, and lactoferrin simultaneously in milk, whey fractions, and milk-derived products is possible using spr (billakanti et al., ) . imaging spr with ab array provided a complete allergen profile of hazelnut content in cookies and chocolate products (rebe raz et al., ) . some other examples are also given in table . . recent developments in genetic engineering and its application in crop production to meet the demands of ever-increasing global population have put many in a dilemma about its use in food production (sicherer and sampson, ) . considering regulatory aspects related to food products of genetically modified (gm) organism origin, a thorough assessment is thus required for risks related to consumption of these products. sociopsychological aspects affect the acceptability of gm foods. protein analysis jiang et al. ( ) by using immunosensors accounts for one of the growing markets in the food industry. sdi europe ltd. has developed an immunoassay that can detect gm food ingredients using dipstick devices. detection of gm food products that are consumed by either humans or animals are based on pcr techniques that analyze specific dna sequences. these developments have led to miniaturization of the instruments that were previously used in laboratories and are now available for on-site analysis of samples using dna chips. these tests can also be modified into dna biosensor devices (tothill, ) . sers-barcoded nanosensors designed by encapsulation of aunps with silica conjugated to oligonucleotides detected b. thuringiensis (bt) gene-transformed rice expressing insecticidal proteins up to . pg/ml . a turning point in packaging is nanoreinforced packaging and active packaging providing an extra tensile strength of food packets. nanosilver in combination with antibacterial agents may prove to be more potent to combat multiple bacterial growths with a smaller amount of dose required. tio has been suggested to improve upon the uv protection barrier, as well as, reduce bacterial contamination in food packaging when used as nps (ranjan et al., ) . several antimicrobial packaging and oxygenscavenging food packages have been developed (saxl, ) . imperm (eastman chemical co., kingsport, tn, usa), aegis, durethan, and others use a nanocomposite of nylon and nanoclay with enhanced barrier properties that can help keep the oxygen out and the carbonation in, especially in polyethylene bottles. beer in nanocomposite bottles can keep for as long as weeks. the same has also been used in soda, milk, and water bottles, as well as, in military food packages (gruère, ) . milk packages made of these materials improved durability of milk up to days, and grains stayed dry. nanowax for fruits also provided better durability and transparency (sekhon, ) . aegis ox (honeywell, inc.) has oxygen scavengers and nanocomposite clay particles within the polyethylene bottle material for fruit juice, soft drink, and beer servings. durethan ku - (bayer ag), composed of polyamide and nanoclay with layered silicate barriers, with enhanced gloss and stiffness, in addition to barrier properties, is commonly used in paperboard juice containers (ranjan et al., ) . nanolok, a polymeric resin composed of nanodispersed silicate, generated superabsorbent-hydrogel nanocomposites. the mcdonald's burger containers contain an chapter evaluation of food quality and safety ecosynthetic adhesive made up of - nm starch nanospheres, which require less water for adhesion with reduced drying time (kumari and yadav, ) . incorporation of enzymes, such as, cholesterol reductase or lactase increases the nutritional value of food. sio nps immobilized with glutamate dehydrogenase and lactate dehydrogenase have shown enhanced enzyme activity (ranjan et al., ) . smart-or intelligent packaging indicates the quality of food within a package through use of intelligent nanosensors devices that are either incorporated into packaging or attached to packaging (ie, nanocomposite smart packaging). for instance, incorporation of oxygen scavengers or indicators within food packaging material would serve as indicators for food spoilage by sensing gaseous analytes and thus provide real-time food freshness (lange et al., ; garcía et al., ) . food-packaging distributors also use nanotechnologybased biosensors for product tracking (nanotagging) by using radiofrequency identification tags to prevent counterfeiting. however, radio frequency identification tags are expensive, with the cheapest tag costing about cents. optic fibers also find wider application with calorimetric and florescent dyes that change florescence and absorbance with a change in ph or oxidation state. motivations to innovate new technology related to the food sector are consumer demands for quality food products globally and the need for faster transport of food. purposes of packaging are to retard food deterioration, increase in shelf life and provide protection from environmental influences, such as, light and moisture. there are materials that change color on exposure to visible-or uv light, indicating the quality of the food product. this technology when coupled with information and communication technology can automatically send data to users or monitoring sections about the condition of food products. this combination can revolutionize the world of the packaging industry both at the consumer level and at the industry level. for example, substances that are produced due to food spoilage processes (lactic and acetic acids, alcohols, and amines) can be detected by the use of smart-packaging materials made of luminescent nanosized zno and organic luminophores. these nanophotonics assemblies can work as novel packaging materials. the principle involved behind this novel packaging is that it detects the change in properties (optic, electric, or mechanical) of sensors. these changes can be analyzed by visual inspection or by external devices that convert the packaging response into electric signals followed by data interpretation using computer systems. this combination of smart packaging with communication technology is cost-effective and utilizes photonics principles at the nanoscale level. this innovative technique of detection is termed nanophotonics with detection limits of × - m/l for zno and - m/l for organic luminophore (sarapulova et al., ) . timestrip has developed an istrip based on aunps that shows red color at temperatures above freezing. freezing causes irreversible agglomeration of the aunps with loss of red color. thus accidental exposure of chilled foods to room temperature could be determined using this istrip. various tio -and sno -based colorimetric oxygen indicators have been developed that bleach the color of redox dyes on exposure to uv irradiation. the color of the films developed depends on the extent of exposure to oxygen (ranjan et al., ) . nanobarcodes consisting of synthetic dna barcodes present in film packages detect the food pathogens by fluorescence of a fluorescent probe under uv (brody et al., ) . guardin fresh, a nanomech subsidiary (fayetteville, ar, usa), commercializes a nanotechnology-based scavenging system that scavenges ethylene gas responsible for hastened ripening of perishable products (sekhon, ). an electronic tongue has also been used in food packaging to detect gases released due to spoilage of food. the gases cause the sensor strip to change its color in the presence of gases, indicating whether the food is fresh or stale (saxl, ) . a research group at netherlands is working on "release on command" food packaging with a nanobased bioswitch that releases preservatives when the food is about to spoil (sekhon, ) . such sensing mechanisms would not only improve the food quality but also reduce food wastage. stringent regulatory guidelines must to ensure "safe" and "quality" food to consumers. there has been a lack of regulatory guidelines on the use of nps in food packaging and storage at the us food and drug administration. this needs to be taken seriously, as lack of guidance will hamper both the growth and the application of nanotechnology in the food industry (servin et al., ) . nanocomposites, the earliest commercial application in the food industry, include use of plastic nanocomposites applicable for packaging of food and beverages. commercial biosensors based on nanocomposites are concise, simple, and easy to use for point-of-care biosensing. there are diagnostic assays that are fabricated using nanosensors for point-of-care assessment of ab in milk samples, but they are not commercially available for field testing. research is ongoing to make them available for testing on farm animals using nonserological milk samples (vyas et al., ) . cellulosic nanowhisker production technology has been developed to replace the use of plastic and fiberglass, by making biocomposite from wheat straw. nanobarcode technology has gained momentum in the past few years because of its ability to form a large number of combinations. but this technology is not yet well exploited (dasgupta et al., ) . inorganic materials like sio , mgo, and tio are being used as coating materials for used as oxygen barriers, and ag for "active coating" for antibacterial activity (chaudhry and castle, ) . nanocomposite technology is an emerging material science. its wider application in the food industry extends from food production to food processing and ultimately to food consumption. tracing food products, quality assessment, safety, and maintaining a nutritional index have all made the food industry take a deeper look into technology involved in innovative diagnostics and biosensing techniques. on-site and point-of-care detection for a large number of increasing analytes requires quick, sensitive, and accurate measurements. this has inspired many researchers in the food industry to develop nanotechnology-based sensors as diagnostic tools. nanotechnology-based biosensors using nanocomposites will reduce the load of laboratory testing and provide on-site applications. there is an urgent need for more available technology in the food industry for easy, affordable, sensitive, and broad-spectrum analysis of food products, both at industrial level and at consumer level. this chapter has specifically emphasized developments in the field of nanotechnology-based biosensors being incorporated in food industry for detection of plant-based pathogens, toxins, gm food products, nutritional index, and regulatory aspects attached to them. a major challenge with nanobiosensors is their use with real samples, as many biosensors fail when they come in contact with real food products because of the complexity of samples. replacement and recalibration of nanobiosensors are another drawback that needs to be considered. nanobiosensor-based on-site tests help in reduction of time for which products are kept in inventory, rapid response time and corporate liability costs (alocilja and radke, ) . most of the research is still in its nascent stage for detection of analytes in real food without disrupting its final form. a nondestructive technology based on information directly available on the final packed food product would be very desirable. spr-based sensors are a promising technique that does not require labeling with molecules and can easily assay crude samples without purification. the need for nanobiosensors has multiplied many fold in the recent past due to increased consumer awareness and regulatory action being imposed about food composition and safety. antibody aunp gold nanoparticle cfu colony-forming unit np nanoparticle qd quantum dot sers surface-enhanced raman scattering spr surface plasmon resonance squid superconducting quantum interference device qcm quartz crystal microbalance the detection of foodborne bacteria on beef: the application of the electronic nose electronic nose system for ganoderma detection hydrogen-bonding recognition-induced color change of gold nanoparticles for visual detection of melamine in raw milk and infant formula quantum dots as cellular probes market analysis of biosensors for food safety nanofibrous membrane based tyrosinase-biosensor for the detection of phenolic compounds real-time multicolor dna detection with chemoresponsive diffraction gratings and nanoparticle probes optical sensors based on nanostructured cage materials for the detection of toxic metal ions identification of salmonella-inoculated beef using a portable electronic nose system development of biosensor based on immobilized l-glutamate oxidase for determination of monosodium glutamate in food developments in mycotoxin analysis: an update for - simultaneous, quantitative detection of five whey proteins in multiple samples by surface plasmon resonance isotachophoresis and isotachophoresis-zone electrophoresis of food additives on a chip with column-coupling separation channels femtogram-level detection of clostridium botulinum neurotoxin type a by sandwich immunoassay using nanoporous substrate and ultra-bright fluorescent suprananoparticles ochratoxin a nanostructured electrochemical immunosensors based on polyclonal antibodies and gold nanoparticles coupled to the antigen detection of escherichia coli o , salmonella enterica serovar typhimurium, and staphylococcal enterotoxin b in a single sample using enzymatic bionanotransduction scientific status summary: innovative food packaging solutions the application of metalloporphyrins as coating material for quartz microbalance-based chemical sensors early discrimination of fungal species responsible of ochratoxin a contamination of wine and other grape products using an electronic nose electrochemical immunosensor for casein based on gold nanoparticles and poly(l-arginine)/multi-walled carbon nanotubes composite film functionalized interface development of a tyrosinase biosensor based on gold nanoparticles-modified glassy carbon electrodes: application to the measurement of a bioelectrochemical polyphenols index in wines fluorescent gold nanoprobes for the sensitive and selective detection for hg + food applications of nanotechnologies: an overview of opportunities and challenges for developing countries enhanced fluorescence sensing of amine vapor based on ultrathin nanofibers ultrasensitive magnetic biosensor for homogeneous immunoassay enhancement of the resolution of surface plasmon resonance biosensors by control of the size and distribution of nanoparticles development of an amperometric enzyme electrode biosensor for sterigmatocystin detection a practicable detection system for genetically modified rice by sers-barcoded nanosensors globotriose-functionalized gold nanoparticles as multivalent probes for shiga-like toxin silver nanorod arrays as a surface-enhanced raman scattering substrate for foodborne pathogenic bacteria detection detection of gliadin in foods using a quartz crystal microbalance biosensor that incorporates gold nanoparticles nanotechnology in agro-food: from field to plate gold nanoparticle-modified carbon electrode biosensor for the detection of listeria monocytogenes label-free capacitive immunosensors for ultra-trace detection based on the increase of immobilized antibodies on silver nanoparticles amperometric determination of xanthine in fish meat by zinc oxide nanoparticle/chitosan/multiwalled carbon nanotube/ polyaniline composite film bound xanthine oxidase a method for determination of xanthine in meat by amperometric biosensor based on silver nanoparticles/cysteine modified au electrode lung cancer identification by the analysis of breath by means of an array of non-selective gas sensors electrospun fibrous polyacrylic acid membrane-based gas sensors electrospun nanomaterials for ultrasensitive sensors nanotechnology: its impact on food safety development of acetylcholinesterase biosensor based on cdte quantum dots/gold nanoparticles modified chitosan microspheres interface covalent coupling of organophosphorus hydrolase loaded quantum dots to carbon nanotube/ au nanocomposite for enhanced detection of methyl parathion acetylcholinesterase biosensor design based on carbon nanotube-encapsulated polypyrrole and polyaniline copolymer for amperometric detection of organophosphates applications of nanotechnology in food packaging and food safety: barrier materials, antimicrobials and sensors nanobiotechnology perspectives: role of nanotechnology in the food industry: a review magnetic glyco-nanoparticles: a unique tool for rapid pathogen detection, decontamination, and strain differentiation chalcone isothiocyanate-mesoporous silicates: selective anchoring and toxic metal ions detection mercury-ion optical sensors applying of gold nanoparticle to avoid diffusion of the conserved peptide of avian influenza nonstructural protein from membrane in western blot setting maximum levels for certain contaminants in foodstuffs (ec no. / ) additives other than authorised colours and sweeteners. e.p.a.c. directive / /ec detecting food-and waterborne viruses by surface-enhanced raman spectroscopy detection and identification of beta-lactam residues in milk using a hybrid biosensor an au/si hetero-nanorod-based biosensor for salmonella detection electronic nose for wine discrimination a brief history of electronic noses glucose biosensor based on graphite electrodes modified with glucose oxidase and colloidal gold nanoparticles rapid biosensor for detection of antibiotic-selective growth of escherichia coli electronic and bioelectronic tongues, two promising analytical tools for the quality evaluation of non-alcoholic beer heterogeneous immunoassay for soy protein determination using nile blue-doped silica nanoparticles as labels and front-surface long-wavelength fluorimetry multiplexed toxin analysis using four colors of quantum dot fluororeagents impedance microbiology-ona-chip: microfluidic bioprocessor for rapid detection of bacterial metabolism electrospinning-a novel nanomanufacturing technique for hybrid nanofibers and their non-woven mats novel materials and applications of electronic noses and tongues detection of bacteria in suspension by using a superconducting quantum interference device implications of nanotechnology growth in food and agriculture in oecd countries perchlorate detection at nanomolar concentrations by surface-enhanced raman scattering biosensor technologies for detecting microbiological foodborne hazards. microbes infect use of a fractal-like gold nanostructure in surface-enhanced raman spectroscopy for detection of selected food contaminants rapid detection of a foreign protein in milk using ims-sers continuous evolution profiles for electronic-tongue-based analysis electrochemical biosensing platforms using platinum nanoparticles and carbon nanotubes a label-free electrochemical immunosensor based on gold nanoparticles for detection of paraoxon a class-specific enzyme-linked immunosorbent assay based on magnetic particles for multiresidue organophosphorus pesticides gold nanoparticle-based immunochromatographic test for identification of staphylococcus aureus from clinical specimens one-step immunochromatographic assay for the detection of staphylococcus aureus fluorescence assay based on aptamer-quantum dot binding to bacillus thuringiensis spores development and application of an optical biosensor immunoassay for α-lactalbumin in bovine milk mast cell-based electrochemical biosensor for quantification of the major shrimp allergen pen a (tropomyosin) piezoelectric immunosensor with gold nanoparticles enhanced competitive immunoreaction technique for quantification of aflatoxin b one-step, nanoparticle-mediated bacterial detection with magnetic relaxation emerging nanotechnology-based strategies for the identification of microbial pathogenesis efficient separation and sensitive detection of listeria monocytogenes using an impedance immunosensor based on magnetic nanoparticles, a microfluidic chip, and an interdigitated microelectrode combining molecular imprinted nanoparticles with surface plasmon resonance nanosensor for chloramphenicol detection in honey spr for molecular interaction analysis: a review of emerging application areas a nanostructured cerium oxide film-based immunosensor for mycotoxin detection fumed silica nanoparticles-chitosan nanobiocomposite for ochratoxin-a detection listeriolysin o: a key protein of listeria monocytogenes with multiple functions nanocrystalline bioactive tio -chitosan impedimetric immunosensor for ochratoxin-a detection of pathogenic salmonella with nanobiosensors carbon nanotube composite as novel platform for microbial biosensor directed self-assembly of gold binding polypeptide-protein a fusion proteins for development of gold nanoparticle-based spr immunosensors self-indicating nanobiosensor for detection of , -dinitrophenol tyrosinase biosensor for benzoic acid inhibition-based determination with the use of a flow-batch monosegmented sequential injection system a voltammetric biosensor based on glassy carbon electrodes modified with single-walled carbon nanotubes/ hemoglobin for detection of acrylamide in water extracts from potato crisps crown ether assembly of gold nanoparticles: melamine sensor nanomaterials for biosensors nanotechnology in agri-food sector complementary metal oxide semiconductor cantilever arrays on a single chip: mass-sensitive detection of volatile organic compounds nanostructured enzymatic biosensor based on fullerene and gold nanoparticles: preparation, characterization and analytical applications chip-nmr biosensor for detection and molecular analysis of cells advances in biosensors for detection of pathogens in food and water amperometric biosensor for aflatoxin b based on aflatoxin-oxidase immobilized on multiwalled carbon nanotubes detection of melamine in gluten, chicken feed, and processed foods using surface enhanced raman spectroscopy and hplc factors influencing biogenic amines accumulation in dairy products gold nanoparticles based dipstick immunoassay for the rapid detection of dichlorodiphenyltrichloroethane: an organochlorine pesticide enhanced visual detection of pesticides using gold nanoparticles research on multi-colony diploid genetic algorithm for production logistics scheduling optimization gold-nanocluster-based fluorescent sensors for highly sensitive and selective detection of cyanide in water use of fe o nanoparticles for enhancement of biosensor response to the herbicide , -dichlorophenoxyacetic acid sub-attomolar detection of cholera toxin using a label-free capacitive immunosensor highly sensitive optical detection of humidity on polymer/metal nanoparticle hybrid films developments and applications of biosensors in food analysis biosensor technology: technology push versus market pull volatiles in grain as an indicator of fungal spoilage, order descriptors for classifying spoiled grain and the potential for early detection using electronic nose technology: a review trends in food packaging and manufacturing systems and technology detection of inv a gene of salmonella by dna-gold nanoparticles biosensor and its comparison with pcr carbon nanotube-ionic liquid (cnt-il) nanocamposite modified sol-gel derived carbon-ceramic electrode for simultaneous determination of sunset yellow and tartrazine in food samples bienzyme amperometric biosensor using gold nanoparticle-modified electrodes for the determination of inulin in foods extraction of aflatoxins from liquid foodstuff samples with polydopamine-coated superparamagnetic nanoparticles for hplc-ms/ms analysis shelf life prediction: status and future possibilities a taste sensor array based on polyaniline nanofibers for orange juice quality assessment a solvent-based intelligence ink for oxygen sensitive voltammetric determination of sudan i in food samples by using gemini surfactant-ionic liquid-multiwalled carbon nanotube composite film modified glassy carbon electrodes biosensors for direct determination of organophosphate pesticides green food: an a-to-z guide applications of biosensors in food industry dextran-coated gold nanoparticles for the assessment of antimicrobial susceptibility carbon dioxide (co ) sensors for the agri-food industry-a review development of carbon dioxide (co ) sensor for grain quality monitoring united states patent b . poly(aniline boronic acid) polymers and methods of use inside microbiology: current microbial concerns in the dairy industry surface plasmon resonance immunosensor for the detection of salmonella typhimurium whole blood screening of antibodies using label-free nanoparticle biophotonic array platform electrochemical glucose biosensing by pyranose oxidase immobilized in gold nanoparticlepolyaniline/agcl/gelatin nanocomposite matrix electrically active polyaniline coated magnetic (eapm) nanoparticle as novel transducer in biosensor for detection of bacillus anthracis spores in food samples rapid and efficient identification of bacteria using gold-nanoparticle-poly(paraphenyleneethynylene) constructs advances in biosensor development based on integrating nanotechnology and applied to food-allergen management preparation of tungsten oxide-tin oxide nanocomposites and their ethylene sensing characteristics a qcm-d-based biosensor for e. coli o :h highlighting the relevance of the dissipation slope as a transduction signal enzyme-linked immunosorbent assay (elisa) based on superparamagnetic nanoparticles for aflatoxin m detection nanoscience and nanotechnologies in food industries: opportunities and research trends biofunctionalized magnetic nanoparticle integrated mid-infrared pathogen sensor for food matrixes food allergens profiling with an imaging surface plasmon resonance-based biosensor instrumental means of monitoring the flavor quality of foods nanomaterials for gas sensing: a review of recent research plasmonic nanosensors with inverse sensitivity by means of enzyme-guided crystal growth gold nanoparticlebased lateral flow assay for detection of staphylococcal enterotoxin b free amino acids and biogenic amines in red and white muscle of tuna stored in controlled atmospheres flow-injection assay of the pathogenic bacteria using lectin-based quartz crystal microbalance biosensor potential for detection and discrimination between mycotoxigenic and non-toxigenic spoilage moulds using volatile production patterns: a review photonics and nanophotonics and information and communication technologies in modern food packaging the national nanotechnology initiative: overview, reauthorization, and appropriations issues. congressional research service. report for congress for members and committees of congress nanotech in food, beverage and related packaging. applications and markets to ion publishers nylon nanofibrous membrane for mediated glucose biosensing glyconanoparticles for the colorimetric detection of cholera toxin nanotechnology in agri-food production: an overview competitive immunoassay for analysis of vitamin b( ) a review of the use of engineered nanomaterials to suppress plant disease and enhance crop yield molecular modeling of polymer composite-analyte interactions in electronic nose sensors development of immunochromatography strip-test using nanocolloidal gold-antibody probe for the rapid detection of aflatoxin b in grain and feed samples food allergy nanopore immunosensor for peanut protein ara h a highly efficient rare earth metal oxide nanorods based platform for aflatoxin detection food analysis using artificial senses human taste receptor-functionalized field effect transistor as a human-like nanobioelectronic tongue the applications of nanotechnology polymer-coated fluorescent cdse-based quantum dots for application in immunoassay homogeneous detection of unamplified genomic dna sequences based on colorimetric scatter of gold nanoparticle probes a mixed self-assembled monolayer-based surface plasmon immunosensor for detection of e. coli o :h shape-controlled synthesis of gold and silver nanoparticles electrochemical biosensor for the detection of cauliflower mosaic virus s gene sequences using lead sulfide nanoparticles as oligonucleotide labels novel antibody/gold nanoparticle/magnetic nanoparticle nanocomposites for immunomagnetic separation and rapid colorimetric detection of staphylococcus aureus in milk nanobioimaging and sensing of infectious diseases magnetic nanogold microspheres-based lateral-flow immunodipstick for rapid detection of aflatoxin b in food detection of anthrax toxin by an ultrasensitive immunoassay using europium nanoparticles disposable screenprinted electrode coupled with recombinant drosophila melanogaster acetylcholinesterase and multiwalled carbon nanotubes for rapid detection of pesticides biosensors in food processing detecting penicillin g in milk with impedimetric label-free immunosensor electrochemical biosensors: recommended definitions and classification label-free immunosensing of microcystin-lr using a gold electrode modified with gold nanoparticles biosensors developments and potential applications in the agricultural diagnosis sector analytical nanotechnology for food analysis magnetic nanoparticle-antibody conjugates for the separation of escherichia coli o :h in ground beef mesoporous silicon with modified surface for plant viruses and their protein particle sensing bioconjugation of cdte quantum dot for the detection of , -dichlorophenoxyacetic acid by competitive fluoroimmunoassay based biosensor sol-gel based optical carbon dioxide sensor employing dual luminophore referencing for application in food packaging technology development of immunochromatographic strip test using fluorescent, micellar silica nanosensors for rapid detection of b. abortus antibodies in milk samples multifunctional magnetic-optical nanoparticle probes for simultaneous detection, separation, and thermal ablation of multiple pathogens aptamer biosensing platform based on carbon nanotube long-range energy transfer for sensitive, selective and multicolor fluorescent heavy metal ion analysis simple, rapid, sensitive, and versatile swnt-paper sensor for environmental toxin detection competitive with elisa a novel cdse/cds quantum dot-based competitive fluoroimmunoassay for the detection of clenbuterol residue in chapter evaluation of food quality and safety carrier quantum dot immunoassays in renewable surface column and -well plate formats for the fluorescence detection of botulinum neurotoxin using high-affinity antibodies developments in nanoparticles for use in biosensors to assess food safety and quality integrated nanoparticle-biomolecule systems for biosensing and bioelectronics high sensitivity electrochemical cholesterol sensor utilizing a vertically aligned carbon nanotube electrode with electropolymerized enzyme immobilization simultaneous aptasensor for multiplex pathogenic bacteria detection based on multicolor upconversion nanoparticles labels nanomaterials-based electrochemical sensors and biosensors for pesticide detection microbial biosensors for environmental monitoring and food analysis ultra-highly sensitive and wash-free bio-detection of h n virus by immunomagnetic reduction assays gold nanoparticle-based enhanced chemiluminescence immunosensor for detection of staphylococcal enterotoxin b (seb) in food self-assembled zno quantum dot bioconjugates for direct electrochemical determination of allergen fabrication of a cholesterol biosensor based on cholesterol oxidase and multiwall carbon nanotube hybrid composites removal of heavy metals from aqueous systems with thiol functionalized superparamagnetic nanoparticles a novel biosensor for sterigmatocystin constructed by multi-walled carbon nanotubes (mwnt) modified with aflatoxin-detoxifizyme (adtz) development of molecular imprinted nanosensor for determination of tobramycin in pharmaceuticals and foods experimental use of a gas sensor-based instrument for differentiation of escherichia coli o :h from non-o :h escherichia coli field isolates electrochemical immunoassay using quantum dot/antibody probe for identification of cyanobacterial hepatotoxin microcystin-lr highly sensitive electrochemiluminescent nanobiosensor for the detection of palytoxin fabrication of sno -zno nanocomposite sensor for selective sensing of trimethylamine and the freshness of fishes characterization of chinese vinegars by electronic nose fluorescent bio-barcode dna assay for the detection of salmonella enterica serovar enteritidis multi-wall carbon nanotube film-based electrochemical sensor for rapid detection of ponceau r and allura red a rapid bioassay for single bacterial cell quantitation using bioconjugated nanoparticles simultaneous detection of multifood-borne pathogenic bacteria based on functionalized quantum dots coupled with immunomagnetic separation in food samples optimization of a sensitive method for the "switch-on" determination of mercury(ii) in waters using rhodamine b capped gold nanoparticles as a fluorescence sensor determination of oxalic acid in spinach with carbon nanotubes-modified electrode nanocolloidal gold-based immunoassay for the detection of the nmethylcarbamate pesticide carbofuran sensitive biosensors based on (dendrimer encapsulated pt nanoparticles)/enzyme multilayers highly sensitive electrochemical sensor for mercury(ii) ions by using a mercuryspecific oligonucleotide probe and gold nanoparticle-based amplification the sol-gel template synthesis of porous tio for a high performance humidity sensor key: cord- -mvl wrsj authors: goulter-thorsen, r.m.; jaykus, l-a title: disciplines associated with food safety: food virology date: - - journal: encyclopedia of food safety doi: . /b - - - - . -x sha: doc_id: cord_uid: mvl wrsj food virology is a relatively young but important field in food safety. viruses in general and human noroviruses in particular, are the leading cause of foodborne disease of known etiology in developed countries. hepatitis a virus is also important, as are a number of emerging viruses. this article identifies the relevant viruses, describes their structural characteristics and the diseases they cause, and what is known about their epidemiological significance. it also describes why their transmission is so difficult to control, their detection difficult to achieve, and future research needs that will facilitate their study by food safety scientists. human enteric viruses are the most common cause of foodborne illness worldwide. these viruses comprise a functional, rather than taxonomic group, almost all of which are nonenveloped (lacking a lipid outer layer) and transmitted by the fecal-oral route. from an epidemiological perspective, human noroviruses (hunov) are now considered the most important of the foodborne viruses, causing % of foodborne illnesses of known etiology in usa. hepatitis a virus (hav) is also important as it causes perhaps the most severe of the viral foodborne diseases. there are other important viruses that can be transmitted by foodborne routes, although their significance is less well characterized. viruses are obligate intracellular parasites that require the metabolic machinery of the host cell to replicate. they are tissue tropic (enteric viruses infect the gastrointestinal tract) and species specific, so human enteric viruses infect humans but not other animals, and vice versa. enteric virus particles are shed in extremely high numbers in the feces of infected individuals, and hence their transmission is usually due to the fecal-oral route. however, epidemiological evidence suggests that nov particles are also shed in vomitus and this may significantly increase transmissibility of these viruses, especially if virus particles become aerosolized during vomiting events. in general, enteric viruses are highly infectious and typically disease can be caused by a small number (perhaps - ) of infectious virus particles. human enteric viruses are spread in a number of ways: by person-to-person contact; through contact with contaminated inanimate objects (fomites); or by consumption of contaminated food or water. most cases of foodborne viral disease are caused by consumption of foods that have been handled or prepared by infected food handlers who have not practiced adequate hygiene, particularly after using the restroom. contamination can also occur preharvest, as a consequence of exposure to human feces (sewage) during irrigation or fertilization of fresh produce, or during production of molluscan shellfish. although the disease caused by the common foodborne viruses is rarely life threatening, the sheer volume of cases places severe burden on the public health system. this article will summarize the early days of food virology, outline key characteristics of important and emerging foodborne viruses, and discuss epidemiological surveillance and control of these important agents of foodborne disease. poliovirus was the first enteric virus to be widely recognized, causing foodborne disease outbreaks in the early s associated with the consumption of contaminated raw milk. raw milk outbreaks of poliomyelitis continued until the s, when an effective vaccine was introduced. molluscan shellfishassociated outbreaks of hepatitis were also reported in the s and s. the cause of this disease was hav, which was identified as an enterically transmitted infectious agent when dr. saul krugman intentionally fed mentally disabled children purified fecal extracts prepared from symptomatic patients; the children subsequently developing classic hepatitis symptoms. during the same era, foodborne outbreaks of nonbacterial gastroenteritis were recognized and although a viral etiology was suspected, it remained difficult to confirm. this changed when, in , dr. albert kapikian identified the first virus to be associated with acute nonbacterial gastroenteritis. appropriately named 'norwalk virus' because of its association with an outbreak in norwalk, oh, in usa, this virus was the first of many that would ultimately be identified as members of the genus norovirus (nov) within the caliciviridea family. electron microscopy was used to identify the norwalk virus, and this method, which requires virus loads particles per g of stool, is still used to this day. the absence of culture methods for both hunov and hav was a major impediment to further study of these agents. in , dr. theresa cromeans developed a method to propagate hav, ushering in a new era for studying this virus. this method, as well as cultivation methods for the vaccine strain of poliovirus, eventually allowed for the quantification of infective virus plaque forming units and facilitated studies on detection and control of enteric viruses in water and foods, with a particular focus on molluscan shellfish. dr. dean cliver, who served as a professor at the university of wisconsin in madison and at the university of california in davis, provided much of the foundation on which current principles in food virology are based. in , dr. mary estes team at baylor college of medicine sequenced the full norwalk virus, and many other nov genomes have been characterized since then. with knowledge of nucleic acid sequence and the rapid adoption of molecular biological methods, scientists were suddenly presented with new tools to study human enteric viruses. particularly important was the nucleic acid amplification method polymerase chain reaction (pcr), which was readily adapted to the detection of rna viruses by preceding pcr with a reverse transcription (rt) step, hence the designation rt-pcr. conventional rt-pcr methods, followed by southern hybridization were quickly developed for the detection of these viruses in clinical (fecal) samples and foods, particularly molluscan shellfish. these were later replaced by more rapid and sensitive quantitative real-time rt-pcr (rt-qpcr) methods. although promising, the utility of these molecular amplification methods for virus detection in food and environmental samples was limited by low levels of contamination; high levels of matrix-associated inhibitory substances that interfered with nucleic acid amplification; and the lack of broadly reactive primers and probes for hunov. in addition, the development of an in vitro cultivation system for hunov has remained elusive. cultivable surrogate viruses (e.g., feline calicivirus and murine norovirus) have been used in a variety of studies but their behavior does not always mimic that of hunov. these impediments to the study of hunov continue to this day. the epidemiological importance of hunov came to the forefront in when mead et al. ( ) suggested that viruses, not bacteria, were the leading cause of foodborne illness of known etiology. this study prompted expanded epidemiological surveillance activities in europe. the mead et al. ( ) publication, along with some high profile outbreaks in the late s and early s, also focused attention on foods other than molluscan shellfish as significant causes of foodborne viral gastroenteritis. in fact, we now know that foods such as salads, bakery products, and sandwiches are responsible for more nov and hav infections than are molluscan shellfish. fresh produce (berries and green onions) have also emerged as important vehicles of infection. the association of disease with foods such as these suggest that the hands of infected food handlers are arguably the most common source of the virus contamination for many if not most foods. recent epidemiological data continue to support the fact that viruses, particularly hunov, are the most common cause of foodborne disease of known etiology in usa. hunov are the most common cause of acute gastroenteritis in industrialized countries. scallan et al. ( b) estimate that these viruses are responsible for approximately % of foodborne disease of known etiology in usa. this amounts to . million infections per year, resulting in approximately hospitalizations and deaths. these numbers reflect only those diseases of known etiology; if foodborne disease of unknown etiology were included, as well as other transmission routes, these estimates would be staggeringly high. for example, of the more than million cases of gastroenteritis that occur in usa each year, the etiology of only about onefifth of them is confirmed, leaving an estimated million cases of gastroenteritis caused by unspecified agents. owing to the frequency of nov infection, it is likely that a large proportion of these are also caused by hunov. similar data are available from europe. the taxonomy of nov has changed substantially over the past years, and what was originally called the 'norwalk-like' virus group is now classified as the nov genus, one of four genera within the caliciviridae virus family. the other genus in this family causing disease in humans is sapovirus, also shown to cause gastroenteritis. hunov are a nonenveloped icosahedral viruses approximately nm in diameter and having a genome consisting of a single strand of positive-sense rna of . - . kb in length. the genome encodes three open reading frames (orf); orf encodes a nonstructural polyprotein that contains the genes for p , ntpase, p , vpg, protease, and rna polymerase; orf encodes the viral capsid protein; and orf encodes a small basic structural protein of unknown function. based on nucleic acid sequence analysis, the nov genus can be further classified into five genogroups, designated gi, gii, giii, giv, and gv, based on % amino acid homology of the viral capsid protein. human infections are caused almost exclusively by genogroups gi and gii, with the vast majority caused by gii strains. each genogroup can be further classified into genotypes, based on a % amino acid homology in the capsid protein. currently, gi strains and gii strains have been identified. the genetic cluster gii. is the most significant of the genotypes, having predominated in outbreaks around the world for over a decade. however, strains other than gii. are most often the cause of foodborne disease outbreaks. outbreaks of nov have involved food products including molluscan shellfish, fresh fruits and vegetables, and 'ready-toeat' (rte) foods. epidemiologically speaking, it appears that rte foods are the most common cause of foodborne nov outbreaks, although high-profile outbreaks have occurred in produce items such as berries. in healthy adults, the incubation period for nov infection ranges from to h, with symptoms lasting - h. the disease is gastrointestinal in nature, typically presenting with vomiting (hallmark symptom), diarrhea, and abdominal cramps that may or may not be accompanied by fever. in certain at-risk groups, particularly the elderly, nov infection can result in a much more severe disease, with symptoms lasting as long as weeks. the hospitalization rate for hunov infection is estimated to be . % and the mortality rate is less than . %. nonetheless, the shear numbers of cases make these viruses one of the leading causes of foodborne disease hospitalizations and deaths. no antiviral strategy exists for prevention or treatment of nov illness. as is the case for all enteric diseases, infected individuals should be treated to maintain hydration and electrolyte balance. although some immunologically based commercial methods are available for detection of hunov in clinical samples, they are licensed in only some parts of the world. this is largely because of poor sensitivity due to the lack of broadly reactive antibodies that will detect all hunov strains. the high degree of genetic diversity for the nov has historically complicated the development of broadly reactive rt-qpcr methods. four 'regions' of the nov genome have been used for primer design (designated regions a, b, c, and d). these regions are generally conserved among hunov strains of the same genogroup. the orf- -orf junction (just downstream of region b) seems to be the most conserved and is frequently used for genogroup-specific detection. for strain comparison (as might be appropriate in outbreak investigation), primers corresponding to the nov capsid region (region d) are usually used. commercial rt-qpcr method detection methods are available for use in the food and environmental sector, but in all cases, substantial sample preparation to concentrate the viruses and remove the sample matrix is required before the application of rt-qpcr for detection. taken together, hunov detection in clinical, food, and environmental samples is not done routinely and there are wide regional variations in protocols. this highlights the need for standardized methods of detection and consistency of surveillance and disease reporting across countries. hav is a - nm, nonenveloped, positive-sense singlestranded rna virus with a . -kb genome and capsid having icosahedral symmetry. this virus is classified in the picornaviridae family under the genus hepatovirus. unlike other rna viruses, the hav genome is highly conserved, with only - % amino acid variation. human isolates of hav comprise a single serotype, but sequence heterogeneity within the vp / a can be used to differentiate hav into seven unique genotypes. of these seven genotypes, genotypes i and iii predominate in human disease. transmitted primarily by contact with the blood of infected individuals or through male homosexual relations, only approximately % of hav cases are foodborne, with transmission almost always in keeping with the fecal-oral route. once infected, the disease incubation period averages weeks (range of - weeks). disease initially presents with a prodrome that includes fever, headache, nausea, vomiting, and diarrhea. these symptoms progress - weeks later into inflammation of the liver and jaundice. hospitalization occurs in . % of cases, with mortality rates estimated at . %. infected young children are frequently asymptomatic, while disease severity increases with age. hepatitis a infection is endemic in developing regions of the world, and foods imported from third world countries where sewage treatment and hygiene advancements are still developing pose an increased risk to naive consumers in developed countries. like nov, outbreaks of hav have involved food products including molluscan shellfish, fresh fruits and vegetables, and rte foods. for example, in approximately people in china contracted hav from consuming partially cooked clams that had become contaminated by release of raw sewage in the proximity of the harvest area. within the fresh produce category, products such as raspberries, strawberries, lettuce, and green onions have caused outbreaks, some quite sizable. a good example is the us outbreak when green onions served at a single pennsylvania restaurant resulted in more than hav cases, with hospitalizations, and deaths. fresh produce most likely becomes contaminated by the use of human sewage-contaminated irrigation water, because of human defecation in production fields, and/or from the hands of infected food handlers during harvest or preparation phases of the farm-to-fork continuum. still, the most common cause of hav foodborne outbreaks in general is poor personal hygiene of infected food handlers. fortunately, an effective vaccine that provides lifelong immunity is now available suggesting that as the immunized population grows the disease will eventually go the route of poliovirus, although it may take decades before this is realized. because hav has a degree of genetic and antigenic homogeneity, its detection is much easier than that of hunov. clinical assays that detect antibodies against hav are commercially available, and for food and environmental samples, rt-qpcr using primers targeting the highly conserved vp / a junction or untranslated region of the viral genome are used. as is the case for nov, substantial preanalytical sample processing must be done when applying these methods to complex sample matrices and this remains the limiting factor in the routine detection of hav in foods. rotaviruses are the leading cause of infantile diarrhea worldwide and are responsible for more than deaths annually, the majority of which occur in developing countries. these viruses are - nm in diameter and contain segmented double-stranded rna molecules encased in a doublelayered protein coat of icosahedral symmetry. the genome segments range in size from bp (segment ) to bp (segment ), for a total of . kb. each of the segments encodes a single protein, with the exception of segments and which encode two proteins. a total of six structural viral proteins form the virus particle (termed vp , vp , vp , vp , vp , and vp ), whereas a further five nonstructural proteins (termed nsp -nsp ) are responsible for rna replication, packing, and other functions. interestingly, nsp is an enterotoxin that induces diarrhea. at least seven different rotavirus groups exist (a-g) based on vp reactivity with monoclonal antibodies. waterborne and person-to-person transmission are the most common causes of rotavirus infection; however, transmission via food products has been documented, with infant populations under years of age most often affected. the incubation period preceding disease is approximately days, and symptoms of disease include vomiting, diarrhea, and fever; dehydration is the most common cause of death. hospitalization rates in usa are estimated at . %, with a mortality rate of less than . %. the world health organization (who) now recommends the use of second generation rotavirus vaccines worldwide in an attempt to reduce the burden of disease in developing countries. a number of enteric viruses have the capacity to be transmitted by foodborne routes, although this is rarely documented or has not yet occurred. a few of these are described briefly in this section. hev is a positive-sense single-stranded rna virus that is transmitted via the fecal-oral route, generally through the consumption of water and sometimes food that has become contaminated with human feces. this virus is endemic in developing countries, particularly those locations having hot climates. large waterborne outbreaks have been recorded in many countries, and it is also possible that the virus is transmitted by the consumption of raw or undercooked pork and deer meat. interestingly, cases of hev have recently been reported in usa, uk, and japan, leading to speculation that the geographic range of this virus is increasing and that hev may become an emerging food and waterborne pathogen in the developed world. the incubation period for hev infection ranges from to weeks, with disease symptoms generally lasting several weeks. frank disease occurs more often in adults, with children often spreading the infection without displaying symptoms. clinical symptoms are very similar to those of hav infection, but unlike hav, the disease is quite severe in pregnant women for whom mortality is approximately %. clinical diagnosis of hev involves detecting antibodies specific to the virus in the blood of patients displaying the symptoms of hepatitis, or by rt-pcr. other human enteric viruses also have the potential to be transmitted by contaminated food products, although their epidemiological significance is not well understood. the human enteroviruses, including poliovirus, coxsackie, and echoviruses, are nonenveloped particles containing singlestranded positive-sense rna, with particle diameter of approximately nm. poliovirus has been all but eradicated in the developed world, coxsackie and echoviruses, which cause a variety of symptoms that can range from gastroenteritis, neurological, and skin manifestations, can be transmitted by foodborne routes, albeit infrequently. like hunov, they are resistant to harsh conditions, making them environmentally persistent. astroviruses are nm single-stranded rna viruses with a star-shaped capsid structure. these viruses cause sporadic disease and outbreaks of diarrhea in children and the elderly, particularly in venues such as day care centers and hospitals. transmission of these astroviruses by food is uncommon but has been documented for molluscan shellfish. human adenoviruses are nonenveloped double-stranded dna viruses that range from to nm in diameter. they can cause gastroenteritis, conjunctivitis, and most frequently, respiratory symptoms. the presence of these viruses in environmental samples such as wastewater, sludge, and drinking water has been reported, and for this reason, their use as an indicator for the presence of human enteric viruses has been proposed. however, the transmission of adenoviruses by foodborne routes has not yet been documented. nipah viruses belong to the genus henipavirus in the family paramyxoviridae, and are relatively large ( - nm diameter), enveloped, single-stranded rna viruses. the nipah virus was first recognized in in malaysia in association with pig farmers who contracted the disease by contact with infected animals. it can also be transmitted by person-toperson contact and can be carried by fruit bats. there have been recorded outbreaks where the vehicle of infection was fruits and vegetables contaminated with the saliva of bats. other outbreaks have involved direct contact with contaminated pigs or their tissues. disease symptoms usually include fever, headache, muscle pain, vomiting, and sore throat. these can progress to pneumonia and other respiratory illnesses. in severe cases, seizure and encephalitis can occur, often resulting in death. currently, there is no vaccine or treatment for nipah virus infection, so control of foodborne disease relies on cleaning and disinfection of pig farms, culling animals suspected of being infected, and controlling bat populations. hpai viruses are large ( nm diameter), negative sense rna viruses having a segmented genome and belonging to the orthomyxoviridae family. domestic and wild birds are the major reservoir for these viruses. there are virtually hundreds of hpai strains, however, only four have been shown to cause infection in humans; h n , h n , h n , and h n . disease in humans is typically mild, except for the h n virus, which has been responsible for a number of human deaths following outbreaks. the potential for spread of this virus through the food chain has been of concern because the virus appears to survive on imported meat. there is also concern for the risk of fecal contamination of water that is subsequently used in production agriculture or even for food preparation. however, it has been documented that hpai is susceptible to thermal processes, meaning that the consumption of properly cooked food poses little risk for hpai infection. coronaviruses are enveloped viruses with positive-sense single-stranded rna that belong to the family coronaviridae. the coronavirus that causes sudden acute respiratory syndrome (sars-cov) was first recognized as a human pathogen in in association with an outbreak in china. the virus was subsequently detected in more than other countries, infecting more than people with a % mortality rate. although generally thought to be spread exclusively by respiratory routes, there is evidence that sars-cov can replicate in the small and large intestines, causing diarrhea that results in fecal shedding of the virus. thus, the fecal-oral transmission route cannot be excluded. however, sars-cov are sensitive to fairly mild heat treatment and commonly used disinfectants, suggesting that attention to proper food handling and preparation measures should control foodborne transmission of the virus. taken together, the spread of sars-cov via contaminated food products remains possible but is now considered unlikely. lv and hv are rna viruses that belong to the arenaviridae and bunyaviridae families, respectively. lv, which is endemic in sub-saharan africa, causes a viral hemorrhagic fever; hv initially presents as a flu-like syndrome that can progress to severe pulmonary disease. the natural reservoir for both of these viruses is the mouse, and although rare, food can potentially be a vehicle of infection if it becomes contaminated with urine and/or feces of mice. the us centers for disease control and prevention (cdc) conducts surveillance of foodborne disease outbreaks, including those caused by hunov and hav, through the national outbreak reporting system (nors). because the program relies on individual states reporting their data, which is quite variable, the database is incomplete. the nors system provides some important information that can be used relative to epidemiological attribution estimates, but it only reports on epidemic disease. in the absence of routine clinical diagnostics, it is very difficult to get estimates for endemic hunov disease. the cdc has also recently launched calcinet, a national hunov sequence database that may eventually have utility similar to that of the pulsenet system for bacterial foodborne pathogens. surveillance for hunov illness in europe has been done by the european centre for disease control and prevention (ecdc) and the foodborne viruses in europe (fbve) network. in australia, the notification of individual nov infections is not required, however, the reporting of two or more infections having a time, place, and/or person association, suggesting an outbreak, is required. in many other countries, foodborne viral disease surveillance is not conducted, making it difficult to estimate the global impact of disease. in a uk study, it was estimated that only in hunov infections was actually reported. this is not surprising due to the mild nature of most infections and the lack of routine clinical diagnostics. of particular interest is the proportion of hunov infections that are caused by contaminated foods as compared to other transmission routes. getting at these estimates will undoubtedly require targeted epidemiological efforts such as active surveillance and/or case control studies, both of which are expensive and timeconsuming. further, until standardized reporting at the country and international level is established, the true burden of foodborne viral disease will remain unknown. as obligate intracellular parasites, enteric viruses cannot replicate in foods or water. in general, if wastewater is adequately treated through primary, secondary, and tertiary steps, and including chlorination, the risk of viral contamination is minimal. when it comes to foods, many measures classically applied to control bacterial growth are not very effective against viruses. for example, exposure to extremes of ph ( . - . ) and water activity will have little or no effect on the infectivity of enteric viruses. refrigeration and freezing actually help to preserve virus infectivity. the efficacy of standard thermal inactivation treatments is dependent on the food matrix and virus studied. as a general rule of thumb, nov and hav appear to be less sensitive to heat than are typical gramnegative bacteria, and more sensitive to heat than spores. high hydrostatic pressure has been recognized as an emerging processing technology for inactivating viruses in molluscan shellfish, however, similar to thermal inactivation, the effectiveness of the treatment is variable and virus specific. enteric viruses are also notably resistant to ionizing radiation. many studies have demonstrated the ability of enteric viruses to survive on abiotic surfaces commonly found in food processing and preparation environments, including stainless steel, aluminum, and polystyrene. viruses also persist in foods, having been found to survive in shellfish for weeks or months and on the surface of fresh produce for days to weeks. to make matters worse, it is well documented that many common sanitizers used in food processing environments have poor efficacy against nonenveloped enteric viruses, at least when used at manufacturer-recommended concentrations. it is for this reason, current control measures focus on the prevention of contamination, rather than treatments to inactivate viruses after a contamination event has occurred. the central tenets of control are good hygiene practices in food processing and handling environments, and prevention of contamination in the preharvest environments. because the decontamination of hands and surfaces in food processing and preparation is critical to preventing virus contamination, an important effort is assuring effective hand decontamination. the best method remains the traditional soap and water wash followed by towel drying. commercial alcohol-based hand sanitizers should not be used in place of adequate hand washing. of course, hand washing compliance in retail, institutional, and home settings remains a challenge and must be continuously advocated. there has been interest in further promoting the need for infected food handlers to report illness symptoms and abstain from work during periods of time in which they are actively shedding virus. however, the latter may be difficult in light of emerging evidence suggesting that shedding of hunov may persist for weeks after symptom resolution. adequate cleaning and disinfection of surfaces is also important to preventing virus contamination of foods, but the availability of disinfecting agents with specific activity against the nonenveloped enteric viruses is a pressing need. also needed are better microbiological indicator systems that have a more direct correlation with virus contamination of water in production environments, as the fecal coliforms and escherichia coli remain poor indicators for this application. this is particularly relevant for molluscan shellfish and fresh produce production. food virology is a relatively young field, at least from the perspective of food safety. the development of molecular techniques during the s, in combination with increased epidemiological surveillance, have raised awareness of the importance of viruses to foodborne illness. although methodological advancements have been made, much still remains unknown. the lack of a culture system for hunov is probably the single most important limiting factor to studying and controlling these viruses. with availability of such a method, or in its absence, availability of better cultivable surrogates or more sensitive detection methods for complex sample matrices, scientists would be able to tackle the challenges associated with trying to control foodborne viruses. likewise, the availability of routine clinical assays would result in greater awareness of these diseases and improvements in reporting and epidemiological surveillance. the field of food virology is set to grow rapidly in the coming years as scientists tackle these problems with the aid of developing technologies. safety assurance systems: personal hygiene and employee health. organisms of concern but not foodborne or confirmed foodborne: foot-and-mouth disease virus. viruses: hantavirus; hepatitis a virus hepatitis e virus; lassa fever virus development of a plaque-assay for a cytopathic, rapidly replicating isolate of hepatitis a virus molecular approaches for the detection of foodborne viral pathogens norovirus gastroenteritis: an update foodborne viral pathogens human pathogenic viruses in food norwalk virus genome cloning and characterization visualization by immune electron microscopy of a nm particle associated with acute infectious nonbacterial gastroenteritis food-borne viruses: progress and challenges food-related illness and death in the united states food-borne viruses: prevention and control foodborne illness acquired in the united states -unspecified agents foodborne illness acquired in the united states -major pathogens development and application of a capsid vp (region d) based reverse transcription pcr assay for genotyping of genogroup i and ii noroviruses study of infectious intestinal disease in england: rates in the community, presenting to general practice, and reported to national surveillance norovirus classification and proposed strain nomenclature food and agriculture organization -world health organization (fao-who) ( ) viruses in food: scientific advice to support risk management activities key: cord- - zqeq se authors: aiking, harry; de boer, joop title: the next protein transition() date: - - journal: trends food sci technol doi: . /j.tifs. . . sha: doc_id: cord_uid: zqeq se background: meeting the un sustainable development goals requires a relatively rapid transition towards a circular economy. therefore, a multidisciplinary perspective is required to sketch why a transition from diets based primarily on animal proteins towards diets based primarily on plant proteins products is extremely urgent for both food security and sustainability. scope and approach: this review starts out by identifying ecological, economic and social aspects of sustainable food consumption. subsequently, it is argued how protein supply is underlying and linking the top- of anthropogenic impacts based on the planetary boundaries concept, i.e. ) biodiversity loss, ) nitrogen cycle acceleration, and ) carbon cycle acceleration (resulting in climate change). these environmental impacts associated with current western food consumption need to be reduced urgently. in order to address the inefficiencies inherent to current dietary patterns, therefore, a ranked list of more sustainable options is proposed, based on their order of magnitude. addressing consumers, industry, and governmental stakeholders plus cultural aspects, challenges and options are sketched. key findings and conclusions: clearly, a dietary transition from primarily animal towards plant protein products is required. fortunately, new dietary guidelines are increasingly taking sustainability into account and the contours of a diet transition are slowly emerging. in september , the united nations (un) general assembly adopted the agenda for sustainable development. as an integral part, sustainable development goals (sdgs) present a novel approach and incentive to prioritize and integrate a number of pressing issues, including food security, food sustainability, climate change, and the broader aim of staying within planetary boundaries. it is evident that a transition towards a circular economy is urgently required to meet the sdgs. since many of the planetary boundaries are strongly interlinked with protein supply, the goal of the current review is to sketch novel trends, resuming where the preceding one (aiking, ) left off. after summarizing and evaluating the impacts of protein production by sustainability pillar, options to reduce these impacts will be identified and ranked with the help of a framework for priority setting. the role of stakeholders including governments, industry and consumers will be highlighted. the sdgs form a perfect starting point for this review. among the sdgs adopted (un, ) , food security (sdg ) evidently ranks higher than climate action (sdg ) . that is only natural, because in the global population reached . billion, but even in the medium growth scenario the un ( ) project a world population of . billion by and almost billion by . furthermore, increasing urbanization and incomes will result in diets containing more animal products (fao, a) . the fao project a % food demand increase by (alexandratos & bruinsma, ) , while many others project a doubling (see : tomlinson, ) . during the previous millennium, crop yield increases more or less kept up with demand, but yield increases are slowing down (ray, mueller, west, & foley, ) . in contrast with the fao's optimistic view, therefore, several financial institutions foresee that food prices may rise rapidly during the next decades, which might fuel conflict and migration (natalini, jones, & bravo, ) . kpmg, a global auditor, in fact forecast a - % food price increase by (de boer & van bergen, . analysis of the trends since the previous review will highlight changes at the production and consumption side. food production is accelerating, and so are its environmental impacts. still, smallholders produce half the world's food (johnson, dudley, & alexander, ) , but development financing remains a bottle-neck (fao, a) . on the consumption side, there is a dual diet transition in progress. booming economies are increasing their consumption of meat (china) and dairy (india) like western europe did half a century ago (grigg, ) . in europe, a reverse transition away from animal products is about to break through (geijer, ) . with respect to sustainability, this is none too early, for there is a growing consensus that animal protein has disproportionate environmental impacts, particularly when produced in intensive production systems employing massive use of feed crops (aiking, ; mcmichael, powles, butler, & uauy, ; smil, ; steinfeld et al., ; westhoek et al., ) . in , rockström et al. quantified a dozen planetary boundaries (rockström et al., ) , including biodiversity loss, nitrogen cycle disruption, climate change (i.e. carbon cycle disruption), phosphate cycle disruption, ocean acidification, land-use change, freshwater use and stratospheric ozone depletion. subsequently, they were ranked (aiking, ) and put in the above order based on their current transgression (aiking, ) . taken together, the rockström boundaries can be seen as the carrying capacity of planet earth, in terms of safe rates of natural resource use and emission of pollutants. human society may be the primary target of phosphate depletion, butwithout exception -earth's ecology is targeted by each of the eight anthropogenic impacts listed above, either by pollution (such as acidifying emissions), or by resource appropriation (such as taking freshwater and land away from natural habitats). in fact, eutrophication, climate change, ocean acidification, hunting, fishing, land conversion, and freshwater use all contribute to biodiversity loss in unison, explaining its high ranking. with respect to biodiversity loss, intensive livestock farming plays a major role both through the immense land area in use for feed crops (over million hectares; one third of all arable land) (tilman, cassman, matson, naylor, & polasky, ; van zanten, mollenhorst, klootwijk, van middelaar, & de boer, ) and by ammonia emissions from livestock manure (erisman, sutton, galloway, klimont, & winiwarter, ; fao, a; machovina, feeley, & ripple, ) . the magnitude of livestock's impact on biodiversity was illustrated by zalasiewicz ( ) : "we humans have obviously left our mark on the earth's biological landscape as well. in particular, our speciesa very minor player amid the planet's biota even a few thousand years agois now the dominant predator on land and sea. we appropriate roughly a quarter of the earth's total biological production for our needs. as a result, we make up about a third of the mass of all land vertebrates (based simply on body weight), and the handful of species we have engineered to become our food make up most of the other two thirds. wild animals, pushed to the margins, constitute percent or less." in other words, the ratio wildlife: humans: farm animals = : : (by weight). considering the projected doubling in meat demand from million tons in to million tons in (steinfeld et al., ) , a rough estimate shows that land vertebrates living in the wild may be reduced to - percent by . not surprisingly, even the intermediate ssp scenario by unccd foresees severe deforestation and land conversion in south asia, middle and south america, and disastrous damage to tropical forests in sub-saharan africa (johnson et al., , p. ) . half the world's food is produced by smallholders, for example, the share of farms smaller than ha is % in china, % in south asia, % in the near east and north africa (fao, b, p. ). nevertheless, the associated economic power does not rest with smallholders. lack of land ownership and availability of capital are important bottlenecks driving them out, and critical parts of the food system are becoming concentrated in fewer hands (fao, a) . a few powerful trade corporations, supermarket chains and financial institutions play important parts. animal protein products such as meat and dairy are important to them from an economic perspective, but when employing intensive production systems these are wasteful of plant protein from an environmental point of view and inherently, therefore, wasteful of the resources required to grow feed crops, such as land, water, phosphate and fuel. more and more, food and feed crops are competing for these increasingly scarce resources. in fact, by "peak oil" has been foreseen. by the same year, "peak phosphate" has been forecast (cordell, drangert, & white, ). in addition, "peak water" has been defined (gleick & palaniappan, ) , and a globally operating bank projected a % freshwater deficit by (crowder, fumasi, soccio, twomey, & williamson, ) . finally, the pressures on land resources are increasing steeply, also leading to compaction by heavy equipment, erosion, and deteriorating soil quality (fao, a; johnson et al., ; pimentel & burgess, ) , with negative feedback on further production increases. in light of the above it is no wonder that kpmg, a global auditor, forecast a - % food price increase by (de boer & van bergen, ) , because every little thing seems to converge then. since it is their core business, it stands to reason that financial institutions, primarily, issue such a warning of impending danger. interestingly, however, the latter is confirmed by an unexpected ally. unprecedentedly, in their ar ( th assessment report), the ipcc incorporated a chapter on h. aiking, j. de boer trends in food science & technology xxx (xxxx) xxx-xxx food security (porter et al., ) , showing a diagram with a time series of food price, cereal price, and crude oil indexes (fig. ). as shown, these indexes behaved in parallel, and initially they were rather constant, fluctuating only slightly. in an increase started, with spikes in - and - . apart from increased volatility, extrapolation of the baseline shows roughly a doubling of the food price index from about in to about in , in line with the kpmg forecast. the volume and type (animal vs. plant protein; intensive vs. extensive production systems) of protein production have evident impacts on society, primarily on food security. moreover, undernutrition is often caused by a lack of protein, rather than a lack of calories. in children under years of age, protein undernourishment is a leading cause of death (mcleod, , p. ) . although hunger and famines are roaming in developing countries primarily, food insecurity in developed countries should not be underestimated. for example, browning et al. note that "food affordability is a critical issue that is likely to rise in prominence. many millions of people currently struggle to be able to afford to eat enough, let alone to eat well and healthily. there are over million people in the uk currently living in food poverty." (browning, hirsch, & lang, ) . with respect to poverty alleviation and rural development, of course, sustenance farming by smallholders (johnson et al., ) and smallholder inclusion by multinational enterprises (sjauw-koen-fa, blok, & omta, ) constitute important aspects. in addition, land grabbing and increasing conflict take their toll (johnson et al., ) . the situation in africa is particularly alarming, because most of the world's population growth in the next few decades will take place there. such will no doubt lead to unprecedented migration and urbanization (johnson et al., ) . the latter generally leads to diet change entailing increased proportions of processed foods and animal products. these are associated with malnourishment, obesity and related diseases such as diabetes and certain types of cancer (mcmichael et al., ) . in addition to health impacts deriving from consumption, there are health impacts resulting from the ever-increasing production of animal protein. the latter include emerging zoonotic diseases, such as avian influenza, human cjd (creutzfeldt-jakob disease) related to bovine bse (bovine spongiform encephalopathy, or mad cow disease), q fever, ehec (enterohemorrhagic e. coli), sars (severe acute respiratory syndrome), mers (middle east respiratory syndrome), etc. (browning, pennington, & rooker, ; world bank, ) . primarily due to indiscriminate use of antibiotics in livestock farming, increasing microbial antibiotics resistance, such as by mrsa (methicillin-resistant staphylococcus aureus), is another effect of intensive animal protein production on human health requiring rapid improvement. of particular concern is the fact that by , antimicrobial consumption has been projected to double in countries such as china and india (van boeckel et al., ) , and that globally two-thirds of the estimated future growth of usage of antimicrobials is expected to occur within the animal production sector, with use in pig and poultry production predicted to double (fao, ) . another societal issue may be animal welfare (fao, c; godfray & garnett, ) , which is stronger in western than in many other countries. finally, politicians anywhere tend to spare farmers and voters. consequently, environmental decision making is slow. the pivotal role of protein is becoming clear in several ways. with respect to food security, the metric of choice is generally calories per capita, even though undernourishment with minerals and vitamins is taken into account (fao, c). however, as argued above, malnutrition is often caused by a lack of protein, rather than a lack of calories, and a leading cause of death in children under years of age (mcleod, , p. ) . with respect to food sustainability, climate change is often considered paramount. however, about a dozen of the most important environmental issues were listed by rockström et al. ( ) , who identified and quantified several boundary values that should not be transgressed. subsequently, these were ranked by aiking ( ) , showing that food production is an important driver of all of them, without exception. moreover, he argued that rockström et al.'s top three ( . biodiversity loss, . nitrogen cycle disruption, . carbon cycle disruptionleading to climate change; transgressed by factors of > , . and . - . , respectively) are strongly interlinked by protein production, with nitrogen cycle acceleration in a pivotal role. by the increasing amounts of animal proteins produced in intensive systems, i.e. with high input of feed crops, the global nitrogen use efficiency keeps dropping, and merely % of the nitrogen from fertilizers ends up in human mouths (erisman et al., ) . the remainder is lost to the environment, with increasing impacts on terrestrial biodiversity (resulting from ammonia emissions due to degradation of livestock manure) (sutton et al., ) , aquatic biodiversity (via eutrophication caused by manure and fertilizer run-off) (carstensen, andersen, gustafsson, & conley, ) , climate (due to the tremendous amounts of energy required for the production of nitrogen fertilizers) (goucher, bruce, cameron, koh, & horton, ; smil, ) and health (mcmichael et al., ) . conversion losses from plant to animal protein by livestock metabolism are % on average, of both (reactive) nitrogen and (embedded) energy (smil, ) . furthermore, intensive animal protein production requires - times more water than plant protein (aiking, ; smil, ) . in addition to pollution by reactive nitrogen (see above), impacts on biodiversity result from resource appropriation (land and freshwater) and land-use change (johnson et al., ) . considering the anticipated trends in animal protein demand in the next few decades, continued increase in all of these impacts will be inevitable. in the next three decades, more food should become available in absolute terms. the good news is that there is a lot of slack in the food system. in fact, even food price increases may have a positive side in that they will reduce food waste, as well as demand of animal protein. furthermore, just following dietary guidelines would reduce ghg emissions significantly, in addition to being much healthier than current dietary habits (macdiarmid et al., ) . even cutting the climate change impact in half is feasible by adopting a culturally acceptable and cheap diet (van dooren, tyszler, kramer, & aiking, ) . nevertheless, the un fail to provide direction and initiate a concerted action, so it is up to stakeholders at the national level, i.e. governments, industry and consumers. in order to make progress swiftly, some priority setting is required. for the food system to become more sustainable it should be made more efficient. from early on it was noted that losses and waste should be reduced all along the global food supply chain and in the household, in particular (eberle & fels, ; fao, a; kummu et al., ; parfitt, barthel, & macnaughton, ; ventour, ) . the consumer phase is important primarily because roughly one third of purchases in western supermarkets is discarded before consumption (ventour, ) . as a first step towards developing a framework to improve western consumption, alexander et al. ( ) established that the magnitude of over-consumption of food, however, surpasses that of food wasted in the household. within western over-consumption as such, protein is evidently more important than fats and carbohydrates, both numerically and environmentally, because the average protein intake in many western countries is - % of recommended values (aiking, ; de boer & aiking, ) . therefore, reducing consumption of protein and calories should be ranked as first and second options, respectively, for turning current western consumption in a more sustainable direction by reducing household food waste should be in third place (table ) . finally, replacing animal protein products (meat and dairy) with plant protein products (analogues and/or whole foods such as beans and nuts) should be ranked fourth, because their inputs and impacts are somewhat reduced, but not averted. in summary, table provides a ranked list of potential improvements of current western consumption patterns. it has to be kept in mind that there is a dual protein transition in the world. in booming economies animal products are increasingly consumed, and in western countries a slow decrease set in. therefore, the appearance of the above table strongly depends on the dietary patterns extant in the countries under consideration. ethical arguments such as equity, animal welfare, and application of fresh fish and meat resources as pet food (de silva & turchini, ; okin, ) have cultural dimensions, as well. at any rate, in addition to quantitative impacts, qualitative aspects relating to feasibility also play a part, and will be addressed in the consumer section below. next to consumption-related improvements, the resource use and pollution associated with production should also decrease along the whole chain. to meet that goal, reducing losses, waste and other emissions are in order. in the production chain, the importance of nitrogen fertilizer has become evident once more, because in a wheat-to-bread supply chain it was shown that the ammonium nitrate fertilizer used in wheat cultivation contributed no less than per cent of greenhouse gas emissions in a full life cycle assessment of a loaf of bread (goucher et al., ) . besides, the importance of food-demand management for climate mitigation had been argued explicitly, confirming that healthy and sustainable food largely go hand-in-hand (bajzelj et al., ) . in that respect it is interesting to note that the dutch gpa (green protein alliance) formulated some smart goals concerning the protein transition. according to this alliance of industry, academia, ngos and government, the current dutch consumption ratio of animal protein: plant protein of : should be changed, via : by , into : by (green protein alliance, ). within their programme for a circular economy (ministry for the environment & ministry of economic affairs, ), the dutch government instated transition teams in cooperation with industry, academia and ngos. even more interesting, therefore, is the fact that the gpa goals were adopted in full in the transition agenda food & biomass, also aiming for - % total protein intake reduction per capita by (transition team biomass & food, ). consumer responses to a potential protein transition have only been studied in a number of (developed) countries, including australia (hoek, pearson, james, lawrence, & friel, ) , the united states (de boer, de witt, & aiking, ), member states of the european union (de boer & aiking, ), and switzerland (siegrist, visschers, & hartmann, ) . the studies show that most consumers in these countries are not yet prepared to make the associated diet changes (for a detailed review see also : hartmann & siegrist, ) . moreover, policy-makers in government, industry, and ngos are often reluctant to engage with this topic (laestadius, neff, barry, & frattaroli, ; lang, ). an additional table improving current western dietary patterns (in descending order of magnitude). reducing over-consumption of protein reducing over-consumption of calories reducing food waste in the household replacing animal protein with plant protein (analogues and/or whole foods) fig. . targets of change strategies at the levels of diets, dishes, ingredients and bites. h. aiking, j. de boer trends in food science & technology xxx (xxxx) xxx-xxx difficulty is that food choice is a seemingly simple, but in fact very complicated behaviour that is influenced by many interacting factors, which cannot be captured by monodisciplinary, single-level research (köster, ) . key to a transition is reducing meat-centred meals and/ or replacing them with meals that are based on alternative protein options (e.g. pulses, vegetables, nuts, mushrooms, algae, seaweed, animal by-products, insects). such a change needs to take place at different levels of detail and context. as described in the literature (meiselman, ) and depicted in fig. , these levels range from diets (i.e. the broad set of food items that is accepted by a population over a period of time), dishes (i.e. food items accepted on a plate in combination with each other), to ingredients (i.e. food items accepted as separate entities) and bites (i.e. single food exposures). each of these levelsand their interactionsshould be considered in order to develop and evaluate realistic, nutritionally, environmentally and culturally acceptable changes in dietary patterns of populations and subpopulations (masset et al., ; van dooren, marinussen, blonk, aiking, & vellinga, ) . fig. demonstrates that alternative protein options should become an important part of the diet and consumers' repertoire of dishes as well as their set of appealing protein ingredients. various recent initiatives are exploring this approach. one of the few examples of an ambitious diet change programme was initiated by gastronomic, nutritional, and environmental specialists in the nordic countries, who developed a new regional (nordic) diet in accordance with healthy dietary recommendations, such as more calories from plant foods and fewer from meat, and more locally grown food in season, including food from the sea and the wild countryside (mithril et al., ) . by presenting the new diet under the nordic label, which already had positive connotations in other domains, the initiators tried to connect to lifestyle changes that are collective and highly visible (byrkjeflot, pedersen, & svejenova, ) . from a sustainability perspective, it has been calculated that the new nordic diet has, in theory, substantial environmental and socioeconomic advantages (saxe, ). an early study among a sample of overweight consumers found that the diet had high eating acceptance (tasty) but low practical acceptance, which the researchers attributed to perceived high price, low product availability, and time-consuming cooking procedures (micheelsen, havn, poulsen, larsen, & holm, ) . the latter might be mitigated through the development of more convenient and cheaper versions of the diet as well as by providing guidance regarding meal ideas, meal planning, and cooking skills. hence, the nordic initiative demonstrates that to effectively stimulate diet changes, the practical aspects at the level of dishes and ingredients are of utmost importance. moreover, other research shows that consumers may have the impression that they are unable to fit healthy eating into what they see as their complex lives, with constraints of time, work and social pressures (macdiarmid, loe, kyle, & mcneill, ) . these barriers make it important to ensure that the recommended changes do not depend solely on individual decisions but become an integral part of regional social and cultural processes with which individuals can identify themselves. at the level of protein ingredients and their interactions with dishes and bites, there is an increasing interest in mixed food concepts in which part of the protein consumed is from plant-based origin and the rest from animal-based origin. these concepts include flexitarian lifestyles, mixed (instead of meat-centred) dishes, and hybrid protein products. the term "flexitarian", coined in (glowka, melancon, & wyckoff, ) , is a union of the words "flexible" and "vegetarian", which has been used by individuals who saw themselves as vegetarians occasionally eating meat. from an alternative perspective, however, the term has recently been reframed to highlight the lifestyles of moderate meat-eaters who do not eat meat every day (de bakker & dagevos, ) . on a meat-free day, their dishes may involve a replacement of meat with a vegetarian version of a meat product, such as a veggie burger, or a variety of vegetables and legumes (schösler, de boer, & boersema, ) . a distinct but overlapping category of moderate meat-eaters is focussing more on smaller portions of meat, which may be of a better quality, such as organic or free-range meat (heerwagen, andersen, christensen, & sandøe, ; de boer, schösler, & aiking, ) . moderate meat-eaters may also like mixed dishes, based on recipes that involve a partial replacement of meat. for regular meat-eaters, however, a partial replacement may be associated with a loss of sensory appeal, which might be compensated by changes at the level of dishes, for instance, by stimulating sensory properties using the flavour of spices (spencer & guinard, ) . this type of research also shows that the combination of the protein ingredient and the rest of the dish has a large impact on consumer responses (elzerman, hoek, van boekel, & luning, ) . changes at the level of protein ingredients, interacting with bites, may include the development of hybrid products, such as beef burger and sausage analogues (neville, tarrega, hewson, & forster, ) . although these products may not be appreciated by "purists" who prefer authentic sources of either meat or environmentally-friendly proteins, such as lentils and seaweed, a hybrid meat product can be acceptable to consumers who are lowly involved with food (de boer, schösler, & boersema, ) . however, some pitfalls should not be ignored. although their current market share is very small, meat and dairy analogues are strongly on the rise (geijer, ; schmidinger, ). yet, their environmental impact reduction is limited compared to consumption reduction, and further improvement of their environmental performance is clearly required (smetana, mathys, knoch, & heinz, ; van mierlo, rohmer, & gerdessen, ). another point is that food choices may be influenced by fads and fashions. for instance, launching new products that contain a high level of proteins may be useful in professional sports, but for the general public experts consider this as a typical food fad (seidell & halberstadt, ) . the results of the recent initiatives can be translated in some strategic recommendations: increase awareness of the impacts of animal-based protein on the environment, the urgency of this issue and the availability of solutions, but take into account that science-based health and sustainability arguments in favour of a diet change do not sufficiently reach consumers or are too difficult for them to comprehend (de boer & aiking, ) . seek ways in which culinary, health and environmental aspects can complement each other. a regional approach may be necessary to bring gastronomic, nutritional, and environmental specialists together and to involve a range of commercial stakeholders, such as farmers, food processors, retailers, restaurant owners and new kinds of food networks. pay attention to mixed strategies and flexible options at the levels of diets, dishes, ingredients and bites. focus on alternative protein options and take into account that these should become an important part of consumers' diet, their repertoire of dishes as well as their set of appealing protein ingredients. develop change options that build on the familiar culinary principles of variety, balance, and moderation, as well as a moderate amount of novelty, and create an affordable diet that is convincingly healthier and more sustainable but not much different from the current one, for instance, due to correspondences in meal ideas, ingredient sourcing, culinary skills and social expectations. support consumers who find it difficult to adopt the diet and who need help with 'protein' literacy. ensure that the recommended changes do not depend solely on individual decisions but become an integral part of regional social and cultural processes with which individuals can identify themselves. the sdgs hold great potential in prioritizing and integrating the different dimensions of food production and consumption, which is urgently required. in order to meet the rapidly increasing demand, food production grew and intensified in parallel (godfray & garnett, ; tilman, balzer, hill, & befort, ; tscharntke et al., ) . so, for a h. aiking, j. de boer trends in food science & technology xxx (xxxx) xxx-xxx number of reasons, the current food system is not sustainable. first, food production is appropriating increasingly unsustainable amounts of natural resources (e.g. land, water, energy and nutrients) with harmful impacts on ecology, economy and society (also known as the three pillars of sustainability). second, food production leads to pollution (e.g. emissions of reactive nitrogen compounds, greenhouse gases, pesticides, antibiotics and biological agents) with unsustainable impacts on biodiversity (ecology) as well as on human health (society). third, intensive production leads to erosion and decreasing soil quality, with negative feedback on further increases (economy). finally, access to food is inequitable, leading to hunger and malnutrition, on the one hand, and to excessive food wastage, over-consumption and obesity, on the other hand. thus, food consumption does not have impacts on human health, exclusively, but huge overall impacts on ecology, economy and society. following the planetary boundaries concept (rockström et al., ; steffen et al., ) , aiking ( ) argued that their top- ( . biodiversity loss, . nitrogen cycle acceleration, and . carbon cycle acceleration) are strongly interlinked by protein production, with nitrogen cycle acceleration in a pivotal role. european protein supply (= production + importexport) in is over g/capita/day (de boer & aiking, ) , which is almost twice the dri (daily reference intake). actual consumption may be - % lower than supply, so conservatively reducing the average eu protein consumption by one third was recommended for health and sustainability as long as one decade ago (aiking, de boer, & vereijken, ) . in order to make western food consumption patterns more sustainable, a number of options were identified and ranked in order of decreasing magnitude. first, over-consumption of protein should be reduced, because ecologically it is the most costly nutrient and the average consumption in many western countries is over % of recommended values (de boer & aiking, ) . second, over-consumption of calories should be reduced, because health-wise it is the most costly nutrient, and because over-eating was found to be at least as large a contributor to food system losses as consumer food waste . third, in the whole chain, food waste should be reduced, in particular, consumer food waste in western countries (on average, about one third of supermarket purchase value). fourth, animal (protein) products (such as meat and dairy) should be replaced with plant (protein) products, because of the low conversion efficiency (ca. %) from crop protein to animal protein in intensive production systems involving massive use of feed crops (aiking, ; smil, ) . moreover, smil summarized: "thinking about the road ahead we must recognize several fundamental realities. solutions will not come from voluntary meatless diets, mass production of mock meat (transformed plant proteins) or muscle tissues cultured in bioreactors. substituting meat intakes by consumption of other high-protein animal foodstuffs is of marginal help. at the same time, meat production based only on truly sustainable grazing, feeding of forages rotated with food crops, and maximum use of crop and processing residues is inherently limited and although, once it is reoriented toward producing less beef and more pork and chicken, it could supply a surprisingly large share of today's meat consumption (as i will show, close to % of supply) it will not be able to satisfy global demand anticipated for and even less so for . innovations and productivity improvements alone cannot prevent further increases in already significant environmental burden of meat production and to reduce them we will also need to moderate our meat consumption." (smil, , p. ) . we couldn't agree more. the problem is that few of the stakeholders involvedgovernment, industry, consumersare inclined to consumption reduction, or even promoting it. in fact, they are looking to one another to take the initiative (roberts, crossley, & barling, ) . fortunately, some consumer groups seem to be sensitive to flexible diet concepts offering a moderate amount of novelty, as shown above in the section on consumers. as mentioned before, it is important to seek ways in which culinary, health and environmental aspects can complement each other (de boer & aiking, ) . in that respect, it is important to note that dietary guidelines are increasingly addressing sustainability in addition to healthy nutrition. in - , these included sweden, uk, germany, and the netherlands, as was shown in two reviews (behrens et al., ; fischer & garnett, ) . in the usa, the dietary guidelines advisory committee's recommendations to the same effect (dgac, ) were not ratified by the us senate. therefore, important sustainability issues (sabaté, harwatt, & soret, ) were omitted from the latest us guidelines. that is unfortunate, because health may be key to entice consumers to drop their conservative attitudes and progress towards a diet transition, which would benefit both the environment, and their health via reduction of obesity and sequelae (hadjikakou, ; you & henneberg, ) . in fact, there is increasing evidence that nutritionally healthy dietsi.e. according to dietary guidelinesgenerally go hand in hand with sustainable diets (buchner et al., ; mason & lang, ) . in that respect, a diet containing less animal products would benefit both public health and environment, but completely doing away with animal protein products would not be optimal for either (van kernebeek, oosting, van ittersum, bikker, & de boer, ) . western diets do not have to go completely vegetarian, therefore, but reducing total protein intake as well as the ratio of animal over plant 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livestock systems the food we waste the protein puzzle -the consumption and production of meat, dairy and fish in the european union towards a one health approach for controlling zoonotic diseases meat in modern diet, just as bad as sugar, correlates with worldwide obesity: an ecological analysis a history of layers: what mark will we leave on the planet? this work reported here is based in part on results from the protein foods, environment, technology and society (profetas) research program funded by the netherlands organisation for scientific research (nwo). declarations of interest: joop de boer: none; harry aiking is a member of the scientific advisory committee of the european natural soyfoods association (ensa). key: cord- -vtt wvm authors: keogh, john g.; rejeb, abderahman; khan, nida; dean, kevin; hand, karen j. title: optimizing global food supply chains: the case for blockchain and gsi standards date: - - journal: building the future of food safety technology doi: . /b - - - - . - sha: doc_id: cord_uid: vtt wvm this chapter examines the integration of gs standards with the functional components of blockchain technology as an approach to realize a coherent standardized framework of industry-based tools for successful food supply chains (fscs) transformation. the globalization of food systems has engendered significant changes to the operation and structure of fscs. alongside increasing consumer demands for safe and sustainable food products, fscs are challenged with issues related to information transparency and consumer trust. uncertainty in matters of transparency and trust arises from the growing information asymmetry between food producers and food consumers, in particular, how and where food is cultivated, harvested, processed, and under what conditions. fscs are tasked with guaranteeing the highest standards in food quality and food safety—ensuring the use of safe and authentic ingredients, limiting product perishability, and mitigating the risk of opportunism, such as quality cheating or falsification of information. a sustainable, food-secure world will require multidirectional sharing of information and enhanced information symmetry between food producers and food consumers. the need for information symmetry will drive transformational changes in fscs methods of practice and will require a coherent standardized framework of best practice recommendations to manage logistic units in the food chain. a standardized framework will enhance food traceability, drive fsc efficiencies, enable data interoperability, improve data governance practices, and set supply chain identification standards for products and assets (what), exchange parties (who), locations (where), business processes (why), and sequence (when). the globalization of food supply chains (fscs) has added significant complexity to food systems and created an information asymmetry between food producers and food consumers. as a result, a growing demand exists for greater transparency into food origins, methods of cultivation, harvesting, and production as well as labor conditions and environmental impact (autio et al., ; bildtgÅ rd, ; donnelly, thakur, & sakai, ) . moreover, the international debate on the integrity of fscs has intensified due to recurring incidents and crises across the five pillars of the food system (earlier referred to as the five consumer reputations): food quality, food safety, food authenticity, food defense, and food security ( fig. . ) . food-related incidents across all five pillars have been amplified through social media platforms (new, ) , creating consumer distrust. according to the most recent edelman trust barometer (etb), trust in the food and beverage industry has declined by two points since (global report: edelman trust barometer ). this decrease is significant as the trust construct in the etb encompasses both competence and ethics. importantly, edelman argued that ethics (e.g., comprised of integrity, dependability, and purpose) is "three times more important to company trust than competence" (global report: edelman trust barometer ). a crucial argument is made in the etb, suggesting that while business is considered competent, only nongovernment organizations (ngos) are considered ethical. this claim may have a profound impact on fscs and strongly suggests that in order to regain citizen-consumer trust, food businesses must be open to feedback and criticisms from ngos. this point should be of particular the vulnerabilities arising from their operations and management (voss, closs, calantone, helferich, & speier, ). an fsc is a network of highly interconnected stakeholders working together to ensure the delivery of safe food products (schiefer & deiters, ) . fsc actors commit to implementing a set of processes and activities that help take the food from its raw material state to the finished product (dani, ) . ensuring the delivery of safe food products is an utmost priority and a primary building block for a healthy and vibrant society. over the years, fscs have witnessed several structural changes and a shift toward the development of more unified, integrated, and coherent relationships between stakeholders (bourlakis & weightman, ) . as such, an fsc has become a "chain of trust" that extends from suppliers, producers, distributors, wholesalers, retailers, and consumers (choi & hong, ; johnston, mccutcheon, stuart, & kerwood, ) . although fscs represent a metaphorical "chain of trust," the trustworthiness of the fsc is as fundamental to the integrity of our food systems as food traceability and transparency and is not without its own unique set of challenges. fscs are vulnerable to natural disasters, malpractices, and exploitative behavior, leading to food security concerns, reputational damage, and significant financial losses. due to the inherent complexities of global fscs, it is almost impossible for stakeholders to police the entire flow of materials and products and identify all possible externalities. recurring disruptions (e.g., natural disasters, avian flu, swine fever, and consecutive food scandals have increased the sense of urgency in the management of fscs (zhong, xu, & wang, ) and negatively impacted consumer trust. the european "horsemeat scandal" in exemplified the vulnerabilities (yamoah & yawson, ) , and legal scholars from cambridge university posited the ability of the eu's regulatory regime to prevent fraud on such a scale was shown to be inadequate. eu food law, with its (over) emphasis on food safety, failed to prevent the occurrence of fraud and may even have played an (unintentional) role in facilitating or enhancing it the cambridge scholars further argued that the free movement of goods within the european union created a sense of "blind trust" in the regulatory framework, which proved to be inadequate to protect businesses and consumers from unscrupulous actors. while natural disasters and political strife are outside of the control of fsc stakeholders, to preserve food quality and food safety and minimize the risk of food fraud or malicious attacks, fsc stakeholders need to establish and agree on foundational methods for analytical science, supply chain standards, technology tools, and food safety standards. the redesign of the fsc is necessary in order to ensure unquestionable integrity in a resilient food ecosystem. this proposal would require a foundational approach to data management and data governance to ensure sources of accurate and trusted data to enable inventory management, order management, traceability, unsafe product recall, and measures to protect against food fraud. failure to do so will result in continued consumer distrust and economic loss. notably, a report by gs uk et al. ( ) reported that eighty percent of united kingdom retailers had inconsistent product data, estimated to cost ukp million in profit erosion over years and a further ukp million in lost sales. the recent emergence of blockchain technology has created significant interest among scholars and practitioners in numerous disciplines. initially, blockchain technology was heralded as a radical innovation laden with a strong appeal to the financial sector, particularly in the use of cryptocurrencies (nakamoto, , p. ). the speculation on the true identity of the pseudonymous "satoshi nakamoto" gave rise to suspicion on the actual creators of bitcoin and their motives (lemieux, ) . moreover, halaburda ( ) argued that there is a lack of consensus on the benefits of blockchain and, importantly, how it may fail. further, rejeb, s} ule, & keogh ( , p. ) argued "ultimately, a blockchain can be viewed as a configuration of multiple technologies, tools and methods that address a particular problem." beyond the sphere of finance, blockchain technology is considered a foundational paradigm (iansiti & lakhani, ) with the potential for significant societal benefits and improve trust between fsc actors. blockchain technology offers several capabilities and functionalities that can significantly reshape existing practices of managing fscs and partnerships, regardless of location, and also offers opportunities to improve efficiency, transparency, trust, and security, across a broad spectrum of business and social transactions (frizzo-barker et al., ) . the technological attributes of blockchain can combine with smart contracts to enable decentralized and self-organization to create, execute, and manage business transactions (schaffers, ) , creating a landscape for innovative approaches to information and collaborative systems. innovations are not only merely a simple composition of technical changes in processes and procedures but also include new forms of social and organizational arrangements (callon, law, & rip, ) . the ubiquitous product bar code stands out as a significant innovation that has transformed business and society. since the decision by us industry (gs , ) to adopt the linear bar code on april , , and the first scan of a -pack of wrigley's juicy fruit chewing gum in marsh's supermarket in troy, ohio, on june , (gs , , the bar code is scanned an estimated billion times daily. gs is a not-for-profit organization tasked with managing industry-driven data and information standards (note, gs is not an acronym). the gs system of interoperable standards assigns and manages globally unique identification of firms, their locations, their products, and assets. they rely on several technology-enabled functions for data capture, data exchange, and data synchronization among fsc exchange partners. in fscs, there is a growing need for interoperability standards to facilitate business-to-business integration. the adoption of gs standards-enabled blockchain technology has the potential to enable fsc stakeholders to meet the fast-changing needs of the agri-food industry and the evolving regulatory requirements for enhanced traceability and rapid recall of unsafe goods. although there is a growing body of evidence concerning the benefits of blockchain technology and its potential to align with gs standards for data and information (fosso wamba et al., ; kamath, ; lacity, ) , the need remains for an extensive examination of the full potentials and limitations. the authors of this section, therefore, reviewed relevant academic literature to examine the full potential of blockchain-enabled gs systems comprehensively, and therefore provide a significant contribution to the academic and practitioner literature. the diversity of blockchain research in the food context is fragmented, and the potentials and limitations in combination with gs standards remain vaguely conceptualized. it is vitally essential to narrow this research gap. this review will begin with an outline of the methodology applied to collect academic contributions to blockchain and gs standards within a fsc context, followed by an in-depth analysis of the findings, concluding with potential areas for future research. in order to explore the full potential of a system integrating blockchain functionalities and gs standards, a systematic review method based on tranfield, denyer, & smart ( ) guidelines was undertaken. the systematic review was considered as a suitable method to locate, analyze, and synthesize peer-reviewed publications. research on blockchain technology is broad and across disciplines; however, a paucity of research specific to food chains exists (fosso wamba et al., ) . similarly, existing research on blockchain technology and gs standards is a patchwork of studies with no coherent or systematic body of knowledge. therefore, the objective of this study was to draw on existing studies and leverage their findings using content analysis to extract insights and provide a deeper understanding of the opportunities for a gs standards-enabled blockchain as an fsc management framework. as stated earlier, the literature on blockchain technology and gs is neither welldeveloped nor conclusive, yet necessary to ensure successful future implementations. in order to facilitate the process of literature collection, a review protocol based on the "preferred reporting items for systematic reviews and meta-analyzes" (prisma) was used (liberati et al., ) . the prisma approach consists of four processes: the use of various sources to locate previous studies, the fast screening of studies and removal of duplicates, the evaluation of studies for relevance and suitability, and the final analysis of relevant publications. fig. . illustrates the prisma process. to ensure unbiased results, this phase of the study was completed by researchers with no previous knowledge or association with gs . conducting the review began with a search for studies on blockchain technology and gs standards. reviewed publications originated from academic sources (peer-reviewed) and included journal articles, conference papers, and book chapters. due to the nascent and limited literature on blockchain technology and gs standards, we supplemented our analysis with other sources of information, including conference proceedings, gray sources, and reports. the survey of the literature was conducted using four major scientific databases: scopus, web of science, sciencedirect, and google scholar. we used a combination of keywords that consisted of the following search string: "blockchain*" and "gs " and ("food chain*" or "food supply*" or agriculture or agro. the google scholar search engine has limited functionality and allows only the full-text search field; therefore, only one search query "blockchain* and gs and food" was used for the retrieval of relevant studies. the titles and abstracts of publications were scanned to obtain a general overview of the study content and to assess the relevance of the material. as shown in fig. . , a total of publications were found. many of the publications were redundant due to the comprehensive coverage of google scholar; studies focused on blockchain technology outside the context of food were removed. a fine-tuned selection of the publications was undertaken to ensure relevance to fscs. table . contains a summary of the findings based on content analysis. the final documents were classified, evaluated, and found to be sufficient in narrative detail to provide an overview of publications to date, specifically related to blockchain technology and gs standards. the loss of trust in the conventional banking system following the global financial crisis laid the groundwork for the introduction of an alternative monetary system based on a novel digital currency and distributed ledger (richter, kraus, & bouncken, ) . "satoshi nakamoto" (a pseudonym for an unknown person, group of people, organization, or other public or private body) introduced an electronic peer-to-peer cash system called bitcoin (nakamoto, , p. ). the proposed system allowed for payments in bitcoin currency, securely and without the intermediation of a trusted third party (ttp) such as a bank. the bitcoin protocol utilizes a blockchain, which provides an ingenious and innovative solution to the doublespending problem (i.e., where digital currency or a token is spent more than once), eliminating the need for a ttp intervention to validate the transactions. moreover, lacity ( , p. ) argued "while ttps provide important functions, they have some serious limitations, like high transaction fees, slow settlement times, low transaction transparency, multiple versions of the truth and security vulnerabilities." the technology behind the bitcoin application is known as a blockchain. the bitcoin blockchain is a distributed database (or distributed ledger) implemented on public, untrusted networks (kano & nakajima, ) with a cryptographic signature (hash) that is resistant to falsification through repeated hashing and a consensus algorithm (sylim, liu, marcelo, & fontelo, ) . blockchain technology is engineered in a way that parties previously unknown to each other can jointly generate and maintain a database of records (information) and can correct and complete transactions, which are fully distributed across several nodes (i.e., computers), validated using consensus of independent verifiers (tijan, aksentijevi c, ivani c, & jardas, ). blockchain is categorized under the distributed ledger technology family and is characterized by a peer-to-peer network and a decentralized distributed database, as depicted in fig. . . a diagrammatic representation of blockchain technology. according to lemieux ( ) , the nodes within a blockchain work collectively as one system to store encrypted sequences of transactional records as a single chained unit or block. nodes in a blockchain network can either be validator nodes (miners in ethereum and bitcoin) that participate in the consensus mechanism or nonvalidator nodes (referred to only as nodes). when any node wants to add a transaction to the ledger, the transaction of interest is broadcast to all nodes in the peer-topeer network. transactions are then collected into a block, where the addition to the blockchain necessitates a consensus mechanism. validators compete to have their local block to be the next addition to the blockchain. the way blocks are constructed and propagated in the system enables the traceback of the whole chain of valid network activities back to the genesis block initiated in the blockchain. furthermore, the consensus methodology employed by the underlying blockchain platform designates the validator, whose block gets added to the blockchain with the others remaining in the queue and participating in the next round of consensus. the validator node gains an incentive for updating the blockchain database (nakamoto, , p. ). the blockchain may impose restrictions on reading the data and the flexibility to become a validator to write to the blockchain, depending upon whether the blockchain is permissioned or permission-less. a consensus algorithm enables secure updating of the blockchain data, which is governed by a set of rules specific to the blockchain platform. this right to update the blockchain data is distributed among the economic set (buterin, b) , a group of users who can update the blockchain based on a set of rules. the economic set is intended to be decentralized with no collusion within the set (a group of users) in order to form a majority, even though they might have a large amount of capital and financial incentives. the blockchain platforms that have emerged employ one of the following decentralized economic sets; however, each example might utilize a different set of consensus algorithms: owners of computing power: this set employs proof-of-work (pow) as a consensus algorithm observed in blockchain platforms like bitcoin and ethereum. each block header in the blockchain has a string of random data called a nonce attached to them (nakamoto, , p. ). the miners (validators) need to search for this random string such that when attached to the block, the hash of the block has a certain number of leading zeros and the miner who can find the nonce is designated to add his local block to the blockchain accompanied by the generation of a new cryptocurrency. this process is called mining. mining involves expensive computations leading to (often massive) wastage of computational power and electricity, undesirable from an ecological point of view (o'dwyer & malone, ) , and resulting in a small exclusive set of users for mining. this exclusivity, however, goes against the idea of having a decentralized set leading blockchain platforms to employ other means of arriving at a consensus. stakeholders: this set employs the different variants of the proof-of-stake (pos) consensus mechanism. pos is a more just system than pow, as the computational resources required to accomplish mining or validation can be done through any computer. ethereum pos requires the miner or the validator to lock a certain amount of their coins in the currency of the blockchain platform to verify the block. this locked number of coins is called a stake. computational power is required to verify whether a validator owns a certain percentage of the coins in the available currency or not. there are several proposals for pos, as pos enables an improved decentralized set, takes power out of the hands of a small exclusive group of validators, and distributes the work evenly across the blockchain. in ethereum pos, the probability of mining the block is proportional to the validator's stake (ethhub, ) just as in pow, and it is proportional to the computational hashing power. as long as a validator is mining, the stake owned by him remains locked. a downside of this consensus mechanism is that the richest validators are accorded a higher priority. the mechanism does, however, encourage more community participation than many other methods. other consensus protocols include the traditional byzantine fault tolerance theory (sousa et al., ) , where the economic set needs to be sampled for the total number of nodes. here, the set most commonly used is stakeholders. hence, such protocols can be considered as subcategories of pos. a user's social network: this is used in ripple and stellar consensus protocols. the ripple protocol, for example, requires a node to define a unique node list (unl), which contains a list of other ripple nodes that the defining node is confident would not work against it. a node consults other nodes in its unl to achieve consensus. consensus happens in multiple rounds with a node declaring a set of transactions in a "candidate set," which is sent to other nodes in the unl. nodes in the unl validate the transactions, vote on them, and broadcast the votes. the initiating node then refines the "candidate set" based on the votes received to include the transactions getting the most significant number of votes for the next round. this process continues until a "candidate set" receives % votes from all the nodes in the unl, and then it becomes a valid block in the ripple blockchain. blockchain technologies are considered a new type of disruptive internet technology (pan, song, ai, & ming, ) and an essential enabler of large-scale societal and economic changes (swan, ; tapscott & tapscott, ) . the rationale for this argument is due to its complex technical constructs (hughes et al., ) , such as the immutability of transactions, security, confidentiality, consensual mechanisms, and the automation capabilities enabled by smart contracts. the latter is heralded as the most important application of blockchain (the integrity of the code in smart contracts requires quality assurance and rigorous testing). by definition, a smart contract is a computer program that formalizes relationships over computer networks (szabo, (szabo, , . although smart contracts predate bitcoin/blockchain by a decade and do not need a blockchain to function (halaburda, ) , a blockchain-based smart contract is executed on a blockchain with a consensus mechanism determining its correct execution. a wide range of applications can be implemented using smart contracts, including gaming, financial, notary, or computation (bartoletti & pompianu, ) . the use of smart contracts in the fsc industry can help to verify digital documents (e.g., certificates such as organic or halal) as well as determine the provenance (source or origin) of specific data. in a cold chain scenario, rejeb et al. ( ) argued that smart contracts connected to iot devices could help to preserve the quality and safety of goods in transit. for example, temperature tolerances embedded into the smart contract can trigger in-transit alerts and facilitate shipment acceptance or rejection based on preset parameters in the smart contract. the first platform for implementing smart contracts was ethereum (buterin, a, pp. e ) , although most platforms today cater to smart contracts. therefore, similar to the radical transformations brought by the internet to individuals and corporate activities, the emergence of blockchain provides opportunities that can broadly impact supply chain processes (fosso wamba et al., ; queiroz, telles, & bonilla, ) . in order to understand the implications of blockchain technology for food chains, it is essential to realize the potentials of its conjunction with gs standards. while the technology is still in a nascent stage of development and deployment, it is worthwhile to draw attention to the potential alignment of blockchain technology with gs standards as proof of their success, and universal adoption is very likely to prevail in the future. traceability is a multifaceted construct that is crucially important in fscs and has received considerable attention through its application in the iso /bs quality standards (cheng & simmons, ) . scholars have stressed the importance and value of traceability in global fscs (charlier & valceschini, ; roth, tsay, pullman, & gray, ) . broadly, traceability refers to the ability to track the flow of products and their attributes throughout the entire production process steps and supply chain (golan et al., ) . furthermore, olsen and borit ( ) completed a comprehensive review of traceability across academic literature, industry standards, and regulations and argued that the various definitions of traceability are inconsistent and confusing, often with vague or recursive usage of terms such as "trace." they provide a comprehensive definition: "the ability to access any or all information relating to that which is under consideration, throughout its entire life cycle, by means of recorded identifications" (olsen and borit, , p. ) . the gs global traceability standard (gs , c: ) aligns with the iso : definition "traceability is the ability to trace the history, application or location of an object [iso : ] . when considering a product or a service, traceability can relate to origin of materials and parts; processing history; distribution and location of the product or service after delivery." traceability is also defined as "part of logistics management that capture, store, and transmit adequate information about a food, feed, food-producing animal or substance at all stages in the food supply chain so that the product can be checked for safety and quality control, traced upward, and tracked downward at any time required" (bosona & gebresenbet, , p. ). in the fsc context, a fundamental goal is to maintain a high level of food traceability to increase consumer trust and confidence in food products and to ensure proper documentation of the food for safety, regulatory, and financial purposes (mahalik & kim, ) . technology has played an increasingly critical role in food traceability over the past two decades (hollands et al., ) . for instance, radio frequency identification (rfid) has been adopted in some fscs to enable nonline-of-sight identification of products to enhance end-to-end food traceability (kelepouris et al., ) . walmart achieved significant efficiency gains by deploying drones in combination with rfid inside a warehouse for inventory control (companik, gravier, & farris, ) . however, technology applications for food traceability are fragmented, often proprietary and noninteroperable, and have enabled trading partners to capture only certain aspects of the fsc. as such, a holistic understanding of how agri-food businesses can better track the flow of food products and related information in extended, globalized fscs is still in a nascent stage of development. for instance, malhotra, gosain, & el sawy ( ) suggested it is imperative to adopt a more comprehensive approach of traceability that extends from source to final consumers in order to obtain a full understanding of information processing and sharing among supply chain stakeholders. in this regard, blockchain technology brings substantial improvements in transparency and trust in food traceability (behnke & janssen, ; biswas, muthukkumarasamy, & tan, ; sander, semeijn, & mahr, ) . however, arguments from many solution providers regarding traceability from "farm to fork" are a flawed concept as privacy law restricts tracking products forward to consumers. in this regard, tracking (to track forward) from farm to fork is impossible unless the consumer is a member of a retailers' loyalty program. however, tracing (to trace backward) from "fork to farm" is a feasible concept enabled by a consumer scanning a gs centric bar code or another code provided by the brand (e.g., proprietary qr code). hence, farm-to-fork transparency is a more useful description of what is feasible (as opposed to farm-to-fork traceability). while a blockchain is not necessarily needed for this function, depending on the complexity of the supply chain, a blockchain that has immutable information (e.g., the original halal or organic certificate from the authoritative source) could improve the integrity of data and information provenance. blockchain is heralded as the new "internet layer of value," providing the trinity of traceability, trust, and transparency to transactions involving data or physical goods and facilitating authentication, validation, traceability, and registration (lima, ; olsen & borit, ) . the application of gs standards with blockchain technology integration enables global solutions linking identification standards for firms, locations, products, and assets with blockchains transactional integrity. thus, the combination of blockchain and gs standards could respond to the emerging and more stringent regulatory requirements for enhanced forms of traceability in fscs (kim, hilton, burks, & reyes, ) . a blockchain can be configured to provide complete information on fsc processes, which is helpful to verify compliance to specifications and to trace a product to its source in adverse events (such as a consumer safety recall). this capability enables blockchain-based applications to solve problems plaguing several domains, including the fsc, where verified and nonrepudiated data are vital across all segments to enable the functioning of the entire fsc as a unit. within the gs standards framework, food traceability is industry-defined and industry-approved and includes categorizations of traceability attributes. these include the need to assign unique identifiers for each product or product class and group them to traceable resource unit (behnke & janssen, ) . fsc actors are both a data creator (i.e., they are the authoritative source of a data attribute) and a data user (i.e., a custodian of data created by other parties such as an upstream supplier). data are created and used in the sequential order of farming, harvesting, production, packaging, distribution, and retailing. in an optimized fsc, the various exchange parties must be interconnected through a common set of interoperable data standards to ensure the data created and used provide a shared understanding of the data attributes and rules (rules on data creation and sharing are encompassed within gs standards). a blockchain can be configured to add value in fscs by creating a platform with access and control of immutable data, which is not subject to egregious manipulation. moreover, blockchain technology can overcome the weaknesses created by the decades-old compliance to the minimum regulatory traceability requirements, such as registering the identity of the exchange party who is the source of inbound goods and registering the identity of the exchange party who is the recipient of outbound goods. this process is known as "one-up/one-down" traceability (wang et al., , pp. e ) and essentially means that exchange parties in an fsc have no visibility on products outside of their immediate exchange partners. blockchain technology enables fsc exchange partners to maintain food traceability by providing a secure, unfalsifiable, and complete history of food products from farm to retail (molding, ). unlike logistics-oriented traceability, the application of blockchain and gs standards can create attribute-oriented traceability, which is not only concerned with the physical flow of food products but also tracks other crucial information, including product quality and safety-related information (skilton & robinson, ). on the latter point, food business operators always seek competitive advantage and premium pricing through the product (e.g., quality) or process differentiation claims (e.g., organically produced, cage-free eggs). this is in response to research indicating that an increasing segment of consumers will seek out food products best aligning with their lifestyle preferences such as vegetarian, vegan, or social and ethical values such as fair trade, organic, or cage-free (beulens, broens, folstar, & hofstede, ; roe & sheldon, ; vellema, loorbach, & van notten, ; yoo, parameswaran, & kishore, ) . in fig. . below, keogh ( ) outlines the essential traceability functions and distinguishes the supply chain flow of traceability event data versus the assurance flow of credence attributes such as food quality and food safety certification. for instance, in economic theory, goods are considered as comprising of ordinary, search, experience, or credence attributes (darby & karni, ; nelson, ) . goods classified as ordinary (e.g., petrol or diesel) have well-known characteristics and known sources and locations to locate and purchase. regarding search, it refers to goods where the consumer can easily access trusted sources of information about the attributes of the product before purchase and at no cost. search is "costless" per se and can vary from inspecting and trying on clothes before buying or going online to find out about a food product, including its ingredients, package size, recipes, or price. in the example of inspecting clothes before purchase, dulleck, kerschbamer, & sutter ( ) differentiate this example as "search" from "experience" by arguing that experience entails unknown characteristics of the good that are revealed only after purchase (e.g., the actual quality of materials, whether it fades after washing). products classified as experience goods have attribute claims such as the product is tasty, flavorful, nutritious, or health-related such as lowers cholesterol and requires the product to be tasted or consumed to verify the claim, which may take time (e.g., lowers cholesterol). verifying the experience attributes may be free if test driving a car or receiving a sample or taster of a food product in a store. nevertheless, test driving or sampling will not confirm how the product will perform over time. generally speaking, verifying experience attributes of food is not free, and it may take considerable time (and likely expense) to verify the claim. credence claims (darby and karni, ) are characterized by asymmetric information between food producers and food consumers. the reason for this is because credence attributes are either intrinsic to the product (e.g., food quality, food safety) or extrinsic methods of processing (e.g., organic, halal, kosher), and consumers cannot verify these claims before or after purchase (dulleck et al., ) . in this regard, a blockchain offers a significant advancement in how credence claims flow (see fig. . ) and are added to a product or batch/lot # record. for instance, the immutability of the data means that a brand owner can add a record such as a third-party certificate (e.g., laboratory analysis verifying a vegan claim or a usda organic certificate), but they cannot edit or change it. this feature adds much-needed integrity to fscs and enhances transparency and consumer trust, especially if the third-party data are made available for consumers to query. in this context, the combination of gs standards and a blockchain provides a consumer with the capability to scan a food product and query its digital record to verify credence claims. at a more detailed level, the fragmentation of fscs and their geographic dispersion illustrates the need for blockchain and gs for achieving an optimal granularity level of traceability units (dasaklis, casino, & patsakis., ) . as such, the combination of blockchain can help in the assurance of food quality and safety, providing secure (toyoda, takis mathiopoulos, sasase, & ohtsuki, ) , precise, and real-time traceability of products. moreover, the speed of food authentication processes makes blockchain a potential enabler of a proactive food systemda key catalyst for anticipating risky situations and taking the necessary preventative measures. triggering automatic and immediate actions in the fsc has been an impetus for large corporations to adopt blockchain technology; for example, walmart leverages gs standards and blockchain technology, defining the data attributes to be entered into their preferred blockchain system, such as the attributes defined under the produce traceability initiative (pti, ). using gs standards as a foundational layer, walmart tracks pork meat and pallets of mangoes, tagged with unique numeric identifiers in china and the united states. walmart has demonstrated the significant value of a gs -enabled blockchain, reducing both business and consumer risk in a product safety recall. more specifically, walmart simulated a product safety recall for mangoes, and this exercise suggested a reduction in time to execute the product safety recall from days pre-blockchain to . s using a blockchain (kamath, ) . the contribution of gs to the de facto individualization of food products has motivated the study of dos santos, torrisi, yamada, & pantoni ( ) , who examine the traceability requirements in recipe-based foods and propose whole-chain traceability with a focus on ingredient certification. with the use of blockchain technology, it is possible to verify the source of any batch or a lot number of ingredients. kim et al. ( ) developed an application called "food bytes" using blockchain technology and enabling consumers to validate and verify specific quality attributes of their foods (e.g., organic) by accessing curated gs standard data from mobile devices, thereby increasing ease of consumer usability and ultimately trust. blockchain technology can help fsc partners develop best practices for traceability and to curb fraudulent and deceptive actions as well as the adulteration of food products. to solve these issues, staples et al. ( ) develop a traceability system based on haccp, gs , and blockchain technology in order to guarantee reliable traceability of the swine supply chain. in their proposed system, gs aids in the coordination of supply chain information, and blockchain is applied to secure food traceability. a pressing challenge facing fscs is the need to coordinate information exchange across several types of commodities, transportation modes, and information systems. by analogy, a similar need was resolved in the healthcare industry through the implementation of electronic health records (ehr) to provide access to an individual patient's records across all subdomains catering to the patient. the healthcare industry is presently working on enhancing ehr through the deployment of blockchain to serve as a decentralized data repository for preserving data integrity, security, and ease of management (shahnaz, qamar, & khalid, ) . closely resembling the role and function of the ehr in the healthcare industry, the creation of a digital food record (dfr) is vital for fscs to facilitate whole-chain traceability, interoperability, linking the different actors and data creators in the chain, and enhancing trust in the market on each product delivered. fsc operators need access to business-critical data at an aggregated level to drive their business strategy and operational decisions, and many of the organizations operate at the global, international, or national levels. data digitization and collaboration efforts of fsc organizations are essential to enable actionable decisions by the broader food industry. currently, much of the data currently exist as siloed, disparate sources that are not easily accessible; including data related to trade (crop shortages/overages), market prices, import/export transaction data, or real-time data on pests, disease or weather patterns, and forecasts. with this in mind, and acknowledging the need for transparent and trusted data sharing, the dutch horticulture and food domain created "horticube," an integrated platform to enable seamless sharing of data and enable semantic interoperability (verhoosel, van bekkum, & verwaart, ) . the platform provides "an application programming interface (api) that is based on the open data protocol (odata). via this interface, application developers can request three forms of information; data sources available, data contained in the source, and the data values from these data sources (verhoosel et al., , p. ). the us food and drug administration is currently implementing the food safety modernization act (fsma) with emphasis on the need for technological tools to accomplish interoperability and collaboration in their "new era of smarter food safety" (fda, ) . in order to enable traceability as envisioned in fsma, a solution is required that incorporates multiple technologies, including iot devices. blockchain is envisioned as a platform of choice in accordance with its characteristic of immutability to prevent the corruption of data (khan, ) . ecosystems suited for the application of blockchain technology are those consisting of an increasing set of distributed nodes that need a standard approach and a cohesive plan to ensure interoperability. more precisely, fscs comprised of various partners working collaboratively to meet the demands of various customer profiles, where collaboration necessitates an exchange of data (mertins et al., ) ; furthermore, the data should be interchanged in real-time and verified to be originating from the designated source. interoperability is a precursor of robust fscs that can withstand market demands by providing small and medium enterprises with the necessary information to decide on the progress of any product within the supply chain and ensure the advancement of safe products to the end consumer. blockchain technology enables an improved level of interoperability as fsc actors would be able to communicate real-time information (bouzdine-chameeva, jaegler, & tesson, ), coordinate functions, and synchronize data exchanges (bajwa, prewett, & shavers, ; behnke & janssen, ) . the potential interoperability provided by blockchains can be realized through the implementation of gs standards. specifically, the electronic product code information standard (epcis), which can be used to ensure the documentation of all fsc events in an understandable form and the aggregation of food products into higher logistic units, business transactions, or other information related to the quantity of food products and their types (xu, weber, & staples, ) . a recent study by the institute of food technologists found evidence that technology providers faced difficulty in collaborating to determine the origin or the recipients of a contaminated product (bhatt & zhang, ) . hence, the novel approach of blockchain provides a specific emphasis on interoperability between disparate fsc systems, allowing technology providers to design robust platforms that ensure interoperable and end-to-end product traceability. the use of iot devices allow organizations within fscs to send and receive data; however, the authenticity of the data still needs to be ascertained. a compounding factor is the technological complexity of fscs (ahtonen & virolainen, ), due to the reliance on siloed systems that hamper collaboration and efficient flow of information. however, blockchain architecture can accommodate interoperability standards at the variable periphery (the iot devices) and other technologies used to connect fsc processes (augustin, sanguansri, fox, cobiac, & cole, ) . blockchain is envisaged as a powerful tool (ande, adebisi, hammoudeh, & saleem, ) and an appropriate medium to store the data from iot devices since it provides seamless authentication, security, protection against attacks, and ease of deployment among other potential advantages (fernández-caramés & fraga-lamas, ) . for fsc, blockchain is seen as the foundational technology for the sharing and distribution (read and write) of data by the organizations comprising the ecosystem, as shown in fig. . . in this model, consumers can read data for any product and trace the entire path from the origin to the destination while relying upon the immutability of blockchain to protect the data from any tampering. supply chain data are stored as a dfr in the various blocks (e.g., b , b , b ) that comprise the blockchain. the first block represented by g in fig. . refers to the genesis block, which functions as a prototype for all the other blocks in the blockchain. • traceability for fresh fruits and vegetables-implementation guide (legacy, developed for gs global traceability standard . . ) (gs , b) • gs global traceability compliance criteria for food application standard (legacy, developed for gs global traceability standard . . ) (gs , b) together, these documents provide comprehensive guidance to fscs on the implementation of a traceability framework. figs. . and . below indicate a single and multiple company view of traceability data generation. underlying the gs traceability standard is the gs epcis (gs , a), which defines traceability as an ordered collection of events that comprise four key dimensions: • what-the subject of the event, either a specific object (epc) or a class of object (epc class) and a quantity • when-the time at which the event occurred • where-the location where the event took place • why-the business context of the event the gs global traceability standard adds a fifth dimension, "who," to identify the parties involved. this can be substantially different from the "where" dimension, as a single location (e.g., a third-party warehouse) may be associated with multiple, independent parties. epcis is supplemented by the core business vocabulary standard (gs , a), which specifies the structure of vocabularies and specific values for the vocabulary elements to be utilized in conjunction with the gs epcis standard. epcis is a standard that defines the type and structure of events and a mechanism for querying the repository. assuming that all parties publish to a common epcis repository (centralized approach) or that all parties make their repositories available (open approach), traceability is simply the process of querying events, analyzing them, and querying subsequent events until all relevant data are retrieved. in practice, neither the centralized nor open approach is possible. in the centralized approach, multiple, competing repositories will naturally prevent a single, centralized repository from ever being realized. even if such a model were to be supported in the short term by key players in the traceability ecosystem, as more and more players are added, the odds of one or more of them already having used a competing repository grows. in the open approach, not all parties will be willing to share all data with all others, especially competitors. depending on the nature of the party querying the data or the nature of the query itself, the response may be no records, some records, or all records satisfying the query. for either approach, there is the question of data integrity: can the system prove that the traceability data have not been tampered with? blockchain is a potential solution to these problems. as a decentralized platform, blockchain integration could provide epcis solution providers with a way of sharing data in a secure fashion. furthermore, the sequential, immutable nature of the blockchain platform either ensures that the data cannot be changed or provides a mechanism for verifying that it has not been tampered with. the critical question is, what exactly gets stored on the blockchain? the options discussed by gs in a white paper on a blockchain (gs , b) are • fully formed, cryptographically signed plain text event data, which raises concerns about scalability, performance, and security if full events are written to a ledger; • a cryptographic hash of the data that has little meaning by itself. this requires offchain data exchange via a separate traceability application and a hash comparison to verify that data have not been altered since the hash was written to the ledger; and • a cryptographic hash of the data and a pointer to off-chain data. this is the same as the above point with a pointer to the off-chain data source. such an approach can enable the ledger to act as part of a discovery mechanism for parties who need to communicate and share data. this then leads to the question of the accessibility of the data: public: everyone sees all transactions; private: this includes a permission layer that makes transactions viewable to only approved parties. integrating epcis (or any other data sharing standard) with blockchain often presents significant challenges: in most cases, volumetric analysis can reveal sensitive business intelligence even without examining the data. for example, if company x is currently publishing records per day, and next year at the same time it is publishing only , it is reasonable to assume that company x's volume is down by % year over year. revealing the subject of an event (the "what" dimension) can reveal who is handling the expensive product, which may be used to plan its theft or diversion. publishing a record in plain text makes the data available to any party that has a copy of the ledger, but not all data should be available to all parties. for example, transformation events in epcis record inputs partially or fully consumed to produce one or more outputs. in the food industry, this is the very nature of a recipe, which is often a closely guarded trade secret. in order to mitigate this risk, the ledger would have to be firmly held by a limited number of parties that could enforce proper data access controls. even if such a system were to be implemented correctly, it means that proprietary information would still be under the control of a third party, which is a risk that many food companies would not be willing to take. publishing a record in an encrypted form would solve the visibility issue, but in order to do so, the industry would have to agree on how to generate the keys for the encrypted data. one option is to use the event's subject (the "what" dimension) as the key. if the identifier for the subject is sufficiently randomized, this ensures that only parties that have encountered the identifier can actually decrypt the data; while other parties could guess at possible values of the identifier, doing so at scale can be expensive and therefore self-limiting. there would also have to be a way to identify which data are relevant to the identifier, which would mean storing something like a hash of the identifier as a key. only those parties that know the identifier (i.e., that have observed it at some point in its traceability journey) will be able to locate the data of interest and decrypt them. parties could publish a hash of the record along with the record's primary key. this could then be used to validate records to ensure that they have not been tampered with, but it means that any party that wishes to query the data would have to know ahead of time where the data reside. once queried successfully, the record's primary key would be used to lookup the hash for comparison. to enable discovery, data consisting of the event's subject (the "what" dimension) and a pointer to a repository could be published. in essence, this is a declaration that the repository has data related to the event's subject, and a query for records related to the event's subject is likely to be successful. to further secure the discovery, the event's subject could be hashed, and that could be used as the key. volumetric analysis is still possible with this option. to limit volumetric analysis, data consisting of the class level of the event's subject and a pointer to a repository could be published. this is essentially a declaration that objects of a specific type have events in the repository, but it does not explicitly say how many or what specific objects they refer to. it still reveals that the company using the repository is handling the product. over and above all of this is the requirement that all publications be to the same type of blockchain ledger. there are currently no interoperability standards for blockchains. the industry would, therefore, have to settle on one, which has the same issue as settling on a single epcis repository. further technical research is required to determine the viability of the various options for publishing to the blockchain. the standardization efforts in global fscs have led to the need for best practice recommendations and common ways of managing logistics units in the food chain. the widespread use of gs standards reflects the tendency of food organizations to operate in an integrated manner with a universal language. this facilitates fscs to structure and align with a cohesive approach to food traceability, empowering multidirectional information sharing, optimizing efficiencies, and added-value activities for fsc stakeholders. moreover, the embeddedness of gs standards in global fscs allows trading partners to work in an industry-regulated environment wherein food quality and food safety are of the utmost priority in delivering sustainable, authentic products to final consumers. today, the usage of gs standards is inevitable as they provide clear guidelines on how to manage and share event data across global fscs (figueroa, añorga, & arrizabalaga, ) . this inevitability is further enhanced through the leadership of the global management board of gs (as of february ) that consists of senior executives from organizations such as procter & gamble, nestle, amazon, google, j.m. smucker, l'oreal, metro ag, alibaba, and others. similarly, the management board for the gs us organization includes senior executives from walmart, wegfern, wendy's, coca cola, target, publix, wegmans, sysco, massachusetts institute of technology, and others. the commitment of these organizations strongly supports the industry adoption of gs standards, and gs enabled blockchain solutions as indicated by walmart in their us-driven "fresh leafy greens" traceability initiative (walmart, ) . moreover, many of these firms have announced blockchain-related initiatives in their supply chains. walmart's traceability initiative reflects growing consumer concerns regarding food quality and safety and the recurring nature of product safety recalls. the combination of gs standards with blockchain can provide immutable evidence of data provenance, enhance food traceability and rapid recall, and increase trust in the quality of food products. gs standards aid organizations in maintaining a unified view of the state of food while transitioning between processing stages across globalized and highly extended supply chains with multiple exchange parties. as such, the broad adoption of electronic traceability as identified by gs can endow the food industry with several capabilities, ranging from the optimization of traceback procedures, the standardization of supply chain processes, the continuous improvement in food production activities, and the development of more efficient and holistic traceability systems. the use of gs standards for the formation of interoperable and scalable food traceability systems can be reinforced with blockchain technology. as envisioned by many food researchers, practitioners, and organizations, blockchain technology represents a practical solution that has a positive impact on fsc collaborations and data sharing. blockchain technology creates a more comprehensive and inclusive framework that promotes an unprecedented level of transparency and visibility of food products as they are exchanged among fsc partners. combined with gs standards, blockchain technology offers a more refined level of interoperability between exchange parties in global fscs and facilitates a move away from the traditional or linear, stove-piped supply chains with limited data sharing. by leveraging blockchain, fscs would be able to develop a management information platform that enables the active collection, transfer, storage, control, and sharing of food-related information among fsc exchange parties. the combination of blockchain and gs standards can create a high level of trust because of the precision in data and information provenance, immutability, nonrepudiation, enhanced integrity, and deeper integration. the development of harmonized global fscs gives rise to more efficient traceability systems that are capable of minimizing the impact of food safety incidents and lowering the costs and risks related to product recalls. therefore, the integration of gs standards into a blockchain can enhance the competitive advantage of fscs. in order to unlock the full potential from the functional components of a blockchain and the integration of gs standards, several prerequisites need to be fulfilled. for example, a more uniformed and standardized model of data governance is necessary to facilitate the operations of fscs in a globalized context. a balance between the conformance with diverse regulatory requirements and the fsc partners' requirements should be established in order to maintain a competitive position in the global market. the inter-and intraorganizational support for blockchain implementations, including the agreement on what type of data should be shared and accessed, the establishment of clear lines of responsibilities and accountability, and the development of more organized and flexible fscs should be considered prior to blockchain adoption (fosso wamba et al., ) . in summary, a blockchain is not a panacea, and non-blockchain solutions are functioning adequately in many fscs today. the business case or use case is crucially important when considering whether a blockchain is required and whether its functionality adds value. moreover, a blockchain does not consider unethical behaviors and opportunism in global fscs (bad character). organizations need to consider other risk factors that could impact ex post transaction costs and reputation. global fsc risk factors include slave labor, child labor, unsafe working conditions, animal welfare, environmental damage, deforestation and habitat loss, bribery and corruption, and various forms of opportunism such as quality cheating or falsification of laboratory or government records before they are added to a blockchain. product data governance and enhanced traceability can be addressed in global fscs, but "bad character" is more difficult to detect and eliminate. essentially, bad data and bad character are the two main enemies of trust in the food chain. this study focused narrowly on existing research combining blockchain, gs standards, and food. due to the narrow scope of the research, we did not explore all technical aspects of the fast-evolving blockchain technology, smart contracts, or cryptography. further research is needed to explore the risks associated with the integrity of data entered into a blockchain, especially situations where bad actors may use a blockchain to establish false trust with false data. in this regard, "immutable lies" are added to a blockchain and create a false sense of trust. because of this potential risk, and because errors occuring in the physical flow of goods within supply chains are common (e.g., damage, shortage, theft) as well as errors in data sharing and privacy, the notion of blockchain "mutability" should be researched further (rejeb et al., (rejeb et al., , . further technical research is encouraged to explore the relationship between the immutability features of a blockchain and the mutability features of the epcis standard. in the latter, epcis permits corrections where the original, erroneous record is preserved, and the correction has a pointer to the original. researchers should 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selection decision fresh leafy greens new walmart food traceability initiative questions and answers food-borne illnesses cost us$ billion per year in low-and middleincome countries example use cases assessing supermarket food shopper reaction to horsemeat scandal in the uk a new era of food transparency powered by blockchain knowing about your food from the farm to the table: using information systems that reduce information asymmetry and health risks in retail contexts current status and future development proposal for chinese agricultural product quality and safety traceability food supply chain management: systems, implementations, and future research the authors are thankful to dr. steven j. simske, dr. subhasis thakur, and irene woerner for their thoughtful commentary on this chapter. abderahman rejeb, coauthor and ph.d. candidate, is grateful to professor lászló imre komlósi, dr. katalin czakó, and ms. tihana vasic for their valuable support. conflict of interests • no funding was received for this publication. • john g. keogh, the corresponding author, is a former executive at gs canada and has not advised or worked with or for gs for more than years. • kevin dean is an independent technical consultant advising gs . key: cord- -qc cps authors: gómez-mascaraque, laura g.; fabra, maria j.; castro-mayorga, jinneth l.; sánchez, gloria; martínez-sanz, marta; lópez-rubio, amparo title: nanostructuring biopolymers for improved food quality and safety date: - - journal: biopolymers for food design doi: . /b - - - - . - sha: doc_id: cord_uid: qc cps food-grade biopolymers, apart from their inherent nutritional properties, can be tailored designed for improving food quality and safety, either serving as delivery vehicles for bioactive molecules, or as novel packaging components, not only improving the transport properties of biobased packaging structures, but also imparting active antibacterial and antiviral properties. in this chapter, the potential of different food-grade biopolymers (mainly proteins and carbohydrates but also some biopolyesters) to serve as encapsulating matrices for the protection of sensitive bioactives or as nanostructured packaging layers to improve transport properties and control the growth of pathogenic bacteria and viruses are described based on some developments carried out by the authors, as well as the most prominent works found in literature in this area. molecular chains (santiago and castro, ) . fig. . shows the chemical structure of several polysaccharides that have been widely explored as encapsulation matrices. other commonly used carbohydrates, such as pectins or some gums are a heterogeneous group of polymers and thus its chemical structure has not been represented. another interesting feature of polysaccharides is the great stability of their structure, even under harsh temperature conditions, in contrast with proteins, which can be denatured during material processing at high temperatures. furthermore, a number of polysaccharides are considered dietary fibers, being resistant to enzymatic degradation during oral, gastric, and small intestine digestion but vulnerable to microbial fermentation in the colon (fathi et al., ) . most of the commonly used polysaccharides for encapsulation have a plant origin, such as starch, pectin, cellulose, alginate, or guar gum, but animal-derived polysaccharides, such as chitosan or those from bacterial origin, such as dextran are also widespread for this application. an exhaustive review highlighting the advantages and disadvantages of each of them as delivery vehicles in food systems has been recently published (fathi et al., ) . food proteins are excellent candidates as microencapsulation matrices because, in addition to the protective effects they might exert on the bioactive ingredients, they have a high nutritional value and generally exhibit functional properties themselves (ma et al., ) , being considered the most nutritionally beneficial delivery systems (mohan et al., ) . moreover, as livney ( ) points out, some proteins are natural vehicles whose main function is to store, transport, and/or deliver essential compounds throughout the organism and, thus, they could also be exploited to deliver other molecules of interest. especially taking into account that proteins are capable of binding both hydrophobic and hydrophilic small molecules (considine and flanagan, ) , and they have self-assembling properties, surface activity, and good gelation characteristics (livney, ) . in general, proteins from animal origin, especially dairy proteins, but also gelatin and egg proteins, are more commonly employed than plant proteins for encapsulation purposes (karaca et al., ) . some of the advantages of milk proteins over plant proteins include their higher solubility over a broader range of ph, their lower molecular weight, and their greater flexibility. on the other hand, plant proteins have a better acceptance from some groups of consumers and are generally less expensive (karaca et al., ) . the most widely used milk proteins are caseins and whey proteins, and their application as encapsulation vehicles has been recently reviewed by tavares et al., ( ) . regarding plant proteins, soy proteins are the predominant choice as wall materials, being those obtained from pulses (such as pea, lentil, or chickpea) and cereal grains (for instance zein or barley protein) the most relevant alternatives (karaca et al., ) . table . shows some examples of food ingredients that have been encapsulated using proteins. α-linolenic acid (gómez-mascaraque and lopez-rubio, ), lycopene (pérez-masiá et al., ) , cardamom essential oil (mehyar et al., ) , folic acid (pérez-masiá et al., ) , probiotics (gomez-mascaraque et al., ; lopez-rubio et al., ) caseins animal (milk) garden cress seed oil (umesha et al., ) , w- fatty acids (santhanam et al., ) , curcumin (pan et al., ) , indonesian propolis (sahlan and supardi, ) gelatin animal green tea polyphenols (gómez-mascaraque et al., , holy basil essential oil (sutaphanit and chitprasert, ) , sunflower oil (piacentini et al., ) soy proteins vegetal polyphenols and anthocyanins from pomegranate (robert et al., ) , w- fatty acids (santhanam et al., ; gómez-mascaraque and lopez-rubio, ) pea proteins vegetal conjugated linoleic acid (costa et al., ) , α-tocopherol (pierucci et al., ) , oils (gharsallaoui et al., ) chickpea proteins vegetal flaxseed oil (karaca et al., ) , folate (ariyarathna and nedra karunaratne, ) , probiotics lentil proteins vegetal flaxseed oil (karaca et al., ) , probiotics (wang et al., ) zein vegetal fish oil (moomand and lim, ) , green tea polyphenols as inferred from the previous discussion, both proteins and polysaccharides are generally good candidates for the encapsulation of bioactive ingredients. however, there is no consensus in the literature regarding the best choice among them. indeed, each particular compound to be protected has unique characteristics and distinct physical-chemical behavior, and thus the choice of an optimal matrix for encapsulation should be done taking into account the properties of both components. bearing in mind that the choice of wall material will have an impact not only on the encapsulation efficiency and protection of the bioactive ingredient of interest, but also in its release behavior (dias et al., ) , the selection of the most adequate encapsulation matrix is of outmost importance in the development of microencapsulation structures. therefore, the purpose of the following sections is to offer a nonexhaustive summary of some relevant findings regarding the selection of carbohydrate or protein matrices for some of the most relevant groups of bioactive ingredients. natural polyphenols are a group of bioactive molecules that attract a great deal of interest in the food industry due to their great antioxidant activity and their many attributed health benefits. however, these compounds are very unstable and some of them have poor bioavailability and unpleasant tastes (munin and edwards-lévy, ) . thus, many scientific works have dealt with microencapsulation of polyphenols to overcome these limitations, using different matrices and processing techniques (fang and bhandari, ) . robert et al., ( ) reported that the encapsulation efficiency for polyphenols extracted from pomegranate was higher when a soy protein isolate (spi) rather than a maltodextrin (md) was used as wall material, while the md matrix provided greater protection during storage at high temperature ( °c). higher encapsulation efficiencies and enhanced protection for (-)-epigallocatechin gallate (egcg, a green tea polyphenol) were also obtained when encapsulated in a protein matrix, namely gelatin, than when entrapped within the carbohydrate chitosan, both by spray-drying (gómez-mascaraque et al., b) and electrospraying (gómez-mascaraque et al., . similar encapsulation efficiencies as those obtained for chitosan (∼ %) had been previously obtained when egcg was encapsulated within other carbohydrate-based matrices . the better results obtained when polyphenols were encapsulated within protein matrices in these works might be related to the fact that these compounds generally exhibit complexing properties toward proteins (munin and edwards-lévy, ) . furthermore, the bioaccessibility of egcg after in vitro digestion was reported to be higher when gelatin was used as delivery vehicle as compared to the chitosan carriers (gómez-mascaraque et al., a,b). attempts have been made to determine which encapsulation matrices (or blends thereof) are suitable for lipid encapsulation. for instance, matsuno and adachi ( ) proposed a method that is based on the determination of the drying rate of the emulsions to measure the ability of the wall material to form a dense protective network during spray-drying. however, this method does not take into account the chemical nature of the wall materials, not being able to distinguish between materials with similar drying curves (pérez-alonso et al., ) . given that many protein and carbohydrate matrices are water soluble or water dispersible, and taking into account that processing in food-grade conditions (i.e., avoiding organic solvents) is imperative in the food industry, the encapsulation of bioactive oils and other lipophilic molecules usually involves the preparation of oil-in-water (o/w) emulsions prior to capsule formation. thus, the ideal wall material for oil encapsulation should have good emulsifying properties (jafari et al., ) . in this sense, the amphiphilic nature of proteins is advantageous as they behave as good emulsifiers (mcclements, ) , allowing improved encapsulation efficiencies and oxidative stabilities (karaca et al., ) . for this reason, proteins have been the preferred matrices for the encapsulation of polyunsaturated fatty acids (gómez-mascaraque et al., a,b; moomand and lim, ; perez et al., ) and essential oils (abd el-salam and el-shibiny, ; baranauskienė et al., ; sutaphanit and chitprasert, ) in many works. in general, carbohydrates have low surface activity (barrow et al., ) and usually yield poor retention efficiencies (jafari et al., ) , although modification of some polysaccharides has also been proposed to overcome this limitation (tesch et al., ; trubiano and lacourse, ) . also, some gums, such as gum arabic, contain small protein fractions that provide them with emulsifying properties (gharsallaoui et al., ) . still, the suitability of some polysaccharides as encapsulation matrices for sensitive oils has been questioned. for instance, kolanowski et al. ( ) reported that encapsulation of fish oil within modified cellulose by spray-drying did not improve its oxidative stability. in another work, gallardo et al. ( ) claimed that microencapsulation of linseed oil within spray-dried gum arabic did increase its thermal stability, but a great loss of α-linolenic acid was observed upon fortification of bread with these capsules, suggesting limited application of the polysaccharidebased formulation in real food systems. on the other hand, addition of a whey protein isolate to the wall material further improved the thermal stability of the encapsulated oil. more recently, santhanam et al. ( ) encapsulated fish oil within sodium caseinate, md, and soy protein and supplemented cakes with the capsules. their results showed that, among the different matrices, the milk protein was the matrix that yielded the best oxidative stability, which also demonstrated desirable organoleptic characteristics. indeed, milk proteins are usually smaller and more flexible than vegetal proteins, being more efficiently absorbed at the w/o interface and hence better stabilizing the emulsions (karaca et al., ) . umesha et al. ( ) also proved that milk proteins (specifically sodium caseinate and whey protein concentrate) achieved higher encapsulation efficiencies and provided enhanced oxidative stability to cress seed oil as compared to a carbohydrate-based matrix (blend of md and gum arabic). conversely, al-ismail et al. ( ) concluded that gum arabic yielded better encapsulation efficiency and oil retention during storage than whey protein isolate for a cardamom essential oil. in summary, although controversy exists among different works, proteins seem to generally yield better results than polysaccharides as wall materials for the encapsulation of oils, which can be explained in light of their excellent emulsifying properties, forming a protective film at the o/w interface. carotenoids are a group of natural pigments with many attributed health benefits when consumed in sufficient levels, some of which also exhibit provitamin a activity (qian et al., ) . together with polyphenols, carotenoids are the most abundant phytochemicals (kaulmann et al., ) . however, they have a very low water solubility and poor chemical stability, resulting in low bioaccessibility upon consumption. dissolution of carotenoids in edible oils has shown to increase absorption in vitro and in vivo (ribeiro et al., ) , and thus o/w emulsions are often prepared before capsule production as a suitable strategy to both increase their bioaccessibility and disperse them in aqueous biopolymer solutions or dispersions. therefore, some of the previous discussion regarding the encapsulation of bioactive oils could be applied to carotenoids. in this sense, pérez-masiá et al. ( ) showed that higher encapsulation efficiencies were obtained when lycopene (previously dissolved in a soy bean oil) was microencapsulated using a whey protein matrix as compared to carbohydrate-based matrices, such as dextran or chitosan. robert et al. ( ) also obtained higher encapsulation efficiencies for the main carotenoid pigments present in an oleoresin from rosa mosqueta upon spray-drying within gelatin capsules than using starch as wall material. furthermore, gelatin provided a greater protective effect on the main carotenoids, especially on trans-β-carotene, than starch. however, information on the bioavailability of these microencapsulated carotenoids during in vitro digestion is scarce (donhowe and kong, ) . being the bioaccessibility of carotenoids one of their main limitations to exert their bioactivities, this feature should be carefully addressed when selecting a wall material for encapsulation. for instance, alginate has been proposed as a desirable encapsulation matrix for its ability to protect carotenoids from the acidic conditions during gastric digestion, and indeed, zhang et al. ( ) have recently shown that it effectively protected β-carotene from degradation during digestion. however, the encapsulation within alginate beads caused a reduction in β-carotene bioaccessibility due to insufficient release. the bioaccessibility of carotenoids relays on their incorporation into mixed micelles (fernández-garcía et al., ; qian et al., ) , and research suggests that some polysaccharides, such as alginates or pectins, significantly inhibit micelle formation; and hence carotenoids absorption (riedl et al., ; yonekura and nagao, ). on the other hand, soluble proteins have also been shown to impede incorporation of carotenoids into the oil phase of the gastric emulsion (rich et al., ) , although this limitation might be overcome if carotenoids are previously incorporated in o/w emulsions prior to their encapsulation within protein capsules. probiotics are a particular group of bioactive ingredients. they are defined as "live microorganisms which, when consumed in adequate amounts, confer a health benefit to the host" (pineiro and stanton, ) , so they must be alive and metabolically active at the time of consumption. however, a number of studies report low levels of viable probiotic cells in commercial products (al-otaibi, ; lin et al., ; shah et al., ; weese, ) , emphasizing the need for their microencapsulation. the choice of potential matrices for this group of ingredients is more restricted, as the processing conditions must be adequate to warranty their survival. moreover, to adequately protect the cells from the acidic environment of the stomach and efficiently deliver them to the intestine, the ideal matrix for their encapsulation should be stable at low phs and disrupt at phs above ( gbassi and vandamme, ) . for these reasons, one of the preferred matrices for the encapsulation of probiotic bacteria is alginate (dong et al., ) . other anionic polysaccharides with gelling capacity, such as carrageenans have also been used, although their processing at mild temperatures is problematic (mangione et al., ; yuguchi et al., ) . proteins, especially milk proteins, are relevant alternatives to alginate for the microencapsulation of probiotics (el-salam and el-shibiny, ). rodrigues et al. ( ) assessed the viability of probiotic bacteria when immobilized in different food-grade polymers and found that whey proteins, together with alginate, were the most adequate materials for most of the strains they tested. nevertheless, the results were strain-dependent, emphasizing the need for designing the encapsulation system for each specific bioactive ingredient. lopez-rubio et al. ( ) also observed that a whey protein concentrate (wpc) exerted enhanced protection to bifidobacterium animalis subsp. lactis bb during storage at high relative humidity as compared with a polysaccharide, namely pullulan, both processed by electrospraying. electrosprayed wpc-based capsules were also used to protect a strain of lactobacillus plantarum (cect t), which experienced a reduced viability loss during in vitro digestion (∼ log cfu g − ) (gomez-mascaraque et al., ) . in contrast, alginateencapsulated l. plantarum (strain ufrgs bl ) suffered a viability loss of almost log cfu ml − when exposed to simulated gastric juice, and an additional drop of log cfu ml − when exposed to simulated intestinal juice (coghetto et al., ) . however, these results are not directly comparable, since the protected l. plantarum strain is different and the protocols employed for simulation of gastrointestinal conditions also differ. it is worth noting that alginate microcapsules have already been successfully incorporated into real food matrices, such as ice creams, frozen yogurts, and mayonnaise (corona-hernandez et al., ) . the microencapsulation of probiotics has been specifically examined in a number of recent review articles (de prisco and mauriello, ; el-salam and el-shibiny, ; iravani et al., ) . as discussed, both polysaccharides and proteins have advantages and limitations as encapsulating agents. therefore, combinations of them have also been studied as wall materials with the aim of improving the attributes of the individual biopolymers (bastos et al., ; fernandes et al., ; smilkov et al., ) . for instance, addition of proteins to mds, which are considered to be one of the best thermal defenders (munin and edwards-lévy, ) for microencapsulation by spray-drying, allows it to increase the powder recovery of the materials (muzaffar and kumar, ; shi et al., ) , while incorporation of dextrins to proteins as encapsulant material for fish oil increased its oxidative stability (kagami et al., ) . aberkane et al. ( ) observed that the combination of pectin with pea protein for the microencapsulation of pufa-rich oil enhanced its oxidative stability as compared with the pea protein alone. however, protein-polysaccharide combinations do not always perform better than the individual components. mehyar et al. ( ) obtained better overall results by encapsulation of cardamom oil within a spithan using mixtures of the protein with either guar gum or carrageenan. also, complexation of proteins with polysaccharides (benichou et al., ) represents a widely used strategy for the encapsulation of bioactive ingredients (gutiérrez et al., ; jain et al., ; nori et al., ; piacentini et al., ) , being coacervation the second most exploited encapsulation technique in the food industry (dias et al., ) . furthermore, proteins and carbohydrates can be conjugated by dry heating through the maillard reaction (martins et al., ) , and these conjugates have also been recently applied to the encapsulation of food ingredients. davidov pardo et al. ( ) developed caseinate-dextran coated zein nanoparticles and used them to encapsulate resveratrol, enhancing its bioaccessibility. coating the nanoparticles with these maillard complexes resulted in a greater stability to aggregation under simulated gastrointestinal conditions as compared to those coated with plain caseinate. ifeduba and akoh ( ) used the maillard reaction to crosslink gelatin-gum arabic coacervates to improve the oxidative stability stearidonic acid soybean oil. in addition, maillard reaction products have been described to exhibit antioxidant properties, but the last stages of the reaction can lead to undesirable color and aromas, and even to toxic compounds in certain cases (tessier and niquet, ) , facts that should be considered when designing this type of carriers. evaluating the release and stability of encapsulation systems is crucial to assess their efficiency and to optimize the developed structures in terms of achieving the desired release rates when subjected to particular conditions. several factors, such as the composition and chemical structure of the encapsulating material (also referred to as "matrix") and the encapsulated bioactive compound, the interactions established between the bioactive and matrix materials and the morphology of the encapsulating system (size distribution, shape, surface area, porosity, etc.) have a strong impact on the stability of the encapsulating systems and, therefore, they should be taken into account when designing a system for a particular application. moreover, understanding the mechanisms controlling the release of the encapsulated compound from the matrix when subjected to specific conditions (relative humidity, ph of the medium, temperature, etc.) is essential to maximize the material performance for its intended application. a wide range of techniques is currently available to investigate the properties and release mechanism in different encapsulating systems. the selection of the characterization methods for a particular encapsulating structure has to be made on the basis of the system composition, release rate and medium. in general, a combination of several techniques, covering from the molecular to the microscale structural levels, is the most efficient approach to thoroughly study the system. the following sections provide a brief overview of the main tools available to characterize encapsulating materials, with special emphasis on the potential of small angle scattering techniques to provide valuable structural information and to exhaustively investigate the release mechanisms under a wide range of conditions. imaging techniques based on microscopy instruments are one of the most widely used methods to characterize the structure of encapsulating systems. they may provide qualitative information on the shape, size, and aggregation state of the materials under study. electron, optical, and laser microscopy methods may be selected depending on the composition of the matrix and the size range of the generated materials. although optical microscopy is the most easily accessible and low-cost imaging technique, its main drawback is its relatively low resolution, which is limited by the diffraction of light to about diameters magnification (luykx et al., ) . as an alternative, electron microscopes offer much higher magnifications, which enable the characterization of particles with size ranges from tenths of nm to tenths of µm. among the electron microscopy techniques, transmission electron (tem) and scanning electron microscopy (sem) are the most widely used ones. tem is a technique that is based on the transmission of a beam of electrons through an ultrathin sample. the major limitation from this technique lays in the tedious sample preparation that is often required. first of all, the samples have to be thin enough to be electron transparent and must be dry to be subjected to the high vacuum present inside the instrument. additionally, negative staining is often required to increase the contrast between the sample and the background. this involves placing a small amount of the sample on a tem grid and staining with a solution (such as uranyl acetate), which provides high contrast. to obtain information about the particle internal structure, the sample can be subjected to the freezefracture technique. in this case, the sample is placed on the tem grid, which is then vitrified by rapid freezing and subsequently fractured under constant cooling and vacuum. it is evident that these preparation procedures are likely to have a strong impact on the structure of the sample, especially in the case of biological samples and moisture sensitive materials. sem presents lower resolution than tem, but it has a greater depth of view (thus providing more information on the particle surface structure) and the sample preparation is usually less complex. this technique is based on scanning a beam of electrons across the surface of the sample, providing information on the sample surface topography and composition. sem requires high vacuum and sample conductivity, which is again translated into possible structural modifications induced by the drying and coating processes applied to the sample specimens. as an alternative, atomic force microscopy (afm) is a more recent technique in which a physical sharp probe is scanned over a specimen that has been previously immobilized onto a surface. the surface topography of the sample is resolved by determining the reaction of the probe to the forces that the sample imposes on it when scanned. one of the main advantages of afm, apart from its high resolution (ca. . nm) is the fact that, unlike sem, the samples do not need to present a conductive surface. this type of microscopy is, however, not suitable for surfaces that are soft or sticky. in those cases, the sample may need to be dried prior to the analysis. although microscopy techniques are routinely used to characterize the structure of encapsulating systems, the results have to be carefully interpreted and any possible structural alterations induced by sample preparations have to be taken into account. therefore, although microscopy methods may be useful, they should be preferably combined with complementary techniques to ascertain the morphology of the encapsulated system in its native state. chromatography methods can be routinely used to separate the components in encapsulating systems, that is, the matrix and the encapsulated compound and, subsequently, quantify the amount of the active compound to, for instance, evaluate the encapsulation efficiency. the separation of different constituents in a sample is done on the basis of the different speeds at which distinct compounds travel through a structure (usually a column) containing a specific material (known as stationary phase) when dissolved in a certain fluid (known as mobile phase). the final step after separating the components in the sample consists in the quantification of each component by using a suitable detector, such as an ultraviolet-visible (uv-vis) light absorbance detector, a fluorescence detector, or a diffractometer. the advantage of chromatographic techniques is that they offer a range of possibilities (mobile and stationary phases, type of separation technique, detector type) that can be adjusted depending on the particular composition and properties of the encapsulated system. depending on the physical state of the mobile phase, we can differentiate gaschromatography (cg) and liquid chromatography (lc) techniques. in particular, highperformance liquid chromatography (hplc) is a widely used technique in the food analysis field. in this particular case, the sample has to be dissolved in a liquid, which is then pressurized and injected into a column containing a stationary phase. depending on the type of stationary phase, the mechanism for the separation of compounds in the sample will be different, giving rise to a range of chromatographic separation methods. for instance, the separation may occur on the basis of the molecular mass of the different compounds [size exclusion chromatography (sec) or gel permeation chromatography (gpc)] or the charge (cation or anion exchange chromatography). in addition to hplc, gc coupled with mass spectrometry (gc-ms) is also one of the most widely used techniques to separate and quantify compounds that can be vaporized without affecting their molecular structure. in this case, after the compounds in the sample travel through the chromatographic column and are released (with different retention times), the coupled mass spectrometer breaks down the molecular structure of each component into ionized fragments, separates the ions of differing masses, and determines their relative abundance by measuring the intensity of the ion flux. some examples of applications of chromatographic techniques include the encapsulation efficiency assessment of gallic acid/cyclodextrin complexes incorporated into electrospun polylactic acid (pla) nanofibers (aytac et al., ) or resveratrol encapsulated in chitosan-sodium tripolyphosphate microspheres (cho et al., ) by using hplc coupled with a uv detector, or the use of gc-ms to evaluate the release of essential oils, such thyme essential oil in β-cyclodextrin capsules (del toro-sánchez et al., ) . although these techniques are useful to determine the encapsulation efficiency of a certain system, they do not provide information on the structure of the system, the interactions established between the matrix, and the encapsulated compound or the release mechanismtaking place under specific conditions. a wide range of techniques can be utilized to investigate the structural changes and the mechanisms controlling the release and stability of encapsulated systems. among the most commonly used methods, spectroscopy and scattering techniques are particularly interesting to study structural changes taking place at the molecular and nano-/microstructural levels. in particular, scattering techniques present an enormous potential, although, to date, their application within this research field is still very limited. this is mainly due to the unfamiliarity of many researchers within the food science field and unawareness of the valuable information that can be extracted from these techniques. however, several works have already demonstrated the great advantages of combining small angle scattering techniques with traditional methods to provide unique insights into the characterization of food systems (blazek and gilbert, ; lopez-rubio and gilbert, ). spectroscopy methods rely in the study of interactions established between a source of radiation (most commonly electromagnetic radiation) and the particles composing a sample and, subsequently, measuring changes in the intensity or frequency of the radiation energy. in particular, nuclear magnetic resonance spectroscopy (nmr) and fourier transform infrared spectroscopy (ft-ir) are widely used to characterize the molecular structure and molecular interactions between the components in encapsulating systems. nmr is based on the measurement of the electromagnetic radiation, which is absorbed by an active nucleus, such as h or c, at a certain frequency. the absorption of an atomic nucleus is conditioned by the surrounding atoms and, thus, detailed information on the molecular structure of a certain compound can be obtained. this technique can be applied to any kind of sample, in the solid or solution state, which contains nuclei possessing spin. in the particular case of encapsulating systems, h-nmr and c-nmr techniques have been used to prove the formation of stabilizing inclusion complexes between β-cyclodextrins and essential oils (del toro-sánchez et al., ; rǎileanu et al., ) or to determine the molecular state of curcuminoids encapsulated in poly(butyl) cyanoacrylate nanoparticles (mulik et al., ) . another interesting fact is that this technique is sensitive to dynamics, that is, it is possible to discern molecular domains with distinct mobility. this can be exploited to determine the level of molecular interaction established between different components in encapsulating materials. for instance, the level of interaction between silica matrices and encapsulated ibuprofen molecules has been estimated based on the ibuprofen molecular mobility deduced from c and h spectra (babonneau et al., ) . in addition, relaxation experiments, that is, measuring how the signal changes with time, have been applied to study the water-polymer interactions in whey protein/alginate beads containing riboflavin (wichchukit et al., ) . the ft-ir technique, as any other absorption spectroscopy technique, consists on measuring the amount of light absorbed by a sample at different wavelengths. the peculiarity of ft-ir is that instead of using a monochromatic beam of light, the sample is radiated by a beam composed of many wavelengths at once and data are subsequently processed to determine the absorption taking place at each measured wavelength. ft-ir can be utilized to confirm the encapsulation of the active compound into the matrix by identifying characteristic absorption bands. for instance, ft-ir has been used to determine the presence of vitamin b and vitamin c encapsulated into different biopolymers by spray-drying (estevinho et al., ) , tea tree oil in sodium alginate/chitosan capsules (chen et al., ) , xylitol in multicomponent microcapsules obtained by complex coacervation (santos et al., ) , and resveratrol in chitosan-sodium tripolyphosphate microspheres (cho et al., ) . scattering techniques are based on the analysis of the scattered radiation produced after a source, such as light, x-rays, and neutrons, interacts with the particles present in a sample. they represent a powerful tool to obtain information about the size, shape, and orientation of components in ordered (long-range or crystalline order), but also disordered systems. in practice, the radiation scattered by the sample of interest is typically measured on a two-dimensional detector; for isotropic scatterers, after being radially averaged, the intensity is plotted versus the magnitude of the scattering vector q, which describes the relationship between the incident and the scattered wave vectors, being defined as: where θ is half the angle through which the radiation is scattered and λ is the wavelength of the incident radiation. combining eq. ( . ) with bragg's law (λ = d sin θ), one can determine the real-space dimension of the scattering object, through the relationship: according to this, scattering methods are classified into wide angle and small angle scattering techniques depending on the range of scattering angles (and corresponding length scales) covered. therefore, whereas wide-angle scattering techniques are used to probe subnanometer dimensions, small angle scattering techniques, are able to cover a size range from nm to several hundreds of nanometers. coupling small angle with ultrasmall angle scattering techniques it is possible to study larger structures, hence extending the size range up to ca. µm. it is important to select the proper source of radiation based on the sample composition and structural features to be probed. while x-rays are scattered by the electrons, being saxs sensitive to variations in electron density, neutrons are scattered by the atomic nuclei and, thus, sans depends on the nuclear structure of the atom. as a result, whereas x-ray scattering intensity is a function of the atomic number of the scattering elements, in the case of neutron scattering, different isotopes of an element may present significantly different scattering intensity. conversely, light is scattered by fluctuations in the dielectric constant of a material. it is worth noting that, because the wavelength of visible light is in the order of hundreds of nanometers, light scattering techniques typically probe larger structural features than x-ray and neutron scattering techniques (i.e., low q values are covered in light scattering experiments). light scattering techniques are widely used for the characterization of colloidal suspensions, such as those typically found in food systems. static light scattering (slc), also known as laser light scattering (lsc), measures particle size based on light scattering intensity, which changes with variation in scattering angle, size of particles, refractive indices of particles, and the medium. slc measures the average intensity of scattered light arriving at the detector, although actually, the intensity shows fluctuations over short time scales. moreover, in the case of solutions, the brownian motion of particles causes fluctuations in the intensity of the scattered light arriving at the detector. dynamic light scattering (dls) is based on the measurements of these fluctuations as a function of time. by analyzing these fluctuations through correlation functions, it is possible to extract information regarding the particle size. dls is commonly used to characterize the particle size of encapsulating systems based on microemulsions (flanagan et al., ; gaysinsky et al., ; yin et al., ; zhong et al., ; ziani et al., ) . the main issue of slc and dls methods is that highly diluted samples are often required to avoid multiple scattering (i.e., the photons are scattered more than once between the light source and the detector). in addition, to ensure a proper data interpretation, the particles should present a narrow size distribution and they must present the same refractive index (which is not true in the case of multicomponent systems). the issue of multiple scattering is often avoided when using x-rays and neutrons, because these radiation sources do not scatter as strongly as light. hence, these techniques are more suitable for the characterization of a wide range of food-based encapsulating systems. the most widely used techniques, classified on the basis of the source of radiation and the covered size ranges, are designed as wide angle and small angle x-ray scattering (waxs and saxs) and small angle neutron scattering (sans). it should be mentioned that waxs is often regarded as identical to the x-ray diffraction technique (xrd), which is not completely true. while waxs is conducted in the transmission geometry, xrd may be performed in the reflection or in the transmission geometry. xrd is the most commonly used method to characterize the crystalline structure in materials presenting long-range order. in addition to the previously mentioned techniques, ultrasmall angle scattering techniques (usaxs and usans) can be utilized to probe larger structural features. fig. . shows the relevant size ranges covered by these techniques and complementary methods, as related to the different structural features found in typical encapsulating systems. the suitability of saxs or sans to characterize a particular encapsulating system depends on the scattering length density (sld) contrast between the sample and the surrounding element materials or between different sample components (i.e., the difference in the scattering intensity of the molecules in the different components). the radiation source should be thus chosen to enhance the sld contrast between the sample components. specifically for sans, the scattering length difference existing between hydrogen (− . × cm - ) and its heavier isotope, deuterium ( . × cm - ), is the basis of the contrast variation method. this is an extraordinary valuable approach used to enhance the sld of hydrogencontaining samples or to selectively match desired components in a multicomponent system by using different h o/d o mixtures. apart from the nondestructive nature of small angle scattering techniques, they have further advantages, such as enabling the study of representative samples with relatively larger volumes as compared to methods, such as tem, in which small sample areas of the order of hundreds of square microns are analyzed. on the contrary, the main drawback of small angle scattering techniques is that they are indirect methods and mathematical models have to be applied to describe the experimental scattering curves. these models require prior knowledge of the system to be built and, therefore, it is of outmost importance to combine small angle scattering techniques with complementary methods, such as microscopy and spectroscopy techniques. a multitechnique approach is the most successful path to obtain detailed knowledge of the sample properties based on realistic physical-chemical parameters (martínez-sanz et al., , . as previously mentioned, the potential of saxs and sans techniques for the characterization of encapsulating systems has not been fully exploited and very few studies, which are relatively recent, report on the use of these techniques within this particular research field. nevertheless, the existing works highlight the adequacy to investigate the release mechanisms and stability of encapsulating materials. as an example, some of the most relevant works are summarized later. gerelli et al. ( ) reported on the structural characterization of soybean lecithin/chitosan nanoparticles loaded with a lipophilic positively charged drug used in breast cancer therapy by combining cryo-tem, static light scattering, and saxs and sans techniques. by applying proper models to describe the experimental scattering data, it was possible to determine the structure of the encapsulating vesicles, as well as the interactions established lopez-rubio, a., gilbert, e.p., . neutron scattering: a natural tool for food science and technology research. trends food sci. technol. ( - ), - ; martínez-sanz, m., gidley, m.j., gilbert, e.p., . application of x-ray and neutron small angle scattering techniques to study the hierarchical structure of plant cell walls: a review. carbohydr. polym. , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] between the matrix and the encapsulated drug. the unilamellar structure of liposomes loaded with antibiotics has also been investigated by means of saxs characterization (colzi et al., ) . the internal structure of poly(lactide-co-glucolide)-block-poly(ethylene glycol) (plga-peg) nanoparticles, commonly used as drug carrier systems, was resolved by finding a proper model (consisting of fractal structures with polydisperse spherical building blocks) to simultaneously fit the sans experimental data from the nanoparticles dispersed in two different h o/d o mixtures (yang et al., ) . this allowed identifying the release mechanism of a hydrophilic anticancer drug, such as carboplatin, when incorporated into the plga-peg nanoparticles. the distinct sld contrast generated when using neutrons and x-rays was exploited to characterize microemulsions embedded in alginate hydrogels (josef et al., ) . whereas x-rays provided a low sld contrast between the microemulsion and the alginate gel (thus probing the structure of the whole system), the use of neutrons enhanced the sld contrast between the two phases, hence highlighting the structure of the microemulsion droplets embedded within the gel. in another study, fractal analysis and evaluation of the particle distance distribution function from saxs experiments evidenced the structural changes undergone by bovine serum albumin when combined with chitosan and poly(sodium- -styrene) sulphonate to produce core-shell nanoparticles loaded with ibuprofen for controlled release of the drug (varga et al., ) . liu et al. ( ) investigated the release of an enzyme encapsulated in freeze-dried chitosan/xanthan gum hydrogels and observed that the release was triggered by lowering the ph of the medium. on the other hand, the addition of montmorillonite (mmt) nanoclay into the hydrogels was seen to stabilize the system, lowering the enzyme release rate. the use of waxs and saxs was crucial to explaining the stabilizing effect of mmt. although waxs evidenced that a high degree of mmt intercalation within the chitosan/xanthan gum blend was achieved, saxs showed that the incorporation of mmt reduced the structural changes undergone by the hydrogels when the ph of the medium was modified. the encapsulation of a vitamin into spray-dried protein-stabilized emulsions was evaluated and the vitamin stability was linked to structural changes by combining light scattering and differential scanning calorimetry with saxs characterization (relkin et al., ) . the formation of lamellar structures as a result of the packing of the fatty phase, evidenced by the presence of a bragg peak in the saxs patterns, was seen to reduce the vitamin degradation. due to the severe environmental pollution caused by plastic food packaging, there has been a growing amount of interest in the production of biodegradable films, which, at least, partially replace nonrenewable conventional petroleum-based packaging materials (faruk et al., ; jiménez et al., ) . among the most widely researched biodegradable thermoplastics, sustainable biopolymers for monolayer packaging applications are starch, polyhydroxyalkanoates (pha), and pla. specifically, starch and pla biopolymers are, undoubtedly, the most interesting families of biodegradable materials, as they have become commercially available, being produced in a large industrial scale. of particular interest in food packaging is the case of pla due to its excellent transparency and relatively good water resistance. however, as already commented, the main challenge for these specific biomaterials is to improve their properties so that they perform (in terms of barrier and thermal properties) like polyethylene terephthalate (pet). biopolymer materials extracted from biomass resources, such as proteins (e.g., zein, wheat gluten), polysaccharides (e.g., starch, chitosan), and lipids (e.g., waxes) have excellent potential as gas and aroma barriers in dry state but they have very strong water sensitivity arising from their hydrophilic nature, which leads to a strong plasticization and the subsequent deterioration of film properties as relative humidity and water sorption in the material increase. in general, one of the main disadvantages of these biopolymers is that they are permeable, in more or less extent, to low molecular weight compounds (i.e., water vapor, oxygen, and aroma compounds), which can compromise packaged food quality and safety. in the particular case of starch, although native starch is not an inherently thermoplastic material, it can be processed like conventional polymers, giving raise to what is known as thermoplastic starch (tps), after some specific processing steps. however, tps shows several drawbacks that reduce their applicability as packaging material, such as their highly hydrophilic character, limited mechanical properties, and the retrogradation phenomenon that occurs during ageing (jiménez et al., ) . to avoid this problem, several studies have been focused on the optimization of the physicochemical properties of packages and the minimization of food-package interactions, such as gas or aroma migration, by developing nanocomposites and multilayer food packaging structures. one of the most used approaches to improve the performance of packaging materials is the use of blends (e.g., plasticizers, other biopolymers) or the addition of nanomaterials (e.g., nanoclays) to achieve the desired properties (bordes et al., ) . however, it is well known that the most efficient structure to constitute high barrier materials using two element components is for them to be disposed in a layered form (fabra et al., ) . this methodology has been widely used in synthetic polymers but it has been barely developed in biodegradable food packaging systems because it is difficult to assemble materials thermodynamically immiscible without the addition of synthetic adhesives. in fact, one of the main challenges in the development of multilayer biobased and biodegradable films is to achieve good adhesion between layers. interestingly, both electrospinning and layerby-layer (lbl) assembly can at the same time be used to enhance physicochemical and barrier properties of packaging materials and for the entrapment of functional compounds to develop active packaging structures (fabra et al., (fabra et al., , (fabra et al., , d . in this regard, fabra et al. ( a fabra et al. ( ,b, have successfully developed hydrophobic coatings or interlayers with bioadhesive properties to improve the barrier and functional performance of biodegradable polymers combining biomass-derived nanocomposites and the electrospinning process. fig. . shows an example of the microstructure reached in multilayer films obtained with pla (outer layer) and electrospun zein interlayer. recently, it has been reported that electrospun zein interlayers have the potential to generate multilayered biopolymeric structures with improved barrier properties in pla (busolo et al., ) and pha-based films (fabra et al., (fabra et al., , a with minimum changes in the optical properties, which could be ascribed to the light scattering generated by the arrangement of the biopolymeric components distributed throughout the inner layer. specifically, fabra et al. ( b) demonstrated that biopolyester-based multilayers prepared with the electrospun zein interlayers significantly improved oxygen permeability values (up to %) of pla and pha biopolymers, although the water vapor barrier properties depended on the biopolymer used as outer layers. as opposed to the pha's materials performance, pla did not improve the water vapor permeability values of these films. however, not only the nature of the outer layers but also the morphology, thickness, and the inherent barrier of the electrospun interlayer materials determine the oxygen and water vapor barrier properties of the overall multilayer. for instance, fabra et al. ( a) reported that fibrillar structures obtained for zein and pullulan electrospun interlayers significantly contributed to improve barrier performance of biopolyester-based multilayer systems whereas bead microstructures obtained by electrospraying a whey protein isolate did not have an impact on it. the methodology already described has also been proven to avoid the moisture uptake of hydrophilic-based thermoplastic materials (i.e., wheat gluten or starch). to this end, biopolyester coatings have been directly electrospun onto both sides of hydrophilic wheat gluten or starch based films (fabra et al., ) . as opposed to the earlier mentioned structures obtained by using electrospun bioadhesives, the structures developed by sandwiching thermoplastic proteins and polysaccharides-based films with electrospun hydrophobic coatings were not high barrier materials and they could be used for some fresh produce (e.g., mushroom, strawberry) with high respiration rates that require packaging films with high oxygen and carbon dioxide permeability values. in this type of multilayer structures, proteins and polysaccharides have to be first plasticized to become thermoplastic and form a continuous film, a fact that made them suitable in terms of barrier properties, for fulfilling the packaging requirements of fresh produce. however, water and oxygen permeability values of the neat thermoplastic wheat gluten or tps films could be detrimentally altered by the presence of plasticizers and these biopolymers could be disintegrated or even dissolved at high relative humidity conditions, limiting their real application. to overcome this issue, electrospun hydrophobic coatings were incorporated as outer layers, avoiding swelling problems of the plasticized wheat gluten or starch-based film. in this regard, fabra et al. ( c) have observed that barrier properties of the developed multilayer systems can be tailored by using different biodegradable electrospun coatings (such as pla, polycaprolactone, pcl, or pha) and by modulating the thickness of the outer layers. in fact, they have found a positive linear relationship between the amount of the electrospun coatings deposited onto both sides of a thermoplastic cornstarch film and the thickness of the electrospun biopolyester coating. interestingly, the addition of electrospun coatings led to an exponential oxygen and water vapor permeability drop as the amount of the electrospun coating increased. another interesting approach to enhance the overall functionalities of tps-based film, with special focus on their barrier performance, is the development of multilayer systems in which the inner layer is a nanobiocomposite starch-based film containing bacterial cellulose nanowhiskers (bcnw). thereafter, the optimized nanobiocomposites were successfully hydrophobized by coating them with electrospun pha or electrospun pha-bcnw fibers. to this end, hybrid electrospun pha fibers reinforced with highly dispersed crystalline bcnw in solutions concentrations up to wt.% were directly electrospun onto both sides of starch based nanobiocomposites containing wt.% bcnw. results showed that the incorporation of bcnw in one of the layers of a multilayer system enhanced oxygen barrier properties to a great extent (fabra et al., e) . therefore, by means of the technology here proposed, one can tailor the barrier properties of food-packaging materials according to the final intended use. interestingly, another advantage arising from this procedure is that this technology also offers the possibility to develop active and bioactive packaging multilayer structures producing simultaneously interlayers or coatings with encapsulation performance of the active/bioactive compounds thus preserving their functional properties. in this sense, fabra et al. ( d) have developed active multilayer food-packaging materials by means of electrospinning. specifically, α-tocopherol, as a model antioxidant, was encapsulated in three different protein-based matrices (whey protein isolate, spi, and zein), which were directly applied as coatings onto a thermoplastic wheat gluten film. the antioxidant activity of the active compound was preserved during the encapsulation process (up to %) and it was seen that the electrospun shell materials were able to protect the antioxidant from degradation during a typical sterilization process. another technique with great potential in the development of nanoscopically structured new materials is the sequential lbl adsorption of polymer of solid substrates (pinheiro et al., ; weis et al., ) . by means of this procedure, several biopolymers with opposite charges can be used to produce nanolayered films assembled through lbl. the lbl technique is quite simple and enables using a wide range of materials (e.g., proteins, polysaccharides, lipids, and nanoparticles). these materials are able to interact either by electrostatic interactions, hydrogen bonding, covalent bonds, complementary base pairing, or hydrophobic bonding. for instance, two polysaccharides with opposite charges, chitosan and sodium alginate, were deposited onto aminolyzed/charged pet (a/c pet) and the resulting multilayer nanofilm showed lower water vapor permeability that could be expected for the materials with which the film was built (carneiro-da-cunha et al., ) . the use of the lbl technique has also been studied for the development of active coatings. in this line, fabra et al. ( ) developed lbl films by alternating layers of alginate and zein/carvacrol nanocapsules with improved barrier properties and antifungal activity against alternaria sp. the globally increasing demand for minimally processed, easily-prepared, and readyto-eat "fresh" food products has encouraged manufacturers to develop new packaging technologies. these demands are strongly influenced by the market trends, which together with globalization of food trade and distribution from centralized processing facilities, are the driving forces for continuous development and upgrade of food packaging (appendini and hotchkiss, ; ozdemir and floros, ) . active packaging is an innovative solution to meet the continuous changes in current consumer demands and market trends because it extends shelf life and improves safety of the food by scavenging of oxygen, moisture, or ethylene, and by promoting emission of ethanol, flavors, and antimicrobial agents (lópez-rubio et al., ) . in particular, antimicrobial packaging is attracting increased attention from the food and packaging industry, because the use of preservative packaging films offers several advantages compared with the direct addition of preservatives into food products (suppakul et al., ) . the incorporation of antimicrobial agents into polymeric films allows industry to combine the preservative functions of antimicrobials with the protective functions of the preexisting packaging concepts (appendini and hotchkiss, ) . antimicrobial activity can be achieved by including pads containing volatile antimicrobial agents into packages, incorporating antimicrobial agents directly into polymers, coating antimicrobials onto polymer surfaces, immobilizing antimicrobials by chemical grafting, or using polymers that are antimicrobial by themselves (malhotra et al., ) . in this context, the application of engineered nanomaterials is considered a promising tool to improve the functionality of biopolymers used in antimicrobial food packaging and antimicrobial food contact surfaces. it has been demonstrated that the high surface-to-volume ratio of nanostructured materials enhance the antimicrobial activity at low concentrations and, additionally, provides exceptional chemical and physical properties as an additive for material for the uv-shielding, deodorizing, antiseptic, and so on. in fact, antibacterial nanoparticles composed of metals, metal oxides, metal salts, metal hydroxides, organic nanocarriers loaded with antibacterial agents, hybrid materials, and polymers exhibiting antimicrobial properties themselves have been recently developed, being the metal nanoparticles of zinc oxide and silver, the most common nanoparticles used (mauriello, ; moritz and geszke-moritz, ) . metal nanoparticles can be used as antimicrobial agents because they have numerous advantages over other antimicrobials. their broad spectrum against foodborne pathogens (even at very low concentration) (lara et al., ; nocchetti et al., ) and their negligible toxicity toward human cells at the same concentration ranges, as well as their improved stability and low volatility in comparison with organic antimicrobial agents (dutta et al., ) , make them a promising materials for food packaging and food contact surfaces applications. however, the main challenge today in producing this kind of antimicrobial is the synthesis of stable nanoparticles in a polymer solution, as their antimicrobial effectiveness not only depends on their size but also on their size distribution and agglomeration state (castro-mayorga et al., b) . in this regard, biopolymers have emerged as suitable platforms for metal nanoparticles because they can act as carriers for stabilizing metal nanoparticles against agglomeration and simultaneously constitute a biodegradable active material. the effectiveness of nanoclays and nanosilver as antimicrobial agents and, hence, their possible use in active packaging systems, has been demonstrated in various in vitro experiments as summarized by kuorwel et al. ( ) . in the case of silver, several research works have investigated the effect of incorporating silver fillers and nanofillers into different biopolymer matrices, such as poly(vinyl alcohol) (fortunati et al., ; krklješ et al., ; mbhele et al., ) pla (martínez-abad et al., ) but these silver particles were not synthesized and stabilized into the matrices, thus causing significant changes in the optical properties and reducing the antimicrobial efficiency. in this way, the pioneering studies made by castro-mayorga et al. ( ) examined not only the role of a pha as stabilizing agent for the in situ synthesis of silver nanoparticles (castro-mayorga et al., ) but also the use of this material as masterbatch for the preparation of active nanocomposites films by direct blending with a commercial poly( -hydroxybutyrate-co- -hydroxyvalerate). the so obtained films led to a surprising oxygen permeability drop of ca. % compared to the neat polymer and had a high and prolonged bactericidal activity against two of the most common food borne pathogens, salmonella enterica and listeria monocytogenes . however, the highest potential of metal nanoparticles as antimicrobial agents can hardly be achieved in most cases because they have low solubility/compatibility with the polymers, leading to the agglomeration of nanoparticles, and the prepared antibacterial polymeric materials present low surface-to-mass ratios. to solve this problem, the metal nanoparticles can be alternatively preincorporated into submicro-or nanofibers by means of electrospinning to generate masterbatches, which are subsequently melt mixed with polymers pellets, or even better, used as active coatings over polymer surfaces (amna et al., ) . the incorporation of metal nanoparticles in electrospun fibers has enabled the development of novel materials with useful features, such as fibrous membranes with antibacterial properties for water filtration (botes and cloete, ) , protective clothing (pant et al., ) , wound dressings, implant materials, or tissue engineering (navalakhe and nandedkar, ) . specifically, in the active food packaging area, the electrospinning technique successfully avoids the agglomeration of metal nanoparticles and greatly increases their antimicrobial activity. for instance, zno nanoparticles showed a more effective and prolonged biocide activity against foodborne pathogens when they were applied as a coating of annealed electrospun pha/zno fiber mat (fig. . a) over a compression molded pha film ( fig. . b) than their counterparts prepared by melt-mixing. this indicated that the biocide potential of metal nanoparticles could be more efficiently exploited when they were incorporated in electrospun coatings, as this processing technique improved the dispersion and distribution of the nanoparticles within the polymer matrix (castro-mayorga et al. a). beside the metal nanoparticles, the incorporation of other natural compounds, such as essential oils by electrospinning is being considered an interesting option for active food packaging, especially taking into account that these compounds are thermally sensitive and, thus, cannot be directly incorporated during typical processing methods used for polymeric materials. for example, wen et al. ( a,b) carried out in vitro studies with cinnamon essential oil, β-cyclodextrin, and polyvinyl alcohol (pva) nanofibrous films, which demonstrated an excellent antimicrobial activity against gram-positive and grztive bacteria. in addition, they also proved that these nanofibrous films were able to prolong the shelf life of strawberries and pork. likewise, munteanu et al. ( ) incorporated allyl isothiocyanate (aitc) and β-cyclodextrin into pva nanofibers via electrospinning and demonstrated that the evaporation of aitc was hindered by ciclodextrin inclusion complexation and thus, their antimicrobial effect against escherichia coli and staphylococcus aureus was enhanced. additionally, natural polymers, such as chitosan and cellulose, have also been used to make nanostructured antimicrobial materials. the original antimicrobial chitosan was used by torres-giner et al. ( ) for the preparation of active fiber using electrospinning and by cárdenas et al. ( ) as polymer matrix for the incorporation of nanocopper, which exhibited antimicrobial activity against s. aureus, and salmonella typhimurium with a - log cfu ml − bacterial reduction. a cellulose-derived polymer, that is, methylcellulose has been utilized to yield good mechanical properties and barrier properties but also to synthesize silver nanoparticles with high antimicrobial activity (maity et al., ) . another interesting application was one developed by munteanu et al. ( ) , who combined the antimicrobial properties of silver nanoparticles with the antioxidant activity of vitamin e within multifunctional electrospun pla/agnp/vitamin e nanofibers, which may be quite applicable for the fabrication of active packaging structures for fruits and juices. enteric viruses are those human viruses that are primarily transmitted by the fecal-oral route, either by person-to-person contact or by ingestion of contaminated food or water, although they may also be shed in vomitus. food may be contaminated by enteric viruses during all stages of the food supply chain, and transmission can occur by consumption of food contaminated during the production process (primary production, or during further processing), or contaminated by infected food handlers. data on viral foodborne diseases are still fragmented, and epidemiological studies have focused either on particular countries or on particular pathogens. epidemiological evidence indicates that enteric viruses, in particular human noroviruses (nov), which cause acute gastroenteritis, are the leading causes of foodborne illnesses in industrialized countries (cdc, ; efsa and ecdc, ) while hepatitis a virus (hav) has recently been considered as a reemerging foodborne public health threat in europe due to the number of foodborne outbreaks associated with imported foods (sprenger, ) . recently, the world health organization estimates the global burden of foodborne diseases, reporting that infectious agents that cause diarrhoeal diseases accounted for the vast majority ( million cases per year), in particular norovirus ( million cases per year) (who, ) . in the eu, foodborne viruses were identified as the most frequently detected causative agent of foodborne outbreaks in , accounting for . % of the reported outbreaks (efsa and ecdc, ) . moreover, the cost of foodborne illness in the usa is estimated to be around billion dollars a year (scharff, ) . other enteric viruses, including sapoviruses, rotaviruses, coronavirus, astroviruses, and hepatitis e virus (hev), are not frequent causes of foodborne disease but can occasionally be transmitted by contaminated foods. although there is an increasing awareness of the importance of foodborne diseases caused by enteric viruses, few studies have confronted the task of evaluating materials with antiviral activity against enteric viruses. in a recent innovative study, an active renewable packaging material with virucide properties was synthesized by the incorporation of silver ions into polylactide acid films. these films showed strong antiviral activity on feline calivicirus (fcv), a norovirus surrogate, using the japanese industrial standard (jis z ) (martínez-abad et al. ) . when films were applied to vegetables, antiviral activity was very much dependent on the food type and temperature. likewise, bright et al. ( ) evaluated the antiviral activity of active packaging, reporting that fcv titers were reduced by log when in contact with plastic coupons impregnated with % silver-copper zeolites. moreover, the antiviral activity of adding grape seed extract (gse), green tea extract (gte), or cinnamaldehyde (cnma) into films has also been reported. amankwaah ( ) developed chitosan edible films incorporated with gte or gse, which showed significantly antiviral activity against murine norovirus (mnv). fabra et al. ( a) showed that the incorporation of an active electrospun interlayer based on zein and . % of cnma to a polyhydroxybutyrate packaging material (phb) in a multilayer form completely inactivated fcv according to iso : , while mnv titers were reduced by . log . when the developed multilayer films were evaluated after month of preparation or at °c, the antiviral activity was reduced as compared to freshly prepared multilayer films evaluated at °c. these studies show the excellent potential of polymers with virucide activity for food contact applications, as well as for active packaging technologies to maintain or extend food quality and safety. summarizing, this chapter, which includes an overview of relevant developments on biopolymer-based materials for encapsulation and packaging applications in the food area, shows the potential of nanostructuring these biopolymers for advanced applications. not only nanostructuring the biopolymers, but also combining them with nanoparticles can 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nanoparticles as drug delivery vehicles stable nano-sized emulsions produced from soy protein and soy polysaccharide complexes soluble fibers inhibit carotenoid micellization in vitro and uptake by caco- cells structural characteristics of carrageenan gels: temperature and concentration dependence. food hydrocoll encapsulation of β-carotene in alginate-based hydrogel beads: impact on physicochemical stability and bioaccessibility formation and characterization of mint oil/s and cs/water microemulsions encapsulation of functional lipophilic components in surfactantbased colloidal delivery systems: vitamin e, vitamin d, and lemon oil this work was supported by the spanish ministry of economy and competitiveness (mineco) (ryc- - , agl - -c - and inia grant rta - -c - ). gs and mjf were supported by the "ramón y cajal" young investigator from the mineco. jlc-m was supported by the administrative department of science, technology and innovation (colciencias) of the colombian government. key: cord- -w m r authors: cardwell, ryan; ghazalian, pascal l. title: covid- and international food assistance: policy proposals to keep food flowing date: - - journal: world dev doi: . /j.worlddev. . sha: doc_id: cord_uid: w m r the covid- pandemic is increasing the need for international food assistance, and disrupting the supply and delivery of food assistance. a series of unprecedented shocks is straining the capacity of food assistance organizations to reach vulnerable populations. we discuss how the covid- pandemic is affecting the demand and the supply of international food assistance, and we propose three policy changes that can keep food flowing to those in need. first, donor countries can prioritize humanitarian spending in aid-allocation decisions. second, governments can exempt food assistance from trade barriers that impede procurement (export restrictions) and delivery (import tariffs). third, donor countries can allow flexibility for implementing agencies by untying food assistance from domestic procurement and shipping restrictions. all of these suggestions are regulatory changes that can be made without requiring increased spending. these options are particularly relevant now because donor-country governments are entering economic recessions, and foreign aid budgets will be constrained. the covid- pandemic has disrupted markets, displaced workers, and interrupted food supply chains. these disruptions have important implications for international food assistance. i a large demand shock (increased need) is combining with unprecedented supply shocks (interruptions to supply chains) to generate a humanitarian crisis. the current situation is unique because it is global-all donor countries and recipient countries are affected. we describe how the pandemic is disrupting food assistance, and discuss policies that can mitigate the negative effects on recipients. the policies that we present can keep food assistance flowing, and would not impose additional costs on donor countries-an important consideration for donor-country governments that are facing economic recessions. the need for food assistance is growing. in addition to the direct health effects of covid- , measures to contain the spread of the coronavirus are creating recessionary economic conditions in almost every country. formal and informal markets are closed, travel is restricted, and incomes are falling; the economies of most countries are in stasis. the economic hardships created by these conditions are most severe in developing countries. the large shares of workers in these countries who rely on income from the informal sector are disproportionately affected. governments in many countries lack the capacity to provide temporary relief to those who have lost income. the global report on food crises (fsin, ) estimates that the number of people facing acute hunger could rise by million in because of this pandemic. the severity of changes to food security is largely unknown, however, because travel restrictions are disrupting real-time monitoring. the world food programme (wfp) has appealed for us$ . billion to cover expected costs over the next several months. more funding will be required to meet longer-term needs. the covid- pandemic is affecting the supply of international food assistance. obstacles have emerged in donor countries, in recipient countries, and in third countries where the wfp buys food. perhaps the most important supply-side factor is that donor countries are entering major economic recessions that will reduce government revenues. donor-country aid effort declines during business-cycle downturns (pallage & robe, ; tingley, ; dabla-norris, minoiu, & zanna, ) , so we expect foreign aid funding to fall in , and remain low in following years. increased need for food assistance will strain donors' and funding agencies' budgets, and reduce capacity to respond to other emerging (non-covid- ) events over the next few years. a more-concerning possibility is that official development assistance (oda) funding may not return to historic levels, even after economies recover. there have been calls in donor countries to withdraw from international engagement in the wake of the pandemic (gramer & lynch, ) ; this could have implications for international trade and for foreign aid. we may observe a structural change in some governments' willingness to fund oda. food assistance funding may be more resilient than funding for other forms of oda, however, for two reasons. first, member countries of the food assistance convention (fac) commit to minimum funding levels each year. these minimum commitments are not binding for many donor countries, so some donors could cut funding without breaking their obligations. however, these commitments establish a floor for donor-country food-assistance funding. ii a second reason is that funding for emergency food assistance, and for humanitarian assistance more generally, has grown as a share of oda ( figure ). humanitarian aid is a small share of oda, so there is room for donors to increase the share of oda spent on humanitarian aid. emergency food assistance may become a larger piece of a smaller pie. source: authors' calculations based on oecd ( ) data a number of food-exporting countries have imposed new export restrictions. for example, governments in kazakhstan, myanmar, russia, and vietnam have constrained cereal exports with bans, quotas, and licencing restrictions (global trade alert, ); these countries are frequent sources for wfp cereal purchases. existing disciplines on food export restrictions in the world trade organization (wto) are not effective (cardwell & kerr, ) , and the wfp reported difficulties sourcing food from countries that imposed export restrictions during the food crisis of / (johnston, ) . some countries provide exemptions for wfp purchases, however the need to acquire waivers slows down procurement and delivery, and adds transaction costs (the world bank, ). nontariff import barriers in recipient countries also restrict the movement of food and supplies. for example, food assistance organizations are reporting significant delays in transporting supplies into countries that have mandatory coronavirus testing at border crossings. measures to contain the spread of the coronavirus are complicating the logistics of distributing food. many distribution centres are closed, and agencies are transitioning to alternative methods, including household delivery. domestic travel restrictions are impeding the movement of food and local staff-for example, travel in and out of refugee camps is restricted, and trucking services switch drivers mid-route to comply with interregional travel restrictions. local workers have also had to acquire personal protective equipment and sanitizers. these factors increase the cost of providing food assistance. market and policy developments since the onset of covid- are increasing costs and slowing down delivery of food assistance. export restrictions will increase transaction costs, including compliance with new export barriers, and search and contracting costs if food has to be sourced from different countries. shipping costs and delivery times could also increase if food has to be purchased in countries that are farther from recipients. border delays and complications in the final stages of delivering food to recipients will also increase costs and slow down delivery. these obstacles will create new rent-seeking opportunities along the food-assistance supply chain. all of these factors increase the costs of providing in-kind food relative to cash-based transfers (cbts), particularly for food that crosses international borders. implementing agencies will be more inclined to buy food in recipient countries (instead of in donor countries or in third countries), and they will be incentivized to provide assistance as cbts. responses to the covid- pandemic among food assistance practitioners and donors have been ad hoc and reactionary. for example, the wfp has transitioned to take-home rations to replace school-lunch programs where schools are closed, and has scaled up cbts where food is available (wfp, a). there have not, to our knowledge, been country-level policy changes to facilitate food assistance flows during this pandemic (though some policy changes, such as export restrictions, could impede operations). we propose three government policy responses that can lessen the adverse effects of this pandemic on food assistance flows. our focus is on high-level policy changes that can allow implementing agencies to adapt their ground-level operations to distinct obstacles in different regions, and keep food flowing. an important feature of our proposals is that they do not require donor-country governments to spend more money on food assistance. more funding for oda, as helpful as it could be, may not be a realistic prospect in the short term. iii donor-country governments can stem the decline in food assistance by prioritizing humanitarian aid. aid budgets are likely to contract in the near-term, however, so increased humanitarian spending may come at the expense of other forms of oda. this could mean cuts to programs that target longer-term objectives (e.g. infrastructure and debt-relief programs). institutional features of donor countries' aid policies could hinder attempts to shift funds between aid sectors, particularly in the short term. many aid-commitment decisions are made well in advance of disbursements, and some funding is not readily fungible across sectors. this is particularly the case in donor countries with less-flexible funding models (e.g. a large share of united states (us) food-assistance funding is appropriated through farm bills, which are passed as new legislation every four-to-five years). member countries of the fac could also resolve to maintain their current commitments, and consider increasing them. it would not be surprising to see an increase in the us commitment if the us department of agriculture (usda) uses food assistance as a vent to dispose of surplus commodities that are purchased to support us farm incomes. pre-emptive commitments to not impose new export restrictions would reduce the risk of upward pressure on global cereal prices. the wfp reports that commercial traders have responded to news of export restrictions by increasing the prices that they charge for commodities used as food assistance (wfp, b). the agenda for the june wto ministerial meeting included discussions on exempting wfp purchases from export restrictions (wto, a), iv but this meeting has been postponed. this means that formal disciplines on export restrictions are not forthcoming. the wto could, however, play an important role in discouraging member countries from blocking exports of food assistance until the issue can be formally addressed at a future wto meeting. formalizing exemptions for food assistance within the wto would eliminate the need to secure waivers on a case-by-case basis, thereby speeding up procurement and delivery. v member countries could also exempt food assistance from import tariffs, which are applied inconsistently across recipient countries. vi exempting food assistance from import tariffs (or refunding tariffs paid) would reduce purchase prices for food-assistance agencies. donor countries can provide implementing agencies with flexibility in sourcing and delivery so they can be nimble in the face of market disruptions. this includes the option to provide food assistance as cbts instead of in-kind food. the increased need for food assistance during this pandemic is mostly the result of negative income shocks, not local supply shortfalls; cbts are often the preferred modalities when market conditions can support local purchases. the arguments for allowing flexibility by untying food assistance are not new (e.g. smith & nabil, ) , but there are additional benefits of untying in the face of new pandemic-related obstacles. implementing agencies that encounter border delays could buy food in the recipient country or provide cbts. also, travel restrictions and social distancing requirements make cbts appealing because they can often be distributed electronically, which reduces personal contact. vii locally-and regionally-purchased food can be more cost effective than direct-transfer assistance (melito, ; lentz, passarelli, & barrett, ) ; these cost savings are particularly relevant as donor-country governments face pressure to cut budgets. food that is purchased in, or near, recipient countries also reaches recipients faster than food shipped from donor countries (lentz, passarelli, & barrett, ; cardwell & ghazalian, ) . untying food assistance allows donor countries to provide more food faster with the same, or even smaller, budgets (cardwell & ghazalian, ) . donor countries' responses to covid- will vary. the us is the largest donor of international food assistance, and ties most donations to domestic procurement and shipping services. there is scope for the us to provide more food, faster, at lower cost, by untying. the us congress has resisted previous calls to untie food assistance, but the current combination of tighter budgets plus increased need for food assistance could be a catalyst for relaxing tying restrictions. recent developments in us agricultural policies could counteract untying efforts, however. members of the us congress are calling for the usda to buy farm commodities to support incomes, and to use those commodities in international food assistance programs (congress of the united states, ). most other major donor countries provide food assistance as untied cash, leaving less space for policy changes to increase efficiency. responses from these donors will depend on how aid budgets react to economic recessions, and to increased need for aid. longer term, a retreat from global markets could affect food assistance, and foreign aid more generally, because commercial trading relationships are important determinants of bilateral aid flows (berthélemy, ; cardwell & ghazalian, ) . covid- -related disruptions to international trade and capital flows (baldwin & tomiura, ; unctad, ; wto, b ) may lead to a decrease in foreign aid. viii this effect could differ across donor countries because some donors are more responsive to their own interests (e.g. bilateral trade ties, foreign direct investment) in allocation decisions (berthélemy, ); more-egoistic countries (e.g. us, japan) may reduce aid flows relatively more than less-egoistic countries (e.g. switzerland, norway). the covid- pandemic is combining unprecedented supply shocks with demand shocks to produce an acute global food security crisis. food-assistance agencies are encountering obstacles in delivering food to a growing number of food-insecure recipients. these obstacles are likely to last several months, and perhaps much longer. there will also be long-term effects of this pandemic on the supply of food assistance. changes to trade patterns and policies, and to aid funding, could constrain the supply of food assistance. furthermore, recessionary impacts on the incomes of food-insecure populations could exacerbate the need for food assistance. we propose policies that can lessen the negative effects of this pandemic on food assistance. donor countries could commit to maintain, or even increase, funding for emergency food assistance. cuts to oda funding in many donor countries are likely inevitable, but there are mechanisms (e.g. fac commitments, diverting non-humanitarian aid funding to humanitarian projects) to reduce the impacts on food assistance. reducing the obstacles to acquiring and distributing food assistance will keep food flowing to those in need. efforts should focus on formalizing rules on trade barriers, and granting implementing agencies flexibility to buy food locally or regionally, or to provide assistance as cash. the policy modifications required for these changes would not impose additional costs on donor countries. the adverse effects of the covid- pandemic will be most severe among food-insecure populations, but high-income countries can mitigate these effects with policies that keep food assistance flowing, without incurring additional costs. thinking ahead about the trade impact of covid- . economics in the time of covid- bilateral donors' interest vs. recipients' development motives in aid allocation: do all donors behave the same? the effects of aid agency independence on bilateral aid allocation decisions the effects of untying international food assistance: the case of canada can export restrictions be disciplined through the world trade organisation? letter to secretary of u.s. department of agriculture business cycle fluctuations, large macroeconomic shocks, and development aid food security information network online database trump seeks to half u.s. funding for world health organization as coronavirus rages covid- -related trade restrictions on rice and wheat could drive up prices and increase hunger. ifpri blog: research post wfp says food export ban hurts aid efforts. reuters the covid- pandemic and agriculture-short and long run implications for international trade relations the timeliness and cost-effectiveness of the local and regional procurement of food aid international food assistance: local and regional procurement can enhance the efficiency of us food aid, but challenges may constrain its implementation. united states government accountability office creditor reporting system online database foreign aid and the business cycle food aid's costly problem: why it's time to eliminate cargo preference donors and domestic politics: political influences on foreign aid effort. the quarterly review of economics and finance united nations conference on trade and development (unctad). ( ). impact of the covid- pandemic on global fdi and gvcs. investment trend monitor trade & humanitarian emergencies: a survey of trade policy issues affecting disaster response, recovery and reconstruction covid- level emergency external situation report # personal communication with arif husain (chief economist) eyeing mc for an outcome, agriculture negotiators focus on doable elements and processes. news item trade set to plunge as covid- pandemic upends global economy the authors thank arif husain of the world food programme and staff at the canadian foodgrains bank for insights in the preparation of this paper. credit is shared equally between authors.the covid- pandemic is creating a global food security crisis need for international food assistance is rising, while supply is being constrained donor countries may cut foreign aid budgets during economic recessions we propose policy responses to keep food assistance flowing, without increasing aid budgets proposals include prioritizing humanitarian aid spending, exempting food assistance from trade barriers, and untying aid i we use the phrase "food assistance" instead of "food aid" to reflect policy and modality changes over the past several years (e.g. increased use of cash transfers and vouchers).ii there are no penalties for donor countries that do not meet their commitments, and countries can update their commitments every year. donor countries might reduce their commitments in coming years.iii addressing demand-side shocks by supporting food consumers' incomes is an important objective over the next months and years. we focus on policies specific to food assistance. iv these exemptions could be extended to other food assistance agencies (e.g. international federation of red cross and red crescent societies, or other non-governmental humanitarian organizations of recognized standing). v a prohibition on all food export restrictions would go further in supporting food assistance agencies because restrictions in any large exporting country apply upward pressure on global food prices (ifpri, ). this is not on the wto negotiation agenda.vi exempting food assistance from tariffs is complicated in cases of locally-purchased food (in the recipient country) because commodities may have been imported by a commercial trader who paid tariffs before selling as food assistance. some countries provide tariff rebates to implementing agencies in these cases.vii travel restrictions have complicated the ground-level market analyses that implementing agencies undertake prior to deciding between in-kind food and cbts. viii kerr ( ) describes a potential offsetting pattern where countries increase cooperation to strengthen post-covid- international supply chains, and to be better prepared for future shocks. key: cord- -y csypc authors: zimmerer, karl s.; de haan, stef title: informal food chains and agrobiodiversity need strengthening—not weakening—to address food security amidst the covid- crisis in south america date: - - journal: food secur doi: . /s - - -x sha: doc_id: cord_uid: y csypc the covid- crisis is worsening food insecurity by undermining informal food chains. we focus on impacts involving the informal food chains that incorporate the resilience-enhancing biodiversity of food and agriculture known as agrobiodiversity. our analysis addresses how informal food chains and agrobiodiversity are impacted by policies and interventions amidst covid- disruptions. our methodology relies on research in peru with a focus on the cites and surrounding areas of lima, arequipa, cusco, huancayo, and huánuco. we extend these insights to similar challenges and opportunities across western south america and other word regions. we utilize the four-part agrobiodiversity knowledge framework to guide our examination of agrobiodiversity-related processes that interconnect governance, nutrition, agroecology, and the covid- pandemic. our results detail three links of informal food chains that are being disrupted and yet can offer resilience. these are food retailing, logistics and transportation, and seed systems. utilization of the agrobiodiversity knowledge framework cuts through highly complex issues to elaborate key food-security difficulties facing informal systems and how they can be strengthened to provide more resilience. we identify the specific roles of agrobiodiversity in resilience-enhancing processes that need strategic policy and program support. results identify ways to augment the resilience of informal food chains using agrobiodiversity and the empowerment of social groups and organizations in urban food systems and rural communities. we conclude that the disruptions triggered by the global covid- pandemic highlight the need to use agrobiodiversity as an instrument for resilience in informal food chains. the covid- pandemic has triggered the extensive worsening of food insecurity worldwide and threatens to create long-term malnutrition and negative health consequences. concentrated among the world's most food insecure, these negative impacts are being exacerbated by certain policies and interventions of governments, ngos, and aid agencies. one major threat is the disruption of informal food chains and the limited efforts to-date of leveraging their resilience capacity. informal networks of food retailing, low-cost transportation and distribution, processing, and agricultural production provide the most secure source of nutritious food for large populations in much of the world (crush and young ; fan et al. ; zimmerer et al. ) . these informal food chains link poorer urban and rural consumers and workers with smallholder growers, thus providing both affordable food and extensive employment among persons that are foodinsecure and near food-insecure (hlpe ; maletta ) . in western south america (colombia, ecuador, peru, and bolivia) and elsewhere the functioning of informal food chains incorporates the extensive biodiversity of food and agriculture (agrobiodiversity). agrobiodiversity produced and distributed via the informal sector is a vital and resilient source of lower-cost nutritious fresh fruit and vegetables, nourishing staples, non-perishables, and locally processed foods for poor urban and rural inhabitants. agroecological resilience of this production includes stabilizing yield, insuring against extreme weather, and generally promoting agroecosystem sustainability. these benefits are vital to a wide spectrum of farmers including smallholders and indigenous people in addition to food chains and consuming populations in general (zimmerer et al. ) . nonetheless, agrobiodiversity continues to decline in western south america and worldwide (pilling et al. ) . responding to the above, our analysis addresses how informal food chains have been impacted by policy responses to the covid- pandemic. we utilize a recent multi-factor framework designed to understand the role of agrobiodiversity in food-system resilience (zimmerer et al. ; zimmerer and de haan ) . we draw on first-hand interviews and informal conversations with diverse stakeholders in western south america. stakeholders consisted of food growers in the informal and formal sectors, organizers of food markets and distribution, and food system experts in governments and ngos. between april and may , we conducted formal interviews with seven individuals and participation in more than conversions with single persons, groups, and workshops representing these stakeholders. subsequently we participated in more than additional informal conversions with individuals and groups representing these same stakeholder groups. these additions were utilized in selectively updating our paper between and june . we also draw on recent publications. for conciseness, our examples below focus on peru, including the cities and surrounding areas of lima, arequipa cusco, huancayo, and huánuco. our analysis is guided by each element of the four-part agrobiodiversity knowledge framework (zimmerer et al. ; zimmerer and de haan ) . this framework examines the interactive functioning of agrobiodiversity in food and nutrition security together with the influence of food-system governance including markets, distribution and logistics networks, and seed systems. the third and fourth themes in the akf are agroecology and global changes, respectively, with the latter including the covid- pandemic, climate change, and urbanization. this framework enables us to focus on key links of informal food chains that are particularly disrupted in the covid- crisis and threaten to undermine food and nutrition security as well as agrobiodiversity. we then briefly describe how the interconnections of informal and formal food chains are important to both food and nutrition security in addition to agrobiodiversity resilience. finally, we conclude with overarching insights and specific inputs to policy and program support. the first example of a seriously disrupted link of informal food chains is retail marketing and vending sites that support the food-acquisition strategies of large vulnerable populations. our sources specified numerous ways in which informal food markets are effectively relied upon by many urban populations in western south america to access affordable and diverse food species and varieties from the andes, amazon, and pacific coastal regions. these details are supported by earlier related research (almekinders et al. ). yet, the covid- crisis prompted strict regulations on food retailing during the first three months of the lockdown starting mid-march. our interviews and conversations detailed these governance impacts including the closures of farmers markets and some informal markets in addition to the near disappearance of urban street venders. curfews further restricted access to informal food markets, although adjustments to-date have proven challenging. knowledge-based governance and enhanced communications connectivity are needed to ensure resilient and affordable, socio-culturally inclusive access to food retailing amidst the covid- crisis. interviewees described innovations that include more spacious open-air market sites and decentralized food-selling directly from trucks and motorcycles. many informal retailers shifted to customized food delivery, accelerating the pace of innovation in these food chains. logistical innovations have encompassed the creation of whatsapp groups, individual residence and neighborhood clustering of product delivery, customized preparation of multi-food baskets, and coordinated delivery schedules. this wave of innovation is supporting the provision of agrobiodiverse food. yet, as was detailed in our interviews, the actual transition is most feasible among those with existing capabilities to access social media, cash-free payments, and transport. new solutions need to span the digital divide and empower those with fewer resources to enable further retailing that strengthens food and nutrition security. the second threatened link stems from the bias of covid- -triggered regulations against the transport logistics, distribution networks, and urban-rural links of informal food chains during the initial lockdown. analysts have highlighted that these typically rely on legions of decentralized buyers and timely transport options to transfer food from farms to wholesale and retail markets (asensio ) . but, as several interviews and conversations outlined, this sector is crucial not only to informal food buying and supply but also to the affordable, nourishing agrobiodiversity consumed among poorer populations. moreover, its importance expanded at the national level as imports declined amid the initial covid- crisis. unfortunately, according to several interviews, initial restrictions undermined the regular harvest-season shipments of foods from smallholder farmers that represent % of farms and account for approximately % of peru's food production (maletta ; undp ) . farm-gate prices and buyer options were lowered among members of this group, many of whom are already food insecure (zimmerer et al. ) . these bottlenecks contributed to higher consumer prices, and reduced supplies of agrobiodiverse food from smallholder farmers. seed is a third major challenge in informal food chains amidst the covid- crisis. informally sourced, affordable seed accounts for % or more of supply in western south america and many regions, being generally critical for food security and agrobiodiversity access globally (almekinders et al. ; mcguire and sperling ) . both farmers and food-system specialists interviewed in the current research placed emphasis on importance of the agrobiodiverse seed lots of multiple food varieties and species in the context of largescale reverse migration. this covid- -driven migration phenomenon is comprised of reverse migrants known as retornantes who have left poor urban neighborhoods in the coastal cities of western south america, such as lima, arequipa, and guayaquil, to return to rural areas of the andes and amazon. many retornantes to rural communities have begun to engage in agriculture and will require seed sources well-suited to locales within these areas. one interviewee located in an area populated by many retornantes highlighted that seed availability has become as important to the food and nutrition security of retornantes as their access to land and water. aid programs and policies should strengthen existing informal seed networks to ensure locally available planting material of the most preferred and well-adapted crop species and varieties. food and seed aid policies and projects often entail single crop and variety types sourced from formal systems (paredes ) . farmers in informal food systems often find these latter seeds less suited to local conditions. interviews for this study reinforce our broader research and work activities in highlighting that local seed directories, seed fairs and digital marketplaces. these can help increase seed supply and meet new demand. the multi-faceted, covid- -triggered shifts faced by retornantes and other vulnerable, demographic groups signal that now is the time to create agrobiodiversitybased seed approaches to support the expanded reliance on community and locally based food chains. formal food chains of agribusinesses, supermarkets, and exporters are dependent upon the effective functioning of informal food chains. throughout western south america and regions worldwide (e.g., in africa; crush and young ; zurayk ), formal food chains rely on farmworkers whose sustenance is derived from informal channels. one interviewee, a quinoa exporter, underscored that this mutual reliance could be threatened by the covid- crisis. food retailing, logistics and distribution, and dynamics of seed networks show similar interdependencies between formal and informal food systems. formal systems of supermarkets and agribusinesses provisioning niche agrobiodiverse foods to middle-and upper-class consumers depend on varied retail outlets, multi-scale transportation options, and seed inputs linked to smallholder and indigenous crops and people. in short, the threats described here impact not only informal food chains but may also impact their formal counterparts. the preceding analysis provides headway in cutting through complex, wide-ranging issues by utilizing the agrobiodiversity knowledge framework to identify and elaborate key points. it leads to our call to strengthen the resilience of informal food chains through coordinated support of agrobiodiversity. adequate management knowledge already exists in western south america and countries elsewhere. these approaches should be built upon policies and programs empowering social groups and organizations and their informal, agrobiodiverse food chains in both urban and rural areas. building deeply participatory institutional, informational, and innovation support of agrobiodiverse seed networks can maximize global-scale benefits to food security, agriculture, and potential sustainability beyond the covid- crisis (baranski and ollenburger ) . finally, the disruptions to informal food chains triggered by the global covid- pandemic highlight urgency of the broad-based integration of agrobiodiversity. innovative support of such initiatives can deliver immediate benefits to foodand nutrition-insecure people while they offer the vitally important potential to promote long-term food sustainability that is environmentally sound and socially just. conflict of interest the authors declare that they have no conflict of interest. local seed systems and their importance for an improved seed supply in developing countries potato seed supply and diversity: dynamics of local markets of cochabamba province, bolivia-a case study seed trade in rural markets: informal food chains and agrobiodiversity need strengthening-not weakening-to address food security amidst the covid- crisis in south america implications for crop diversity and agricultural development crónica del gran encierro: pensando el perú en tiempos de pandemia how to improve the social benefits of agricultural research resituating africa's urban informal food sector. urban forum food security and nutrition in an urbanizing world investing in smallholder agriculture for food security. a report by the high level panel of experts on food security and nutrition of the committee on world food security la pequeña agricultura familiar en el perú. una tipología microrregionalizada seed systems and smallholder farmers use. food security de la inseguridad a la soberanía: alimentación en tiempo de pandemia. presentation to the colloquium "(in) seguridades en fase coronavirus declining biodiversity for food and agriculture needs urgent global action agrobiodiversity: integrating knowledge for a sustainable future the biodiversity of food and agriculture (agrobiodiversity) in the anthropocene: research advances and conceptual framework indigenous smallholder struggles in peru: nutrition security, agrobiodiversity, and food sovereignty amid transforming global systems and climate change pandemic and food security karl zimmerer is miller professor in the department of geography and programs in ecology and rural sociology at pennsylvania state university. he directs the geosyntheses lab (https:// zimmerergeosyntheses.psu.edu/). karl's research, teaching, and related activities focus on the transformative resilience and sustainability of food systems, land u s e , a n d s e e d s y s t e m s utilizing agrobiodiversity. he integrates environmental, social science, and spatial techniques with models and theory in social-ecological systems and political ecology. karl's projects work to strengthen the resilience and sustainability of smallholders and indigenous people, agrobiodiversity, and food and nutrition security amid global changes (climate change, urbanization, globalization, covid- ), while applying landscape and territorial analysis for sustainable development. his - articles with co-authors in diverse countries appear in anthropocene, j. latin american geography, global change biology, j. nutrition, land use policy, international j. agricultural sustainability, geoforum, revista: harvard review of latin america, current opinion in sustainability, and issues in science and technology.stef de haan is a researcher with the international potato center (cip) and currently coordinates cip's new andean initiative with emphasis on agrobiodiversity, climate action, and food for health. he has a particular interest in contemporary on-farm management and use of crop genetic resources with a geographical focus on the andes. his main research focus has been on understanding the conservation and use of genetic resources under farmer management, including ongoing evolution, seed systems, geospatial patterning and nutrition. he previously worked for the international center for tropical agriculture (ciat) coordinating food system research in southeast asia. stef holds a phd in biosystematics and msc. in agroecology from wageningen university, as well as a bsc. in agronomy. key: cord- -fsj dg authors: patterson, grace t.; thomas, lian f.; coyne, lucy a.; rushton, jonathan title: moving health to the heart of agri-food policies; mitigating risk from our food systems date: - - journal: glob food sec doi: . /j.gfs. . sha: doc_id: cord_uid: fsj dg our food systems are progressively more industrialized and consolidated with many modern food value chains involving multiple countries and continents, and as such being associated with changes in risk profile and impacts of emerging and re-emerging diseases. disease outbreaks that sweep through a single region can have massive impacts on food supply, while severe outbreaks of human pathogens can disrupt agricultural labor supply or demand for products perceived as ‘unsafe’. market pressures have generally rewarded production of cash crops for fuel and energy dense, low nutrient processed foods over production of fruits and vegetables for local consumption. climbing rates of food-related ncds and pre-existing conditions leave the population increasingly susceptible to infectious diseases that are often driven by or arise from the food system. therefore disease and diet from our food systems cause impacts on human health, and human health issues can impact on the functioning of the food system. the covid- outbreak is the most recent example of food system driven disease emergence and of massive supply and demand shocks in the food system, experienced as a direct and indirect result of this disease. the effects of the food system on disease spread (and vice versa) must be addressed in future plans to prevent and mitigate large scale outbreaks. health policies must acknowledge the food system as the base of our health system, as must agri-food policy recognize the pre-eminence of human health (directly and indirectly) in decision making. the health of the global population is underpinned by our food systems, yet these systems are often only nominally included in health policy. in recent times, attention has been given to reformulation and marketing policies in moderate attempts to reduce climbing rates of obesity and non-communicable diseases (ncds) (oecd, ) . others focus on reducing foodborne pathogens by regulating processing and enacting trade restrictions (trienekens and beulens, ) . many of these policies focus on downstream actors and processes in the food system and neglect the foundations of how our food is produced. while such interventions are easier to enact, they have limited effects on health and are generally reactionary and insufficient to reverse the trajectory of increasing health burdens. in this manuscript we review some of the major human health externalities driven by our current food systems, with an emphasis on livestock-systems and their linkages to the wider food system, the impacts of our response to these externalities and outline key areas in which better integrated health & agri-food policy may mitigate these factors. although the interactions between food systems and our health are many and complex, we outline here four key health externalities arising from these systems of concern across the globe; ) the dual burden of malnutrition, ) foodborne disease, ) antimicrobial resistance and ) emergence of novel pathogens. despite an increasing ability to produce sufficient calories for the growing human population, distributional inequalities have produced a situation where we face the dual burden of chronic under-nutrition (black et al., ) and a global pandemic of overweight and obesity and related ncds, often within the same geographical locality (shrimpton and rokx, ) . diet related risks are estimated to be responsible for million ( - mn) disability adjusted life years (dalys) a year globally, and dietary improvements could potentially prevent one in every five global deaths (afshin et al., ) . diet related risks also monopolize large portions of many national health-care budgets (phe, ) . from - , it is estimated that an average of ⋅ % of healthcare expenditure in the organisation for economic co-operation and development (oecd) member countries will be spent treating obesity-related diseases, equivalent to us dollars (usd) purchasing power parity billion per year (oecd, ) . current food systems exploit demand for affordable, convenient, and tasty food to encourage consumption of nutritionally poor, ultraprocessed foods in both high, middle and low income countries. as economic markets incentivize expanded food value chains, they inevitably produce food with more and more processing to improve taste, texture, and longevity (swinburn et al., ) . the processed state of these foods, not necessarily the macronutrient content or energy density, induces increased calorie intake and weight gain associated with exposure to ultra-processed foods (hall et al., ) . marginalized groups in high income countries are often reliant on these highly processed, energy-dense, nutrient poor foods to meet their energy needs. ultra-processed foods can be aspirational in low and middle income countries (lmics) and are becoming more affordable and convenient (swinburn et al., ) . these foods (and the value chains that produce and market them) are among the most impactful determinants of the growing global burden of food-related ncds. food-related ncds also increase susceptibility to infectious disease. for diseases such as zika, west nile, and dengue death is rare in the absence of any pre-existing conditions (badawi et al., ; chan-yeung and xu, ) and preliminary analysis suggests that the likelihood of adverse outcomes in sars-cov- are significantly higher in patients with hypertension and diabetes (zhou et al., ) . this increased risk may be driven by upregulation of the sars-cov- receptor ace or heightened inflammation in people with these comorbidities (pinto et al., ) . these diet-related co-morbidities are visible symptoms of underlying structural inequalities which result in marginalized communities bearing disproportionate disease burdens (garg et al., ; icnarc, ) . whilst the quantity and nutritional quality of our global diets gains increasing attention, foodborne diseases are also associated with a substantial human health burden, with approximately million dalys lost annually through of the major foodborne diseases, the burden of which are disproportionately borne by lmics (jaffee et al., ; li et al., ) . thirty-five percent of this burden is attributable to pathogens from animal source foods (asfs) (li et al., ) , the increasing demand for which, particularly across lmics, is a major driver in an increasing foodborne disease burden (quested et al., ) . specific aspects of livestock value chains associated with an increase foodborne disease risk may differ across 'informal' and 'formal value chains. high prevalence foci of the zoonotic tapeworm taenia solium, etiological agent of neurocysticercosis, are found where free-ranging pig husbandry practises coincide with low levels of sanitation and insufficient implementation of meat inspection . informal value chains, which supply - % of food needs in sub-saharan africa, and the poorly regulated slaughter, processing and retail practises associated with them can result in extensive microbial contamination of products, which may not be sufficiently mitigated by consumer food preparation practises (jaffee et al., ) . the formalisation of livestock value chains does not completely mitigate all foodborne disease risks. longer value chains with increasing number of processing or handling steps between 'farm and fork' provide opportunities for cross-contamination, adulteration or spoilage without sufficiently enforced regulation. the progressively intensified systems of livestock production seen increasingly across the globe may also exacerbate the risk posed by microbial hazards. intensive systems bring animals into close proximity under circumstances which induce metabolic and psychological stress (humphrey, ; martínez-miró et al., ) , increasing the contact opportunities and susceptibility of these populations for disease transmission, including those pathogens which have important implications for food safety. this is particularly evident in monogastric systems, where intensive production contributes to over half of the global pork production and over % of global poultry production (steinfeld et al., ; thornton, ) , and where campylobacter and salmonella spp. have been increasingly prevalent (carrique-mas et al., ) . in order to mitigate the effects of high pathogen challenge, which also have production-limiting effects, intensive livestock systems have been heavily reliant on antimicrobials for prophylactic, treatment and growth promotion reasons . resistant bacteria reside in humans, animals, food and the environment and there are no barriers to the transmission of resistance genes between these sites or amongst bacterial species (holmes et al., ) . pathways for the spread of resistant organisms, from within animal populations to humans, are well recognized and result from the selective pressures from antimicrobial use in livestock. consequently, antimicrobial use in food-producing animal species represents an important driver of antimicrobial resistance (amr) (marshall and levy, ) . the human health burden from amr is forecasted to reach trillion usd by with a worldwide mortality around million (o'neill, ) . in response to the amr crises, there is growing international pressure to reduce the use of antimicrobials within livestock systems and to prohibit the use of antimicrobial growth promoters (agps) in livestock. trade-offs exist, however, between the risks of antimicrobial use and the pressure to ensure global food security. a ban on agps could be associated with a reduction in the value of global meat production of between and billion usd and restricting the use of antimicrobials for prophylactic and therapeutic use whilst retaining current intensive husbandry practices will impact both productivity and animal welfare. lastly, disease emergence and transmission are of growing concern within our intensive, increasingly homogenous and interconnected food systems. lack of genetic diversity has become commonplace in our global food systems, within both livestock and crop production (bennett et al., ; khoury et al., ) , and is a risk factor for heightened susceptibility to outbreaks of plant and animal disease. this 'monoculture effect' is best illustrated in agronomy, where non-diverse cropping can lead to large scale losses, such as those suffered through rice blast (zhu et al., ) and the panama disease epidemic of bananas in the s (ordonez et al., ) . similar genetic susceptibilities exist within livestock. porcine reproductive and respiratory syndrome virus, a major disease burden to the global pork sector, has led to exacerbated losses within genetically homogenous herds as compared to herds with a wider genetic pool (lunney et al., ; halbur et al., ) . as well as the emergence of production limiting pathogens within livestock systems, the emergence of novel, zoonotic pathogens from our food systems is at the forefront of the global consciousness, of which sars-cov- is only the latest example in an increasing frequency of such events. novel zoonoses have emerged most commonly from wild mammals such as rodents and bats, which have either adapted to anthropogenic habitat changes, or have increased contact with humans or livestock through agricultural incursions into habitats or establishment of bush-meat value chains (johnson et al., ) . examples of direct pathogen spillover from wildlife directly to humans, predominantly associated with formal or informal bushmeat value chains, include hiv and ebola (hahn et al., ; kock et al., ) . there is also a potential threat to human health from the transmission of disease from wildlife into livestock populations and then further propagation through intensive production (wilcox et al., ) . in cases of the novel febrile encephalitis, nipah virus (niv), emerged amongst pig farmers in malaysia. the intensification of mango and pig production within a localised geographical area are believed to have provided a pathway for the virus, circulating in fruit bats, to infect an intensively managed commercial pig population and subsequently spread to farmers (pulliam et al., ) . zoonotic and non-zoonotic disease outbreaks and our responses to the presence or risk of these pathogens can destabilize food systems, leading to increased food insecurity and downstream health and economic effects. fig. illustrates several of the key disease outbreaks of the previous three decades which have had profound impacts on human health and food-security. in europe, outbreaks of bovine spongiform encephalitis (bse) and food and mouth disease (fmd) led to large scale supply and demand shocks in the beef and dairy industries. the use of meat and bone meal in cattle feed was associated with the mid 's emergence of the degenerative prion disease bse, which was later found to cause newvariant crutzfeldt-jacob disease (nvcjd) in humans (anderson et al., ) . this led to a raft of mitigation measures with short and long-term costs, including large scale culling programmes, new harvesting and processing regulation, a ban on animal by-product use in animal feeds and restrictions on beef and other animal products (including milk, semen and embryos) export from affected countries (kimball and taneda, ; thiermann, ) . the effects on the food system and health from the fmd outbreak in the uk also extended beyond production losses (knight-jones and rushton, ) . trade restrictions between fmd free and fmd affected countries were sometimes extended to unrelated products. culls produced public outrage against the livestock industry that outlasted the outbreak itself, which together likely contributed to the observed spike of depression and suicide among farmers (thomas et al., ) . in areas where a large proportion of the population is dependent on agriculture for both income and food supply, such as ethiopia, endemic fmd has direct effects on the food security of farmers by reducing milk production and oxen availability for cropping (knight-jones and rushton, ) . pork is now the most frequently consumed meat per capita worldwide and is responsible for over half of meat consumption in asia (ritchie and roser, ) . introduction of african swine fever virus (asfv) into china, home of approximately % of the global herd (ritchie and roser, ) , resulted in rapid spread throughout the naive pig population. over % of pigs have died or been culled (fao, ), causing an estimated $ billion in direct economic losses (moore, ) and reverberations through industries including feed mills, veterinary services, restaurants, and tourism. pork prices soared to a peak of % year-on-year (moore, ), increasing demand for and price of other meat products and leaving poorer households at increased risk of food insecurity and malnutrition (rocha et al., ) . similar patterns were seen across the same region less than a decade before in response to outbreaks of highly pathogenic avian influenza where aggressive containment measures drove increases in meat prices and heightened local food insecurity (burgos et al., ) . lmics, particularly those in southeast asia, are the site of the majority of industrialized poultry farming. large scale flocks are more likely to contract hpai (h n ) than small, personal flocks (otte et al., ) and experience the greater share of economic effects. yet smallholders, traders, slaughterers, and transporters are at greatest risk of personal negative health outcomes as a result of such diseases, as they often belong to poor households that are unable to weather economic shocks and are sensitive to food insecurity and malnutrition. the west african ebola outbreak of provides an example of severe, localized effects of an outbreak on the food system due to travel restrictions and market closures (mann et al., ) . panic buying caused shortages of some items and dramatic increases in prices. labor shortages resulted in decreased food production and loss of income across communities, particularly in rural regions (de la fuente et al., ) . nutrition operations were a low priority among humanitarian response groups and were inadequately supplied (kodish et al., ) . they also neglected to consider the needs of communities that did not have ebola outbreaks but had become food insecure from food production losses. after the outbreak, many ebola disease survivors were denied the opportunity to purchase food due to lingering fear of infection. on a global scale, the ongoing covid- outbreak has also led to massive perturbations in food systems. lockdowns and retail closures directly cause food insecurity among vulnerable populations, national stockpiling has prompted some countries to halt or reduce exports of staple grains and legumes (reuters, ) , and travel restrictions have inhibited farmers across europe from hiring seasonal migrant workers to harvest fruit and vegetable crops (carroll et al., ) . workers in food retail and transport that remain employed are experiencing unexpected health risks, severely reducing the ability of some sectors of our food-systems to operate as has been particularly noticeable in the vulnerability of meatpackers and subsequent covid- -related shutdown of some meat processing plants in usa (apostolidis, ) . workers provided with little protection or compensation have in some instances organized strikes to protest their lack of economic and health protection (mcginnis, ) and lengthy screening proceedures or social-distancing measures have the potential to dramatically reduce production capacity in some sectors (hailu, ) . once social distancing protocols are lifted, medium to large enterprises will likely be best poised to recover and many small businesses integral to local food systems will be unable to bounce back, producing economic knock-on effects on wholesalers, processors, and producers across the supply chain. while food insecurity surges as a result of control measures, food waste is also increasing. it is estimated that over a third of all food produced for human consumption is wasted (fao, ), a figure which will grow as shopping patterns change from multiple small shops per week to larger, more infrequent shops (cranfield university, ). food systems lack the flexibility needed to adjust to rapidly evolving situations within disease outbreaks, causing still more waste (evans, ) . restaurant and coffee shop closures have decreased demand for milk and dairy farmers have been told to pour milk down the drain, yet supermarkets have restricted purchase of milk and other core products (keane, ) . closures of large meat processing plants due to worker illness will result in large scale culling of animals across the usa. meanwhile, emergency assistance agencies are running low on supplies to support the deluge of the newly food insecure (power et al., ) . despite the undeniable link between our food systems and health, the sustainable development goals (sdgs) do not explicitly link these areas other than within the context of malnutrition (un, ) . public health policies must pay greater consideration to the role of food systems as the baseline of population health, while agri-food policies should consider human health as their raison d'être. agri-food policies can promote health in direct and indirect waysglobally % percent of employment is in agriculture, this rises to % in low income countries (world bank, ). sustainable agriculture supports economic prosperity, environmental wellbeing, and social equity (i.e. the triple bottom line), all of which further support stable access to healthy diets and healthy environments. well executed, integrated health-agri-food policy should improve baseline health, mitigate infectious disease risks and increase the resilience of our food systems to protect food security, particularly for the most vulnerable. herein we highlight some key examples of these policies in action, where further strengthening is required, and the dynamics that complicate enactment of health-centered agri-food policy (fig. ) . evidence-based health-agri-food policies that support access and uptake of healthy diet and exercise, particularly in communities with high inequality, can help reverse the growing trend towards obesity and minimize morbidity and mortality from infectious disease. a multipronged approach is needed to set healthy food preferences at an early age, change the environment to encourage healthy choices (particularly fig. . integration of health and agri-food policy. current and recommended agri-food and health policies to reduce the frequency and impact of disease outbreaks. at the point of purchase), and reduce barriers to expression of healthy preferences (hawkes et al., ) . policies that limit consumer exposure to less healthy foods by reducing portion sizes, reformulating foods, and regulating advertising are often blocked or weakened by lobbying groups (swinburn et al., ) . there is little immediate financial motivation to adopt more environmentally and health friendly standards, though social demand is increasingly reorienting markets to value transparency and social and environmental aspects of corporate performance. policy interventions that rely on behavioral change, such as consumer awareness campaigns and front of pack labeling, are relatively easier to enact but have limited longevity or effectiveness in the presence of other food stimuli or under stress (hill, ; leng et al., ) . the dynamics surrounding the adoption, implementation, and effectiveness of regulatory health policy are exemplified by the high fat, salt, and sugar (hfss) taxes that have been adopted across diverse nations with a wide range of outcomes (world health organization regional office for europe, ). most slightly reduced consumption of hfss foods but it is unclear what affect, if any, these taxes have on other health indicators in isolation. low income consumers that rely on affordable, energy-dense foods may be unduly burdened by hfss taxes but benefit from alternative price interventions such as subsidization of fruit and vegetables (neff et al., ) . while current regulatory interventions in isolation have minimal effect on downstream health indicators, they provide precedent for future regulatory policy and encourage action surrounding the role of large companies in shaping the food environment. significant improvements in global population health will require cooperation of people and companies involved in food systems to fundamentally change how they operate, but some communities have overhauled their local food environments with a ground-up, systemic approach that bypasses many of the barriers encountered on a national level and inspires awareness and innovation. in baltimore, usa, policies have been enacted to re-familiarize consumers with the systems and people that produce their food (department of planning, ), incentivize wholesaler produce distribution to small convenience stores, and encourage grocery chains to move into low income communities. city government also supports local ownership of food retail outlets in underserved neighborhoods, cultivating economic growth, a sense of community, and the agency to improve the health issues people see in their neighborhood. baltimore's food policy initiatives demonstrate how to mobilize community members to incorporate agri-food policies across city operations and government, business and economic development, and community organizations to combat the multifactorial roots of poor dietary health. even prior to the covid- pandemic the international community had been aware of the increasing threat from emerging zoonotic pathogens, the 'dual burden' imposed by endemic zoonoses on livestock productivity and human health, the biological and chemical hazards present in our food and the looming spectre of a post-antibiotic world. the protection of consumers from zoonoses and foodborne diseases acquired from the consumption of diseased animals or via unhygenic slaughter and processing has been a concern for centuries and formal meat inspection, still broadly recognisable today, was instigated in europe in the 's (edwards et al., ) . the multi-faceted nature of infectious disease risks within our food-systems and the plethora of public and private actors working within them, with differing roles and responsibilities has driven calls for an integrated 'one health' approach, endorsed at the highest level by the who, oie, fao tripartite and the world bank. despite growing acceptance of this concept internationally and the establishment of several regional and national one health units, there are still major challenges in operationalization. power struggles between ministries for 'ownership' of the movement, poorly integrated policies, lack of interoperability in data systems, and resource constraint for frontline services have all been identified as key barriers, and the multiplication of one health initiatives, specifically those with single issue focus, may risk undermining the strength of the moment (spencer et al., ) . this splintering and 'siloisation' of one health can be illustrated by kenya, where four separate one health bodies now exist with separate remits for zoonoses, amr, aflatoxins and pesticides but with no over-arching co-coordinating mechanism across these areas, and with other one health issues such as foodborne disease lacking an inter-ministerial 'home' (kimani et al., ) . although challenges exist, the one health approach has been repeatedly employed to mitigate animal and human disease threats, as exemplified by the response to colistin resistant e. coli (crec) in china (wang et al., ) . colistin is used predominantly in the livestock sector but is an important antimicrobial of last resort for human disease. following the discovery of widespread distribution of colistin resistance gene mcr- in e. coli, the chinese ministry of agriculture and rural affairs banned use of colistin as a growth promoter in livestock. three years on, significant reduction was observed in the relative abundance of mcr- in pigs, crec carriage in pigs and chickens, human carriage of mcr- positive e. coli, and human infection with crec. a clearly defined problem and solution, strong political support, and effective inter-agency enforcement contributed to the success of this policy and provides guidance for future approaches to threats to animal and human health. the one health approach will only be as strong as its constituent parts; environmental stewardship is often missed completely, whilst veterinary and human public health systems have often been chronically under-funded in favor of support to primary food production and curative human medicine. strengthening these capacities and meeting countries' commitments under the international health regulations and the oie pathway for veterinary services programmes is integral to the global health security agenda (belay et al., ) . the capacity building activities within the ghsa thus far have relied predominately on external donor funding. ultimately, the sustainability of these activities will require resource commitments by national government and a greater acknowledgement of the role of private actors across food systems (kelly et al., ) . there an increasing number of private standard setting organizations to enhance global food safety such as the global-good agricultural practises standard (king et al., ) . private standards can be excessively high, which improves food safety but may be unattainable for smallholders or farmers in lmics, effectively shutting them out of global markets and further highlighting the need for a collaborative, multi-sectoral approach to food safety. responses to emerging pathogens and outbreaks are often fear driven and reactionary. during the swine flu (h n ) outbreak, egypt culled their entire pig population, despite pigs not transmitting the virus to humans (atlani-duault and kendall, ). traceability systems have become more sophisticated and widespread and can support narrower outbreak responses, yet retailers and governments often issue blanket recalls and import restrictions during health crises (van der vorst, ) . similar to other components of food safety programs, development of and compliance with better traceability systems largely rest with private companies and may not be harmonized with standards set by public health bodies. to improve response time and accuracy during outbreak events, quality traceability systems across the value chain must be combined with transparency and communication with decision makers. prior to such events, governments should develop and train networks of communication that connect food systems agents, trustworthy spokespeople, and consumers to minimize panic and reactionary measures (who et al., ) . national outbreak preparedness plans and risk reduction strategies concerning diseases that originate outside the food system typically do not include considerations for protecting food systems but should be a key factor in planning potential response efforts (ortu et al., ) . localities can contribute to outbreak preparedness by conducting food system vulnerability assessments using fault tree analysis across a range of emergencies (biehl et al., ) . even when food systems are considered in planning exercises, insufficient follow through, lack of resources, or unwillingness to allocate available resources may render such exercises meaningless. policymakers must prioritize action following planning exercises, as emerging infectious disease and food safety events are increasingly likely as food systems become more globalized. corporate concentration of agricultural sectors both horizontally and vertically has resulted in centralizing control of large swaths of the food system among a few companies, reducing the resilience of food system to internal and external shocks (howard, ) . these oligopolies have vast lobbying power, making it difficult to enact structural change. positive change at this level will require market incentives and non-governmental accountability systems similar to what is seen in current efforts to combat climate change (heymann et al., ) . reliance on food imports also increases vulnerability to food insecurity. an estimated / th of the global population in were dependent on food imports for their basic dietary needs (fader et al., ) , leading to an unequal power dynamic between net-exporters & net-importers and undermining the development of locally appropriate value-chains. at the production level, agri-food policies which support local farmers and smallholders can strengthen food system resiliency by increasing the diversity of local food systems and protecting against economic shock. one example is the uk government department for the environment food and rural affairs' farm diversification grant scheme, which helped farmers in the uk develop a diverse portfolio of income sources (turner et al., ) for this reason. support for agricultural diversification among smallholders in lmics can improve food security, reduce poverty, and strengthen resilience to climate change and market instability, resulting in long term increases in productivity (joshi et al., ; world bank, ) . however, there are several obstacles to farm-level adoption of diversified farming systems, including start-up costs, potential initial productivity losses, lack of access to technical guidance or support, and market disencentives such as commodity crop subsidies and insurance (harvey et al., ) . some farm level barriers can be overcome with an institutionally organized systems or landscape approach that incorporates multiple stakeholders to achieve a collective diversification goal. policymakers should work to increase accessibility of diversification tactics, support research to provide further evidence and guidance for diversification, and ensure follow through on these commitments. while the countries in the african union have pledged to enhance financial investment in agriculture, only nine are on track to reach agricultural research spending goals (vilakazi and hendriks, ) . at the consumer level, stable access to food during periods of crisis can be ensured by policies that support emergency food access and flexibility within supply chains. the covid- outbreak underscores the need for policies to support and improve access to food assistance agencies, which not only supply emergency food but also help those in need access benefits, job training, and medical resources (environmental audit committee house of commons, ). food systems have wide and far-reaching impact on health, economy, and society locally and globally, while health issues and our response to them have major impacts on how food systems operate. a sustainable and healthy food system supports fair wages for individuals across the food value chain, provides affordable, nutritious, diets that are culturally acceptable, operates in an environmentally sustainable manner, and is resilient and adaptable. foodborne disease and emerging infectious disease events should naturally decrease as food systems approach these ideals. this vision is far-removed from the current reality but provides a set of priorities through which agri-food policies should be developed. major challenges exist concerning the reorientation of market incentives and food systems standards, heightened 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countries: status, drivers, trends the global syndemic of obesity, undernutrition, and climate change: the lancet commission report emerging diseases and implications for global trade mental health of british farmers livestock production: recent trends, future prospects the implications of eu food safety legislation and consumer demands on supply chain information systems the effects of public funding on farmer's attitudes to farm diversification transforming our world: the agenda for sustainable development global trends in antimicrobial use in food animals product traceability in food-supply chains handbook of quality of life in african societies. international handbooks of quality-of-life changes in colistin resistance and mcr- abundance in escherichia coli of animal and human origins following the ban of colistin-positive additives in china: an epidemiological comparative study taking a multisectoral, one health approach: a tripartite guide to addressing zoonotic diseases in countries role of urbanization, land-use diversity, and livestock intensification in zoonotic emerging infectious diseases productive diversification of african agriculture and its effects on resilience and nutrition, productive diversification of african agriculture and its effects on resilience and nutrition world health organization regional office for europe emergence of african swine fever in china genetic diversity and disease control in rice the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. key: cord- -qylkm tn authors: khosravi, mohsen title: the challenges ahead for patients with feeding and eating disorders during the covid- pandemic date: - - journal: j eat disord doi: . /s - - - sha: doc_id: cord_uid: qylkm tn the coronavirus disease (covid- ) became a global pandemic only a few months after it emerged in china. besides, this pandemic imposed adverse consequences on public health, particularly on the mental health status of individuals with serious mental illness. however, the adverse effects of the covid- pandemic on the patients with feeding and eating disorders (feds) are at this stage unclear. in this letter, the author seeks to acknowledge the risks of worsening feds during this uncertain period. a public health emergency may affect both individuals and communities. individual health, well-being, and safety may be influenced due to feelings of confusion, emotional isolation, insecurity, and stigma. furthermore, communities are affected due to the inevitable closure of schools and workplaces, the economic loss, in addition to the increased demands for medical equipment. these effects may be reflected in a variety of emotional reactions, e.g., distress or psychiatric disorders, as well as unhealthy behaviors, e.g., maladaptive eating behaviors, in both the healthcare professionals and the general population. research has found that emotional distress is ubiquitous in affected populations. indeed, this finding will be echoed in the affected populations in the coronavirus disease (covid- ) pandemic [ ] . despite a lack of definitive studies to evaluate the impact of covid- pandemic on mental health, survey research conducted in china has suggested moderate to severe adverse effects on the mental health in over half of participants [ ] . furthermore, considering the effects of the previous major worldwide health disasters, this pandemic is expected to increases the individuals' stress level and lead to an increased rate of depression and anxiety [ ] . furthermore, individuals who have a previous mental disorder are at higher risk of experiencing mental health status exacerbation owing to the current pandemics [ , ] . thus, this pandemic is expected to worsen the severity of the feeding and eating disorders (feds) symptomatology due to several reasons, some of which are discussed below: food insecurity is defined as the food intake disruption or alteration of eating patterns caused by a shortage of money or other resources. several factors, such as employment, income, ethnicity/race, and disability, affect food insecurity. food insecurity risk is intensified by a shortage of money or lack money [ ] . the covid- pandemic can potentially aggravate feds and the associated mental health symptoms because of the intensified economic limitations resulting in food insecurity (that is, restricted food access caused by economic problems). many studies have suggested an association between food insecurity and binge eating, bulimia nervosa, and obesity [ ] [ ] [ ] . this may be because people have insufficient funds to purchase sufficient food. these episodes of restriction will increase the risk of binge eating through food cravings as well as biological effects of starvation. another explanation, which is maybe complementary, is the stress caused by economic strains may, in turn, promote binge eating. furthermore, it can be stated that the cost of binge eating or the adverse effects of experiencing feds on educational accomplishment or employment visions causes economic disadvantage and food insecurity. additionally, it is established that in families with food shortage, the family members may grow a sense of shame regarding their appetite or a sense of guilt about eating without concerning to take food from others in the family. these guilt feelings may be worsened in underweight patients who are encouraged to eat more than their family members to support weight restoration [ ] . feds may be initiated due to psychosocial stress. studies have suggested that some individuals use disturbed eating behaviors, including binging and purging, for coping with their negative emotions. according to the previous studies on the clinical populations, an association has been found between the stressful events and the worsening of disturbed eating behaviors [ ] . these exacerbations may be caused due to several reasons, such as the stress-triggering impacts of the daily reports of new cases and mortality rate of the disease (some mental health professionals call it "headline stress disorder" [ ] ; worrying about infection and death of their family members [ ] ; the inescapable media coverage on the grocery shopping, food safety, food shortages threats, and "how to control emotional eating"; or the focus of some online contents regarding the pandemic on "how to appear perfect on a webcam") as well as at-home workout challenges can involuntarily strengthen the eating-disorder behaviors and cognitions [ ] . concerns regarding the health and fitness in the quarantine may contribute to feds development in prone individuals. moreover, additional risk factors may increase the risk of feds development. these risk factors include spending more time on social media, and the destructive impact of the thin ideal objectification. loneliness and isolation are common causes of anorexia nervosa, which may be intensified due to the imposed quarantine. the emotional imbalance may cause feds symptoms (i.e., episodes of binge eating episodes followed by purging behaviors) [ ] , while increases external control may reduce the food intake [ ] . family members' maladaptive emotional reactions caused by the quarantine stress may result in aggression and/or splitting and fragmentation [ ] . moreover, the orders of staying at home and the limited food selection choices in stores may make it look rational for some individuals to skip meals or restrict their calorie intake, which will subsequently worsen the preexisting restrictive tendencies [ ] . obeying physical distancing as well as the global mantra of staying at home has challenged the face-to-face hospital programs [ ] . the current disrupted access to reliable cares may attract feds patients to unreliable sources, e.g., social media (i.e., whatsapp, instagram, telegram, etc.) [ ] . moreover, professionals' time limitation for the preparation of feds patients and their families for the treatment change was associated with an intensified fear and feeling of losing control, which was already felt with the covid- spread. online therapy is available for some patients, though experts agree that in the case of absent face-to-face accountability (i.e., absence of weigh-ins), increased self-management is vital for feds patients [ ] . to summarize, the covid- pandemic probably leads to an exacerbation of the mental health of patients with feds owing to the logistic challenges caused by safety protocols developed for covid- [ ] . to conclude, taking into account the confinement and the uncertainty-caused distress in the feds patients who are at higher physical risks (including frailty caused by anorexia nervosa, electrolyte imbalance due to bulimia nervosa, and the cardiovascular risk caused by binge eating) as well as reduced access to the usual treatments [ ] , it is crucial to develop evidenced-based practice. this is in order to diminish the adverse consequences of covid- and learn from this unpredictable crisis for future benefits. availability of data and materials n/a ethics approval and consent to participate n/a consent for publication n/a mental health and the covid- pandemic immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china covid- and mental health: a review of the existing literature timely mental health care for the novel coronavirus outbreak is urgently needed relationship of household food insecurity to health-related quality of life in a large sample of rural and urban women food insecurity and bulimia nervosa in the united states household food insecurity is associated with binge-eating disorder and obesity food insecurity and eating disorder pathology access to evidence-based care for eating disorders during the covid- crisis stressful life events and disordered eating behaviors: findings from project eat letter to the editor: headline stress disorder caused by netnews during the outbreak of covid- the psychological impact of quarantine and how to reduce it: rapid review of the evidence are individuals with loss-of-control eating more prone to dietary lapse in behavioural weight loss treatment? an ecological momentary assessment study binge abstinence is associated with reduced energy intake after treatment in patients with binge eating disorder and obesity covid- and implications for eating disorders eating disorders in the time of covid- covid- related misinformation on social media: a qualitative study from iran publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the author read and approved the final manuscript. the author declares that he has no competing interests.received: july accepted: august key: cord- -a ni s e authors: jackson, ronald s. title: wine, food, and health date: - - journal: wine science doi: . /b - - - - . -x sha: doc_id: cord_uid: a ni s e wine has historically been associated with religious rights, used as a salubrious beverage, employed as a medication as well as a medicinal solvent, and consumed as a food accompaniment. it is the last use that is most intimately associated in the minds of most modern consumers. despite this, there is little flavor commonality on which pairing could be based. the first section of the chapter examines this feature and wine's primary role as a palate cleanser and food condiment. the synergistic role of food and wine in suppressing each other's least pleasant attributes is also explained. the final section deals with the latest evidence relating to the many beneficial health effects of moderate wine consumption, shortfalls in the data, headache induction, dental erosion, and conditions under which wine intake is contraindicated. wine and its association with food have generated an incredible cornucopia of literature. amazingly, few of the views and assumptions have been subjected to scientific scrutiny. only a few research papers deal with the topic. this may relate to their subject disciplines (enology and food science) being in separate departments. also, the funding is different. that for enology and viticulture comes largely from government or industry grants, often based on levies on vineyards and wineries. funding in the food sciences comes largely from commercial firms, much of it done internally by food companies, and such research remains proprietary. funding from disparate industries provides little incentive for collaboration on interdisciplinary projects, such as food and wine combination. much of what is written is by those with an arts rather than a science background. sommeliers, for whom the combination of wine and food is their field, are more practitioners than researcher/academicians. thus, the topic has experienced languor, devoid of scientific rigor. only recently have scientists ventured into a subject normally the prerogative of the epicurean. scientists, being inherently doubters, demand experimental verification. the latter is difficult as designing adequate controls is next to impossible. in addition, the laboratory conditions, required for experimentation, make the relevance of finding to "real life" situations dubious. with food and wine combinations, the social context is often more important to perception than actual sensory clues. finally, social pressures often lead to acceptance of supposed norms. what follows is a brief discussion of the issue of food and wine combination and what can be said with a degree of confidence. in addition, it is hoped that it will provide "food for thought" to those seriously interested in wine. the traditional view is that wine is in some fundamental way designed to be consumed with food. however, when one searches for evidence, it seems to be a mythda view so oft repeated as to be taken as gospeld an example of social contagion of collective memory. wine appears to have been the standard food beverage in the greek or roman worlds. in the near east and egypt, wine was almost the exclusive preserve of the secular and religious oligarchy. in contrast, beer was the beverage of the laboring classes. wine is mentioned in the bible but recommended primarily in relation to religious ceremonies and weddings. it is only in regions where wild grapes grew indigenously that vines came to provide the drink for the masses. its acidity, alcohol, and phenolic contents enhanced its antimicrobial property, making it considerably safer to drink than water. wine's mildly antiseptic properties became increasingly important as population numbers grew, hygienic conditions deteriorated, and water supplies became more polluted. although production was seasonal (unlike beer based on dry grains), wine's comparative resistance to spoilage (isolated from air) permitted wine to become the preferred beverage. in addition, wine's higher alcohol content could temporarily numb the afflictions of a peasant life. although safe and nutritious (calorie rich), there is nothing in its attributes that inherently makes wine ideal as a food beverage. it is actually better suited for one of its ancient secondary roles, a solvent in preparing extracts from medical herbs. the sharp acidity of many ancient wines, often extended with aged seawater and vinegar (especially for slaves), can hardly be considered an ideal food accompaniment, at least from a modern perspective. the resinous flavor donated by storage in standard amphoras (made watertight with an inner coating of pitch) would not have facilitated detecting any subtle fragrances they might have had. the quality of the ordinary wine available to the average roman is probably best left to the imagination. finer wines were available for the patrician classes. these were probably stored in amphoras with a vitreous inner surface, without the need for a pitch lining. the most famous seem to have been or became highly concentrated with age, being almost syrup-like, usually diluted before being consumed. several roman poets eulogized the wonders of particular vintages. even modern wines, with their predominant acidic, bitterish, and astringent character have little to suggest food compatibility. these characteristics are simply the natural consequence of grape chemistry, not conscious intent. admittedly, consuming wine with food does mollify its less pleasant aspects, unless one develops an appreciation for sour beverages with a bitter/astringent aspect. some humans seem adept at coming to appreciate, even crave, perceptions initially repulsive to painful. black coffee, capsicum peppers, durian, and limburger cheese are classic examples. in some instances, the iron content of the wine can induce a metallic sensation, by catalyzing lipid oxidation. this may be masked in combination with food. however, this appears to be unrelated to the fishy aftertaste associated with some white wines taken with seafood (tamura et al., ) . in most "compatible" combinations, both the cheese and wine appear betterdnot by directly enhancing their respective qualities but by mutually suppressing their less pleasing attributes (nygren et al., (nygren et al., , a (nygren et al., , b . other studies have extended these findings, lending support to the view that red wines pair better with cheeses, due to wine tannins appearing more silky (bastian et al., ) . the fatty acid content of the cheese may also contribute to reduced bitterness (homma et al., ) , possibly by coating taste receptors. lipoproteins, typically found in foods, can react with taste receptors, suppressing the perception of bitterness (katsuragi et al., ) . however, the bitter-suppressing aspect of cheeses may also relate to its salt content (frijters and schifferstein, ; breslin and beauchamp, ; keast et al., ) or the presence of glutamate and adenosine monophosphate (keast and breslin, ) . the fruity aspect of wine may also be enhanced when sampled with cheese (galmarini et al., ) . although most cheese/wine associations seem mutually beneficial, some are not, for example, sweet wines and cheese (bastian et al., ) . that compatibility originates from the negation of unpleasant sensations may not be what wine pundits and sommeliers profess, but it seems closer to the truth. this phenomenon may also apply to many supposedly food and wine "marriages." salt's suppression of bitterness (nakamura et al., ) might explain the seemingly ancient habit of adding seawater to wine, e.g., oinos thalassikos (younger, , p. ) . pliny (historia naturalis, . ) also records that salt enhanced the perceived smoothness of wines. columella (de res rustica . ) recommends the addition of salt, apparently to avoid moldy tastes. he also notes salt addition in a recipe for preparing "greek" wine. salt water was even used until recently in preparing new barrels to receive wine (nègre and françot, ) . salt is well known as a flavor enhancer. this may involve disrupting weak, nonvolatile complexes between matrix and aromatic compounds, promoting their liberation and retronasal detection (linscott and lim, ) . in addition, sodium ion hydration may decrease "free water," changing solution polarity. although salt increases aromatic volatility, saltiness is by itself appreciated (bolhuis et al., ) . when one searches for affinities among the attributes of food and wine, one comes up empty-handed. in contrast, there is extensive incongruity. table wines possess gustatory attributes predominantly characterized by sourness, bitterness, astringency, and burning sensations. although pronounced sour tastes are inherently unpleasant, wine's acidity is of value when used as a marinadedpromoting acid-induced hydrolysis of food proteins. wine phenolics can also act as antioxidants, reducing the toxicity of heterocyclic amines (viegas et al., ) and acrylamide (qi et al., ) generated during frying (viegas et al., ) . phenolics are also antimicrobial (nisiotou et al., ) . by comparison, sourness is a rare attribute in most world cuisines (see moskowitz et al., for a marked exception). acids typically are added only as a component in some condiments or flavorants, notably vinegar, lemon juice, or tamarind. they can enhance the flavor of otherwise bland foods. the bitterness and astringency of most red wines also find no equivalent in meat and fish. the protein content of food reacts with both wine acids and phenolics, limiting their activation of taste and touch receptors. in comparison with wines, solid foods are characterized salty, savory (glutamate), sweet, and sebaceous (fatty acids) sensations. sour, bitter, astringent, and hot spicy attributes are (or have been) less common in western cooking and then usually in condiments. the inherent, aversive reactions to such sapid sensations probably arose as a protective response to avoid or limit the consumption of potentially toxic (or rotten) foods. conversely, bitter/astringent/toxic compounds were probably selected during plant evolution to discourage their consumption, with the principal exception of ripe fruit. during domestication, crop variants with reduced aversive and enhanced pleasant-tasting constituents have been propagated. thus, lettuce and other vegetables became less bitter; apples, cherries, and other fruits sweeter and less sour or astringent, citrus fruit less acidic, and legumes less flatulent. food preparation, notably cooking, further facilitated the inactivation or removal of potential food toxins and antimetabolites. examples include fungal toxins, potato alkaloids, and casava cyanogenic glycosides. cooking meat also facilitates digestion (promoting collagen and protein fiber breakdown) and enhances flavor. disappointingly, some cooking processes generate their own toxins, notably roasting and searing. examples are acrylamide (a maillard by-product) and a variety of toxic, pyrolytic, smoke by-products. fermentation is another ancient technique that helped destroy antimetabolites. an example is the action of rhizopus oligosporus degrading soybean flatulence compounds during tempeh production. lactobacillus can also destroy soy saponins. fermentation also has the potential to break down difficult-to-digest oligosaccharides as well as help preserve perishable foods. the aromatic aspects of food and wine equally show little similarity, on which supposed compatibility could be based. wine aromas are most frequently described in terms of fresh fruit, jam, or flowers. none of these is characteristic of the main components of a meal and would be considered odd if present. the hints of "apple" in chardonnay wine may be compatible with chicken, the "pepper" of a shiraz pair with pepper steak, and the "walnut" of some sherries combine with nutcontaining salads (without vinaigrette). however, does the box wood or cat urine of sauvignon blanc, the rose of riesling, and the black currant of cabernet sauvignon really match with any main course? in addition, does the vanilla/coconut of oak or the leather aspect of aged red wines have any inherent compatibility with food? the supposed spiciness of gewü rztraminer wines is given as a reason for its combination with spicy asian foods. however, the wine has more litchi aroma than spiciness, making the stated logic dubious. it is only its intense aroma that may permit its presence to remain noticeable. personally, the best aspect of wine and food association is not their complementary natures but their contrasts. each cleanses the palate between alternate samplings, allowing fresh perceptions of each. thus, wine permits swift shifts in savory sensitivity. without comparable tastes or flavors, where is the supposed inherent rapport between food and wine? is its only justification the reduction of undesirable aspects of the partnership and as a palate cleanser? certainly, wine's ability to partially rinse the palate between food samples is important. it offers both gustatory, olfactory, and trigeminal receptors time to reestablish their native receptive state, countering adaptation and loss of sensory appeal. thus, food appreciation is enhanced by being sampled afresh. wine can, unromantically, be viewed as a savory mouthwash. in addition, volatility of food and wine flavorants is influenced by the dynamically changing concentrations of ethanol, phenols, carbohydrates, etc. supplied with the wine. conversely, food dilutes, masks, and eliminates most wine flavors. the result being that the next sample can be appreciated to its full, adaptation having been avoided. the other aspect of potential compatibility arises from their dissimilar attributes. they act in concert, in a manner similar to condiments, providing flavor accents to enhance and maintain flavor interest throughout the meal. the result can be the creation of a stimulating holistic experience. the typical starchy elements in a meal (rice, potatoes, pasta, bread) supplement the synergy, helping to cleanse the palate and generate a feeling of satiation. however, statements like "wine cuts through fat" are unsupported. if this view has any validity, the partial fat solubility of ethanol may reduce the oily mouth-feel of fats as well as limit the activation of fatty acid taste receptors (running et al., ) , but this is no more than speculation. the acids in wine might also have a similar effect. in addition, wine tannins may denature the g protein receptors responsible for detecting fatty acids in the oral epithelium, giving the impression of less fattiness. conversely, fatty acids can reduce the perception of sourness, astringency (peyrot des gachons et al., ) , and bitterness (mattes, ) , possibly improving mouth-feel. wine phenolics can either reduce (jung et al., ) or enhance (mitropoulou et al., ; villamor et al., ) volatility, depending on the phenolic and aromatic involved. carbohydrates also have the ability to bind aromatics, reducing volatility and significantly modifying wine flavor and its retronasal attributes (voilley and lubbers, ; villamor et al., ) . thus, both synergies of flavor as well as suppression could be involved in "ideal" pairings. saliva-induced changes in flavor chemistry is another compounding issue little investigated. whether such potential reactions are sufficiently marked and rapid to have significance, within the time frame of food consumption, is currently terra incognita. in all the standard discussions of wine and food combinations, the obvious is rarely if ever mentioned. it limits the rate and maximum amount of alcohol reaching in the blood ( fig. . ) . correspondingly, it reduces breath-alcohol content (sadler and fox, ) and diminishes alcohol's performance impairment (millar et al., ) . in addition, by reducing alcohol uptake, its tendency to promote overeating is represseddby limiting activation of hypothalamic agrp neuron activity (cains et al., ) . many aspects of food preference appear to develop in utero, based on what the mother ate during pregnancy (mennella et al., ) and infancy. thus, early exposure can play a significant role in developing personal preferences. subsequently, peer pressure and cultural influences may combine to modify these early dispositions. habituation may not be imbued with the effusive and social appeal associated with the image of predestined food and wine marriages but far better fits the facts than any supposedly heaven-inspired pairings. thus, there is little wonder why there has been scant inclination to investigate lovingly held shibboleths about food and wine associations. however, a dose of reality does not have to destroy long-held views. knowing that michelangelo's sistine chapel consists of no more than brush strokes of pigment on plaster, perceived by photoreceptors in the eye, converted to synaptic impulses reconstructed piecemeal into a perception at the back of the brain, need not ruin art appreciation. ideally, it should enhance the wonder it instills. scientific understanding augments adds new layers of appreciation. if supplemental knowledge were not considered to augment appreciation, why would connoisseurs be so concerned with vintage dates, wine geography, cultivars, or details of vineyard sites and wine producers? with knowledge, it really is the more the merrier. admittedly, scientific realism injected at the wrong time may be a despoiler. for special events, psychological appeal can be more significant than sensory reality. as in other aspects of life, science can occasionally be set aside to permit spontaneity and anticipated pleasure presides. the intrigue of magic is being fooled so effectively. under most circumstances, though, some basic rules of pairing should be kept in mind, to avoid glaring mistakes. in most fine cuisine, flavor balance, combined with suitable complexity, is central. nonetheless, the vagueness of this concept is evidenced by the almost infinite variety of combinations seen in cookbooks, food magazines, and culinary shows. accepted norms also vary markedly among cultures (rozin, (rozin, , . thus, it should not be surprising that almost any wine can pair with almost any meal. there are limits, however, for example a dry gewü rztraminer with dessert or a riesling auslese with bouillabaisse. to almost everyone, these would not be considered "marriages made in heaven." cabernet sauvignon and dark chocolate is another clash but seeming appreciated by some connoisseurs. except where there are clear flavor or intensity disparities, notably sweet/ acid or sweet/bitter-astringent, almost any combination will be found pleasing to some and acceptable to most. of the generalities oft quoted, the "white with white, red with red" dictum bears logic, within the context of balanced flavor intensity. nonetheless, it is often the food preparation mode (e.g., poached, fried, baked, broiled, barbequed) or the condiments added (e.g., chilies, curry, relish, olive oil, tomato sauce, garlic, herbs) that often have the greatest influence on flavor intensity, the basic character of the meal, and correspondingly a compatible wine. in most instances, premium-quality table wines are best sampled prior to the meal and premium-quality dessert wines after the meal. because of their aromatic complexity, detection of these attributes is compromised by combination with food or dessert. alternatively, the food or dessert should be designed to be a foil for the wine and be mild in character. in contrast, the more markedly acidic or bitter/astringent the wine, the more effectively these features will be mollified by association with food. might not this be the most justifiable reason for the pairing most wines with food (other than reduced alcohol uptake)? in addition, a lack in the wine's aromatic interest can be camouflaged by flavors from the food. where little attention is likely to be paid to the wine, inexpensive, nondescript red or white wines are both financial and logical choices. if some food and wine pairings are ill-conceived, are there seraphic duets? clearly some do pair better than others, but transcendental experiences? published accounts of such paradisaical experiences may be no more than figments of a fertile imagination, created to sell wine, newspapers, or magazines. admittedly there is an incredible range in human sensory sensitivityd those having higher than average acuity tending to prefer milder flavored foods, and those with below average acuity tending to prefer more intensely flavored foods. but these are no more than tendencies, with experience and social pressures capable of inducing significant shifts in preference, if not perception. psychological influences and a desire to be influenced can distort perception, creating impressions that are "real," only because of the conditions under which the experience occurred. the more unexpected and astounding the sensation, the stronger the memory trace created. the more the mind is studied, the more we come to realize how the brain can distort perception, based on past experiences. they generate mental models of reality, against which sensations are judged, interpreted, and potentially modified. thus, it is wise to doubt perceptions and attempt to separate experience-based memory patterns from actuality, unless it is a selective choice to allow the mind to potentially deceive us. in addition to the sensory pleasure wine can supply when taken with a meal, it also has health benefits. among other direct benefits noted below, dining with wine can reduce the absorption of oxidized lipids and thereby limit their cardiovascular damage (natella et al., ) . the contrasting social and antisocial effects of alcohol consumption must have become evident shortly after the discovery of winemakingdthe negatives being noted early in the old testament (genesis . ) and vividly described by pliny (historia naturalis, . ). time has only expanded our understanding of this dr. jekyllemr. hyde relationship. it is clear that excessive alcohol consumption, both acute and chronic, can have devastating effects on physical and mental well-being. abusive ethanol consumption can cause cirrhosis of the liver, increase the likelihood of hypertension and stroke, favor the development of breast and digestive tract cancers, induce fetal alcohol syndrome, among others. many of these effects seem to arise from excessive alcohol intake activating of free-radical release and associated immune perturbations (meagher et al., ) . other, more severe, negative consequences may arise indirectly, via the accumulation of acetaldehyde, a major breakdown product of ethanol metabolism (lachenmeier et al., ) . because the problems associated with alcoholism (abrams et al., ; schmitz and gray, ) and its eventual, irreversible, chemical modifications in the brain (nestler and malenka, ; heinz, ) have been extensively reported, they need not be elaborated here. on the other hand, it is becoming equally clear that moderate wine consumption (approximately ml/day) can potentially have health benefits. this is considerably less than the two bottles per day that brillat-savarin ( ) considered a healthy man could consume and live long; or the amounts considered appropriate in times past (younger, , p. ) . mark twain, in characteristic style, crystalized moderation in his view of the temperance movement: "temperate temperance is best" (mark twain's notebook, ) multiple epidemiological studies suggest that daily, moderate, alcohol consumption (thun et al., ; doll et al., ) , and notably wine (grønbaek et al., ; renaud et al., ) , is associated with a reduction in allcause mortality. this is expressed in the now famous jshaped (hormesis) curve ( fig. . ), with earlier mortality being associated with both excess alcohol intake and abstinence. this is particularly evident in the reduced incidence of cardiovascular disease in moderate alcohol consumers. in addition, it reduces the likelihood of type diabetes, combats hypertension, and is correlated with reduced frequency of certain cancers (boffetta and garfinkel, ) . although encouraging to those who enjoy wine, the sharp rise in death risk at much above moderate consumption is of concern. presumably, this relationship would apply equally to morbidity figures, were such data available. however, morbidity unlike mortality is qualitative rather than quantitative and thus its measurement fraught with difficulty. additional dangers associated with anything more than moderate consumption, especially alone, comes from alcohol's progressive enhancing of the memory circuitry involving addictive cravings. these epidemiological correlations are supported by in vivo studies that provide potential molecular explanations for these associations. the principal elements missing, in confirming a causal relationship, involves detailed information on the dynamics of absorption, metabolism, and elimination of the proposed active ingredients. faced with a chemical and beverage that can be not only salubrious but also addictive, the fluctuations in society's attitude toward alcohol are not surprising (musto, ; pittman, ; vallee, ) . thankfully for those in the wine industry, wine drinkers appear less likely to become heavy drinkers (jensen et al., ) or to illustrate those alcohol-related problems that have given alcohol a bad reputation (smart and walsh, ) . in addition, wine has a more positive social image than other alcohol-containing beverages (klein and pittman, ; unwin, ) . the major caveat is the derogatory epithet, wino, ascribed to some unfortunate members of society. the use of wine as a medicine or carrier for herbal extracts has an extensive history. it goes back at least to pharaonic egypt (lucia, ; soleas et al., ) . ancient greek and roman society used wine extensively as a solvent for medicinal infusions. this practice continued largely unabated until the beginning of the twentieth century. the excessive abuse of distilled alcoholic beverages, combined with religious and political conservatism, created a backlash against all beverages containing alcohol, notably in north america. alcohol was viewed as an agent of corruption to be annihilated. following the failure of prohibition, humans themselves, not alcohol, came to be viewed as the source of iniquity. alcoholism is now viewed as a developmental, multistage, chronic dependence, possessing a complex etiology (nurnberger and bierut, ) , with both genetic and environmental aspects. in this regard, it is similar to other addictions (ersche et al., ) . thus, the social climate is changing and the relationship between wine (as opposed to alcohol) and health is again being reassessed and investigated seriously. it is unlikely that doctors will soon be prescribing wine for its health benefits. too often, people have difficulty recognizing the limits of rational use and differ markedly in their metabolism (gross et al., ) . in addition, detrimental influences rapidly counter any benefits at more than light to moderate consumption (often viewed as< mg ethanol/day) (rehm et al., ) . erring on the side of restraint seems judicious, without excessively assuaging pleasure, especially if combined with food. even dietary flavonoid supplements (one of the benefits of wine consumption) can be detrimental, if taken in excess (skibola and smith, ) . wine can be wonderful in moderation but is no panacea. alcohol is the primary by-product of fermentation in many organisms. ethanol is also an energy source for an even larger number of species. thus, it is not surprising that enzymes involved in ethanol metabolism are found in most life forms. in humans, ethanol enters the bloodstream either via the consumption of beverages containing alcohol, and/or from ethanol synthesized by members of the intestinal flora. when the concentration of alcohol is low, most of it is metabolized in the liver before it enters the systemic blood supply. most of the blood coming from the digestive tract passes through the liver before being dispersed to the rest of the body. the liver metabolizes about % of the blood alcohol content, at about ml/h. the rest tends to be lost via the breath or secreted in the urine and other bodily fluids. the rate of alcohol loss is relatively constant over time, with w % reduction within h ( fig. . ). the liver possesses two ethanol metabolizing pathways. the primary, constitutive mechanism involves the oxidation of ethanol to acetaldehyde, via cytoplasmic alcohol dehydrogenases (adhs). of the seven known adh genes (crabb et al., ) , three function in the liver. the others act in the gastric epithelium and other tissues. subsequent metabolism converts acetaldehyde to acetic acid. this occurs principally under the action of mitochondrial acetaldehyde dehydrogenase (aldh ). the cytoplasmic acetaldehyde dehydrogenase (aldh ) is less active. acetic acid is subsequently secreted into the blood or directly converted to acetyl coa. from this point, metabolism may flow along any standard biochemical pathway (see fig. . ). alcohol metabolizing enzymes frequently occur in allelic forms (isozymes). their relative occurrence also tends to vary among ethnic groups. some isozymes possess distinct physiological attributes. for example, adh b* codes for a subunit that oxidizes ethanol slowly, whereas adh b* encodes a highly active subunit of the dimeric enzyme (about times more efficient) (thomasson et al., ) . correspondingly, those individuals who are homo-or heterozygous for the adh b* subunit, eliminate alcohol from the blood more rapidly. rapid alcohol oxidation may donate a degree of protection against alcoholism, by quickly converting ethanol to acetaldehyde. however, if combined with slow-acting alleles for acetaldehyde dehydrogenase (aldh ) (crabb et al., ) , the accumulation of toxic acetaldehyde is enhanced, predisposing the bearer to cancers of the oropharynx and esophagus. those also possessing malfunctional glyoxalase and methylglyoxalase repair enzymes are those most susceptible to such damage (see dingler and patel, ) . a second, ethanol-degradation hepatic pathway becomes activated when blood-alcohol levels become elevated. it involves a microsomal cytochrome, p e (cyp e ). it oxidizes ethanol to acetaldehyde, using molecular oxygen rather than nad þ . regrettably, the microsomal pathway generates free oxygen radicals (meagher et al., ) dmolecules (or ions) with one or more unpaired electrons. these highly reactive oxidants, or reactive oxygen species (ros), can be generated long after alcohol intake ceases. another variant of cyp e occurs in the gastric mucosa, seemingly being more active in men. although most ros are inactivated by glutathione, superoxide dismutase, and catalase, long-term exposure to their presence may induce the slow, progressive accumulation of irreparable cellular damage. metabolizing ethanol to acetate (acetic acid) has the advantage that tissue cells can regulate its transport. this is not the situation with ethanol, which can diffuse freely across cell membranes. transport control is a central tenet in proper cellular function. the ability of ethanol to displace water and its unregulated passage across cell membranes explains much of alcohol's toxicity. in addition, its oxidation to acetaldehyde tends to be more rapid than acetaldehyde's oxidation to acetate. thus, acetaldehyde may accumulate in the blood and other bodily fluids. this is often viewed as an important contributor to the toxicity associated with excessive alcohol consumption (lachenmeier et al., ) . differentiating between these direct and indirect toxic effects of excessive ethanol intake has proven difficult. one of the first physiologic effects of alcohol consumption is a suppression of cognitive brain function. this is most noticeable in enhanced sociabilitydby blocking social inhibitions regulated by higher brain functions. for others, it quickly induces drowsiness (stone, ) . this probably explains why taking a small amount ( e ml) of wine before sleeping often helps those suffering from insomnia (kastenbaum, ) . this amount often provides the benefits of sleep induction, without causing subsequent agitation and sleep apnead often associated with greater alcohol consumption. the effect on sleep may arise from alcohol's modulating the action of inhibitory g-aminobutyric acid (gaba) receptors, while suppressing the action of excitatory glutamate receptors. gaba and glutamate are estimated to be involved in about % of the neurocircuitry of the brain. the level of melatonin in wine is well below those prescribed as an insomnia medication (rodriguez-naranjo et al., ) . another effect on brain function results from a reduction in the secretion of vasopressin. as a consequence, urine production increases, producing the frequently reported diuretic effect associated with alcohol consumption. less well known is how alcohol acts as a crucial regulator of the hypothalamicepituitaryeadrenal axis, modulating the release of hormones such as adrenocorticotropic hormone and corticosterone (haddad, ) . although alcohol has a general depressive action on brain function, the levels of some brain modulators show transitory increases. examples are serotonin and histamine. the latter may activate a cascade of reactions leading to headache production. another of the multiple influences of alcohol is the conversion of hepatic glycogen to sugar. this results in a short-lived increase in plasma glucose content. this, in turn, can cause glucose loss in the urine as well as an increase in insulin release by the pancreas. both result in a drop in blood sugar content. if sufficiently marked, hypoglycemia results. this apparently causes the temporary weakness occasionally associated with alcohol consumption, especially excess intake. in addition to direct effects, the accumulation of acetaldehyde, as a by-product of ethanol metabolism, may have several undesirable consequences. at low rates of alcohol intake, acetaldehyde metabolism is sufficiently rapid to limit its accumulation and liberation from the liver. at higher concentrations, acetaldehyde production rapidly consumes the liver's glutathione reservesda central cellular antioxidant. this coincides with activation of the microsomal ethanol oxidation pathway that generates toxic free-oxygen radicals. in the absence of sufficient glutathione, free-oxygen radicals can accumulate, disrupting mitochondrial function. elsewhere in the body, acetaldehyde can bind with proteins and cellular constituents, forming stable complexes (niemela and parkkila, ) . these can lead to the production of immunogenic determinants, which can stimulate antibody production against acetaldehyde adducts (romanazzi et al., ) . this may induce some of the chronic tissue damage associated with alcohol abuse (niemela and israel, ) . the binding of acetaldehyde to the plasma membrane of red blood cells is known to increase rigidity. by limiting their ability to pass through the narrowest capillaries, oxygen supply to tissue cells may be restricted. this could participate in suppressed brain function. it is estimated that the brain consumes up to % of the blood's oxygen supply but constitutes only about . % of body mass. in addition, acetaldehyde can disrupt dna repair mechanisms. fortified wines (notably sherries) can be a significant source of acetaldehyde (lachenmeier and sohnius, ) . although ethanol and acetaldehyde can produce severe, progressive, and long-term damage to various organs, and incite alcohol dependence, these consequences are minimal to undetectable when alcohol consumption is moderate and taken with meals (serianni et al., ) . as the sections below demonstrate, moderate, daily, wine consumption can have health benefits for the majority of people. wine's major nutritional value comes from its rapidly metabolized, ethanolic, caloric content. alcohol does not need to be digested, prior to being absorbed through the intestinal wall. in rural viticultural areas, wine historically provided a significant source of metabolic energy for the adult population. the caloric value of ethanol ( . kcal/g) is nearly twice that of carbohydrates ( . kcal/g). thus, it constituted a valuable caloric source. it is estimated that alcohol may supply about % of the energy in the average american diet (halsted, ) .wine was also a potable beverage and helped disinfect water to which it was addeddsome bacterial inactivation occurs within seconds (vaz et al., ) . wine contains small quantities of several vitamins, notably several b vitamins, such as b (thiamine), b (riboflavin), and b (cobalamin). however, wine is virtually devoid of vitamins a, c, d, and k. in excess, ethanol can impair vitamin uptake. wine contains various minerals in readily available forms, especially potassium and iron (in the ferrous state). nevertheless, excessive alcohol consumption can disturb the uptake of calcium, magnesium, selenium, and zinc and increase the excretion of zinc via the kidneys. the low sodium/high potassium content of wine makes it one of the more effective sources of potassium for individuals on diuretics. although wine contains soluble dietary fiber, especially red wines (díaz-rubio and saura-calixto, ) , it is insufficient to contribute significantly to the daily recommended fiber content in the human diet. wine has several direct and indirect effects on food digestion. its phenolic (hyde and pangborn, ) and alcohol (martin and pangborn, ) contents activate the release of saliva. in addition, wine promotes the release of gastrin as well as gastric juices. the principal constituent activating the release of gastric juices in red wines is apparently succinic acid, whereas in white wines it is malic acid (liszt et al., ) . they do not activate gastrin release, however. the substance(s) involved in stimulating gastrin secretion are unknown. wine also significantly delays gastric emptying, both on an empty stomach (franke et al., ) or when consumed with food (benini et al., ) . the latter favors digestion by extending the duration of acid hydrolysis. delayed gastric emptying may be a consequence of wine phenolics activating stanniocalcin- cells in the stomach. these possess the same tas r system as bitter-sensitive receptors in the mouth (see finger and kinnamon, ). on stimulus, they release cholecystokinin, a peptide hormone that reduces gut mobility. in addition, wine slows plasma glucose uptake, independent of any insulin response (benini et al., ) . furthermore, at the levels found in most table wines, ethanol activates bile release. wine acids and aromatics also have the same effects. in contrast, the high alcohol contents (e.g., distilled spirits) can suppress digestive juice flow, the release of bile, and induce stomach spasms. wine also aids digestion indirectly by inactivating gastrointestinal pathogens. despite the general beneficial effects of moderate amounts of alcohol on digestion, the phenolic content of red wine may counter some of these influences. for example, tannins and phenolic acids can interfere with the action of certain digestive enzymes, notably a-amylase, lipase and trypsin (rohn et al., ; gu et al., ) . digestion may be further slowed by phenolics polymerizing with food proteins. these effects may be mollified by the presence of ionic carbohydrates found in food (gonçalves et al., ) as well as by salivary proteins. both monomers and proanthocyanidins bind with basic, proline-rich, and histatin proteins in the saliva. their bonding is reversible, depending on equilibrium conditions. they can become irreversible, though, in the presence of metal ions, upon oxidation, or with ph changes (luck et al., ) . normally, these insoluble saliva/tannin complexes remain stable in the stomach and upper alimentary tract (lu and bennick, ) . thus, the inactivation of digestive enzymes or the disruption of mineral uptake by tannins may be limited. degradation of tannin-protein polymers and their moieties subsequently occurs in the colon. in contrast, some pepsin-activated protein breakdown is activated by monomeric phenolics, notably quercetin, resveratrol, catechin, and epigallocatechin gallate (tagliazucchi et al., ) . clearly the action of wine phenolics is complex and much more needs to be known. not only are the effects potentially different in the stomach from that in the small and large intestines, but also the chemical composition of wine phenolics changes during passage through the digestive tract. the wine's phenolic content can also decrease iron and copper absorption in the intestinal tract (cook et al., ) . although nutritionally undesirable, limiting iron bioavailability may reduce the formation of toxic lipid hydroperoxides during digestion. the antioxidant effect of polyphenolics also applies to peroxide generation in the stomach kanner and lapidot ( ); fig. . . the activation of gastric juice release not only aids food digestion but also inactivates enzymes involved in ulceration. even more significant may be the antibiotic action of wine constituents against helicobacter pylori (fugelsang and muller, ) . h. pylori is often considered the primary causal agent of stomach ulceration. thus, moderate wine consumption may have a prophylactic effect in limiting ulcer initiation (brenner et al., ) . the bacterium has also been implicated in gastritis, vitamin b malabsorption, and gastric adenocarcinoma. however, chronic secretion of gastric juice can produce irritation and may provoke ulceration, heartburn, and favor the development of adenocarcinomas in the lower esophagus. wine may further aid human sustenance by increasing nutrient uptake. congeners in wine combine with metallic ions, vitamins, and fatty acids, facilitating their transport across the intestinal wall. consuming wine with food slows the rate of alcohol uptake in the blood ( fig. . ) . in the absence of food, w % of the alcohol is absorbed through the intestinal wall. although the absolute proportion absorbed via the intestines increases when wine is jointly consumed with food, uptake is dispersed over a much longer period. this results primarily by food retarding gastric emptying. consequently, alcohol transfer into the intestines is delayed. this gives the liver more time to metabolize the alcohol, lowering the maximal blood-alcohol level reached. however, taking sparkling wine on an empty stomach can increase short-term alcohol uptake by about % (ridout et al., ) . because the same wine, with its carbon dioxide removed, did not have the same influence, it is suspected that carbon dioxide was the active ingredient (ridout et al., ) . it has occasionally been proposed that carbon dioxide relaxes the pyloric sphincter, allowing earlier transfer of fluids from the stomach into the duodenum and thereby its absorption into the blood. the rate of alcohol metabolism differs considerably among individuals, with rates commonly varying between and mg/kg/h. a person's hormonal and nutritional state also affects their ethanol metabolic rate. gender is also an influencing factor (kaltenback et al., ) . the tendency of women to have a higher body fat content (into which ethanol does not infiltrate), results in their being more rapidly influenced by similar amounts of alcohol (kalant, ) . additional benefits that may accrue from wine consumption are derived from metabolic by-products of proanthocyanin degradation in the colon. they assist protecting the colonic mucosa from the toxic effects of p-cresol production (generated from l-tyrosine) (wong et al., ) . furthermore, wine phenolics may prevent or delay intestinal diseases associated with inflammation and oxidative stress (e.g., inflammatory bowel disease) (biasi et al., ) . finally, wine can have a beneficial cultural/psychologic effect on food intake and digestion. the association of wine with refined eating promotes slower food consumption, potentially permitting biofeedback mechanisms to regulate food intake. in addition, wine consumption can promote a more relaxed lifestyle, something increasingly valuable in our overly compulsive society. whether this explains the reported improved appetite of many elderly and anorectic patients, when wine is taken with the meal, is unknown. wine taken with a meal can enhance the pleasures derived from both but not necessarily those suffering gastroesophageal reflux (acid reflux). this is apparently correlated more with the consumption of white than red wines (pehl et al., ) . most investigations on the health benefits of moderate wine consumption have involved population (epidemiologic) and tissue-culture studies. however, to be confident in their interpretation, intermediate stages needs to be known. this involves details on the uptake and degradation in the intestinal tract, metabolism in the liver, transport, binding, and modification in the blood and lymph, elimination by the kidneys, and cellular uptake and metabolism. although absorption via the intestinal tract is a priori requirement for most activity, it alone does not imply bioavailability at the cellular level. however, this does not apply to influences in the oral cavity and digestive tract. in the mouth and upper intestinal tract, a wine's phenolic constituents remain largely unmodified, except for binding with proteins. in contrast, considerable degradation occurs in the colon. here, large phenolics tend to be metabolized, depending on an individual's colonic flora. for example, hydrolyzable tannins are converted to more easily absorbed, antiinflammatory/anticarcinogenic urolithins (tomás-barberán et al., ) . if absorbed, most phenolics are quickly metabolized in the liver, conjugated with various moieties (e.g., methyl or sulfur groups) by plasma enzymes, and/or eliminated via the kidneys. amounts found in the plasma are often % of that consumed, although this may increase with repeated daily exposure. the proportion of wine-derived flavonoids is estimated at about mg/day/person in the united states (chun et al., ) . this compares with about mg/day/person from all sources. this value would increase to about mg flavan- -ols and mg procyanidin dimers, based on ml of red wine per day (forester and waterhouse, ). that volume is near the upper limit of what is typically considered moderate wine consumption. in the mouth, mid-sized flavonoid polymers often bind to salivary proteins, forming stable complexes (de freitas and mateus, ; pizarro and lissi, ) , slightly delaying their transport to the stomach. passage through the stomach does not modify the majority of wine phenolics. among wine flavonoids, anthocyanins appear to be those that most quickly traverse the stomach and pass into the blood (passamonti et al., ) . flavonoid glucoside uptake is facilitated by gastric glucose transporters (oliveira et al., ) , whereas aglycone uptake occurs by passive diffusion. flavonoids are also effectively translocated across the small intestine lining (talavéra et al., ) . phenolic acids, such as caffeic acid (simonetti et al., ) and resveratrol (soleas et al., ) also readily pass into the plasma via the intestinal tract. in contrast, flavonoid polymers tend to remain in the intestine, until degraded to phenolic acids and aldehydes by the colonic flora (aura, , fig. . ) . also metabolized in the colon are any anthocyanins or catechins monomers that have not already been absorbed and/or microbially degraded. these may enhance the growth of beneficial bacteria (e.g., bifidobacterium and lactobacillus spp.) or their attachment to the intestinal wall (bustos et al., ) . depending on the compound, variable amounts may be absorbed into the blood (ward et al., ) . studies on the bioavailability of phenolics, once in the bloodstream, are still preliminary (williamson and manach, ) . although many simple flavonoids are quickly absorbed into the plasma, most appear to be rapidly conjugated (methylated or sulfated), bound to proteins, transformed to glucuronides, or otherwise modified (williams et al., ; forester and waterhouse, ; xiao and högger, ) . hydroxycinnamic acids are also rapidly absorbed and metabolized into glucuronide and sulfate conjugates (nardini et al., ). this both reduces their toxicity (potential carcinogenicity) as well as facilitating their excretion by the kidneys. however, the latter reduces their potential beneficial effects. in contrast, anthocyanin seems to be efficiently absorbed via the stomach wall, and their metabolites appear to remain in the plasma for several days (kalt et al., ) . short-term studies primarily detect the uptake of phenolic metabolites, whereas long-term studies detect more parental constituents (sandoval-ramírez et al., ) . small amounts of cinnamic acid-tartrate esters are also found in the plasma. these transformations could significantly affect their antioxidant and other attributes as well as their ability to move into tissue cells and their surrounding fluids. most phenolic metabolites retain one or more hydroxyl groups and thus may still possess antioxidant properties. nevertheless, there is growing evidence that phenolic metabolites act primarily as signaling molecules, notably in oxygen-stress-related pathways (williams et al., ) . consequently, smaller amounts are needed than for direct antioxidant reactions. this might explain the discrepancy between the low levels of free phenolics in the plasma and their apparent effects. an example may be the increased activity and the presence of phenolics in the plasma permits their likely uptake into most body tissues. this generality does not necessarily apply to the brain. except where there are specific transport proteins, most compounds above a molecular weight of da are excluded from the brain by the bloodebrain barrier. the barrier consists of tight connections between the endothelial lining of cerebral capillaries. it prevents the diffusion of most molecules from the blood into the cerebrospinal fluid. however, with anthocyanins (passamonti et al., ) and simple flavonols (youdim et al., ) , access to the brain apparently can occur within minutes of consumption. initial animal studies suggest uptake levels in the brain occur at about % that of other tissues (wu et al., ) . although fascinating, consumers are more interested (if at all) in what wines provide the maximal health benefits and under what conditions. regrettably, data on these vital concerns are lacking. grape cultivar, maturity, wine production, maturation and aging conditions all influence the amounts and types of phenolics present and thus their activity. the prophylactic action of wine against gastrointestinal diseases has been known for millennia, long before their microbial origins were ever suspected. in spite of this, the mechanism(s) by which this occurs remain poorly understood. the antimicrobial effect of alcohol was discovered in the late s. nevertheless, alcohol is not particularly antimicrobial, certainly at the concentrations found in wine (its sterilant action is optimal at about %). the antimicrobial action of wine is closely related to that of crushed grapes (Ö ncü l and karabiyikli, ). thus, the antibiotic action of wine likely relates more to its phenolic and acidic (vaz et al., ) contents, although wine's alcohol content undoubtedly augments their effectiveness. anthocyanins, which are weakly toxic to viruses, protozoans, and bacteria, become more so as a consequence of fermentation. other phenolic compounds in wine are bacteriostatic and fungistatic. for example, p-coumaric acid is particularly active against grampositive bacteria (e.g., staphylococcus and streptococcus), whereas compounds, such as quercetin, inhibit pathogenic gram-negative bacteria (e.g., escherichia, shigella, proteus, and vibrio) (vaquero et al., ) . phenolics may also be inhibitory to intestinal pathogens such as clostridium difficile, c. perfringens, and bacteroides (lee et al., ) . despite wine being more effective than mildly antimicrobial agents, such as bismuth salicylate (weisse et al., ) , full action may take several hours (møretrø and daeschel, ; dolara et al., ) . although most studies have involved bacteria grown on culture plates, wine has also been shown to be antimicrobial under simulated gastrointestinal conditions (vaz et al., ) . an indirect effect, limiting intestinal problems, is illustrated by the action of the colon flora on anthocyanin structure. it favors the growth of bifidobacterium and lactobacillus-enterococcus spp. (hidalgo et al., ) . these have been associated with a healthy gut microflora (hord, ) . there is also considerable variation in the effects of different flavanols and procyanidins, both promoting and inhibiting the adhesion of probiotic lactobacilli to the intestinal wall, depending on their metabolic modification during passage through the intestinal tract (bustos et al., ) . in addition, viniferin (a resveratrol derivative) can inhibit biofilm formation by pathogenic pseudomonas aeruginosa and escherichia coli (cho et al., ) . red wine can suppress biofilm formation by oral pathogens (muñ oz- . in most instances, the mechanism by which phenolics have their action is unknown. however, in the case of quercetin, the effect may be partially attributed to its inhibition of dna gyrase, whereas with epigallocatechin, disruption of cell membrane function appears central to its antibiotic action. alternative methods of action may involve suppression of cell adherence and colony formation on the gut lining (selma et al., ; truchado et al., ) . adherence is often a prerequisite for the cascade of events leading to disease development. low ph and the presence of various organic acids appear to accentuate the antimicrobial action of both wine phenolics and ethanol. organic acids may themselves be antimicrobial, as is the case with bacillus cereus (vaz et al., ) . wine is also active against several viruses including the herpes simplex virus, poliovirus, hepatitis a virus as well as rhinoviruses and coronaviruses. the effect on the latter two groups appears reflected in the reduced incidence of the common cold in moderate alcohol consumers (cohen et al., ) , particularly those drinking red wines (takkouche et al., ) . if you have to gargle, port is certainly one of the more pleasant. the antioxidant action of wine phenolics not only appears to play an important role in limiting low-density lipoprotein (ldl) peroxidation (maxwell et al., ; rice-evans et al., ) but also the action of lipoxygenases and enzymes generating ros. phenolics can also directly scavenge (quench) these radicals (e.g., superoxide and hydroxyl radicals), contributing to the action of cellular antioxidants. the oxidized flavonoid byproducts are much more stable (nonreactive) and tend to be quickly metabolized or eliminated by the kidneys. a flavonoid's quenching ability is largely dependent on the location and number of its oh groups as well as its glycosylation, sulfation, methylation, and acylation status (plaza et al., ) . in addition, phenolics can chelate iron and copper, limiting their involvement in radical formation (morel et al., ; rice-evans et al., ) or access to bacterial pathogens. phenolic can also limit the influx of calcium ions associated with oxidative stress (ishige et al., ). an antioxidant relatively unique to wine is resveratrol. it is a stilbene phenolic produced in response to plant stresses. it has greater antioxidant activity than common dietary antioxidants, such as vitamin e and ascorbic acid (frankel et al., ) . there is also direct evidence that resveratrol can enter the blood system at levels sufficient to suppress cyclooxygenase and lipoxygenase pathways. these are involved in the synthesis of proinflammatory mediators (bertelli, ) . in addition, resveratrol can activate proteins involved in nerve cell differentiation, synaptic plasticity, and neuronal survival (tredici et al., ) . supplemental protection may result from ethanol activating the cellular biosynthesis of hydroxytyrosol (a dopamine metabolite) (de la torre et al., ) . hydroxytyrosol is an important antioxidant and antiinflammatory agent. the most clearly established benefit of moderate alcohol consumption, notably wine, relates to a nearly %e % reduction in death rate due to cardiovascular disease (klatsky et al., (klatsky et al., , renaud and de lorgeril, , fig. . ) . alcohol consumption is also correlated with a decrease in the likelihood of intermittent claudication (pain or cramping in the calf of the leg). claudication is a common indicator of peripheral arterial disease. recent studies have confirmed that incidental factors, such as gender, race, lifestyle, educational level, etc. do not affect these results (see mukamal et al., ) . studies have also demonstrated that daily consumption of alcohol significantly reduces the incidence of other cardiovascular diseases, such as hypertension (keil et al., ) , heart attack (gaziano et al., ) , stroke (truelsen et al., ; hillbom, ) , and peripheral arterial disease (camargo et al., ) . those who consume wine moderately live, on average, . e . years longer than teetotalers and considerably longer than heavy drinkers. the prime area of contention is the degree to which these benefits accrue from the effects of ethanol vs. phenolic and/or other constituents (rimm et al., ) . atherosclerosis is the principal cause of most cardiovascular disease (libby, ) . it apparently results from chronic injury to the arteries ( fig. . ) . although associated with several independent factors, most damage is correlated with lipid oxidationda subgroup of cholesterol-apoproteins complexes (ldls). because of the hydrophobic nature of cholesterol and triglycerides, their transport in the plasma requires a special structure. as illustrated in fig. . , lipoprotein complexes consist of an outer membrane of phospholipids, within which apoproteins and free cholesterol occur. they enclose a hydrophobic core possessing numerous triglycerides and cholesteryl esters. metabolism of the enclosed lipids is regulated by the apoproteins in the outer membrane. normally, ldls supply cholesterol for cellular membrane repair and steroid synthesis. however, in high concentrations, they may accumulate in the artery wall. if they remain there for an extended period, their lipid content tends to become oxidized. in an oxidized state, lipids are cytotoxic and indirectly irritate the artery wall. as a consequence, special adhesion proteins attach to the artery wall. monocytes and helper t-cells of the immune system bond to these proteins. in addition, affected endothelial cells may secrete compounds, such as endothelin- . endothelin- activates monocyte and t-cell migration into the artery wall. procyanidins, principally found in red wines, are particularly effective in suppressing the production of endothelin- (corder et al., ) . anthocyanin metabolites are also effective modulators of endothelial function (edwards et al., ) . in the layer just underneath the endothelial lining (intima), accumulated monocytes mature into macrophages. both macrophages and t-cells may release a range of cytokines that further activate the immune system, involving localized inflammation. activated macrophages tend to engulf oxidized ldls. however, as the ldls are not degraded, their progressive accumulation gives the macrophage the appearance of being full of bubbles (termed foam cells). they are the first clear evidence of localized arterial swelling (plaques). occasionally plaques bulge into the vessel. more frequently, they initially enlarge outward into the surrounding tissue. action of immune cells in the plaque also induces migration of smooth muscle cells from the artery wall into the intima. here they proliferate and produce collagen, forming a fibrous cap over the plaque. additional ldls slowly collect, provoking further rounds of inflammation and plaque enlargement. these accretions may develop their own vasculature, becoming fibrous and inelastic. as the plaques enlarge, they may produce irregular protrusions into and block the artery lumen. even without restricting blood flow, plaques set the stage for platelet aggregation, clot formation (thrombus) and the blockage that can precipitate a heart attack or stroke. in the later phases of plaque formation, unknown factors enhance inflammatory changes in the plaque. these disrupt the integrity of the cap. for example, collagenases secreted by macrophages inhibit collagen synthesis by smooth muscle cells. sudden rupture of a plaque permits blood infiltration into the plaque. because plaques contain potent blood clotting factors, thrombus development is almost instantaneous. it is currently thought that plaque rupture is the principal factor inducting thrombus formation and precipitating a heart attack, stroke, or other cardiovascular trauma. atherosclerosis appears to be at least partially reversible, if risk factors such as smoking, high blood pressure, high dietary sources of cholesterol, and possibly infection by pathogens such as chlamydia pneumoniae and cytomegalovirus are eliminated. part of the reversal process involves the action of high-density lipoproteins (hdls). of the two principal forms, ethanol augments the presence of hdl , whereas exercise increases the level of hdl . the effect of ethanol on hdl concentration appears independent of beverage type (van der gaag et al., ) . either form of hdl favors the removal of cholesterol from the arteries, transferring it to the liver for metabolism. hdls also appear to interfere with ldl oxidation. because the hdl/ldl ratio affects the degree and rate of cholesterol turnover, the slower the rate, the greater the likelihood of oxidation (walzem et al., ) and eventual plaque formation. the beneficial effect of moderate alcohol consumption on the hdl/ldl ratio is now relatively clearly established. less well understood is its effect in lowering the concentration of c-reactive protein (crp) (levitan et al., ) . crp is an indicator of inflammation. its level usually rises in correlation with the risk of atherosclerosis. moderate alcohol consumption also reduces the incidence of another risk factor for cardiovascular diseased type diabetes. chronically high values of circulatory glucose, associated with type diabetes, appear to generate high plasma triglyceride and ldl levels. however, the benefits of wine's alcohol content on glucose and insulin metabolism appear not to occur if intake is not coincident with meal consumption (augustin et al., ) . phytoestrogens, such as resveratrol, have a similar effect in reducing triglyceride and ldl contents in the circulatory system (see bisson et al., ) . another of alcohol's beneficial influences involves disruption of events leading to clot formation. platelets are less "sticky" in the presence of alcohol and thus less likely to aggregate, limiting clot formation. alcohol also increases the level of prostacyclin (interferes with clotting) and raises the level of plasminogen activator (a clot-dissolving enzyme). clots, adhering or becoming stuck to the roughened surfaces of narrowed atherosclerotic vessels, may block blood flow. the oxygen deficiency and cell death that result are central to the damage caused by a heart attack or stroke. thus, it is not surprising that inhibitors of platelet aggregation reduce the frequency of these cardiovascular crises and their sequelae. it is the rationale for recommending the daily consumption of acetylsalicylic acid (an inhibitor of platelet aggregation). ethanol (renaud and ruf, ) as well as wine phenolics, such as resveratrol and anthocyanins, have similar effects (fig. . ). an additional example of the beneficial effects of limited alcohol intake is the relation between alcohol dehydrogenase (adh) genotype and the incidence of myocardial infarction. individuals homozygous for adh c* (slow metabolizers of ethanol) are significantly less likely to have a heart attack than heterozygous individuals and even less likely than homozygous individuals for adh c* (fast metabolizers of ethanol) (hines et al., ) . individually, many phenolics, such as resveratrol, catechin, epicatechin, and quercetin appear to have inhibitory effects on platelet aggregation (keli et al., ) . in an in vitro study, though, monomeric or low-molecular-weight flavonoids and hydroxycinnamic acids enhanced platelet aggregation and ldl oxidation, with only large polymers being inhibitory (shanmuganayagam et al., ) . in another investigation, the combined effect of several phenolics was superior to single compounds (wallerath et al., ) . the action partially results from the enhanced synthesis and release of nitric oxide by endothelial cells. this has been found to occur at resveratrol concentrations associated with moderate wine consumption (gresele et al., ) . chlorogenic acid also appears to activate nitric oxide production (mubarak et al., ) . nitric oxide induces vasodilation (by relaxing vascular smooth muscle), reduces blood pressure, and limits platelet adhesion to blood vessel endothelia. indicative of the complexities of such interactions is the observation that flavonoids may also inactivate nitric oxide (verhagen et al., ) . in addition, nitric oxide, notably as peroxynitrite, oxidizes ldls. clearly, much more still needs to be known before a clear picture emerges. in addition to affecting platelet aggregation, wine phenolics can bind directly with ldls (limiting their oxidation), indirectly reduce macrophage-mediated oxidation and preserve the action of paraoxonase (further protecting ldls from oxidation) (aviram and fuhrman, ) . furthermore, red wine phenolics directly or indirectly limit the migration of smooth muscle cells into the intima of artery walls. these influences probably explain some of the added benefits of wine vs. other alcoholic beverages in reducing the incidence and severity of cardiovascular disease. although flavonoids tend to suppress inflammation, conflicting observations put the clinical significance of their antiinflammatory action to atherosclerosis in question. whether this might also apply to the antiinflammatory effects of wine phytoprostanes (degradation products of linolenic acid) is unknown. red wines usually have been credited with superior health-related benefits than white wines, especially relative to cardiovascular disease. this presumably results from their higher flavonoid content (tian et al., ) . this view is supported by studies where white wine has shown the same effects as red wine, when supplemented with grape polyphenolics (fuhrman et al., ) . nevertheless, prolonged skin contact, or choice of particular cultivars, can enhance the presence of phenolic acids in white wine. common phenolics in white wine, such as caffeic and coumaric acids as well as flavonols such as quercetin, are well-known potent antioxidants. the low sodium content of wine is an incidental benefit. it may permit wine consumption by those on a low-sodium diet, for example those with high blood pressure or heart attack victims. the high potassium to sodium ratio of wine ( : ) is also advantageous. as noted, many of the beneficial influences of alcohol and wine consumption show a j-shaped curve ( fig. . ). this also applies to its effect on age-related macular degeneration (obisesan, ; fraser-bell et al., ) . the disease expresses itself as a progressive degeneration of the central region of the retina (macula), leading to blurred or distorted vision. it results as a consequence of local atherosclerosis that deprives the retina of oxygen and nutrients. it is the leading cause of blindness in adults over the age of . a similar relationship has been found for cataract development. in both conditions wine antioxidants are suspected to be the active protective agent. in this regard, quercetin appears to be more protective (against light-induced lipid peroxidation) than either anthocyanin-or phenolic acid-rich constituents (liu et al., ) . however, wines high in ethanol content may undo these benefits, by promoting pro-oxidant action. alzheimer's, a devastating neurodegenerative disease, afflicts more than million people. not surprisingly, researchers have investigated whether wine consumption affects the incidence of this and other neurodegenerative diseases (barnham et al., ) . flavonoids not only activate key respiratory enzymes in mitochondria (schmitt-schillig et al., ) , but also decrease the production of reactive oxygen species, by stimulating the production of catalase, superoxide dismutase, glutathione reductase, and glutathione peroxidase . a pattern appears to apply here, as with most health-related benefits of wine and alcohol consumptiondmoderate intake bing beneficial, whereas high consumption or abstinence is deleterious. alzheimer's disease has been correlated with the accumulation of extracellular amyloid b-peptide (plaque) and the formation of intracellular neurofibrillary tangles containing tau-protein. many in vitro studies have shown that antioxidant compounds, such as vitamin e, protect neurons from b-amyloid accumulation. tannins also inhibit the formation of and destabilize preexisting b-amyloid fibrils (ono et al., ; guéroux et al., ) , whereas resveratrol promotes the degradation of amyloid b-peptides (marambaud et al., ) . wine consumption is also linked to a reduction in the incidence of alzheimer's disease (truelsen et al., ; letenneur, ; luchsinger et al., ) . even mild cognitive impairment and the progression of idiopathic dementia may be reduced with moderate alcohol consumption (solfrizzi et al., ) . grape juice has also been found to be effective in this regard (krikorian et al., ) . like other health benefits, these finding may not, in and by themselves, justify wine consumption, but they are encouraging to those who choose wine as part of their preferred lifestyle. age-related bone mass loss affects both sexes but is more frequent in postmenopausal women. many risk factors including dietary influences and hormonal supplements, can affect its progress and severity. of these factors, moderate alcohol consumption has been found to favor bone retention (ganry et al., ; ilich et al., ) . tucker et al. ( ) found data consistent with higher benefits from wine than other alcoholcontaining beverages. the source of these benefits may be a combination of enhanced calcium uptake, associated with alcohol consumption (ilich et al., ) , the phytoestrogen effects of phenolics, such as resveratrol and kaempferol, or other unsuspected influences. a number of drugs used in treating arthritis tend to irritate the stomach lining. this side-effect may be counteracted by the mildly acidic, dilute alcohol content of table wines. other beneficial effects connected with moderate wine consumption may accrue from its mildly diuretic and muscle relaxant properties. the diuretic action of wine can help reduce water retention and minimize joint swelling. wine can also directly reduce muscle spasms and the stiffness associated with . wine, food, and health arthritis. the antiinflammatory influences of wine phenolics, notably resveratrol (yang et al., ) , may also play a role in diminishing the suffering associated with arthritis and other diseases associated with chronic inflammation (schueller et al., ) . wine consumption has been shown to attenuate insulin-resistance in type diabetes (dixon et al., ; napoli et al., ) . this may result from wine phenolics quenching oxygen radicals, thought to be pivotal in the damage associated with the disease. type diabetes appears to result when body cells fail to respond properly to the presence of insulin. the incidence of metabolic syndrome is also lower in wine drinkers (rosell et al., ) . these effects may be due to one or more of the following: the influences of alcohol on metabolism; the antidiabetic properties of the element vanadium (for which wine is a significant source) (brichard and henquin, ; teissèdre et al., ) ; the hypoglycemic and hypolipidemic effects of phenolics such as resveratrol (su et al., ) ; and/or through some effect on endothelial nitric oxidase synthase (leighton et al., ). it appears there may be considerable specificity. for example, in a comparison between malvidin-and delphinidin- -o-glucosides, only the predominant anthocyanin in grapes (malvidin) seems to have a significant hypoglycemic effect (lida et al., ) . relative to diabetes mellitus (type diabetes), moderate consumption of dry wine was found to present no adverse effects on sugar control (gin et al., ; bell, ) . although wine does contain residual sugars, the most common, fructose, is poorly transported across the gastrointestinal tract. most of what is absorbed is rapidly removed from the blood by the liver, where it is metabolized into glycerol and often stored as fat. it does not stimulate pancreatic insulin release. red wine (and a diet rich in antioxidants) appear to slow the progression of kidney damage (necropathy), occasionally associated with diabetes (zhu et al., ) . in an epidemiological study, knudsen et al. ( ) found a strong link between alcohol consumption and a reduced prevalence of goiter and solitary thyroid nodules. the origin of this apparent protective effect is unknown. drinking water has long been associated with reducing the development of kidney stones. increased urine production is thought to limit calcium oxalate crystallization. what is new is the observation that wine consumption further reduces the production of these painful and dangerous inclusions (curhan, ) . moderate wine consumption has been correlated with reduced incidence in some cancers (see bianchini and vainio, ) (e.g., the kidney) but increased risk for others (notably the throat and gastrointestinal tract) (ebeler and weber, ; parry et al., ) . this potential varies markedly, primarily based on the amounts habitually consumed. for other cancers, moderate consumption appears to be neither protective nor a risk factor (e.g., prostate cancer) (chao et al., ) . conversely, excessive consumption of alcoholic beverages increases the risk of a range of cancers, notably those of the oropharynx, larynx, esophagus, liver, colon, rectum, and breast (connor, ) . because ethanol is not directly carcinogenic, negative associations with alcohol consumption presumably relate to carcinogens potentially present in wines (e.g., ethyl carbamate). thankfully, its carcinogenicity is reduced at the alcohol concentration typical of table wines. more significant, though, maybe acetaldehyde, a common denominator in gastrointestinal cancers (salaspuro, ) . depending on the type of wine consumed, short-term but high concentrations of acetaldehyde may occur in the saliva and gastric juice (lachenmeier and sohnius, ) . acetaldehyde may also accumulate due to the action of alcohol dehydrogenase in the digestive tract, microbial alcohol metabolism (notably the colon), and malfunction of cellular acetaldehyde dehydrogenase. certain wine phenolics can be protective, whereas others mutagenic, especially at high concentrations. for example, quercetin can induce mutations in laboratory tissue cultures but is a potent anticarcinogen in whole-animal studies (fazal et al., ). this apparent anomaly may result from differences in the concentrations of quercetin used, and/or the low levels of metal ions and free oxygen found in the body (vs. tissue culture). in addition, quercetin, along with several other phenolics that are potential carcinogens, lose this attribute when present as a glycoside. most phenolics in the plasma occur in some conjugated state, not as free phenolics. in addition, phenolics may detoxify the small quantities of nitrites commonly found in food. however, in the presence of high nitrite concentrations (a preservative found in smoked and pickled foods), nitrites are converted into diazophenols (weisburger, ) . these appear to favor the development of oral and stomach cancers. potential health issues several phenolics can limit or prevent cancer development through a diversity of effects, such as dna repair, carcinogen detoxification, enhanced apoptosis (programmed cell death), disrupted cell division (hou, ; aggarwal et al., ) , or enhanced immunostimulation (tong et al., ) . for example, resveratrol induces the redistribution of the fas receptor. it is a cellular attachment site for tnf (tumor necrosis factor). its action is part of a sequence that can lead to cancer cell apoptosis (delmas et al., ) . resveratrol is an inhibitor of angiogenesisdthe production of new vasculature essential for most tumor growth. other effects of resveratrol include inhibition of cyclooxygenase- (subbaramaiah et al., ) and cytochrome p a (chun et al., ) . cyclooxygenase- is thought to be involved in carcinogenesis, whereas p a is an important hydroxylase. it can convert several environmental toxicants and procarcinogens into active carcinogens. flavones and flavonols strongly restrict the action of common dietary carcinogens, notably heterocyclic amines (kanazawa et al., ) . it is estimated that these amines, produced during cooking, are consumed at a rate of approximately . e mg per day (wakabayashi et al., ) . antitumor activity is also associated with acutissimin, a flavono-ellagitannin found in oakmatured red wine. the antiallergic and antiinflammatory properties of flavonoid phenolics probably also contribute to the anticancer aspects of these flavonoids (see middleton, ) . the major exception to the general benefit of moderate wine consumption may be breast cancer (viel et al., ) . the connection is more evident in those with the adh c* (fast metabolizers of ethanol to acetaldehyde) (terry et al., ) . however, findings from the long-duration framingham study indicate no relationship between moderate alcohol consumption and the incidence of breast cancer (zhang et al., ) . ethanol, although not itself a carcinogen, can enhance the transforming effect of some carcinogens. another example of a negative effect of wine consumption, at least in excess of moderate intake, is to increase the incidence of mouth and throat cancers (barra et al., ) . alcoholic beverages may also induce a diversity of allergic and allergy-like reactions. in sensitive individuals, these may express as rhinitis, itching, facial swelling, headache, cough, or asthma. the primary culprit inducing bronchial constriction, at least in some asthmatics, is sulfur dioxide (dahl et al., ) . wine containing an abnormally high sulfur dioxide concentration ( ppm sulfite) induce a rapid drop in forced expiratory volume (vally and thompson, ) , recovery taking about e min. the same individuals did not respond to wine containing , , or ppm sulfite. fig. . illustrates the range of sulfur dioxide contents potentially found in californian wine. thus, the sulfite levels normally found in wine seem not to be a major factor in wine-induced asthmatic responses (vally et al., ) . why sensitive asthmatics episodically react to wines with low so content may be related to changes in their asthma control. surprisingly, red wines appear to provoke more asthma problems than white wines, even though red wines typically have lower sulfur dioxide contents than white wines. californian wines (mg/l). reprinted from peterson, g.f., kirrane, m., hill, n., agapito, a., . a comprehensive survey of the total sulfur dioxide concentrations of american wines. am. j. enol. vitic. , e , permission conveyed through copyright clearance center. . wine, food, and health the rapidity of the reaction to sulfite suggests some malfunction in the amount of glutathione in lung tissue or the activity of glutathione s-transferase in reducing sulfite to glutathione s-sulfonate. normally, sulfite is rapidly converted to sulfate by sulfite oxidase in the blood. however, low levels of this enzyme could permit sulfite to persist, provoking a heightened response in hypersensitive individuals. at greater risk are individuals afflicted with a rare, autosomal, genetic disease, caused by a deficiency in sulfite oxidase (shih et al., ; crawhall, ) . affected individuals must live on a very restricted diet, low in sulfur-containing proteins. it is estimated that the synthesis of sulfite, associated with normal food metabolism, generates approximately . g sulfite/day. the sulfites in wine contribute only marginally to this amount but may be temporally significant. because of the gravity of sulfite oxidase deficiency, most affected individuals do not reach adulthood. another allergy-like reaction provokes rapid facial and neck flushing (cutaneous erythema). it develops shortly after alcohol consumption. other symptoms often include peripheral vasodilation, elevated heart rate, nausea, abdominal discomfort, and bronchoconstriction. the syndrome is associated with a malfunctional form of mitochondrial acetaldehyde dehydrogenase (aldh * ) (enomoto et al., ; eriksson et al., ) and is particularly pronounced in the homozygous state. aldh is the principal enzyme oxidizing acetaldehyde to acetic acid. it is estimated that up to % of eastern asians possess at least one malfunctional aldh allele and express some degree of allergy-like reaction to alcohol consumption. it has been suggested that the aldh mutant, frequently found in eastern asians, may reflect an evolutionary adaptation to the endemic occurrence of hepatitis b (lin and cheng, ) . the mutation could have induced alcohol aversion, thereby avoiding synergism between alcohol and hepatitis b-induced liver damage. elevated levels of acetaldehyde appears to activate the release of histamine from mast cells. it subsequently induces vasodilation and an associated influx of blood (flushing). the connection between acetaldehyde and histamine is supported by the action of antihistamines in reducing the reaction, if taken in advance of an alcohol challenge (miller et al., ). an alternative proposal is that this flushing reaction results from a direct, cutaneous, alcohol-induced vasodilation. the phenomenon tends to be suppressed by acetylsalicylic acid (aspirin), if taken in advance (truitt et al., ) . the unpleasant side-effects of acetaldehyde accumulation is used in treating alcoholism. it involves taking disulfiram (a potent inhibitor of aldh) prior to alcohol consumption. a facial flushing, concomitant with alcohol consumption but devoid of other symptoms, is occasionally experienced by caucasians. whether this is related to an aldh malfunction is unclear. the histamine content of wine has frequently been thought to contribute to several allergy-like reactions. however, wine is typically low in histamine content. fig. . illustrates the range found in some wines. thus, it seems unlikely that a wine's histamine content is a major inducer of allergy-like reactions. this is supported by a double-blind study of people, selfreportedly wine intolerant. reactions to two pinot noir wines, differing in histamine content ( . vs. . mg/ l) were not significantly different (kanny et al., ) . other common foods are considerably higher in histamine content, for example cheeses. this does not necessarily exonerate biogenic amines from being somehow involved. people vary in diamine oxidase activity (a histamine inactivator) (wantke et al., ) and how alcohol (via acetaldehyde) suppresses its action . alcohol also can enhance the permeability of the intestinal lining to histamine. in addition, acetaldehyde accumulation can activate histamine release (harada et al., ) . this may explain the benefit antihistamines have in diminishing the rhinitis occasionally associated with wine consumption (andersson et al., ) . in addition, antihistamines counteract the broncho constriction in individuals showing histamine intolerance. idiopathic allergic and other immune hypersensitive responses to wine are difficult to predict or diagnose. reactions may include the induction of headaches, nausea, vomiting, general malaise, or a combination of these. in a few instances, ige-related anaphylaxis reactions have been reported to grape pr proteins (endochitinase and thaumatin) (pastorello et al., ) . the effects may involve urticaria/angioedema (red patches or wheals on the skin/swelling) and occasionally shock. residual amounts of fining agents, such as egg whites, have also been implicated in some allergic reactions (marinkovich, ) . in a double-blind, placebocontrolled trial, wines fined with egg white, isinglass, or nongrape derived tannins presented "an extremely low risk of anaphylaxis" to egg-, fish-, or peanutallergic consumers (rolland et al., ) . in an elisa analysis, only egg white and lysozyme could be detected in wine samples (weber et al., ) . nevertheless, with more than compounds potentially occurring in wine, it is not surprising that some individuals may occasionally show some form of adverse reaction to some wines. in addition to physiological reactions to wine constituents, there is a wide range of equally important psychological responses (rozin and tuorila, ) , both positive and negative. traumatic memories, associated with the first exposure to, or excessive consumption of, a particular beverage can create an association that lasts a lifetime. other people have come to associate certain products with social groups, lifestyles, or behaviors. such attitudes can make the beverage either unacceptable or desirable as the case may be. in the s, there were many reports linking gout with wine consumption, notably port. gout is caused by the localized accumulation of uric acid crystals in the synovium of joints. their presence stimulates the synthesis and release of humoral and cellular inflammatory mediators (choi et al., ) . gout is also associated with reduced excretion of uric acid in the kidneys. mutations in the gene that encodes urease, the enzyme that metabolizes uric acid to allantoin (a soluble by-product), is often implicated in gout. dietary predisposing factors for gout include red meat, seafood, and beer. this is presumably because purines, the principal source of uric acid, are found in higher concentrations in these products than many other foods or beverages. alcohol consumption may occasionally aggravate gout by increasing lactic acid synthesis. it, in turn, favors uric acid reabsorption by the kidneys. despite this, wine consumption appears not be associated with an increased risk for gout. in contrast, it seems to favor reduced serum urate levels (choi and curhan, ) . medical historians suspect the nineteenth century gouteport association was connected with leadinduced kidney damage (yu, ; emsley, emsley, / . samples of port from the nineteenth century show high lead contents. lead contamination probably came from the stills used in preparing the wine spirits added in port production. in addition, the former use of pewter and lead-glazed drinking cups and prolonged storage of port in lead crystal decanters or stemware could have further augmented lead content (falcone, ; guadagnino et al., ) . people occasionally avoid wine because it induces headaches. regrettably, the wine/headache connection is still poorly understood. however, effective differentiation between wine-induced headaches may be pivotal to discovering their causes and possible solutions. one of the most severe headache syndromes, potentially associated with wine consumption, is the migraine. migraines appear to be induced, but inconsistently, by a wide range of environmental stimuli, often in tandem. an association between it and red wine consumption has been noted since roman times. the dilation of cerebral blood vessels, partially associated with histamine release, appears to be a common element in many headache syndromes. migraines may be one of them, although current thought suggests a neurological rather than a vascular origin. in addition, a double-blind study seemingly has exonerated histamine in most redwine-induced migraine headaches (masyczek and ough, ) . in addition, migraine attacks are more often associated with consuming spirits and sparkling wines, both lower in histamine content that table wines or beer (nicolodi and sicuteri, ) . however, the former are often taken alone, leading to more rapid and higher spikes in blood alcohol content. alcohol may be directly involved in migraine induction through vasodilationdby activating meningeal vessel-associated trigeminal neurons (nicoletti et al., ) . alcohol's potential to reduce cerebral glucose metabolism (volkow et al., ) could also be a contributing factor. other potential disruptive aspects on brain function may relate to the slow rate of alcohol metabolism by cerebral adh. thus, more alcohol may be metabolized by cytochrome p e, a process that generates acetaldehyde as well as ros. the more frequent association of red wines with several headache sequelae may be due to their higher phenolic content. on average, red wines contain about mg/l phenolics, vs. mg/l for white wines. some phenolics can suppress the action of platelet phenol sulfotransferase (pst) (jones et al., ; yeh and yen, ) , several isozymic forms (m and p) of which detoxify biogenic amines and phenolics via sulfation. low levels of platelet-bound pst-p have been correlated with migraine susceptibility (alam et al., ) . the accumulation of small phenolics (those readily absorbed) in the blood could prolong the action of potent hormones and nerve transmitters (e.g., histamine, serotonin, dopamine, adrenalin, and noradrenaline). small phenolics can also promote platelet aggregation and blood vessel dilation. the associated increase in intercranial pressure may participate in a migraine attack (pattichis et al., ) . abnormal and cyclical patterns in platelet sensitivity to -ht release in migraine-prone individuals (jones et al., ; peatfield et al., ) may explain the inconsistent association of wine consumption with migraine induction. in the treatment of cluster-headaches, small doses of lithium have been suggested as preventive (steiner et al., ) . because some red wines have a higher than average lithium content, the possibility exists that they might limit the development of, rather than induce, this headache syndrome. another recognized headache syndrome is called the red wine headache (kaufman, ) . it may develop within minutes of consuming red wine, often being dose-related. the headache reaches its peak within w h, tends to fade but returns roughly h later. the headache seems related to the release of type e prostaglandins, important chemicals involved in dilating blood vessels. their release can be activated by phenolics (padilla et al., ) as well as alcohol (parantainen, ) . prostaglandins may also activate pain receptors around blood vessels (wienecke et al., ). this association may explain why prostaglandin synthesis inhibitors (e.g., acetylsalicylic acid, acetaminophen, or ibuprofen) may limit the development of some winerelated headaches (if taken about h before consumption) (kaufman, ) . a separate wine-related headache has been dubbed the red head (goldberg, ) . it develops within an hour of waking, after drinking no more than two glasses of red wine the previous evening. the headache, associated with nausea, is particularly severe when reclining. although the headache is somewhat relieved by standing, it itself exacerbates the nausea. the headache usually lasts a few hours before dissipating. a similar phenomenon has been reported with some white wines, or mixtures of white wine, taken alone or with coffee or chocolates. its chemical cause is unknown (kaufman, ) . because tannins are poorly absorbed in the upper digestive tract, in contrast to monomeric phenolics, the latter are likely the primary phenolic headache activants. this may explain why aged red wines (in which most phenolics occur as large polymers) tend to be less associated with headaches than their younger counterparts. large tannin polymers remain largely unmodified until reaching the colon, where bacteria degrade them (déprez et al., ) . because this can take up to days, they presumably are not (or not recognized to be) involved in wine-induced headaches. phenolic absorbed into the blood are primarily detoxified by being methylated or sulfated but may also become more "toxic" (to o-quinones). the latter can retard the breakdown of dopamine and restrict access to m-opioid (painkilling) receptors, exacerbating the pain associated with cerebral blood vessel dilation. nonetheless, some phenolics (e.g., resveratrol) limit, rather than augment, headache development. it inhibits the expression of cyclooxygenases, involved in the synthesis of prostaglandins (jang and pezzuto, ) . although red wines are generally associated with headache production, white wines are occasionally associated with their production (relja et al., ) . their characteristics and etiology are even less well understood than those evoked by red wines. in some individuals, this situation may be associated with a sensitivity to sulfites but atypically. one of the most recognized alcohol-related headache phenomena is associated with binge drinkingdthe hangover (veisalgia) (wiese et al., ) . although not consistently associated with a headache, it is frequently part of the sequelae. hangovers are characterized by tremulousness, palpitations, tachycardia, sweating, loss of appetite, anxiety, nausea, and possibly vomiting and amnesia . when accompanied with a headache, it possesses symptoms resembling a migraine. the headache may be global but frequently concentrated anteriorly, associated with heavy, pulsesynchronous throbbing. it usually starts a few (w h) after the cessation of drinking, when blood alcohol level is declining and other hangover symptoms have already developed (sjaastad and bakketeig, ; verster et al., ) . duration is seldom more than h. despite its all-too-frequent occurrence, the causal mechanism(s) remains unclear. most data suggest that alcohol-induced cerebral inflammation is the primary cause . this may operate directly via tissue dehydration and electrolyte imbalance (due to vasopressin enhanced urination) or indirectly via the toxic effects of acetaldehyde (quertemont et al., ) . ethanol can also promote hepatic glycogen breakdown, glucose release, loss via the kidneys, and induction of hypoglycemia. in addition, activation of the liver's microsomal ethanol oxidation pathway releases ros, causing cellular damage and multiple metabolic disruptions. that the severity of a hangover may be reduced by prostaglandin synthesis inhibitors suggests that they may also play a role in hangover sequelae (kaivola et al., ) . as the old spanish proverb noted: wine hath drowned more men than the sea because glutathione inactivates free radicals, taking an amino acid supplement (n-acetyl-cysteine) has been suggested as a partial remedy. it is rich in cysteine, an amino acid that forms the core of glutathione. in addition, glutathione facilitates the conversion of acetaldehyde to acetic acid. disruption of membrane function and cerebral neurotransmitter action by acetaldehyde is presumably the rationale for commercial products, such as hangover helper and rebound. they are designed to counter the effects of acetaldehyde. congeners (such as fusel alcohols and methanol) could exacerbate the effects of ethanol and acetaldehyde. however, because their content in wine is low, they are unlikely to be involved in wine-induced hangovers. some purported remedies, such as artichoke extract, have not stood up to rigorous clinical testing (pittler et al., ) , but others, such as an opuntia fiscus-indica (prickly pear) extract, apparently reduced the severity of some hangover symptoms (wiese et al., ) . that hangovers have been associated with deregulation of cytokine pathways (kim et al., ) , may explain the reported value of pyritinol (a vitamin b derivative) as a treatment (khan et al., ) . mineral deficiencies have also been correlated with hangovers (min et al., ) . combined with restraint, taking wine with a meal is probably the best means by which to avoid a hangover. food delays the movement of alcohol into the intestinal tract, thereby slowing alcohol uptake ( fig. . ) and correlating uptake closer to the liver's ability to metabolize ethanol. in addition, delayed transfer to the intestinal tract slows phenolic uptake (and other potential provocateurs). wine tasting is not normally considered a hazardous occupation. however, recent studies show that dental erosion is an occupational hazard (mok et al., ; mandel, ; mulic et al., ) . damage results from the frequent and extended exposure to wine acids, correspondingly, white wines are generally more corrosive than reds (willershausen et al., ) . saliva is diluted and washed away, resulting in the oral ph falling to that of the wine (obreque-slier et al., ) . this causes calcium to dissolve out of tooth enamel, softening and making it susceptible to erosion by masticatory forces and tooth brushing. exposure times as short as min can be harmful (lupi-pegurier et al., ) . demineralization commences at about ph . . dental erosion is unlikely to be a significant problem for the typical consumer who takes wine with meals. food and salivary secretion limit, if not prevent, tooth enamel demineralization. after many years, professional wine tasters may experience tooth disfiguration, affecting both tooth shape and size. cupping, a depression in the enamel, exposing dentine at the tip of molar cusps, is a frequent clinical sign. erosion can also contribute to severe root abrasion at the gum line. the good news is that not all tasters are equally at risk (mulic et al., ) . protection is partially achieved by rinsing the mouth with an alkaline mouthwash after tasting, application of a fluoride gel (such as apf) and refraining from tooth brushing for at least h after tasting. the delay permits minerals in the saliva to rebind with enamel. for more protective protocols see ranjitkar et al. ( ) . the use of remineralizing agents, such as tooth mousse, also helps prevent dental erosion (piekarz et al., ) . in contrast to this risk factor, consuming red wine may have some direct oral benefits. proanthocyanidins can limit the adherence and biofilm-forming activity of caries-inducing streptococcus mutans (daglia et al., ) . gibbons ( ) provides a fascinating insight into the association of this bacterium with changes in human diet which resulted from a switch from a hunter-gather to an agriculture lifestyle. mark twain also made pronouncements about dental health, which might be equally applied to wine: "i always take it (scotch whiskey) at night as a preventive of toothache. i have never had the toothache; and what is more, i never intend to have it". from europe and elsewhere. fetal alcohol syndrome refers to a set of phenomena including suppressed growth, mild mental retardation, and subtle facial abnormalities (wattendorf and muenke, ) . it was first described in and appeared most markedly in the children of alcoholic mothers. they tended also to be heavy smokers, users of illicit drugs, consumers of large amounts of coffee, had poor nutrition, or a combination of these (scholten, ; whitten, ) . although associated with alcohol uptake, the accumulation of acetaldehyde may be the principal toxicant. even more subtle effects have now been associated with alcohol consumption, generating the fetal alcohol spectrum disorders. because the consequences may be lifelong, it is generally recommended that pregnant women, or those desirous of becoming pregnant, refrain from alcohol consumption. although abstinence may be unnecessary (kesmodel et al., ) , erring on the side of caution can supply desired peace-of-mind. this also applies to breast feedingd alcohol in breast milk could be detrimental to infant development. the presence of toxins in wine is seldom mentioned, outside academic circles, presumably because of their minimal presence. the only mycotoxin for which there may be regular analysis is ochratoxin a (o'brien and dietrich, ; varga and kozakiewicz, ) , produced by several black aspergilli (notably aspergillus carbonarius) (somma et al., ) . preliminary data suggests that most ochratoxin a is eliminated (destroyed/precipitated) during and after fermentation/maturation (fernandes et al., ) . other potential mycotoxins that could occur in wine include isofumigaclavine, festuclavine, and roquefortine, all produced by penicillium spp. (moller et al., ) , aflatoxins (el khoury et al., ) from aspergillus flavus, fumonisins from aspergillus niger (mogensen et al., ) , and trichothecenes by trichothecium roseum (schwenk et al., ) . because these fungi are secondary saprophytes, they typically occur only on rotted grapes (thankfully, unlikely on noble-rotted grapes). although the exclusion of all diseased grapes is essentially impossible, their inclusion is limited as much as feasibly possible. pesticide residues are other potential toxins. their levels are usually below those known to be toxic, partially due to regulations limiting their use, precipitation or metabolism during winemaking and degradation during maturation. in addition, most importing countries possess regulations on permissible levels and systems to check for compliance. achieving a zero concentration is probably impossible, if only because of our increasing technical ability to detect their presence at increasingly infinitesimal levels. methanol is present but in amounts insufficient to have any known negative consequences. the same also appears to be true for diacetyl and other potentially toxic compounds. ethyl carbamate, a carcinogen, is no longer likely to occur, since its origin during wine production can be effectively avoided. it may initially be disconcerting to think of trace amounts of toxins in wine, but this situation applies to all food, water, and air. xenobiotics are an inescapable aspect of life, both modern and ancient. their universal presence in the natural environment presumably provided the selective pressures that favored the evolution of organs of detoxification (e.g., the liver and kidneys) and the presence of multiple detoxifying enzyme systems. thankfully, our bodies inactivate most xenobiotics rapidly and effectively, without our conscious knowledge. in addition, governmental agencies set regulations and assess compliance to limit most toxicants to well below known safe limits. as long as exposure to toxicants is kept to a bare minimum, consumers can basically forget they exist. the most important wine contraindication relates to those with a past history of alcohol abuse. for the majority of adults (except pregnant women), moderate wine consumption appears to have significant health benefits. nevertheless, there are several situations in which wine consumption, even in moderate amounts, can complicate or diminish the effectiveness of disease treatment. the acidic nature of wine can aggravate inflammation and slow the healing of ulcers in the mouth, throat, stomach, and intestinal tract. other constituents in wine may also be detrimental in this regard. thus, all beverages containing alcohol are usually contraindicated in cases of gastritis, gastric cancer, and bleeding in the upper digestive tract. nevertheless, the prophylactic action of red wine against helicobacter pylori and the suppression of histamine production by the gastric mucosa (masquelier, ) may require a reconsideration of the old prohibition in mild cases. in the presence of pancreatitis, alcohol is absolutely contraindicated. wine, along with other alcoholic beverages, may provoke gastroesophageal (acid) reflux in individuals prone to this syndrome. with liver disease, the consumption of wine is normally contraindicated. the presence of alcohol puts additional stress on an already weakened vital organ. chronic alcohol abuse can lead to cirrhosis of the liver. in acute kidney infection, wine should be avoided. the consumption of alcohol increases the burden on an organ essential to eliminating toxic metabolic wastes. with prostatitis or genitourinary infections, the consumption of alcohol can complicate matters. the diuretic action of wine may increase the frequency of urination, or conversely it may induce highly painful urinary retention. in epilepsy, the consumption of even moderate amounts of wine may increase the frequency of seizures. consumption should be strictly limited in most situations of hypertension, hemorrhagic stroke, or atrial fibrillation. patients, about to undergo surgery, are advised to avoid all alcoholic beverages well before surgery. this avoids increasing any tendency to enhance intra-and postoperative bleeding (wolfort et al., ) , due to alcohol's reduction of platelet clotting. the consumption of alcohol is also ill advised when eating certain mushrooms. the most well-known example is the antabuse reaction associated if alcohol is consumed with coprinus atramentarius (inky cap). another mushroom generating the same response is boletus luridus (budmiger and kocher, ) . the antabuse reaction derives its name from the trade name of disulfiram, a medication used in the treatment of alcoholism. it functions as an inhibitor of acetaldehyde dehydrogenase. even small amounts of alcohol consumed while taking disulfiram can generate very unnerving reactions (e.g., flushing, sweating, weakness, vertigo, blurred vision, difficulty breathing, nausea, chest pain, palpitation, and tachycardia). in severe cases, the reaction can provoke acute congestive heart failure, convulsion, and death. similar symptoms may develop in sensitive individuals when alcohol beverages are consumed while taking certain medications (e.g., cephalosporins, griseofulvin, chloramphenicol, sulfonylurea, metronidazole). in addition to the reactions noted above, consumption of alcohol while taking certain medications can generate dangerous conditions. most of the literature comes from studies on alcoholics or binge drinkers. this limits the potential applicability of the data to conditions of moderate consumption and when taken with food. nevertheless, even small amounts of alcohol may cause loss of muscle control in people taking tricyclic antidepressants. in addition, red wines can reduce the effectiveness of mao (monoamine oxidase) inhibitors, used in controlling hypertension. long-term acetaminophen use can enhance alcohol-induced kidney damage. other contraindications involve the intensification of the effects of barbiturates and narcotics. in combination with certain antidiabetic agents, such as tolbutamide and chlorpropamide, alcohol can cause dizziness, hot flushes, and nausea. mild reactions may occur with a wide range of other medications, such as sulfanilamide, isoniazid, and aminopyrine. additional details may be found in adams ( ) , fraser ( ) , and weathermon and crabb ( ) . in conclusion, mark twain crystalizes what so often seems to be the 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key: cord- -riu jdc authors: hassink, sandra g.; fairbrother, gerry title: obesity and hunger threaten the foundations of child health date: - - journal: acad pediatr doi: . /j.acap. . . sha: doc_id: cord_uid: riu jdc nan on the face of it, childhood obesity and child hunger seem like very different problems. however a deeper look reveals that the root causes of each are intertwined and overlapping. both are conditions of poverty, both result from lack of nutritious food, and both lead to disease and affect large numbers of children. childhood obesity and food insecurity can co-occur, and in some children food insecurity is associated with an increased risk of obesity. , further, and especially important now: both obesity and food insecurity confer increased risk from covid- and are potentially exacerbated by the stress of food scarcity during the pandemic. food insecurity and obesity in children co-exist with childhood poverty and both are most prevalent in the poorest regions. , , , in , nearly % of households with children and incomes below % of the federal poverty level, were food insecure compared to < % among more affluent households. a study of school districts in massachusetts found an independent relationship between community income status and rates of childhood overweight/obesity indicating that the economic status of a family may be more important than race and ethnicity in childhood obesity prevalence. common systemic factors that may lead to both obesity and food insecurity in economically disadvantaged populations include, poorer access to and higher cost of nutritious foods and a shared food system that advantages lower-cost, high energy dense foods. not surprisingly given the connection with poverty, food insecurity rates vary with economic conditions, with greater food insecurity in economic downturns. in the great recession, food insecurity in households with children jumped from . % in december to a high of . % in june of . by , pre covid- , the overall rate dropped to . %. with the sharply enhanced and continuing rise in unemployment due to covid- restrictions, food insecurity has increased and may even exceed levels seen in the great recession. both obesity and food insecurity result from lack of nutritious food childhood obesity and food insecurity coexist but their relationship is complex. no consistent theories have yet emerged to explain these relationships. however, we know that availability of nutritious food is key to reducing both obesity and food insecurity in children. the underlying causes of food insecurity and obesity have to do with our inability to ensure that all children have a daily food intake that "contains an appropriate density of nutrients, is sufficiently diverse that it supplies adequate but not excessive amounts of nutrition, is palatable and culturally acceptable, affordable and available year round and overall supports normal growth and development". food insecurity may compromise nutritional quality with the purchase of cheaper, more energy dense foods. findings suggest prices of fruits and vegetables and fast food may have some influence on consumption in certain subgroups, such as children and low income families. , in a longitudinal study, children's weight was positively related to fruit and vegetable prices with children in poverty and children at risk for overweight the most price sensitive. affordable food pricing for nutritious foods should be considered when policy makers look at economic strategies to drive purchasing. both obesity and food insecurity lead to disease. both obesity and food insecurity negatively affect child and later adult health and wellbeing. children in food-insecure households have worse general health and are more likely to have asthma, chronic skin conditions and depressive symptoms, colds, stomach problems, and stress. , compromise in immune functioning associated with food insecurity may also compromise overall child health status. in addition, children who are food insecure have a greater risk of hospitalization, and food-insecure households have higher mean health care expenditures than food-secure households. childhood obesity is a multisystem chronic disease and children with obesity are more likely to have high blood pressure, non-alcoholic fatty liver disease, asthma, type diabetes mellitus, polycystic ovary syndrome, sleep apnea, musculoskeletal disorders, and psychological problems. these underlying disease states make children more vulnerable to adverse outcomes if they do contract covid- . cardiovascular disease and type diabetes in adulthood are linked to obesity in childhood. , childhood obesity results in increased healthcare costs from prescription drugs, emergency room visits and outpatient expenditures. it is important to appreciate that access to healthy food is not only crucial to prevention of childhood obesity and hunger, it also constitutes treatment for childhood obesity and the health effects of hunger. withholding healthy food from children with obesity and obesity-related comorbidities is essentially withholding treatment for their disease. both obesity and food insecurity affect large numbers of children. in the united states in - the prevalence rates for childhood obesity were . % in children - yr., . % in children [ ] [ ] [ ] [ ] [ ] [ ] yr., and . % in adolescents - yrs. with an overall prevalence of . %. in , . % of households with children under years were food insecure. if these households were headed by a single man or woman, rates of food insecurity increased to . % and . % respectively. childhood obesity rates have progressed steadily upward from - % in the s to . % in . in contrast, food insecurity rates vary with economic conditions as described earlier. not surprisingly, given the level of food insecurity among low-income households, there are a number of federal programs that provide food for low-income children and families- in the us department of agriculture alone. specific federal programs which "serve as critical supports for the physical and mental health and academic competence of children " are snap, wic, child and adult care food program, school breakfast and lunch program, and the summer food service program food programs like these are opportunities to provide healthy food for children most at risk for food insecurity and obesity. these programs serve a critical role, but they are lacking in important ways, primarily in having inadequate levels of funding and in having requirements that make it difficult for families to access the benefit. both snap and wic are important sources of nutrition for children and infants. snap is the largest federal nutrition assistance program. it provides benefits to eligible low-income individuals and families via an electronic benefits transfer card. this card can be used like a debit card to purchase eligible food in authorized retail food stores. wic provides federal grants to states for supplemental foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and nonbreastfeeding postpartum women, and to infants and children up to age five who are found to be at nutritional risk. , in fiscal year , snap served an average of . million households with children each month, representing % of all snap households. since the recession snap caseloads have declined with states having fewer snap recipients in than in . in states by snap participation had fallen to pre-recession levels and was expected drop even further because of the improving economy instead, in response to widespread unemployment, school and child care closures due to covid- snap enrollment is expected to increase for the foreseeable future. snap is even more crucial in the economic downturn because increased access to and participation in snap reduces the rise in food insecurity for children and risk of obesity in children under . households that experience reduction of snap benefits have increased household food insecurity, child food insecurity, housing instability and energy insecurity. in contrast, wic participation initially dropped with the onset of the covid pandemic due to in person visit requirements, closure of wic offices and enrollment timing limitations. these added to known barriers to wic participation which include ) eligible families not knowing they can apply ) at risk families not perceiving a need for the program ) fears that wic participation may threaten immigration status ) fear of stigma from receiving government aid ) difficulty with transportation ) need to miss work ) stress and ) language concerns. . making wic widely accessible to families hit hard by covid- is crucial because wic has been shown to both reduce the prevalence of food insecurity , and obesity and is an important contributor to early childhood health. . in contrast to snap and wic, which provide funds to households so that they might buy food, other programs provide food directly to recipients in specific sites. both types of programs lessen the burden of food costs on families. the child and adult care food program (cacfp), one of the latter types of program, provides cash reimbursement to family day care, child care centers, homeless shelters, and after-school programs for meals and snacks served to children. attending a cacfp-participating center has been associated with reduction of underweight and overweight with a possible reduction in food insecurity. there have been successful multicomponent intervention trials in child care centers which have prevented excess weight gain especially for children higher weight categories and children with lower socioeconomic status. both center and home-based child care are subject to state and sometimes local or federal regulatory control, representing an opportunity to influence nutrition and feeding practices in a systematic way. participation in school meal programs decreases food insecurity of low-income students during the school year. , and decreases risk of overweight for girls who have food-insecurity school closures due to the covid- pandemic have exacerbated food insecurity by reducing children's access to school meals. summer food assistance via electronic benefit cards, reduced the prevalence of very low food security among school aged children by one third and improved children's dietary quality. food insecurity and obesity are damaging to child health and negatively impact their health as adults. focusing on policies and programs that take aim at the double burden of food insecurity and obesity is a population health priority. this is especially urgent in light of the effects of covid- on availability and access to healthy food. poor diet is now the leading cause of poor health in the us, causing more than half a million deaths per year. the country needs to correct this. the covid- pandemic is laying bare the inequalities in availability of and access to nutritious food. federal nutrition assistance programs should provide access to the healthiest possible nutrition for children and should ensure that all eligible children and families have healthy nutrition year round. overall funding for both snap and wic need to be increased, and specific benefits to families need to rise as well. snap benefits to families were derived from the most meager of usda's four food plans, and even before the pandemic, were inadequate and needed to be increased. , the flexibility of snap-ed to assist in food distribution and enrollment in snap and the pandemic electronic benefit transfer should be increased through and beyond the pandemic. to maximize the health impact of this program particularly in light of the covid- pandemic, barriers to enrollment and participation should be aggressively addressed by state and federal agencies as well as health care systems. studies have shown that adults receiving snap benefits improved their diet quality with an increase of fruit and vegetable intake when they received incentives such as; for every dollar of snap benefits the household spent on fruits and vegetables in participating retailers, cents in snap benefits was added back to their ebt card. , , incentives for healthy food are supported by both adult snap participants and eligible non participants. snap is an ideal vehicle for incentivizing healthy eating both within program requirements and in snap education. states should view increasing participation and lowering barriers to participation part of their public health strategy. healthcare systems should consider snap enrollment part of chronic disease treatment. school meals and snacks may fulfill up to / of a child's daily nutritional however the nutritional content of these meals can be highly variable. policies need to assure that all children will receive a healthy high quality school meal and snack in their school setting. emergency relief during covid- should include requiring fema in conjunction with the usda to coordinate meal distribution through the course of the pandemic, similar to natural disaster relief, extend the expanded electronic benefits transfer through and beyond the pandemic , provide funding relief for school nutrition programs to cover losses incurred during school closures and allow free meals to all children to allow time for processing of new school meal applications in the transition back to school. compared to non-immigrant families, immigrant families are more likely to experience food insecurity. . one quarter of children under , ( , , children in ), have at least one parent who is an immigrant with . % of children in these families born in the us. adults who are documented immigrants who are not part of specific exempt groups i.e. refugees, lawful permanent residents, and have been in the us fewer than years cannot receive snap benefits. however, these families have the right to apply for snap their u.s. citizen children. . nevertheless, studies have shown that eligible children of parents who are immigrants are less likely to participate in snap when their parents are ineligible. a recent study documented a decrease in snap participation among immigrant families and the authors and others suggest that fear among immigrant families related to participation in snap due to public charge rulings, lack of education about enrollment of citizen children, need for assurances of data confidentiality of applicant families, and need to reduce anti-immigrant rhetoric are all important strategies to address food insecurity in this population. , conclusion food insecurity and obesity are damaging to child and adult health. childhood, a time when optimal nutrition essential for healthy growth and development, is being compromised by systemic factors that we can change. understanding the impact and overlap of obesity and food insecurity on child health can help us focus on policies that address the overall state of 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evidence and policy implications for taxes and subsidies body mass index in elementary school children, metropolitan area food prices and food outlet density. public health food prices and weight gain during elementary school: -year update food insecurity and child health maternal depression, changing public assistance, food security, and child health status poverty, material hardship, and depression psychological stress in children may alter the immune response impact of food insecurity and snap participation on a systematic review and meta-analysis estimating the population prevalence of comorbidities in children and adolescents aged to years health consequences of obesity the impact of childhood and adolescent obesity on cardiovascular risk in adulthood: a systematic review investigating the role of childhood adiposity in the development of adult type diabetes in a -year follow-up cohort: an application of the parametric gformula within an agent-based simulation study the impact of obesity on health service utilization and costs in childhood expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report sarah e. barlow pediatrics prevalence of obesity among adults and youth: united states usda nutrition assistance programs characteristics of supplemental nutrition assistance program households: fiscal year caseload and spending declines have accelerated in recent years june snap data tables loss of snap is associated with food insecurity and poor health in working families with snap, young children's health, and family food security and healthcare access associations of food stamp participation with dietary quality and obesity in children special supplemental nutrition program for women, infants, and children participation and infants' growth and health: a multisite surveillance study immigration legal status and use of public programs and prenatal care sources of stigma for means-tested government programs concerns and structural barriers associated with wic participation among wic-eligible women a longitudinal study of wic participation on household food insecurity identifying the effects of wic on food insecurity among infants and children state-specific prevalence of obesity among children aged - years enrolled in the special supplemental nutrition program for women, infants, and children -united states the child and adult care food program and food insecurity the child and adult care food program and the nutrition of preschoolers obesity prevention and obesogenic behavior interventions in child care: a systematic review early child care and education: a key component of obesity prevention in infancy children receiving free or reduced-price school lunch. have higher food insufficiency rates in summer the school breakfast program strengthens household food security among low-income households with elementary school children lower risk of overweight in school-aged food insecure girls who participate in food assistance: results from the panel study of income dynamics child development supplement a summer nutrition benefit pilot program and low-income children's food security us burden of disease collaborators. the state of us health, - : burden of diseases, injuries, and risk factors among us states more adequate snap benefit would help millions of participants better afford food report of the th anniversary of the white house conference on food, nutrition, and health: honoring the past, taking actions for the future early childhood program participation, from the national household education surveys program of effects of subsidies and prohibitions on nutrition in a food benefit program: a randomized clinical trial evaluation of the healthy incentives pilot (hip): final report: prepared by abt associates for the us department of agriculture, food and nutrition service improving the nutritional impact of the supplemental nutrition assistance program: perspectives from the participants feeding low income children during the covid- pandemic nejm a historical review of changes in nutrition standards of usda child meal programs relative to research findings on the nutritional adequacy of program meals and the diet and nutritional health of participants: implications for future research and the summer food service program children in immigrant families: essential to america's future; the foundation for child development the health and well-being of young children of immigrants trends in food insecurity and snap participation among immigrant families u.s.-born young children approaches to protect children's access to health and human services in an era of harsh immigration policy key: cord- - ob okeh authors: feng, tianjun; keller, l. robin; wang, liangyan; wang, yitong title: product quality risk perceptions and decisions: contaminated pet food and lead‐painted toys date: - - journal: risk anal doi: . /j. - . . .x sha: doc_id: cord_uid: ob okeh in the context of the recent recalls of contaminated pet food and lead‐painted toys in the united states, we examine patterns of risk perceptions and decisions when facing consumer product‐caused quality risks. two approaches were used to explore risk perceptions of the product recalls. in the first approach, we elicited judged probabilities and found that people appear to have greatly overestimated the actual risks for both product scenarios. in the second approach, we applied the psychometric paradigm to examine risk perception dimensions concerning these two specific products through factor analysis. there was a similar risk perception pattern for both products: they are seen as unknown risks and are relatively not dread risks. this pattern was also similar to what prior research found for lead paint. further, we studied people's potential actions to deal with the recalls of these two products. several factors were found to be significant predictors of respondents’ cautious actions for both product scenarios. policy considerations regarding product quality risks are discussed. for example, risk communicators could reframe information messages to prompt people to consider total risks packed together from different causes, even when the risk message has been initiated due to a specific recall event. the year was called "the year of the recall" due to the recalls of pet food and children's toys in the united states. ( ) in particular, the pet food contamination crisis led to the widespread recall of more than , pet food products, mainly from menu foods, beginning in march . ( ) according to the u.s. food and drug administration (fda) newsletter, ( ) as of april , , the fda had received consumer reports of approximately , deaths of dogs and , deaths of cats with cases confirmed. further investigation revealed that, though not yet proven, the presence of melamine and melamine-related compounds, such as cyanuric acid, in the ingredients of the affected food appears to be the cause of kidney failure that killed thousands and sickened tens of thousands of pets. meanwhile, on august , , the toy-making giant mattel recalled , toys, including dora the explorer and sesame street toys, due to violations of lead paint standards, which was followed by a rash of toy recalls in august and september . ( ) children who suck on or ingest toys with high lead content may have elevated blood lead levels and may get lead poisoning. this can lead to learning and behavior problems, and at very high levels, seizures, coma, and even death (u.s. centers for disease control and prevention (cdc)). we are interested in how consumers perceive the quality risk of a product under threat of recall and how they make a decision about actions to take upon hearing news of an actual or threatened product recall. here, product quality risk refers to the risk of a product (e.g., health, financial, safety risk, etc.) caused to customers and generated by its inherent quality problems (e.g., in raw materials, ingredients, production, logistics, or packaging). we examine risk perceptions and decisions using the contaminated pet food and lead-painted toys as examples in the same study for a number of reasons. first, pets and children are vulnerable members of a household that adults have a responsibility to protect. second, both involved potentially serious health threats. third, the recalls occurred in the same time span. finally, both products originated in china and were destined for the u.s. market. for these two recalls, there was a great deal of media attention, including anecdotal stories of relatively extreme actions by consumers. for instance, in response to the recall of lead-painted toys, some parents were so concerned and scared that they tested all of their children's toys for lead and threw away the toys on the recall list. ( ) for regulators, consumers, and the companies in the supply chain for these products, it will be valuable to understand the components of people's reactions to such events. this line of work should be helpful in future recalls of other products to gain a quick understanding of likely patterns of consumer reactions. to explore risk perceptions of these two product recalls, we used two approaches that have been widely adopted in the risk perception literature. the first approach was to elicit judged probabilities of the adverse quality risk with respect to these two product recalls. ( , ) specifically, we elicited judged more information about children's risks and opportunities to manage them can be found at http://www.kidsrisk.harvard.edu/, a project created and directed by professor kimberly thompson at the harvard school of public health. the public tends to have different perceptions and attitudes toward risks faced by children and adults, respectively, ( ) and probably the same is true for humans and pets. in addition, while our study focused on making decisions on behalf of a child or a pet, similar decisions might also apply when made for adults (e.g., johnson et al.) . ( ) probabilities that ( ) a dog will die from eating contaminated dog food within the next month (in the case of the dog food recall) and ( ) an under-sixyear-old child will have elevated blood lead levels from playing with lead-painted toys within the next couple of months (in the case of the children's toys recall). we then examined biases in judged probabilities of quality risks of these two products due to using a packed frame (lumping together multiple items) or unpacked frame (listing items separately). we chose to investigate this since companies or regulators in future recall crises would have the ability to frame probability information and other messages using packed or unpacked probability frames. people tend to have an overall higher judged probability for a focal event's occurrence when the description of an event is unpacked into its individual components. ( − ) also tversky and kahneman ( ) showed that when a described specific case seems very representative of a general category, this "representativeness" may lead to higher judged probabilities. in this study, an adverse health effect from the recalled product may be incorrectly seen as more likely to occur than that same health effect from any cause. in the second approach, we applied the wellknown psychometric paradigm ( − ) developed by slovic and his colleagues to further examine risk perceptions of the two product recalls. this approach has been widely adopted to understand and predict people's responses to various risks by identifying similarities and differences among those risks. analyzing newly arising risks and comparing them with existing ones along a number of dimensions will help policymakers understand each new risk and potentially help the general public accurately perceive the risks. accordingly, we considered eight hazardous products and risky situations, including the two recalled products and six additional risks spanning sickness risks from food and nonfood consumer products, on seven qualitative rating scales. the six comparison risks include avian flu (because it poses severe health risks to both birds and humans), ( − ) mad cow disease (bovine spongiform studies of perceived health risks of various human food products have been done on modified food, ( − ) organic food and conventional food, ( − ) salmonella food poisoning, ( ) and general food safety issues. ( − ) little or no attention in this stream of work has been on pet food. perceived health and safety risks of technologies have been done on gene technology, ( ) biotechnology, ( ) nuclear power, ( ) environmental risk and technology, ( − ) and other technologies. ( ) , which has raised consumer anxiety about beef consumption, ( − ) severe acute respiratory syndrome (sars), contaminated spinach, smoking cigarettes, ( − ) and cell phone radiation. this allows us to establish the risk perception map, which helps investigate how these newly recalled products score on factors shown in the past to influence risk perception and how they compare with the six comparison risks. as discussed before, both recalled products originated in china. the well-documented country-oforigin literature emphasizes that a product's origin plays an important role in consumers' perceptions of the product. ( ) thus, we conjecture that the country of origin may influence risk perceptions of the two contaminated products. in this study, we examined this issue for four original sources of products (the united states, china, japan, and mexico). finally, it has been shown that risk perceptions influence people's decisions in risky situations. ( , ) accordingly, we examined people's actions in response to the product recalls. for example, a pet owner may choose to gain more information about the recalls before taking further actions, or a child's parents may decide to throw away all toys at home when they hear about the recall announcements. further, we identified the factors most predictive of their cautious actions. our survey had three versions depending on the information format of the focal events. table i shows the main difference between these three versions of the survey. first, we asked all participants to think about dogs that had eaten the contaminated dog food. in version a, one group of participants reported their estimate of the probability of one of those dogs dying due to eating the contaminated dog food. the version b group was asked what the probability is of one of those dogs dying (with no cause mentioned). in contrast, the version c group received an unpacked framing of the question in version b, in which they judged the probability of one of those dogs dying from eating contaminated food and then judged the probability of one of them dying from other causes. the question design of these three versions was similar for the scenario of lead-painted children's toys, except that we asked respondents to estimate the probability of one of those under-sixyear-old children having elevated blood lead levels (from playing with lead-painted toys, from unspecified causes, or from other causes). each participant received the same version of the questions for both the food and toy scenarios. all the other questions in the survey were the same across all participants, including questions on the characterization of perceived quality risks on various dimensions and on trust in the original sources of products. several other short questions were designed to measure participants' knowledge and actions toward the recalls of contaminated pet food and lead-painted children's toys. to identify there are several other causes that could lead to elevated blood lead levels for young children. according to the case studies from the u.s. center for disease control (cdc), the primary source of lead exposure to children in the united states is leadcontaminated household dust. landrigan ( ) claimed that childhood lead poisoning is the major factor that contributes to the costs of all pediatric environmental disease in the united states, which amount to approximately $ . billion every year. determinants that are significant predictors of respondents' potential actions, we also asked for information about demographic characteristics, such as gender and personal experience with dogs or cats. two hundred and five survey participants, ranging in age from to , were recruited from the human subject pool at the university of california, irvine. (in total, respondents, all enrolled in undergraduate classes, participated in our study. among them, five participants did not complete their survey and thus were removed from the data analysis.) they were randomly assigned to three groups of , , and participants for versions a, b, and c. note that college student samples have been used in several prior risk perception papers. ( − ) participants received one hour of course extra credit. table ii provides the demographic data. eighty-eight percent of the participants were female. approximately % of the respondents and their families have had - dogs and % of them have had more than two dogs. nearly % of the respondents do not have siblings under six years old, but % of them had been a babysitter. survey data were collected through surveymonkey.com, recorded in a microsoft excel spreadsheet and analyzed using the spss statistical software. participants took about to minutes to complete this online survey. statistical analyses included tests of differences in means, factor analysis, anova, multiple regression, and logistic regression. for comparability, a common set of independent variables was used to estimate all regression models. after reading a short description of both the food and toys recalls, respondents gave an estimate of how many dogs died in the united states from contaminated dog food in and how many undersix-year-old children got elevated levels of lead in their blood in the united states from playing with lead-painted toys in . the median responses on these two questions were , dogs (mean: , , sd: , ) and , children (mean: , , sd: , , ), respectively. note that for pet food, approximately , dog deaths were attributed to the contaminated food, according to the fda. the large standard deviations indicated that respondents held varied opinions about impact of the recalled products. trust in institutions is closely related to subjective risk judgments regarding human food quality risks. ( , , ) an individual who trusts less in institutions for food quality information tends to perceive a higher probability of risk. using three -point rating scales, we also asked questions related to participants' trust in institutions, information while this uneven gender distribution was partly due to the fact that female students account for a majority of the university's human subject pool, we believe that such a distribution would also hold for pet food and children's toy shoppers. participants selfselected the experiments they would participate in. those selecting our study were told: "we are conducting a study on how people react to product quality related crises, with a focus on the recent recalls of contaminated pet food and lead-painted children's toys." we further analyzed the relationship between participants' gender and their subjective probability judgment for all three versions, and we did not find significant differences. therefore, we conducted the analyses based on the pooled data from both male and female respondents. sufficiency, and overall concerns about these product quality risks, as shown in table iii . respondents had a fairly good level of trust in the information that the authorities provided on both food (mean = . out of , where is full trust) and toys (mean = . ), but did not think that they had fully received enough information for either recall (mean = . for food, and mean = . for toys). participants were highly concerned about the safety of dog food (mean = . ) and had significantly more concern about toys (mean = . , p < . ). since respondents had a relatively high level of trust in the authorities and concern about these products' safety, but felt they did not have enough information, government agencies and companies could provide people with more information to aid them in making more informed decisions. we first elicited judged probabilities in response to the two product recalls, which are shown in table iv . in survey version a, participants gave an estimate of the number of dogs dying from eating the food within the next month. for instance, if an estimate was , , this participant's judged probability of dogs dying from eating the contaminated food was % = , / , (i.e., participants were told in the survey to suppose that , dogs ate the same contaminated dog food). a similar structure was used for toys. thus, using version a, we elicited participants' subjective probabilities for the two scenarios and found that the mean judged probability of dogs dying from eating the contaminated food was . % and the mean judged probability of children having higher blood lead levels from lead-painted toys a version c (unpacked condition) had a significantly higher mean judged probability than version b (packed condition) at the % level using a t-test (p = . for contaminated dog food and p = . for lead-painted toys). was . %. we believe that our participants tended to overestimate their probability judgments for the potential adverse reactions with these two recalls. this is very likely due to the availability heuristic, ( ) which states that people predict the frequency and probability of an event by the extent to which occurrences of that event are easily "available" in memory. clearly, there was extensive media coverage on the two product recalls during the recall crisis and thus adverse examples could be readily brought to mind for respondents. note that a similar pattern has also been observed in the prior literature on risk perception. for example, by using a large-scale national survey, viscusi ( ) found that both smokers and nonsmokers significantly overestimated the lung cancer risk of cigarette smoking. interestingly, when participants focused on the adverse effects due to the recall event (version a), their answers were higher than when they considered all adverse effects from any cause (version b). this may be seen as falling prey to the representativeness according to the u.s. pet ownership & demographics sourcebook, ( ) there are approximately , , pet dogs in the united states, so roughly every fourth person owns a pet dog (the total population of the united states by july , was around , , based on the population estimates from the u.s. census bureau). the fda received reports that about , dogs died from eating contaminated food with cases confirmed, including the confirmed deaths of cats. assume that only . % of the dogs in the united states had eaten the contaminated dog food during the recall crisis in , which is a relatively low estimate since several major pet food manufacturers recalled more than , products, with most of the recalls coming from menu foods, the largest maker of wet dog and cat food in north america. then the "actual" probability of a dog dying from eating the contaminated food would be as low as . % (i.e., , / , = . %). as a result, respondents apparently generally overestimated the probability of a dog dying from eating the contaminated food. in the case of children's toys, although the real data about the number of under-six-year-old children who had elevated blood lead levels from playing with lead-painted toys during the recall were not available, we suspect that respondents' judged probabilities were higher than the actual probabilities. in , mattel inc., the world's largest toy company, recalled over million chinese-made toys, including dolls, cars, and action figures. from this, one might expect that at least several millions of children could have played with the lead-painted toys. on the other hand, there was very little news coverage on the reports of children's lead poisoning cases due to playing with the lead-painted toys in . consequently, we are led to believe that the actual probability of an under-six-year-old child having elevated blood lead levels from playing with lead-painted toys would be much lower than . %. we are grateful to an anonymous referee for this suggestion. it is possible that participants tend to err on the high side since pets and children are vulnerable in general and there is no cost to overestimating. heuristic of tversky and kahneman. ( ) more specifically, since the vivid and recent stories about product recalls seem to represent well the category of dog deaths or sources of lead paint for children, when people were asked just about adverse effects of the recall event in version a, the high representativeness of the recall to the category may have led to higher probability estimates. in contrast, in version b, the general set of causes of the adverse event may not have been very available in people's imagination, and thus their estimates for the probability of the larger category of adverse events from all causes may have been lower, since it might have been harder to bring to mind other instances of the adverse event not from the recalls. next, we examined biases in judged probabilities of quality risks of these two products due to using a packed frame or unpacked frame. in version b, participants estimated the number of those dogs dying within the next month. since those dogs might die from other possible causes in addition to the contaminated food in the next month (e.g., natural death from aging, dying from a car accident, etc.), version b is a packed frame of the focal event of death. in contrast, version c is an unpacked frame, in which participants explicitly provided an estimate of the number of those dogs dying from eating contaminated food and the number of those dogs dying from other causes. by comparing responses between versions b and c, we examine biases in probabilities due to packing or unpacking of the focal event. for children's toys, we asked respondents to think about those under-six-year-old children who played with the lead-painted toys. hence the focal event in the scenario of lead-painted toys is that an under-sixyear-old child has a higher blood lead level from any cause within the next couple of months. shown in table iv , in the packed condition (b) of the contaminated dog food scenario, the mean probability of dogs dying (from any cause) was . %, while the mean probability of dogs dying from any cause calculated by summing the responses for food-caused and other deaths in the unpacked condition (c) was significantly higher ( . %, t = . , d.f. = , p = . ). the pattern also held in the lead-painted toys scenario (t = . , d.f. = , p = . ). specifically, the mean probability in the packed condition and unpacked condition was . % and . %, respectively. so our result is consistent with support theory ( ) in that people tend to judge an overall higher probability when the description of the focal event is unpacked. this suggests that extensive recall publicity that may focus people's attention on the focal recall event, and thus lead them to mentally unpack adverse health effects into different causes, could lead to overestimating the actual probability. using the psychometric paradigm, we now examine the ratings on seven risk perception dimensions of eight hazardous products or risky situations, including contaminated dog food, lead-painted toys, contaminated spinach, avian flu, mad cow disease, sars, cell phone radiation, and cigarette smoking. we chose to examine contaminated spinach, since it is a contaminated food, like the dog food. we chose to examine sars, avian flu, and mad cow disease since they are health risks beginning in outbreaks outside of the united states with the potential to spread to the united states, like both the dog food and toys. (contaminated beef from mad cow disease could be seen as contaminated food or as a disease without the focus on food.) we chose to examine cell phones and smoking since they involve nonfood consumer products with ear/mouth/nose contact leading to possible adverse health effects, like the toys. for some items, we provided participants with a onesentence description. the seven -point psychometric scales reflecting risk characteristics have been used to characterize perception of risk in previous research. ( , ) the potential influence of these dimensions was suggested in early risk research, ( , ) verified by fischhoff et al. ( ) and applied widely in further work, such as slovic et al. ( ) and mcdaniels et al. ( ) table v describes the seven rating scales of controllability, dread, severity of consequences, voluntariness, known to the exposed, immediacy of effect, and risk newness. four items were described. the contaminated spinach outbreak occurred in september and people faced a risk of getting sick or even dying due to infection from eating uncooked spinach with e. coli bacteria. ( ) avian flu refers to an illness mainly caused by the influenza subtype h n virus adapted to birds and it could lead to clinically severe and fatal human infections through bird-to-human transmissions. ( ) mad cow disease, also known as bse, is a degenerative neurologic disease of cattle that affects the central nervous system and humans could have degeneration of physical and mental abilities, and ultimately die from eating contaminated beef. ( ) severe acute respiratory syndrome (sars) is a viral respiratory disease in humans caused by the sars coronavirus and this highly contagious virus could cause substantial illness and death among the general population. ( ) the mean ratings on the risk dimensions for the eight risks are shown in table vi . among the eight risks, contaminated dog food had the highest mean ratings on the - scale on the dimensions of unknown to the exposed (mean = . , where = precisely known to the dog owners) and newness (mean = . where = old), but the lowest mean ratings in terms of dread (mean = . , where = not dreaded). compared to other contaminated food for human consumption (i.e., spinach and beef), respondents viewed the risk of contaminated dog food to be the least dread. the lead-painted toys were the third most unknown (mean = . ), third most new (mean = . ), and second least dread (mean = . ). meanwhile, sars was rated to be the most uncontrollable risk (mean = . ), the most dread risk (mean = . ), the risk with the most fatal consequence (mean = . ), the most involuntary risk (mean = . ), and the risk of the most immediate effect (mean = . ). this was likely because of the extensive media coverage on the rapidly increasing number of infected cases and death during the outbreak of sars between november and july . in contrast, perhaps due to its prevalence in the general population, cigarette smoking received the lowest ratings on four scales, including controllability (mean = . ), voluntariness (mean = . ), known to the exposed (mean = . ), and newness (mean = . ). cell phone radiation was seen to be the least fatal (mean = . ) and to have its negative effect delayed the most (mean = . ). table vii provides the intercorrelations among the mean ratings of the seven risk characteristics. there were high associations between many scales and no association between a few others (e.g., dread and known to the exposed, r = . ). given that there were sufficiently high intercorrelations for several pairs of the seven risk characteristics, we conducted a principal component factor analysis with a varimax rotation to seek any key factors underlying the seven risk characteristics. the seven characteristics loaded onto the two factors displayed in table viii . the two orthogonal factors explained almost % of the variance, which was sufficiently high to account for the observed intercorrelations. factor was highly correlated with all risk characteristics except risk dread and severity of consequence. factor was highly correlated with both the risk's severity of consequence and risk dread, and moderately highly associated with risk controllability, though a little bit lower than the two risk characteristics mentioned above. thus, as used in the previous literature, we refer to factor as the "unknown risk factor" and factor as the factor of "dread risk." ( , ) following the procedures of slovic et al., ( ) we computed two factor scores for each risk item by weighting the ratings on each risk scale proportionally to the scale's importance in determining each factor and then summing across all scales. note that respondents' ratings on each risk dimension were recoded from the - scale into a scale with endpoints − and , with a midpoint , to highlight the relationship between responses and the scale midpoints. fig. depicts the relative position of each of the eight risks within the two-factor space, with factor on the vertical axis (i.e., "unknown risk") and factor on the horizontal axis (i.e., "dread risk"). this figure is also known as a risk perception map in the literature. ( , ) the upper extreme of factor is associated with risk being unknown, new, involuntary, uncontrollable, and having delayed consequences. items at the far right of factor are construed as dread, having fatal consequences, new, and uncontrollable. from fig. , we observe that contaminated dog food and lead-painted toys almost overlapped in the upper left quadrant, with both being perceived as moderately unknown and relatively neutral on the scale of dread to not dread risks. their location is similar to that found in prior work for lead paint. ( , ) cell phone radiation was also in this quadrant. the most extreme item in the upper right quadrant was sars, which was perceived as highly unknown and dread. in that quadrant, avian flu had a pattern similar to sars, except that it was seen as slightly less dread. one possible explanation is that both of them were contagious diseases and had recently broken out primarily in asia. the two contaminated human food items, mad cow disease (i.e., contaminated beef) and contaminated spinach, were also located in this upper right quadrant. respondents perceived nearly the same level of un-known risks for both contaminated human food and pet food and they considered contaminated human food to be more dread than contaminated dog food. cigarette smoking was located at the lower left quadrant, seen as rather known and slightly not dread. this is consistent with the pattern of smoking found previously. ( , ) finally, note that none of the eight items considered in this study was included in the lower right quadrant, in which risks were perceived to be known but dread (e.g., handguns were found to be located in this quadrant in prior research). ( , ) in this section, we examine country-of-origin effects on risk perceptions of the two contaminated products. specifically, using a -point scale, we asked participants to rate how much they trust products made in the united states, china, japan, and mexico in terms of health and safety risks, how much they are satisfied with those products in terms of a good affordable price with decent product quality, and how much they are satisfied with those products in terms of product quality. as shown in table ix , there were significant differences in the respondents' evaluations between the four countries for each of the three ratings scales above based on an anova. this is consistent with the literature that country of origin has a strong influence on perceived quality or product evaluation. ( , ) moreover, through tukey's tests, we found that for each of the three scales, the united states and japan on average received significantly higher ratings than both china and mexico. however, for each of the three scales, there was no significant difference between the two developed countries, the united states and japan. similarly, between the two developing countries, china and mexico, we might have found insignificant differences since china and mexico were the second a the hypothesis that the means of these three scales between the four countries are equal was rejected at the % level using anova. and third largest countries that the united states imported products from in , with each country accounting for . % and . % of the u.s. annual total imports, respectively (according to the u.s. census bureau, the year report of ). but, interestingly, we found that respondents had significantly higher (more favorable) ratings of products made in china than those of products made in mexico for all three rating scales despite the fact that the focus of our study was on recalled pet food and children's toys that were made in china. we provide an alternative explanation as follows. prior literature suggested that differences in economic development or industrialization levels are an important factor in accounting for the country-of-origin effect, that is, the higher the level of economic development or industrialization, the more favorable is the perception of the quality of its workers, as well as the perceived quality of its products. ( − ) despite the privileged tariff status set by the north american free trade agreement, mexico appears to be losing its u.s. export marketing shares; whereas with its accession to the world trade organization, china has played a very important role in today's world economy, that is, china has become the world's third largest economy since , behind only japan and the united states (cnn news, january , ). this might lead to a difference in people's perceived quality between products made in china and products made in mexico. more interestingly, we found that there was a significant difference in perception of products from asian countries between the asian-american and non-asian-american subjects. the general quality index of products from each country was considered by averaging respondents' ratings of products made in that country on the three scales above, where represents "do not trust/not satisfied," and represents "fully trust/satisfied." specifically, asian- nearly half of the respondents were asian americans in our study (note that according to the undergraduate profile of university of california, irvine, in fall , our sample was quite representative in terms of distribution by race). although we did not ask our subjects how long their family had been in the united states, one may expect a difference in risk perception based on how many years their family has been in the united states, or even a difference in risk perception among different generations of family members. wong-kim et al. ( ) suggested that length of stay in the united states and fluency with the english language affected people's beliefs. bonin et al. ( ) found that there was a difference in risk preference between first-generation immigrants (born abroad) and the second generation (born in the immigrated country). future studies could investigate this. american respondents had significantly lower general quality ratings of products made in china (mean = . ) than non-asian-american respondents (mean = . ) (p < . ). on the contrary, products made in japan received significantly higher ratings from asian-american respondents (mean = . ) relative to non-asian-american respondents (mean = . ) (p < . ). we did not find a significant difference in perceived quality of products made in the united states or mexico between these two groups. this finding makes a contribution to the country-of-origin literature and complements results from public opinion surveys. respondents' possible actions to deal with the product recalls are in table x . participants said they would take a variety of actions when they were asked what they would do with the pet food or the toys at home when they heard about recalls of contaminated pet food and lead-painted children's toys. the pattern was similar for food and toys in that the top three options for both scenarios included "check websites for more information," "read/listen to news coverage," and "throw away all dog food/toys," each of which had more than % of the respondents selecting it. (some participants provided other alternatives, such as "take dogs to the vet for checkup," "purchase dog food without contaminated ingredients," "test child for lead poisoning," "return item and ask for refund," "put them away for a period of time until i have more information about the topic," "sue toy makers if my child has been poisoned," etc.) this suggested that when faced with a product recall event, people may collect more information about the product itself before taking any further actions or simply proceed to take cautious actions (i.e., our results on perceptions of country sources are fairly consistent with other surveys of adult consumers in the united states. in the context of imported food, dewaal ( ) found of the survey respondents who answered a question to place countries/regions in order of concern from greatest to least concern, on average gave the order of china (greatest concern), mexico, european union, australia, canada (least concern). similarly, weise ( ) reported on a usa today/gallup poll of adults (who shop for groceries) showing that products "from china rank highest on those shoppers' suspicion scale: % are concerned about food from china, compared with % concerned about foods from mexico and % concerned about foods from the usa." what would you do with the dog food at your home when you heard that some dog food has recently been contaminated? check all that apply. • check websites for more information * % contaminated • throw away all dog food * % • read/listen to news coverage * % pet • talk with friends about what their experience is with this issue % • cook dog food from fresh ingredients % food • trust store to remove recalled items % • modify use (e.g., give food to bigger dogs, not puppies) % • other % what would you do with the toys at your home when you heard that some toys have recently been recalled due to lead-paint? check all that apply. • check websites for more information * % lead • read/listen to news coverage * % • throw away all toys * % painted • talk with friends about what their experience is with this issue % • test toys for lead % toys • trust store to remove recalled items % • wash toys % • modify use (e.g., give toys to bigger kids, not infants/toddlers) % • other % * actions in bold italic font were selected by more than % of respondents. dispose of the products before complete information has been obtained). we were interested in identifying the determinants of respondents' cautious actions to "throw away all dog food/toys." thus we developed two logistic regression models using maximum likelihood estimation to determine the factors most predictive of their cautious actions for both the contaminated dog food scenario and the lead-painted toys scenario based on the data in version a. table xi shows the results from the two logistic regression models. from this table, we can see that both models had moderate explanatory power in predicting respondents' actions to "throw away all dog food/toys." specifically, respondents' subjective probabilities were found to be a consistent predictor of their cautious actions to "throw away all dog food/toys" at the . level for both product scenarios (wald statistic = . , p = . for dog food, and wald statistic = . , p = . for toys). for example, respondents who had higher subjective probabilities were more likely to choose cautious actions, that is, throwing away all dog food/toys. several other factors were found to be significant predictors in specific product scenarios. in the logistic regression model for the dog food scenario, race was a significant predictor of throwing away all dog food at the . level (wald statistic = . , p = . ), that is, asian-american respondents were more likely to choose to throw away all dog food than non-asian-american participants. this is consistent with the previous country-of-origin finding that asian-american respondents perceived significantly lower quality for products made in china (where the recalled dog food was from) than their non-asian-american counterparts. two of the seven risk dimensions were found to be significant predictors of throwing away all dog food at the . level. dread was positively associated with throwing away all dog food (wald statistic = . , p = . ), which implies that respondents who perceived the risk of contaminated dog food to be more dread were more likely to take cautious actions. conversely, newness was negatively associated with this cautious action (wald statistic = . , p = . ), since, for a new risk, respondents might need to know more about it before they decide to throw away all dog food. respondents who more frequently wear a seatbelt when riding in a car were generally more cautious and more likely to choose to throw away all dog food (wald statistic = , p = . ). in the logistic regression model for the children's toys scenario, trust in authorities was positively associated with the cautious action of throwing away the toys (wald statistic = . , p = . ). this implies in the contaminated dog food scenario, the dependent variable is the action of "throw away all dog food." in the lead-painted toys scenario, the dependent variable is the action of "throw away all toys." b = do not trust/not satisfied; = fully trust/satisfied. we averaged respondents' ratings of products made in china on the three scales to be the general quality index of china in both logistic regression models. * significant at . level; * * significant at . level; * * * significant at . level. that respondents who had more trust in the product recall information provided by the government were more likely to adopt cautious actions against potentially contaminated products. the risk being known to those exposed was also found to be a significant predictor of the cautious action of throwing away all toys at the . level (wald statistic = . , p = . ). so, respondents who perceived the risk of lead-painted toys to be known precisely were more likely to throw away the toys. we examined both the pet food and children's toys product recalls in a single study since we felt that both would have similar response patterns, being products for protected household members where their adverse effects come from ingestion via the mouth. when participants focused on the adverse ef-fects due to just the recall event, their probability answers were higher than when they considered all adverse effects from any cause. so, when faced with a product recall event, extensive news coverage could make the public overestimate the actual probability for potential adverse outcomes. thus, companies or regulators could provide information about future recall risks by putting the current risk in perspective by lumping it with other similar risks. a focus on all risks might lead consumers to display less bias in their probability judgments. however, we also found that when risks are unpacked, the probability judgment is higher than when they are packed together. the challenge for risk communication is to reframe information messages to get people to consider total risks from different causes in a lumped together way, even when the risk message has been prompted by a specific recall event. our results also suggest that there might be a paradox in the value of information when people are faced with a product recall event. on one hand, we find that when a recall is publicized, it can lead to greater overestimation of the actual probability for potential adverse outcomes associated with the focal recall event. this implies that more information leads to an upward bias in people's subjective risk judgments. on the other hand, we found that "check websites for more information" is the option that people choose the most during the outbreak of a product recall. that is, more information is desirable for the general public before they make their product use/disposal/repurchase decisions. more empirical research is needed to examine this possible paradox in the effect of added information when product quality risks are involved. our results could also help policymakers frame additional information gathering efforts. questions that could be investigated regarding pet food and toy safety include: at what level of perceived risk would individuals call the emergency ( ) number or the poison control center? when would they use government resources to help mitigate risk? if the government or an agency recommended that they throw out the items, would they comply? are the respondents concerned about the businesses that might suffer from the recall? risk communication has also been examined from a sociological perspective. ( , ) for instance, mileti and fitzpatrick ( ) constructed a model to describe public perception and response to communication about natural hazards risks. they found that additional communications encouraged personal search for more information. more specifically, from the information processing perspective, people's response to hazard information can be divided into eight stages: ( − ) ( ) receiving the warning; ( ) understanding the warning; ( ) believing the warning; ( ) confirming the threat; ( ) personalizing the threat; ( ) determining whether or not protective action is needed; ( ) determining whether protective action is feasible; and ( ) taking protective action. note that although our work originated from a psychological perspective, our study does contribute to several stages in the above framework, such as stage (how probabilistic information is understood in different formats), stage (participants' trust in institutions), and stages , , and (analysis of participants' actions). our results on perceptions of toys with lead paint risks are timely since the united states has recently enacted higher safety standards for toys with lead paint risks via the consumer product safety improvement act (cpsia), which added certification and testing requirements for all products subject to cpsc standards or bans, including lead in paint on toys. this is consistent with consumers' opinions regarding lead paint in toys. however, the cpsc recently issued a one-year stay of enforcement until february , for certain testing and certification requirements of the cpsia for manufacturers and importers of regulated products, including products intended for children years old and younger. the stay of enforcement permitted toy providers to not have to prove they had tested their products, but they were still required to meet the lead standards. food safety also is a continuing public concern. at the national center for food protection and defense, founded in at the university of minnesota, researchers are working on developing best practices for effective risk communications related to potentially catastrophic food bioterrorism incidents from a practice-oriented viewpoint. they have developed a risk communication tool kit and several case studies, including one on the schwan's salmonella crisis ( ) and one on tainted strawberries. ( ) similarly, our findings on country of origin of products are timely, since the u.s. department of agriculture's mandatory country-of-origin labeling program's final regulation became effective on march , , requiring labels for meat, fish, fruits, vegetables, and some nuts. this recent labeling policy is also consistent with consumers' opinions. in addition, the american veterinary medical more specifically, lead paint in toys is of broad concern as demonstrated in the nationwide pew food safety survey ( ), where , u.s. adult interviewees were asked whether they considered "toys for children being made with unsafe materials, such as lead-based paint" to be a serious problem. fifty-seven percent said it was a "serious problem that is fairly common," and % said it was a "serious problem that rarely occurs." a larger percentage felt that toys were a fairly common serious problem than were prescription medications marketed prior to adequate testing ( %), fresh fruits and vegetables contaminated with bacteria that make them unsafe to eat ( %), or automobiles having flaws or faulty parts making them unsafe to drive ( %). for example, among u.s. respondents (who described themselves as interested in food safety) in an august u.s. food safety survey by the center for science in the public interest, . % were very concerned with the safety of domestically produced foods and . % were very concerned with the safety of imported foods. regarding u.s. food safety, % of the consumers in the dewaal ( ) survey were very supportive of association also approved policy changes on june , to use "pet food health claims" to replace the existing policy on "pet food therapeutic claims," which indicated the increasing attention on health aspects of pet food. during the summer of , there was a new food contamination outbreak of the salmonella saint paul strain in the united states, apparently from fresh vegetables. ( ) at first thought to be in tomatoes, later investigations pointed toward jalapeño or serrano peppers grown with contaminated water on a farm in the state of nuevo leon in northeastern mexico as the potential source. ( ) our work can help shed light on such an evolving issue in the multinational food supply chain, both by providing a template for future surveys on evolving risks and by examining our results on the pattern of responses for products from different countries (in this case from mexico) and where other contaminated food items fell in the factor analysis in fig. . contaminated spinach was near dog food on the vertical axis at moderately unknown risk and spinach was a bit more dread than dog food on the horizontal axis. mad cow disease was even more dread. for future recall events, an examination of where the new risk falls on these dimensions could aid in understanding how the public might react. following the recent media focus on product quality risks in the contaminated pet food and leadpainted toy recalls, we examined risk perceptions and decisions related to these two recalls. two approaches were used to explore risk perceptions of the product recalls. in the first approach, we elicited judged probabilities and found that people appear to have greatly overestimated the actual risks for both product scenarios. in the second approach, we applied the psychometric paradigm to examine risk perception dimensions among eight health risks. it was found that the contaminated dog food was most unknown, most new, but least dread. the lead-painted toys were the third most unknown, third most new, and second least dread. examining these results via factor analysis, we found that both contaminated dog food and lead-painted toys were near each other and near contaminated spinach and cell phone radiation in the two-factor space of the risk perception map, country-of-origin labeling. eighty percent would support more detailed labeling, down to region, country, state, and farm. and had similar patterns to what prior research found for lead paint. further, we found that the top three actions would be the same under the scenario of people hearing of pet and child risks: "check websites for more information," "read/listen to news coverage," and "throw away all dog food/toys." as could be expected, a higher subjective probability of quality risks was significantly associated with arguably more cautious actions, such as "throwing away all dog food/toys." taken together, our results suggest that educating consumers about product quality risks can ultimately help them make better informed decisions, based upon more realistic assessments of actual risks. the year of the recall fda limits chinese food additive imports food and drug administration (fda) news alert consumer product safety commission news. mattel recalls various barbie r accessory toys due to violation of lead paint standard valuation of childhood risk reduction: the importance of age, risk preferences, and perspective are adult patients more tolerant of treatment risks than parents of juvenile patients? risk analysis thomas tank engine toy recall angers parents violence risk assessment and risk 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studies in crisis communication crisis plans and interagency coordination: lessons learned from tainted strawberries in the school lunch program salmonella "smoking gun" located grown jalapeño and serrano peppers not connected to salmonella saintpaul outbreak the authors gratefully thank the editor michael greenberg, the area editor ann bostrom, and three anonymous reviewers for their extremely thoughtful and constructive reviews, which have significantly helped improve the article. portions of this work were supported by grants to professor tianjun feng from the national natural science key: cord- -zkavusvu authors: benton, tim g. title: covid- and disruptions to food systems date: - - journal: agric human values doi: . /s - - - sha: doc_id: cord_uid: zkavusvu nan we live in a world dominated by the neo-liberal idea that consumption-driven growth of economies, accessing globalised trade, is the best way to drive global development. global competition drives down prices, allowing countries with comparative advantage to create goods for consumption elsewhere. efficiency, in the name of cheaper goods, means redundancy is removed. the food system is a crucial exemplar of this: in the uk food comes into the country at more-or-less the speed it is sold in supermarkets. the downside from supplying an abundance of cheap goods is that the globalised system is also fragile. if it breaks, then goods we rely on disappear off shelves and prices rocket. in / and again in / climate shocks, coupled with low transparency of international stocks, led to the perception that food would be rare, countries instituted export bans, markets panicked, international food prices spiked, and food riots broke out around the world (homer-dixon et al. ; puma et al. ) . amongst other things, the food price riots sparked the arab spring (natalini et al. ), contributing to a long-lasting geo-political reconfiguration of the middle east. the last decade's food price spikes created a focus on the potential for climate-change driven disruptions on food systems (challinor et al. ). climate change is not only about new extremes of weather that may disrupt on our food systems, but is also likely to create new challenges through new pests and diseases of crops and livestock, that disrupt agriculture: as climate changes, pests and diseases move, and there are opportunities for them to escape from natural ecological mechanisms that keep them under control (bebber et al. ) . these same issues also affect the diseases that infect wildlife, and, potentially humans: like most emerging diseases, covid- comes from wildlife. as we change ecology, through habitat loss, degradation and climate change we change the way animals, reservoirs, vectors and pathogens mix, paving the way for pathogens to leap into new hosts. couple this with increasing urbanisation, wildlife encroaching on cities and people and animals interacting in new ways, emerging diseases may, likely climate change itself, be seen as a symptom of environmental degradation (brooks et al. ) . in other words, extreme as it is, perhaps covid is not a one-off, but more an exemplar of the short of disruptive shocks we need to adapt to in the anthropocene. as countries have locked-down to reduce covid- spread, it has exposed the strengths and weaknesses of our food systems. shoppers "stocking up", in response to rational needs, have led to empty shelves that just-in-time supply chains have struggled to cope with. vulnerable people have been exposed by their inability to get to shops as home-delivery systems have been swamped by demand. food prices are rising locally and globally. the amount of food available has not caused any problems to date: its distribution has. looking ahead, however, there is a potential problem in supply. in the northern hemisphere, planting is largely over, but harvesting is soon to come. what happens if the labour is not available? harvests in the early-maturing fresh produce areas in southern europe has been problematic due to "social distancing" and labour shortages. in the southern hemisphere, harvesting is underway, just as lock-downs roll out. for large scale mechanised farms, harvesting will continue, but for smaller farming systems, manual labour is key. will supply become an issue, as well as distribution? some countries clearly think so, as they start to introduce export bans to keep food within their bordersexactly the policies that drove the last food price spikes. once harvests are done, farmers then have to decide what to plant. they therefore have to bet on what foods there will be demand for in the following months. with so much change in demand driven by changing markets, supply chains and lock-downs there is huge uncertainty about what demand might be in the months ahead: will farmers make the right decisions, and who will guide them, to ensure the effects of covid do not ripple into global food disruptions? so covid- might contribute to food supply issues in the following months. on top of that, is already shaping up to be a very hot year from a climate perspective. at a time when our food systems are under significant pressures, there is capacity to absorb any other supply-side shock-whether from a drought, heatwave or locust swarm. recovery from a deep recession will be so much harder if food prices go through the roof: the poor and vulnerable will, as ever, suffer most. will covid- , as an exemplar of a shock to our globalised systems, promote us to reconstruct it in a way that puts people and the planet's well-being at its heart? or will we simply seek to recover our unhealthy, unsustainable but consumption-promoting economy? crop pests and pathogens move polewards in a warming world the stockholm paradigm : climate change and emerging disease transmission of climate risks across sectors and borders synchronous failure: the emerging causal architecture of global crisis global food security and food riots-an agent-based modelling approach assessing the evolving fragility of the global food system professor tim benton is research director in emerging risks at the royal institute of international affairs at chatham house and professor at the university of leeds, where he was formerly, dean of strategic research initiatives. from - he was the "champion" of the uk's global food security programme which is a multi-agency partnership of the uk's public bodies (government departments, devolved governments and research councils) with an interest in the challenges inherent in delivering food security around the world. he was an ipcc author on the special report on food, land and climate, and an agenda steward of the world economic forum. he has published over academic papers, many on the topics of agriculture and its sustainability. his particular interest is currently on food system resilience in the face of climate change. key: cord- -bajpr a authors: watson, c. james; whitledge, james d.; siani, alicia m.; burns, michele m. title: pharmaceutical compounding: a history, regulatory overview, and systematic review of compounding errors date: - - journal: j med toxicol doi: . /s - - - sha: doc_id: cord_uid: bajpr a introduction: medications are compounded when a formulation of a medication is needed but not commercially available. regulatory oversight of compounding is piecemeal and compounding errors have resulted in patient harm. we review compounding in the united states (us), including a history of compounding, a critique of current regulatory oversight, and a systematic review of compounding errors recorded in the literature. methods: we gathered reports of compounding errors occurring in the us from to from pubmed, embase, several relevant conference abstracts, and the us food and drug administration “drug alerts and statements” repository. we categorized reports into errors of “contamination,” suprapotency,” and “subpotency.” errors were also subdivided by whether they resulted in morbidity and mortality. we reported demographic, medication, and outcome data where available. results: we screened reports and identified errors. twenty-one of were errors of concentration, harming patients. twenty-seven of were contamination errors, harming patients. fifteen errors did not result in any identified harm. discussion: compounding errors are attributed to contamination or concentration. concentration errors predominantly result from compounding a prescription for a single patient, and disproportionately affect children. contamination errors largely occur during bulk distribution of compounded medications for parenteral use, and affect more patients. the burden falls on the government, pharmacy industry, and medical providers to reduce the risk of patient harm caused by compounding errors. conclusion: in the us, drug compounding is important in ensuring access to vital medications, but has the potential to cause patient harm without adequate safeguards. in the modern-day united states (us), medications are by-inlarge manufactured in commercial facilities, and this production is regulated and overseen by the us food and drug administration (fda). historically, however, medications were mixed-or compounded-by independent pharmacists for use by individual patients. while traditional compounding is becoming less prevalent, it still occurs in instances where a particular patient may require a formulation of a medication that is not otherwise available. furthermore, a new form of large-scale compounding has become commonplace, whereby pharmacies produce bulk volumes of medications which are not available commercially, and broadly distribute them to healthcare practices and individual patients. compounding does not traditionally fall under the purview of fda oversight, instead being regulated by individual states' boards of pharmacy. this approach has resulted in a patchwork and oftentimes underfunded regulatory framework, which has subsequently harmed patients [ ] [ ] [ ] [ ] . morbidity and mortality frequently result either from a compounded medication that is contaminated with bacteria, fungi, or another medication during production, or from an error whereby the concentration of the drug dispensed is not as intended, which can lead to inadvertent over-or underdosing. patient harm caused by compounded medications has been the focus of media, medical, and legislative attention in recent years, especially following a multistate, multi-fatality outbreak of fungal meningitis caused by contaminated steroid injections compounded at a pharmacy in framingham, ma [ , , , ] . this article seeks to provide a comprehensive review of the state of outpatient compounding in the us. compounding performed by hospital pharmacies for inpatient use is beyond the scope of this paper. much has been written on compounding pharmaceuticals; this paper is an effort to succinctly address the history, purpose, and regulatory framework in a unified location, as well as to perform a systematic review of all us compounding errors over the past years. to our knowledge, no systematic review of both contamination and non-contamination errors has to this point been undertaken. we will first explore the definition and modern role of compounding. then, we will briefly discuss the modern us history of compounding, with a particular focus on factors influencing the current state of compounding. next, we will examine compounding through a legislative and regulatory lens, to better decipher how governmental oversight-or a lack thereof-may contribute to errors in compounding resulting in patient harm. understanding the interventions being made on a federal level can help improve the safety of compounding. finally, we have performed a systematic review of documented compounding errors and categorized those errors by type and patient outcome. whereby, we elucidate just how and with what frequency patients are harmed by compounding errors, with the ultimate aim of identifying potential strategies for reducing these adverse events. compounding is defined by the fda as the combination, mixing, or alteration of drug ingredients to create medications tailored to individual patient needs [ ] . the united states pharmacopeia (usp), which sets quality standards for drugs, describes compounding as "the preparation, mixing, assembling, altering, packaging, and labeling of a drug … in accordance with a licensed practitioner's prescription …" [ ] put simply, it is the creation of a medication that is not commercially available. in the us, compounding is performed in both the inpatient hospital setting and in outpatient pharmacies, with a trend in recent decades towards larger scale outpatient production [ ] . as will be discussed later in this paper, compounding may now occur in newly defined "outsourcing facilities," which are designed to compound in bulk; some examples of these facilities include quva pharma and leiters [ ] . there are many indications for compounding. some patients may not tolerate pills and require a compounded liquid drug formulation; examples include young children taking antibiotics, feeding tube-dependent patients, or patients with dysphagia from neurologic compromise such as a stroke [ , ] . patients may be allergic to binding agents, dyes, diluents, or other inactive ingredients in commercially available formulations. dietary restrictions, such as a ketogenic diet in pediatric epilepsy patients, may necessitate compounding of sugar-free medications [ ] . refractory neuropathic pain may benefit from compounded analgesic topical creams containing multiple medications not commercially available in combination; examples include ketamine, baclofen, gabapentin, amitriptyline, bupivacaine, and clonidine [ ] . painful oral lesions can be treated with "magic mouthwash" and dyspepsia can be treated with a "gastrointestinal (gi) cocktail"; these are terms that actually encompass a range of compounded preparations [ ] . total parenteral nutrition (tpn) is needed for patients unable to take in sufficient oral nutrition, and numerous chemotherapy regimens must be compounded for cancer treatment [ , ] . healthcare providers may need compounded medications to perform specialized procedures such as intraarticular or intravitreal injections. in some instances, commercial preparations may be available but expensive, and a compounded equivalent is more affordable [ ] . drug shortages, a longstanding healthcare problem exacerbated by crises such as the covid- pandemic and the devastation of puerto rico by hurricane maria, may be addressed by compounding as well [ , ] . the fda has responded to significant shortages during the covid- pandemic by temporarily relaxing restrictions on compounding of commercially available drugs [ , ] . when a compounded medication is prescribed or administered, patient safety depends on adherence to current good manufacturing practices (cgmp), which are outlined in chapter of the usp for non-sterile preparations and chapter for sterile preparations. appropriateness of the prescription indication, safety, and dosing should be assessed by the pharmacist. ingredient quantities must be meticulously calculated, and the source quality of those ingredients assured. compounding facilities and equipment must be clean and monitored continuously. staff must routinely practice and be assessed for competency in proper hygienic measures. sterile preparations, by definition, require a higher level of care to prevent contamination than do non-sterile preparations, including differences in staff training and personal protective equipment (ppe), environment and air quality monitoring, and disinfection. compounded sterile preparations are further subdivided into low-, medium-, and high-risk depending upon the quantity of ingredients, number of manipulations required during compounding, and whether nonsterile ingredients requiring subsequent sterilization are incorporated. multiple medications must not be simultaneously compounded in the same workspace. the compounding process must be reproducible such that medication quality is consistent throughout many production cycles. finally, prescriptions must be correctly labeled and patients instructed in appropriate use [ , [ ] [ ] [ ] . failure to adhere to these standards has the potential to result in patient harm through multiple mechanisms including medication suprapotency, subpotency, contamination, and consumer misuse. throughout pre-industrial history, pharmacists played the critical role of admixing various materials to produce a finished therapeutic substance. this role was, in essence, one of compounding [ , ] . however, the industrial revolution and the resultant mass production of pharmaceuticalscoupled with the increasing presence of synthetic proprietary medications-led to a change in pharmacists' primary role. instead of compounding, community pharmacists in the early s turned their focus to the dispensing of previously manufactured medications as well as to general retail, including operating the soda fountains which came into vogue with the prohibition of alcoholic beverages. in fact, by the s, fewer than % of pharmacies in the us made a majority of their income from pharmaceutical sales [ ] . the decline in community pharmacy compounding was precipitous through the mid- s. in the s, % of prescriptions required some sort of in-pharmacy compounding. that number fell to % by the s, less than % by , and to % by [ ] . interestingly, there was a concurrent increase in the need for hospital pharmacy compounding during the same period; largely due to the advent of chemotherapy, tpn, and cardiac surgery which necessitated the administration of complex cardioplegic regimens. by the s, these advanced therapeutics began to spill into the outpatient setting, generating a novel home infusion industry for treatments such as tpn, antibiotics, and chemotherapeutics [ ] . as a result, the s and s yielded further diversification within the compounding industry as pharmacies began to compound in bulk. this development was brought about by expanding home infusion programs, the more frequent outsourcing of hospital compounding to the outpatient setting, and the rise of hormone replacement therapy. large volume compounding blurs the line between traditional compounding which has state-based regulatory oversight, and the mass manufacture of pharmaceuticals which falls under wellestablished federal fda regulations [ ] [ ] [ ] . the inspiration for this article is a well-documented history of medication errors attributable to pharmaceutical compounding, for which a lack of regulatory oversight persists as a common thread [ , , , ] . the most lethal and infamous of these cases occurred in , when an outbreak of fungal meningitis occurred amongst patients who had received epidural spinal injections. the outbreak affected patients across states, killing [ , , , ] . ultimately, the outbreak was linked to a compounding pharmacy, the new england compounding center (necc, located in framingham, ma). amongst other pharmaceuticals, necc produced injectable sterile methylprednisolone acetate for epidural injections, which it then distributed nationally. following the outbreak (hereafter "framingham"), the fda determined that the pharmacy had disregarded basic sanitary standards and had not taken corrective measures despite internal knowledge of potential contamination [ , , , [ ] [ ] [ ] . as with many compounding pharmacies, necc operated in a historically murky regulatory space, producing medications in bulk as would a commercial pharmaceutical manufacturer, while only being subjected to reduced state oversight given to compounding pharmacies. in fact, in the years preceding the outbreak, the fda had thrice investigated necc and found sterility violations, but they were unable to enforce any interventions or penalties due to the fda's contested regulatory jurisdiction [ ] . both preceding and following framingham, efforts have been made at the federal level to improve oversight of compounding; these are reviewed in depth later in this article. currently, there is incomplete tracking of compounded pharmaceuticals in the us, though they are estimated to comprise - % of all prescriptions [ , , , ] . ultimately, compounding is highly prevalent, and so clinicians must be familiar with the risks associated with compounded medications as they care for patients who may be suffering from a related adverse event. prior to framingham, modern compounding pharmacies evolved within a regulatory framework that lacked distinct federal or state oversight roles. in , the federal food, drug, and cosmetic act (fdca) authorized fda oversight of pharmaceutical manufacturing [ ] . however, because compounders traditionally produced drugs in response to individual prescriptions and on a much smaller scale than conventional drug manufacturers, pharmaceutical compounding developed and remained under the regulatory purview of individual state boards of pharmacy [ , ] . towards the end of the twentieth century, pharmacies began bulk compounding in response to ( ) the home infusion industry and ( ) hospitals' financial interest in outsourcing compounding from their inpatient pharmacies to the outpatient setting [ ] . concerned that bulk compounders were self-classifying as pharmacies to avoid the rigorous federal oversight required of drug manufacturers under the fdca, congress passed the food and drug administration modernization act (fdama) [ ] . fdama addressed the changing nature of compounding pharmacies by creating a "safe harbor" exempting pharmacies from the more stringent fdca regulations so long as compounders refrained from advertising their product and abided by requirements designed to increase drug safety [ , ] . despite congress's attempt to strengthen oversight of compounding pharmacies, litigation challenging fdama tempered the fda's authority to regulate compounders. in , a narrowly divided us supreme court ruled in thompson v. western states medical center that the fdama advertising prohibition was unconstitutional on first amendment free speech grounds [ ] . the ensuing regulatory confusion is well described in the literature, and the details are beyond the scope of this review [ , , , , , ] . for reference, a summary of the relevant legislation and litigation is provided in fig. . decades of regulatory uncertainty culminated in the framingham incident, which revived congressional efforts to address pharmaceutical compounding industry safety concerns. in response to framingham, congress passed and president barack obama signed into law the bipartisan-supported compounding quality act (cqa) as part of a broader legislative package (the drug quality and security act) [ ] . the cqa delineated state and federal oversight authority by defining two distinct categories of compounding pharmacies. the first category is traditional compounding pharmacies, or " a" pharmacies [ ] . a pharmacies under the cqa may compound only in response to individual prescriptions. importantly, a pharmacies may not compound bulk medications either in anticipation of receiving prescriptions or with plans to distribute broadly to healthcare facilities [ , ] . in exchange for complying with these limitations, a pharmacies largely avoid the more burdensome regulations required of drug manufacturers under the fdca, including adhering to cgmp [ , , [ ] [ ] [ ] . accordingly, state boards of pharmacy continue to serve as the primary regulators of a pharmacies [ ] . the cqa created a second category of compounding pharmacy, called an "outsourcing facility." [ ] unlike a pharmacies, outsourcing facilities voluntarily opt-in to this category by paying the fda a user fee (approximately $ , in fy ) [ ] , and comply with stringent cgmp standards as well as reporting requirements [ , ] . because they submit to more robust fda oversight, outsourcing facilities are permitted to compound in bulk in advance of receiving a prescription, and may distribute their products across state lines [ , ] . though the fda enjoys primary regulatory authority over outsourcing facilities, states are not precluded from imposing additional requirements [ ] . should a compounding pharmacy fail to comply with the a criteria or voluntarily register as an outsourcing facility, it is subject to the full breadth of regulations required of drug manufacturers under the fdca [ ] . the distinctions between a pharmacies and outsourcing facilities are illustrated in fig. . following enactment of the cqa, states have taken numerous steps to further develop their respective oversight structures under the new framework. a majority of states have strengthened regulations empowering state boards of pharmacy to hold a pharmacies accountable to higher safety practices, such as requiring conformation with recognized sterile compounding guidelines. however, state oversight of a pharmacies continues to vary, with fewer than half of all states reporting annual inspections of a pharmacies in [ ] . the fda has similarly adjusted its enforcement priorities [ , ] . for example, the cqa permits a a pharmacy to distribute no more than % of its total prescriptions out of state . the goal of this provision is to avoid another national outbreak by reducing the likelihood that contaminated drugs cross state lines. if a given state enters into a mou with the fda, a pharmacies in that state may distribute a higher percentage of prescriptions (now up to %) across state lines in exchange for that state's board of pharmacy agreeing to identify, investigate, and report associated adverse events [ ] . importantly, the mou standardizes procedures for state boards of pharmacy to report concerns to the fda and other states; however, the agreement also grants states significant discretion in how states conduct investigations [ ] . in short, states that participate in the mou, rather than the fda, will undertake primary responsibility for detecting poor quality or dangerous compounded medications distributed by a pharmacies from their state. the fda also announced an effort to entice more compounding pharmacies to register as outsourcing facilities by embracing a risk-based approach [ ] . since enactment of the cqa, far fewer pharmacies have registered as outsourcing facilities than the fda had expected. in fact, the fda anticipated pharmacies to register per year, but only total were registered as of may (even fewer than the registered in ) [ , , ] . to attract compounding pharmacies-some of which have cited cost of compliance with cgmp as a prohibitively expensive barrier to registering as an outsourcing facility-the fda plans to reduce cgmp requirements for compounding pharmacies it deems as "lower risk." [ ] though the fda published draft guidance in describing how the agency may tailor cgmp requirements for outsourcing facilities, the fda has yet to issue final guidance on this matter [ , ] . critics warn that fda and state efforts to implement the cqa regulatory scheme excludes compounding pharmacies from the decision-making process and may limit patients' access to compounded medications. for example, the preserving patient access to compounded medications act (h.r. ) introduced in the us house of representatives attempts to address complaints expressed by compounders [ ] . the proposed legislation seeks to ensure that compounders and other interested parties have an opportunity to comment on (and influence) fda compounding regulations. furthermore, the proposed legislation would explicitly allow physicians who engage in in-office sterile compounding, or who otherwise maintain a supply of compounded medications for "office use," to avoid complying (where state law permits) with outsourcing facility regulations [ ] . meanwhile, the sterility practices of some compounding pharmacies continue to raise alarm: between and , the fda issued more than warning letters to compounding pharmacies, resulting in approximately recalls. as acknowledged by the agency, the fda's transition to a risk-based approach may assist the agency in more efficiently targeting its limited resources, but it could also increase the likelihood of compounders engaging in unsafe practices that elude regulators [ ] . in sum, the cqa and subsequent state and fda actions have somewhat clarified oversight roles after framingham, largely by defining separate a pharmacies and outsourcing facilities. seven years after its enactment, however, uncertainty regarding the relative strength and consistency of said regulatory framework remains. we performed a systematic review of compounding errors, including both errors that resulted in patient harm and those that did not, as reported in the academic literature. we searched the national center for biotechnology information (pubmed; u.s. national library of medicine: bethesda, m a r y l a n d ) a n d e m b a s e ( e l s e v i e r : amsterdam, the netherlands) using the following search criteria: "'compounding and pharmacy' and 'error,' 'overdos*,' 'toxicol*,' 'infect*,' 'death,' 'outbreak,' 'injur*,' or 'case report.'" this search was limited to january through march . additionally, we reviewed abstracts for years - for the following conferences using keyword searches for "compound" and "compounding": american college of medical toxicology (acmt) annual scientific meeting, north american congress of clinical toxicology (nacct), american college of emergency physicians (acep) scientific assembly, society for academic emergency medicine (saem) annual meeting, american academy of pediatrics (aap) national conference & exhibition, and the pediatric academic societies (pas) meeting. we also reviewed the fda's online "drug alerts and statements" repository for alerts regarding compounding pharmacies' failures in sterility and potency standards. authors cjw and jdw screened reports by title and, when necessary for clarification, by abstract. under manual review, articles were excluded if they were obviously irrelevant, consisted of research comparing samples of compounded and commercial pharmaceuticals, were in a non-english language, regarded medications compounded outside of the us, were redundant with another included report, represented misuse of properly compounded medications, regarded veterinary patients, were compounded by an inpatient hospital pharmacy (including chemotherapeutics and parenteral nutrition), were published prior to , or if the report lacked sufficient information to provide substantive value. redundant reports of the same error were included for analysis only once, but efforts were made to reference all identified reporting sources. for included reports, cjw and jdw extracted information including date, type of error, cause of error, number of patients affected, age of patients affected, and clinical course of patients affected. incomplete data was acknowledged and by-inlarge was not grounds for exclusion from the study. we categorized errors under the conceptual framework described by sarah sellers, pharmd, mph, former board member for the fda's advisory committee on pharmacy compounding, in testimony to the us senate committee on health, education, labor, and pensions, namely, that "suprapotency," "subpotency," and "contamination" are the primary risks associated with pharmaceutical compounding [ ] . we further broke down "contamination" into subgroups of "microbiologic contamination" for cases of bacterial, viral, or fungal contamination and "toxic contamination" for noninfectious contaminants. when available, we documented patient age and outcome, route of administration, and medication-in-question, so as to better characterize the types of medications, errors, and patients most associated with adverse events. we referenced and applied the principles for authoring review articles delineated within the journal of medical toxicology when feasible and appropriate during the review process [ ] . our search terms identified potential articles in pubmed and potential articles in embase. the review of conference abstracts yielded additional potential cases as follows: [ , ] . in total, a total of articles, statements, and reports were identified and underwent our manual review (performed by cjw and jdw). after the application of our exclusion criteria, a total of errors were included. these errors are documented as harming patients. when broken down by type, contamination accounted for errors adversely affecting patients (appendix table ) and errors in concentration accounted for events adversely affecting patients (appendix table ). there were reports of identified compounding errors which potentially exposed innumerable patients but did not end up causing any known harm; these were predominantly errors of contamination (appendix table ). the number of patients exposed to potential harm cannot be calculated based on the available data, but reaches at least the several thousands (framingham alone exposed , patients with documented instances of patient harm). table is a summary of the included contamination errors. with patients over errors, the median number of patients affected per error is . the mean number of patients affected per error is ; however, by excluding framingham, that number is . with deaths over errors, the mean number of fatalities per error is ; however, excluding framingham drops that number to less than ( . ). the median number of deaths per error is . five out of the contamination errors were from intraarticular (including epidural) steroids, and eight of were from medications injected intravitreally. a total of of the errors were from medications administered parenterally, in healthcare settings. three of were from toxic contamination rather than microbiologic contamination. interestingly, six of errors with documented adverse outcomes occurred following the cqa. table is a summary of the included sub-and supratherapeutic errors. one report describes a subtherapeutic error affecting pediatric patients who were on posttransplant immunosuppression with tacrolimus. the remaining reports involved errors of supratherapeutic drug concentrations; they affected a total of patients, of which ( %) were pediatric. of the total patients affected by concentration errors, ( %) were pediatric and ( %) were over the age of years. three patients died, all of whom received supratherapeutic intravenous colchicine at an alternative medicine infusion clinic for chronic back pain [ ] . appended to this article are appendix tables , , , which respectively catalog all contamination errors causing patient harm, all sub-and suprapotency errors causing patient harm, and all potential compounding errors identified and rectified before patient harm occurred. of the potential errors identified before patient harm occurred, came after the enactment of the cqa. in this study, we separated compounding errors into the categories of contamination, suprapotency, and subpotency. we found that medications with contamination errors are frequently ( ) bulkproduced and distributed, ( ) used parenterally, and ( ) administered by physicians. because of their parenteral administration, medications contaminated with otherwise benign environmental flora are able to disseminate throughout the body and cause the devastating outcomes documented here. furthermore, because contamination errors are often associated with larger-even multistate-distribution networks, the reach of their impact is large. framingham was the archetypal contamination error. it woke much of the medical and lay communities to the potential dangers of compounding. it inspired the federal government to enact the cqa in and create an entirely new form of compounding facility-the outsourcing facility-to attempt to regulate the subsection of pharmacies who were bulk-compounding medications not available (or not available cheaply) through commercial channels, and who exported [ ] certainly, contamination has persisted despite the cqa and the fda's efforts to oversee outsourcing facilities. given this ongoing concern, the medical community must bear some of the responsibility for reducing the number of medications manufactured in substandard environments. it should be the expected standard for healthcare practices to purchase exclusively from compounding pharmacies strictly adherent to cgmp standards and formally approved as outsourcing facilities by the fda. leading expert outterson referenced the potential for this approach in [ ] , and it is unclear how purchasers have responded. while these policies may be more expensive; the physical, ethical, and even financial [ ] consequences of purchasing compounded medications from organizations not sufficiently invested in safety are clearly documented here. subpotency and suprapotency can be considered as the single category of errors of concentration, as the sources and scope of concentration errors are largely similar. our findings demonstrate that subpotency is largely not a reportable issue, but that does not mean it is not a danger. as an example, beyond the cited series of subtherapeutic tacrolimus concentrations [ ] , another case series (excluded for location outside the us) identifies dozens of patients who received subtherapeutic chemotherapy treatments [ ] . these subtherapeutic errors are difficult to capture. identification must be done during routine serum testing, as occurred with the tacrolimus series; or on the supply side, as occurred with the chemotherapy series. when considering subtherapeutic and supratherapeutic errors together as errors of concentration, we found a somewhat different pattern than that which we identified amongst errors of contamination. the concentration errors we were able to identify, with a few notable exceptions [ , ] , were caused by traditional compounding pharmacies. these pharmacies, labeled as a pharmacies under the cqa, are limited in their scope to producing compounded medications only after an individual prescription is in-hand. per the cqa, a pharmacies are still solely regulated by state boards of pharmacy, meaning that oversight is patchwork across the us. many concentration errors are of orders of magnitude, suggesting that simple mathematical and measurement mistakes are to blame. in addition to hoping that states will implement greater oversight of these a pharmacies, we call on the pharmacy industry to emphasize and standardize compounding training amongst its students and even consider a mandatory credential before allowing a pharmacist or pharmacy technician to compound a medication [ , [ ] [ ] [ ] . it is worth noting that -aminopyridine and liothyronine are fairly uncommon medications, however they accounted for a large number of compounding concentration errors. there is nothing particularly special about these medications which make them prone to concentration errors, except for the fact that they are not readily commercially available, and so they must be compounded. the prescribers of these medications need to carefully consider the benefits and risks of prescribing a treatment which requires compounding; especially when the risks are so great (status epilepticus with -aminopyridine and thyrotoxicosis with liothyronine). liothyronine, in particular, has had its clinical utility recently questioned. for example, the national health service (uk) has recently called on general practitioners to stop prescribing liothyronine without specialist consultation, as most patients benefit equally from commercially prepared levothyroxine [ ]. given the risks of inadvertent overdose due to compounding errors, providers must consider commercially available alternatives whenever able. in fact, it has been questioned w h e t h e r p r o v i d e r s w h o k n o w i n g l y p r e s c r i b e a compounded medication despite commercially available alternatives might be legally liable for any harm resulting from compounding errors [ ] . at the very least, it is incumbent on prescribers as well as pharmacists to educate their patients on the risks of taking a compounded medication-both from errors in concentration and contamination-and to instruct them on when to present to a healthcare provider. additionally, practitioners must be aware of their patients' medication lists, and consider a possible compounding error as a cause of medical illness. notably, we found that the majority of concentration errors were made in pediatric and geriatric patients, vulnerable populations who are already at increased risk of providers failing to diagnose toxicity from prescription medications. in and beyond, we anticipate the demand for compounding to only increase. the number of novel therapeutics continues to rise rapidly, as do their approved routes of administration. the anti-angiogenesis medication bevacizumab is a classic example; it is commercially manufactured but is frequently compounded into smaller aliquots for intravitreal administration. as we have seen, this process has unfortunately resulted in multiple outbreaks of endophthalmitis [ ] [ ] [ ] [ ] [ ] . furthermore, regional and global disasters have recently resulted in significant pharmaceutical supply chain issues. examples of this phenomenon include hurricane maria's impact on puerto rican manufacturers in and the covid- pandemic [ ] [ ] [ ] [ ] . these disruptions place increased demand on alternative means of supply, including via pharmaceutical compounding. in fact, the covid- pandemic and its associated drug shortages has already resulted in the loosening of fda restrictions, including allowing outsourcing facilities to compound copies of commercially available drugs for hospital use [ ] . our study has its limitations. while we made every effort to capture published cases of compounding errors, it is possible that our search criteria missed some cases that would have impacted our analyses. while we also strove to review less-traditional sources, including conference abstracts and fda alerts, we are not free of publication bias and are at risk for having excluded compounding errors not associated with adverse events, or with very small numbers of patients affected. similarly, it must be noted that compounding errors can only be identified following adverse events, laboratory screening, or industry or governmental report. even once identified, we were dependent on the publication of the error in order to capture it here. as such, we are likely underreporting the frequency with which compounding errors occur. compounding is more relevant than ever. appreciating that the need for compounding is unlikely to diminish in the near future, we can only re-emphasize the critical nature of our recommendations for the federal and state governments to fully fund the oversight of outsourcing facilities, for healthcare practices to refuse medications compounded without strict adherence to cgmp and fda regulations, for pharmacy schools to expand compounding training and certification, and for physicians to think critically about the risks of prescribing medications that are not commercially produced. conversely, we must remain aware that compounding pharmacies frequently provide an essential service and poorly calibrated regulations may contribute to issues of access. ultimately, medical providers must remain vigilant, especially when caring for members of vulnerable populations, and consider the possibility that a new-onset illness may very well be the result of a compounding error. supplemental outsourced compounding can be problematic meningitis outbreak reveals gaps in us drug regulation regulating compounding pharmacies after necc 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administration fda alerts patients and healthcare professionals to infusion options' voluntary recall due to quality issues. united states food and drug administration dba amex pharmacy, voluntary recall of all sterile compounded drugs. united states food and drug administration publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -l q lhp authors: jacob, michelle cristine medeiros; feitosa, ivanilda soares; albuquerque, ulysses paulino title: animal-based food systems are unsafe: severe acute respiratory syndrome coronavirus (sars-cov- ) fosters the debate on meat consumption date: - - journal: public health nutrition doi: . /s sha: doc_id: cord_uid: l q lhp objective: the current pandemic restarts a debate on permanently banning wildlife consumption in an effort to prevent further public health threats. in this commentary, we offer two ideas to enhance the discussion on foodborne zoonotic diseases in food systems. design: first, we focus on the probable consequences that the loss of access to wildlife could cause to the status of food and nutrition security of many people in developing countries that rely on bushmeat to subsist. second, we argue that all animal-based food systems, especially the ones based on intensive husbandry, present food safety threats. conclusion: to ban the access to bushmeat without a rational analysis of all human meat production and consumption in the global animal-based food system will not help us to prevent future outbreaks. the proximal origin of severe acute respiratory syndrome coronavirus (sars-cov- ) involves bushmeat, such as bats (rhinolophus affinis) and malayan pangolins (manis javanica) ( ) , but we have a lack of evidence about the intermediary sources of origin and transfer to humans ( ) . bushmeat or wild meat is defined as meat derived from any wild animal, especially non-aquatic vertebrates, harvested for subsistence or trade, most often illegally ( ) . it is not the first time that a virus that originated from animals infected humans. up to % of emerging infectious diseases in humans are of zoonotic origin, most of which originate in wildlife ( ) . in the last few years, attention has been paid to epidemic zoonoses such as avian influenza (h n ) and the sars. sars-cov- fosters a debate on permanently banning wildlife consumption in an effort to prevent further public health threats related to foodborne zoonotic diseases ( ) . such zoonoses are a global menace, and little is known about the mechanisms that make these diseases emerge. spatial modelling demonstrates the significant risk of these zoonoses appears in regions of tropical forests, which are also associated with a high diversity of mammals ( ) . in these regions, there is great cultural diversity associated with these animals and many thousands of people whose ways of life depend on them. we offer two ideas to contribute to this discussion. first, we argue that the loss of access to wildlife can compromise the status of food and nutrition security of many people in developing countries that rely on bushmeat to subsist. second, we argue that environmental impacts bred by factory farming are important drivers of outbreaks of foodborne zoonotic diseases in animal-based food systems. our main arguments and conclusions are summarised in fig. . for better comprehension, we start each argument by presenting the concepts of food and nutrition security (fns) and food safety. bushmeat contributes to food and nutrition security of people in developing countries fns is defined as a state in which people access proper food, in quantity and quality, without compromising other basic needs, while safeguarding cultural diversity, and economic, social and environmental sustainability ( ) . this concept is sustained by four critical pillars: availability (reliable food supply), accessibility (resources to obtain proper food), utilisation (food quality and health conditions) and stability (permanent access to food). in our current global food systems, whose high productivity is based on models with controversial socio-environmental and human health impacts, we still need to deal with endemic hunger due to political, economic and social constraints ( ) . one of the most unfortunate human achievements is that one-third of all food produced globally is lost or goes to waste, while a little over million people suffer from hunger. most of this vulnerable population lives in africa and latin america, where the rates of undernourishment have increased in recent years ( ) . by analysing the current state of evidence, we argue that bushmeat contributes to the fns of millions of these people by three central channels: by improving diets, by generating income and by protecting cultural heritage. first, bushmeat makes a significant contribution to diets because, in many situations of severe food insecurity, it is one of the only foods accessible to people, besides being the primary source of protein. bushmeat contributes up to % of the animal protein consumed in certain rural regions of west and central africa and over % of that eaten by several indigenous groups in the amazon ( ) . bat bushmeat is a core dietary component for people living in madagascar ( ) . in several south american countries, the meat of capybara (hydrochoerus hydrochaeris) is an essential resource for the subsistence of many traditional communities ( ) . in ghana, fruit bat bushmeat provides an at-cost protein source when agricultural production drops in the dry season ( ) . in são tomé, the rural population is largely dependent on the protein of wild animal species ( ) . finally, in several countries in the congo basin, the dependence on bushmeat protein is emphasised by the fact that the countries do not produce enough amounts of non-bushmeat protein to feed their populations ( ) . to date, from a nutritional point of view, there is no consistent data to compare bushmeat and domesticated meat composition values, considering species and consumed parts. besides, bioavailability makes animal sources of foods higher in macro and micronutrients than vegetable sources, which in the case of populations with limited access to food needs to be considered. some studies assess the impact of bushmeat in the nutritional status of humans. golden et al. ( ) , for example, in a prospective longitudinal cohort of seventy-seven preadolescent children in rural northeastern madagascar, show that consuming more animal wildlife was associated with significantly higher hb concentrations. removing access to wildlife would induce a % increase in the number of children suffering from anaemia and a tripling of anaemia cases among children in the poorest households. other studies indicate that wild natural resources may be central to fns coping strategies of orphans and vulnerable children affected by hiv/aids. considering the heightened nutritional needs of children, as well as poverty and disease, mcgarry and shackleton ( ) show that bushmeat represents the last freely attainable protein food source available to them. second, bushmeat represents a full-time source of income in many households. even in cases in which bushmeat is not the primary source of income, it can serve as a safety net that complements household income in challenging times (e.g. droughts, unemployment and illness) or a source of extra cash for special needs (e.g. school fees, festivals and funerals) ( ) . on the other hand, bushmeat trade can also figure as a profitable global industry that threatens certain animal species with extinction. conservation strategies, for this reason, should consider the complexity of its uses. uses of bushmeat vary from commentary snapshot sars-cov- fosters a debate on permanently banning wildlife consumption in an effort to prevent further public health threats related to foodborne zoonotic diseases. conservation and public health strategies concerning banning bushmeat should address fns in order to avoid trapping vulnerable rural households in poverty as traditional avenues for escaping poverty become illegal. the environmental impacts bred by industrial livestock production is a major driver of outbreaks from foodborne zoonotic diseases impacting public health globally. to ban the access to bushmeat without a rational analysis of all human meat production and consumption in the global animal-based food system will not help us to prevent future outbreaks. individuals and governments, especially in developed countries where choice is available, should consider that decreasing meat consumption can bring health benefits to humans and the environment. fig. to ban bushmeat consumption is not the solution to prevent future outbreaks in animal-based food systems. fns, food and nutrition security; sars, severe acute respiratory syndrome subsistence-based rural consumption and subsistencecommercial hunting to a luxury commodity in urban areas ( ) . in a study about economic and wildlife uses conducted in households from ninety-six settlements in ghana, cameroon, tanzania and madagascar, golden et al. ( ) argue that wildlife hunting and consumption in rural areas increase when alternative livelihoods collapse. they also found an opposite pattern in the urban context, where there was a consistent relationship between wealth and wildlife consumption. for these reasons, efforts to conserve wildlife will need to study rural and urban consumers and the drivers and patterns of consumption and trade. third, bushmeat hunting and consumption are embedded in several communities as their cultural heritage ( ) . and fns is also about cultural acceptability, as shown in comment ( ) on the right to adequate food by the united nations. it says: fns implies the need also to consider, as far as possible, perceived non-nutrientbased values attached to food and food consumption and informed consumer concerns regarding the nature of accessible food supplies (p. ). the flavour perception, for example, has a strong cultural background that can play a significant role in the acceptance of food by human groups. in a study about hunters' preferences and perceptions as drivers to hunt in a semiarid ecosystem, chaves et al. ( ) found that flavour preference can increase the odds of a species being hunted almost %. furthermore, in several traditions around the world, bushmeat is a central part of rituals, traditional ceremonies, linked with social status and power, and ancestral ties. frequently, bushmeat is considered sacred, and so its consumption is taboo and forbidden. some studies defend that social taboos, as informal institutions that determine human behaviour, can be useful in partnership designs to prevent bushmeat consumption ( ) . on the contrary, ndlovu ( ) warns from his experience in zimbabwe that reinforcing taboos to discourage the eating of some meats can lead to people suffering from starvation. the effects of cultural acceptability on fns and biological conservation deserve better comprehension to improve political decision-making in this field. in terms of conservation, several considerations need to be made, as we need to clearly discern whether fns is, in fact, dependent on bushmeat to improve diet. brazil can be a typical case in this sense because while in the amazonian forest, there seems to be a strong dependence on bushmeat, in the semiarid portion, consumption appears to be related only to cultural heritage without direct implications for the fns of the people who live there ( , ) . food safety refers to conditions and practices that preserve the quality of food to prevent contamination and foodborne illnesses across the whole food system. ( ) sars-cov- brought the topic of consumption of bushmeat and zoonotic diseases back to the agenda since threefourths of emerging infectious diseases to humans have a zoonotic origin (includes ebola virus, hantaviruses, sarscoronaviruses, hiv- , hiv- and influenza) ( ) . however, the proposition to ban bushmeat as a measure of food safety is not as simple as it seems to be. this argument is narrow for two main reasons. first, it does not consider that rural and urban communities living in poverty rely on bushmeat to subsist. second, it is constructed upon ethnocentric bias that undermines our ability to analyse the whole picture: our westernised intensive industrial food system is a significant part of the problem. hell is other people, to paraphrase the idea of the philosopher jean-paul sartre. no, it is not just the others, we are hell, also. in fig. , we show a summary of animal-based food systems strengths, opportunities, weaknesses and threats. pathogens that we see as new, previously existed in nature. for example, hiv- and have chimpanzees and sooty mangabey as reservoir species in the wild, as does anthrax in species of ungulates ( ) . its spillover success to receptive hosts depends on environments that offer favourable conditions ( ) . the analysis of epidemiological characteristics of viral transmission between animals and people shows that a series of high-risk human activities have allowed viruses to spread in the past, enabling the approximation between wild species, domesticated animals and people ( ) . industrial livestock production is one of these activities. much of the deforestation of tropical forests is justified by promoting areas for raising livestock ( ) . according to volpato et al. ( ) , the invasion of human activities in forests is among the main factors that offer the necessary conditions for the transmission of viruses to humans, through the proximity of bats and intermediate hosts, including cattle. after the sars epidemic in , there was a growing interest in investigating coronavirus in bats. it is estimated that more than new types have been identified, and % have already been sequenced. this discovery makes bats the main reservoirs and transmitters of coronavirus, although many other animals can also perform this function ( ) . a notable example was observed in eastern australia, where bats after the forest were cleared for pasture, remained perched in the trees cut down. this proximity to domesticated animals allows them to transmit coronavirus through their urine and faeces ( ) . the invasion of humans in settlements and the establishment of agriculture in natural ecosystems result in the expansion of ecotones, that is, transition zones between adjacent ecological areas where species are artificially mixed ( ) . as human occupy and transform these environments, they disrupt the ecology of wild animals, altering the ecosystem balance and increase the likelihood that viruses (see fig. ) will find intermediate hosts (wild or domesticated) ( ) . for example, there is evidence of a relationship between the increased spread of the encephalitis virus and production of rice and pig culture in southeast asia ( ) . deforestation, habitat destruction and mining are drivers of the resurgence of rabies spread by the hematophagous bat to humans in the amazon ( ) . the emergence of haemorrhagic fever in central-west argentina in the s was linked to the development of agricultural activities, mainly the cultivation of maize that sustains its main reservoir (calomys musculinus) ( ) . the expansion of agricultural frontiers promotes the degradation of habitats, bringing humans and cattle closer to vectors and sylvatic cycles of possible zoonotic pathogens. repeated outbreaks associated with the production of meat, eggs and milk demonstrate that the risks of pathogens arising from livestock activity are maximised by intensive production. additionally, the human contact with hunting and preparing wild animals for consumption has led to a wide transmission of diseases. the volume of consumption of wild meat for the subsistence of humans is less than that of domestic origin. the substitution of wild meat with meat produced from domesticated animals must be considered carefully because it can favour the emergence of new pathogens ( ) . many foodborne zoonoses are enzootic in cattle (e.g. bovine tuberculosis). livestock can become an intermediate or amplifier where pathogens can evolve and overflow to humans ( ) . factors such as stocking rates, mixtures of species and lack of disease control methods promote the spread of this type of disease and new infections in humans ( ) . animals can be a source of pathogens in food products through faecal contamination, water and zoonotic diseases transmitted directly from animals to humans, among others. the conditions in which thousands of animals live on industrial farms are unhygienic. allied to this, stress, lack of exercise and unnatural diets increase the chances of their immune system being compromised, leading to being affected by diseases ( ) . the sum of all these factors turns breeding grounds into perfect places for the spread of new pathogens. to combat this problem, these animals are subjected to the use of antibiotics regularly, which makes them many times more resistant to certain types of pathogens ( ) . although these environments are reservoirs for zoonotic diseases, studies show that ranchers are aware that their management practices are responsible for significant environmental impacts and the consequent transmission of these diseases to several species of domesticated animals ( , ) . cases of zoonotic diseases that were also hosted by other domesticated animals were responsible for several epidemics in different parts of the world (e.g. h n avian influenza, nipah virus in pigs). therefore, sars-cov- , instead of being a scenario to feed our prejudice and cultural stigmas towards others, can be an opportunity to analyse with a critical and honest view our appetite for meat ( ) . conservation and public health strategies concerning banning bushmeat should address fns to avoid trapping vulnerable rural households in poverty as traditional avenues for escaping poverty become illegal. furthermore, sars-cov- can be a warning that indicates the need for a holistic and transformative shift in our food system. these changes should include the development of food production methods capable of limiting environmental degradation. finally, considering that all animal-based food systems offer food safety threats, individuals and governments, especially in developed countries where choice is available, should consider that decreasing meat consumption can bring health benefits to humans and the environment. the proximal origin of sars-cov- covid- infection: origin, transmission, and characteristics of human coronaviruses the bushmeat and food security nexus: a global account of the contributions, conundrums, and ethical collisions zoonosis emergence linked to agricultural intensification and environmental change permanently ban wildlife consumption global hotspots and correlates of emerging zoonotic diseases draft declaration of the world summit on food security geografia da fome (the geography of hunger). são paulo: civilização brasileira state of food security and nutrition in the world bats as bushmeat in madagascar capybara meat: an extraordinary resource for food security in south america uncovering the fruit bat bushmeat commodity chain and the true extent of fruit bat hunting in ghana wild meat consumption on são tomé island, west africa: implications for conservation and local livelihoods bushmeat and food security in the congo basin: linkages between wildlife and people's future benefits of wildlife consumption to child nutrition in a biodiversity hotspot children navigating rural poverty: rural children's use of wild resources to counteract food insecurity in the eastern cape, south africa conservation, and sustainable use of wildlife-based resources: the bushmeat crisis bushmeat hunting and extinction risk to the world's mammals the right to adequate food (art. ), cescr general comment hunters' preferences and perceptions as hunting predictors in a semiarid ecosystem social taboos: "invisible" systems of local resource management and biological conservation names as indigenous knowledge for making meat edible and/or inedible: implications on food security in zimbabwe romania: proceedings of iconn non-legalized commerce in game meat in the brazilian amazon: a case study assessment of the hunting of mammals using local ecological knowledge: an example from the brazilian semiarid region the future of food safety. addis: fao bushmeat hunting, deforestation, and prediction of zoonoses emergence saúde e ambiente: as doenças emergentes no brasil (health and environment: emergent diseases in brazil) global shifts in mammalian population trends reveal key predictors of virus spillover risk policies for reduced deforestation and their impact on agricultural production baby pangolins on my plate: possible lessons to learn from the covid- pandemic novel human coronavirus (sars-cov- ): a lesson from animal coronaviruses -ncov in context: lessons learned? wildlife, exotic pets, and emerging zoonoses ecology of zoonoses: natural and unnatural histories the hidden cost of eating meat in south africa: what every responsible consumer should know awareness, knowledge, and risks of zoonotic diseases among livestock farmers in punjab knowledge, attitude, and practice toward zoonotic diseases among different professionals at selected coastal areas in barguna district acknowledgements: the authors thank dr renato maluf, who kindly reviewed our manuscript, providing some useful thoughts. the authors also want to thank dr thiago gonçalves-souza who helped us with the figure number two. finally, the authors are grateful to teacher jonathan who reviewed our english and polished our writing. key: cord- -ejkgune authors: ball, andrew s; patil, sayali; soni, sarvesh title: chapter introduction into nanotechnology and microbiology date: - - journal: methods in microbiology doi: . /bs.mim. . . sha: doc_id: cord_uid: ejkgune abstract the current chapter summaries the world of microbiology and boom of nanotechnology and how both the exciting fields come together to help men kind with various new applications in water, food, medical biology and immunology. furthermore synthesis of nano materials utilising the potential of microorganisms also opens a newer avenue for ‘green’ synthesis. the discipline of 'microbiology' deals with the microscopic analysis of living and non-living entities such as bacteria, viruses, yeast, fungi and protozoans, which are organisms that are invisible to naked human eyes. bacteria, viruses and yeast represent three types of microorganisms, which form a significant component of biota, exhibiting unique functions due to their peculiar cell structure. for example, yeast are eukaryotic, while bacteria belong to the prokaryotic group. however, viruses are obligate intracellular parasites which are considered non-living organisms. due to the genetic diversity of microorganisms, it is believed that microbes were the first life recorded on earth, long before the existence of any plant or animal. some microorganisms have been studied for their unique ability to survive at extreme environmental conditions. for example, some species of microbes can survive well in extreme cold regions of antarctica, while others survive in hot water springs at °c and above, in places with highly alkaline soils, high concentrations of heavy metals and sulphur and in locations where no other forms of life can survive. millions of microbial species exist in the natural environment but only % of these (totalling , known species) have been identified so far (minocheherhomji, ) . the field of microbiology began with the advent of the first microscope in the year when antony van leeuwenhoek visualized bacteria for the first time. the visual microbiological world was further extended in the s by the combined work of ernst abbe and carl zeiss further advancing the field of light microscopy. ernst ruska made it possible to study the structure of viruses with the advent of the electron microscope in . subsequently, crystallization of tobacco mosaic virus (tmv) was carried out by wendall stanely in . more recently, the atomic force microscope (afm) has opened a new path for the investigation and manipulation of structures on a very small scale in the study of biological structures by providing high resolution images under physiological conditions, and to investigate the binding forces between microorganisms and target surfaces. microbiology mainly deals with visual characterization of various microbial groups (fig. ). the era of nanotechnology, based on the precise development, manipulation and application of materials at a nanoscale ( À m) is evolving at a very rapid pace. the u.s. national nanotechnology initiative (nni) defines nanotechnology as the research and development efforts at the atomic or molecular level to create structures and systems applicable in diverse aspects (balzani, ; drexler & peterson, ) . the history of nanotechnology lies in the th and th centuries bc, when traditional medicinal practitioners in india and china succeeded in preparing gold colloids (known as 'suwarna bhasma' in ancient ayurveda in india) for therapeutic purposes (paul & chugh, ) . during the middle ages in europe, paracelsus applied colloidal gold in treating mental disorders and syphilis (dykman & khlebtsov, ) . with the periodical advancement in , a book on the preparation and therapeutic applications of colloidal gold was published by the philosopher and doctor, francisco antonii. the first scientific publication of colloidal gold was published by michael faraday in . however, real interest in the field of nanomaterial science was (feynman, ) . this concept of nanomaterial science was further popularized by eric drexler through his book engines of creation: the coming era of nanotechnology in the s. currently, the field of nanotechnology has spread its wings in medical, pharmaceutical, industrial, food and agriculture, and environmental sectors with a wide range of applications (fig. ) . it is now possible to build materials atom by atom and impose desired characteristics for numerous applications in almost every area, such as composite materials development, electronics, nano-electro-mechanical systems (nems), biomedical technologies, renewable energy solutions and environmental remediation (navya & daima, nanomaterials are classified into nine major groups based on their shape, size, composition, surface charge, aggregation and chemical nature. table gives an overview of these nine nanomaterial classes. the coming together of science and technology: microbiology and nanotechnology the disciplines of microbiology and nanotechnology individually have strengthened the field of science and technology by delivering novel solutions for human well-being and maintaining environmental and ecological balance. however, due to instances where the frequent use of drugs has led to antibiotic/multidrug resistance in microorganisms, and the delivery of metal nanoparticles is impacting the food chain, it is now necessary to develop interdisciplinary approaches combining microbiology and nanotechnology to combat secondary human health, and environmental and ecological damage. the amalgamation of these fields offers innovative and sustainable solutions in a rational manner. in the present chapter, we highlight the relationship between these disciplines identifying the great potential resulting from interdisciplinary research. nanoscience impacts several areas of microbiology. it allows for the study and visualization at the molecular-assembly levels of a process. it facilitates identification of molecular recognition and self-assembly motifs as well as the assessment of these processes. specifically, there are three areas where microbiologists use nanotechnological techniques: -imaging single molecules -manipulating nanoscale objects (laser traps and optical tweezer) and; -determining spatial organization in living microbes (afm, near/far field microscopy) below we present a number of key examples illustrating the application of nanotechnology to microbiology. as stated by the world health organization (who, ), around . billion people in the world do not have access to safe drinking water, leading to deaths per day due to waterborne diseases. it has taken $ billion to bring safe drinking water and sanitation to everyone over - years, especially in african and asian countries. an important challenge is therefore the rapid, specific and sensitive detection of waterborne pathogens in water sources. presently, microbial detection is based essentially on time-consuming culture methods like most probable numbers, defined substrate method, antibody-based detection and others. however, newer enzymatic, immunological and genetic methods are being developed to replace and/or support classical approaches to microbial detection. moreover, innovations in nanotechnology and nanosciences are having a significant impact in wastewater or sewage wastewater decontamination. for example, a nanomembrane is a porous thin-layered material that allows water molecules to pass through while restricting the passage of bacteria, viruses, salts, and metals. electrospun nanofibres and nanobiocides have shown potential in the improvement of water filtration membranes. biofouling of membranes caused by the bacterial load in water reduces the quality of drinking water and has become a major problem. several studies showed inhibition of these bacteria following exposure to nanofibres with functionalized surfaces. nanobiocides such as metal nanoparticles and engineered nanomaterials have been successfully incorporated into nanofibres showing high antimicrobial activity and stability in water (botes & cloete, ) . carbon based surfaces (cnts) as well as metal based (feo, tio , al) nanoadsorbents with a highly specific surface and excellent adsorption capacity have been shown to remove organic and inorganic contaminants and bacteria during industrial or sewage wastewater treatment (kunduru et al., ) . for example, monodispersed nanosilver bioconjugate particles ( nm), synthesized using fungal mycelia (rhizopus oryzae) have been shown to be effective adsorbents and antimicrobial agents, significantly reducing ( - %) the concentration of pesticides (parathion and chlorpyrifos) in wastewater. in addition, the amount of escherichia coli (initial concentration- cells/ml) was negligible after treatment. similarly, nano-ag and cnts prevent membrane biofouling due to their antimicrobial properties. inhibition of bacterial attachment or biofilm formation was observed with doping or surface grafting of nano-ag on polymeric membranes (mauter et al., ) . in addition, photocatalysis is an advanced oxidation process employed in the treatment of water and wastewater which is based on the oxidative elimination of micropollutants and microbial pathogens using titanium oxide nanoparticles (gehrke, geiser, & somborn-schulz, ) . current disinfection methods applied to the treatment of drinking water can effectively control microbial pathogens. the commonly used chemical disinfectants in the water industry are chlorine, chloramines, and ozone. however, they can react with other constituents in the water and generate harmful disinfection byproducts (dbps). most are carcinogenic (hossain, perales-perez, hwang, & roman, ) ; there have been more than dbps reported, such as halogenated dbps, carcinogenic nitrosamines and bromate (krasner et al., ) . uv-disinfection represents an alternative for oxidative disinfection, since they generate fewer dbps, but a high dosage is required for certain viruses, such as adenoviruses. all these limitations suggest the need for the development of alternative methods that can enhance the robustness of the disinfection process, while avoiding dbp formation (li et al., ) . materials such as nano-ag, nano-zno, nano-tio , cnts and fullerenes exhibit antimicrobial properties without strong oxidation because they have a lower tendency to form dbps (hossain et al., ; li et al., ) . the antimicrobial properties of such nanomaterials has already proved to be effective for surface, drinking and waste-water treatment (table ) . although nanotechnology is proving beneficial for sewage or industrial wastewater treatment, there are human and environmental challenges, risk and safety issues that need to be addressed. many applications of nanomaterials have been developed and demonstrated in the laboratory; however, scaling up for commercialization remains a significant hurdle. this is due to a lack of clear understanding of the fate of nanoparticles (nps) when entering the natural environment with the notable exceptions of tio , feo and nanofibres. long term risk assessment of engineered nanoparticles (enps) is crucial when applying nanotechnology to freshwater, groundwater or wastewater treatment. in addition, the costs associated with the large-scale production of nps hinders the widespread application of nps. cost efficiency could be achieved by reusing or recycling nanomaterials. overall future research must be aimed towards safety evaluation, large scale production facilities, safe disposal practices, cost and energy efficiency for nps production and disposal to address the key issues related to scaling up of nanomaterials for environmental benefit. broader spectrum of activity against bacteria, viruses, and fungi, and less toxicity towards animals and humans; positively charged chitosan particles that interact with negatively charged cell membranes, causing an increase in membrane permeability, and eventual rupture and leakage of intracellular components li et al. ( ) . applications of nanotechnology in food microbiology one-third of the food produced in the world for human consumption (approx. . billion tonnes p.a.) gets wasted through spoilage and poor handling. in australia alone the cost of food waste to the economy is more than $ billion each year. as a result of intensification of food production over the past years there are now four major food safety challenges including: (i) emergence of new food pathogens, (ii) adulteration of food materials, (iii) unknown effects from long term consumption of genetically modified food and (iv) the presence of significant amounts of chemical contaminants/pollutants in our food (yuan et al., ) . numerous factors are contributing towards an increase in different food safety issues. these include the industrialization and mass production of agricultural products, the growing number of imported food products and variations in food consumption patterns due to changes in consumer lifestyle (motarjemi, stadler, studer, & damiano, ) . moreover, consumers are leaning towards ready-to-eat meals and fast foods to save cost and time. as a result many new food borne pathogens have emerged or existing pathogens have re-emerged because of these new types (e.g. raw and fast food) of transmission vehicles. as a result, many foodborne outbreaks have occurred in the last years by bacteria, viruses and protozoa, and many more pathogens are being introduced via food contamination every year (maruši c, ). the annual cost of medical treatment, lost productivity, and illness-related mortality is estimated at $ . billion in the united states alone (kowitt fortune magazine, may ). nanotechnology is becoming increasingly important for the agri-food sector to (i) improve shelf life, food quality and safety, control delivery, storage and packaging and (ii) in the development of nanosensors for contaminated food detection (ranjan et al., ) . as conventional food technologies are proving inefficient with growing consumer demand, the nanofood sector is proving an ideal option for fulfilling ever-increasing consumer demands. for example, essential oils are bioactive compounds and proven antimicrobial agents which have been shown to increase the shelf life of food. however, the same bioactive compounds in nanoemulsion form exhibit enhanced antimicrobial activities compared to their conventional forms due to their minute droplet size (ranjan, dasgupta, ramalingam, & kumar, ) . nanoemulsions of various essential oils such as carvacrol, cinnamaldehyde and limonene have shown significant antimicrobial activity against three microorganisms e. coli, saccharomyces cerevisiae and lactobacillus delbrueckii (ranjan et al., ) . in addition, several nanoparticles, such as silver, gold, zinc, copper, and cerium have been applied based on their antimicrobial activity (ismail, pinchuk, pinchuk, & pinchuk, ) . among all, silver acts differently from other antimicrobials and showed broad-spectrum toxicity to numerous strains of bacteria, fungi and algae and possibly to some extent for some viruses (rai, yadav, & gade, ). nanosilver causes significant structural changes in bacterial cell wall and cell membrane due to its binding to key proteins causing cell disruption and eventually death. the binding of nanosilver to dna and rna can also cause death by inhibiting bacterial replication. hence, silver nanoparticles are widely applied as a sterilizer of freezedried foods and an antiripening agent by food companies. two other antimicrobial mechanisms exhibited by nanoparticles were proposed by rabea, badawy, steven, smagghe, and steurbaut ( ) , based on the chelation of trace metals by chitosan, inhibiting microbial enzyme activities, and (in fungal cells) penetration through the cell wall and membranes to bind dna and inhibit rna synthesis. carbon nanotubes (cnts) have also been reported to have antibacterial properties as direct contact with aggregates of carbon nanotubes can kill e. coli, possibly due to the puncturing of microbial cells by the long, thin nanotubes, causing irreversible damage and leakage of intracellular material. oxygen (o ) is responsible in many ways for food deterioration, such as oxidative reactions causing browning reactions and rancid flavours, etc. food deterioration by the indirect action of o includes food spoilage by aerobic microorganisms. in such circumstances, o scavengers could inhibit the spoilage process by the incorporation of o scavengers into food packaging systems to maintain very low o levels. such o scavenging films were developed by xioa-e, greens, haque, mills, and durrant ( ) by adding tio nps to different polymers. nanocomposite materials can also be used as packaging film for a variety of oxygen sensitive food products. the role of nanosensors incorporated in food packaging in the detection of pathogens and toxins in food products represents a key emerging field of application (bhattacharya, jang, yang, akin, & bashir, ) . the application of fluorescent nanoparticles for the detection of pathogens and toxins in food is of particular interest (burris & stewart, ) ; foodborne pathogenic bacterial species such as salmonella typhimurium, shigella flexneri and e. coli can be detected by quantum dots coupled with immunomagnetic (due to fe o nanoparticles) separation in milk and apple juice (zhao et al., ) . light scattering is another way of detecting the presence of e. coli in food products. the technique works on the principle that a protein of a known and characterized bacterium set on a silicon chip can bind with any e. coli present in the food sample resulting in nanosized light scattering, detected by analysing the digital image (horner, mace, rothberg, & miller, ) . a similar technique was reported by fu, huang, and feng ( ) for the detection of salmonella in food products. silicon/gold nanorods were incorporated with anti-salmonella antibodies and fluorescent dye, which became visible when attached to bacteria. despite the advantages of nanotechnology in the agri-food sector, food nanotechnology represents a relatively new concept and issues relating to product labelling, potential health risks and lack of unifying regulations currently hinder the development of the sector (handford et al., ) . consequently, more research on the application of nanomaterials to the food sector is required. specifically: • a clear, strict definition of nanoparticles is needed. • validated methods for in situ detection and characterization of nanomaterials in complex food matrices should be developed. • precise toxicology studies should be conducted. • the long-term health consequences of ingesting nanoparticles via food have to be investigated. • finally, adequate regulations on nanotechnology applications for food and related products should be developed by food regulatory authorities. recent advances in the nanotechnological world have drawn considerable attention on the new horizons of the application of nanoscience to the fields of medical biology, pharmaceutics and immunology. miscellaneous nanoscopic vectors including polymeric nanoparticles, liposomes, micelles, dendrimers, nano-emulsions, polymeric conjugates, carbon/metal and bio-based nanoparticles have been engineered to deliver promising diagnostic effects (fig. ) . numerous therapeutic substances such as drugs, genes, proteins, sirna, peptides are being delivered in a smarter way for precise targeting to diseased tissue. nanomedicine is paving the way in early detection, cure and diagnosis of cancer, parkinson's disease, alzheimer's disease, tuberculosis and ophthalmology. nanotags, nanolabels, nanoshells, quantum dots as nanoprobes nanotechnology tools and devices for medical biology and immunology schematic diagram of various bio-nanotechnological tools and devices in medical biology and immunology. today diarrhoea-causing viruses represent a major public health concern. norovirus is a leading cause of gastroenteritis in many parts of the world. peptide sequencing using nanospray tandem ms has been reported to be the best method for the identification of capsid protein in stool extracts at a concentration as low as fm (colquhoun, schwab, cole, & halden, ) . the biosensing method most explored in virus detection is surface-enhanced raman spectroscopy (sers). it has shown great promise for the detection of even a single virus particle. recently it has been shown that a silver nanorod array, fabricated using obliqueangle deposition (oad) acts as an extremely sensitive sers substrate. nanotechnology is functional in the design of biochips as they enable the diagnosis at the molecule and single cell level and hence serve as a great advance in molecular diagnostics. recently, functionalized nps, covalently linked to biological molecules such as antibodies, peptides, proteins, and nucleic acids have been developed as nanoprobes for molecular detection. these functionalized nps can provide a direct, rapid, highly sensitive virus detection method (tang et al., ; tripp et al., ) . waveguide technology is another nanomedicinal tool for rapid pathogen detection. the application of the technology was demonstrated for the detection of herpes simplex virus type (hsv- ) by coating one of the waveguide channels with the appropriate herpes antibodies. the technique detected the virus over a range of concentrations ranging from as low as /ml to /ml. the technology is claimed to have wide application, as any antibody can be used to coat a channel for detection (jain, ) . this sensor can be extended to any virus including human immunodeficiency virus (hiv), severe acute respiratory syndrome (sars) corona virus, hbv, hcv, or the avian influenza virus (h n ), among others (ymeti et al., ) . the hbv, hcv, and hbv/hcv gene chips together with the gold/silver np staining amplification method were shown to be useful in detecting these viruses in patient samples. a method for the respiratory syncytial virus (rsv) consisting of functionalized nps conjugated to monoclonal antibodies was shown to be used to rapidly and specifically detect rsv in clinical samples with a great degree of sensitivity (tripp et al., ) . another area of development is nanobiosensors, in which antibody-based piezoelectric nanobiosensors are applied for point-of-care viral diagnostics (jain, ) based on interferometric biosensor immunoassay for the direct and label-less detection of viruses. monochromatic light from a laser source is coupled to a channel waveguide and is guided into four parallel channels (one reference channel and three measuring channels). this facilitates simultaneous detection of three different viruses as the individual channels were coated with specific antibodies (ymeti et al., (ymeti et al., , . the detection of avian influenza virus through whole-virus capture on a planar optical waveguide has already been described (xu, suarez, & gottfried, ) . the assay response is based on the index of refraction changes that occur upon binding of virus particles to unique antigen-specific (haemagglutinin) antibodies on the waveguide surface. quantum dots (qd) is another aspect of nanobiotechnology, composed of fluorescent semiconducting nanocrystals which have broad excitation spectra and narrow emission spectra with good stability on exposure to light (chan et al., ) . these are effective nanolabels and have been successfully used to study rsv pathogenesis using antibody or oligorna probes. research is now ongoing to develop qd mixes to simultaneously detect multiple respiratory viruses (demidov, ; jain, ) . a new nanoparticle-based biobarcode amplification (bca) assay has been developed for early and sensitive detection of hiv- capsid (p ) antigen. cantilever technology, the recently emerging tool in nanomedicine uses microscale and nanoscale cantilever beams as highly sensitive mass detectors with antibodies efficiently bound on cantilevers. this technology has been successfully demonstrated for the detection of a single vaccinia virus particle (average mass of . fg). these devices can be very useful as components of biosensors for the detection of air-borne virus particles (abraham, kannangai, & sridharan, ) . likewise, nanomaterials have high surface area and nanoscale effects, and are therefore being employed as a promising tool for the advancement of drug and gene delivery, biomedical imaging and diagnostic biosensors. in future, it will enable researchers to customize immune responses in new and unexpected ways. through the absorption of nps that have unique combinations of antigens and cytokines, rapid activation of innate and adaptive immune responses is allowed within hours for improved protection against the outbreak of endemic viruses (smith, simon, & baker, ) . there is a very bright future for nanotechnology, by its merging with other technologies and the subsequent emergence of complex and innovative hybrid technologies for early detection, control and diagnosis of human and animal diseases (nikalje, ) . biology-based technologies intertwined with nanotechnology are already used to manipulate genetic material. furthermore, nanotechnology-based screening strategies using silicon nanowires in combination with sirna and transcriptional profiling over time has shown promise for the selective perturbation of the immune response. medicine, regenerative medicine, stem cell research and nutraceuticals are among the leading sectors that will be modified by nanotechnology innovations. there has been tremendous development in the field of nanotechnology in terms of nanoparticle synthesis pathways, their mode of action, characterization techniques and applications. physical and chemical methods of nanoparticle synthesis have proven to be efficient, less time consuming and effective. however, an increasing production of metal nanoparticles and oxides by chemical and physical methods are showing ecotoxicological effects when released into the environment. hence, 'green synthesis' or 'biosynthesis' of nanoparticles using microorganisms (bacteria, fungi, viruses), yeasts, algae is gaining considerable attention. different microorganisms have different mechanisms of forming nanoparticles (pantidos & horsfall, ) . however, nanoparticles are usually formed via: (i) metal ions are first trapped on the surface or inside microbial cells; (ii) the trapped metal ions are then reduced to nanoparticles in the presence of enzymes. nowadays, a variety of inorganic nanoparticles with well-defined chemical composition, size, and morphology have been synthesized using different microorganisms, and their applications in many cutting-edge technological areas have been explored including targeted drug delivery, cancer treatment, gene therapy, dna analysis, antibacterial agents, biosensors, enhancing reaction rates, separation science and magnetic resonance imaging (mri) (hulkoti & taranath, ) . recently, scientists have become more and more interested in the interaction between inorganic molecules and biological species. studies have found that many microorganisms can produce inorganic nanoparticles through either intracellular or extracellular routes (luo, shanmugam, & yeh, ) . semi-conductive qds are the most promising potential materials used in biomedical diagnosis. xiong et al. ( ) designed targetable cellular beacons for diagnosis of pathogens using the biosynthesis strategy coupled with the antibody-combination ability of staphylococcus aureus. taherkhani, mohammadi, daoud, martel, and tabrizian ( ) presented another facile strategy in an application for cancer therapy using the magnetosomes derived from the bacteria magnetospirillum marinus mc- . ghosh et al. ( ) used engineered m virus combined with phage display technique and magnetic nanoparticles for targeting diagnosis of prostate cancer. furthermore, quasi-biosynthesized ag se qds were good candidates for use as lowtoxicity fluorescent tags for in vivo imaging diagnosis (gu, cui, zhang, xie, & pang, ) . overall, these cases provide selected examples of the biomedical application of biosynthesized nanomaterials. however, more comprehensive studies using biosynthesized nanoparticles as nanomedicine have yet to be explored. with the prevalence and increase of microbial resistance to multiple antibiotics, the application of silver-based antiseptics have been examined in recent years. silver nanoparticles have been biosynthesized using the fungus trichoderma viride (fayaz et al., ) . durán, marcato, de souza, alves, and esposito ( ) showed that extracellularly produced silver nanoparticles using fusarium oxysporum can be incorporated into textile fabrics to prevent or minimize infection with pathogenic bacteria such as s. aureus (durán et al., ) . spherical selenium nanoparticles formed by bacillus subtilis with diameters ranging from to nm have been reported (wang, yang, zhang, & liu, ) with a high surface-to-volume ratio, good adhesive ability and biocompatibility that were employed as enhancing and settling materials for use in a hrp (horseradish peroxidase) biosensor. furthermore, magnetic particles conjugated with biological molecules, which represent attractive materials for building assay systems, have been proposed for use as a biological label. competitive chemiluminescence enzyme immunoassays using antibodies immobilized onto bacmps were developed for the rapid and sensitive detection of small molecules, such as environmental pollutants, hormone, and toxic detergents (matsunaga, ueki, obata, et al., ; tanaka, takeda, ueki, et al., ) . nanoparticle biosynthesis is gradually attracting considerable interest because of its simplicity, cost effectiveness and eco-friendliness in various sectors. however, cellular, molecular and biochemical mechanisms that mediate the synthesis of biological nanoparticles should be studied in detail to increase their application rates in various sectors. the wealth of information gained from the science of microbiology and nanotechnology is enormous and despite the fact that it is a recent interdisciplinary science, benefits have already appeared to human, environmental and ecological sciences. nanotechnology has been effectively combined with microbiology in areas such as medicine, pharmaceutical, industrial, agricultural and environmental applications to overcome existing microbiological limitations. further innovations are inevitable as this interdisciplinary science develops. however, though the application of nanotechnology and microbiology represents an exciting and formidable combination, the toxicity of the engineered nanomaterials/nanoparticles (enps) to the environment and human health could raise serious concerns. therefore, it is important to ensure that potential ecotoxicity, health and environmental impacts of enps in terms of the fate of enps when released into the environment through various pathways is fully considered. no matter the numerous avenues of nanoscience applied in medical, immunology, agriculture and the food sector, the positive and negative roles of nms needs to be investigated prior to in vivo studies. there is an urgent need to understand their mechanism of action, life cycle, targeted and non-targeted delivery system and fate in the food chain of living organisms. adequate regulations on nanotechnology applications in food and related agri-food products, surface, fresh or waste-water, drug development and delivery should be developed and monitored stringently. once these limitations have been solved, approved nanotechniques can be used safely and effectively in various arenas making the most of their excellent properties for human well-being, 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nanoliposomes to the surface of magnetotactic bacteria for the synthesis of self-propelled therapeutic agents rapid and sensitive detection of β-estradiol in environmental water using automated immunoassay system with bacterial magnetic particles nanoparticle based biobarcode amplification assay (bca) for sensitive and early detection of human immunodeficiency type i capsid (p ) antigen bioconjugated nanoparticle detection of respiratory syncytial virus infection extracellular biosynthesis and transformation of selenium nanoparticles and application in h o biosensor progress on drinking water and sanitation light-driven oxygen scavenging by titania/polymer nanocomposite films uniform fluorescent nanobioprobes for pathogen detection differential effect of common ligands and molecular oxygen on antimicrobial activity of silver nanoparticles versus silver ions negligible particle-specific antibacterial activity of silver nanoparticles detection of avian influenza virus using an interferometric biosensor fast, ultrasensitive virus detection using a young interferometer sensor integration of microfluidics with a four channel integrated optical young interferometer immunosensor shear-stress-mediated refolding of proteins from aggregates and inclusion bodies simultaneous detection of multifood borne pathogenic bacteria based on functionalized quantum dots coupled with immunomagnetic separation in food samples catching bird flu in droplet a sensitive adenovirus immunoassay as a model for using nanoparticle label technology in virus diagnostics key: cord- -dzma ye authors: rippin, holly l.; wickramasinghe, kremlin; halloran, afton; whiting, stephen; williams, julianne; hetz, kathrin; pinedo, adriana; breda, joão j. title: disrupted food systems in the who european region – a threat or opportunity for healthy and sustainable food and nutrition? date: - - journal: food secur doi: . /s - - -y sha: doc_id: cord_uid: dzma ye dietary health and sustainability are inextricably linked. food systems that are not sustainable often fail to provide the amount or types of food needed to ensure population health. the ongoing pandemic threatens to exacerbate malnutrition, and noncommunicable diseases (ncds). this paper discusses threats and opportunities for food environments and health status across the who european region in the current context . these opportunities and threats are focused around four key areas: ncds and health systems; dietary behaviour; food insecurity and vulnerable groups; and food supply mechanisms. food systems were already under great stress. now with the pandemic, the challenges to food systems in the who european region have been exacerbated, demanding from all levels of government swift adaptations to manage healthiness, availability, accessibility and affordability of food. cities and governments in the region should capitalize on this unique opportunity to ‘build back better’ and make bold and lasting changes to the food system and consequently to the health and wellbeing of people and sustainability of the planet. dietary health and sustainability are inextricably linked. food systems that are not sustainable fail to provide the amount or types of food needed to ensure population health. the current global situation is significantly challenging food systems at supranational, national and local levels. it threatens to exacerbate the current health crisis by increasing the problem of malnutrition, particularly in the form of noncommunicable diseases (ncds). within the who european region ncds (cardiovascular diseases, cancers, chronic respiratory diseases and diabetes) are the biggest causes of morbidity and mortality. overweight and obesitya major ncd risk factor affected % of adults in the who european region in (who ) . how are food environments and health status across the who european region transforming during the pandemic, and how will they continue to change after response measures have been lifted and in the months and years to come? millions across europe and the world are experiencing lockdown restrictions of varying severity, drastically changing the way we live, including our dietary and health-related behaviours. the future consequences of these changes are uncertain, but initial evidence shows that these measures contradict established public health advice, particularly regarding eating healthily and sustainably, and being active. the impacts of the covid- pandemic, together with the public health outcomes of widespread lockdown measures, create a perfect storm for ncd risk factors including obesity and poor diet, physical inactivity, alcohol consumption and tobacco use. in italy, % of deceased patients with covid- suffered co-morbidities, primarily ncds, and there is evidence for this elsewhere across europe and globally (istituto superiore di sanità ; instituto de salud carlos iii ; china cdc weekly ; cdc covid- response team ). evidence also suggests that body mass index (bmi) is positively associated with worse outcomes (peng et al. ) . covid- can present more severe symptoms in people with obesity-related conditions, due to the increased risk of obesity-related ncds such as diabetes (hussain et al. ) . in many who european region countries, more than % of adults are overweight or obese, putting them in a particularly vulnerable position (who a). further, individuals with obesity experience stigma and may suffer higher rates of mental health issues (emmer et al. ) , which may be exacerbated by self-isolation. the link between covid- and ncds means that despite the apparent immediate severity of this pandemic, its long-term health consequences have the potential to outweigh the short-term impact. health systems and society therefore need to fight both risk factors for and bias against overweight and obesity in order to improve health outcomes in a sustainable manner. if used correctly, the pandemic could represent an opportunity to shift towards a health system that better fulfills the role of health promoting settings. it could provide the impetus needed to move from a system built around retrospective reaction, to one that is proactive and based on prevention and promotion of wellbeing in a holistic fashionhighly relevant in a region with high ncd prevalence. in the immediate and short-term, health services should continue to provide essential nutrition services for vulnerable groups including pregnant women, newborns, the elderly and sick children. they should also provide appropriate support for mothers to breastfeed, including those with covid- , and communicate accurate information on maternal, infant and young child nutrition, particularly on complementary feeding. a modern and coherent food systems approach must be conducive to food and nutrition-related behaviors that contribute to a more efficient health system by reducing the burden of diet-related diseases. lockdown measures have shifted the dynamics of dietary behaviour. many national governments in the region forced the closure of non-essential services for an extended period, including food provision businesses such as restaurants and cafes. this could impact population dietary habits in various ways, both positive and negative, in the immediate and medium to long-term. people may engage in more home gardening and cooking out of necessity and pleasure, potentially leading to better quality diets (nielsen ) . this may also have a beneficial impact on mental health. conversely, lack of routine caused by restricted movement may encourage a 'holiday eating' pattern, potentially resulting in over-consumption (venema ) . however, whether these trends are playing out at all socioeconomic levels is also unclear. it is also uncertain as to whether these new patterns will be sustained as lockdown measures are relaxed and the out-of-home food sector reopens. alternatively, individuals may opt for food delivery rather than venturing outside to purchase food at supermarkets or fresh markets. even pre-pandemic, increasing numbers of urban-dwellers in the region were purchasing from online food delivery services due to time scarcity, a major inhibiting factor in the preparation of home-cooked meals. a pre-covid- non-representative survey of european countries found that every fifth meal was consumed outside of the home, of which % were from commercial outlets (iri ). many of these convenience options are high in fat, saturated fat, sugar and salt and are associated with ncd risk. however, lack of supermarket visits may reduce the bulk purchase of such unhealthy, ultra-processed foods and limit exposure to in-store promotions that might otherwise encourage over-consumption. while these adjustments may be temporary, evidence from previous intense social transformations shows that times of crisis can accelerate transformation in the food system, for better or for worse. there exists an opportunity to harness and encourage healthier cooking and eating, both at home and within the out of home sector as this reopens. communication and multisectoral collaboration will be required to facilitate this across all socioeconomic levels, ensuring that no population group is left behind. restricted movement and temporary business closures are affecting normal food-related practices. in a globalized food system, limited access to fresh foods due to panic buying, stockpiling and food shortages may compromise the ability to eat a balanced diet and increase consumption of highly processed foods, often high in fats, sugars and salt (world economic forum ; world health organization ). good nutrition is crucial for health, particularly in times when the immune system might need to fight disease. school closures negatively affect the food environment and possibilities for physical activity among children (world food programme ). among these effects are greater risk of food insecurity, as well as sedentary behaviours, both of which are linked to childhood overweight and obesity (rundle et al. ) . schools can play a vital part in mitigating the risks of both over and undernutrition, as there is evidence that food insecurity increases during school holidays, particularly for vulnerable groups (graham et al. ) . the health and economic implications of this crisis are intertwined. in the wake of the pandemic, many face job insecurity and reduced income, and the economic costs of social distancing tend to hit the poorest, most vulnerable and marginalized members of society. there have been reports of charities tackling such food insecurity, like food banks, experiencing higher demand across the who european region. over % of european food banks have seen increased requests for food aid and emergency food assistance (european food banks federation ). healthy and sustainable food systems must also serve these vulnerable populations. increased unemployment and financial insecurity may also lead to elevated alcohol and tobacco consumption, worsening ncd risk and outcomes (who b; henkel ). further, the elderly population and those with compromised immune systems across the who european region have been specifically instructed to strictly self-isolate for an extensive period. there are particularly strong associations of covid- incidence, hospitalization risk and poorer outcomes in the elderly and those with diabetes, obesity and hypertension. older people may face unique food and nutrition challenges, especially in contexts of isolation and/or poverty (starr et al. ) . elderly care homes are at high risk of residents contracting covid- , and there is evidence that deaths in care homes are increasing in some countries at alarming rates (office for national statistics ). additionally, older populations are often not adequately considered when food systems and nutrition issues are discussed. this double burden may put this group at particular risk of poorer outcome for covid- and ncds. the supply side of the food system is also impacted by covid- (torero ) . labour and logistics capacity issues mean that companies are struggling to meet consumer demand for fresh food (cbi ministry of foreign affairs ). restricted movement has prevented migrant seasonal workers from picking fruit and vegetables, resulting in food loss and waste, and potentially food safety risks. no food can be considered healthy if it is unsafe to eat, and it is important that neither health nor environmental sustainability are compromised due to spoiled food or increased food loss and waste. the covid- crisis may provide an opportunity to reassess our diets and food systems and to explore ways to add diversity. traditional and regional diets could play a significant role in responding to local and national challenges in ensuring healthy and sustainable diets, by promoting sustainable farming practices and smarter and shorter food supply chains to buffer against the multiple shocks created in times of crisis. a move towards such diets could also provide an opportunity for individuals to reflect and adapt their dietary choices related to food access and consumption. investment initiatives aimed at maintaining food systems as part of the covid- response and beyond should be an integral part of helping individuals and society recover better, both from a nutritional and an environmental perspective. the current pandemic poses significant challenges to food systems in the who european region, demanding from all levels of government, particularly cities, swift adaptations to manage the healthiness, availability, accessibility and affordability of food. there is no 'business as usual'we cannot afford to ignore the issues raised in this think piece. food security and nutrition are emerging as one of the biggest concerns as a collateral effect of the pandemic. immediate action is needed to address, monitor and understand this changing situation. governments in the region should capitalize on this unique opportunity to 'build back better' and make bold and lasting changes to the food system and consequently to people's health and wellbeing. work is urgently needed to gain a better understanding of and to help countries navigate this rapidly changing landscape. this includes a need to innovate surveillance systems to track the impact and to anticipate mitigation measures in terms of food systems for populations and at-risk subgroups in urban and rural contexts. we must leverage these opportunities to contribute to a more sustainable environment and to future proof against the next pandemic. author contributions all authors have contributed to the concept and design of the research and to the writing and/or revision of the manuscript and have approved the manuscript for submission. funding information this research was funded by the who regional office for europe. funding for the publication was received from the government of the russian federation within the context of the who european office for the prevention and control of noncommunicable diseases (ncd office). data availability all data and material are appropriately referenced. code availability not applicable. conflict of interest the authors declare that they have no competing interests for the content of this paper. jb is the head, who european office for the prevention and control of noncommunicable diseases. kw, sw and jw are technical officers, hlr and ah are consultants of the same office, kh and ap are interns of the same office. ah is also a postdoctoral researcher at the university of copenhagen. the authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated. open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/ . /. dr. holly rippin is a consultant at the world health organization regional office for europe and is a registered nutritionist in the uk. she spent her early career in the food industry, before completing a phd and postdoctoral position in the university of leeds nutritional epidemiology research group. her research interests span european national dietary surveys, food portion sizes and trans fatty acids, sustainable and healthy diets and ncd prevention. rippinh@who.int high demand for processed fruit and vegetables due to covid- . cbi. the hague preliminary estimates of the prevalence of selected underlying health conditions among patients with coronavirus disease the association between weight stigma and mental health: a meta-analysis school holiday food provision in the uk: a qualitative investigation of needs, benefits, and potential for development unemployment and substance use: a review of the literature ( - ) covid- and diabetes: knowledge in progress situación de covid- en españa a de marzo de in meals eaten out of home as european consumers favour service over home cooking report sulle caratteristiche dei pazienti deceduti positivi a covid- in italia il presente report è basato sui dati aggiornati al marzo . covid- while still in lockdown, many europeans expect the impact of covid- to last another year number of deaths in care homes notified to the care quality commission clinical characteristics and outcomes of cardiovascular disease patients infected by -ncov covid- related school closings and risk of weight gain among children nutritional vulnerability in older adults: a continuum of concerns without food, there can be no exit from the pandemic europe's fresh food supply is being threatened by coronavirus european food and nutrition action plan - . copenhagen: who regional office for europe. world health organization overweight. european health information gateway stepwise approach to surveillance (steps) dr kremlin wickramasinghe mbbs, msc, phd is a technical officer on noncommunicable diseases (ncd) risk factors. his work focuses on integrating responses to addressing ncd risk factors in the region. before joining who, he was co-director of the who collaborating centre on population approaches to n c d p r e v e n t i o n a t t h e university of oxford, united kingdom. he was also course dir e c t o r o f t h e u n i v e r s i t y 's accredited short course on ncd prevention. he co-edited the text book "an introduction to populationlevel prevention of non-communicable diseases" published by the oxford university press. he has a special interest in multisectoral responses to health promotion, quantifying the outcome of health policies and implementation science. kremlin graduated as a medical doctor from the university of colombo. he holds an msc in global health science and a phd in public health from the university of oxford. wickramasinghek@who.int disrupted food systems in the who european regiona threat or opportunity for healthy and sustainable food and nutrition?dr. joão j. breda is the head of the ncd office in moscow, russian federation. this office leads who work on strengthening national capacity in all countries in the who european region to prevent and control ncds, promote an intersectoral approach and develop policies to tackle ncds. the office has been set up as the innovation powerhouse for ncds prevention and surveillance in europe and beyond.during the previous years before taking office in moscow joão breda was the programme manager: nutrition, physical activity and obesity at who regional office for europe based in copenhagen, responsible for providing support to member states of the who european region on the implementation of the european food and nutrition action plan - & the physical activity strategy for the who european region - , as well as evaluating their implementation process.joão breda is a phd in nutritional sciences from porto university where he defended a thesis focused on alcohol and young people. he has done his master degree in public health by the faculty of medical sciences of lisbon university and an mba from the european university in barcelona. rodriguesdasilvabred@who.int key: cord- -wllc gl authors: kent, katherine; murray, sandra; penrose, beth; auckland, stuart; visentin, denis; godrich, stephanie; lester, elizabeth title: prevalence and socio-demographic predictors of food insecurity in australia during the covid- pandemic date: - - journal: nutrients doi: . /nu sha: doc_id: cord_uid: wllc gl the covid- pandemic has exacerbated economic vulnerabilities and disrupted the australian food supply, with potential implications for food insecurity. this study aims to describe the prevalence and socio-demographic associations of food insecurity in tasmania, australia, during the covid- pandemic. a cross-sectional survey (deployed late may to early june ) incorporated the u.s. household food security survey module: six-item short form, and fifteen demographic and covid-related income questions. survey data (n = ) were analyzed using univariate and multivariate binary logistic regression. the prevalence of food insecurity was %. the adjusted odds of food insecurity were higher among respondents with a disability, from a rural area, and living with dependents. increasing age, a university education, and income above $ , /year were protective against food insecurity. food insecurity more than doubled with a loss of household income above % (adjusted odds ratio (aor): . ; % ci: . , . ; p = . ), and the odds further increased with loss of income above % (aor: . ; % ci: . , . ; p = . ). our results suggest that the prevalence of food insecurity may have increased during the covid- pandemic, particularly among economically vulnerable households and people who lost income. policies that support disadvantaged households and ensure adequate employment opportunities are important to support australians throughout and post the covid- pandemic. food security is achieved "when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life" [ ] . this broad definition emphasizes four distinct dimensions of food security [ ] which include the availability, accessibility and utilization of food, in addition to the stability of each of these factors, which refers to an ability to withstand shocks to the broader food system. food insecurity occurs when at least one of these domains are not met, where the experience at a household level may be temporary or longer-term [ ] . access to adequate food is a core social determinant of health, and food insecurity is related to poor nutritional intake and higher mortality the survey used the u.s. household food security survey module: six-item short form (hfssm) to determine the prevalence of food insecurity [ ] . this validated screening tool [ ] sought responses to six questions self-reporting of uncertain, insufficient or inadequate food access, availability and utilization, due to limited financial resources, and the compromised food consumption that may result. the hfssm generally applies a reference timeframe of months; however, it was less applicable for this study which was conducted at the beginning of the covid- pandemic. therefore, the acceptable shorter reference period of days was selected to capture the prevalence of food insecurity during the covid- pandemic only [ ] . responses to the six questions were coded and assessed in accordance with the user notes [ ] , where each affirmative response was assigned a score of , and summed raw scores were used to describe food insecurity at the household level. scores were then used to categorize respondents as having high ( ), marginal ( ), low ( ) ( ) ( ) or very low food security ( ) ( ) . in previous australian studies [ ] , scores of and have been grouped together, while international studies have reported these scores separately. our analyses kept these scores separate, due to the short reference period, and the fact that the majority of respondents who scored reported running out of food and could not afford to buy more. an affirmative response to this question would indicate household food insecurity with other scales, including the single-item measure of food insecurity which is commonly used in australian studies of food insecurity [ ] . fifteen socio-demographic variables were collected, including age (in years), gender (male, female, other), local government area of residence, if they identified as from aboriginal and/or torres strait islander descent, whether they have a health condition or disability that limited their activity, citizenship status (born in australia, australian citizen, permanent resident or temporary resident), the highest level of education, relationship status, household composition, employment status, total household income bracket and whether they were the main shopper for their family. additional questions asked respondents about how the covid- pandemic affected their household finances and job status, including whether the covid- pandemic resulted in a change in their employment and/or a decrease in household income, and whether they were receiving covid- related australian nutrients , , of government benefits (jobkeeper or jobseeker). the study was conducted in accordance with the declaration of helsinki, and the protocol was approved by the university of tasmania's social sciences human research ethics committee (ethics project id: ). data sets were exported from the online survey platforms to ibm spss statistics for windows, version . (ibm corp., armonk, ny, usa), cleaned and prepared for statistical analysis which was performed in stata . (statacorp, ) . all available survey data were used in the analyses. the significance level for all analyses was set at p < . . a binary variable of food security status was generated for application in the univariate and multivariate logistic regression, where food secure was determined by a score of , and food insecure was a score of - on the hfssm. in addition, several of the socio-demographic variables were recoded into a smaller number of categories, due to low cell counts and for ease of interpretation. recoded variables included coding thirty local government areas (lga) of residence categories into three regions (north, south, north-west and west) (see figure for graphical representation) and rurality (urban and rural dwelling regions). age categories were developed from the continuous variable ( - years, - years, - years, - years, - years, + years). disability status was recoded from three options (no, yes a little, yes a lot) to two (yes, no) by collapsing the affirmative responses. relationship status was recoded from seven to four groups (married/de facto, never married, previously married, living apart) by combining widowed, divorced, and separated into previously married. household composition was reduced from ten options to five (couple with no dependents, couple with dependents, single adult with dependents, single person house, other (group/share)). highest education status achieved was recoded from eight options into three (university degree, diploma/technical and further education (tafe) qualification, high school qualification). employment status was recoded from eight options to three (employed [including self-employed]), unemployed and other [which included student, volunteer, retired and other]). household income was recoded into three categories (au$ < , , , - , and , +). all socio-demographic variables were either categorical or ordinal and were cross-tabulated and summarized with frequencies and proportions. cross-tabulations with chi-square statistic were employed to generate descriptive statistics related to food security status, including responses to each of the six food security questions, and with each of the socio-demographic variables. univariate logistic regression was performed individually for each socio-demographic characteristic to generate unadjusted odds ratios for food insecurity. correlation coefficients between all variables were calculated to demonstrate the interrelationships and inform the multivariate analysis. a multivariable logistic regression was performed, including all measured variables to yield adjusted odds ratios (aor) for food insecurity. variables were retained in the final model if any level of the variable had p < . . almost three-quarters of the respondents (n = ) were categorized as having high security (n = , . %), with . % reporting marginal food security (n = ), . % low food security (n = ) and . % (n = ) having very low food security. socio-demographic characteristics of the survey respondents according to food security categories and assessments of the impact of the covid- pandemic on employment and income are presented in table . the majority of respondents were female ( %), and a large proportion ( %) were aged over years. most respondents ( %) were in a married or de facto relationship, and % of respondents had dependents living with them. with regards to income, % of respondents had incomes over au$ , per year, and a majority ( %) had a university education (bachelor's degree or higher). main household shoppers were the predominant survey respondents ( %). the prevalence of household food insecurity ranged from % in the south, to % in the north-west and west regions ( figure ). the greatest proportion of respondents with very low food security were in the north ( %), compared with % in the north-west and west and % in the south. despite a lack of statistically significant regional differences, a larger proportion of respondents residing in rural regions (table ) were classified in the marginal, low and very low food security groups ( %) in comparison to their urban-dwelling counterparts ( %). the proportions of respondents in each food security group who provided affirmative responses to each of the six hfssm questions are represented in table . of the six questions, marginally food secure respondents were most likely to respond affirmatively to the first question: "the food that (i/we) bought just didn't last, and (i/we) didn't have money to get more". however, none of the respondents in the marginally food secure group reported eating less than they wanted or being hungry because there was not enough money for food. in comparison, nearly all respondents ( %) in the very low food security category responded affirmatively to the first question, and a further % reported experiencing hunger. in addition, % of respondents in the low food security category reported they cut down on food or skipped meals for least three days in the past days because they could not afford to buy more, but only % in this group reported experiencing hunger. while the majority of respondents in the low food security group ( %) did not cut down on the size of meals, % reported being unable to afford to eat balanced meals. the proportion of respondents in food secure groups rose with increasing age (table ) . a significantly greater proportion of younger respondents aged - years were classified as having low ( %) or very low food security ( %) over the past month in comparison to older age brackets. while there was no significant difference between men and women in the food secure categories (~ %), a greater proportion of female respondents reported very low food security ( %) in comparison to males ( %). a significantly greater proportion of respondents with a disability reported experiencing low and very low food security ( % and %, respectively) in comparison to respondents without a disability ( % and %). a small proportion of respondents identified as aboriginal and/or torres strait islander ( . %), but less than half of these respondents were food secure, and more than in of these respondents reported experiencing low and very low food security, which was statistically significantly greater than those who did not identify as aboriginal and/or torres strait islander (table ) . a significantly greater proportion of university-educated respondents had high food security ( %) in comparison to smaller proportions of those with a diploma/tafe qualification ( %) and those who obtained a high school qualification ( %). a significantly larger proportion of australian citizens born in australia ( %) and overseas ( %) were classified as having high food security in comparison to permanent residents ( %) and temporary residents ( %). of note, are the high proportions of temporary residents in the marginal ( %), low ( %) and very low ( %) food security groups in comparison to other residents. significantly higher proportions of those respondents who were never married ( %) and separated ( %) were in the very low food security group, and only % of respondents in households of single adults with dependents were classified as having high food security. half ( %) of respondents on the lowest income were classified as having high food security, with a further % in the low food security group and % in the very low food security group, which is much higher than other income brackets (table ) . lga-local government areas. tafe-technical and further education. nutrients , , of similar proportions of respondents who indicated that the covid- pandemic had impacted their job were classified as having marginal food security ( %) in comparison to respondents without a job change. however, a significantly higher proportion of those whose job had been impacted by the pandemic were in the low ( %) and very low ( %) food security groups. fewer respondents who had lost income as a result of the covid- pandemic ( %) had high food security table ). of note, % of respondents who had lost over % of their income reported some degree of food insecurity. interestingly, a similar proportion of respondents receiving the jobkeeper government benefit had high food security, in comparison to less than half ( %) of respondents receiving the lower jobseeker payment ( %), with % of these respondents classified as having marginal food security and a further % in the low and very low food security groups. the prevalence of household food insecurity ranged from % in the south, to % in the north-west and west regions ( figure ). the greatest proportion of respondents with very low food security were in the north ( %), compared with % in the north-west and west and % in the south. despite a lack of statistically significant regional differences, a larger proportion of respondents residing in rural regions (table ) were classified in the marginal, low and very low food security groups ( %) in comparison to their urban-dwelling counterparts ( %). the proportions of respondents in each food security group who provided affirmative responses to each of the six hfssm questions are represented in table . of the six questions, marginally food secure respondents were most likely to respond affirmatively to the first question: "the food that (i/we) bought just didn't last, and (i/we) didn't have money to get more". however, none of the respondents in the marginally food secure group reported eating less than they wanted or being hungry because there was not enough money for food. in comparison, nearly all respondents ( %) in the very low food security category responded affirmatively to the first question, and a further % reported experiencing hunger. in addition, % of respondents in the low food security category reported they cut down on food or skipped meals for least three days in the past days because they could not afford to buy more, but only % in this group reported experiencing hunger. while the majority of respondents in the low food security group ( %) did not cut down on the size of meals, % reported being unable to afford to eat balanced meals. table . distribution of responses to the six-item food insecurity screen across food security status. response the food that (i/we) bought just didn't last, and (i/we) didn't have money to get more. in the last days was this: often true ( . ) ( . ) ( . in the last days, how many days did this happen? in the last days, were you ever hungry but didn't eat because there wasn't enough money for food? table presents crude and adjusted odds ratios of household food insecurity for the variables considered. adjustment for socio-demographic characteristics considered in our multivariable model yielded modest decreases in the strength of some effects, highlighting the co-occurrence of factors associated with elevated risk, especially for income variables. in the multivariate analysis, two demographic variables were removed from the final model, which were also not independently significantly associated with higher food insecurity (main shopper, region). the region was also highly colinear with rurality, which was retained (see table for correlations between variables). as the covid variables were assessing different aspects of the effect of covid- on income, only one (income decrease) was retained in the final model, due to collinearity. the adjusted model had pseudo r = . , and likelihood ratio test statistics χ = . , p < . . the adjusted model indicates that increasing age was protective against food insecurity, with the odds of experiencing food insecurity reducing by % with every decade of life. respondents who identified as aboriginal and/or torres strait islander had more than three-fold greater odds of experiencing food insecurity; however, after adjustment for other household characteristics, this difference did not remain significant despite the aor of . , which may reflect the small proportion of respondents who identified as aboriginal and/or torres strait islander. respondents with a disability had more than two-fold increased odds of experiencing food insecurity compared with those without a disability, which was modestly reduced (aor: . ) after adjusting for other characteristics. an % increase in the odds of experiencing food insecurity was evident for respondents in rural areas after adjusting for other characteristics. higher levels of education were protective against food insecurity, with respondents with a diploma/tafe or high-school qualification showing a two-fold increase in the odds of experiencing food insecurity compared to those with a university-level education (bachelor's degree or higher), which remained significant after adjusting for other characteristics. temporary residents had a four-fold increase in the odds of experiencing food insecurity compared to australian citizens, which was modestly reduced after adjusting for other characteristics and did not remain significant. the multivariate model showed that respondents who were previously married had two-fold higher odds of food insecurity than respondents who were currently married or in a de facto relationship. compared to couple families without dependents, all other household types had increased odds of food insecurity. interestingly, the odds ratio for food insecurity associated with being a single parent household fell from . to . with adjustment for other household characteristics, and this group was no longer statistically significantly different from other household types. household income was independently associated with food insecurity, with incomes above au$ , /year seemingly protective against food insecurity, and income below au$ , per year associated with a two-fold increase in the odds of food insecurity. respondents who reported that the covid- pandemic had resulted in a change in their employment had a % increase in the odds of experiencing food insecurity in comparison to those not impacted. in comparison to those who were employed and not receiving government benefits, respondents who were receiving the jobkeeper government support payment had % higher odds of experiencing food insecurity, and those who were receiving jobseeker support payments (a smaller fiscal amount) had a three and a half-fold increase in the odds of experiencing food insecurity. a gradient was apparent for respondents who had lost income as a result of the covid- pandemic, where an income loss of % or more significantly increased the odds of experiencing food insecurity. independently of other factors, including household income, a loss of more than % of income was associated with a seven-fold increase in the risk of food insecurity. in the adjusted model, similar effects for income decrease were observed, demonstrating that income loss is independently associated with higher odds of food insecurity. this study presents results from a survey of adults in tasmania, australia, assessing the prevalence and socio-demographic predictors of household food insecurity during the covid- pandemic. our results demonstrate that between late april and early june , a time when wide-spread social distancing restrictions were in place, more than in ( %) respondents had experienced food insecurity to some degree. concerningly, % of respondents experienced more severe food insecurity, which meant they were regularly going hungry and were unable to afford balanced meals over the previous month. these statistics are substantially higher than the tasmanian food insecurity prevalence of . %, preceding the covid- pandemic [ ] , and higher than the national reported prevalence of % [ ] . comparable to the results of our study, previous research has shown that food insecurity was highest in the north ( . %) of tasmania, and lower in the south ( . %) and north-west ( . %) [ ] . the tasmanian survey used a single item food insecurity question, meaning these results are not directly comparable to the current study. however, given that more than % of respondents to our survey provided an affirmative response to the equivalent question (see table ), this indicates that the burden of food insecurity in tasmania is substantially higher than pre-covid- levels. there are emerging reports of much higher levels of food insecurity being experienced by populations across the world during the covid- pandemic. a cross-sectional study of low-income adults in the us reported that % of respondents were marginally food insecure, and a further % were food insecure [ ] . however, this study was limited by its focus on low-income households, and the results are, therefore, not generalizable to the wider population. our results demonstrate that the experience of food insecurity was not limited to only those on low incomes, and that loss of income at any level above % contributed to substantially higher odds of experiencing food insecurity. results from a survey in the north-eastern us state of vermont, identified a % increase in food insecurity since the beginning of the pandemic, with % of households experiencing food insecurity (up from %) [ ] . a canadian survey [ ] conducted during april-may found that almost one in seven ( . %) canadians experienced food insecurity to some degree in the previous days, and those who had reduced employment due to covid- , were more likely to be food insecure ( . %) than those who were working ( . %) [ ] . a study in the uk reported that . % of adults had experienced food insecurity since the covid- lockdown began [ ] , up from . % in . interestingly, in this study, a lack of food available in the shops contributed to % of food insecurity experienced, highlighting the importance of stability in the food supply as an overarching domain of food security. the proportions of more severe food insecurity were comparable with our study, where it was reported that % of adults skipped meals, and % regularly went without food [ ] . our study was unable to determine the extent to which food shortages, resulting from food hoarding, impacted food insecure responses. however, it is likely that food-insecure households were left at an extreme disadvantage because of food hoarding. in addition to the wide-spread unavailability of some foods, australian retail outlets and supermarkets placed strict limits on the amount of staple food items that could be purchased in one transaction, which further reduced the ability of households to buy adequate food, especially for larger families living far away from their nearest shop, who need to buy in bulk. while an investigation of the coping strategies adopted by food-insecure households was not a focus of our study, the fact that many respondents reported running out of food, but did not report being hungry shows coping strategies being employed to some degree, especially for those in the marginal and low food security groups ( table ) . such strategies could have included accessing emergency food relief, in addition to restaurants and community groups providing no-cost or low-cost meals and food boxes. our analyses demonstrate that the higher probability of household food insecurity was closely associated with many socio-demographic factors, especially financial factors specific to the covid- pandemic. the most substantial factor in our regression analyses was loss of income related to covid- , with respondents who had lost the majority of their income showing up to a seven-fold increase in the odds of food insecurity. similarly, in the uk, adults reported that loss of income above % resulting from the covid- pandemic were found to be at significantly higher risk of food insecurity, even after accounting for background socio-economic status [ ] . prior to the covid- pandemic, % of tasmanian households were reportedly in financial stress, which means they did not have or could not raise au$ in an emergency [ ] , with this factor closely related to food insecurity in the state. food insecurity has worsened within economically vulnerable populations under covid- conditions, with a loss of income in already low-income households putting individuals at even higher risk of food insecurity. additionally, covid- has also created new economic vulnerability for people were previously food secure and who are now experiencing income losses. previous research has shown that loss of an income or large household bills (also known as bill shock), can require temporary reallocation of financial resources away from groceries, which can result in food insecurity [ ] . previous research during global recessions has shown increased household food insecurity, which can take years to return to pre-recession levels [ ] . our study is limited in that we were unable to control for household savings or other assets, which may explain a large variation in a household's ability to adjust to periods of economic shock in comparison to others. however, low-income households are unlikely to ever accrue substantial savings or assets which could cushion against financial shocks. our analyses demonstrate that a substantial proportion ( %) of our respondents' employment status had been impacted by the covid- pandemic, and that these respondents were at higher risk of moderate to severe food insecurity. positively, government financial support payments were being received by % of our respondents and those receiving the higher jobkeeper payment through their employer showed a similar level of food insecurity to those currently employed. however, approximately half of respondents receiving the lower jobseeker payments reported experiencing food insecurity. this finding is somewhat at odds with national reports of how this new government supplement, which is higher than the usual unemployment benefits, has reduced financial and personal distress, and reduced food insecurity for people who normally access unemployment schemes [ ] . however, the majority of respondents to the national survey had been receiving an income support payment for more than two years, and therefore, our results may reflect the experience of individuals newly claiming this scheme [ ] . in published research, low income is the most consistent and often the strongest predictor of food insecurity [ ] . in our study, those who were food insecure are more highly represented among lower-income brackets, especially for those on incomes lower than au$ , per year. incomes above au$ , per year, which is higher than the median household income in tasmania of approximately au$ , [ ] , were associated with lower odds of food insecurity. low-income households may be larger, and therefore, may be unable to purchase sufficient food to meet their needs, or they may be required to purchase smaller quantities of food, which are sold at a higher unit price, further increasing the prevalence of food insecurity in these households. interestingly, food insecurity was still evident in respondents with the highest incomes (>au$ , per year), indicating that income does not always reflect the economic conditions of the household. of note, the increased food insecurity reported in our study and other studies during the covid- pandemic suggests that the financial impact of covid- on food insecurity is far-reaching in the population, and has affected both households with high socio-economic risk of food insecurity and those not typically perceived to be at risk of food insecurity. in addition, our analyses demonstrate that younger age, rurality, disability, lower education levels, and having dependents were also all independently associated with food insecurity, indicating that the socio-demographic and covid-related factors cannot be explained merely in terms of their association with income. other factors which were associated in the univariate analysis, but not the multivariate, included being of aboriginal/torres strait islander decent, temporary residency, and being single (never married or previously married). for these factors, the relationship with food insecurity may be due to lower-incomes and other factors. in our study, increasing age was protective against food insecurity. these results align with published literature, which demonstrates that even after controlling for economic factors, the probability of moderate or severe food insecurity decreased with age [ , ] . studies of older australians have similarly reported a lower prevalence than in the general population, with prevalence rates of % for australians aged over years [ ] and % of australians aged over years [ ] . compounding this effect, the impact of the covid- pandemic has disproportionately affected younger australians [ ] , due to a large reduction in casual and part-time jobs predominantly held by younger people (e.g., hospitality). interestingly, our study showed that gender was not associated with an increased risk of food insecurity. this is somewhat at odds with the results of other studies, which have explained the increased burden of food insecurity experienced by women to be associated with gender-related economic factors, including lower employment opportunities and child-related duties [ ] . additionally, higher educational attainment was independently associated with lower odds of experiencing food insecurity, which is consistent with other australian research [ , ] , and international studies of food insecurity during the covid- pandemic [ ] . in line with our findings, the greater likelihood of food insecurity among australians from aboriginal and/or torres strait islander descent has been documented previously [ ] , with the prevalence of food insecurity ranging from % in remote areas [ ] to % in the state of victoria [ ] . additionally, respondents reporting health conditions and disabilities that limited their daily activities were more likely to be food insecure than those without a disability and were also shown to experience more severe forms of food insecurity. these results are echoed in previous australian [ ] and international studies [ ] from before the covid- pandemic. while our study did not examine the cause of food insecurity in this group, an uk survey during covid- identified that respondents with a disability had between two and four-fold increased risk of experiencing food insecurity as a result of economic hardship, a lack of food available in shops, and social isolation [ ] . respondents living in rural areas experienced a higher burden of food insecurity in comparison to respondents living in urban areas and were % more likely to be food insecure after accounting for other socio-demographic factors. in rural australia, fresh and healthy food is very expensive in some areas, due to transportation and storage costs [ ] . during the covid- pandemic, reduced access to food and fewer shops in these areas was coupled with media reports of price gouging of foods in response to increased demand [ ] , and these factors may have infringed upon the ability of rural residents to buy enough healthy food to meet their needs. pre-covid- evidence has inconsistently linked immigration status to food insecurity [ , ] . in our study, temporary residents were four times more likely to experience food insecurity compared with australian citizens, which did not remain significant after controlling for other variables. this may either reflect the small number of temporary residents who responded to our survey, or reflect the exacerbated economic hardship experienced by temporary residents during the covid- pandemic. in australia, temporary residents were ineligible for government support payments, and were therefore, at a much higher risk of food insecurity due to loss of income. comparable with published research [ , ] , being married or in a de facto relationship was negatively associated with food insecurity. during the covid- pandemic, this may be related to the increased financial buffer of two potential income streams in comparison to those in single adult households, or that our study investigated household income, not income per-person, so the adjustment for income may be less appropriate for single respondents. additionally, we found that households with dependents were more likely to be food insecure compared with those without dependents. interestingly, households headed by a single parent were at three-fold greater risk of food insecurity. however, after adjustment for other variables, this difference was no longer significant, indicating that other variables, such as lower-income or loss of income accounted for this increased risk during the covid- pandemic. this study has a number of strengths. to our knowledge, this may be one of the few studies that have examined the impact of the covid- pandemic on food insecurity in australia. moreover, we were able to assess the prevalence of food insecurity in a large sample size relative to the population of tasmania, using a multiple item food security tool, which has shown to be more comprehensive than the single item food security question applied in many australian studies [ , ] . despite these strengths, these findings must be considered within the context of a number of potential limitations. our study was cross-sectional in nature, and therefore, our analyses are purely descriptive, and inferences are limited by the design of the study [ ] . importantly, despite the wide recruitment methods used, the likelihood of participating in the survey may be associated with food insecurity (participation bias), and the use of an online survey may have excluded some groups, including those with low literacy or people without internet access. further, our sample may not be representative of the wider tasmanian population [ ] , as our sample contained a higher proportion of female respondents ( . %) compared with the demographic profile of the tasmanian population ( . % female). this over-representation may be explained by the food-based theme of the survey and that women have been reported to predominantly manage household meals [ ] . despite this, our results are supported by reports that women provide more reliable estimates of the food insecurity experiences of a household [ ] . our sample shared similar proportions of married and separated respondents with the tasmanian population ( . % married, . % previously married, and . % never married) [ ] . however, our survey had a lower proportion of respondents who identified as aboriginal and/or torres strait islander ( . %) than the wider tasmanian population ( . %), and a lower proportion of unemployed respondents ( . %), compared to the general tasmanian population ( %). our respondents were overall very highly educated, with % having a university education, compared with . % having tertiary qualifications in the wider tasmanian community [ ] , which may be a result of our convenience sampling methods. as higher education has shown to be protective against food insecurity, actual levels of food insecurity may be higher in the general tasmanian population. lastly, the -item hfssm is slightly less reliable than -item measure, does not measure the most severe levels of food insecurity and does not measure the food security of children in the household [ ]. where to next? as the covid- pandemic continues around the world, it is likely that more severe economic vulnerabilities will emerge towards the end of and beyond. further monitoring of food insecurity across australia and internationally is needed to support the ongoing recovery from the covid- pandemic. prior to the pandemic, food-insecure households have reported numerous coping strategies for making ends meet, including seeking resources from within their social network in addition to emergency food relief. however, social distancing restrictions, business closures and other public health measures may infringe upon these coping strategies, and newly food-insecure households may not have appropriate knowledge of support services. therefore, further australian research is urgently needed to examine the coping strategies that food-insecure households are utilizing during the covid- pandemic, including the appropriateness of income support payments for alleviating more severe food insecurity during the covid- pandemic. our results indicate higher levels of food insecurity in australia during the covid- pandemic and could inform responsive policy interventions. while government support measures, including the jobkeeper and jobseeker payments, appear to be assisting vulnerable australian households, significant financial distress will follow once they are removed or reduced. as loss of income was a major factor in our analyses, effective government responses should center around providing opportunities for secure employment that pays a living wage, rather than a minimum wage. additionally, strengthening social protection mechanisms and emergency food relief programs may protect those at risk of food insecurity. lastly, systems that support the physical access to food, and protect the stability of the food supply must be strengthened. this should involve shortening and localizing food supply chains and bolstering local food systems, where food is grown, packaged, and consumed within the same community. food policy coalitions could provide the mechanism to work at the intersection of health, social justice and environmental sustainability to improve local and regional food systems, positively influencing the food environment [ , ] . given the urgent and widely accepted need to transition to a more circular, just, and sustainable economy, the government in partnership with the community should explore setting up appropriately constituted local food councils in each region. these could support community food hubs to enhance market access for farmers, create jobs, build resilience, promote local and sustainable food procurement, and ultimately improve food security by increasing access to local, healthy food [ , ] . author contributions: conceptualization, k.k., s.m., b.p., s.a., s.g. and e.l.; methodology, k.k., s.m., b.p., s.a., s.g. and e.l.; software, e.l.; formal analysis, d.v. and k.k.; writing-original draft preparation, k.k.; writing-review and editing, all authors; funding acquisition, k.k. all authors have read and agreed to the published version of the manuscript. funding: this research received no external funding and the apc was funded by the university of tasmania's centre for rural health. the food and agriculture organization fao. the state of food insecurity in the what are we assessing when we measure food security? a compendium and review of current metrics the food security continuum: a novel tool for understanding food insecurity as a range of experiences. food secur what does increasing severity of food insecurity indicate for food insecure families? relationships between 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rural and remote australia coronavirus and price gouging-let's put a stop to it food insecurity and public assistance single-item measure of food insecurity used in the national health survey may underestimate prevalence in australia being honest with causal language in writing for publication development of a food security measurement tool for new zealand households food policy development in the australian state of victoria: a case study of the food alliance the role of a food policy coalition in influencing a local food environment: an australian case study. public health nutr tasmanians seeking more circular and sustainable food systems report of the tasmania project community food hubs: an economic and social justice model for regional australia? this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors would like to acknowledge the members of the tasmania project and thank them for their assistance in collecting data for this study, in particular nyree pisanu and ella horton. the authors declare no conflict of interest. key: cord- -y p iznq authors: keogh, john g.; rejeb, abderahman; khan, nida; dean, kevin; hand, karen j. title: data and food supply chain: blockchain and gs standards in the food chain: a review of the possibilities and challenges date: - - journal: building the future of food safety technology doi: . /b - - - - . - sha: doc_id: cord_uid: y p iznq this chapter examines the integration of gs standards with the functional components of blockchain technology as an approach to realize a coherent standardized framework of industry-based tools for successful food supply chain transformation. the vulnerability of food supply chains is explored through traceability technologies and standards with particular attention paid to interoperability. fscs are vulnerable to natural disasters, malpractices, and exploitative behavior, leading to food security concerns, reputational damage, and significant financial losses. due to the inherent complexities of global fscs, it is almost impossible for stakeholders to police the entire flow of materials and products and identify all possible externalities. recurring disruptions (e.g., natural disasters, avian flu, swine fever, and consecutive food scandals have increased the sense of urgency in the management of fscs (zhong, xu, & wang, ) and negatively impacted consumer trust. the european "horsemeat scandal" in exemplified the vulnerabilities (yamoah & yawson, ) , and legal scholars from cambridge university posited the ability of the eu's regulatory regime to prevent fraud on such a scale was shown to be inadequate. eu food law, with its (over) emphasis on food safety, failed to prevent the occurrence of fraud and may even have played an (unintentional) role in facilitating or enhancing it the cambridge scholars further argued that the free movement of goods within the european union created a sense of "blind trust" in the regulatory framework, which proved to be inadequate to protect businesses and consumers from unscrupulous actors. while natural disasters and political strife are outside of the control of fsc stakeholders, to preserve food quality and food safety and minimize the risk of food fraud or malicious attacks, fsc stakeholders need to establish and agree on foundational methods for analytical science, supply chain standards, technology tools, and food safety standards. the redesign of the fsc is necessary in order to ensure unquestionable integrity in a resilient food ecosystem. this proposal would require a foundational approach to data management and data governance to ensure sources of accurate and trusted data to enable inventory management, order management, traceability, unsafe product recall, and measures to protect against food fraud. failure to do so will result in continued consumer distrust and economic loss. notably, a report by gs uk et al. ( ) reported that eighty percent of united kingdom retailers had inconsistent product data, estimated to cost ukp million in profit erosion over years and a further ukp million in lost sales. the recent emergence of blockchain technology has created significant interest among scholars and practitioners in numerous disciplines. initially, blockchain technology was heralded as a radical innovation laden with a strong appeal to the financial sector, particularly in the use of cryptocurrencies (nakamoto, , p. ). the speculation on the true identity of the pseudonymous "satoshi nakamoto" gave rise to suspicion on the actual creators of bitcoin and their motives (lemieux, ) . moreover, halaburda ( ) argued that there is a lack of consensus on the benefits of blockchain and, importantly, how it may fail. further, rejeb, s} ule, & keogh ( , p. ) argued "ultimately, a blockchain can be viewed as a configuration of multiple technologies, tools and methods that address a particular problem." beyond the sphere of finance, blockchain technology is considered a foundational paradigm (iansiti & lakhani, ) with the potential for significant societal benefits and improve trust between fsc actors. blockchain technology offers several capabilities and functionalities that can significantly reshape existing practices of managing fscs and partnerships, regardless of location, and also offers opportunities to improve efficiency, transparency, trust, and security, across a broad spectrum of business and social transactions (frizzo-barker et al., ) . the technological attributes of blockchain can combine with smart contracts to enable decentralized and self-organization to create, execute, and manage business transactions (schaffers, ) , creating a landscape for innovative approaches to information and collaborative systems. innovations are not only merely a simple composition of technical changes in processes and procedures but also include new forms of social and organizational arrangements (callon, law, & rip, ) . the ubiquitous product bar code stands out as a significant innovation that has transformed business and society. since the decision by us industry (gs , ) to adopt the linear bar code on april , , and the first scan of a -pack of wrigley's juicy fruit chewing gum in marsh's supermarket in troy, ohio, on june , (gs , , the bar code is scanned an estimated billion times daily. gs is a not-for-profit organization tasked with managing industry-driven data and information standards (note, gs is not an acronym). the gs system of interoperable standards assigns and manages globally unique identification of firms, their locations, their products, and assets. they rely on several technology-enabled functions for data capture, data exchange, and data synchronization among fsc exchange partners. in fscs, there is a growing need for interoperability standards to facilitate business-to-business integration. the adoption of gs standards-enabled blockchain technology has the potential to enable fsc stakeholders to meet the fast-changing needs of the agri-food industry and the evolving regulatory requirements for enhanced traceability and rapid recall of unsafe goods. although there is a growing body of evidence concerning the benefits of blockchain technology and its potential to align with gs standards for data and information (fosso wamba et al., ; kamath, ; lacity, ) , the need remains for an extensive examination of the full potentials and limitations. the authors of this section, therefore, reviewed relevant academic literature to examine the full potential of blockchain-enabled gs systems comprehensively, and therefore provide a significant contribution to the academic and practitioner literature. the diversity of blockchain research in the food context is fragmented, and the potentials and limitations in combination with gs standards remain vaguely conceptualized. it is vitally essential to narrow this research gap. this review will begin with an outline of the methodology applied to collect academic contributions to blockchain and gs standards within a fsc context, followed by an in-depth analysis of the findings, concluding with potential areas for future research. in order to explore the full potential of a system integrating blockchain functionalities and gs standards, a systematic review method based on tranfield, denyer, & smart ( ) guidelines was undertaken. the systematic review was considered as a suitable method to locate, analyze, and synthesize peer-reviewed publications. research on blockchain technology is broad and across disciplines; however, a paucity of research specific to food chains exists (fosso wamba et al., ) . similarly, existing research on blockchain technology and gs standards is a patchwork of studies with no coherent or systematic body of knowledge. therefore, the objective of this study was to draw on existing studies and leverage their findings using content analysis to extract insights and provide a deeper understanding of the opportunities for a gs standards-enabled blockchain as an fsc management framework. as stated earlier, the literature on blockchain technology and gs is neither well-developed nor conclusive, yet necessary to ensure successful future implementations. in order to facilitate the process of literature collection, a review protocol based on the "preferred reporting items for systematic reviews and meta-analyzes" (prisma) was used (liberati et al., ) . the prisma approach consists of four processes: the use of various sources to locate previous studies, the fast screening of studies and removal of duplicates, the evaluation of studies for relevance and suitability, and the final analysis of relevant publications. fig. . illustrates the prisma process. to ensure unbiased results, this phase of the study was completed by researchers with no previous knowledge or association with gs . conducting the review began with a search for studies on blockchain technology and gs standards. reviewed publications originated from academic sources (peer-reviewed) and included journal articles, conference papers, and book chapters. due to the nascent and limited literature on blockchain technology and gs standards, we supplemented our analysis with other sources of information, including conference proceedings, gray sources, and reports. the survey of the literature was conducted using four major scientific databases: scopus, web of science, sciencedirect, and google scholar. we used a combination of keywords that consisted of the following search string: "blockchain*" and "gs " and ("food chain*" or "food supply*" or agriculture or agro. the google scholar search engine has limited functionality and allows only the fulltext search field; therefore, only one search query "blockchain* and gs and food" was used for the retrieval of relevant studies. the titles and abstracts of publications were scanned to obtain a general overview of the study content and to assess the relevance of the material. as shown in fig. . , a total of publications were found. many of the publications were redundant due to the comprehensive coverage of google scholar; studies focused on blockchain technology outside the context of food were removed. a fine-tuned selection of the publications was undertaken to ensure relevance to fscs. table . contains a summary of the findings based on content analysis. the final documents were classified, evaluated, and found to be sufficient in narrative detail to provide an overview of publications to date, specifically related to blockchain technology and gs standards. the loss of trust in the conventional banking system following the global financial crisis laid the groundwork for the introduction of an alternative monetary system based on a novel digital currency and distributed ledger (richter, kraus, & bouncken, ) . "satoshi nakamoto" (a pseudonym for an unknown person, group of people, organization, or other public or private body) introduced an electronic peer-to-peer cash system called bitcoin (nakamoto, , p. ). the proposed system allowed for payments in bitcoin currency, securely and without the intermediation of a trusted third party (ttp) such as a bank. the bitcoin protocol utilizes a blockchain, which provides an ingenious and innovative solution to the doublespending problem (i.e., where digital currency or a token is spent more than once), eliminating the need for a ttp intervention to validate the transactions. moreover, lacity ( , p. ) argued "while ttps provide important functions, they have some serious limitations, like high transaction fees, slow settlement times, low transaction transparency, multiple versions of the truth and security vulnerabilities." the technology behind the bitcoin application is known as a blockchain. the bitcoin blockchain is a distributed database (or distributed ledger) implemented on public, untrusted networks (kano & nakajima, ) with a cryptographic signature (hash) that is resistant to falsification through repeated hashing and a consensus algorithm (sylim, liu, marcelo, & fontelo, ) . blockchain technology is engineered in a way that parties previously unknown to each other can jointly generate and maintain a database of records (information) and can correct and complete transactions, which are fully distributed across several nodes (i.e., computers), validated using consensus of independent verifiers (tijan, aksentijevi c, ivani c, & jardas, ). blockchain is categorized under the distributed ledger technology family and is characterized by a peer-to-peer network and a decentralized distributed database, as depicted in fig. . . a diagrammatic representation of blockchain technology. according to lemieux ( ) , the nodes within a blockchain work collectively as one system to store encrypted sequences of transactional records as a single chained unit or block. nodes in a blockchain network can either be validator nodes (miners in ethereum and bitcoin) that participate in the consensus mechanism or nonvalidator nodes (referred to only as nodes). when any node wants to add a transaction to the ledger, the transaction of interest is broadcast to all nodes in the peer-to-peer network. transactions are then collected into a block, where the addition to the blockchain necessitates a consensus mechanism. validators compete to have their local block to be the next addition to the blockchain. the way blocks are constructed and propagated in the system enables the traceback of the whole chain of valid network activities back to the genesis block initiated in the blockchain. furthermore, the consensus methodology employed by the underlying blockchain platform designates the validator, whose block gets added to the blockchain with the others remaining in the queue and participating in the next round of consensus. the validator node gains an incentive for updating the blockchain database (nakamoto, , p. ). the blockchain may impose restrictions on reading the data and the flexibility to become a validator to write to the blockchain, depending upon whether the blockchain is permissioned or permission-less. a consensus algorithm enables secure updating of the blockchain data, which is governed by a set of rules specific to the blockchain platform. this right to update the blockchain data is distributed among the economic set (buterin, b) , a group of users who can update the blockchain based on a set of rules. the economic set is intended to be decentralized with no collusion within the set (a group of users) in order to form a majority, even though they might have a large amount of capital and financial incentives. the blockchain platforms that have emerged employ one of the following decentralized economic sets; however, each example might utilize a different set of consensus algorithms: owners of computing power: this set employs proof-of-work (pow) as a consensus algorithm observed in blockchain platforms like bitcoin and ethereum. each block header in the blockchain has a string of random data called a nonce attached to them (nakamoto, , p. ). the miners (validators) need to search for this random string such that when attached to the block, the hash of the block has a certain number of leading zeros and the miner who can find the nonce is designated to add his local block to the blockchain accompanied by the generation of a new cryptocurrency. this process is called mining. mining involves expensive computations leading to (often massive) wastage of computational power and electricity, undesirable from an ecological point of view (o'dwyer & malone, ) , and resulting in a small exclusive set of users for mining. this exclusivity, however, goes against the idea of having a decentralized set leading blockchain platforms to employ other means of arriving at a consensus. stakeholders: this set employs the different variants of the proof-of-stake (pos) consensus mechanism. pos is a more just system than pow, as the computational resources required to accomplish mining or validation can be done through any computer. ethereum pos requires the miner or the validator to lock a certain amount of their coins in the currency of the blockchain platform to verify the block. this locked number of coins is called a stake. computational power is required to verify whether a validator owns a certain percentage of the coins in the available currency or not. there are several proposals for pos, as pos enables an improved decentralized set, takes power out of the hands of a small exclusive group of validators, and distributes the work evenly across the blockchain. in ethereum pos, the probability of mining the block is proportional to the validator's stake (ethhub, ) just as in pow, and it is proportional to the computational hashing power. as long as a validator is mining, the stake owned by him remains locked. a downside of this consensus mechanism is that the richest validators are accorded a higher priority. the mechanism does, however, encourage more community participation than many other methods. other consensus protocols include the traditional byzantine fault tolerance theory (sousa et al., ) , where the economic set needs to be sampled for the total number of nodes. here, the set most commonly used is stakeholders. hence, such protocols can be considered as subcategories of pos. a user's social network: this is used in ripple and stellar consensus protocols. the ripple protocol, for example, requires a node to define a unique node list (unl), which contains a list of other ripple nodes that the defining node is confident would not work against it. a node consults other nodes in its unl to achieve consensus. consensus happens in multiple rounds with a node declaring a set of transactions in a "candidate set," which is sent to other nodes in the unl. nodes in the unl validate the transactions, vote on them, and broadcast the votes. the initiating node then refines the "candidate set" based on the votes received to include the transactions getting the most significant number of votes for the next round. this process continues until a "candidate set" receives % votes from all the nodes in the unl, and then it becomes a valid block in the ripple blockchain. blockchain technologies are considered a new type of disruptive internet technology (pan, song, ai, & ming, ) and an essential enabler of large-scale societal and economic changes (swan, ; tapscott & tapscott, ) . the rationale for this argument is due to its complex technical constructs (hughes et al., ) , such as the immutability of transactions, security, confidentiality, consensual mechanisms, and the automation capabilities enabled by smart contracts. the latter is heralded as the most important application of blockchain (the integrity of the code in smart contracts requires quality assurance and rigorous testing). by definition, a smart contract is a computer program that formalizes relationships over computer networks (szabo, (szabo, , . although smart contracts predate bitcoin/blockchain by a decade and do not need a blockchain to function (halaburda, ) , a blockchainbased smart contract is executed on a blockchain with a consensus mechanism determining its correct execution. a wide range of applications can be implemented using smart contracts, including gaming, financial, notary, or computation (bartoletti & pompianu, ) . the use of smart contracts in the fsc industry can help to verify digital documents (e.g., certificates such as organic or halal) as well as determine the provenance (source or origin) of specific data. in a cold chain scenario, rejeb et al. ( ) argued that smart contracts connected to iot devices could help to preserve the quality and safety of goods in transit. for example, temperature tolerances embedded into the smart contract can trigger in-transit alerts and facilitate shipment acceptance or rejection based on preset parameters in the smart contract. the first platform for implementing smart contracts was ethereum (buterin, a, pp. e ) , although most platforms today cater to smart contracts. therefore, similar to the radical transformations brought by the internet to individuals and corporate activities, the emergence of blockchain provides opportunities that can broadly impact supply chain processes (fosso wamba et al., ; queiroz, telles, & bonilla, ) . in order to understand the implications of blockchain technology for food chains, it is essential to realize the potentials of its conjunction with gs standards. while the technology is still in a nascent stage of development and deployment, it is worthwhile to draw attention to the potential alignment of blockchain technology with gs standards as proof of their success, and universal adoption is very likely to prevail in the future. traceability is a multifaceted construct that is crucially important in fscs and has received considerable attention through its application in the iso /bs quality standards (cheng & simmons, ) . scholars have stressed the importance and value of traceability in global fscs (charlier & valceschini, ; roth, tsay, pullman, & gray, ) . broadly, traceability refers to the ability to track the flow of products and their attributes throughout the entire production process steps and supply chain (golan et al., ) . furthermore, olsen and borit ( ) completed a comprehensive review of traceability across academic literature, industry standards, and regulations and argued that the various definitions of traceability are inconsistent and confusing, often with vague or recursive usage of terms such as "trace." they provide a comprehensive definition: "the ability to access any or all information relating to that which is under consideration, throughout its entire life cycle, by means of recorded identifications" (olsen and borit, , p. ) . the gs global traceability standard (gs , c: ) aligns with the iso : definition "traceability is the ability to trace the history, application or location of an object [iso : ] . when considering a product or a service, traceability can relate to origin of materials and parts; processing history; distribution and location of the product or service after delivery." traceability is also defined as "part of logistics management that capture, store, and transmit adequate information about a food, feed, food-producing animal or substance at all stages in the food supply chain so that the product can be checked for safety and quality control, traced upward, and tracked downward at any time required" (bosona & gebresenbet, , p. ). in the fsc context, a fundamental goal is to maintain a high level of food traceability to increase consumer trust and confidence in food products and to ensure proper documentation of the food for safety, regulatory, and financial purposes (mahalik & kim, ) . technology has played an increasingly critical role in food traceability over the past two decades (hollands et al., ) . for instance, radio frequency identification (rfid) has been adopted in some fscs to enable non-line-of-sight identification of products to enhance end-to-end food traceability (kelepouris et al., ) . walmart achieved significant efficiency gains by deploying drones in combination with rfid inside a warehouse for inventory control (companik, gravier, & farris, ) . however, technology applications for food traceability are fragmented, often proprietary and noninteroperable, and have enabled trading partners to capture only certain aspects of the fsc. as such, a holistic understanding of how agri-food businesses can better track the flow of food products and related information in extended, globalized fscs is still in a nascent stage of development. for instance, malhotra, gosain, & el sawy ( ) suggested it is imperative to adopt a more comprehensive approach of traceability that extends from source to final consumers in order to obtain a full understanding of information processing and sharing among supply chain stakeholders. in this regard, blockchain technology brings substantial improvements in transparency and trust in food traceability (behnke & janssen, ; biswas, muthukkumarasamy, & tan, ; sander, semeijn, & mahr, ) . however, arguments from many solution providers regarding traceability from "farm to fork" are a flawed concept as privacy law restricts tracking products forward to consumers. in this regard, tracking (to track forward) from farm to fork is impossible unless the consumer is a member of a retailers' loyalty program. however, tracing (to trace backward) from "fork to farm" is a feasible concept enabled by a consumer scanning a gs centric bar code or another code provided by the brand (e.g., proprietary qr code). hence, farm-to-fork transparency is a more useful description of what is feasible (as opposed to farm-to-fork traceability). while a blockchain is not necessarily needed for this function, depending on the complexity of the supply chain, a blockchain that has immutable information (e.g., the original halal or organic certificate from the authoritative source) could improve the integrity of data and information provenance. blockchain is heralded as the new "internet layer of value," providing the trinity of traceability, trust, and transparency to transactions involving data or physical goods and facilitating authentication, validation, traceability, and registration (lima, ; olsen & borit, ) . the application of gs standards with blockchain technology integration enables global solutions linking identification standards for firms, locations, products, and assets with blockchains transactional integrity. thus, the combination of blockchain and gs standards could respond to the emerging and more stringent regulatory requirements for enhanced forms of traceability in fscs (kim, hilton, burks, & reyes, ) . a blockchain can be configured to provide complete information on fsc processes, which is helpful to verify compliance to specifications and to trace a product to its source in adverse events (such as a consumer safety recall). this capability enables blockchain-based applications to solve problems plaguing several domains, including the fsc, where verified and nonrepudiated data are vital across all segments to enable the functioning of the entire fsc as a unit. within the gs standards framework, food traceability is industry-defined and industry-approved and includes categorizations of traceability attributes. these include the need to assign unique identifiers for each product or product class and group them to traceable resource unit (behnke & janssen, ) . fsc actors are both a data creator (i.e., they are the authoritative source of a data attribute) and a data user (i.e., a custodian of data created by other parties such as an upstream supplier). data are created and used in the sequential order of farming, harvesting, production, packaging, distribution, and retailing. in an optimized fsc, the various exchange parties must be interconnected through a common set of interoperable data standards to ensure the data created and used provide a shared understanding of the data attributes and rules (rules on data creation and sharing are encompassed within gs standards). a blockchain can be configured to add value in fscs by creating a platform with access and control of immutable data, which is not subject to egregious manipulation. moreover, blockchain technology can overcome the weaknesses created by the decades-old compliance to the minimum regulatory traceability requirements, such as registering the identity of the exchange party who is the source of inbound goods and registering the identity of the exchange party who is the recipient of outbound goods. this process is known as "one-up/one-down" traceability (wang et al., , pp. e ) and essentially means that exchange parties in an fsc have no visibility on products outside of their immediate exchange partners. blockchain technology enables fsc exchange partners to maintain food traceability by providing a secure, unfalsifiable, and complete history of food products from farm to retail (molding, ). unlike logistics-oriented traceability, the application of blockchain and gs standards can create attribute-oriented traceability, which is not only concerned with the physical flow of food products but also tracks other crucial information, including product quality and safety-related information (skilton & robinson, ). on the latter point, food business operators always seek competitive advantage and premium pricing through the product (e.g., quality) or process differentiation claims (e.g., organically produced, cage-free eggs). this is in response to research indicating that an increasing segment of consumers will seek out food products best aligning with their lifestyle preferences such as vegetarian, vegan, or social and ethical values such as fair trade, organic, or cage-free (beulens, broens, folstar, & hofstede, ; roe & sheldon, ; vellema, loorbach, & van notten, ; yoo, parameswaran, & kishore, ) . in fig. . below, keogh ( ) outlines the essential traceability functions and distinguishes the supply chain flow of traceability event data versus the assurance flow of credence attributes such as food quality and food safety certification. for instance, in economic theory, goods are considered as comprising of ordinary, search, experience, or credence attributes (darby & karni, ; nelson, ) . goods classified as ordinary (e.g., petrol or diesel) have well-known characteristics and known sources and locations to locate and purchase. regarding search, it refers to goods where the consumer can easily access trusted sources of information about the attributes of the product before purchase and at no cost. search is "costless" per se and can vary from inspecting and trying on clothes before buying or going online to find out about a food product, including its ingredients, package size, recipes, or price. in the example of inspecting clothes before purchase, dulleck, kerschbamer, & sutter ( ) differentiate this example as "search" from "experience" by arguing that experience entails unknown characteristics of the good that are revealed only after purchase (e.g., the actual quality of materials, whether it fades after washing). products classified as experience goods have attribute claims such as the product is tasty, flavorful, nutritious, or health-related such as lowers cholesterol and requires the product to be tasted or consumed to verify the claim, which may take time (e.g., lowers cholesterol). verifying the experience attributes may be free if test driving a car or receiving a sample or taster of a food product in a store. nevertheless, test driving or sampling will not confirm how the product will perform over time. generally speaking, verifying experience attributes of food is not free, and it may take considerable time (and likely expense) to verify the claim. credence claims (darby and karni, ) are characterized by asymmetric information between food producers and food consumers. the reason for this is because credence attributes are either intrinsic to the product (e.g., food quality, food safety) or extrinsic methods of processing (e.g., organic, halal, kosher), and consumers cannot verify these claims before or after purchase (dulleck et al., ) . in this regard, a blockchain offers a significant advancement in how credence claims flow (see fig. . ) and are added to a product or batch/lot # record. for instance, the immutability of the data means that a brand owner can add a record such as a third-party certificate (e.g., laboratory analysis verifying a vegan claim or a usda organic certificate), but they cannot edit or change it. this feature adds much-needed integrity to fscs and enhances transparency and consumer trust, especially if the third-party data are made available for consumers to query. in this context, the combination of gs standards and a blockchain provides a consumer with the capability to scan a food product and query its digital record to verify credence claims. at a more detailed level, the fragmentation of fscs and their geographic dispersion illustrates the need for blockchain and gs for achieving an optimal granularity level of traceability units (dasaklis, casino, & patsakis., ) . as such, the combination of blockchain can help in the assurance of food quality and safety, providing secure (toyoda, takis mathiopoulos, sasase, & ohtsuki, ) , precise, and real-time traceability of products. moreover, the speed of food authentication processes makes blockchain a potential enabler of a proactive food systemda key catalyst for anticipating risky situations and taking the necessary preventative measures. triggering automatic and immediate actions in the fsc has been an impetus for large corporations to adopt blockchain technology; for example, walmart leverages gs standards and blockchain technology, defining the data attributes to be entered into their preferred blockchain system, such as the attributes defined under the produce traceability initiative (pti, ). using gs standards as a foundational layer, walmart tracks pork meat and pallets of mangoes, tagged with unique numeric identifiers in china and the united states. walmart has demonstrated the significant value of a gs -enabled blockchain, reducing both business and consumer risk in a product safety recall. more specifically, walmart simulated a product safety recall for mangoes, and this exercise suggested a reduction in time to execute the product safety recall from days pre-blockchain to . s using a blockchain (kamath, ) . the contribution of gs to the de facto individualization of food products has motivated the study of dos santos, torrisi, yamada, & pantoni ( ) , who examine the traceability requirements in recipe-based foods and propose whole-chain traceability with a focus on ingredient certification. with the use of blockchain technology, it is possible to verify the source of any batch or a lot number of ingredients. kim et al. ( ) developed an application called "food bytes" using blockchain technology and enabling consumers to validate and verify specific quality attributes of their foods (e.g., organic) by accessing curated gs standard data from mobile devices, thereby increasing ease of consumer usability and ultimately trust. blockchain technology can help fsc partners develop best practices for traceability and to curb fraudulent and deceptive actions as well as the adulteration of food products. to solve these issues, staples et al. ( ) develop a traceability system based on haccp, gs , and blockchain technology in order to guarantee reliable traceability of the swine supply chain. in their proposed system, gs aids in the coordination of supply chain information, and blockchain is applied to secure food traceability. a pressing challenge facing fscs is the need to coordinate information exchange across several types of commodities, transportation modes, and information systems. by analogy, a similar need was resolved in the healthcare industry through the implementation of electronic health records (ehr) to provide access to an individual patient's records across all subdomains catering to the patient. the healthcare industry is presently working on enhancing ehr through the deployment of blockchain to serve as a decentralized data repository for preserving data integrity, security, and ease of management (shahnaz, qamar, & khalid, ) . closely resembling the role and function of the ehr in the healthcare industry, the creation of a digital food record (dfr) is vital for fscs to facilitate whole-chain traceability, interoperability, linking the different actors and data creators in the chain, and enhancing trust in the market on each product delivered. fsc operators need access to business-critical data at an aggregated level to drive their business strategy and operational decisions, and many of the organizations operate at the global, international, or national levels. data digitization and collaboration efforts of fsc organizations are essential to enable actionable decisions by the broader food industry. currently, much of the data currently exist as siloed, disparate sources that are not easily accessible; including data related to trade (crop shortages/overages), market prices, import/export transaction data, or realtime data on pests, disease or weather patterns, and forecasts. with this in mind, and acknowledging the need for transparent and trusted data sharing, the dutch horticulture and food domain created "horticube," an integrated platform to enable seamless sharing of data and enable semantic interoperability (verhoosel, van bekkum, & verwaart, ) . the platform provides "an application programming interface (api) that is based on the open data protocol (odata). via this interface, application developers can request three forms of information; data sources available, data contained in the source, and the data values from these data sources (verhoosel et al., , p. ) . the us food and drug administration is currently implementing the food safety modernization act (fsma) with emphasis on the need for technological tools to accomplish interoperability and collaboration in their "new era of smarter food safety" (fda, ) . in order to enable traceability as envisioned in fsma, a solution is required that incorporates multiple technologies, including iot devices. blockchain is envisioned as a platform of choice in accordance with its characteristic of immutability to prevent the corruption of data (khan, ) . ecosystems suited for the application of blockchain technology are those consisting of an increasing set of distributed nodes that need a standard approach and a cohesive plan to ensure interoperability. more precisely, fscs comprised of various partners working collaboratively to meet the demands of various customer profiles, where collaboration necessitates an exchange of data (mertins et al., ) ; furthermore, the data should be interchanged in real-time and verified to be originating from the designated source. interoperability is a precursor of robust fscs that can withstand market demands by providing small and medium enterprises with the necessary information to decide on the progress of any product within the supply chain and ensure the advancement of safe products to the end consumer. blockchain technology enables an improved level of interoperability as fsc actors would be able to communicate real-time information (bouzdine-chameeva, jaegler, & tesson, ), coordinate functions, and synchronize data exchanges (bajwa, prewett, & shavers, ; behnke & janssen, ) . the potential interoperability provided by blockchains can be realized through the implementation of gs standards. specifically, the electronic product code information standard (epcis), which can be used to ensure the documentation of all fsc events in an understandable form and the aggregation of food products into higher logistic units, business transactions, or other information related to the quantity of food products and their types (xu, weber, & staples, ) . a recent study by the institute of food technologists found evidence that technology providers faced difficulty in collaborating to determine the origin or the recipients of a contaminated product (bhatt & zhang, ) . hence, the novel approach of blockchain provides a specific emphasis on interoperability between disparate fsc systems, allowing technology providers to design robust platforms that ensure interoperable and end-to-end product traceability. the use of iot devices allow organizations within fscs to send and receive data; however, the authenticity of the data still needs to be ascertained. a compounding factor is the technological complexity of fscs (ahtonen & virolainen, ), due to the reliance on siloed systems that hamper collaboration and efficient flow of information. however, blockchain architecture can accommodate interoperability standards at the variable periphery (the iot devices) and other technologies used to connect fsc processes (augustin, sanguansri, fox, cobiac, & cole, ) . blockchain is envisaged as a powerful tool (ande, adebisi, hammoudeh, & saleem, ) and an appropriate medium to store the data from iot devices since it provides seamless authentication, security, protection against attacks, and ease of deployment among other potential advantages (fernández-caramés & fraga-lamas, ) . for fsc, blockchain is seen as the foundational technology for the sharing and distribution (read and write) of data by the organizations comprising the ecosystem, as shown in fig. . . in this model, consumers can read data for any product and trace the entire path from the origin to the destination while relying upon the immutability of blockchain to protect the data from any tampering. supply chain data are stored as a dfr in the various blocks (e.g., b , b , b ) that comprise the blockchain. the first block represented by g in fig. . refers to the genesis block, which functions as a prototype for all the other blocks in the blockchain. gs ratified version . of the gs global traceability standard (gs , b), documenting the business process and system requirements for full-chain traceability. the document is generic by design with supplemental, industry-specific documents developed separately. of interest to fscs are together, these documents provide comprehensive guidance to fscs on the implementation of a traceability framework. figs. . and . below indicate a single and multiple company view of traceability data generation. generation of traceability data in a multiparty supply chain (gs , a) underlying the gs traceability standard is the gs epcis (gs , a), which defines traceability as an ordered collection of events that comprise four key dimensions: • whatdthe subject of the event, either a specific object (epc) or a class of object (epc class) and a quantity • whendthe time at which the event occurred • wheredthe location where the event took place • whydthe business context of the event the gs global traceability standard adds a fifth dimension, "who," to identify the parties involved. this can be substantially different from the "where" dimension, as a single location (e.g., a third-party warehouse) may be associated with multiple, independent parties. epcis is supplemented by the core business vocabulary standard (gs , a), which specifies the structure of vocabularies and specific values for the vocabulary elements to be utilized in conjunction with the gs epcis standard. epcis is a standard that defines the type and structure of events and a mechanism for querying the repository. assuming that all parties publish to a common epcis repository (centralized approach) or that all parties make their repositories available (open approach), traceability is simply the process of querying events, analyzing them, and querying subsequent events until all relevant data are retrieved. in practice, neither the centralized nor open approach is possible. in the centralized approach, multiple, competing repositories will naturally prevent a single, centralized repository from ever being realized. even if such a model were to be supported in the short term by key players in the traceability ecosystem, as more and more players are added, the odds of one or more of them already having used a competing repository grows. in the open approach, not all parties will be willing to share all data with all others, especially competitors. depending on the nature of the party querying the data or the nature of the query itself, the response may be no records, some records, or all records satisfying the query. for either approach, there is the question of data integrity: can the system prove that the traceability data have not been tampered with? blockchain is a potential solution to these problems. as a decentralized platform, blockchain integration could provide epcis solution providers with a way of sharing data in a secure fashion. furthermore, the sequential, immutable nature of the blockchain platform either ensures that the data cannot be changed or provides a mechanism for verifying that it has not been tampered with. the critical question is, what exactly gets stored on the blockchain? the options discussed by gs in a white paper on a blockchain (gs , b) are • fully formed, cryptographically signed plain text event data, which raises concerns about scalability, performance, and security if full events are written to a ledger; • a cryptographic hash of the data that has little meaning by itself. this requires off-chain data exchange via a separate traceability application and a hash comparison to verify that data have not been altered since the hash was written to the ledger; and • a cryptographic hash of the data and a pointer to off-chain data. this is the same as the above point with a pointer to the off-chain data source. such an approach can enable the ledger to act as part of a discovery mechanism for parties who need to communicate and share data. this then leads to the question of the accessibility of the data: public: everyone sees all transactions; private: this includes a permission layer that makes transactions viewable to only approved parties. integrating epcis (or any other data sharing standard) with blockchain often presents significant challenges: in most cases, volumetric analysis can reveal sensitive business intelligence even without examining the data. for example, if company x is currently publishing records per day, and next year at the same time it is publishing only , it is reasonable to assume that company x's volume is down by % year over year. revealing the subject of an event (the "what" dimension) can reveal who is handling the expensive product, which may be used to plan its theft or diversion. publishing a record in plain text makes the data available to any party that has a copy of the ledger, but not all data should be available to all parties. for example, transformation events in epcis record inputs partially or fully consumed to produce one or more outputs. in the food industry, this is the very nature of a recipe, which is often a closely guarded trade secret. in order to mitigate this risk, the ledger would have to be firmly held by a limited number of parties that could enforce proper data access controls. even if such a system were to be implemented correctly, it means that proprietary information would still be under the control of a third party, which is a risk that many food companies would not be willing to take. publishing a record in an encrypted form would solve the visibility issue, but in order to do so, the industry would have to agree on how to generate the keys for the encrypted data. one option is to use the event's subject (the "what" dimension) as the key. if the identifier for the subject is sufficiently randomized, this ensures that only parties that have encountered the identifier can actually decrypt the data; while other parties could guess at possible values of the identifier, doing so at scale can be expensive and therefore self-limiting. there would also have to be a way to identify which data are relevant to the identifier, which would mean storing something like a hash of the identifier as a key. only those parties that know the identifier (i.e., that have observed it at some point in its traceability journey) will be able to locate the data of interest and decrypt them. parties could publish a hash of the record along with the record's primary key. this could then be used to validate records to ensure that they have not been tampered with, but it means that any party that wishes to query the data would have to know ahead of time where the data reside. once queried successfully, the record's primary key would be used to lookup the hash for comparison. to enable discovery, data consisting of the event's subject (the "what" dimension) and a pointer to a repository could be published. in essence, this is a declaration that the repository has data related to the event's subject, and a query for records related to the event's subject is likely to be successful. to further secure the discovery, the event's subject could be hashed, and that could be used as the key. volumetric analysis is still possible with this option. to limit volumetric analysis, data consisting of the class level of the event's subject and a pointer to a repository could be published. this is essentially a declaration that objects of a specific type have events in the repository, but it does not explicitly say how many or what specific objects they refer to. it still reveals that the company using the repository is handling the product. over and above all of this is the requirement that all publications be to the same type of blockchain ledger. there are currently no interoperability standards for blockchains. the industry would, therefore, have to settle on one, which has the same issue as settling on a single epcis repository. further technical research is required to determine the viability of the various options for publishing to the blockchain. the standardization efforts in global fscs have led to the need for best practice recommendations and common ways of managing logistics units in the food chain. the widespread use of gs standards reflects the tendency of food organizations to operate in an integrated manner with a universal language. this facilitates fscs to structure and align with a cohesive approach to food traceability, empowering multidirectional information sharing, optimizing efficiencies, and added-value activities for fsc stakeholders. moreover, the embeddedness of gs standards in global fscs allows trading partners to work in an industry-regulated environment wherein food quality and food safety are of the utmost priority in delivering sustainable, authentic products to final consumers. today, the usage of gs standards is inevitable as they provide clear guidelines on how to manage and share event data across global fscs (figueroa, añorga, & arrizabalaga, ) . this inevitability is further enhanced through the leadership of the global management board of gs (as of february ) that consists of senior executives from organizations such as procter & gamble, nestle, amazon, google, j.m. smucker, l'oreal, metro ag, alibaba, and others. similarly, the management board for the gs us organization includes senior executives from walmart, wegfern, wendy's, coca cola, target, publix, wegmans, sysco, massachusetts institute of technology, and others. the commitment of these organizations strongly supports the industry adoption of gs standards, and gs enabled blockchain solutions as indicated by walmart in their us-driven "fresh leafy greens" traceability initiative (walmart, ) . moreover, many of these firms have announced blockchain-related initiatives in their supply chains. walmart's traceability initiative reflects growing consumer concerns regarding food quality and safety and the recurring nature of product safety recalls. the combination of gs standards with blockchain can provide immutable evidence of data provenance, enhance food traceability and rapid recall, and increase trust in the quality of food products. gs standards aid organizations in maintaining a unified view of the state of food while transitioning between processing stages across globalized and highly extended supply chains with multiple exchange parties. as such, the broad adoption of electronic traceability as identified by gs can endow the food industry with several capabilities, ranging from the optimization of traceback procedures, the standardization of supply chain processes, the continuous improvement in food production activities, and the development of more efficient and holistic traceability systems. the use of gs standards for the formation of interoperable and scalable food traceability systems can be reinforced with blockchain technology. as envisioned by many food researchers, practitioners, and organizations, blockchain technology represents a practical solution that has a positive impact on fsc collaborations and data sharing. blockchain technology creates a more comprehensive and inclusive framework that promotes an unprecedented level of transparency and visibility of food products as they are exchanged among fsc partners. combined with gs standards, blockchain technology offers a more refined level of interoperability between exchange parties in global fscs and facilitates a move away from the traditional or linear, stove-piped supply chains with limited data sharing. by leveraging blockchain, fscs would be able to develop a management information platform that enables the active collection, transfer, storage, control, and sharing of food-related information among fsc exchange parties. the combination of blockchain and gs standards can create a high level of trust because of the precision in data and information provenance, immutability, nonrepudiation, enhanced integrity, and deeper integration. the development of harmonized global fscs gives rise to more efficient traceability systems that are capable of minimizing the impact of food safety incidents and lowering the costs and risks related to product recalls. therefore, the integration of gs standards into a blockchain can enhance the competitive advantage of fscs. in order to unlock the full potential from the functional components of a blockchain and the integration of gs standards, several prerequisites need to be fulfilled. for example, a more uniformed and standardized model of data governance is necessary to facilitate the operations of fscs in a globalized context. a balance between the conformance with diverse regulatory requirements and the fsc partners' requirements should be established in order to maintain a competitive position in the global market. the inter-and intraorganizational support for blockchain implementations, including the agreement on what type of data should be shared and accessed, the establishment of clear lines of responsibilities and accountability, and the development of more organized and flexible fscs should be considered prior to blockchain adoption (fosso wamba et al., ) . in summary, a blockchain is not a panacea, and non-blockchain solutions are functioning adequately in many fscs today. the business case or use case is crucially important when considering whether a blockchain is required and whether its functionality adds value. moreover, a blockchain does not consider unethical behaviors and opportunism in global fscs (bad character). organizations need to consider other risk factors that could impact ex post transaction costs and reputation. global fsc risk factors include slave labor, child labor, unsafe working conditions, animal welfare, environmental damage, deforestation and habitat loss, bribery and corruption, and various forms of opportunism such as quality cheating or falsification of laboratory or government records before they are added to a blockchain. product data governance and enhanced traceability can be addressed in global fscs, but "bad character" is more difficult to detect and eliminate. essentially, bad data and bad character are the two main enemies of trust in the food chain. this study focused narrowly on existing research combining blockchain, gs standards, and food. due to the narrow scope of the research, we did not explore all technical aspects of the fast-evolving blockchain technology, smart contracts, or cryptography. further research is needed to explore the risks associated with the integrity of data entered into a blockchain, especially situations where bad actors may use a blockchain to establish false trust with false data. in this regard, "immutable lies" are added to a blockchain and create a false sense of trust. because of this potential risk, and because errors occuring in the physical flow of goods within supply chains are common (e.g., damage, shortage, theft) as well as errors in data sharing and privacy, the notion of blockchain "mutability" should be researched further (rejeb et al., (rejeb et al., , . further technical research is encouraged to explore the relationship between the immutability features of a blockchain and the mutability features of the epcis standard. in the latter, epcis permits corrections where the original, erroneous record is preserved, and the correction has a pointer to the original. researchers should explore current epcis adoption challenges and whether epcis could provide blockchain-to-blockchain and blockchain-to-legacy interoperability. the latter may mitigate the risks associated with fsc exchange partners being "forced" to adopt a single proprietary blockchain platform or as a participant in multiple proprietary blockchain platforms in order to trade with their business partners. researchers should explore if the latency of real-time data retrieval in blockchain-based fscs restricts consumer engagement in verifying credence claims in real time due to the complexity of retrieving block transaction history. supply strategy in the food industry e value net perspective internet of things: evolution and technologies from a security perspective recovery of wasted fruit and vegetables for improving sustainable diets bringing farm animal to the consumer's platedthe quest for food business to enhance 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new walmart food traceability initiative questions and answers food-borne illnesses cost us$ billion per year in low-and middleincome countries example use cases assessing supermarket food shopper reaction to horsemeat scandal in the uk a new era of food transparency powered by blockchain knowing about your food from the farm to the table: using information systems that reduce information asymmetry and health risks in retail contexts current status and future development proposal for chinese agricultural product quality and safety traceability food supply chain management: systems, implementations, and future research the authors are thankful to dr. steven j. simske, dr. subhasis thakur, and irene woerner for their thoughtful commentary on this chapter. abderahman rejeb, coauthor and ph.d. candidate, is grateful to professor lászló imre komlósi, dr. katalin czakó, and ms. tihana vasic for their valuable support. • no funding was received for this publication. • john g. keogh, the corresponding author, is a former executive at gs canada and has not advised or worked with or for gs for more than years. • kevin dean is an independent technical consultant advising gs . key: cord- -zrlqzbss authors: de faria coelho-ravagnani, christianne; corgosinho, flavia campos; sanches, fabiane la flor ziegler; prado, carla marques maia; laviano, alessandro; mota, joão felipe title: dietary recommendations during the covid- pandemic date: - - journal: nutr rev doi: . /nutrit/nuaa sha: doc_id: cord_uid: zrlqzbss optimal nutrition can improve well-being and might mitigate the risk and morbidity associated with coronavirus disease (covid- ), caused by the severe acute respiratory syndrome coronavirus (sars-cov- ). this review summarizes nutritional guidelines to support dietary counseling provided by dietitians and health-related professionals. the majority of documents encouraged the consumption of fruits, vegetables, and whole grain foods. thirty-one percent of the guidelines highlighted the importance of minerals and vitamins such as zinc and vitamins c, a, and d to maintain a well-functioning immune system. dietary supplementation has not been linked to covid- prevention. however, supplementation with vitamins c and d, as well as with zinc and selenium, was highlighted as potentially beneficial for individuals with, or at risk of, respiratory viral infections or for those in whom nutrient deficiency is detected. there was no convincing evidence that food or food packaging is associated with the transmission of covid- , but good hygiene practices for handling and preparing foods were recommended. no changes to breastfeeding recommendations have been made, even in women diagnosed with covid- . in january , the world faced an outbreak of coronavirus disease , caused by the severe acute respiratory syndrome coronavirus (sars-cov- ). evidence of high human-to-human transmissibility of sars-cov- has made social isolation the best preventive measure to avoid the spread of covid- . this pandemic is substantially affecting lifestyles, healthcare systems, and national and global economies. social isolation is often an unpleasant experience that may have negative effects on mental health. it has been suggested that, until quarantine ends, self-isolation is likely to cause psychological and emotional symptoms, changes in mood and altered sleep or eating patterns, worsening of chronic health conditions, weight gain, and increased use of alcohol, tobacco, or illegal drugs. optimal nutrition is one of the main determinants of health that can improve well-being and mitigate the harmful health consequences associated with social distancing by helping to prevent or control most chronic diseases (eg, diabetes, hypertension, and excess body weight/obesity); aid in the regulation of sleep and mood; and prevent fatigue. , nutritional modulation of the immune system is also important across the age spectrum. during early childhood, breastfeeding can provide protection against infections and respiratory diseases, as breast milk contains antibodies, enzymes, and hormones that can offer health benefits. in older adults, the group at most risk for covid- , changes in dietary habits lead to significant alterations in immunity and inflammation, termed immunosenescence and inflammaging. some nutrients, such as omega- polyunsaturated fatty acids and probiotics, have been linked to anti-inflammatory responses and enhanced resistance to upper respiratory tract infection. in individuals infected with sars-cov- , nutritional status is a crucial factor for optimal prognosis and can determine the clinical severity of covid- . dietary supplementation with selected vitamins (eg, a, b, c, and d), minerals (eg, selenium, zinc, and iron), and omega- fatty acids was suggested by zhang and liu as a treatment option for covid- patients and as preventive therapy against lung infection. however, the use of micronutrient supplements to prevent infections remains questionable. since to date there is no vaccine or evidence-based treatment for covid- , the optimization of nutrient intake through well-balanced meals and the use of good hygiene practices in food selection, preparation, and conservation is probably the most effective approach for managing the continuous risk of viral infection. to this end, dissemination of healthy eating guidelines for healthcare professionals and the general public is a crucial strategy. despite intense efforts by international nutrition organizations and other health-related societies to produce guidelines and advice related to the covid- pandemic, literature is still scarce. meanwhile, the general public has been bombarded with a vast array of nutritional information from governmental authorities, the dietary supplement industry, nutrition enthusiasts, healthcare professionals, and others on how to prevent covid- . this information, however, may be conflicting or non-evidence based. therefore, a systematic search of guidelines and official documents related to nutrition and covid- was conducted. the search included information obtained from several countries affected by the pandemic as well as manuscripts identified in scientific databases. the goal was to address one main question: what nutritional advice is being offered for individuals in quarantine during the covid- pandemic? the aim of this review was to summarize nutritional guidance related to the novel coronavirus (sars-cov- ) in order to support dietary counseling provided by dietitians and healthcare professionals during this pandemic. this narrative review was carried out from december to april , during the covid- pandemic. guidelines and official documents from governmental and nongovernmental health agencies or institutions worldwide, all providing recommendations on food and nutrition during the covid- pandemic, were eligible for inclusion. literature related to specific nutritional or pharmacological treatment of patients already infected was excluded. the descriptors "coronavirus," "covid- ," "covid" and "nutrition" or "diet" were used to search for guidelines, position papers, and official documents in the pubmed, scielo, cochrane, and google databases. the boolean operators "and" and "or" were used to combine the terms used in the literature search. publications in the following languages were searched: italian, english, spanish, and portuguese. two authors (j.f.m. and f.c.c.) conducted the search and screened all references independently in a -step process. all selected documents were retrieved, and duplicates were excluded. titles and abstracts were then screened to identify studies that potentially met the eligibility criteria. of the documents retrieved, were included in this narrative review. of these, dietary recommendations were issued from nutrition societies and associations and from national governments (australia, brazil, canada, italy, spain, united states). five guidelines from health organizations (food and agriculture organization of the united nations, world health organization, united nations children's fund, center for disease control and prevention, and european food information council) were included. a summary of the guidelines, main advice, and other information is provided in table . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] four major nutrition-related topics-overall dietary recommendations, dietary supplements, breastfeeding, and food hygiene-were identified. nearly % of the documents retrieved encouraged the consumption of fruits, vegetables, and whole grain foods. two nutrition societies, from italy and spain, , recommended at least servings of fruits and vegetables per day. diets rich in fruits and vegetables contain high maintain good hydration; consume at least servings of fruit and vegetables per day; consume whole-grain products and legumes; choose low-fat dairy products (milk and fermented milks or yogurt); consume other foods of animal origin in moderation; consume nuts, seeds, and olive oil; avoid processed foods and fast food na na asbran ( ) prioritize fresh or minimally processed foods; use oils, fats, salt, and sugar in small amounts when preparing meals; limit consumption and purchase of processed and ultraprocessed foods such as french fries, soft drinks, cookies, and ice cream, which are rich in empty calories; use all parts of fruits and vegetables in recipes; avoid buying commercially prepared meals that are rich in sodium, trans fat, and calories na before placing supplies in cupboards or pantries, wash the packaging with soap and water and spray with % alcohol or a chlorinated solution; fruits and vegetables that are stored in the refrigerator should be removed from packaging and sanitized beforehand; before consumption, raw fruits and vegetables should be washed under running water and sanitized with sodium hypochlorite, which should always be used diluted, as instructed on the packaging asn ( ) the healthiest meals emphasize whole grains, vegetables, and fruits; meat portions should be smaller to limit intake of saturated fat; limit consumption of commercially prepared frozen dinners; stock up on nutrition-packed foods that will stay fresh for a week or longer na when grocery shopping, use a disinfecting wipe to wipe hands and grocery cart handle cdc ( ) washing hands with soap ( seconds) before preparing or eating food is important for general food safety; (continued) consume a healthy diet rich in fruit and vegetables, protein foods, and whole grains; there is no single food, supplement, or natural health product that will prevent, treat, or cure covid- women who choose to breastfeed should be allowed to do so after appropriate handwashing and while wearing a mask there is no evidence that covid- is spread through eating or touching raw fruits or vegetables; prior to consumption, fresh fruits and vegetables should be washed or scrubbed under cold, running, potable tap water; while there are no special precautions for storing food, handwashing after putting away purchased food and before preparing food is recommended; hands should be washed before and after food containers are washed eufic ( ) appropriate intakes of copper, folate, iron, selenium, zinc, and vitamins a, b , b , c, and d play an important role in the immune system; in general, these nutrients should be obtained through foods supplements can be used to add nutrients to the diet in individuals who have specific challenges in meeting dietary requirements wash hands for seconds with soap before and after preparing or eating foods; wash fruits and vegetables before eating; disinfect surfaces and objects before and after use; keep raw and cooked foods separate from each other; use different utensils/chopping boards for raw and cooked foods; cook and reheat foods to adequate temperatures ( c for min); there is no need to disinfect food packaging items fao ( ) consume a healthy diet to support a strong immune system; eat a variety of foods within each food group; eat plenty of fruits and vegetables; consume a diet rich in whole grains, nuts, and healthy fats; limit intakes of fat, sugar, and salt; drink water regularly; limit consumption of alcohol; continue to practice good food hygiene; there is no evidence that covid- can be spread through contact with purchased foods; store raw and cooked foods separately; keep food preparation surfaces clean; cook foods thoroughly; store food at safe temperatures; and use safe water and raw materials (continued) amounts of vitamins and minerals, including vitamins a, c, d, e, and b complex, as well as zinc and selenium, which are important modulators of the immune system. in addition, fruit and vegetables are good sources of water, antioxidants, and fiber, all of which play a role in the control of hypertension, diabetes, and weight gain, some of the most important risk factors for covid- complications. micronutrients contribute to immune function through a variety of pathways in both innate and adaptive immune responses. vitamins a, c, d, e, b , and b and zinc are important for the maintenance of structural and functional integrity of physical barriers (eg, skin, gastrointestinal lining, respiratory tract, and others) as well as for the differentiation, proliferation, function, and migration of innate immune cells. meanwhile, vitamins c and e, along with zinc and selenium, protect against free radical damage during increased oxidative stress. vitamins a, c, d, e, b , and b and zinc and selenium support the adaptive immune response by influencing the differentiation, proliferation, and normal function of t and b cells. these nutrients also affect antibody production and function, contribute to cell-mediated immunity, and support the recognition and destruction of pathogens. lastly, they have antimicrobial activity and regulate the inflammatory response. approximately one-third of the identified guidelines mentioned at least one of these nutrients as being important for optimizing the immune system, placing special emphasis on zinc and vitamins c, a, and d. , , adequate intakes of these micronutrients may be attained through a daily diet that includes meat, fish, lentils and beans, dairy foods, nuts, seeds, eggs, citrus fruits (eg, orange, lemon, grapefruit), kiwi, strawberries, and vegetables such as broccoli, cauliflower, pumpkin, spinach, sweet potato, and carrots. while vitamin d can be obtained from some dietary sources, it is mainly synthesized endogenously through exposure of the skin to ultraviolet b irradiation. in fact, sunlight exposure can increase serum vitamin d levels to the same extent as an oral dose of to lg of vitamin d. the societ a italiana di nutrizione umana recommended exposure to sunlight for to minutes every day to promote the synthesis of vitamin d. however, in latitudes outside north and south, ultraviolet b radiation is greatly reduced during winter. as a result, an increased intake of vitamin d-rich foods, as well as vitamin d supplementation, might be necessary to maintain adequate serum levels in winter. , almost, one-third of the organizations and societies recommended avoiding the intake of salt, fat, and sugar and encouraged reductions in sugary drinks, other sugar-rich products, meat portions, and other foods of animal origin to lower the intake of saturated fat. [ ] [ ] [ ] in addition, they suggested that low-fat dairy foods and healthy fats (eg, olive oil and fish oil) be included in the diet , and recommended sauces, spices, and herbs as salt substitutes. over the last years, the literature has described a definitive role of fat in immunity. saturated fatty acids act on toll-like receptor , a sensor that binds bacterial lipopolysaccharide and thus acts in the innate immune response. as a result, a high intake of saturated fatty acids favors low-grade inflammation. on the other hand, monounsaturated and polyunsaturated fatty acids are known for their favorable immune-modulatory action. omega- polyunsaturated fatty acids present in seafood, algal oil, marine fish, and flaxseed support the immune system by activating cells from both the innate and the adaptive immune systems, while omega- monounsaturated fatty acids found in olive, sunflower, and safflower oils and nuts have antioxidant, antimicrobial, and antiviral effects. for adult males and nonpregnant/nonlactating adult females, the recommended dosage of omega- polyunsaturated fatty acids (eicosapentaenoic acid plus docosahexaenoic acid) is mg/ d. this recommendation can be met by consuming at least portions ( g each) of fatty marine fish, such as mackerel, salmon, sardine, herring, and smelt, per week. drinking water or maintaining adequate hydration was suggested in documents, , , but no guidance on water requirements (eg, cups or milliliters per day) was provided. the evidence in favor of a direct association between hydration status and health has been previously confirmed. water is essential for cellular homeostasis, kidney function, body temperature control, mood regulation, cognitive function, gastrointestinal and heart function, and headache prevention. it is important to note that diets low in water and rich in salt can negatively impact kidney function. in addition, the consumption of sugary drinks instead of water increases the intake of carbohydrates and calories, thereby raising blood glucose and exacerbating obesity and other related chronic diseases. because of their low water reserves, older adults can be affected more seriously by hypohydration. furthermore, water intake comes mostly from beverages (about %) and food intake (about %), especially from fresh food such as fruits and vegetables. therefore, advice on the importance of drinking water, tea, and milk and consuming other water-containing foods should be delivered by dietitians and healthcare professionals during the covid- pandemic. since the daily water requirement is influenced by age, sex, level of physical activity, diet, body composition, pregnancy, environmental conditions, and the presence of disease, the recommended intake of water varies widely and can reach . l/d for older adults (including all water contained in food, beverages, and drinking water). according to the dietary reference intakes for water, potassium, sodium, chloride, and sulfate, adults with moderate levels of physical activity who consume approximately kcal/ d can meet water recommendations by drinking cups of water and beverages daily, while children require to cups per day, adolescents ( to years) to cups per day, and older adults to cups per day. while some organizations recommend choosing unprocessed foods, , , - healthy dried, frozen, or canned foods (eg, fish, fruits, soups) are suggested as alternatives when fresh produce is not available. , there is a current trend for guidelines to support homemade and fresh meals instead of processed foods. several countries, including, brazil, chile, australia, and canada, have recommended limiting the intake of processed foods, which are linked to cancer, obesity, hypertension, and diabetes. interestingly, there has been a worldwide trend for individuals to stock up on processed foods during the quarantine. this has been recommended by governmental agencies such as the centers for disease and control and prevention for individuals at risk or for the general population by health canada to avoid social contact during the peak of the covid- outbreak. it is likely that many individuals have stocked up on unhealthful food items that will eventually be consumed. therefore, clearer guidelines and recommendations about what foods to purchase are needed. although there is some lack of clarity and guidance regarding obesity as a risk factor for covid- , substantial preliminary data demonstrate that higher body mass index is a considerable risk factor for hospitalization and development of severe pneumonia. [ ] [ ] [ ] [ ] in fact, a systematic review and meta-analyses showed that % of the adult patients infected with the middle east coronavirus presented with hypertension and diabetes, while obesity was present in % of the cases. moreover, a recent study found a significant inverse correlation between body mass index and age: young individuals admitted to hospitals were more likely to have obesity. the study suggested that obesity could shift the incidence of severe covid- disease to younger ages in countries where the prevalence of obesity is high. obesity restricts respiration, weakens immune responses, and is proinflammatory. it is also associated with an increased risk of diabetes mellitus, cardiovascular disease, and kidney disease, all of which contribute to increased vulnerability to pneumonia-associated organ failure. thus, healthy weight loss could be a good strategy to reduce the risk of covid- complications. although none of the institutions mentioned weight loss in their guidelines, of them highlighted the importance of avoiding weight gain. specific guidelines for obese individuals are nonetheless needed to promote gradual weight loss without compromising the body's lean mass. considering the difficulty to achieve significant weight loss through physical activity during the pandemic, protein intake of around % of energy requirements may be considered for adults under energy-restricted diets. this level of protein intake can prevent or attenuate the loss of lean muscle mass while also promoting greater satiety during weight loss. in their discussion of nutritional recommendations during covid- quarantine, muscogiuri et al highlighted the role of tryptophan, an amino acid and a precursor of serotonin, in the regulation of satiety and caloric intake, suggesting protein-rich foods such as milk, yogurt, seeds, and nuts as good sources. it is worth noting that web-based weight-loss approaches are becoming popular and are effective for patients with obesity. such tools may be useful during the covid- pandemic. probiotics were recommended by only one institution, which did not provide a specific amount or examples of food sources. probiotics are defined as "live microorganisms that, when administered in adequate amounts, confer a health benefit on the host." they can act through diverse mechanisms, including modulation of immune function, production of antimicrobial compounds and organic acids, improvement of gut barrier integrity, formation of enzymes, and interaction with resident microbiota. studies of probiotic species belonging to the lactobacillus and bifidobacterium genera have shown promising results regarding improved immune function. fermented dairy products might be a good option to improve the gut microbiota, although further studies are needed to better elucidate the modulatory mechanisms of the microorganisms in these foods. only one agency provided guidance on alcohol consumption. the food and agriculture organization of the united nations recommended that alcohol intake be limited, but no specific amounts were provided. excessive alcohol consumption is associated with reduced host immunity to viral infections and increased susceptibility to tuberculosis and bacterial and viral pneumonia in humans and animals. on the other hand, some benefits of moderate alcohol consumption have been reported, including reduced risk of cardiovascular disease, alleviation of acute stress, improved mood, and increased relaxation. current guidelines for moderate intake recommend no more than drink per day for women and no more than drinks per day for men. it should be noted that individuals who do not drink alcohol should not start drinking. finally, generic terms and phrases such as "healthy diet," "variety of foods in each group," "variety of fresh and unprocessed foods," and "varied diet" were observed in the majority of the documents. these messages might not be clear enough to encourage people to make healthy food choices. specific recommendations, including examples of food and instructions for food preparation, would improve the public health message. all documents reported that there are currently no known supplements to prevent covid- . only documents mentioned that it might be possible to use supplements to meet dietary recommendations. , some vitamins and minerals improve immunity; however, the idea that more is better is a misconception. megadoses of vitamins and minerals can induce toxic and adverse effects , or interact with medications, leading to enhanced or reduced pharmacological effects. on the other hand, it is important to note that dietary reference intakes have been established for healthy individuals and are based on a diet providing kcal/d. thus, healthcare professionals should individualize dietary plans by considering factors that can increase nutrient requirements, such as specific diseases/conditions, medications, dietary patterns (eg, vegetarianism), and exercise intensity. for this purpose, the range from the recommended dietary allowance to the tolerable upper intake level can be used to optimize the dietary plan. the brazilian association of clinical nutrition reported that vitamin c supplementation may be useful for individuals at risk of respiratory viral infections. vitamin c is a recognized antioxidant nutrient that can enhance chemotaxis, phagocytosis, generation of reactive oxygen species, and, ultimately, microbial killing. however, a systematic review involving participants showed that doses of vitamin c exceeding g/d were not beneficial in reducing the incidence of colds among the overall population. on the other hand, such doses might be effective in reducing the duration of colds by % to %. in addition, vitamin c may be useful to prevent the development of colds in people exposed to brief periods of intense physical activity or to cold temperatures. vitamin d is another antioxidant that has been associated with a reduction in pulmonary infections. , evidence that vitamin d can prevent or treat influenza is inconclusive, but vitamin d status has been associated with the severity of covid- . potential mechanisms include increased secretion of antimicrobial peptides, decreased production of chemokines, inhibition of dendritic cell activation, and altered t-cell activation. none of the documents reviewed here suggested vitamin d supplementation as preventive therapy against covid- . however, rhodes et al suggested that countries south of latitude north have low population mortality, which might indicate a role of vitamin d in determining outcomes from covid- . when deficiency is detected, oral supplementation with doses between and iu/d is indicated. although a higher dose has been recently proposed with the aim of reducing the risk of infection (vitamin d , iu/d for a few weeks to rapidly raise (oh)d concentrations, followed by iu/d), this is still controversial and contradicts other recommendations. since it is not feasible to recommend biochemical analysis of vitamin d levels during a pandemic, targeting vulnerable populations for vitamin d supplementation can mitigate the health risks associated with covid- , especially since vitamin d deficiency has been shown to correlate with hypertension, diabetes mellitus, obesity, and darker skin pigmentation. although it may be controversial, vitamin d supplementation to prevent deficiency may, at the very least, provide benefits by sustaining bone mass during lockdown. zinc and selenium are antioxidant micronutrients often considered for supplementation. , zinc is a cofactor of superoxide dismutase, an enzyme present in the mitochondria and cytosol of cells that suppresses oxidative stress. excess zinc, however, also causes cellular oxidative stress. a narrative review showed ample evidence of the antiviral activity of zinc ( mg/kg of body weight, up to mg/d total) against a variety of viruses, such as influenza. in addition, zinc is critical in generating both innate and acquired (humoral) antiviral responses. however, the authors concluded that further research is needed on the antiviral mechanisms and clinical benefits of zinc supplementation as a preventative and therapeutic treatment for viral infections. a recent study suggested that the elderly are at risk for zinc deficiency, which increases susceptibility to infections such as pneumonia. zinc supplementation (ie, elemental zinc, mg/d) might be adequate to improve immune function and to reduce the risk of infections in this group. selenium has been found to increase the activity of glutathione peroxidase, another antioxidant enzyme, and to augment a number of host immune responses, including interferon c production, t-cell proliferation, antigen stimulation, and natural killer cell activity. in fact, an experimental study with mice and influenza virus showed that selenium deficiency led to more severe disease and an increased proinflammatory immune response, resulting in increased pathology in the lungs. selenium is an important trace element that can be found in nuts, breads, grains, meat, poultry, fish, and eggs and is easily obtainable from dietary sources (see the dietary recommendations section). in summary, it is preferable to obtain antioxidants from food rather than from supplements. however, supplements are recommended for individuals who have specific challenges in meeting dietary requirements. the key message regarding dietary supplements is that individuals should not rely on supplements to prevent covid- . further studies into the effects of vitamin and mineral supplementation on outcomes related to covid- (eg, disease severity, inflammatory status, hospitalization, death, etc) are warranted. currently, several clinical trials on vitamin d (n ¼ ), vitamin c (n ¼ ), zinc (n ¼ ), and selenium (n ¼ ) supplementation are under way (www.clinicaltrials. gov). it is hoped that the results of these studies will lead to a better understanding of the relationship between micronutrients and covid- . breastfeeding provides a multitude of benefits for both mother and child. breast milk contains important antibodies that benefit the child's immune system, protecting against viral and bacterial infections. according to the world health organization, breastfeeding must be exclusive until months of age (no water, other fluids, or solids) and continued until years of age or beyond. only of the documents included in this review addressed this topic. , , , , , all recommended that breastfeeding be maintained during the covid- pandemic, even in women diagnosed with the disease. however, good hygiene practices are recommended, including mask wearing, handwashing before and after touching the infant, and disinfecting frequently used surfaces. approximately % of the documents selected for this review included guidance on food hygiene. , , [ ] [ ] [ ] there is currently no convincing evidence that food or food packaging is associated with the transmission of covid- . , , the risk of fecal-oral transmission, while low, can persist even after viral clearance from the respiratory tract. this highlights the need for routine stool testing and transmission-based precautions for hospitalized patients and probably for those recovering at home. all documents emphasized the importance of adequate personal hygiene when handling food, highlighting the need for frequent handwashing with soap and water or alcohol-based hand sanitizers. in food and beverage stores, the greatest risk of contamination is through contact with other people and "high touch" surfaces such as food scales, shopping-cart handles, and elevator buttons. unlike some viruses that can live on food or other surfaces for several days, sars-cov- can survive on metal or plastic surfaces for days and on cardboard surfaces for day. infectious disease authorities in several countries are recommending the use of soap or alcohol-based hand sanitizer for handwashing, reinforcing the importance of strict hygiene measures to prevent the spread of contamination. , according to the european food safety authority, there is no need to disinfect food packaging itself, as long as some precautions are taken: ( ) wash hands for seconds with soap and water before and after grocery shopping, unpacking foods, and after receiving delivered food; ( ) maintain a safe distance ( to meters) from other people when shopping; ( ) do not go shopping when sick; instead, when possible, order groceries online or have family members or friends help with shopping; ( ) avoid touching foods unless you plan to buy them; ( ) limit trips to the supermarket by planning meals; ( ) cover your mouth and nose with a tissue or your sleeve when coughing or sneezing, and wash hands afterward; and ( ) after touching surfaces, avoid touching your face, nose, and mouth until after hands have been washed. in contrast, the brazilian association of clinical nutrition advocates the use of hygiene practices when handling food packaging of purchased items. they recommend washing food packages with soap and water and spraying with % alcohol or a chlorinated solution before storing them. fresh foods such as vegetables and fruits can be frozen after they are sanitized with sodium hypochlorite. blanching of vegetables is also suggested to reduce spoilage. the food and agriculture organization of the united nations proposes the use of core messages for safer food: ( ) keep food clean; ( ) separate raw and cooked foods; ( ) cook food thoroughly; ( ) keep food at safe temperatures; and ( ) use safe water and raw materials. although sars-cov- can survive in water for a short time, the european food information council has noted that the virus has not been detected in drinking water, which is generally subjected to several treatment steps, making both tap water and bottled water safe for human consumption and food hygiene. the main concern lies in low-to middle-income countries, where access to treated water may be limited or nonexistent. figure describes the rationale behind the dietary guidance and the personal hygiene practices recommended during the covid- pandemic, along with the potential mechanisms linking diet and the prevention of covid- complications. this review summarizes recent scientific literature and existing recommendations from national and international nutrition agencies on an optimal diet, vitamin and mineral supplementation, and good hygiene practices for food preparation during the covid- pandemic. the findings can be used to help dietitians and healthcare professionals better address dietary recommendations during the covid- pandemic. guidance related to the safe handling of food, from production to consumption, is critical to reduce the risk of viral dissemination. the general recommendation is to consume a diet based predominantly on fresh foods such as fruits, vegetables, whole grains, low-fat dairy sources, and healthy fats (olive oil and fish oil) and to limit intakes of sugary drinks and processed foods high in calories and salt. dietary supplements (ie, vitamins c and d, zinc, and selenium) should be administered to individuals with, or at risk of, respiratory viral infections or in whom deficiency is detected. breast milk is the safest and healthiest food for infants, and breastfeeding should be encouraged, even in women diagnosed with covid- . ) pandemic. key nutrients that support the immune system can be obtained through dietary components that include fresh foods (eg, fruits and vegetables), fish, lean meat, dairy, water and other non-sugary beverages, and healthy fats. a healthy diet can also decrease the risk of, or help control, hypertension, diabetes, obesity, and muscle atrophy, which are all considered risk factors for covid- complications. there are no known supplements that can prevent covid- ; however, in populations at risk of deficiency, supplements can mitigate the public health risks associated with covid- . breastfeeding benefits an infant's immune system, protecting against viruses and bacterial infections. the use of personal protection, such as masks, along with good hygiene practices, such as frequent handwashing with soap and water or alcohol-based sanitizers, can prevent covid- transmission and immune system impairment. symbol: (-): inhibitory effect. social distancing: keep your distance to slow the spread. centers for diseases control and prevention website the psychological impact of quarantine and how to reduce it: rapid review of the evidence sars control and psychological effects of quarantine nutritional recommendations for covid- quarantine us department of agriculture. dietary guidelines for americans mood and food breast feeding physical activity and diet shape the immune system during aging nutrition support in the time of sars-cov- (covid- ) potential interventions for novel coronavirus in china: a systematic review associac¸ão brasileira de nutrologia [brazilian association of clinical nutrition position of the brazilian association of clinical nutrition (abran) regarding micronutrients and probiotics in covid- infection academia española de nutrici on y diet etica (la academia) y el consejo general de colegios oficiales de dietistas-nutricionistas. recomendaciones de alimentaci on y nutrici on para la poblaci on española ante la crisis sanitaria del covid- associac¸ão brasileira de nutrologia [brazilian association of clinical nutrition guide to healthy eating in times of covid making health and nutrition a priority during the coronavirus (covid- ) pandemic coronavirus disease (covid- ) and breastfeeding. centers for disease control and prevention website food safety and coronavirus disease (covid- ) covid- tips and resources. dietitians australia website advice for the general public about covid- covid- ): what you need to know. european food information council website maintaining a healthy diet during the covid- pandemic ad interim indications of the italian society of neonatology endorsed by the union of european neonatal & perinatal societies nutrition advice for adults during the covid- outbreak. world health organization regional office for the eastern mediterranean website immune function and micronutrient requirements change over the life course does comorbidity increase the risk of patients with covid- : evidence from meta-analysis a review of micronutrients and the immune system-working in harmony to reduce the risk of infection optimisation of vitamin d status for enhanced immuno-protection against covid- vitamin d status in the tropics: is sunlight exposure the main determinant? editorial: low population mortality from covid- in countries south of latitude degrees north supports vitamin d as a factor determining severity the relation of saturated fatty acids with low-grade inflammation and cardiovascular disease immune dysfunction and increased oxidative stress state in diet-induced obese mice are reverted by nutritional supplementation with monounsaturated and n- polyunsaturated fatty acids effects of omega- fatty acids on immune cells potential health benefits of olive oil and plant polyphenols food and agriculture organization of the united states. fats and fatty acids in human nutrition acute and chronic effects of hydration status on health water, hydration, and health panel on dietary reference intakes for electrolytes and water. dietary reference intakes for water, potassium, sodium, chloride, and sulfate dietary guidelines for the brazilian population informe de evaluaci on de la implementaci on de la ley sobre composici on nutricional de los alimentos y su publicidad eat for health: australian dietary guidelines summary office of nutrition policy and promotion. the new food guide ultra-processed foods, diet quality, and health using the nova classification system what you can do coronavirus disease (covid- ): coronavirus disease (covid- ): measures to reduce covid- in your community covid- and obesity-lack of clarity, guidance, and implications for care obesity could shift severe covid- disease to younger ages factors associated with hospitalization and critical illness among , patients with covid- disease in new york city obesity and covid- severity in a designated hospital in shenzhen high prevalence of obesity in severe acute respiratory syndrome coronavirus- (sars-cov- ) requiring invasive mechanical ventilation prevalence of comorbidities in the middle east respiratory syndrome coronavirus (mers-cov): a systematic review and meta-analysis obesity and impaired metabolic health in patients with covid- effects of energy-restricted high-protein, low-fat compared with standard-protein, low-fat diets: a meta-analysis of randomized controlled trials web-based weight loss in primary care: a randomized controlled trial expert consensus document. the international scientific association for probiotics and prebiotics consensus statement on the scope and appropriate use of the term probiotic probiotics and prebiotics in intestinal health and disease: from biology to the clinic probiotic species in the modulation of gut microbiota: an overview a recent perspective on alcohol, immunity, and host defense health risks and benefits of alcohol consumption vitamins, are they safe? vitamin and mineral supplements: do we really need them? safety considerations and potential interactions of vitamins: should vitamins be considered drugs? subcommittee on interpretation and uses of dietary reference intakes. dietary reference intakes: applications in dietary assessment guiding principles for developing dietary reference intakes based on chronic disease hemil€ a h, chalker e. vitamin c for preventing and treating the common cold the effect on winter illness of large doses of vitamin c high-dose monthly vitamin d for prevention of acute respiratory infection in older long-term care residents: a randomized clinical trial vitamin d for prevention of respiratory tract infections: a systematic review and meta-analysis vitamin d and influenza-prevention or therapy? vitamin d effects on lung immunity and respiratory diseases evidence that vitamin d supplementation could reduce risk of influenza and covid- infections and deaths critical role of zinc as either an antioxidant or a prooxidant in cellular systems the role of zinc in antiviral immunity low zinc status: a new risk factor for pneumonia in the elderly? selenium, immune function and resistance to viral infections selenium deficiency and viral infection world health organization, department of nutrition for health and development. the optimal duration of exclusive breastfeeding. report of an expert consultation folha informativa-covid- (doenc¸a causada pelo novo coronav ırus organizac¸ão pan-americana da sa ude website evidence for gastrointestinal infection of sars-cov- aerosol and surface stability of sars-cov- as compared with sars-cov- united nations website key: cord- -a cepu h authors: lorenzo, jose m.; munekata, paulo e.; dominguez, ruben; pateiro, mirian; saraiva, jorge a.; franco, daniel title: main groups of microorganisms of relevance for food safety and stability: general aspects and overall description date: - - journal: innovative technologies for food preservation doi: . /b - - - - . - sha: doc_id: cord_uid: a cepu h microbiology is important to food safety, production, processing, preservation, and storage. microbes such as bacteria, molds, and yeasts are employed for the foods production and food ingredients such as production of wine, beer, bakery, and dairy products. on the other hand, the growth and contamination of spoilage and pathogenic microorganisms is considered as one of the main causes to loss of foodstuff nowadays. although technology, hygienic strategies, and traceability are important factors to prevent and delay microbial growth and contamination, food remains susceptible to spoilage and activity of pathogen microorganisms. food loss by either spoilage or contaminated food affects food industry and consumers leading to economic losses and increased hospitalization costs. this chapter focuses on general aspects, characteristics, and importance of main microorganisms (bacteria, yeasts, molds, virus, and parasites) involved in food spoilage or contamination: known and recently discovered species; defects and alterations in foodstuff; most common food associated with each foodborne disease; resistance to thermal processing; occurrence in different countries; outbreaks; and associated symptoms. food preservation, since ancient times, played a central role in survival of mankind enhancing the safety and stability of different foodstuffs. traditional techniques used to prevent food deterioration in the past as salting, drying, fermentation, and heating prevail in modern food industry. the knowledge about the main causes of deterioration has increased substantially since then and losses due to spoilage and food contamination were reduced (gram et al., ) . the knowledge about the composition, origin, ph, water activity (a w ) of food and storage conditions (e.g., temperature, atmosphere, and pressure) along with the information about the characteristics of most prevalent and resistant microorganism predicts the composition of microflora during processing and storage. from this scenario, the adequate use of technology (such as pasteurization and sterilization), hygienic strategies (e.g., good hygiene practices and good manufacture practices), and traceability (prevent and reduce the distribution of unsafe and poor quality food) can prevent and delay the colonization of spoilage and pathogenic microorganisms in foodstuff. however, food remains susceptible to spoilage and contamination of pathogenic microorganism throughout food chain, retail shops, restaurants, and house of consumers (aung & chang, ; gram et al., ) . the damage from spoilage and contaminated food affects the food industry (economic loss, damage to reputation, and punishment according to local food spoilage causes not only economic loss, but also loss of edible foods. in countries where foods are produced and procured from many countries much more than the need, spoilage up to a certain level is not considered serious. however, in many countries where food production is not efficient, food spoilage can adversely affect the availability of food. with the increase in world population, serious consideration needs to be given on not only increasing food production but also reducing food spoilage, because in some countries it could reach % or more. the acceptance qualities of a food can be lower because of infestation with insects and rodents, undesirable physical and chemical actions, and microorganisms' growth. microbial spoilage occurs either because of microbial growth in a food or because of the action of some microbial enzymes present in the food (ray, ) . the food microbiological profile is quite different from an unspoiled and nonsterile food, to the same food spoiled. the first case generally contains many types of microorganisms, such as bacteria, yeasts, and molds (also viruses) from different genus, maybe more than one species from the same genus, and even more than one strain from the same species. however, when the same food is spoiled, it is found to contain predominantly one or two types, and they may not even be present initially in the highest numbers in the unspoiled or fresh product. among the different species initially present and capable of growing in a particular food, only those with the shortest generation time under the storage conditions attain the numbers rapidly and cause spoilage. theoretically, any microorganism (including microorganisms used in food fermentation and pathogens) that can multiply in a food to reach a high level (spoilage detection level) is capable of causing it to spoil. yet, in reality, bacterial species from only several genera have been implicated more with spoilage of most foods. this is dictated by the bacterial characteristics, food characteristics, and the storage conditions (ray, ) . this point describes a limited number of nonspore-forming bacteria as representative of the major groups of food spoilage. the predominant bacteria associated with spoilage are brochothrix thermosphacta, carnobacterium spp., lactobacillus spp., lactococcus spp., leuconostoc spp., pediococcus spp., stretococcus spp., kurthia zopfii, and weisella spp. the main defects that these bacteria cause in foodstuffs are off-odors and off-flavors, discolorations, gas production, slime production, and decreases in ph. brochothrix spp. is a common spoilage organism of meat and meat products stored at chilled temperatures. b. thermosphacta and brochothrix campestris are the two species assigned to the genus brochothrix. b. thermosphacta is the predominant spoilage organism in pork, lamb, and fish, particularly on fatty surfaces, chilled raw, and processed products stored aerobically or under modified atmospheres (borch, kant-muermans, & blixt, ; gardner, ) . it is a gram-positive rod, nonsporing, nonmotile, and facultative anaerobe. there is no evidence to support that it is pathogenic (kilcher, loessner, & klumpp, ) . as a facultative anaerobe, b. thermosphacta is well suited for growing under modified atmosphere environments. the successful spoilage of chilled products is due mainly to its psychotropic nature. it has a growth range from c to c, with an optimum of À c. refrigeration temperatures will selectively favor its growth. its ph growth range (ph À ) is well adequate within most meat products. these factors, along with its ability to tolerate low a w values and remain relatively resistant to curing agents, increase its ability to outgrow with respect to other food spoilage microflora. spoilage is greatest in depleted aerobic conditions, often aided by increased carbon dioxide levels. such conditions are common in vacuumpacked products (pin, garcía de fernando & ordóñez, ) , where it produces undesired volatile compounds such as acetoin, diacetyl (aerobic growth), or lactic acid and ethanol (anaerobic growth) (pin et al., ; stanley, shaw, & egan, ) . moreover, it can lead to the formation of slime textures on cured and processed meat products (frankfurters, bologna, sausage, and luncheon meats) (jackson, marshall, acuff, & dickson, ) . lactobacillus casei is a species of genus lactobacillus found in dairy products as nonstarter lab, which has a wide ph and temperature range. it is present in ripening cheddar cheese and in sicilian green olives. their subspecies casei and pseudoplantarum have been associated with soft body defects and gas production in mozzarella cheese, respectively (hull, roberts, & mayes, ; hull, toyne, haynes, & lehmann, ) . regarding alactosus and rhamnosus species, they have been associated with the development of a phenolic flavor in cheddar cheese (hull et al., ) . lactobacillus curvatus is a gram-positive, rod shape, nonsporulating and facultative heterofermentative, which is not able to grow well in high salt concentration. it can be present in a wide range of foods including raw sausage, milk, grapes, and plant material coming into the winery. as mentioned previously, these bacteria can lead to the formation of slime textures on cured and processed meat products (marshall & bal'a, ) . lactobacillus delbrueckii subsp. bulgaricus (until known as lactobacillus bulgaricus) is one of several bacteria found in other naturally fermented products. it is a gram-positive rod, nonmotile, and does not form spores. it is regarded as aciduric or acidophilic, since it requires a low ph (around . À . ) to grow effectively with an optimal range of À c. l. delbrueckii subsp. bulgaricus is commonly used alongside streptococcus thermophilus as a starter for making yogurt (courtin & rul, ) . however, it produces some defects such as pink discoloration on cheese (ride, ) . moreover, it has also been considered as a contaminant of beer due to its homofermentative production of lactic acid, an off-flavor in many styles of beer. in other styles of beer, however, lab can contribute to the overall appearance, aroma, taste, and/or mouthfeel, and generally produce an otherwise pleasing sourness (priest & campbell, ) . lactobacillus plantarum is a widespread member of the genus lactobacillus, commonly found in meat and processed foods, in many fermented food products as well as anaerobic plant matter. l. plantarum has one of the largest genomes known among the lab and is a very flexible and versatile species. it is gram-positive aerotolerant bacteria that grows at c and with concentration of % of nacl, but not at c, and produces both isomers of lactic acid (d and l). l. plantarum is commonly found in many fermented food products including sauerkraut, pickles, brined olives, korean kimchi, nigerian ogi, sourdough, and other fermented plant material, some cheeses, fermented sausages, and stock fish. the high levels of this organism in food also make it an ideal candidate for food spoilage. its growth rates have been found to be higher on fat than on lean beef and pork tissues (vanderzant, savell, hanna, & potluri, ) . regarding processed products, slimy, souring, and greening defects can be generated. slimy spoilage is usually confined to outside product surface and may start developing as discrete colonies that expand to form a uniform gray layer of slime (jackson et al., ) . the role of lab in wine spoilage is well recognized, to assess the risk associated with the residing species, it is important to identify and enumerate the bacteria during the different stages of vinification (du toit & pretorius, ) . spoilage by this organism is common in musts and wines, and is caused by its heterofermentative property of converting malic acid into compounds other than lactic acid. of these, acetic acid is of concern and biogenic amines and ethyl carbamate may be produced (du toit & pretorius, ) . lactobacillus sakei is a bacterium species of the genus lactobacillus. it is a facultative heterofermentative able to produce either alcohol or lactic acid from sugars. l. sakei is used in europe for the production of traditional dry sausage as starter and can be used for the conservation of fresh meat (bredholt, nesbakken, & holck, ) . it was therefore of interest for its application in cooked ham and sausages during processing in the factory. regarding spoilage effect, they have negligible effect on the sensory properties of the products; however, it can lead to the formation of slime textures on cured and processed meat products (marshall & bal'a, ) . pediococcus is a genus of gram-positive lab usually occurring in pairs or tetrads, and purely homofermentative (haakensen, dobson, hill, & ziola, ). its bacteria are usually found in fermented products and are considered contaminants of beer and wine. thereby, the species pediococcus damnosus frequently grow in wine and beer, where they overproduce glucan and spoil products by increasing their viscosity (delaherche, claisse, & lonvaud-funel, ). streptococcus is one of nonspore-forming bacteria responsible for fermentative spoilage of dairy products (frank, ) . s. thermophilus is one of the most widely used bacteria in the dairy industry. it is a gram-positive, anaerobic fermentative facultative. it is nonmotile and does not form endospores with an optimal growth temperature range of À c. although its genus, streptococcus, includes some pathogenic species, food industries consider s. thermophiles a safer bacterium than many other streptococcus species. s. thermophiles is found in fermented milk products, and is generally used in the production of yogurt and cheese. it helps make reduced-fat cheese with similar characteristics to regular, full-fat cheese. these bacteria are selected because they produce exopolysaccharide that give reduced-fat cheese a similar texture and flavor as regular cheese. in addition, s. thermophiles produced low moisture cheese and decreased the cheese bitterness (awad, hassan, & muthukumarappan, ) . lactococcus is a genus of lab that are known as homofermentors. it means that they produce a single product, lactic acid in this case, as the major or only product of glucose fermentation. their homofermentative character can be altered by adjusting environmental conditions such as ph, glucose concentration, and nutrient limitation. they are gram-positive, catalasenegative, nonmotile cocci that are found single, in pairs, or in chains. the genus contains strains known to grow at or below c (james, ) . these organisms are commonly used in the dairy industry in the manufacture of fermented dairy products such as cheeses. they can be used in single-strain starter cultures, or in mixed-strain cultures with other lab such as lactobacillus and streptococcus. special interest is focused on the study of lactococcus lactis and their subspecies lactis and cremoris, as they are the strains used as starter cultures in industrial dairy fermentations (vos & simons, ) . l. lactis is a gram-positive bacterium used in dairy industry that has a homofermentative metabolism and it has been reported to produce exclusively l-( )-lactic acid (roissart & luquet, ). however, Å kerberg, hofvendahl, zacchi, and hahn-hägerdal ( ) reported that d-( )-lactic acid can be produced when cultured at low ph. on the other hand, l. lactis subsp. lactis, formerly streptococcus lactis (chopin, chopin, rouault, & galleron, ) is used in the early stages for the production of many cheeses, including brie, camembert, cheddar, colby, gruyère, parmesan, and roquefort (coffey & ross, ) . spoilage by these bacteria can produce malty flavors and "ropy" textures in fluid milk and dairy foods (morgan, ) . leuconostoc is a genus of gram-positive bacteria, heterofermentative, and are able to produce dextran from sucrose. they are generally slime forming (björkroth & holzapfel, ) . regarding its species, it is important to highlight that leuconostoc carnosum is a lactic acid bacterium. its name derives from the fact that it was first isolated from chill-stored meats. it is also a spoilage bacterium in vacuum-packaged, cooked meat products as sliced cooked ham. its significance that it thrives in anaerobic environments with a temperature around c, thus, it has been known to spoil vacuum-packed meat (björkroth, vandamme, & korkeala, ) . spoilage by l. carnosum produces typical sensory changes, such as souring, gas formation, and/or slime formation, at the stationary phase; and a vacuum-packaged product is usually expected to maintain good sensory quality for at least À weeks. however, due to an increased level of contamination or particularly active spoilage strains, spoilage may occur during the shelf-life period, subjecting to defects aforementioned (korkeala, suortti, & mäkelä, ). kurthia is the little known genus of the coryneform bacteria group. young cultures form chains or rods, rather than the usual v-shaped appearance. its bacteria are strictly aerobic and so far there is no evidence of pathogenicity (gardner, ) . the species kurthia zopfiienus is mainly known as food spoilage organisms predominately associated with the off-flavors and taints of both cured and fresh meat and meat related products that are stored at elevated temperatures (holzapfel & schillinger, ) . weissella is a genus of gram-positive bacteria catalase-negative, nonendospore forming cells with coccoid or rod-shaped morphology (björkroth, dicks, & endo, ) and belongs to the group of bacteria generally known as lab. its species are important from a technological point of view, and should be taken into account in any envisaged biotechnological applications (fusco et al., ) . weissella species have been isolated from a wide range of habitats, for example, on milk, vegetables, as well as from a variety of fermented foods such as european sourdoughs and asian and african traditional fermented foods. spoilage by weissella minor produces typical slime textures and due to be heterofermentative, producing co from carbohydrate metabolism with either d( )-, or a mixture of d( )-and l( )-lactic acid and acetic acid as major end products from sugar metabolism (nychas, drosinos, & board, ) . this point explores the main spore-forming bacteria involved in the spoilage of various processed foods. due to changes in the design of industrial food processing and increasing international trade, highly thermoresistant sporeforming bacteria are an emerging problem in food production. this type of bacteria is considered a major threat in heat-treated foods. spore-formers causing food spoilage are particularly important in low-acid foods (ph $ . ) packaged in hermetically sealed containers, which are processed by heat (setlow & johnson, ) . certain spore-formers also cause various types of spoilage of high-acid foods (ph , . ), while psychrotrophic spore-formers have also been recognized to cause spoilage of refrigerated foods (moir, ; setlow & johnson, ) . both, chemical and physical treatments used in the food-processing industry are not enough to eliminate the spores (carlin, ) . endospore formers may thrive in different parts of the foodprocessing plant (kalogridou-vassiliadou, ) . a number of agents cause spore activation, including low ph, some chemicals, and sublethal heat. although spores are metabolically dormant and can remain in this state for many years, if they receive the proper stimulus and conditions, they return to active metabolism through the spore germination (setlow & johnson, ) . the spore-forming bacteria can be divided into two major groups: the aerobic bacillus species and the strictly anaerobic clostridium species (heyndrickx, ) . thermophili acidophilic spore-forming bacteria such as alicyclobacillus can also cause spoilage of acidic beverages. they grow without the production of gas and no changes in the appearance of the beverage containers are observed. unfortunately, this type of spoilage is discovered only when the consumer opens and begins to consume the product. the economic losses might be extremely high. generally, bakery products are specifically spoiled by bacillus species while different clostridium species classically contaminate refrigerated vacuum-packed meats (andré, vallaeys, & planchon, ) . there are three main differences between clostridium and bacillus genus. the first difference, as commented earlier, is that clostridium is strictly anaerobic, while bacillus is an aerobic bacterium. the second difference is the spores. clostridium forms bottle-shaped endospores, while bacillus forms oblong endospores. the last difference is that clostridium does not form the enzyme catalase, while bacillus secretes catalase to destroy toxic byproducts of oxygen metabolism (maczulak, ) . microbial spoilage of food is usually indicated by changes in texture or the development of off-flavors. the primary sources of food contamination are probably soil and air. being a soil resident bacillus and clostridium species are part of the microbiota of plant raw materials (used as ingredients for many foods), attached as vegetative cells or spores (heyndrickx, ) . the main groups of bacteria that cause deterioration of food are described as follows. the family bacillaceae represents a very large, diverse set of bacteria that have one common yet distinct feature: the ability to make dormant endospores aerobically when challenged with unfavorable growth conditions (zeigler & perkins, ). these are gram-positive and most of them are mesophiles, psychrotrophs, and thermophiles (jay, ) . the genus still contains about species. bacillus species inhabit soils, air, and dust (jay, ) . many species and strains can produce extracellular enzymes that hydrolyze carbohydrates, proteins, and lipids. the main nonpathogenic bacillus, geobacillus, and alicyclobacillus species that produce food spoilage are as follows: bacillus sporothermodurans produces highly heat-resistant spores that may survive at ultra-high temperature (uht) treatment or industrial sterilization (pettersson, lembke, hammer, stackebrandt, & priest, ; scheldeman, herman, foster, & heyndrickx, ) . according to meier, rademacher, walenta, and kessler ( ) , the spores of b. sporothermodurans are more resistant than the spores of many thermophiles. affected milk products include whole, skimmed, evaporated or reconstituted uht milk, uht cream, and chocolate milk in different kinds of containers and also milk powders (hammer, lembke, suhren, & heeschen, ; klijn et al., ) . b. amyloliquefaciens is a gram-positive soil bacteria closely related to the species bacillus subtilis. the two species share many homologous genes and appear so similar, that it is not possible to visually separate the two species (priest, goodfellow, shute, & berkeley, ) . b. amyloliquefaciens and its closely related species are particularly known to be involved in ropy bread spoilage that is characterized by an unpleasant fruity odor followed by enzymatic degradation yielding soft, sticky, and stringy bread crumb making the bread inedible (valerio et al., ) . ropiness is usually occurring in the summer season when the climate is warm ( c and c) and humid as in the mediterranean countries. this species is able to grow from c to c and from ph to (valerio et al., ) . g. stearothermophilus is a common thermophilic spoilage organism that normally produces acid but no gas in spoiled packs that have been held at elevated temperatures around À c. if readily fermentable sugars are in limited supply, a study has found that this organism can elevate ph. the minimum ph for growth is around . (brenner, villar, angulo, tauxe, & swaminathan, ) . g. stearothermophilus is also significant because of its role in food spoilage, mostly milk and dairy. during the pasteurization process of these products, dairy is often heated to temperatures that denature the molecules of pathogenic bacteria. however, in g. stearothermophilus, unusually heat-tolerant enzymes and proteins allow it to survive this process (furukawa et al., ; hwang & huang, ) . b. coagulans is also a thermophile, but differs from b. stearothermophilus in being able to grow at ph values below . . b. coagulans, facultative anaerobic, thermotolerant, and acidophilic bacteria, is an important food spoilage microorganism (haberbeck, alberto da silva riehl, de cássia martins salomão, & falcão de aragão, ) . in the canned vegetable industry where foods are acidified to ph values between and . , this bacterium is frequently found, since spores of b. coagulans are able to grow and germinate at ph values as low as (de clerck et al., ; lucas et al., ) . it produces off-flavors and souring of product during spoilage. b. coagulans has caused considerable economic loss for the food industry because of the "flat sour spoilage," which is a drastic acidification of the food product due to the production of lactic acid without gas formation (lucas et al., ) . a. acidoterrestris is an obligate acidophilic, which grows optimally at ph . À . and has a minimum and maximum ph for growth of . and approximately . . at these ph values, alicyclobacillus is the only acidophilic spore-producing genus described up to now as a cause of spoilage. a. acidoterrestris spores are generally more heat-resistant than those of other acidophilic spore-formers, and cause spoilage of processed fruit and vegetables juices (evancho & parish, ; silva & gibbs, ) . in addition, a. acidoterrestris is able to grow over a temperature range of c to c (yamazaki, teduka, & shinano, ) . the most likely cause of contamination of the fruit is from soil contamination during harvesting. the heat resistance of the spores is such that pasteurization will not guarantee freedom from the organism (brown, ) . some strains in the genus alicyclobacillus have greater spoilage ability because they can produce large amounts of guaiacol that adversely affects the odor of the product (danyluk et al., ) . clostridia is one of the largest bacterial class, including more than validly described species. among these, there are several with enormous biotechnological potential and also a few well-known pathogens (dürre, ) . clostridia are obligate anaerobes and not osmotolerant. they are typically involved in the spoilage of foods such as canned or vacuum-packaged foods. clostridia in the public opinion is associated with production of a bad smell. in most cases, this is caused by butyric acid, one of the major fermentation products (dürre, ) . the main mechanism of spoilage is protein hydrolysis. anaerobic proteolysis by clostridium spp. can result in a noxious putrefaction of the food. clostridium species inhabit soils and the intestinal tract of animals, including humans (maczulak, ) . as occurs with some bacillus, some species of clostridium also produce enzymes that hydrolyze carbohydrates and proteins in food processing. the main nonpathogenic clostridium and desulfotomaculum species that produce food spoilage are as follows: the butyric anaerobes, as these three clostridium species causing spoilage in low-acid canned foods, are usually associated with spoilage of products with ph values between . and . producing blown cans and a butyric odor (hersom & hulland, ) . these bacteria, especially clostridium butyricum and clostridium tyrobutyricum, can also cause spoilage and gas production (blowing) in hard cheeses (brown, ) . clostridium sporogenes is closely related to the proteolytic strains of clostridium botulinum. spoilage from this organism produces typically blown or burst packs with a strong putrefactive odor. according to brown ( ) , if spoilage from c. sporogenes is experienced, all suspect packs should be recalled and investigations into the cause of spoilage should be undertaken. a process fault that allowed c. sporogenes to survive and proliferate may also have been serious enough to allow spores of c. botulinum to survive, germinate, and produce toxin. therefore, its physiological and genetic similarity to c. botulinum group i is often used as a surrogate for this organism in demonstrating the effectiveness of food processes (brown, tran-dinh, & chapman, ; diao, andré, & membré, ; taylor et al., ) . the most heat-resistant spores are those of clostridium thermosaccharolyticum (brown, ) . the spores survive thermal processing to germinate and grow when the product is stored at elevated temperatures around À c. canned food products spoiled by this organism are of the swell or gaseous type, with the foods having a depressed ph and cheesy odor (ashton, ) . these organisms occur widely in soil and therefore, they are found on raw material such as mushrooms and onion products (ashton, ) . clostridium putrefaciens was of considerable concern to the ham curing industry. studies by roberts and derrick ( ) demonstrated that this organism was able to grow in % nacl and ppm of nano at ph . even at c. the odor produced by this species in meat is very characteristic. one accustomed to these odors has no difficulty in differentiating pure cultures of this anaerobe from other putrefactive organisms by this means. a marked softening of the meat without evident reduction in bulk is characteristic of c. putrefaciens (sturges & drake, ) . modern processing trends are to use lower levels of salt and nitrite, increased ph levels of . À . , and chill storage that would tend to favor the growth of c. putrefaciens. desulfotomaculum nigrificans are moderately thermophilic members of the polyphyletic spore-forming genus desulfotomaculum in the family peptococcaceae. nowadays, the spoilage caused by d. nigrificans is quite rare, however, in the past, an entire season's production of canned sweet corn could be lost from this organism (brown, ) . d. nigrificans causes "sulfur stinker" spoilage often resulting in blackened product when the steel in cans reacts with the h s produced. although sporogenesis is considered an important environmental survival and food contamination mechanism in bacteria, several pathogenic bacteria that do not form spores remain involved in the main food contamination outbreaks in the last decade. the most relevant bacterial species in this group are brucella spp., campylobacter spp., salmonella spp., yersinia spp., listeria spp., and escherichia coli spp. which are involved in most of the foodborne outbreaks registered in europe union in (european food safety authority, ; mccabe-sellers & beattie, ) . the constant evolution, adaptation, and exploitation of new vehicles generated from current technology, new trends of retail shops/food commercialization, and changes in the behavior of food consumption impose challenges in the control of these pathogenic bacteria. in this scenario, the constant monitoring of transmission routes, outbreaks, clinical manifestations, and emerging new strains of well-known food pathogens are necessary to increase knowledge and develop new strategies of prevention and management of food-related diseases (newell et al., ) . brucellae are a group of gram-negative, nonspore-forming, nonencapsulated coccobacilli composed by six recognized species (b. abortus, b. melitensis, b. suis, b. ovis, b. canis, and b. neotomae) that can infect animals and humans. animals are considered as the main reservoirs of these bacteria where b. abortus infects bovines, b. melitensis causes brucellosis in caprine and ovine and b. suis is the agent associated with swine species which can lead to abortion and economic loss in meat chain. other brucella species were reported to infect dogs (b. ovis and b. canis) and rats (b. neotomae) although some strains were isolated from bison, wild boars, caribou, seals, and dolphins, and were also reported as carriers of these bacteria. particularly for marine mammals, two new brucella species were proposed: b. pinnipediae and b. cetaceae (cloeckaert et al., ; pathak et al., ) . pasteurization is a well-known thermal processing that effectively reduces brucella spp. counts. the time required to kill % of b. abortus counts (d-value) in milk at À c was between . and . min (katzin, sandholzer, & strong, ) . increasing in temperature reduces the time of thermal processing since at c requires À min, whereas c demands À s to reduce b. abortus counts in milk (kronenwett, lear, & metzger, ) . similarly, b. suis could also be destroyed by pasteurization as reported for milk heated at c for at least min (park, graham, prucha, & brannon, ) . the ph value can also influence the development of brucella spp. since the optimal range of ph is between . and . , which is close to that observed for milk (ph . À . ). however, in ph values lower than . À . , the development of these bacteria is inhibited (falenski et al., ) . however, the consumption of unpasteurized food increases the risk of brucellosis. the infection in humans mainly occurs by contact or consumption of raw or undercooked meat, unpasteurized milk, and dairy products and raw fish. the occupational exposure is the main cause of transmission in humans in farmers, slaughterhouse workers, veterinarians, and researchers (franco, mulder, gilman, & smits, ) . the clinical manifestations associated with brucellosis are wide: intermittent fever, headache, nausea, vomiting, night sweats, progressive deterioration in visual function, periorbital pain, and periodic generalized tonic-clonic seizures, and other impacts in hepatobiliary, genitourinary, musculoskeletal, cardiovascular, and integumentary systems. however, the information available about this disease is limited (atluri, xavier, de jong, den hartigh, & tsolis, ; franco et al., ; sohn et al., ) . the data from the efsa regarding the cases of brucellosis revealed that in europe union cases were registered in . in food-related cases, milk was the source of infection (european food safety authority, ). regarding studies that evaluated brucella spp. outbreaks, an outbreak in nigeria in the late s occurred due to the settling of nomadic populations after the local civil war. after this event, improvements were done in intend to reduce future outbreaks but the combination of pastoralist movements and growing demand for food poses the risk of brucella outbreaks in recent days (ducrotoy et al., ) . in arab countries, the incidence of human brucellosis was reported high in saudi arabia, iran, palestinian authority, syria, jordan, and oman, where the main species was b. melitensis. in addition, the consumption of unpasteurized dairy products was associated with brucellosis in algeria, jordan, kuwait, oman, saudi arabia, lebanon, palestinian authority, and syria (refai, ) . brucellosis is also considered as a travel disease. the occurrence of new cases in regions where this illness is under control is usually traced back to endemic regions along with consumption of contaminated nonpasteurized milk products (norman, monge-maillo, chamorro-tojeiro, pérez-molina, & lópez-vélez, ) . the occurrence of new cases in areas with low or zero cases of brucellosis can also be associated with gastronomic habits of immigrants as reported for moroccan immigrants in spain. all nine cases in this outbreak were caused by consumption of unpasteurized raw milk (ramos et al., ) . campylobacteraceae are a group of microaerophilic gram-negative, nonspore-forming, cytochrome oxidase positive, curved, and commensal bacteria composed by species: campylobacter avium, c. canadensis, c. coli, c. concisus, c. corcagiensis, c. cuniculorum, c. curvus, c. fetus, c. gracilis, c. helveticus, c. hominis, c. hyointestinalis, c. insulaenigrae, c. iquaniorum, c. jejuni, c. lanienae, c. lari, c. mucosalis, c. peloridis, c. rectus, c. showae, c. sputorum, c. subantarcticus, c. troglodytis, c. upsaliensis, c. ureolyticus, and c. volucris. the most common reservoirs of campylobacter spp. are the intestine of many animals such as cattle, sheep, poultry, pets, and wild animals (huang, brooks, lowman, & carrillo, ; ngulukun, ; silva et al., ) . poultry and turkeys are considered as the primary reservoirs of campylobacter spp. and usually show little or no symptoms of infection that could be associated with campylobacter infection (lam, damassa, morishita, shivaprasad, & bickford, ) . campylobacter species require temperature around c which reduces the ability of these bacteria to develop outside hosts and during processing and storage of food. thermal processing such as pasteurization is effective in the inactivation of vegetative cells since the d-values for À c are between . and . min. reduction of ph to values below . can inhibit campylobacter spp. development. the optimal ph range for campylobacter spp. development is . À . (silva et al., ) . gastrointestinal infection in humans caused by campylobacter species is mainly associated with c. jejuni, c. coli, and c. lari species (huang et al., ) . the clinic manifestation of campylobacteriosis includes watery diarrhea (with blood in some cases), fever, and abdominal cramps. regarding fever, more than % of cases reported fever for almost week with temperature lower than c when the diseases resolve without antibiotic treatment (allos, ; black, levine, clements, hughes, & blaser, ) . according to data from the european food safety authority (efsa), campylobacteriosis was the leading zoonotic disease in humans with more than . cases in with an average of . cases per . habitants in europe union. the efsa also highlights that campylobacteriosis rates have been increasing since and occurrence in broiler meat remains high although the case fatality rate remained low, around . %. the seasonality is also an important factor to consider in campylobacteriosis since the incidence of new cases increases during summer (european food safety authority, ). regarding cases of campylobacteriosis and campylobacter crosscontamination incidents, an outbreak of campylobacteriosis in east of england in occurred due to consumption of undercooked chicken liver pâté causing cases. microbiological assays revealed that this outbreak was caused by c. jejuni and c. coli. ingestion (edwards et al., ) . in a restaurant in liverpool (england), one confirmed case and two probable cases were associated with campylobacter infection in . although the microbiological counts of food from the day of infection were not determined due to delay onset and reporting, the most probable infected food were king prawns and chilli sauce. cross-contamination between raw chicken liver and cooked food was suggested to explain this outbreak (farmer, keenan, & vivancos, ) . similarly in barcelona (spain), a campylobacter outbreak was caused by poor food handling hygiene and deficient kitchen facilities. raw chicken meat contaminated cooked food served to primary school children in canteen that means indicated cross-contamination (direct transfer of bacteria to cooked food). a total of cases were registered in this outbreak (calciati et al., ) . salmonellae are a group of facultative anaerobic, gram-negative, rod-shaped bacteria in only two species: salmonella enterica and s. bongori with more than serovars. the six subspecies of s. enterica are: s. enterica subsp. enterica, s. enterica subsp. salamae, s. enterica subsp. arizonae, s. enterica subsp. diarizonae, s. enterica subsp. houtenae, and s. enterica subsp. indica according to world health organization (who) collaborating centre for reference and research on salmonella (brenner et al., ; issenhuth-jeanjean et al., ) . although these bacteria are present in intestine of mammals, birds (particularly poultry), and man worldwide (ellis, ; hoelzer, moreno switt, & wiedmann, ) , the presence of salmonella spp. has also been reported in water, sediments, aquatic flora (jyoti et al., ) , and reptiles (schröter et al., ) . thermal processing such as pasteurization can reduce the salmonella spp. counts since the d-value at c is between . and . min for whole egg and scrambled egg mix, respectively (garibaldi, straka, & ijichi, ) . in chicken skin, the d-value at c was reported in a range of . À . min (yang, li, & johnson, ) . the ideal ph for s. enteritidis was noticed between . and . (blackburn, curtis, humpheson, billon, & mcclure, ) , although the growth of salmonella spp. can occur at ph . (chung & goepfert, ) . ingestion of s. enterica species is associated with one of the following syndromes: enteric fever, enterocolitis with diarrhea, bacteremia (bacterial infection in the blood), and chronic asymptomatic carriage. the intensity and extension of symptoms depend on host susceptibility and s. enterica serovar (coburn, grassl, & finlay, ) . salmonellosis was the second most common zoonotic disease in europe union in with more than , cases (average of . cases per , habitants). among all salmonella serovars, s. enteritidis and s. typhimurium were responsible for more than half of all confirmed salmonellosis cases. the main contaminated foods with salmonella spp. were poultry (minced or meat preparations) and turkey meat although a smaller number of cases was associated with pig and bovine meat consumption. eggs were rarely involved in salmonellosis cases. another important data revealed was the seasonality of salmonellosis because it is a disease with peaks during the summer months when the average of cases increase since (european food safety authority, ). outbreaks of foodborne and cross-contamination with salmonella are associated with a variety of foodstuff due to poor sanitation practices, poor equipment design, deficient control of ingredients, and inadequate thermal processing (carrasco, morales-rueda, & garcía-gimeno, ) . s. enterica serovar enteritidis was the pathogen responsible for cases at a london prison in when the prison inmates displayed diarrhea, headache, abdominal pain, fever, and vomiting. the most probable cause was associated with consumption of egg cress rolls (davies et al., ) . in turkey, two outbreaks occurred in : four youth hostels and two private schools in diyarbakir. in youth hostels, a meal composed by chicken and potatoes was the main cause, whereas a green salad was the cause in the private schools. in both incidents, investigation of probable causes revealed that the contaminated food was bought from the same company. a total of cases were registered in these two outbreaks (dorman et al., ) . in birmingham (united kingdom) apparently nonrelated gastroenteritis cases were associated with consumption of iceberg lettuce contaminated with salmonella braenderup in during a period of days. among the cases, diarrhea, abdominal pain, and nausea were the predominant symptoms. however, the mechanism of contamination remains unclear (gajraj, pooransingh, hawker, & olowokure, ) . in , a s. enterica outbreak in pennsylvania (united states) was caused by inappropriate cooking of turkey pot pie. a total of cases were registered with diarrhea or bloody diarrhea. this incident was associated with inadequate information in products labeled as inconsistent information and undefined microwave wattage since the frozen pie was a not-ready-to-eat microwavable food (mody et al., ) . the genus yersinia is characterized by its gram-negative, rod-shaped, nonspore-forming bacteria. fifteen species are included in this genus: y. pestis, y. pseudotuberculosis, y. enterocolitica, y. aldovae, y. bercovieri, y. entomophaga, y. frederiksenii, y. intermedia, y. kristensenii, y. mollaretii, y. rohdei, y. ruckeri, y. aleksiciae, y. massiliensis, and y. simili (hurst, becher, young, nelson, & glare, ) . in history, y. pestis is the most relevant species due to the two pandemics events known as the justinian plague (roman empire between and anno domini) and the black death (europe between and th century), which have evolved and may cause isolated cases (achtman et al., ) . y. enterocolitica is commonly found in many farm animals (particularly pig), mammals (e.g., rodents, dogs, and cats), surface water, and sewage. this species is the main common cause of yersinosis in humans (bottone, ) . pasteurization is suitable to reduce the counts and even kill y. enterocolitica in minced beef. the d-value at c was reported between . and . min, while at c the time was reduced to . À . min, and at c, the d-value was in the range of . À . min (bolton et al., ; doherty et al., ) . in milk, d-values of y. enterocolitica at . c ( . À . min) and . c ( . À . min) were dependent on the strain (lovett, bradshaw, & peeler, ) . the control of ph value is also an important factor in the growth of y. enterocolitica since these bacteria can develop in values between . and . (bhaduri, buchanan, & phillips, ) . yersinosis, particularly from y. enterocolitica, displays diarrhea and abdominal pain as main symptoms although pseudoappendicitis (similar to appendicitis but without inflammation) may occur in older children and young adults (rosner, werber, höhle, & stark, ) . yersiniosis was third most common zoonotic disease in europe union in with cases (average of . cases per . habitants). y. enterocolitica was the most common species in all reported cases. although yersinosis cases usually increase during mayÀaugust period (summer), the average rate decreased since (from . to . cases per . habitants) (european food safety authority, ). the incidence of yersinosis associated with food contamination was reported worldwide. a case in yersinosis (y. pseudotuberculosis) was noticed in taiwan. only one case was registered in that occasion and symptoms were intermittent fever, abdominal pain, diarrhea, and progressive jaundice (yellowish skin pigmentation) for days. the suggested cause of infection was raw food: sashimi (from fish and cattle liver), raw tako (octopus), and semiboiled pig's ear (lai et al., ). an outbreak in pennsylvania, united states in , was caused by consumption of glass-bottled pasteurized milk contaminated with y. enterocolitica. a total of cases were registered along with one death. the most common symptoms were diarrhea and fever although abdominal cramping, nausea, sore throat, and rash were also reported (longenberger et al., ) . similarly, in finland an outbreak caused by contaminated raw milk affected people in . microbiological assays revealed that y. pseudotuberculosis was the pathogen and associated the contamination to single producer. the contamination occurred in the filter and after the notification; the producer recalled the milk (pärn et al., ) . in , a yersinosis outbreak was reported from a military base and civilians from the northern norway. that incident was associated with consumption of iceberg lettuce and radicchio rosso contaminated with y. enterocolitica that produced cases (macdonald et al., ) . in japan, the contamination of y. enterocolitica promoted different clinic manifestations in member of family. three people in the same family carried the bacteria: two (grandmother and child) suffered from enterocolitis and the other one was asymptomatic (did not show any symptoms). the source of infection was not determined and the most probable explanation is that the grandmother was infected by the consumption of improperly cooked pork and the child by person-to-person (moriki et al., ) . in the genus listeria comprises rod-shaped, gram-positive, catalase positive, nonspore-forming, noncapsulated bacteria. this genus includes species: l. monocytogenes, l. ivanovii, l. aquatica, l. booriae, l. cornellensis, l. fleischmannii, l. floridensis, l. grandensis, l. grayi, l. innocua, l. marthii, l. newyorkensis, l. riparia, l. rocourtiae, l. seeligeri, l. weihenstephanensis, and l. welshimeri. however, only l. monocytogenes and l. ivanovii are considered pathogens to humans (orsi & wiedmann, ) . the main suggested niches for listeria species are soil and water although plants, animals (particularly farm animals), and man are also considered as reservoirs of listeria spp. (linke et al., ; pelisser, mendes, sutherland, & batista, ) . the pasteurization of food contaminated with listeria spp. can reduce the counts of these bacteria. in mince beef, the d-values at c, c, and c are . À . , . À . , and . À . min, respectively (bolton et al., ; doherty et al., ) . the minimum ph value that allows l. monocytogenes development was reported around . À . (farber, sanders, dunfield, & prescott, ) . when humans are contaminated with listeria, particularly l. monocytogenes, a variety of symptoms can be observed as: abdominal cramps, diarrhea, headache, nausea, vomiting, fever, myalgia, general malaise, arthralgia, confusion, and neck stiffness (awofisayo-okuyelu et al., ) . in the case of pregnant women, other symptoms reported were anisocoria (pupils of different sizes), aphasia (communication disorder), facial nerve paralysis, pleural effusion (excessive amount of fluids around the lung), sepsis (infection in the blood), ascites (accumulation of fluid in the membrane of abdominal organs), and tachycardia (kiefer et al., ) . among countries of ue more than cases of listeriosis were registered in (average of . cases per . habitants). although listeriosis affected a less people in europe union in , the number of deaths was the highest since : deaths that mainly affected elder people over years old (european food safety authority, ). outbreaks due to contaminated food are registered worldwide with elevated number of deaths. in , an outbreak of listeriosis involved cases and deaths in united states due to consumption of ricotta salata (a semisoft cheese produced from sheep milk) produced in italy. the investigation revealed that processing plants of italian cheese producer was contaminated with l. monocytogenes (acciari et al., ) . in , a municipal hospital in vaasa (finland) reported an outbreak among elderly patients. initially, two patients displayed septicemia due to l. monocytogenes infection and after the evaluation of other patients in the same ward revealed that patients were also infected (febrile gastroenteritis). the investigation revealed that jelly meat was the most probable cause that also infected individuals in finland in that summer (jacks et al., ) . in north-east scotland, three cases of listeriosis (two elderly people and one baby) were registered due to consumption of ready-to-eat food contaminated with l. monocytogenes. the probable cause of infection was linked to inadequate sanitary practices, poor hand hygiene, and cross-contamination in a producer of meat products and ready-to-eat food (okpo et al., ) . the genus escherichia is characterized by gram-negative, nonsporeforming, and facultative anaerobes rod bacteria, which is composed by six species: escherichia coli, e. blattae, e. hermannii, e. vulneris, e. fergusonii, and e. albertii (abbott, o'connor, robin, zimmer, & janda, ; gaastra, kusters, van duijkeren, & lipman, ) . among all escherichia species, e. coli is the most relevant due to the health impact associated with ingestion and colonization in human digestive system. e. coli bacteria are considered as worldwide intestinal pathogen with defined phenotypes: diffusely adherent e. coli (daec), enteroaggregative e. coli (eaec), enteroinvasive e. coli (eiec), enteropathogenic e. coli (epec), enterotoxigenic e. coli (etec), and shiga toxin-producing e. coli (stec)/verocytotoxin-producing e. coli (vtec) (enterohemorrhagic e. coli [ehec] is also included in this phenotype) (cho et al., ; scheutz, ) . e. coli is present in the intestinal microflora of many farm animals (cattle, sheep, and swine), wild animals (birds and deer), pets (dogs and cats), and humans as commensal bacteria (bach, mcallister, veira, gannon, & holley, ) . particularly for cattle, stec poses an important risk due to production of milk, meat, and derived products (hussein & sakuma, ) . thermal processing such as pasteurization of food can reduce the e. coli counts. the d-value at c in meat and meat products ranges between . and . min, while at c the time required is reduced to . À . min and at c less than min is required ( . À . min) (ahmed, conner, & huffman, ) . in apple juice, d-value at c was min that was shown to be reduced by reduction of ph ( . ) and malic acid ( . %) to and min, respectively (splittstoesser, mclellan, & churey, ) . however, when thermal processing fails or posterior contamination occurs, the ingestion of e. coli imposes a severe risk to host health. symptoms of intoxication by e. coli depend on many factors such as phenotype and host immune susceptibility that may lead to mild diarrhea, infection of urinary tract, bloodstream, and central nervous system (hussein & sakuma, ) . stec/vtec and ehec induce the hemolytic uremic syndrome (hus) which is characterized by progressive renal failure and bloody or nonbloody diarrhea induced by shiga toxins: stx and stx . etec clinic manifestations involve profuse watery diarrhea in adult travelers although the dehydration can be severe in children as a result of heat-labile and heat-stable toxin produced by this e. coli species. epec symptoms are characterized by fever, nausea, vomiting, watery diarrhea with mucus and dehydration (severe and even fatal in children). eiec induces fever, abdominal cramps, and dysentery (hunt, ) . in ue, stec infection affected people in (average of . cases per , habitants) with deaths. the main food associated with stec contamination was meat from sheep, goat, cattle, and wild ruminants followed by raw milk and dairy products. the occurrence of stec cases displays a seasonal trend when peaks were observed during summer (european food safety authority, ). the occurrence of outbreaks was documented in the literature. in , cases were related to stec in oklahoma due to consumption of contaminated food in a buffet-style restaurant. although the most probable cause of infection was cross-contamination, cases developed hus and case died. the most common symptoms were diarrhea, abdominal pain, nausea, headache, fatigue, myalgia, and blood in stools (bradley et al., ) . in , a large outbreak spread throughout germany leading to cases wherein evolved to hus symptoms and people died due to stec contamination. women were particularly affected during the outbreak when gastroenteritis symptoms evolved to hus ( % of all women). this outbreak was linked to consumption of sprouts and the stec isolated from confirmed cases indicated that stec was shiga toxin- producer (frank et al., ) . in , an outbreak of ehec was reported in skania (sweden). thirtyeight cases were registered with abdominal pains, and/or diarrhea (watery or bloody) and/or hus. the investigation revealed that a fermented sausage was contaminated with ehec. the lack of thermal processing, use of dormant starter culture, and short curing period were indicated as main factors that ehec contamination (sartz et al., ) . a large ehec outbreak was reported in japan in with cases. the most common clinical manifestations were diarrhea and bloody stool wherein cases evolved to hus, cases displayed acute encephalopathy and cases died from ehec infection. the investigation revealed that raw beef liver and yukhoe, traditional korean seasoned raw beef rib (yahata et al., ) was the foodborne cause. an outbreak in norway was linked to etec contamination. a total of cases displayed diarrhea, abdominal pain, nausea, fever, and vomiting as common symptoms. the investigation revealed that contaminated scramble eggs was the most probable cause of contamination during a christmas buffet served in the hotel (macdonald et al., ). pathogen spore-forming bacteria are a big challenge for the food industry in its continuing concern to produce safe food, reducing the number of foodborne illness. a particular emphasis is necessary with this class of microorganisms, due to their inherent ability to survive extreme processing conditions. indeed, the bacterial spores are among the most resistant forms of living organisms. their resistance favors their survival to food processing and long-term persistence in foods (carlin, ) . traditional microbiological detection methods used in the food industry have restrictions in terms of time, efficiency, and sensibility. food microbiology has undergone considerable development in recent years, largely due to predictive modeling (mcmeekin et al., ) and risk assessment (augustin, ) . in spite of that, its application in diverse areas of the food industry to improve the safe food security is still limited. according to augustin ( ) , the microbiological risk assessment related to probabilities and severities of adverse health effects for consumers have to include four steps: ( ) hazard identification, ( ) exposure assessment, ( ) hazard characterization, and ( ) risk characterization. this risk analysis for improving food control systems is necessary to develop the different processing methodologies for the elimination of these microorganisms, such as heat treatments, chemical based on acidification or the combination of them. besides, in the last years, emerging technologies such as plasma and advanced oxidation have been developed. however, not all of them are efficient in eliminating spores due to the morphological features that provide resistance to hostile conditions. because of their ubiquitous nature, bacterial spore-formers are widely located in all types of foods. from the beginning of the th century, it has been studied the spore-forming bacteria, especially the pathogenic species, but rapidly, spoilage spore-forming bacteria were also investigated (remize, ) . indeed, in recent years, there has been an increasing interest in spore-forming bacteria, because they are considered a major risk in heat-treated food production plants. mesophilic spore-forming bacteria belong essentially to two taxonomic groups: the bacillales order and the clostridium genus, depending on whether they are aerobic or not. bacillales gathers aerobic, facultative aerobic, or facultative anaerobic bacteria. the bacillaceae family covers genera including bacillus and anoxybacillus, which comprise several thermophilic species, whereas inside the genus clostridium a total of species are described (garrity & bergey, ). the order bacillus, clostridium, sporolactobacillus, soporosarcin, and desulfotomaculum are capable of forming endospores. for food microbiology, the first two have a special interest because of the problems caused by some species of these orders. of the many species of bacillus and related genera, most do not cause disease. however, there are some species that generate important diseases in humans. bacillus cereus is known to be responsible for two types of foodborne diseases: the diarrheal and the emetic type. in addition, b. cereus is related to diseases transmitted by food. it has been isolated from other species such as b. subilis, b. licheniformis, and b. pumilus that have gained great importance due to the type of pathology that they produce (scheldeman et al., ) . diarrheal disease is often associated with protein rich foods (meat, vegetables, puddings, and milk products) and is thought to be caused by vegetative cells (ingested as viable cells or spores) that produce enterotoxins in the small intestine (abee et al., ) . the emetic disease is often associated with starch-rich foods (fried and cooked rice, pasta). it was identified for the first time in the united kingdom in the early s, when microorganisms from b. cereus were linked to several outbreaks caused by eating cooked rice. the b. cereus emetic toxin, cereulide, produces the emetic disease that is present in foods before ingestion (abee et al., ) . within the genus bacillus, b. cereus and its closest relatives form a highly homogeneous subdivision, which has been termed the "b. cereus group." this group comprises the species b. cereus, b. anthracis, b. thuringiensis, b. mycoides, b. pseudomycoides, and b. weihenstephanensis (jensen, hansen, eilenberg, & mahillon, ; tourasse, helgason, Økstad, hegna, & kolstø, ) . b. cereus group have been isolated from a broad range of environments, ranging from soils, plant rhizospheres, insects, animals, and obviously humans (jensen et al., ; vilain, luo, hildreth, & brözel, ) . most studies related to genomic analysis have indicated that b. cereus is specialized on protein metabolism; therefore, this fact suggests that it has adapted toward a symbiotic or parasitic life cycle (ivanova et al., ; stenfors arnesen, fagerlund, & granum, ) . clostridium are rod-shaped, gram-positive bacteria capable of producing spores. the genus clostridium gathers all mesophilic anaerobic sporeformers encountered in food. according to the health protection agency, the clostridium genus consists of more than a hundred known species, including harmful pathogens such as c. botulinum, clostridium difficile, clostridium perfringens, clostridium tetani, c. butyricum, and clostridium sordellii. the anaerobic status of these bacteria is a strong driver for niche differentiation compared to bacillales representatives. besides, they can be differentiated based on their biochemical activities, including saccharolysis and proteolysis. the first four members produce powerful toxins released from vegetating (growing) bacteria, that is, c. botulinum, produces the most powerful toxin known to man, which is the key virulence factor responsible for the pathogenesis of disease. its action is the reverse of that of tetanus toxin, that is, it prevents muscle contraction, leading to flaccid paralysis of important muscles. it inhibits the release of acetylcholine at motor nerve endings in the parasympathetic nervous system. this potent toxin is relatively heat-resistant (although destroyed by temperatures . c). c. difficile is found in the feces of À % of humans, in the gut of several animals and in the environment. the organism produces at least two potent toxins that are responsible for severe and occasionally fatal diarrhea. c. perfringens produces a number of potent toxins, the most important of which is the a-toxin (phospholipase c), which causes host cell lysis and finally c. tetani produces an extremely potent single toxin (tetanus toxin) which underlies the pathogenesis of tetanus. tetanus toxin consists of two components, including the neurotoxic "tetanospasmin" and the hemolytic tetanolysin. the toxin prevents muscle relaxation, leading to persistent contraction of facial and body muscles. formation, resistance, and germination of spores have been widely studied, essentially for bacillus. according to several authors (piggot & hilbert, ; sonenshein, ) sporulation occurs in response to a high cellular density, nutritional limitations, or cellular communication. the resistance of spores is developed during the sporulation. these spores are metabolically dormant and resistant to heat, radiation, desiccation, ph extremes, and toxic chemicals (setlow, ) . the dormant spores also monitors the environment around theirs, and when conditions are again favorable (presence of germinants as nutrients such as amino acids, sugars, purine nucleosides, or other agents as lysozyme or salts) for growth, the spore germinates and goes through outgrowth, ultimately being converted back into a growing cell (paidhungat & setlow, ) . the transition from spore to vegetative cell involves three distinct phases: activation, germination, and growth. in fig. . , schematic diagram of the sporulation and cycle of germination of the b. subtilis can be observed. spore wraps are multilayered, and usually are distinguished from spore core to external medium. they are composed of an internal membrane, a cortex, an external membrane, a coat, and possibly an exosporium. each layer presents specific structural, biochemical, and permeability properties (remize, ) . exosporium is a thin delicate covering made of proteins. inner and outer spore coats are composed of layers of spore-specific proteins. the cortex is composed of loosely linked peptidoglycan and contains dipicolinic acid, which is particular to all bacterial endospores. this acid cross links with calcium ions embedded in the spore coat and contributes to the extreme resistance capabilities of the endospores because it creates a highly impenetrable barrier. finally, they contain the usual cell wall and, cytoplasmic membrane, nucleoid, and cytoplasm. the core only has %À % of the water content of vegetative cells; therefore, the core cytoplasm is in a gel state. the low water content contributes to the endospores' success in dry environments. schematic example of spore-forming bacteria structure is depicted in fig. . . soil is considered as a major habitat of spore-forming bacteria. b. cereus and c. botulinum have been detected worldwide in soil samples (dodds, ) with levels in soil that can reach À spores/g of soil (lund, ; te giffel, beumer, slaghuis, & rombouts, ) . the spores ingested with fecal and other soil materials colonize the gut of animals and may develop a symbiotic relation with their hosts (könig, ) . besides, soil contamination can transfer to plant material (silage) and to feed. according to magnusson, christiansson, and svensson ( ) , the major cause of contamination into foods is related to dispersion of spores by fecal material of warm-blooded animals. indeed, the microorganism, c. perfringens is a common colonizer of the gastrointestinal tract of mammals (including man) (brynestad & granum, ) and c. botulinum has been identified in cow and pig feces collected in abattoirs (dahlenborg, borch, & rådström, ) . on the other hand, food-processing facilities can be also the source of spores in foods, in fact milking machinery and apparatus have been indicated as sources of milk contamination (scheldeman, pil, herman, vos, & heyndrickx, ) . specifically, svensson, ekelund, ogura, and christiansson ( ) have noticed the presence of a persistent b. cereus spore, due to their resistance to cleaning operations because many of them have strong adhering properties and ability to form biofilms (auger et al., ) . overall, it is worthy to say that processed foods are increasingly a mixture of multiple ingredients and additives, each bringing its own sporeforming bacteria into the final food products. works in the literature clearly demonstrate that the origins of b. cereus spores are very diverse, depending on factors such as the microbial ecology, animal feeding, the farming management, the climate, and the hygienic practices during food processing. a wide variety of methods have been developed for producing safe foods, classified in ( ) physical, ( ) chemicals, and ( ) others, within which emerging technologies can be mentioned. physical methods of inactivation of microorganisms are those, based on the use of temperatures and modified pressures with the aim of altering cell structures or essential biomolecules for their metabolism as high-pressures (hpp) and ionizing radiations (ultraviolet and infrared). regarding the first methodology, zhang and mittal ( ) reported successful conditions with hpp for the inactivation of spores of various species. however, these authors affirm that due to the complicate intrinsic and extrinsic factors, hpp conditions should be verified case by case for required sterility. it has been studied that the effect of infrared radiation on the inactivation of spores, due to this radiation is quickly converted to heat, producing an intense local heating on spores (mamouni, tang, wu, vlahovic, & yang, ) . explanation is based on local heating over the spores produce mechanical abrasion causing the germination by the activation of the lysis enzymes (dong, tang, wu, vlahovic, & yang, ) . these enzymes are present in the spore in an active form, but they do not act until they are activated by the mechanical damage. within the chemical processes, the most used are acidification and smoking. such processes can generate added value to the product by improving sensorial characteristics of the final product. however, these treatments are not effective in spore elimination. spores are extremely resistant to a variety of chemicals, including acids, bases, oxidant and alkylating agents, aldehydes and organic solvents. however, treatments with strong acids can eliminate spores, probably due to the rupture of the inner membrane (setlow, ) . on the contrary, treatment with a strong alkali is less effective because they can be reactivated with an adequate recovery by lysozymes (setlow, ) . within emerging technologies, we can highlight plasma and advanced process of oxidation based on radical generation. plasma has been reported to inactivate both vegetative cells and bacterial endospores. three basic mechanisms have been attributed to the inactivation of spores: ( ) dna degradation by uv radiation, ( ) volatilization of compounds of the spore surface by uv photons, and ( ) erosion of the spore surface by the adsorption of reactive molecules as free radicals (philip et al., ) . finally, advanced oxidation processes are based on the generation of hydroxyl radicals using different precursors (uv, hydrogen peroxide, ozone, electrons, photo catalysis with titanium dioxide, fenton reagent, etc.). all of these treatments have been reported as highly efficient in the elimination of microorganisms (bondala, castillo, gonzález, & sanchez-salas, ) , because they produce damage on external spore (mainly in inner membrane). then when the treated spores germinate, these ruptures in the membrane have a fatal consequence in its viability (shapiro, setlow, & setlow, ) . in particular, the fenton reaction has been tested for elimination of spores in water with successful results (bondala et al., ) . however, studies to establish whether these processes can be widely used in other foods, without a possible change in sensory characteristics must be developed. the use of microorganisms to obtain different types of food, such as beer, wine, bread, cheeses, and fermented milk is very old. there have been reports of application of fermentation processes for the production of foods from times before christ. in the th century, the industrial microbiology expanded even more, because they perceived new possibilities for obtaining large variety and quantity of products by fermentative processes. yeasts are fungi that grow as solitary cells that reproduce by budding and can be classified either to ascomycetes (e.g., saccharomyces, candida) or basidiomycetes (e.g., filobasidiella, rhodotorula) (see table . ). yeast taxa are distinguished on the basis of the presence or absence of capsules, the size and shape of the yeast cells, the mechanism of daughter cell formation (conidiogenesis), the formation of pseudohyphae and true hyphae, and the presence of sexual spores, in conjunction with physiologic data. morphology is employed primarily to distinguish yeasts at the genus level, whereas the ability to assimilate and ferment various carbon sources and to utilize nitrate as a source of nitrogen are used in conjunction with morphology to identify species. currently, there are approximately recognized yeast species listed in the latest edition of the yeasts: a taxanomic study (fell, kurtzman, & boekhout, ) and estimated total number is around , forming roughly %À % of estimated fungal species. of all these yeast species, only about are employed at industrial scale, and around À species were used at laboratory scale to possess potential value in biotechnology (deak, ; fell et al., ) . traditionally, the yeast has been used for the production of alcoholic beverages, biomass, and glycerol. in this regard, saccharomyces cerevisiae is famously known for its role in food production. it is the critical component in the fermentation process that converts sugar into alcohol; an ingredient shared in beer, wine, and distilled beverages. it is also used in the baking process as a leavening agent; yeast-releasing gas into their environment results in the spongy-like texture of breads and cakes. because of its role in fermentation, humans have known about and used s. cerevisiae for a long time. other yeast involved in the common fermented foods and beverages such as breads and bakery products, dairy products (e.g., kefir; yoghurt, fermented milk), fermented meat and sausages, cheeses, beers, wines, etc. are: kluyveromyces, galactomyces, hyphopichia, pichia, saccharomycodes, rhodotorula, metschnikowia, saccharomycopsis, yarrowia, cryptococcus, brettanomyces, debaryomyces, hansenula, schizosaccharomyces, hanseniaspora, trichosporon, torulopsis, geotrichum, zygosaccharomyces, and candida. in addition to traditional industrial use, there are applications of yeasts in several food fermentations such as alcoholic beverages, sausages, cheese, bakery products, and other fermented foods. modern applications of yeasts involve the production of single-cell proteins, ethanol, industrial enzymes, foodstuffs and fodder, and small molecular weight metabolites (see fig. . ) . finally, yeasts also have important roles in agriculture as agents of biocontrol, bioremediation, and as indicators of environmental quality. on the other hand, the spoilage yeasts of drinks and foods have gained an increasing importance in food technology, being responsible for significant (johnson, a (johnson, , b ascomycetous basidiomycetous saccharomyces cerevisiae rhodotorula spp. schizosaccharomyces pombe rhodosporidium spp. kluyveromyces lactis trichosporon spp. schwanniomyces occidentalis cryptococcus spp. lipomyces spp. phaffia rhodozyma saccharomycopsis spp. ogataea polymorpha scheffersomyces stipitis pichia spp. candida spp. economic losses (thomas, ) . in this regard, pitt an hocking ( ) noticed that only about species of yeasts (dekkera bruxellensis, zygosaccharomyces bisporus, schizosaccharomyces pombe, issatchenkia orientalis, debaryomyces hansenii, candida holmii, pichia membranifaciens, zygosaccharomyces bailii, saccharomyces cerevisiae, zygosaccharomyces rouxii, and kloeckera apiculata) are responsible for the spoilage of foods that have been processed and packaged. the deterioration of food and drinks caused by yeasts is summarized in table . . the term mold is commonly applied to certain multicellular, filamentous fungi whose growth on foods is usually readily recognized by its fuzzy or cottony appearance. generally, molds are concerned in the spoilage of foods where moldy or mildewed foods are considered unfit to eat. the gross bioremediation, pollutant degradation beer, wine, sake, soy sauce, other food fermentations enzymes, flavors, pigments, amino acids, organic acids bioethanol, biodiesel, faee, biobutanol, sesquiterpenoids farnesene, bisabolene, and amorphadiene protein pharmaceuticals, enzymes, hormones, vaccines, toxins molecular and cellular biology, genomics, functional genomics, pathway engineering, system biology mechanisms drug discovery, drug resistance and metabolism, elucidation of disaese mechanism crop protection, food and feed safety, probiotics ( ) . yeast physiology and biotechnology. chichester: wiley (walker, ) . appearance of a mold growing on a food is often enough to indicate its genus. in this regard, some look dry and powdery, some look velvety on the upper surface, and others gelatinous or wet, whereas some molds are compact and others are loose and fluffy. in addition, the pigments in the mycelium (black, purple red, gray, etc.) are also characteristic. molds are characterized by the development of hyphae (a mass of branching, interwined filaments), which result in the colony characteristics (known as a mycelium). in general, most molds require less available moisture than required for most yeast and bacteria and the optimal temperature for most molds range from c to c. in addition, molds grow on the surface of food (they require free oxygen for growth) and in a wide range of ph values (from to . ), but the majority is favored by an acid ph. the most important molds from the industrial point of view are as follows: mucor that have been used for centuries in food manufacturing for cheese ripening or asian fermented food production. the genus mucor contains several species. the most common ones are mucor amphibiorum, m. circinelloides, m. hiemalis, m. indicus, m. racemosus, and m. ramosissimus. aspergillus molds are very widespread, they are involved in the spoilage of foods, and some are useful in preparation of fermented foods. this genus grows well in high sugar and salt concentrations and hence in many foods with low moisture content. the aspergillus genus comprises species (samson et al., ) , and the chemodiversity among these species is very high. rhizopus are involved in the spoilage of many foods such as vegetables, berries, bread, and fruits. the genus rhizopus includes several species. the most common ones are, namely, rhizopus arrhizus, rhizopus azygosporus, rhizopus microsporus, rhizopus schipperae, and rhizopus stolonifer. penicillium is well known and one of the most common fungi. it has a worldwide distribution and a large economic impact on human life. its main function in nature is the decomposition of organic materials, where species cause devastating rots as pre-and postharvest pathogens on food crops (frisvad & samson, ; pitt & hocking, ) , as well as producing a diverse range of mycotoxins (frisvad & samson, ) . in addition, some species also have positive impacts, with the food industry exploiting some species for the production of specialty fermented sausages (lópez-díaz, santos, garcía-lópez, & otero, ; ludemann, greco, rodríguez, basílico, & pardo, ) and cheeses, such as camembert or roquefort (giraud et al., ) . alternaria are involved in the spoilage of many foods such as potato and tomatoes. alternaria spp. are among the most well-known producers of diverse secondary metabolites, especially toxins (montemurro & visconti, ) . the most common species are alternaria citri, alternaria tenuis, and alternaria brassicae. bothrytis are important pathogens of many agronomically important crops, such as grapevine, tomato, bulb flowers, and ornamental crops (jarvis, ) . molds also play an important role in the ripening of some dryfermented products. the uses of mold cultures contribute to the development of the typical flavor through its proteolytic, lipolytic, β-oxidative, and deaminitive activities (sunesen & stahnke, ) . in addition, molds growth on the surface food products exerts antioxidative effects due to their obligate requirement for oxygen consumption for respiratory purposes and physical barrier effects due to the presence of their mycelial growth, which reduces the penetration of oxygen, and light into the product (bruna et al., ) . additionally, surface molds can also have a protective role against pathogenic or spoilage microorganisms by colonizing product surfaces and out-competing microbial competition (ludemann, pose, pollio, & segura, ) . viruses are obligate intracellular parasites that cause a wide range of diseases in plants, animals, and humans. as obligate parasites, viruses must continue to find new host cells and individuals, and be able to use the biochemical reactions of the cell to replicate. consequently, virus multiplication will not occur in foods that can act only as a passive vehicle in the transmission of infection (adams & moss, ) . they can be transmitted in different ways but the infection of the cells lining the intestinal tract and dispersed by shedding into the stool or through emesis were the most important foodborne infections. several different viruses may cause a single disease, as determined by the tissue or organ that is affected, or one virus may cause a unique disease due to the nature of its interaction with the body (rosenthal, ) . numerous viruses can be found in the human gut, but only few are commonly recognized as important foodborne pathogens. according to the type of illness that they produce, viruses can be classified into three groups (koopmans & duizer, ) : g viruses that causes gastroenteritis g enterically transmitted hepatitis viruses g viruses that cause illness after they migrate to other organs, such as the central nervous system or the liver. the number of foodborne viruses is relatively small, but the norovirus and hepatitis a are currently recognized as the most important human foodborne pathogens with regard to the number of outbreaks and people affected in the world (cliver, ) . both viruses are highly infectious and may lead to outbreaks. there are other viruses involved in the transmission of food or waterborne but they occur occasionally: hepatitis e, aichivirus, astrovirus, coronavirus, rotavirus, and saporavirus. norovirus is a very contagious virus that can infect anyone, from an infected person, contaminated food or water, or by touching contaminated surfaces. the clinical manifestation of the norovirus is relatively mild, about % of all outbreaks of food-related illness are caused by norovirus. the virus causes inflammation of stomach or intestines or both. this leads to have stomach pain, nausea, and diarrhea and to throw up. these symptoms can be serious for some people, especially young children and older adults (cdc, a) , and many people are infected in a very short time. most outbreaks of norovirus illness happen when infected people spread the virus to others. however, norovirus can also be spread by consuming contaminated foods or water. food can be contaminated with norovirus at any point when it is being grown, shipped, handled, or prepared. foods that are commonly involved in outbreaks of norovirus illness are: leafy greens (such as lettuce), fresh fruits, and shellfish (such as oysters). hepatitis a virus (hav) is classified as a picornavirus. primates are the only natural host (balayan, ) . there is only hav serotype, and immunity after infection is lifelong (lemon, jansen, & brown, ) . after ingestion, uptake in the gastrointestinal tract, and subsequent replication in the liver, hav is excreted in bile, and high concentrations are found in stool specimens. transmission occurs by the fecal-oral route, by direct contact either with a hav-infected person or by ingestion of hav-contaminated food or water (adams & moss, ) . hepatitis a is an increasing problem because of the decrease in immunity of populations in countries with high standards of hygiene. hav contamination of a food product can occur at any point during cultivation, harvesting, processing, distribution, or preparation. hav can be spread either by eating or drinking food or water contaminated with the virus, including frozen or undercooked food. the food and drinks most likely to be contaminated are fruits, vegetables, shellfish, ice, and water (cdc, b). recognizing foodborne transmission using routine surveillance data may be difficult because: ( ) case patients may have difficulty recalling food histories during the À weeks before illness, ( ) cases may accrue gradually or not be reported, ( ) a food item may be focally contaminated, ( ) some exposed persons have unrecognized hav infection, ( ) some exposed persons have preexisting immunity (from a previous infection or previous vaccination), ( ) persons who acquire infection through contaminated food are not recognized amid an ongoing high incidence in the community, and ( ) cases are geographically dispersed over several public health jurisdictions (fiore, ) . hepatitis e is common in many parts of the world, especially in oriental and meridional asia, and it is transmitted from ingestion of fecal matter, even in microscopic amounts, and is usually associated with contaminated water supply in countries with poor sanitation (cdc, b) . there are at least four different genotypes: and have only been found in humans, while and circulate in several animals (including pigs, wild boars, and deer) without causing disease, and occasionally infect the human being (who, ) . in developing countries, hev genotypes and are spread by fecally contaminated drinking water. hev genotype causes sporadic cases that have occurred following consumption of uncooked/undercooked pork or deer meat. consumption of shellfish was a risk factor in a recently described outbreak in a cruise ship. hev genotype , detected in china, taiwan, and japan, has also been associated with foodborne transmission. the aichivirus (aiv) is a member of the kobuvirus genus (picornaviridae family) that includes three different species (aichivirus a, b, and c). the picornaviruses isolated from human were termed aichivirus. transmission occurs by the fecal-oral route, by direct contact either with a hav-infected person or by ingestion of hav-contaminated food or water. their foodborne diseases have been potentially linked with gastroenteritis (khamrin, maneekarn, okitsu, & ushijima, ) . astrovirus (astv) is a type of viruses classified as astroviridae family genus mammoastrovirus that cause gastroenteritis. astv are widespread globally (bosch, pintó, & guix, ) . food plays an important role in its transmission. foods may become contaminated with astv at the preharvest stage, as with bivalve mollusks grown in polluted water or fresh produce, lettuce, green onions, raspberries, and strawberries irrigated with contaminated water, observing high level of contamination in oysters and shellfish (rzezutka & cook, ) . astv is stable in drinking water, fresh surface water, and seawater, indicating another means of transmission. young children in childcare backgrounds or adults in military barracks are most likely to develop the disease (lukashov & goudsmit, ) . coronaviruses are an extensive family of viruses, some of which may be the cause of various human diseases, ranging from the common cold to severe acute respiratory syndrome. coronaviruses are enveloped viruses with a positive-sense rna genome. the virus derives its name from the "corona" seen in electron micrographs around the virion created by the viral glycoproteins. this structure also protects the virion from harsh conditions and allows this enveloped virus to be transmitted by the fecal-oral route in addition to the respiratory route (rosenthal, ) . coronaviruses may represent potential foodborne disease agents (koopmans & duizer, ) . rotavirus (rv) is a double-stranded rna virus of the family reoviridae. rv is a contagious virus that can cause gastroenteritis (inflammation of the stomach and intestines) by the fecal-oral route (cdc, c). symptoms include severe watery diarrhea, often with vomiting, fever, and abdominal pain. infants and young children are most likely to get rotavirus disease. rv can be spread by contaminated water and food, especially shellfish (bishop, ) . sapovirus (sav) is an important pathogen causing acute gastroenteritis in humans globally, especially in infants and young children. sav are widespread and its outbreaks have become more frequent recently (oka, wang, katayama, & saif, ; todd & greig, ) . this point describes a limited number of parasitic diseases as representative of the major groups of foodborne parasitic organisms. numerous parasites can be transmitted by food including many helminths and protozoa. in developing countries, the most common way that parasites are transmitted in foods occur by consumption of undercooked fish, crabs, mollusks, meat, raw aquatic plants such as watercress and raw vegetables that have been contaminated by human or animal feces. symptoms of foodborne parasitic infections vary greatly depending on the type of parasite. helminthic infections can cause abdominal pain, diarrhea, muscle pain, cough, skin lesions, malnutrition, weight loss, neurological, and many other symptoms depending on the particular organism and burden of infection. protozoa such as cryptosporidium spp., giardia intestinalis, and cyclospora cayetanensis most commonly cause diarrhea and other gastrointestinal symptoms. therefore, the foodborne parasites could be classified as described later. a variety of human helminthic infections could be acquired through the consumption of food products from infected animals and plants, through the accidental ingestion of infected invertebrates in foodstuffs or drinking water, or through inadvertent fecal contamination by humans or animals. trichinella is the etiological agent of trichinosis, the roundworm disease that has been of greatest concern from the standpoint of food transmission (jay, loessner, & golden, ) . people acquire trichinosis by consuming raw or undercooked meat infected with the trichinella parasite, particularly wild game meat or pork. even tasting very small amounts of undercooked meat during preparation or cooking puts you at risk for infection. several different species of trichinella can cause human disease; the most common species is trichinella spiralis, which has a global distribution and is the species most commonly found in pigs. however, there is an increasing number of reports of trichinella britovi as a cause of human infection caused by meat from domestic pigs (gamble, zarlenga, & kim, ; pozio, rosa, & morales, ) . trichinosis is considered a zoonosis because infection occurs after ingestion of raw or poorly cooked meat from infected animals. one to two days after the ingestion of heavily encysted meat, trichinae penetrates the intestinal mucosa, producing nausea, abdominal pain, diarrhea and sometimes, vomiting. the larvae begin to invade striated muscles about À days after the initial symptoms. about weeks after the initial infection, encystment occurs, accompanied by tissue pain, swelling, and fever (jay et al., ) . taeniasis is the result of ingesting tissue cyst of either t. saginata from cows or t. solium/t. asiatica from pork. flatworm and roundworm parasites in humans are their definitive hosts (jay et al., ) . people with taeniasis may not know they have a tapeworm infection because symptoms are usually mild or nonexistent. although most cases of taeniasis are asymptomatic, up to one-third of patients complain of nausea or abdominal pain that is often relieved by eating. generally, epigastric pain may be accompanied by weight loss, increased appetite, headache, constipation, dizziness and diarrhea. allergic reactions, such as urticarial and pruritus may also be due to the worm and its metabolites (gamble et al., ) . anisakiasis is a parasitic disease caused by anisakid nematodes that can invade the stomach or intestine of humans. this roundworm infection is caused by two closely related genera and species: anisakis simplex and pseudoterranova decipiens. both of these organisms have several intermediate hosts and generally more than one definitive host (jay et al., ) . the transmission of this disease occurs when infective larvae are ingested from fish or squid that humans eat raw or undercooked (sakanari et al., ) . the noninvasive form of anisakiasis is generally asymptomatic, resulting in tingling throat syndrome when worms are released from seafood following digestion and migrate up the esophagus into the pharynx, where they subsequently may be expectorated (sakanari & mckerrow, ) . in the invasive form, worms typically penetrate the mucosa of the stomach or small intestine, resulting in epigastric pain, nausea, vomiting, and diarrhea, usually h after consumption of the infected seafood (hayunga, ) . in some chronic cases, the only treatment is the removal of the larvae via endoscopy or surgery. diphyllobothrium latum are the largest tapeworms that can infect people and can grow up to m long. the definitive hosts of d. latum are humans and other fish-eating mammals (jay et al., ) . while most infections are asymptomatic, complications include intestinal obstruction, nausea, abdominal pain, diarrhea, and weakness. d. latum may also cause pernicious anemia and vitamin b deficiency (hayunga, ) . diagnosis is made by identification of eggs or segments of the tapeworm in a stool sample with a microscope. safe and effective medications are available to treat diphyllobothrium. infections, as in the case of anisakiasis, are acquired by eating raw or undercooked fish, usually from the northern hemisphere (europe, north america, and asia), but cases have also been reported in uganda and chile. fish infected with diphyllobothrium larvae may be transported to and consumed in any area of the world. adequately freezing or cooking fish will kill the parasite. although the four helminths discussed earlier are the most important, there are many of them that can be transmitted by other sources of food (hayunga, ) such as clonorchis sinensis, paragonimus westermani, capillaria philippinensis, gnathostoma roundworms, heterophyles heterophyles, metagonimus yokagawai, echinostomum, nanophyetus salmincola, eustrongylides, phylometra, and nybelinia surmenicola from fish or marine source, faciola hepatica, fasciolopsis buski, dicrocoelium, angiostrongylus costaricensis, trichostrongylus, and echinococcus granulosus acquire from vegetation or dracunculus medinensis and gnathostoma spinigerum acquire from drinking water. protozoan parasites have long been associated with foodborne and waterborne outbreaks of disease in humans. difficulties arise with the inactivation of these organisms because of their resistance to environmental stresses (ortega, ) . cryptosporidium is a microscopic parasite that causes the diarrheal disease cryptosporidiosis. there are many species of cryptosporidium that infect animals, some of which also infect humans such as c. felis, c canis, c. meleagridis, c. baileyi, c. muris, and c. parvum (ortega, ) . these species can infect humans, occurring most frequently in human immunodeficiency virus (hiv)-positive individuals (cacciò, pinter, fantini, mezzaroma, & pozio, ; fayer et al., ; gatei et al., ; matos, alves, xiao, cama, & antunes, ) . the parasite is protected by an outer shell that allows it to survive outside the body for long periods and makes it very tolerant to chlorine disinfection. while this parasite can be spread in several different ways (as food contaminated with cryptosporidium oocytes), water (drinking water and recreational water) is the most common way to spread the parasite. generally, c. parvum infects the border of the intestinal epithelium and causes villous atrophy. immunocompetent patients develop a profuse diarrhea accompanied by epigastric cramping, nausea, and anorexia (ortega, ) . cyclospora cayetanensis is a coccidian that is closely related to the cryptosporidia, and some human infections by the latter it has been misdiagnosed as cyclosporiasis (jay et al., ) . people become infected with cyclospora by ingesting sporulated oocysts, which are the infective form of the parasite. this most commonly occurs when food or water contaminated with feces is consumed. an infected person sheds immature and noninfective cyclospora oocysts in the feces. the oocysts are thought to require days to weeks in favorable environmental conditions to become infective. therefore, direct person-to-person transmission is unlikely, as is transmission via ingestion of newly contaminated food or water. cyclospsoriasis is characterized by mild-to-severe nausea, anorexia, abdominal cramping, mild fever, and watery diarrhea (ortega, ) . t. gondii is a coccidian parasite that infects a variety of warm-blooded hosts. cats are the definitive hosts, while other warm-blooded animals serve as intermediate hosts. the oocytes are environmentally resistant and can survive several years. infections are acquired principally by ingestion of food and water containing oocysts, ingestion of animal tissues containing cystic forms or transplacental transmission (dubey & beattie, ) . the unsporulated oocysts require h outside the host to differentiate and become infectious. when the oocysts are ingested, the sporozoites are released and they invade epithelial cells and rapidly multiply asexually, producing tachyzoites. choriorentinitis is frequently observed in adults who acquire the infection. other symptoms as fever with rash, headache, muscle aches, and pain and swelling of the lymph nodes were described (jay et al., ) . in immunosuppressed patients, toxoplasmosis could be reactivated from latent infections (reiter-owona et al., ) . toxoplasmosis can also be acquired by transplacental transmission when a pregnant woman becomes infected. most infected children do not show any signs of the disease until later in life, when they may present with choriorentinitis and mental retardation (ades, ; brady-mccreery, hussein, & paysse, ; de marco, ceccarelli, frulio, palmero, & vittone, ) . giardia is a protozoan flagellate that belongs to the phylum sacomastigophora. the prothozoites have eight flagella that arise on the ventral surface near the paired nuclei and give rise to falling-leaf motility (jay et al., ) . most human infections result from the ingestion of contaminated water or food or direct fecal-oral transmission. giardia is protected by an outer shell that allows it to survive outside the body for long periods. five different species of giardia have been described (g. muris, g. lambia, g. agilis, g. ardeae, and g. psittaci) (erlandsen & bemrick, ; ortega, ) . giardia can be observed in the form of trophozoite and the cyst. the cyst is the infectious form and is relatively inert. after cysts are ingested, excystation occurs in duodenum after exposure to the acidic gastric ph and the pancreatic enzymes. the majority of giardia infections are asymptomatic, but they can present a chronic diarrhea. symptomatic patients present with loose, foul-smelling stools, and increased levels of fat and mucus in fecal samples. flatulence, abdominal cramps, bloating, nausea, anorexia, and weight loss are common. fever is occasionally present at the beginning of the infection (ortega, ) . there are thousands of different types of microorganisms everywhere in air, soil, and water, and 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in nonthermally processed canned butter occurrence and characterization of (psychrotrophic) bacillus cereus on farms in the netherlands yeasts as spoilage organisms in beverages viruses of foodborne origin: a review the bacillus cereus group: novel aspects of population structure and genome dynamics comparison of three bacillus amyloliquefaciens strains growth behaviour and evaluation of the spoilage risk during bread shelf-life a comparison of growth of individual meat bacteria on the lean and fatty tissue of beef, pork and lamb analysis of the life cycle of the soil saprophyte bacillus cereus in liquid soil extract and in soil gene cloning and expression systems in lactococci yeast physiology and biotechnology epidemiological analysis of a large enterohaemorrhagic escherichia coli o outbreak in japan associated with haemolytic uraemic syndrome and acute encephalopathy isolation and identification of alicyclobacillus acidoterrestris from acidic beverages survival and death of salmonella typhimurium and campylobacter jejuni in processing water and on chicken skin during poultry scalding and chilling the genus bacillus effects of high-pressure processing (hpp) on bacterial spores: an overview key: cord- -x oywbrj authors: wilson, brenda a. title: global biosecurity in a complex, dynamic world date: - - journal: complexity doi: . /cplx. sha: doc_id: cord_uid: x oywbrj biosecurity is emerging as a major global health priority for which innovative and unprecedented solutions are needed. biosecurity is a challenging biocomplexity problem involving multifaceted processes such as interactions between humans and nonhuman biota, anthropogenic environmental and ecological factors, and socioeconomic and political pressures. key to an effective biosecurity strategy will be fundamental understanding of evolutionary, anthropogenic and environmental driving forces at play in transmission and perpetuation of infectious diseases. biosecurity solutions will depend on increased support of basic biomedical research and public education, enhanced healthcare preparedness, alternative strategies for ensuringsafety, and improved interagency cooperation regarding global health policy. © wiley periodicals, inc. complexity, . i t is widely accepted by historians that there are certain dates upon which history seems to pivot, turning points that forever change the course of future events. the momentous months of september and october mark such a critical period in our recent history. our world as we knew it shifted, not just for the united states, but all nations. as a consequence, defense against bioterror agents came to the forefront as a major health priority in the u.s. and elsewhere. indeed, we were still reeling from the impact when sars swept across the globe in - , followed closely behind by the still ongoing worldwide spread of avian flu and the concomitant fear of it transforming into a human flu pandemic on the scale of that experienced in . but, these events are only at the pinnacle of a mounting number of impinging natural and imposed biohazards (table ) [ ] [ ] [ ] [ ] [ ] . importantly, these manmade and natural events have revealed a number of glaring gaps in our knowledge about infectious diseases, their transmission and perpetuation, and how to effectively combat them. existing and looming biological threats have now made biosecurity, which includes biodefense, the most pressing global health priority. in a rapidly changing world, biosecurity is at the intersection of every sphere of medical, biological, ecological, socioeconomic, and political system. although one might argue that the principal difference in the infectious disease threat today versus say , , or years ago is bioterrorism, the resources spend on preparing for a bioterror attack is viewed by most scientists as grossly exorbitant [ ] , particularly considering the small numbers of individuals who have been or could be affected by this type of attack and considering the relatively low medical relevance or prevalence of the diseases caused by the limited number of highpriority bioterror bioagents, the socalled ''category a select agents.'' and, while admittedly the preparedness and surveillance measures put in place for one has certainly helped to protect against the other (the improved global response to and curtailment of sars coming after the anthrax bioterrorist attacks is a prime example of this), most scientists feel that the limited resources available from an already overburdened system should instead be used for studying and preparing against the looming and potentially more devastating infectious disease threats from natural or accidental exposure [ ] , which could affect millions of people and animals and could have huge health and economic consequences. and thus, while the threat of bioterrorism must be considered, many scientists propound that the focus should be on the more urgent and dire problem of biosecurity, rather than just bioterrorism. it has been argued by many that there is no better creator of new highly potent biological threats than nature itself. however, there is also little doubt that anthropogenic environmental, socioeconomic, and ecological influences can have devastating impact on the extent and severity of the outcome of these natural biological hazards. risks to public health come from diverse scenarios ranging from epidemics to outbreaks during natural disasters to accidental exposures through poor food processing to deliberate releases or fear thereof ( table ) . finding solutions to these challenging biocomplexity problems will require integrated, multilevel, flexible, and interdisciplinary approaches that stretch traditional concepts. key to an effective global biosecurity strategy will be improved detection, prevention, treatment, and management of infectious diseases, but also better understanding of the intrinsic and extrinsic factors that contribute to their virulence and influence their transmission, prevalence, and perpetuation. thus to achieve this, we first need a better understanding of the critical evolutionary, anthropogenic, and environmental driving forces that contribute to natural and man-made biological threats. to gain a sense of the potential impact of biological threats on biosecurity, it is best to begin by considering the source and nature of the biological agents that pose biosecurity risks (table ) . manmade biological threats come in two flavors, deliberate and accidental. the concept of intentionally using biological agents as weapons is nothing new to warfare, and we are all aware of the american, russian, and other state-sponsored programs to develop biological agents as ''weapons of cases/ deaths total in from anthrax (perpetrator still at large) > , hospitalized/ deaths total in - from sarin gas (aum shinrikyo) cases/ deaths total in from salmonella (rajneeshee) death in from ricin (assassination of georgi markov) natural casualities: - m cases/ million deaths per year from malaria world-wide m cases/ , hospitalizations/ , deaths per year from foodborne illnesses in usa - m cases/ million deaths per year from tuberculosis world-wide > m cases/> m deaths total from hiv/aids world-wide, > . m deaths in usa m cases/ , deaths total from hepatitis c in usa mass destruction'' (wmd). these state-sponsored wmd programs have been largely dismantled [ ] , and instead the concept of using biological agents as bioweapons has now been usurped by individuals or small groups acting as terrorists engaged in a different form of warfare, where these agents are perhaps more accurately described as ''weapons of mass disruption'' (still wmd). we experienced a vivid and horrible display of this new brand of wmd with the anthrax attacks of , in which the u.s. postal system was utilized to dispense deadly disease, but even more notably, fear and turmoil. the cost of mounting a response to this new wmd has been enormous, not only in terms of billions of u.s. taxpayers' dollars, particularly directed toward biodefense (table ), but also in countless man-hours expended in ramping up other areas of security and healthcare preparedness and in the astounding disruption of lifestyle (e.g. inconveniences caused by intensified travel-related security measures). a growing number of scientists feel that the bioterror threat is exaggerated [ ] and that it is highly unlikely that any terrorist organization, foreign or domestic, could on their own develop from scratch a bioweapon capable of causing mass casualties. instead, it is more likely that the potential terrorists would steal or procure existing material and deploy it on a much smaller scale. in contrast, manmade threats resulting from inadvertent release, accidental contamination, or even from non-malicious intentional introduction of biological agents represent much more measurable concerns with known likelihood of risk. there have been a number of recent high-profile incidences that illustrate the havoc, alarm, and economic consequences that can result from widespread distribution of contaminated food because of accidental introduction of harmful microbes during food processing. what previously was seen only sporadically, such as at church socials, family gatherings or community picnics, moved abruptly into the public's eye with the largescale problem of undercooked fastfood hamburger meat contaminated with e. coli o :h , a toxin-producing bacterium that causes dysentery-like diarrhea and can cause kidney failure and death, especially in children and the elderly. this dangerous microbe has since been associated with over multistate or multination outbreaks of contaminated food, including meat, radish sprouts, apple juice, let-tuce, and most recently spinach. late last summer, e. coli o :h contamination of prepackaged fresh spinach led to cases of illness across states, with hospitalizations, kidney failures, and deaths [ ]. the outbreak, which was traced back to spinach obtained from a few fields in california [ ] , shook consumer confidence and cost the industry an estimated $ m in economic losses [ ] . there are many other examples of how the spread of natural threats can be greatly facilitated by our modern technologies, practices, and behaviors. viruses such as the marburg and ebola viruses, first discovered in the s and s, are examples of biological agents responsible for recently emerged diseases [ ] . ebola and marburg viruses are considered to be zoonotic diseases that are transmissible by close contact with animal species, but their spread has been facilitated by conditions in the country of outbreak, including political upheavals, reuse of needles, and cultural burial practices. zoonotic diseases are often perceived as only a problem of developing countries, where there is much closer contact with animals, both domestic and wild. however, living with animals is not limited to the third world. consider how many americans alone live with pets, sleeping with them, and even kissing them. it is interesting to consider that measles virus is closely related to canine distemper virus [ , ] , suggesting that at some point a dog-human transmission occurred or a common ancestral virus may have infected both. of particular and growing concern are high impact, foreign animal diseases, such as mad cow and foot-and-mouth diseases (table ). bovine spongiform encephalopathy (bse), commonly known as mad cow disease, is a fatal, progressive neurodegenerative disease of cattle caused by an infectious form of misfolded protein called a prion [ ] . transmission of bse occurs when healthy animals come in close contact, usually through ingestion, with prion-containing tissues from animals that have the disease. the first probable occurrence in cattle was in the early s, possibly as a result of feeding cattle meat and bone meal that contained scrapie-infected sheep products. scrapie is a prion disease of sheep and goats. industrial cattle-farming practices in europe prior to used rendered meat and bone meal, instead of the more common soybean meal used elsewhere, as a protein supplement in cattle feed. in the early s, a change in the rendering process in the u.k., in which a lower sterilization temperature was used for the steam boiling step in the process, is thought to be the major contributing factor to an increase in prions in the cattle feed that resulted in the bse epizoonotic outbreak. the uk epidemic peaked in with nearly , new cases per week, and by the end of there were over , cases of bse confirmed in the u.k. [ , ] . bse attracted particular attention because it now appears that it can also be transmitted to humans that consume tainted meat. since the first reported case in , at least people, in the u.k. and elsewhere, have died of a disease with similar neurological symptoms to bse, called variant creutzfeldt-jakob disease (vcjd) [ ] . for many of the vcjd cases, there is direct evidence that they had consumed tainted beef years before. the connection between bse and vcjd has a wider impact than just food safety--blood, tissues and organ donation programs are also affected and anyone having exposure to bse is a potential carrier [ ] . because of the long incubation period for prion diseases (years to decades), the full extent of the human vcjd outbreak is still not fully known, although the number of new cases appears to be declining. the long incubation period also makes testing for the disease in animals difficult because most livestock are slaughtered long before noticeable symptoms occur or even before plaques in the brain can be readily detected during inspection by necropsy. although many foreign animal diseases are not of serious concern to human health (i.e. humans may be affected only very rarely through direct contact with infected animals), they do pose considerable threat to our agricultural and food industries and could cost millions or even billions of dollars in economic and trade losses (hence their status as ''high impact'' diseases). foot-and-mouth disease (fmd) is a highly contagious, sometimes fatal viral disease primarily of cattle and pigs, but it has a wide host range. fmd occurs worldwide, but a number of areas, including north america, australia, new zealand, japan, most of europe, and parts of south america have been fmd-free for some time, mainly due to eradication through rigorous vaccination and culling programs. however, in , a major outbreak of fmd in the u.k. resulted in the slaughter of millions of animals, huge economic and trade losses estimated in the range of £ m, the temporary cancellation of sporting events and other outdoor events attended by farmers or those living in the country, and the implementation of strict policies on the sale and trade of livestock, as well as disinfection of all persons entering or leaving farming areas [ , ] . countries are recognized to be in one of three fmd categories: fmd present with or without vaccination, fmd free with vaccination, and fmd free without vaccination [ , ] . understandably, countries designated as fmd free without vaccination have the greatest export markets, so most developed countries have greatly enhanced their agricultural surveillance and trade policies to maintain their fmd-free status. innocuous introduction of foreign plants, animals, or insects can also have considerable ecological and economic impact on horticultural and agricultural industries. kudzu, a member of the pea family that is native to southeast asia, is an example of an invasive alien plant species that has caused considerable damage since its introduction to the southeastern regions of the u.s., where it is sometimes referred to as ''the plant that ate the south'' [ ] . kudzu was first intro-duced from japan into the u.s. in at the philadelphia centennial exposition, after which it gained some popularity as an ornamental shade vine. but, from to , the soil conservation service promoted its use as a means for controlling soil erosion. once established with a root system that can reach depths of up to feet, kudzu vines grow as much as a foot per day during a season with lengths up to feet. kudzu now covers over m hectares and poses a considerable threat to the otherwise high biodiversity of flora found in the south [ ] . a tremendous amount of money and effort is spent each growing season to prevent the highly prolific kudzu from overtaking roads, bridges, powerlines, local vegetation, and even homes, barns and other buildings. it costs an estimated $ m annually in lost cropland and management resources [ ] . for successful long-term control, the entire root system must be destroyed or the plant will grow back, and considerable effort has been made to find pesticides that can control this plant pest. key to an effective strategy to combat complex biological problems to ensure biosecurity will be a greater understanding of the driving forces that are important for transmission and perpetration of infectious disease and then the management and implementation of effective preventive or containment measures. the potential power of natural selection is obvious. time and again we have seen how rapidly microbes can evolve in response to selective pressure, such that certain behaviors or genetic traits tend to be eliminated from the gene pool, while others are maintained or changed. as a consequence, new biological threats are bound to emerge as we impose our influence on the environment. the goal of most pathogenesis research, of course, is to use our understanding of the ecology of host-microbe interactions and their role in pathogenesis to develop predictive models for disease progression and transmission. unfortunately, our current understanding is rudimentary at best, and we are just now beginning to tease out the intricacies of the co-evolution of pathogens with their hosts and environment and the role that these host-microbe interactions play in emergence of disease. human-induced evolution can be extraordinarily rapid and pervasive. the natural history of myxoma virus in american rabbits and its introduction into european rabbits as a means for controlling the rabbit populations in australia provides an interesting example of the co-evolution of a virus and its animal host [ ] . it also provides a glimpse into understanding the emergence of infectious disease. shortly after european rabbits were first brought to the americas in , they were found to succumb to a deadly and extremely infectious disease, which nearly half a century later was found to be caused by a vector-borne myxoma virus acquired through contact with the native, more resistant host, the common wild rabbit of south america. european rabbits were first introduced into australia in for hunting, but by the s they had become a major pest. to help in controlling the rabbit population, rabbits infected with this deadly virus were introduced in and the favorable weather conditions for mosquitoes that year helped to rapidly spread the disease, killing millions of rabbits. but, evolution and the power of natural selection then came into play. the myxoma virus that was first introduced killed over . % of infected rabbits, yet a few rabbits survived the exposure. within a year, new strains of the virus appeared that killed only % of infected rabbits, and in subsequent years even more attenuated viral strains appeared. under such strong selective pressure, the rabbits, too, evolved to gain increased resistance such that the original, highly lethal virus would no longer kill more than % of the rabbit offspring. clearly, genetic changes in both the viral and rabbit populations quickly altered the outcome of the disease in terms of severity and persistence. today, only % of infected rabbits succumb during a myxomatosis epidemic. one of the most devastating recently emerged diseases, whose initial and continuing spread can be attributed to human behavior, is that of hiv/aids. hiv is thought to have originated in nonhuman primates [ ] , but has become established in humans and is now transmitted human-tohuman through unprotected sexual practices, reuse of needles, and at first (although no longer) through contaminated blood supplies [ , ] . aids was first noticed in the early s as unusual occurrences of a rare cancer, kaposi's sarcoma, in young homosexual men. the social stigma associated with the disease gradually shifted with the realization that other populations were also at risk, including heterosexual and bisexual women, drug addicts, hemophiliacs, blood transfusion recipients, and babies born to hiv-positive mothers. the annual death toll rose linearly from with over , deaths to a height of nearly , in , before a noticeable decline was observed with the introduction in of a cocktail of three anti-hiv drugs. by the annual death toll was down to , and has since declined to around the , mark [ ] . however, although the death rate has declined, the number of cases reported annually in the u.s. still hovers around , [ , ] . host-microbe co-evolution over time appears to be in effect for hiv/ aids. there are now a considerable number of hiv-positive individuals who have survived for many years without acquiring aids. a large part of this is due to advances in anti-hiv medications and improved healthcare. however, even before the increased availability of hiv medications, there were a significant number of individuals engaging in high-risk behavior that appeared to be resistant to acquiring hiv. by examining these ''survivors,'' scientists found a genetic mutation (allele) in a surface receptor, called ccr- , which prevents the hiv virus from entering host cells [ ] . these individuals having the mutant receptor allele are mostly of european decent. in some parts of europe, up to % of the population carry at least one copy of the mutant receptor allele, while populations in the rest of the world do not carry the same allele [ ] . it is believed that this allele might have arisen through selective pressure from previous exposure of the population to another plague (perhaps bubonic plague, although this is not certain). but, importantly, the strong selective pressure that the new antiviral medications have placed on hiv has led to an accelerated deadly arms race. current antivirals, at an annual cost of over $ , per person, are targeted mainly against the viral outer coat proteins gp and gp , the processing protease, and the reverse transcriptase. although these viral protein targets are less variable than others in the viral genome, hiv has a high mutation rate and the strong selective pressure has caused the virus to rapidly evolve in response [ ] . the ever-evolving hiv makes developing new drugs a constant, and costly, challenge [ ] . other pathogens have been around for quite some time, but have recently acquired new properties making them increasingly more deadly. during the s, staphylococcus aureus emerged as one of the most common causes of hospital-acquired infections in the us. drug-resistant infections increase the risk of death, as well as the cost and duration of hospital stays. over a relatively short period of time s. aureus acquired genes that increased the bacterium's resistance to antibiotics [ ] . a timeline of the emergence of these new strains of s. aureus clearly demonstrates the evolution of a pathogen that is under strong selective pressure to survive (table ). once acquired, antibiotic genes can be spread from one microorganism to another through a process known as horizontal gene transfer, which involves uptake or transfer of dna encoding those resistance genes within or between different bacterial species. importantly, the antimicrobial resistance is maintained even after the selective pressure is removed. this exchange of genetic information is believed to contribute to the alarming rise in multidrug resistant bacteria [ ] . rapid development of antimicrobial resistance is forcing clinical and pharmaceutical researchers to devise alternative, innovative approaches to respond to this threat [ ] . hospitals are thought to be a major source of multidrug resistant bacteria, but agricultural practices involving usage of antibiotics as prophylactics and growth promoters in feed and crops have also played a role in its emergence [ ] . eye-opening evidence for just how prevalent genetic exchange occurs in natural environments is provided by the example of the substantial increase in antibiotic resistance among both community and clinical isolates of bacteria in the gut [ ] . tuberculosis (tb) is the leading cause of death in the world, and after a century of decline in the u.s., tb is once again on the rise, and alarmingly multiple drug-resistant strains have emerged. this increase in cases worldwide is attributable to a number of complex factors, including changes in the social structure and socioeconomic upheaval, the hiv epidemic, and a failure in some countries to improve public treatment programs. multidrug resistance in tb is a growing international health concern, because it has dramatically increased the difficulty in controlling the spread of tb and because of the high mortality rate associated with co-infection with hiv [ ] . co-infection of multidrug-resistant tb with hiv fuels the transmission of tb by accelerating the progression of latent tb into active disease because of the damage that hiv causes to the host immune system, which normally controls tb infection. individuals that test positive for both tb and hiv often die with - months. a major epidemic of tb-hiv infections has spread across the former soviet union due to socio-economic changes in the country that have led to overcrowded housing, and in particular overcrowded prisons [ ] . unfortunately, the pharmaceutical industry has largely abandoned tb drug development due to perceived nonprofitable consumer market--at risk populations are also the poorest [ ] . the spread of any disease that is transmitted from human to human is greatly facilitated under crowded conditions, which allow for efficient exposure to a higher initial inoculum of the infectious agent. sporting events, concerts, and other gatherings of large numbers of people in a confined area can promote human-to-human transmission, as well as exposure to new populations. legionnaire's disease, caused by the bacterium legionella pneumophila, was first recognized in when it struck a group of american legion conference attendees in philadelphia [ ] . this bacterial pathogen normally lives in fresh water as a parasite of amoeba, but unfortunately for us it can also live and thrive inside one type of our immune cells called a macrophage. the disease is acquired through aerosol exposure from contaminated water in ventilation systems, such as the air conditioning units in a hotel, or through aspiration during nasogastric tube feedings diluted with contaminated potable water in hospital or nursing-home settings [ ] . since the first widely publicized incident on the holland-america cruise line in , there have been numerous reports of cruise ship passengers succumbing to acute gastroenteritis caused by the norwalk virus [ ] . a cruise, where hundreds of passengers and crew mingle in close contact, can provide optimum conditions for a virus to spread through food, water, and direct contact. cruise ships are now required to report all gastrointestinal illnesses to the cdc before entering a u.s. port, especially if % or more of the passengers or crew are ill. what has been most economically troubling for the cruise line industry is the recalcitrant nature of the virus to decontamination efforts [ ] . overcrowding often leads to poor sanitation, resulting in accumulation of refuse, sewage, and vermin that thrive under such unsanitary conditions. natural disasters, civil disturbances, and war have caused large population displacements, with millions of people (and their animals) worldwide today living in refugee camps, which are overcrowded with poor sanitation and often without adequate food or clean water. these crowded camps provide ideal conditions for brewing and transmitting new infectious agents in malnourished or immunocompromised populations of humans and animals. the norwalk virus reared its ugly head once again during the katrina crisis in [ ] . of the estimated , evacuees sheltered temporarily at facilities in reliant park, a sports and convention complex in houston, texas, , persons reported symptoms of acute gastroenteritis during a -week period at the beginning of september. medical personnel, police, and volunteers having direct contact with patients also reported symptoms, suggesting secondary transmission. although the local public health officials and the cdc implemented extensive infection-control measures, including publicizing the need for enhanced hygiene techniques, the outbreak continued for an additional week before declining. habitat destruction (e.g. deforestation, slash-burn practices) and urban expansion can uncover natural reservoirs and expose humans and domestic animals to new disease-causing microbes. each year - zoonotic cases of the pneumonic disease tularemia, caused by the bacterium francisella tularenesis, are reported in the us, primarily in arkansas, missouri, and oklahoma [ ] . transmission usually occurs through arthropod bites, especially ticks or deerflies, but it can also occur through inhalation of contaiminated aerosols. in the late s, rabbits from arkansas and missouri were introduced to cape cod and martha's vineyard, and cases of tularemia in massachusetts were reported shortly thereafter. martha's vineyard experienced two larger outbreaks in and , which were linked to outdoor activities of mowing lawns and cutting brush [ ] . the humans were presumably infected by inhalation of microbe-contaminated animal remains mechanically aerosolized by the cutting action of the mowers or brush cutters. pollution and exposure to waste water or sewage can also lead to the emergence of new diseases. coral black-band disease is a globally distributed disease that has been causing the degradation of coral reef ecosystems. first reported in the s, the disease is observed as a pathogenic microbial consortium (mat) that migrates from the top to bottom of healthy coral, leaving behind dead exposed skeleton that disrupts the ecological and geological structures of coral reefs (see figure ) [ ] . a factor that appears to be contributing to the development and spread of coral black band disease is the pollution of seawater from industrial, municipal, and other terrestrial waste sites near the coral reefs [ ] . modern technologies have led to greater efficiency in production, marketing, and commerce of goods around the world. rapid transport of imported material and tourism related travel facilitate the spread of infectious diseases around the globe and are clearly contributing to the increased prevalence and severity of the diseases. exotic souvenirs, including wild animals and their associated microbes, have been imported illegally into the u.s. from various parts of the world. an outbreak of monkeypox in among residents of wisconsin, northern illinois, and northwestern indiana was the result of infection from prairie dogs bought at a pet shop in texas that became infected after contact with various exotic african rodents shipped from ghana and then distributed by other pet shop outlets in the midwest [ ] [ ] [ ] [ ] . rare zoonotic cases of monkeypox in humans had been reported previously only in remote villages of central and western africa near tropical rainforests where there is close contact with infected animals [ , ] . recent studies suggest that exposure to monkeypox in these areas has increased due to encroachment of humans into animal habitats. the cdc and fda subsequently embargoed all african rodents into the u.s. and banned the distribution or sale of african rodents and prairie dogs in the u.s. [ ] . trade routes and human practices have contributed to the spread of numerous diseases throughout history, but the speed with which they are spreading today have demanded the need for ever more rapid response and containment measures to be in place. an interesting example is that of cholera, caused by the cholera toxin-producing bacterium vibrio cholerae. in asia, cholera has been endemic for hundreds, maybe thousands of years, and cholera-like disease has been described in a number of ancient texts. the first well-documented epidemic in europe occurred in . since , seven major cholera pandemics have occurred [ ] . the first six were caused by the classical o biotype, whereas the seventh, which began in and persists today, is caused by the el tor o biotype. in , el tor reemerged in peru after a hiatus of over years, and rapidly spread throughout central and south america over the following couple of years, with more than . million cases and over , deaths [ ] . the spread of el tor in these countries could be traced along the major north-south coastal trucking route and is attributed to poor sanitation in these areas. the most recent cholera outbreaks have occurred in developing countries, such as angola, where civil strife has hindered water treatment and sanitation efforts [ , ] . the extent of the global cholera burden has been grossly underreported [ ] , in part due to limited resources, but also due to the detrimental effects such news can have on trade and travel to those regions. in some endemic areas, such as bangladesh, improved management strategies by the government and who, including aggressive rehydration therapy and antibiotics, have shortened the duration of illness and have reduced the fatality rates from natural cholera epidemics, which are largely seasonal in nature. in , a new strain of vibrio cholerae, designated o or ''bengal,'' caused a massive cholera epidemic in south asia [ ] . what was most disturbing about this new strain was its high prevalence in adults, suggesting that prior immunity gained during childhood through exposure to the classical or el tor o strains offered little or no protection against this new o strain. its subsequent spread to other asian countries lead some to worry that it may cause an eighth cholera pandemic, but luckily so far this has not materialized due to timely mobilization of effective control measures by researchers and healthcare officials. however, an emerging concern is the increased incidence of antibiotic resistant strains of vibrio cholerae in bangladesh. nearly all isolates are now resistant to the less expensive antibiotics, tetracycline, trimethoprinsulfamethoxazole, and erythromycin. although most are still sensitive to ciprofloxacin, the effective doses needed for treatment are increasing. seasonal changes in rainfall and sunlight can trigger periodic or transient emergence of some human pathogens such as cholera. an intriguing observation comes from the study of the annual epidemic profile of endemic cholera in the bengal region of bangladesh and india, where nearly all cases occur in a synchronized, explosive outbreak during major transitions of climate in the post-monsoon months of october and november [ ] . as the rains decline and sunlight increases there is a burst of algal and zooplankton bloom. it has been proposed that the increased concentrations of these particles (surfaces to which the bacteria adhere) in drinking water sources consequently increase the rates of ingestion [ , ] . during other times in the year, cholera cases occur only sporadically because the zooplankton sediment and there is less ingestion of bacteria-coated particles. recently, an additional factor has been credited toward the seasonal cholera epidemics, namely predation of the v. cholerae bacteria by bacteriophage (viruses that infect bacteria) due to amplification of the phage in the intestines of humans, followed by release into the environment [ ] . support for this model comes from the inverse correlation of the phage count with the abundance of toxigenic v. cholerae in water samples and with the incidence rates of cholera [ , ] . climate change can also dramatically alter the spread of arthropodborne diseases, which are most prevalent in a limited range of temperatures or environments preferred by these vectors. shifts in warming or cooling trends may extend or narrow the range of such vectors and the diseases they transmit. drought or flooding can also lead to spread of disease into new populations of animals or humans. the west nile virus is an example of a recently emerged vector-borne disease that has been introduced to a new geographic area. the virus was first isolated in uganda in and has since been known to cause disease in africa, west asia, europe, and the middle east [ ] . until when it caused a deadly outbreak in the new york metropolitan area, it had never been observed in the u.s., but now it has spread to every state, except alaska and hawaii, as well as canada and mexico. as of march , the cumulative number of human disease cases in the u.s. is , [ ] . the west nile virus is usually transmitted between birds by mosquitoes, but can be transmitted to humans and other hosts, particularly during favorable seasonal conditions with a hot dry summer followed by a wet fall, as what occurred in the new york area in . its introduction into the u.s. is thought to have occurred recently since the genetic profiles of the new york virus isolates suggest they came from a single source, which is related to a virus isolated in in israel [ ] . although not known for certain, it is possible that an infected bird could have been imported or an infected mosquito or tick may have hitched a ride on an international flight or on a ship carrying old imported tires infested with mosquito larvae. large holding and storage facilities for meat, grains, dairy and produce provide new habitats and breeding grounds for insects and vermin such as mice and rats. humans can be infected with the deadly hantavirus through inhalation of aerosolized virus present in dried rodent urine in grains or feedstuffs. in the southwestern u.s. experienced a mysterious outbreak of a new deadly respiratory illness in healthy people, which within a couple of months was identified by the cdc as a previously unknown type of hantavirus [ , ] . because the researchers knew that other hantaviruses were transmitted by rodents, they began trapping mice and rats in the area around the victims' homes and discovered that the deer mouse was the primary natural reservoir. further investigation revealed that there had been earlier unexplained deaths due to this hantavirus, but these cases were sporadic. the reason for the clustered outbreak in the could be connected to the unusually high numbers of mice in the area during that season [ , ] . for several years, the region had experienced drought, but in early , heavy snows melting and rainfall helped revive the flora and fauna in the region, such that the deer mice had plenty to eat. the mice increased dramatically in numbers, and consequently increased the likelihood of transmission to humans. intense cross and intraspecies interactions are conducive to transmission of a pathogen from one host to another. the rapidity with which microbes and viruses are able to evolve increases the likelihood of such close host-host contacts to cause the pathogen to ''jump'' across species barriers. like bse, chronic wasting disease (cwd) is a prion-mediated transmissible spongiform encephalopathy of cervids, such as mule deer, white-tailed deer, and rocky mountain elk [ ] . the potential for cwd to similarly cross the species barrier from cervids to humans is considered unlikely. but, because bse has been transmitted from cattle to humans (as vcjd), it is feared by some that cwd might also ''jump'' the species barrier. although cwd can be transmitted to cattle, sheep, and goats by direct inoculation into the brain [ ] , studies have not yet demonstrated that domestic livestock are susceptible via oral exposure, the presumed natural route of exposure to bse [ ] . it is feared that homology within critical amino acid sequences of the human and cervid proteins might facilitate cross-species transmission of cwd to humans, as what appears to have occurred for bse. thus, understanding how prions overcome resistance to transmission between species is crucial if we are to prevent future epidemics. although surveillance efforts for cwd in captive and free-ranging cervids are continu-ing, eradication of cwd from wild populations of cervids is unlikely with currently available management techniques. the potential emergence of a new disease-causing zoonotic agent that is transmissible between humans is a major concern. constant exposure and certain behaviors increase the likelihood that a virus will ''jump'' species. we experienced a frightening example of this with the rapid worldwide spread of the sars virus. alarmingly, we are currently at the brink of experiencing another such emergence, which could have devastating consequences on the human population. already the current spread of avian influenza a virus has resulted in the death from disease or culling of over m domestic poultry in asia, with an estimated $ b in economic losses to the asian poultry sector (table ) [ ] . a question on many people's mind today is whether another pandemic flu like the one in is inevitable [ ] . we already know that the circulating influenza h n virus can ''jump'' from birds to humans [ ] , but luckily we have not yet observed significant human-tohuman transmission other than a few cases through intimate unprotected contact with a critically ill index patient [ ] . will this fine dividing line be crossed soon? or, will this threat diminish before it evolves into a more human-specific virus? the truth is that we know very little about the specific factors that trigger a ''jump'' between species or a transition into a rapidly transmissible virus [ ] . we know even less about how to prevent these events from occurring or how to predict when they will occur. the current h n strain, first limited to poultry, quickly spread to migrating birds, but has now emerged in mammals and humans mostly through zoonotic contact. previously, it was widely accepted that avian viral strains could only readily infect humans after first having undergone genetic shuffling within swine, but now it appears that direct transmission from bird to human can occur [ ] . although its transmission from human-to-human is (luckily) still inefficient, the who, the cdc, and other organizations have already mobilized for just such an event [ ] . distinguishing a deliberately introduced infectious disease from a naturally occurring or emerging infectious disease is inherently more difficult due to their ''dual-use'' nature. the good news, though, is that effective medical treatment and prevention strategies for combating a naturally occurring infectious disease will most likely work just as well for one that is deliberately introduced. the exponential advances that have been made in the life sciences, medicine, and biotechnology have not only dramatically enabled our ability to respond to biological threats, but, sadly they have also increased the potential risks of malevolent exploitation and inadvertent misuse. indeed, a report from the u.s. national research council and the institute of medicine concluded that the breadth of potential biological threats is far wider than is commonly appreciated and will continue to expand in the future [ ] . the nih invests over $ b annually in medical research. since , nih has directed over $ b toward countering bioterrorism alone and currently spends over $ b of its annual budget on infectious diseases with over $ . b going toward emerging infectious diseases (table ) [ ] . considerable attention has been recently focused on developing better preparedness and surveillance (early warning) as strategies for more effective response to biological threats. this depends on having reliable, sensitive and rapid means for recognition of unusual events or unexpectedly high levels of common events. a number of animal and human health laboratory response networks have been established with the goal of maintaining an integrated national and international system for facilitating standardization and movement of information, for expansion of detection and diagnostics measures, for coordinating responses among federal, state, university and commercial clinical laboratories, and for identification of common source outbreaks. on the international front, the who and cdc have increased activities to build capacity for global disease detection and response, with immediate focus on and strengthening of influenza surveillance. the global alert and response network (goarn) was established in by who as a partnership of > institutions and networks to mobilize human and technical resources for the rapid identification and control of disease outbreaks that are of international importance [ ] . the global livestock early warning system (glews) has been formed by the food and agricultural organization (fao) of the united nations and the world health organization for animal health (oie) to strengthen epidemiological analysis and prediction of major animal diseases and zoonoses and to improve reporting from a variety of data sources that might impact disease transmission from animals to humans [ ] . the recent pandemics have also mobilized strengthening of the international health regulations, which were first established by who in to ensure maximum security against international spread of certain diseases (cholera, plague, yellow fever, and smallpox--although smallpox was removed from the list in ) with minimum interference of world commerce. in a revised set of regulations was adopted unanimously at the world health assembly to increase the roles and responsibilities of who and member states, including financing, developing, strengthening, maintaining and implementing core surveillance, and response capacities [ ] . biosecurity requires multipronged, flexible, and interdisciplinary approaches to combat the perpetuation and spread of infectious diseases. in all, simultaneous use of multiple strategies will be necessary for effective infection control and disease management. one such strategy is to use evolutionary engineering (combining predictive evolution and genetic engineering) to design vaccines and drugs based on predictive targets. for example, an innovative approach for control of e. coli o :h contamination of food and water was recently employed to eliminate the source for the organism. by vaccinating the animal reservoir--cattle--the researchers were able to prevent colonization of the cattle with the microbe, reducing the levels of bacteria shed in feces and thereby reducing the risk of human disease [ ] . this strategy was shown to significantly decrease the prevalence of e. coli o :h in a clinical trial conducted in a feedlot setting. improved sanitation and use of chlorinated drinking water has dramatically reduced the incidence of waterborne disease. evidence suggests that the cholera epidemic in south and central america was caused by a complex set of circumstances, including poor sanitation conditions, poor separation of drinking water and waste streams, and inadequate water treatment and distribution systems [ ] . indeed, outside of peru's capital lima, chlorination of drinking water supplies at the time of the epidemic was limited at best. improved water quality and sanitation have since reduced the incidence of cholera in south american countries. another simple, yet surprisingly effective strategy recently implemented has been the use of filtering water through multilayered cloth filters to remove the plankton and other particles to which the vibrio bacteria adhere [ ] . over the past years an unprecedented mobilization of resources have been directed at stopping the hiv pandemic, ranging from preventive strategies for persons at high risk for contracting hiv, such as educational counseling, testing, and referral services, to treatment with multiple drug regimens, to management measures aimed at improving the healthcare of persons living with hiv and preventing further transmission [ ] . although enormous success in prevention of hiv/aids in the u.s. has been achieved and we have learned a lot about how to approach rapidly evolving diseases from this experience, a number of prevention and treatment challenges remain. hiv prevalence remains high among homosexual men [ ] and racial/ethnic disparities have increased, especially among african-american men and women [ ] with prevalence among african-american men reported as high as % [ ] . new programs are needed to more effectively reach these populations [ ] . one approach toward improved treatment and reduction of drug resistance is the use of multidrug overkill (triple drug therapy). administration of just a single drug often leads to the development of resistance to that drug, but strong multidrug doses decrease the likelihood of multidrug resistance. for example, recent studies have shown that triple drug combination antiviral therapy in treating hivinfected persons offer superior viral suppression over other drug regimens [ ] . when two or more drugs are used simultaneously, each helps prevent the emergence of resistance to the other drug. effective regimens for the treatment of tb must contain four different drugs to which the organisms are susceptible. to illustrate how this might be so effective, consider that mutation rates in the tb-causing bacterium lead to a frequency of resistance to isonazid of in , to streptomycin of to , to ethambutol of to , and to rifampicin of to . bacterial mutants resistant to any single drug are naturally present in any large bacterial population. an inactive tb granuloma contains - bacteria, whereas an active tb lesion contains - bacteria. this means that the chance of gaining resistance to any one of the drugs is relatively high in an active lesion, but the chance of gaining resistance to multiple drugs is considerably less [ ] . the course of the four-drug treatment for tb usually lasts from to months. when adherence with the regimen is assured, the four-drug regimen is highly effective; however, a problem with tb treatment is that the drugs used are often counter-indicated, cause unpleasant side effects, and must be administered in series over a long period of time rather than simultaneously, which leads to problems with patient compliance [ ] . nearly half of individuals with tb do not complete their treatments. reduction of noncompliance can be achieved by direct observation of the patient to ensure full dosage. in developed countries, such as the u.s., this is relatively easy to achieve with the use of healthcare workers and family members. however, in developing countries, there are many obstacles to adhering to treatment regimens, and alternative strategies to improve compliance are needed. in addition to direct observation of treatment, other tactics include sending reminder cards or phone calls, monetary incentives, health education and counseling, and making access to clinic facilities easier [ ] . another strategy for reducing the prevalence of antimicrobial resistance is to remove the overall selection pressure by minimizing exposure to the drug, and especially withholding the most effective drugs, i.e. the ''drugs of last resort,'' until absolutely needed. this is becoming more and more difficult to accomplish with the accelerated rate of spread of antibiotic resistance through the overuse and over-prescription of antibiotics [ , , ] . indeed, many researchers were dismayed at the large distribution of ciprofloxacin (cipro tm ) to treat over , people after the anthrax attack in and warned that this widespread use could lead to resistance in other bacteria [ ] . the strain of bacillus anthracis strain used in the attack was equally sensitive to other less expensive and more commonly used drugs. ciprofloxacin is considered a ''drug of last resort'' because of its broad-spectrum and efficacy against many pathogenic bacteria, particularly those (such as staphylococcus) that are already resistant to other drugs. prescreening for sensitivity is another approach that allows for use of narrow-range rather than broad-spectrum antimicrobials, which further reduces the likelihood of resistance developing and spreading to other pathogens. management and implementation of effective preventive or containment measures in the event of natural or man-made biological threats will require increased infrastructure and diagnostic and surveillance capabilities. for example, the tremendous scale-up in food production, from the vast herds of cattle to the huge confined feedlots to the slaughterhouses to the many hundreds of distributors and supermarkets, has undoubtedly contributed to the emergence and prevalence of food-borne diseases such as that caused by e. coli o :h . the complexity of the modern food preparation and distribution process makes epidemiological tracking of the sources of contamination difficult, although there have been noticeable advances. in response to the need for improved agriculture and food biosecurity, congress passed the national agriculture and food defense act of , which will require enormous effort and financial commitment on the part of the government and agricultural and food industries. the logistics involved are daunting, particularly in coordinating efforts among many different agencies. one example is the food-borne diseases active surveillance network (foodnet), which is a collaborative project of the cdc, the usda, and the fda to monitor and q wiley periodicals, inc. study the epidemiology of food-borne diseases [ ] . in response to the growing need for better food surveillance, the fda implemented the hazard analysis and critical control point (haccp) program for prevention of food-borne diseases, which involves monitoring food distribution at critical control points where contamination is most likely to occur [ , ] . in the food safety and inspection service (fsis) of the usda established the food emergency response network (fern), which will work with the fda and its haccp program to integrate a laboratory network across the u.s. that can quickly respond to food-related emergencies [ ] . the fsis, as part of its task of protecting public health through food safety and defense, recently implemented a new assessment method, called carver shock [ ] , for identifying the most vulnerable target sites within a food processing system (table ). in considering the gaps in the u.s. agriculture and food defense capabilities, the main question that must be addressed is: exactly what level of security do the people of the usa want the agricultural industry to achieve, and our government to enforce, in terms of food safety and biosecurity? it is clear that we (as a nation and international community) are not happy with the current security status of our food and agricultural supplies. the outbreaks and ensuing deaths, economic losses and drop in consumer confidence resulting from contaminated spinach by e. coli o :h [ ] , mentioned above, amply demonstrate this point. but, if we take this episode as an example, one must question exactly what could have been done to prevent or further mitigate this outbreak than was already done. by all accounts, the surveillance, detection, evaluation, containment, and recovery measures were remarkably fast, accurate, and as good as one could possibly hope, considering the circumstances-far better than in previous incidents of a similar nature, thanks to improved measures newly in place. this was considered an accidental outbreak, but what if it had been a deliberate attack? undoubtedly, the response would have been little different. yet, what happened is still deemed by most as unacceptable. so, how could this be improved? most current measures are aimed at further improvements to detect or con-tain a future incident by increasing surveillance at the front-end, increasing diagnostics or enhancing epidemiological monitoring capabilities once an incident has occurred. but, just how much of an improvement would that be? clearly, what the public wants is a near certainty that such an event as occurred with the spinach will not happen again. part of the difficulty in adequately addressing this need is that current efforts are focused on too broad and vast a target (there are just too many steps in the food processing, where things can go wrong and something could slip through the cracks). instead, the focus for ensuring near complete biosecurity should be at the very end of the food processing chain, namely at the packaging and delivery stage. while all the proposed surveillance, detection, evaluation, containment and recovery measure will significantly reduce the possibility of future contamination, and thus should be done to the extent possible, they will not ensure the desired near-complete protection from an incident (which is what the consumer is demanding). so, how can this be achieved? many scientists see food irradiation as one viable solution. food irradiation of already processed and packaged food through promising new technology can eliminate disease-causing microbes from foods. the effects of ionizing radiation on food and on animals and people eating the irradiated food have been extensively studied and deemed safe [ ] [ ] [ ] , and indeed this technology has been implemented already for certain foodstuffs. yet, bringing this technology into use for most foods has been challenging, primarily due to misconceptions and fear about its safety on the part of the public and policymakers. closing this gap will require a ramping up of public engagement by the scientific community. somehow scientists must better communicate with the public and policymakers, convincing them of the benefit criticality-measure of public health or economic impacts of an attack to achieve terror goals accessibility-ability to physically access and egress from the target recuperability-ability of system to recover from an attack vulnerability-ease in accomplishing the attack effect-amount of actual direct economic loss from an attack as measured by loss in production recognizability-ease of identifying the target shock-the combined physical, health, economic and psychological effects of an attack the carver shock method rates each of seven attributes on a scale of - for identification of vulnerable sites in food processing and distribution system that might be targets for attack or points of contamination. of this technology and at the same time alleviating their fears of its use. to achieve global health biosecurity it is critical that the communication and educational barriers between nonscientists and scientists are overcome and that efforts by public healthcare, scientific and security policy communities are better integrated. enhanced coordination between multiple agencies is essential for implementing and maintaining global disease surveillance systems, public healthcare, and diagnostic and basic research laboratories. thus far, many redundancies in effort remain and interagency cooperation is still fragmentary. international cooperation has improved with regard to regulatory and containment (import/ export) policies, particularly in the area of travel restrictions during pandemics, but cooperation is still a bit shaky in other areas where commerce and political issues are concerned. and, much work remains in the areas of regulation of agricultural, societal and medical practices, pollution control, and prevention of habitat destruction. strengthening national and international capacities to prevent and control disease epidemics will require continued promotion of international cooperation and technical partnerships with institutions and networks around the globe to mobilize resources for control of disease outbreaks. regulation and oversight of research and use of potentially dangerous bioagents (''select agents'' or highrisk or high-impact bioagents) is well underway, but there remain disparities between that conducted in the u.s. and that done elsewhere in the world. biosafety and biosecurity of pathogens in laboratories and healthcare settings will require enhanced education for better preparedness and increased confidence of the public and policy makers in science. many scientists feel that policymakers have not fully understood the difference between biosafety and biosecurity and have consequently imposed a number of mandates and regulations that equate enhanced need for security with enhanced danger, i.e. greater biosafety risk. balancing biomedical and biotechnological advancement with biosecurity will always be at odds due to the ambiguous definition of what constitutes a potential biosecurity threat, but improved education will help with making those decisions. although warning and prevention are preferable to coping with the consequences of an attack, an emphasis must also be placed on improving public healthcare and basic research and education. it is critical that we develop a homeland and global biosecurity strategy that is applicable to both intentional and unintentional disease outbreaks. the best defense against any microbial threat is a robust public healthcare system in regard to its science understanding, capacity, and practice. there has been considerable advancement in the area of prevention, with improved surveillance and detection, and with new drugs becoming available at a remarkably rapid pace, but we are still only at the tip of the iceberg in our understanding of pathogen evolution, post-exposure 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generation biowarfare threats on ''globalization, biosecurity, and the future of the life sciences global outbreak alert and response network (goarn) world health organization, global early warning system for major animal diseases world health organization decreased shedding of escherichia coli o :h by cattle following vaccination with type iii secreted proteins reduction of cholera in bangladeshi villages by simple filtration evolution of hiv/aids prevention programs -united states hiv/aids diagnoses- states racial/ethnic disparities in diagnoses of hiv/aids- states unrecognized infectin, and hiv testing among men who have sex with men -five us cities an updated systematic overview of triple combination therapy in antiretroviral-naive hiv-infected adults the resumption of consumption -a review on tuberculosis interventions for promoting adherence to tuberculosis management playing chicken with our antibiotics. overtreatment is creating dangerously resistent germs researchers question obsession with cipro foodborne diseases active surveillance network the integration of process analytical technologies, concurrent validation, and parametric release programs in aseptic processing use of microbial data for hazard analysis and critical control point verification-food and drug administration perspective food emergency response network -fern cooperative agreement food and drug administration center for food safety and applied nutrition, carver shock software tool for food defense and terrorism the role of irradiation in food safety irradiation of food-helping to ensure food safety food irradiation: a safe and useful technology key: cord- - ez lif authors: caron, patrick title: from crisis to utopia: crafting new public–private articulation at territorial level to design sustainable food systems date: - - journal: agric human values doi: . /s - - - sha: doc_id: cord_uid: ez lif nan increasingly numerous authors and evidence call for an urgent and profound transformation of food systems (caron et al. ) . despite the remarkable and necessary increase of food availability in a context of intense demographic transition, food insecurity has not been eradicated, with a persistent number of persons suffering from undernutrition while obesity spreads dramatically in all countries. in addition, diets (willett et al. ) and food systems stand at the heart of a nexus that links nutrition, health, the viability of ecosystems, climate change, political stability and social justice, and can be considered a lever to address the whole agenda. yet, although we have been claiming for years "business as usual is not an option", we continue performing as usual and this procrastination may be explained by conflict of interests, increasing asymmetries and the difficulty to enforce right based approaches and agreements (hlpe ) . the world will change, as a result of the systemic crisis generated by the covid- pandemic. change is not taking place since we wisely decided to do so and to craft a sustainable world, but under an unexpected mobility constraint. most of us rightly focus on the best way to cope with the current nightmare. the priority for mitigating its impact calls for safety nets for the most vulnerable and for preventing the breaking risk of supply chains and associated speculation. what was unthinkable and taboo yesterday is becoming a reality and, beyond such a drama, a new architecture of food systems will emerge. new connections between the environment, health and the food sectors are already made (morand et al. ) . new behaviors and norms will affect consumption and international exchanges rules and patterns. the lock-in of frontiers, supply disruptions and global trade dysregulation will contradict the governance doctrine which has prevailed for the last decades to ensure food supply. the unquestioned faith in the trade capacity to ensure supply will give way to sovereignty, a forgotten approach at the national level and left to promote local alternative to globalization. as local processes will undoubtedly gain traction, organizing the right balance between local, national and international supplies will be challenging, in order to ensure access to healthy food everywhere, at all moments, at an affordable price, while limiting loss and waste and preventing global overproduction and related impact on the environment. opposing scales is not appropriate, as processes taking place at each of them are strongly articulated. national and international contexts and regulations should not be omitted as they influence the potential of local initiatives to serve as models and to structure in return national action and global frameworks. along with the concentration in agricultural value chains and states' dispossession of part of their power to the benefit of large enterprises and social networks, claims grow for the private sector to play an important role in transitions (hlpe ) . this lead biénabe et al. ( ) to urge public and private actors to invent regulations in agri-chain. time has come to do so, providing that social and greenwashing are avoided. in innovatively articulating long and short distance supply chains, territory will play a key role. this is the level at which consistency and arbitration between economic, social and ecological dimensions of all sectors may be politically achieved through inclusive process. commons offer an asset (elinor ) and the design of common projects a way between state and market for addressing future challenges. territory can be considered an alternative to embed and anchor economic dynamics into political regulation. territorial development may contribute to reframing public action and policies at all levels and open an avenue to transform the world (caron et al. the risk exists to forget about the crisis and continue until the next one as if nothing happened. it is amplified by the irreducible dualism which has taken place between those who deny sustainability concerns and oppose any change and those who advocate for a revolution to prevent an announced collapse. all are convinced they defend the general interest. strategies to delegitimize opponents of all sides, as well as doubt or certainty selling behaviors will not make transformation easy. all knowledge resources will be required as well as reshaping the role of technology to move beyond binary opposites between positivism versus reject stances. as we are facing a crossroad for better or worse, moving forward calls for mediation, with special focus on transcending lock-in and strengthening collective intelligence at all scales. this implies moving beyond the fragmentation of expertise, to confront convergences and divergences and to explore possible sustainable futures. crisis is the right time to be proactive rather than reactive, to build new paradigms and craft an utopia based on a renaissance of the articulation between collective locally driven processes and international cooperation. sustainable development and tropical agri-chains . living territories to transform the world. versailles : ed. quae, afd, p. (agricultures et défis du monde food systems for sustainable development: proposals for a profound four-part transformation governing the commons. the evolution of institutions for collective action multi-stakeholder partnerships to finance and improve food security and nutrition in the framework of the agenda. a report by the high level panel of experts on food security and nutrition of the committee on world food security Émergence de maladies infectieuses risques et enjeux de société food in the anthropocene: the eat-lancet commission on healthy diets from sustainable food systems key: cord- -xqmir ca authors: olaimat, amin n.; shahbaz, hafiz m.; fatima, nayab; munir, sadia; holley, richard a. title: food safety during and after the era of covid- pandemic date: - - journal: front microbiol doi: . /fmicb. . sha: doc_id: cord_uid: xqmir ca the coronavirus disease (covid- ) is a clinical syndrome caused by severe acute respiratory syndrome corona virus- (sars-cov- ). covid- was declared a pandemic by the world health organization (who) on march , due to its rapid and extensive spread among many countries through its very contagious nature and its high mortality among the elderly and infirm. recently, data on the survival of sars-cov- on contact surfaces has been reported, but there is none on the survival of covid- on food surfaces and packages. the potential survival and transmission of sars-cov- on/via food and packages are discussed based on data available for other respiratory viruses such as sars-cov and mers-cov. however, studies are needed to explore its transmission via food and survival on food packaging materials. the implementation of food safety management systems such as hazard analysis and critical control points (haccp), and good manufacturing practices (gmp) are important to reduce the risk of covid- infection. cleaning, sanitation, good hygienic practices, and active packaging are also needed from farm to fork. in december , sars-cov- was initially detected in patients who suffered from unusual viral pneumonia in wuhan, hubei, china (kaul, ; naserghandi et al., ; petrosillo et al., ) . the virus was first named novel coronavirus ( -ncov) by the who and later, when it was found that . % of the novel virus genome was similar to the sars-cov genome, the virus was renamed sars-cov- (chang et al., ; the lancet infectious diseases, ) . covid- is the clinical syndrome caused by sars-cov- infection which is characterized by a respiratory disease with symptoms ranging from mild influenza (flu-like) to severe pneumonia and acute respiratory distress syndrome (petrosillo et al., ) . the clinical manifestations of covid- are non-specific and variable among patients, and between countries. generally, covid- symptoms involve fever, sore throat, runny or stuffy nose, dry cough, headache, myalgia or fatigue, sputum production, dyspnea, chest pain or pressure, joint pain, chills, loss of taste or smell, and a rash on the skin or discoloration of toes or fingers. abdominal pain, dizziness, diarrhea, nausea, and vomiting are less common symptoms (kaul, ; naserghandi et al., ; petrosillo et al., ) . borges do nascimento et al. ( ) found that covid- -related symptoms among , patients in studies were: fever ( %), cough ( %), muscle aches and/or fatigue ( %), dyspnea ( %), headache ( %), sore throat ( %), and gastrointestinal symptoms ( %). on average, the incubation period takes - days for a patient to show the symptoms after infection, however, it may reach up to days (world health organization [who] , ). covid- infection is highly contagious among the population and now almost all countries have reported cases and deaths. on march , , covid- was characterized as a pandemic by the who. as of early july, over million confirmed cases and , deaths of covid- have been reported worldwide (world health organization [who], ). at the beginning of the pandemic, two-third or out of reported cases had previously visited the huanan seafood wholesale market where live animals were sold close to seafood and meat products, suggesting that the virus was transmitted from animals to humans (guan et al., ; harapan et al., ; naserghandi et al., ) . the genome of sars-cov- is closely related to the genomes of the sars-cov that caused the sars epidemic during and the sars-related-covs (sarsr-covs) that was isolated from horseshoe bats. this suggested that the primary host of sars-cov- was a bat and other animals including pigs, or pangolins are potential secondary hosts to the virus (lai et al., ; sun et al., ) . to date, the impact of the seafood market in spreading covid- is not fully understood (harapan et al., ) . it has been proposed that sars-cov- was introduced to the seafood market in wuhan, hubei, china and then the disease spread more rapidly through human-to-human interactions, which has been confirmed by the occurrence of infection among the family members and medical workers attending the victims (chan et al., ; yu et al., ) . the most plausible transmission routes are respiratory droplets dispersed via talking, sneezing and coughing or direct contact with infected persons. other suggested routes are fecal-oral transmission, contaminated fomite transmission and mother-fetal vertical transmission (naserghandi et al., ; wang et al., ) . it has been demonstrated that covid- can also be transmitted by asymptomatic patients who are harboring the virus during its early incubation period before symptoms appear ye et al., ; zhang et al., ) . additionally, sars-cov- has reappeared in recovered patients leading to a reoccurrence of illness. this has been confirmed through the detection of viral nucleic acid using a real-time rt-pcr after patient recovery and discharge from the hospital lan et al., ; qiao et al., ) . however, the exact reason for the reappearance of sars-cov- is not well understood. foodservice operators were among the first workers in frontline employment sectors experiencing the impact of the covid- pandemic. however, there is no study to date which reports that covid- spreads via food products. further, no evidence is available showing that viruses which infect the respiratory tract can be transmitted via food or food packaging (food and agriculture organization of the united nations [fao] and world health organization [who] , ). the transmission of sars-cov and mers-cov through the consumption of foods does not appear to have occurred yet (european food safety authority [efsa], ). however, it has been reported that human coronavirus e (hucov- e) survived for at least days on the surfaces of polyvinyl chloride (pvc), polyfluorotetraethylene (teflon, ptfe), glass, ceramic tiles, and stainless steel and for days on silicon rubber surfaces at • c with a relative humidity of - % (warnes et al., ) . similarly, sars-cov- survived on stainless steel and plastic up to and days, respectively, at - • c and a relative humidity of %; however, the virus was not detected on copper and cardboard, after and h, respectively (van doremalen et al., ). these results indicated that sars-cov- can be transmitted via contact surfaces because of the ability of the virus to survive on the surfaces for several days. coronaviruses can persist for long periods in environmental samples which may enhance the probability of transmission via package contact surfaces (geller et al., ) . it has been confirmed that virulence of variola (smallpox) virus and influenza virus were positively correlated with survival time in the external environment, which explained their high mortality rate compared to other viruses with low survival rates in environmental samples such as the virus causing parainfluenza and rhinovirus (walther and ewald, ) . food and agriculture organization of the united nations [fao] and world health organization [who] ( ) proposed that touching food packages or containers contaminated with sars-cov- could transmit the virus to the mouth, nose, or eyes. however, this is not considered the main route for disease spread because the virus shows poor survival on these surfaces. a previous study reported that food products were a plausible transmission route for respiratory viruses including sars-cov- and influenza (klein, ) . in another study, the risk of ebola infection to individual humans in the united states resulting from contaminated cocoa beans, palm oil, or cashews imported from south africa was considered negligible to low (bergeron et al., ) . in addition, several studies showed that transmission of avian influenza through poultry products (golden et al., ; bauer et al., ; sánchez-vizcaíno et al., ) or water consumption was a remote possibility, but possible (schijven et al., ) . similarly, the probability that consumers from the united kingdom might get infected with covid- via the consumption of food or the handling of material contacting food or packaging was considered negligible to very low. as mentioned, the genome of sars-cov- is closely related to sars-cov for which the transmission via foods has not been confirmed. it has been suggested that the potential foodborne transmission of sars-cov- may occur due to the consumption of foods originating from infected animals or the consumption of cross-contaminated foods (oakenfull and wilson, ) . more effort is needed to address the transmission of sars-cov- from the respiratory tract to food package surfaces or through food consumption. the food and drug administration [fda] ( b) proposed guidelines for consumers during food shopping, food handling and food preparation. it is worth mentioning that food handlers including food establishment employees and consumers should adhere to good sanitation and hygienic practice guidelines to avoid sars-cov- transmission and comply with at least the minimum requirements of the food safety system. it is widely known that viruses cannot multiply in food products because they need an animal or human host to grow. however, to date, no study has investigated the survival of sars-cov- in foods. to the best of our knowledge, only two studies reported the survival of infectious respiratory viruses in food products. adenovirus survived on both lettuce and strawberries at • c for up to days. in contrast, coronavirus survived only days on lettuce, and it was not recovered from the surface of strawberries after inoculation (yépiz-gómez et al., ) . these results indicated that respiratory viruses may transfer from food surfaces to the hands and subsequently to the mouth, nose or eyes. the survival of mers-cov in different types of milk (camel, goat and cow milk) at or • c has been investigated. mers-cov titers were decreased by less than log in all types of milk after h at • c. higher log reductions were observed when milk was stored at • c since the virus titers decreased by ≤ . log with h of storage. low temperature, long time pasteurization ( • c/ min) of raw milk completely eliminated the virus from the milk of the three different animals (van doremalen et al., ) . the infectious dose of most respiratory viruses is low; thus, the handling or consumption of food products could represent a risk for infection. as a result, preventive measures such as washing and sanitizing of fresh produce surfaces as well as the implementation of good personnel hygiene and practices among workers would seem reasonable ways to reduce the risk of virus transmission. another issue is that several viruses that cause respiratory infections have been found in the human gastrointestinal tract and were capable of proliferation there. these include enterovirus (coxsackie a, b virus), parechovirus, orthomyxovirus (avian influenza virus), henipavirus (nipahand hendra viruses), mastadenovirus (adenovirus), alphatorquevirus (torque teno virus), and coronavirus (bosch et al., ) . in the later case, lymphocytes and mucosal epithelial cells of the patients' intestine were positive for sars-cov (shi et al., ) . this may mean that the viruses can be acquired by humans via the consumption of contaminated foods. however, these results may not apply to sars-cov- , which points out the need for studies to investigate the survival of sars-cov- in different foods and on food packages. as mentioned, covid- virus has an ability to stay alive for up to h as a virion on inanimate objects after completing its life cycle in the body of an infected person (van doremalen et al., ) . therefore, if the respiratory discharges of the covid- patient come in contact with food, the food items can become a fomite (carrier), and if these items are contacted by other individuals, the virus is more likely to gain entry to their respiratory epithelium when unsanitized hands touch the nose, eyes, and mouth (bundesinstitut für risikobewertung [bfr], ; centers for disease control and prevention [cdc], ). the surfaces of utensils, packaging material, counters, conveyor belts, interiors of transport vehicles, and all other food work stations where there might be human contact with food should remain a focus of attention where food handlers can act to impede the spread of covid- . therefore, the proper use of personal protective equipment and adherence to the guidelines issued by public health authorities that include regular hand washing when exchanging goods, plus the use of hand sanitizers, wearing masks and gloves, and the maintenance of at least feet between personnel are most important. a range of disinfectants and sanitizers are available in the marketplace. if disinfectant labels suggest that they are effective against coronaviruses or norovirus, then they should be effective against sars-cov- as well. additionally, complete instructions are given on epa disinfectant labels regarding the contact time, concentration, and appropriate surfaces for application (environmental protection agency, ). all food industry organizations should strictly follow the protocols of food safety management systems (fsms) given by authorities based on haccp principles and should be kept updated in response to new pieces of evidence for viruses when required. in food companies where haccp protocols are not being implemented, an expert should be appointed who will remain in contact with public health authorities to seek advice during the pandemic situation. hand washing stations should be maintained for the workforce with the provision of normal soap, warm running water, hand sanitizers, and posters designed for displaying information regarding effective hand washing and sanitization. the physical distancing of feet should be implemented among workers as infected people may remain asymptomatic or be pre-symptomatic during the course of the disease and may spread the infection when close to others (kimball et al., ; pan et al., ; tong et al., ; wei et al., ; yu et al., ) . the introduction of staggered workstations is an effective method to overcome the challenge of physical distancing in food industry facilities. it is advised to minimize the contact between people during the outbreak; therefore, online food deliveries are more desirable. these allow physical distancing between customers and sales personnel. at this stage, proper dissemination of information on food handling practices is also required. since food packages and paper currency are exchanged between consumers and retailers, proper precautions are needed to minimize the potential for virus transfer during the transaction. some third-party delivery companies have also introduced contact-free delivery to homes. the packaging can be discarded after keeping track of important information mentioned on it. the proper use of gloves, sanitizers, and disinfectants can minimize the risk of virus spread and disease transmission (food and agriculture organization of the united nations [fao] and world health organization [who], ; food and drug administration [fda], a). maintaining the movement of food along the food chain is an important function that requires all involved to contribute and stay vigilant. it is necessary to maintain the confidence and trust of consumers regarding food safety and food availability. in case of limitations on the foodservice industry, home deliveries can be promoted, however, a safe and secure environment for food retail shops and canteens must be ensured at both the consumer's and retailer's end. retailers can play their roles by ensuring the provision of sanitary facilities including wipes, disinfectants, sanitizers, and display of sanitary practices through visual aids. physical distancing can be maintained by having the floors marked as a reference for maintaining minimum distance required. plexiglass can be installed to avoid contact at cashier counters, and food tasting for promotional campaigns should be avoided ( at the consumer end, people should make sure that family members belonging to vulnerable groups (immunecompromised, elderly, children, should stay at home (centers for disease control and prevention [cdc] , ). besides, the use of masks, wearing gloves, using hand sanitizers, using wipes before handling food carts, avoiding reusable shopping bags and opting for acceptable respiratory etiquette should be prioritized. if reusable bags are deemed regionally acceptable, their disinfection should be done instantly after use. it is advised to stock food items according to their perishability in order to minimize the number of visits to markets. after safe purchasing with all protocols, the most neglected thing is the safe handling of food. with respect to food handling practices in our kitchens, evidence that has been obtained with coronaviruses indicated that they cannot survive cooking, but if food remains unwashed and is frozen afterward, the virus can survive up to years during frozen storage (bundesinstitut für risikobewertung [bfr], ). therefore, scrubbing of food items like fruits and vegetables is essential if they are not to be cooked for longer periods or to be eaten uncooked. for canned foods, the lids should be wiped before opening. ensure the disinfection of utensils, pots, countertops, and fridge at every use and minimize the risks of cross-contamination among food items during storage. in addition, respect cooking protocols to ascertain food safety and avoid a false sense of security by following proper cooking time, temperature, and thawing protocols. consumers' concern regarding the ability of sars-cov- to survive on the surface of packages has led to an increasing interest in the development of polymers and biopolymers with antiviral properties. the applications of polymers and biopolymers have shown high efficacy against hepatitis a virus (hav) and human norovirus (hunov) (randazzo et al., ) . a previous study showed that the release of copper ions can help in the inactivation of hucov- e on copper or copper alloy surfaces (warnes et al., ) . these findings are a source of validation for the recent findings by van doremalen et al. ( ) regarding the decreased viability of sars-cov- on copper surfaces and inactivation within h. the lack of trials on food matrices and related food regulatory requirements remain the hurdles to the adoption of novel food packaging. the development of biopolymers with antiviral properties and their applications in the food area remains an open field of research. for example, it has been recently reported that the use of nanomaterial coatings or films containing copper, silver, and zinc nanoparticles has a potential against sars-cov- to prevent contamination of food packaging surfaces and thus reduce its transmission (sportelli et al., ) . in conclusion, there are only shreds of evidence regarding the duration of coronavirus survival on different contact surfaces and in foods under certain conditions which suggests the need for advanced studies in understanding the risk of covid- spread associated with food and food packages. research trials are required to find a link between the ingestion of food contaminated with sars-cov- and the probability of infections as well as the development of antiviral active packaging using nano-based biopolymer materials. the current guidelines issued by public health authorities are based on the disease patterns of previously encountered coronaviruses and they need to be updated according to the novel coronavirus sars-cov- as this virus is likely to persist and people will have to modify their "normal behavior" to a "new normal." all datasets generated for this study are included in the article/supplementary material. ao, hs, and nf wrote the draft of the manuscript. ao, hs, nf, and sm reviewed and edited the final manuscript version. rh critically revised the final manuscript version. all authors contributed to the article and approved the submitted version. interagency risk assessment for the public health impact of highly pathogenic avian influenza virus in poultry, shell eggs, and egg products. food safety and inspection service (fsis), food and drug administration (fda) and animal and plant health inspection service (aphis) joint document rapid-response risk evaluation of ebola spread via the food system novel coronavirus infection (covid- ) in humans: a scoping review and meta-analysis foodborne viruses: detection, risk assessment, and control options in food processing can the new type of coronavirus be transmitted via food and objects how coronavirus spreads a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster coronavirus disease : coronaviruses and blood safety recurrence of positive sars-cov- rna in covid- : a case report list n: disinfectants for use against sars-cov- covid- , and food safety. guidance for food businesses. interim guidance, april, - . geneva: who. food and drug administration [fda] ( a). food safety and the coronavirus disease (covid- ) human coronaviruses: insights into environmental resistance and its influence on the development of new antiseptic strategies risk assessment to estimate the probability of a chicken flock infected with h n highly pathogenic avian influenza virus reaching slaughter undetected clinical characteristics of coronavirus disease in china coronavirus disease (covid- ): a literature review an overview of coronaviruses including the sars- coronavirus -molecular biology, epidemiology and clinical implications asymptomatic and presymptomatic sars-cov- infections in residents of a long-term care skilled nursing facility spread of viruses through the food chain severe acute respiratory syndrome coronavirus (sars-cov- ) and coronavirus disease- (covid- ): the epidemic and the challenges positive rt-pcr test results in patients recovered from covid- asymptomatic and symptomatic patients with non-severe coronavirus disease (covid- ) have similar clinical features and virological courses: a retrospective single center study all about covid- in brief qualitative risk assessment: what is the risk of food or food contact materials being a source or transmission route of sars-cov- for uk consumers asymptomatic cases in a family cluster with sars-cov- infection covid- , sars and mers: are they closely related? re-positive cases of nucleic acid tests in discharged patients with covid- : a follow-up study polymers and biopolymers with antiviral activity: potential applications for improving food safety a quantitative assessment of the risk for highly pathogenic avian influenza introduction into spain via legal trade of live poultry quantitative risk assessment of avian influenza virus infection via water severe acute respiratory syndrome associated coronavirus is detected in intestinal tissues of fatal cases can nanotechnology and materials science help the fight against sars-cov- ? clinical characteristics of hospitalized patients with sars-cov- infection: a single arm meta-analysis challenges of coronavirus disease potential presymptomatic transmission of sars-cov- stability of middle east respiratory syndrome coronavirus in milk aerosol and surface stability of sars-cov- as compared with sars-cov- pathogen survival in the external environment and the evolution of virulence unique epidemiological and clinical features of the emerging novel coronavirus pneumonia (covid- ) implicate special control measures human coronavirus e remains infectious on common touch surface materials presymptomatic transmission of sars-cov- -singapore coronavirus disease (covid- ) pandemic delivery of infection from asymptomatic carriers of covid- in a familial cluster survival of respiratory viruses on fresh produce a familial cluster of infection associated with the novel coronavirus indicating potential person-to-person transmission during the incubation period covid- transmission within a family cluster in yancheng the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © olaimat, shahbaz, fatima, munir and holley. this is an openaccess article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord- -reoa kcw authors: botreau, hélène; cohen, marc j. title: gender inequality and food insecurity: a dozen years after the food price crisis, rural women still bear the brunt of poverty and hunger date: - - journal: nan doi: . /bs.af s. . . sha: doc_id: cord_uid: reoa kcw the global food price crisis of – had devastating impacts for the world's poorest people, especially for smallholder farmers and in particular for women, who face discrimination and a heavy burden of household responsibility. the international policy response to the crisis saw the launch of numerous new initiatives and instruments, but funding has been insufficient and policies have failed to address the structural deficiencies in the global food system. a dozen years on, in light of climate change and increased conflict, new policies are needed to reorient the food system so that it prioritizes smallholder communities, with a renewed focus on the needs and aspirations of women. . introduction . underlying structural factors and their impacts on women . what led to the food price crisis? . impacts and long-term effects on women smallholder farmers . how effective was the global response in tackling the structural causes of the crisis? . the global response after - . responding to the crisis with business as usual . a lack of coherent governance for global food security . addressing women's food insecurity in a (more) unstable and broken food system . increased challenges for food and nutrition security for women . what changes have there been in the institutional and funding agenda to address women's food insecurity? . closing the gender gap: transforming rather than mainstreaming . conclusion and recommendations . guarantee participation and inclusiveness . increase aid to agriculture . increase national public investments in agriculture in developing countries . ensure women's access to resources, competitive markets and farmers' rights the global food price crisis of - underscored how fragile livelihoods are among the world's extremely vulnerable people, as it drove million people in developing countries into poverty (world bank, ) . in the aftermath of the crisis, in the food and agriculture organization of the united nations (fao) estimated in a that almost billion people worldwide were undernourished (fao, a) . as this chapter will show, the crisis disproportionately affected women. in the un world food programme (wfp) calculated that women and girls accounted for % of chronically hungry people around the world (wfp, ; see also scott-villiers et al., ) . the flurry of policy action in the months and years following the price spike brought some hope that the world's governments were prepared to tackle the structural factors behind the crisis, which had a severe impact on vulnerable people's resilience to shocks. the effects proved especially severe for women small-scale agricultural producers. a dozen years later, despite the international commitment to sustainable development goal (sdg) of zero hunger, too many of the policies that precipitated the food price crisis remain in place (wise and murphy, ) . the united nations food, agriculture, and health agencies estimate that the number of hungry people in the world increased by million in , and rose by million over the preceding years (fao et al., ) . viewing food insecurity through a somewhat different lens, the agencies also a following these estimates of hunger, the committee on world food security (cfs) recommended that fao revise its much-criticized methodology for counting the number of undernourished people. this new methodology included updated population estimates and household surveys on food consumption, and took into account food waste at the distribution level. it was used for the first time in the state of food insecurity security in the world (sofi ) (fao, ) report, and the hunger trends observed showed significant changes. the methodology has been under constant revision since then, with new indicators added to make it more complete. therefore, it is not possible to compare figures across annual volumes of the sofi report. estimated that over billion people ( . % of the world's population) cannot afford a healthy diet (fao et al., ) . women smallholder farmers are among the worst affected, and remain far from realizing their human right to adequate food. looking back in , reconsideration of the long-term impacts of the food-price crisis and the impacts of the policy response is long overdue. it has become clear that we will not achieve sdg , given that the structural causes of hunger remain unaddressed and that additional issues have become more salient since . this chapter will proceed as follows: • reflecting on how the existing challenges faced by women smallholder farmers were exacerbated by the structural causes of the food price crisis; • examining major policy responses from governments and the private sector and analyzing their effectiveness in addressing the structural causes of the crisis; • setting out the lessons learned from the major failures of this policy response; • identifying key challenges and gaps in financial aid to women smallholder farmers and, more specifically, looking at the level of official development assistance (oda) targeted to them since ; and • providing policy recommendations to address all of these issues. the challenges and questions raised by this chapter remain substantial, diverse and context-specific. although we cannot explore these topics exhaustively, we hope to contribute to renewed calls for justice and the right to food for the hundreds of millions of people who remain hungry in a time of plenty. their impacts on women . what led to the food price crisis? the term "global food price crisis" usually refers to one of the biggest price surges (de schutter, ) in a period of extreme volatility for primary commodities, mainly the most widely consumed cereals, which had peaks in the second half of and the first half of and another spike in - . between march and march prices rose %, those of soybeans jumped % and wheat prices ballooned % (fao and oecd, ) . the price of rice climbed fourfold during january-april , as several major exporters embargoed foreign sales of this lightly traded commodity (fao and oecd, ) . b global food prices declined from their peak in june , as the world economy fell into recession (fig. ) . prices remained relatively stable until the first half of and then began rising again, reaching an all-time high in february (fao, ) (fig. ). severe drought in major exporting countries was the key short-term factor contributing to this second spike (trostle, ) . as a study by the institute of development studies conducted for oxfam noted, the rise in prices pushed low-income people, who precrisis frequently spent % or more of their incomes to buy food, further into poverty and increased their difficulties in maintaining basic consumption levels: people for whom securing food has already absorbed a large share of their resources and energies before the food crisis came under intense pressure to alter their relationship to food and thus to the economy-to spend more time earning more money to cover basic provisioning and to extract more value from whatever they consumed. scott-villiers et al. ( ) . in other words, the crisis posed a severe threat to the right to adequate food for millions of people (de schutter, ) . . . a broad variety of causes led to the - food price crisis, and views on the weight to give to long-term trends vary in the literature (scott-villiers et al., ) . nevertheless, as olivier de schutter, then the un special rapporteur on the right to food, observed in , "the disaster which results from the increase of international prices of food commodities is a man-made disaster. the causes are identifiable" (de schutter, ) . the agri-food system and its contradictions contain a number of hidden causes of the crisis, what we call "structural factors": liberalization of agriculture and trade, concentration of distribution and inputs marginalizing smaller production units and decreases in investments in agriculture and development assistance to the sector in a context of increasing climate change. these long-term trends made smallholder farmers more vulnerable to shorter-term "conjunctural factors" experienced in the more immediate run-up to the crisis. these conjunctural factors consist mainly of an evolution of fundamentals of the market-supply and demand (bricas and goïta, ; clapp and cohen, )-and marked an increased level of globalization (scott-villiers et al., ) , creating an even more unfavorable economic context for smallholder farmers. in the decade prior to the crisis and following adoption of the world trade organization (wto) agreement on agriculture of and the world food summit in , there was a major shift in global food and agriculture, with lower trade barriers and more open markets. however, countries with weak market infrastructures and those that relied on a small number of export commodities did not gain from liberalization and faced risks associated with increases in world food prices, which would mean considerably higher import bills, potentially requiring them to spend their foreign-exchange reserves (trueblood and shapouri, ) . for farmers, this shift encouraged less production of traditional food cropswhich frequently were the crops that women farmers produced-in favor of crops for domestic and export markets, increasing their exposure to the volatility of those markets and their dependence on purchased inputs (un women, ) . most low-income countries moved rapidly away from self-sufficiency in food and in turn opened their domestic markets to external produce. from , sub-saharan africa became a net food importer (fig. ) , despite an impressive increase in regional production of major crops. between and , only one-fifth of african food exports stayed in african countries, and % of agricultural imports came from other continents (rakotoarisoa et al., ) . west africa tripled its rice imports in the s (fig. ) (oecd, ) . outside of africa, haiti reduced its tariff on imports of rice-the daily staple for most haitians-from % to %. from near self-sufficiency, the country went to importing % of its rice consumption, and has now become the second largest market for us rice (cohen, ; oxfam, ) . liberalization policies have also facilitated the overwhelming market supremacy of a small number of large companies, from farm inputs to sales of food to consumers. as mckeon ( ) has observed, "corporate power in food chains has continued to grow unabated, with the mega-mergers of major agribusiness multinationals threatening a further concentration'" over the past few decades, four firms, known as the abcd companies-archer daniels midland (adm), bunge, cargill and louis dreyfus-have come to virtually control trade in grain and oilseeds plume, ) . such concentrated market power is often seen in low-income countries that typically have at best insubstantial market regulation. in the agrochemical sector in the late s, the top companies accounted for % of global sales. by , seven companies controlled the same market share (humphrey and memedovic, ) . in , as a result of the mega-mergers that mckeon highlights, three companies (bayer, dowdupont c and chemchina) stood poised to claim a % share of global commercial seed and agro-chemical sales (friends of the earth europe et al., ). however, the ability of these firms to administer the prices of seeds, for example, varies according to crop and country context (cavero and galiá, ; oecd, a) . the rate of growth of public spending on agriculture slowed dramatically during - , and it stagnated in africa. however, spending rose steadily in asia, and doubled during the two decades after . in the absence of public funding, smallholder producers, particularly women farmers, had little ability to bargain with large agribusiness firms, middlemen or credit providers (un women, research is unlikely to address the problems facing low-income farmers, given the unlikelihood of a sufficient return on investment in the shortto-medium term. . . . decreased aid to agriculture the public expenditure trend was not offset by oda to agriculture. the period between and was marked by low food prices and a sharp reduction in aid to agricultural development and investments from oecd countries and multilateral agencies ( fig. ; see also hlpe, ) . most of the aid that there was continued to focus on staples productivity; greater support for fruits, vegetables and legumes could have benefited smallholders (pingali, ) . by , agriculture's share of bilateral aid had fallen to a quarter of its former level, and the trend was similar for multilateral agencies: agriculture fell from % of world bank lending in to just % in - (brock and paasch, ). climate change is resulting in more frequent and more severe heat waves, droughts and floods, which can decimate farm production. its effects contributed to food price increases in - and also in , with severe droughts in australia, canada, argentina and the united states, all major cereals producers (fao and oecd, ) . there were droughts in east africa in , (bailey, . the last of these affected more than million people and resulted in the famine in somalia that killed , people (news centre, crops to weather indicate that global maize and wheat yields between and may have been, respectively, . % and . % lower than they would have been without the effects of climate change (lobell et al., (mittal, )-growth in food crop production slowed from the mid- s. for cereals, which cover over half of the world's farm land, yield growth fell from % annually in the s to a little more than half of that in the s, then increased to nearly % in the s (fao, a). . . . . escalating crude oil prices have led to rising farm production costs in the st century, increases in the prices of fertilizer and oil, which are key farm inputs, have exceed those for agricultural produce (fig. ). this has created further financial difficulties for farmers, as most developing country governments have reduced or eliminated subsidies on inputs and assistance with credit and marketing for smallholders (un women, (world bank, ) , and this was associated with a growing urban middle class. food consumption habits evolved and all regions in the world saw increased meat consumption and thus a rising demand for grains for animal feed (see fig. ). during this same period, global food trade concentrated on just four main crops: rice, maize (this, in particular, is an important animal feed as well as a major direct source of human food in sub-saharan africa and parts of latin america) and wheat, plus soybeans (directly consumed by humans, an input into processed foods, an animal feed and also a source of biodiesel) (mccreary, ) . the trends of dependence on the three major global cereals and on imports for food supplies have been simultaneous and mutually reinforcing. in sub-saharan africa and south asia-which are home to the majority of the world's food insecure people and thus constitute hunger's center of gravity-consumption of these cereals has steadily displaced traditional staples such as millet, sorghum, bananas, cassava, potatoes, sweet potatoes and beans over a long period. the trend was remarked on by people interviewed during the - crisis, who repeatedly mentioned the decline of "traditional" foods due to reduced availability, higher cost and longer preparation time (scott-villiers et al., ) . . . . . rapid expansion of biofuels production the expanded production of biofuels was a key driver of the food price crisis: increased biofuel demand in the united states, due to legal mandates to blend ethanol into petrol, pushed up maize prices and probably also those of soybeans, while eu and european expansion of oilseed production for biofuel led to higher wheat prices ( fig. ; see also headey and fan, ) . governments across the world attempted to reduce dependency on oil, increase the use of renewable energies and halt declines in farm income, and approved legislative instruments that encouraged the biofuels industry. those policies, led mainly by rich countries, created a demand shock in international markets (wise and murphy, ) . during a very short period before the crisis, % of the global maize supply was diverted to the us ethanol program. moreover, biofuels have direct impacts on land use and land rights, compromising food security. the eu's bio-energy policy helped biofuels industries to prosper, but the , km of eu land devoted to biofuels crops in could have grown enough food for million people that year (herman and mayrhofer, ) . . . . . declining stocks a low "stock-to-use" ratio due to low stocks, high demand or both creates upward price pressure (fao, b) . low stocks are a vulnerability factor, especially for countries already at high risk vis-à-vis prices, since reserves provide a buffer against both rising prices and poor harvests (wise and murphy, ) . in - the world cereal stockto-use ratio stood at an all-time low of . % (fao, b). . . . . dollar devaluation depreciation of the us dollar also played a role in food price escalation. in general, a weaker dollar is associated with commodity price increases (fao, b; headey and fan, ) . for countries that tie their currency to the dollar or that have a weaker currency, dollar depreciation makes food imports more expensive (fao, b). . . . . increasing speculation in commodities dollar depreciation also made food commodities attractive to investors, especially as technology and housing "went bust" (clapp, ). the growth of food commodities investment became mixed up with the financial crisis of - , which persuaded many noncommercial traders (whether considered "investors" or "speculators") to move their money away from collapsing stock, bond and property markets and into the commodity futures trade (fao, b) . such large-scale speculation contributes to commodity price volatility and gives inappropriate market signals to agricultural producers (fao, b). from the beginning of the food price crisis, the rice market came under pressure because some governments imposed bans on exports (such as restrictions on non-basmati exports by india, e a leading exporter) (usda/fas, ) and major importers such as the philippines made large-scale purchases, seeking to lock in prices as a hedge against further increases (childs and kiawu, ) . like the diversion of maize to biofuels, all this created distrust on the global markets and exacerbated upward pressure on prices. because of the large amount of international trade in wheat and maize at a time of extremely low global stocks, the price increases quickly spread to many national markets. however, transmission of world market prices to domestic markets varied greatly from country to country: in china and india, domestic prices were virtually unaffected; in brazil and south africa e india lifted this ban, imposed in april , in . during the period of the ban, thailand, pakistan and vietnam, among others, moved in to replace indian exports. it served to keep rice affordable for indian consumers, but adversely affected (albeit marginally) india's foreign exchange earnings. since lifting the ban, india has become the world's largest exporter of rice. the authors are grateful to ranu bhogal of oxfam india for pointing this out. prices increased in line with international markets; but in ethiopia and nigeria domestic prices increased dramatically. in general, according to one analysis, there were "higher price transmission rates for import dependent countries, including rice in senegal, mali, burkina faso, niger… and uganda, maize in malawi and uganda, and wheat in ethiopia" (baltzer, ) . the degree of price transmission was affected by domestic and trade policies in importing countries. f the events of - brought into plain view the cracks in an unsustainable food system that was already having severe negative effects on the basic livelihoods of smallholder farmers (murphy and schiavoni, ) . the structural factors outlined above (liberalization of the agri-food system, concentration in input and output markets, a decrease in public investments in agriculture, declining aid to agriculture) showed how unbalanced the system had become, privileging big agri-food businesses and making low-income people even more vulnerable to the conjunctural factors of the crisis. these short-term factors triggered the crisis and further impoverished the poorest people, denying them their human right to adequate food and nutrition and illustrating the global food system's failures (murphy and schiavoni, ) . rural people, and especially farmers, were on the front line. people living in rural areas are among the poorest in the global south and at the time of the crisis three-quarters of them were living on less than the equivalent of $ a day, and spending up to % of their earnings on food (coon, ) . already precarious rural livelihoods (due to geographic, economic and political isolation, poor access to markets, limited opportunities for work, low productivity and seasonal and long-term migration) (coon, ) amplified the threat of soaring agricultural prices, which affected not only consumers and urban dwellers but also food producers. the overwhelming majority of small-scale farmers are also net food purchasers, with very high exposure to price increases (murphy and schiavoni, ) . in theory, higher prices offered opportunities to farmers who are net food sellers, but price increases for agricultural inputs (fertilizers, fuel etc.) offset this possibility (quisumbing et al., ) . f according to baltzer ( ) , 'much of this variation [in the price transmission patterns] can be explained by price stabilization policies, public policy failure, incomplete market integration, and coinciding domestic shocks.' . . women smallholder farmers have been disproportionately affected because gender inequalities remain very strong in agriculture, women farmers are particularly at risk of food insecurity, especially in times of crisis (fao, ). rural women account for one in four people on earth and on average for nearly half the agricultural labor force in developing countries (fao, a) . women play crucial food-security roles, which include farming, food processing, marketing and ensuring household consumption and nutrition (fao, a) . nevertheless: • they face discrimination and frequently are in a weak bargaining position. in addition, other forms of discrimination (based on, e.g., race, class, caste or religion) often intersectionally reinforce gender inequality (un women, ). • the diminished state role in agriculture in the s and s added to female farmers' marginalization, as it reduced their access to inputs, resources and services (un women, ) . rural women also face unequal power relations within both the household and wider society, which have impacts on many aspects of food security. at the level of society: social inequalities come from socially constructed barriers to accessing productive and financial resources that also hinder social participation and political representation. patriarchal norms leading to power imbalances between women and men create disadvantages for women in agriculture, specifically in land rights (small plots, difficulties accessing ownership, discriminatory inheritance rights), productive resources (no access to credit markets, extension services or inputs), unpaid work, insecure employment and low levels of participation in decision making (sexsmith et al., ) . in the household: cultural practices and intra-household bargaining power can also determine the allocation of household incomes to food and care needs. women's weaker position within the family and social standards that favor boys over girls lead to poorer nutrition among women and girls (fao, a; lourme-ruiz et al., ) . . . . the challenges already facing women smallholder farmers were exacerbated by the food price crisis even though there is as yet inadequate research on the gender differentiated impacts of the food price crisis, it is clear that women bore the brunt of it and came under the most pressure to cope with its effects (quisumbing et al., ) . as hossain and green ( ) have observed: the effects differ by gender…women come under more pressure to provide good meals with less food, and feel the stresses of coping with their children's hunger most directly. these stresses push women into poorly paid informal sector work, competing among themselves for ever more inadequate earnings. the crisis really was a matter of inequalities in achieving the right to adequate food and nutrition, and the short-term factors involved in it exacerbated all the gendered dynamics of the food system (un women, ). discrimination against women at these different levels affects their capacity to respond to shocks and cope with food crises (fao, ; un women, ) . because of the constraints they face in accessing extension services and financial and agricultural resources, limited legal benefits and protection, heavy time burdens and limited decision-making power, women have fewer options for overcoming any crisis and face more risks than men of losing their assets or formal sector jobs. price spikes have particularly negative effects on women heads of household, for several reasons: they suffer labor market discrimination, which confines them to informal, vulnerable and casual employment; they often receive less pay than men doing the same work and they usually spend a higher share of their income on food than male household heads (holmes et al., ) . when looking at intra-household dynamics, it is crucial to highlight women's food-security roles: they usually have the primary responsibility for procuring and preparing food within the household (ford, ) . with regard to nutrition, they play an important role in providing dietary diversity through their vegetable gardens (which are often not considered "agriculture"), and also because they grow a large share of the cereal or root crops that the household consumes (doss et al., ) . during - , improvements in women's education and social status accounted for more than % of the substantial reductions in child malnutrition that occurred (smith and haddad, g ). in times of crisis, poor rural households face losses in assets, productivity and income. men use their income to pay past debt and seek new farm production loans. when women's intra-household bargaining position is weak, g here is the methodology used: 'ifpri…examined the factors that helped reduce child malnutrition by % in the developing world between and . the evidence shows that increases in women's education accounted for % of the total reduction in child malnutrition, by far the largest contribution. improvements in women's status accounted for another %. improvements in food availability came in a distant second to women's education, contributing % to the rate of reduction.' the frequent result is less spending on nutrition and children's wellbeing. indeed, when poor households face a decline in food purchasing power, their coping strategies often include buying cheaper items and moving to less diverse diets, depriving pregnant and nursing women and young children of essential nutrients (holmes et al., ) . women often turn to extreme coping strategies: reducing their food consumption to make more available to others in the family (quisumbing et al., ) , collecting wild food or even migrating in distress or selling assets (holmes et al., ) . during the food crisis in chad, khadija khazali, a widow with seven children from azoza village, said, "we have reduced the number of meals daily, and women are digging in anthills to recover grainsa practice which our community has not had to resort to for a very long time" (ford, ) . women may also take unsafe jobs to boost their incomes, at the expense of their own security and health, e.g. working in mines (quisumbing et al., ) or going into prostitution (cohen and smale, a) . men have more access to social capital and have more pathways out of a crisis, whereas women often face severe time burdens, given the pressure on them to ensure the household's food security. therefore they do not enjoy the same opportunities (ford, ) . men can migrate more easily to find a job in urban areas, and this affects the coping capacity of the women who are left behind: they now must manage the family farm, but may still have to get approval from their absent husbands on key agricultural decisions (coon, ) . the structural causes of the crisis? . . putting food security back on the political front burner the crisis and the subsequent media coverage created an opportunity to put food and agriculture back at the core of global development policies, following years of neglect. after - there was a flurry of action, from countries and regions on the front line of the crisis to oda, multilateral initiatives for reinvestment in agriculture and intergovernmental action, to elevate the place of food security on the global policy agenda. as noted in table , in the first years following the crisis the global policy responses and funding commitments focused on macro-level relief such as support for production, food aid and preventing export bans (quisumbing et al., ) . help million africans get out of poverty by . source: authors' analysis; specific sources for each initiative indicated in the relevant row. the fao was the first institution to react, establishing the initiative on soaring food prices in december , with a budget of $ . bn. this provided countries with technical advice through fao's guide for policy and programmatic actions at country level to address high food prices (maetz et al., ) . then in april world bank president robert zoellick pushed for a "new deal for a global food policy" and established the global food crisis response program (gfrp), with a view to the "expedited processing" of assistance and an initial budget of $ . bn. similar to fao's initiative, the gfrp provided technical and policy advice to severely affected, low-income countries (world bank, ). the first coordinated international response was the high-level conference on world food security, held in rome in june and attended by over heads of state from the global south and north. a group of international organizations produced the comprehensive framework for action (cfa), which was launched at the conference; this called for an additional $ bn-$ bn per year for food aid and oda for agriculture and social protection, and advocated allocating % of international aid to agriculture for the next years. the conference resulted in greater collaboration among the rome-based un food and agriculture agencies, but it also led to greater fragmentation of food-related international institutions as yet more new ones were created. then the world summit on food security in rome in november agreed to the rome principles for sustainable global food security, which called for better coordination and more stable funding (fao, c) . both the group of (g ) "leading" countries and the larger group of (g ) then agreed to food security initiatives, including at every annual g /g summit meeting from to . at the g summit in l'aquila, italy member governments pledged $ bn, but it turned out that a large part of this consisted of recycled promises or even money previously spent. in september the pittsburgh g summit asked the world bank "to work with interested donors and organizations to develop a multilateral trust fund to scale-up agricultural assistance to low-income countries" (g information centre, ). the resulting global agriculture and food security program (gafsp) (world bank, a) currently is providing $ . bn to countries through two windows: one focused on supporting public sector action in developing countries, and the other providing loans, guarantees and equity to the private sector to support investment in agricultural development (gafsp, ). following the second spike of the crisis in , there was an additional set of global responses. this time there was a greater focus on long-term agricultural investments, especially through partnerships with other actors like the private sector, whereas in - the response was mainly through the public sector. reflecting on the policy responses to soaring food prices, de schutter ( ) commented: today, too many [governments] continue to see hunger as a problem of supply and demand, when it is primarily a problem of a lack of access to productive resources such as land and water, of unscrupulous employers and traders, of an increasingly concentrated input providers sector, and of insufficient safety nets to support the poor. too much attention has been paid to addressing the mismatch between supply and demand on the international markets […] while comparatively too little attention has been paid both to the imbalances of power in the food systems and to the failure to support the ability of small-scale farmers to feed themselves, their families, and their communities. . responding to the crisis with business as usual . . addressing supply and demand factors: increasing productivity as a major solution, but neglecting the issue of marginalization the marginalization of whole segments of the population in attaining food security and nutrition throughout the food price crisis made it clear that the main issues were access and inequality, rather than food production. however, the policy discussion tended to focus on the need to double production, both to dampen short-term price increases and also to meet projected population growth through to . efforts and plans tended to focus on this perceived need for increased production, even though supplies were already in substantial surplus (bricas and goïta, ) . between june and july , wfp provided short-term food aid valued at $ . bn, nearly double the $ . bn in agricultural aid mobilized by the world bank, fao and the international fund for agricultural development (ifad) (brock and paasch, ). wfp's big fundraising push sought to compensate for the effects of rising food prices on its ability to procure commodities (golay, ) , but in fact global food aid volumes in - were below those of - , as a direct result of the and price spikes (brock and paasch, ) . although some of the early initiatives did provide resources to smallholder agriculture, not all smallholders benefitted equally. thus, these programs fell short on delivering fully on the promise that smallholder-led agricultural development was back prominently on the development agenda. for example, an actionaid assessment showed that gafsp projects successfully targeted small-scale food producers. some projects emphasized women's empowerment, through income-generating opportunities for women and strengthening women's organizations. however, the study also pointed out that women were not adequately consulted in project design and activity planning, and their under-representation prevented them from receiving information about projects (actionaid, ). in addition, much of the funding provided to address the crisis aimed to promote the growth of productivity in staple grains. this was true of the majority of grants from gafsp and the us feed the future (ftf) program for example, with much less attention paid to horticulture crops (pingali, ) , even though horticulture production had the potential to boost the livelihoods and food security of smallholders, including women farmers (ulrich, ) . as table shows, targeting women was not a priority for most of the initiatives that sought to address the food price crisis. for those that did aim to make gender equality a high priority, such as the cfa, the gafsp and ftf, the impacts were limited because these initiatives focused on enhancing the productivity of "market-ready" farmers, who frequently tend to be male. although the cfs champions tackling gender inequalities in food security and nutrition, some member states have sought to weaken it over the past decades, leaving it with less influence. the g responded to the price spikes by encouraging the development of the agricultural marketing information system (amis). this initiative seeks more transparent commodity markets and information exchange among producer and consumer countries. however, amis has no control over many of the drivers of price volatility, and it is not able to monitor privately held stocks (e.g., those of grain traders) (murphy and schiavoni, ) . equally, it cannot tackle all the major market failures that lay behind the crisis. global policy makers largely failed to enact needed reforms to financial markets to prevent destabilizing speculation in commodity markets, due to pressure from industry lobbyists to maintain the status quo (see, for example, fang, ) . the high-level conference on world food security in , the g summit and the world food summit all pointed to the potential table attention to gender issues in initiatives undertake to tackle the food price crisis. gender focus? no mention of gender inequalities or specific focus on women in the guide. comprehensive framework for action (cfa) recognizes the disadvantages that women face in the food price crisis and their disproportionate vulnerability, especially to the long-term effects. the "menu of actions" recommends that "channeling food assistance via women should be encouraged and opportunities to improve program efficiency should be pursued." global food crisis response program (gfrp) no information found. purchase for progress (p p) takes a "gender transformative approach, directly focusing on women to ensure that they benefit from the project source." hokkaido, japan g summit no mention of gender inequalities. committed to a rights-based approach to support small-scale food producers, gender mainstreaming and ecological sustainability. feed the future the usaid forward policy framework and the feed the future guide, which support ftf operations, emphasize gender equality. the policy framework seeks to ensure women's engagement throughout the project cycle. the guide makes gender a cross-cutting priority, and aims to recognize women's often unsung contributions in agriculture, rights to resources and needs as food producers. l'aquila, italy g summit only one mention of women farmers as food security actors. makes "gender, food security and nutrition" a pillar of cfs work. the committee urged member states to undertake policy reforms to ensure gender equality in achieving the right to adequate food and nutrition, and to include women in food security decision making at all levels. it also asked member states to produce gender-disaggregated data. continued role that food reserves could play in the international response to the crisis (gubbels, ) . in the early s, under pressure from the international financial institutions due to the high cost, many developing country governments had abandoned the use of food stocks to counter physical shortages or reduce price fluctuations (see, for example, devereux, ) . but as prices rose in - , some countries sought to collaborate on a regional basis to create reserves to dampen the effects: new regional stocking systems were set up in west africa by the economic community of west african states (ecowas) and in southeast asia by the association of southeast asian nations (asean) (lines, ) . many governments reacted to the crisis, sometimes without efforts to coordinate their actions. however, many low-income, food-importing countries had limited capacity to respond (golay, ) and they also suffered impacts from the actions of other countries, such as export bans. gafsp directly supports achievement of sdg , encouraging gender equality. beyond increasing productivity and linking farmers to markets, gafsp's sustainable agriculture interventions have an impact on gender equality issues, such as women's agricultural empowerment, job creation on and off the farm and the enhancement of women's and girls' nutritional status. agricultural action plan mostly gender-blind, with a single "add women and stir" line in the action plan: "focus on the ultimate client, especially women." gender-blind: does not address gender issues, and evaluated by fao as "neutral" on gender, with no specific gender component or strategy. no mention of gender. weak on the recognition of women's rights and women's empowerment. source: authors' analysis; see table for specific sources for each initiative. in west africa in the majority of states lowered tariffs and taxes on some cereals, and some decided to control their domestic prices. although such measures can ease the food price burden on consumers, including politically restive urban populations, they cannot ensure efficiency and sustainability or target all vulnerable people, and may be very costly to maintain (cohen and smale, b; hathie, ) . most of the programs implemented after the crisis only targeted cereal production to reach national sufficiency and did not target other segments of the value chain. this strategy was conducted through national agricultural investment plans (naips), which originally were meant to tackle structural constraints and encourage sustainable agricultural growth as part of national development planning processes but which led to dependency on input subsidies and created a higher dependence on external markets (hathie, ) . fao examined the measures taken in more than countries from to , and found that policy decisions paralleled those of - ( fig. ) (see also maetz et al., ) . these measures included support for farmers' access to inputs and facilitating access to credit. however, such policies do not necessarily favor smallholder production, and many of the policies that on paper targeted small-scale producers excluded those considered to be nonviable economically, leaving many out (wise and murphy, ) . moreover, some of the policies emphasized inclusion of small-holders in export value chains without evaluating the environmental and economic risks (wise and murphy, ) . such policies often had disastrous impacts on small-scale farmers, especially on women farmers who relied on production of non-staple crops. these are key sources of micronutrients, but were crowded out by efforts to promote staple production with fertilizer and credit subsidies and price supports. in many instances, this led to increased prices for non-staples, such as fruit and vegetables (pingali, ) . . . . . liberalization of agricultural trade trade-oriented measures evolved as a medium-term trend. some exporting countries still observed export restrictions after to keep their domestic prices low but several countries, in contrast, put in place export facilitation measures (maetz et al., ) . h in addition, some governments lowered tariffs on imported food in order to improve food access (maetz et al., ) . overall, the policy responses did not reverse the direction of global agricultural trade liberalization. governments continued to reduce agricultural tariffs, and many offered preferential market access via bilateral agreements. world agricultural trade grew an average of . % per year during the two decades following enactment of the wto agreement on agriculture, i.e., (beckman et al., . . . . . acquisition of large tracts of land and biofuel policies one consequence of the food price crisis was a scramble to gain control of large tracts of land in developing countries. wealthy-country governments and private companies acquired much of the land in question. between and , the five leading investor countries were malaysia, singapore, cyprus, the united kingdom and china (grain, ; nolte et al., ) . large-scale land acquisitions (in excess of hectares) often dispossessed smallholders (geary, ; wise and murphy, ) . in most instances, these investments focused on export production rather than growing food h these countries included argentina, brazil, chile, ecuador and paraguay in south america, syria and yemen in the middle east and asian nations including china, pakistan and thailand, as well as india to some extent. countries limiting exports included cambodia, china, india, pakistan and vietnam. crops for local consumption, often with little regard to environmental consequences (geary, ) . two-thirds of these acquisitions occurred in countries facing significant food insecurity (geary, ) . usually, investors sought to acquire land in order to produce biofuel crops such as sugarcane, soy and jatropha for export (geary, ) . meanwhile, biofuels policies in rich countries remain largely unchanged. the united states, the main producer of maize-based ethanol, continues to require the blending of ethanol into petrol (bracmort, ) . legislative work to install a ceiling on the share of biofuels coming from food crops has continued at the eu level over the past decade. however, the eu's renewable energy directive (red ii) of still allows member states to burn massive amounts of food as fuel (oxfam international, ) . . . . . national public investments in agriculture continue to fall short food security and agriculture also gained regional and national policy salience after the food price crisis. for example, the comprehensive africa agriculture development program (caadp) (see box ), the comprehensive africa agriculture development program (caadp) (au, a) seeks to promote agricultural development, food security and good nutrition on the continent. it was endorsed at the au's summit meeting under the maputo declaration in (au, b) . from the start, it grabbed headlines by setting a target for every african government to devote a minimum of % of its budget to agriculture. the program is intended to end a long-ingrained habit of dependence on external resources. as a oxfam report noted, "international aid has long represented the bulk of agricultural sector financing in many west african countries. in , it accounted for % of the domestic agriculture budget of niger [and] over % in ghana…." (guereña, ) . oda remains a key source of finance for burkina faso's agriculture budget. i this situation has led the work of governments in unusual directions. thus, "national agriculture co-ordination bodies do exist…, but they serve more to exchange information than to actually co-ordinate interventions on the ground" (guereña, ) . by agriculture's share of public expenditure by african governments was just . %, although the share differed greatly from country to (anisimova, ) , and few have done so consistently. the au agreed to a new agenda in , marking years since the foundation of the organisation of african unity. its call to action for the next years included the following among its targets for african agriculture and agro-businesses by the time of the th anniversary: • achieve zero hunger; • lower food imports while boosting intra-africa food and agricultural trade to % of total agricultural trade; and • increase women's access to land and agricultural inputs, and allocate at least % of agricultural finance to women (au, ) . one year later in , the malabo declaration introduced a system of biennial reviews of countries' achievements under caadp (au, ). the first review, covering and , found that au members' expenditure on agriculture ranged from . % to . % of their budgets. ten countries met the % target, but this was no more than in , when the star performers were zimbabwe, malawi and ethiopia. however, malawi had fallen back from . % in to . %, ethiopia to . % and zimbabwe to . % (au, ). there are concerns that the review process is excessively "state-centric." popular narratives dwell on the argument that if the review process is there to ensure accountability, it must provide for inclusivity and the participation of all stakeholders. j indeed, the caadp framework remains very weak in terms of gender inclusion: the only caadp commitment related to gender is about women's involvement in agribusiness. in other words, the caadp commitments themselves are largely gender-blind. and although the technical guidance of caadp asks countries to collect gender-disaggregated data, there is minimal reporting on how women smallholder farmers are progressing under these commitments. . % of their expenditures that year to the military (world bank, ), despite the role played by conflict in increasing hunger in the region. despite renewed policy attention to agriculture, current public investment levels remain woefully inadequate. the un conference on trade and development (unctad) estimates an annual investment gap in developing country agriculture of $ bn over the period - (out of a total annual sdg financing gap of $ . trillion) (unctad, ). an analysis of national government and aid donor investments in ethiopia, ghana, nigeria, pakistan, the philippines and tanzania was unable to trace the flow of funds to women farmers. it found diversion of resources away from smallholders, and a lack of government capacity to ensure support for small-scale producers (either men or women) (mayrhofer and saarinen, ) . social safety nets put in place by governments are often efficient in targeting vulnerable populations; however, their efficiency is limited depending on the objective (e.g., assistance through cash transfers during lean periods) and there are multiple approaches (a short-term approach providing food assistance or long-term approaches aimed at strengthening resilience and fighting poverty). while donors' efforts to target support for social protection programs based on poverty criteria show decent results (schnitzer, ) , there could be better inclusion of women by adding gender-specific requirements (e.g., direct inclusion of female heads of household or women with children under the age of five). investments in r&d and in infrastructure have often focused on export agriculture and cereals at the expense of food crops oriented toward the consumption of local communities (de schutter, ) . the consultative group for international agricultural research's (cgiar) r&d expenditures on wheat, maize and rice, for example, more than doubled from $ m in to $ m annually during - (pingali, ) . the share of oda dedicated to food security and nutrition (fsn) has remained largely constant (fig. k ) : oecd data show that this kind of aid grew at the same rate as total oda, without major increases in response to the food price spikes. k we use the same methodology as presented in mowlds et al. ( ) to calculate gross oda disbursements for food and nutrition security (fns). we therefore consider all aid reported under agriculture, agro-industries, forestry, fishing, nutrition and development food aid/food security assistance as being aid for fns. while this approach will include some aid that is not specifically targeted to fns and will also exclude some that is, we feel that in the absence of a specific fns classification it provides a reasonable picture of trends in aid in this area. although the $ bn pledge made in l'aquila in did lead to additional oda resources for agriculture, the increase in funds for fsn was modest, as less than one-third of the pledges ($ . bn) represented additional money above spending that donors had already planned. also, the funds promised at l'aquila were one-time pledges, not multiyear commitments of additional money (mowlds et al., ; wise and murphy, ) . as the global economy fell into recession in the second half of , donors turned to austerity measures that limited oda increases (wise and murphy, ) . analyzing two major donors, the eu and the us, over a period of years shows that they are far from delivering. smallholders are central to the eu's international food security policy (ec, ) and its $ bn food facility, launched in , had a specific focus on small-scale producers. however, mayrhofer and saarinen ( ) found that less than one-quarter of eu aid for agriculture between and explicitly targeted small-scale producers. only %- % of eu agricultural funding promoted gender equality, and there was little attention to environmental sustainability. furthermore, with the exception of just year ( due to the food facility), the eu's agricultural oda has consistently supported industrial and export crops with significantly higher budgets than food crops. the destination of oda can also contradict aid effectiveness principles when it does not match policy commitments. in contrast with the eu commitment to target a substantial share of its aid to africa, oda for agricultural fig. ). the us created a -year, $ . bn agriculture, food security and nutrition initiative, feed the future (ftf), after l'aquila. since , the program has continued with funding of about $ bn annually. ftf has attempted to integrate the principles of aid effectiveness, particularly country ownership, into its programming, along with women's empowerment and sustainable natural resource management. its main emphasis is on working with "market-ready" smallholders who have high potential to engage in commercial agriculture, often however at the expense of farmers who have the least access to resources (land, labor, capital). also, the focus is more often on approaches to yield gains that require high levels of external inputs. the gains have been impressive: farm outputs in ftf focus countries over the period - exceeded those of other low-and low-middle-income countries by $ bn (feed the future, ). however, it is not clear whether these gains are sustainable once us aid ends. there also appears to be a real trade-off between aligning aid with national development plans missing out on small is beautiful: the eu's failure to deliver on policy commitments to support smallholder agriculture in developing countries. oxfam briefing paper. https://policy-practice.oxfam.org.uk/publications/missing-out-onsmall-is-beautiful-the-eus-failure-to-deliv-er-on-policy-commitme- . on the one hand and some other aspects of country ownership on the other, such as broad consultation with stakeholders and provision of resources through local systems and actors (muñoz and tumusiime, ) . . . . . growing role for multinational enterprise since the food price crisis, global policy has given more space to the private sector: for instance, the g launched its new alliance for food security and nutrition in africa in may , with a goal of "unleashing the potential of the private sector." developing country governments, bilateral and multilateral aid agencies, and multinational firms have all joined in promoting private investment in agriculture in the global south. but there is a big risk that this emphasis will bypass smallholder farmers (see box ). the g launched the new alliance on the eve of its camp david meeting in . this initiative represents a major scaling back of public funds provided by g countries for global agricultural development, leaving africa much more reliant on public-private partnerships (ppps) and private capital. the alliance has been denounced as "the new colonialism" by some organizations in the region (provost et al., ) . the new alliance has benefited the biggest agribusiness multinationals through legal changes and new investor frameworks in african countries, while family and smallholder farming is to a great extent excluded. of new alliance projects, only three are led by producers' organizations (one each in burkina faso, benin and malawi). the agricultural model supported resembles that of the green revolution of the s and s, i.e., monoculture, mechanization, very heavy dependence on purchased inputs, long distribution channels and production for export. it also puts considerable emphasis on the role of biotechnology. by focusing narrowly on technology-driven productivity gains, this approach misses much of the complexity that underlies hunger, and ignores the ways that the interests of powerful actors affect food and agriculture. there is evidence that the alliance has supported the enactment of laws conferring intellectual property rights to plant breeders; this impinges on traditional farming practices such as saving, reusing and trading seeds (qiu, ) . a uk government fact sheet on the new alliance makes no mention of gender or women's roles in food security (dfid, n.d.), and a new alliance progress report published in points out that only % of smallholder farmers taking part in new alliance projects are women (acf et al., ) . a new trend in development finance is private finance (pf) blending: during the past years, donors and international agencies have increasingly sought to engage the private sector in development, using oda to "leverage" private finance through "blending" the latter with public resources. the data on how much oda is going into pf blending arrangements remain unclear (eurodad, ) . although the absolute figures appear still to be relatively low, it is expected that they will increase rapidly over the coming years. such a financing mechanism could benefit smallholders in low-income developing countries, including women, by de-risking the provision of credit for on-and off-farm activities. for example, ftf in ghana has worked with a local financial institution to expand the provision of microcredit in the northern part of the country, which has higher poverty rates than the national average (saarinen and godfrey, ) . a study of pf blending programs in agriculture found serious data limitations (both quantitative and qualitative). it concluded that "donors have more work to do to ensure that private finance blending is an effective tool for financing smallholder agriculture and promoting inclusive and sustainable transformation in the sector" (saarinen and godfrey, ). the following broad conclusions have been drawn from a analysis by eurodad and oxfam (which is not specific to agriculture and food security). pf blending poses risks to the quality of aid (eurodad, ): • it is less transparent and accountable than other forms of aid. • development finance institutions (dfis) that engage in pf blending often do not operate according to the principles of development effectiveness, particularly country ownership. • so far, there is inadequate evidence on impacts and inadequate monitoring and evaluation. • pf blending opens up the possibility of supporting donor-based commercial interests, rather than local smallholders. this increases the risk that it will support tied aid. blending also could drain oda resources from high priority development programs and is unlikely to offer an effective means to finance development in poorer countries or for the poorest farmers. based on return on investment considerations, pf blending resources tend to go to middle-income countries and are geared toward better-off farmer groups who already have access to resources and knowledge (eurodad, ; see also saarinen and godfrey, ) . a recent study by the overseas development institute (odi) reinforces these concerns. it found that, despite donor claims of high leverage ratios, each $ . of blended development finance from multilateral development banks and dfis in fact leverages just $ . in private finance. the figure falls to $ . for lowincome countries (attridge and engen, ). adaptation to climate change is also an issue that needs high-level funding if the world is to reach zero hunger. the united nations environment program (unep) has found that developing countries' annual adaptation costs could reach $ bn-$ bn by (unep, ), with much of those costs agriculture-related. pearl-martinez ( ) found that adaptation finance still accounts for less than half of all climate finance. only a very small share is targeted to smallholders; in , the figure was just $ m. the food price crisis of - generated a strong reaction and opened the door to civil society and the scientific community to push for a radical transformation of agri-food systems that would take account of environmental, social and health challenges and would promote fairness and sustainability, through balanced governance (bricas and goïta, ) . despite these opportunities, however, the governance of global food security is under threat and its shake-up after the food price crisis has not led to smooth coordination, coherence or convergence among the multiple stakeholders. multilateralism and global governance are more and more hybrid and fragmented: numerous parallel and overlapping initiatives and platforms deal with food security and operate without coordination. so far, they have not proved able to converge to attain sdg (zero hunger), (gender equality) or (combat the impacts of climate change). since the food price crisis, the decision-making center has shifted uncertainly between the cfa, the high-level task force on global food and nutrition security (hltf), the g , the g and the world bank and the international monetary fund (imf), with strong influence from the private sector. the decision-making power of the cfs has been reinforced since its restructuring, but its recommendations to member states remain purely advisory. paradoxically, food security governance has also been more concentrated among just a few actors since the food price crisis. after the crisis, we can identify four relevant types of international agency involved in food security governance: • general political direction: the g /g and the g . these groupings are powerful as they are dominated by richer countries, include all the main aid donors and can take big decisions at moments of crisis. even in the more broadly based g , the representatives of the global south are either bigger countries (e.g., indonesia), members of the brics group (e.g., south africa) or both (e.g., brazil, china and india). africa is represented only by south africa, while small island states, which are extremely vulnerable economically and climatically, are not represented at all. • development aid: e.g., wfp, the world bank, ifad, usaid, eu institutions, such private foundations as the bill & melinda gates foundation and the rockefeller foundation and private ventures like the alliance for a green revolution in africa (agra). the world bank and the imf wield outsized influence on countries through their loans, conditionalities, policy advice and technical assistance, much of which is followed by bilateral aid agencies as well (eurodad, ; stichelmans, dispute settlement mechanism is currently in crisis due to a withdrawal of cooperation by the us, which is seen in some quarters as an effort to undermine the organization (bey, ) . other analysts see us obstruction as part of that country's negotiating posture tied to its trade disputes with china, and note that the us continues to win a substantial share of the complaints it brings to the disputes body (hanke and von der burchard, ; lamy, ) . this fragmentation leads to a lack of coordinated policies and coherent governance, with strong competing perspectives. the un system has promoted a rights-based approach to food security through the cfs, encouraging the implementation of more holistic tactics to achieve the sdgs, advocating for sustainable food systems and agroecology, launching the un decade of family farming ( - ) and, in , adopting the un peasants' rights declaration ( un news, ) . on the opposite side, some aid donors have provided short-term responses that have not always been consistent with long-term needs. and in terms of policy, the response to the food price crisis served to reinforce the emphasis on productivity and producing more food "to feed billion by ," failed to address ecological challenges and the rights and practices of small-scale farmers and practically ignored gender inequalities (duncan and margulis, ) . increased multinational corporate influence within the governance landscape has resulted in a limited interpretation of sustainability. for example, some global supermarket firms include in their sustainability plans the integration of smallholder farmers into their value chains, including training in sustainable agriculture techniques. at the same time, the growing market power of these firms allows them to enforce production standards within those value chains and to determine contract terms (barling and duncan, ) . such private power often contradicts and undermines efforts undertaken by civil society actors and some states to promote a rights-based approach to food security (duncan and margulis, ) , and raises accountability questions. states continue to play a key role in global food security governance across the different platforms of engagement and at multiple scales (duncan and margulis, ) . however, the increased complexity of governance can permit states to pursue contradictory policy goals. they may place food security high on their policy agendas, strongly advocate for it in forums like the g or the g and provide contributions of aid for agriculture, but at the same time they may try to limit the political influence of the cfs and its multi-stakeholder process, prevent institutionalization of the human right to food as a fundamental principle of food security and pursue aggressive trade liberalization policies vis-à-vis developing countries (duncan and margulis, ) . the body that was supposed to give general political direction is the cfs, which was reformed in the wake of the food price crisis to be a broad, multistakeholder platform for food security governance, incorporating civil society organizations, in particular organizations and movements of the people seriously affected by hunger and undernutrition, as part of the decisionmaking procedures with the status of empowered (though non-voting) participants (mckeon, ) . this process is facilitated through the civil society and indigenous peoples' mechanism (csm). member states remain the principal decision makers and accountable stakeholders (mckeon, ) . this structural reform qualifies as a significant effort to address the underlying causes of the food crisis. however, the cfs faces a multitude of challenges, despite evaluations that find its work positive and pertinent; this is symptomatic of a global contraction of civil-society space in all governance platforms. the challenges concern (mckeon, ): • the actors-some governments do not wish to be held accountable; big corporate actors seek a privileged place at the expense of smallholders and civil society organizations (csos). • the process-some states favor technical and institutional solutions that privilege investments over public policies and make extra use of their red lines to prohibit discussion of certain topics. • the finances-inadequate funding of the platform constrains its potential. • the content-the agenda is overly influenced or controlled by a few states with strong vested interests in expanding current agriculture models while civil society voices and farmers organizations are marginalized. it took the csm several years to bring agro-ecology before the cfs, and debate on contentious questions such as food sovereignty, climate change, biofuels and the food and nutrition impacts of international trade liberalization remain taboo. in contrast, the g expanded its area of influence after the food price crisis, seeking to coordinate the global response. the g action plan did not address the root causes of the problem, however, and au countries criticized it for fostering continuing dependence on food imports in an era of volatile global prices. these countries demanded policies to support food self-reliance (wise and murphy, ) . the g includes the governments of some of the world's wealthiest and most powerful countries, as well as those of middle-income and developing countries that have no mandate to speak for other countries. this arrangement poses a problem of legitimacy, especially when the countries representing the global south in the group are major net food exporters, such as brazil (wise and murphy, ) . since the food price crisis the private sector, another key player, has acquired increasing influence over food security governance, adding another layer of complexity to the panorama of actors and decision making. the rhetoric of mobilizing "billions to trillions" to finance achievement of the sdgs (world bank, ) elevates the private sector and private finance to an ever more privileged position. a analysis examined the key elements of the growing influence of agri-food multinationals in discussions on the fight against hunger at a governance level (acf et al., ) and syngenta (now owned by bayer and chemchina, respectively) established or ramped up their philanthropic arms to engage in advocacy in international forums, including the cfs, as well as in discussions on trade and the environment. • multinational firms have proved influential in development discussions through their corporate social responsibility activities. their public relations efforts highlight the convergence of corporate and government interests and priorities. a good example is the food company nestl e's decade-long emphasis on "creating shared value" which, according to the firm, reflects "our ongoing commitment to achieving the un sustainable development goals…." (nestl e, ). • undertakings such as the new alliance and grow africa seek to mobilize private funds to overcome public sector disinvestment in the agricultural sector in developing countries. donors have established these entities to offer the private sector vehicles to promote their approaches, technologies and policy prescriptions. large philanthropies such as the rockefeller foundation and the bill & melinda gates foundation in particular have a great deal of financial clout: between and private foundations spent $ . bn on agricultural development, and % of these funds went to africa. over the same period, private foundations spent $ . bn on agricultural research, primarily on inputs and specifically seeds (mainly hybrids and genetically modified organisms (gmos)) (inter-r eseaux, ). their financial clout and investment mean that they exert influence over the agricultural models that developing countries adopt. organizations that have received substantial foundation funding, such as agra, have sought to shape the design of policies in africa: in ghana, the agra working group on seeds drafted corporateoriented amendments to the national seed policy that were submitted to the ministry of food and agriculture (inter-r eseaux, ). as the influence of private sector actors in food security policy has grown, it has tended to overwhelm that of small and family-owned business. corporate actors usually promote technological approaches to development, including high-external-input agriculture, and generally steer clear of any holistic rights-based approach. multinational firms also structure their own governance along top-down lines, leaving out farmers' organizations, organizations of rural women and women's rights organizations, national private sectors and civil society in general (inter-r eseaux, ). unstable and broken food system the lack of progress on realization of the right to adequate food for all-and specifically for women smallholder farmers-and thus on achieving sdg by results from instability in the factors that contribute to achieving food security, and this has led to food price volatility. all this is largely the consequence of gender-blind political choices that have failed to tackle the broken agri-food system. twelve years after the - food price spike, the main structural factors that marginalized women smallholder farmers have still not been addressed and the most likely food security scenarios do not seem to have become any more optimistic. according to the un report on the state of food security and nutrition in the world (sofi ), the number of hungry people globally rose by million in and by million over a -year period. looking at food insecurity thorough a different optic, the report also found that more than billion people ( . % of the world's population) cannot afford a healthy diet (fao et al., ) . the number of people facing acute food insecurity rose to million in (fsin, ). the number of african countries relying on external food aid rose from in to in (caramel, ) . early projections of the effects of the coronavirus pandemic suggest that it will have catastrophic food security consequences. sofi reports that covid- could add million- million people to the ranks of the hungry, depending on the depth and duration of the resulting global recession (fao et al., ) . the virus, combined with insecurity, extreme weather, desert locusts and economic instability will likely contribute to increased acute food insecurity as well (fsin, ) . violent conflict is the key factor in the severe food crises in south sudan and yemen (fsin, ) . according to the latest intergovernmental panel on climate change (ipcc) report (ipcc, ), there is already evidence of farmers migrating as temperatures increase, exacerbating inequality as those least able to cope are forced to uproot their lives. marginalized communities-including indigenous, pastoral, agricultural and coastal communities-will suffer the most as food and water become less available, health risks increase and their lives and livelihoods are jeopardized. women farmers remain on the razor edge of extreme shocks to the system and in a warming world, with a growing number of hungry people and more conflicts, they face ever greater risks. indeed, according to fao, "women are slightly more likely to be food insecure than men in every region of the world" (fao et al., : ) , especially if they live in rural areas, where poverty and food insecurity are very much linked, and especially in a context of increased reliance on markets and a decrease in subsistence agriculture. current food stresses are linked to prices and access to markets rather than to production (gaye et al., ) , but women are vulnerable in all dimensions of food security: availability, access, utilization and stability. twelve years on, food production has increased and remains adequate to feed all of the increased population in all of the world's regions. per capita food availability has increased globally over the past years (un women, ). nevertheless, climate change and its impacts on agriculture constitute a substantial threat to food availability. fao projects that global average cereal yields will decrease by %- % for each degree of warming . africa and a belt stretching from the middle east through south asia to mainland south-east asia and on into indonesia and the philippines are forecast to be the regions worst affected by disasters caused by natural hazards associated with climate change . this is likely to cause severe harm to harvests and external trade, among other things . it is also forecast to increase food prices, most of all in west africa and india; people's purchasing power is expected to decline by nearly % in west africa and . % in india (fao, ). reduced buying power will have severe impacts on rural poor people . climate variability and extreme weather events can have negative local impacts even when overall national food production figures look good, and this can lead to serious hunger problems in the affected areas . rural people in developing countries, who usually have low carbon footprints (pearl-martinez, ) and depend on renewable natural resources, are acutely vulnerable to climate shocks and natural hazards, which can result in devastating production losses and undermine their food security and nutrition . women have especially high vulnerability as they tend to have less access than men to the resources that can facilitate climate change adaptation, such as social capital, land, finance, credit, health, education, information, mobility and formal employment, and they frequently lack a seat at the decision making table pearl-martinez, ; quisumbing et al., ) . climate change related drought and water scarcity add to their gender-related workloads, such as collecting fuel wood and water (fao, ). even when food is available, poor and marginalized people may lack the resources to access it through purchase or production, and too often neither public social protection programs nor private charity reach them, if these even exist in poor countries (drèze and sen, ) . most often women are expected to find ways to cope with their families' hunger (un women, ) . within concentrated global and domestic value chains, women farmers are at risk because of their weak bargaining position: global food industries and supermarket chains play an increasingly prominent role in food supply, and access to food depends on income, price levels and social transfers, factors over which women have no power or in which they face discrimination (un women, ) . smallholders find that they are being driven out of markets, squeezed by corporate entities on both the input side (seeds, machinery) and the buyer side (traders, food industry, supermarket chains). willoughby and gore ( ) found that in the context of patriarchal norms and social practices, women feel the effects most severely. they are relegated to low-paying and often informal work within agri-food systems, are denied most socioeconomic and political rights and are under the threat of sexual harassment and violence. all these factors constrain their ability to access food. a survey of south african grape farm workers in found that over % said that they did not have enough to eat during the prior month. nearly a third said that they or someone in their family had missed at least one meal in that month (willoughby and gore, ) . when policies have been implemented to give women better access to markets, they have not necessarily been beneficial. entering into market relations usually brings large changes-negative or positive-to the ways that people live. these changes can alter relations within the household, to the benefit or detriment of women. in general, it is widely thought that direct access to income increases a woman's autonomy, but in the household economy it is not always that simple (britwum, ) . within farming households, there are often gender differences in revenue earning from crops. men tend to produce high-value crops, leaving women to cultivate traditional produce which may be rich in critical micronutrients but has been neglected by post-crisis policies that have primarily targeted cereal production to reach national sufficiency. an fao analysis of gender and cash crop production in ghana found that women cocoa farmers are as productive as men. but because they tend to be more cash strapped than male producers, women cultivators tend to use more labor-intensive and less high-tech approaches than men, which adds to their workloads (fao, c) . conflict also has gendered impacts on food security (fao et al., ) : • men tend to do the bulk of the fighting, leaving women in charge of household livelihoods and wellbeing. • violence can directly harm women, and can also reduce their capacity to provide for their families. • conflict related displacement also is a major reason for food insecurity, and affects women and children disproportionately. at the household level, women are frequently the ones who eat least, last and least well. increased poverty in female-headed households affects women's nutrition: to adjust to the decline in their capacity to purchase or grow highquality, diverse foods, they often shift to cheaper and less diverse diets, which frequently lack the key nutrients that pregnant women and young children require. as fao (n.d.) has observed, "more often than not, the face of malnutrition is female." in , global food insecurity rose for the third consecutive year , and women were the most affected: a third of the world's women of reproductive age suffer from anemia, usually due to iron-deficient diets. this also means risks for the health and nutrition of their children (fao et al., ) and has long-term impacts on development. worldwide, anemia is a contributing or sole cause of %- % of maternal deaths. anemic women are twice as likely to die during or shortly after pregnancy as nonanemic mothers . because anemia caused by iron deficiency results in reduced learning capacity and less productive workers, it is estimated to reduce gross domestic product (gdp) by % annually, particularly in african and south-east asian countries (world bank, ) . women's malnutrition frequently stems from poverty and unequal intrahousehold relations. women who have access to financial resources enjoy greater dietary diversity, and in rural areas women farmers who control resources tend to have better-quality diets (lourme-ruiz et al., ) . even when food is available and relatively accessible, people may not fully meet their nutritional needs. in countries where the calorie supply is adequate, there are still high levels of child stunting, e.g., bangladesh, burkina faso, ghana, mali and nepal (dury and bocoum, ; un women, ) . climate shocks, conflicts and social factors that increase women farmers' work burdens put their own health at risk and limit their ability to engage in recommended feeding practices for infants and young children . in many developing countries staples price volatility has persisted, with fresh spikes in and , and prices have remained above the level of the early s. in the face of volatile prices, people shift their income from other necessities to maintain their access to food, and this means that stable prices are a crucial element of food security (fao, ; murphy and schiavoni, ) . instability on the dimensions of food security over the past years has driven the failure to attain the right to adequate food. this is largely due to political choices concerning food security but also to funding, in terms of quantity, quality, targets and accountability. funding agenda to address women's food insecurity? . . an institutional step forward some major institutions have shifted their narratives to factor gender into their policies and strategies. the un agencies in particular have worked toward the empowerment of rural women and have helped reframe the agricultural development narrative. after the food price crisis, the rome-based un agencies developed their own gender strategies: • wfp-in wfp implemented its policy on gender equality for all its programs and projects through an action plan for operability in the field. the objectives were to bring an adapted approach to food aid considering specific needs, increase women's participation in program design, empower women and girls in decision making and protect women from sexual and gender-based violence (wfp, ). • fao-in march fao adopted its policy on gender equality. the objective was to better target women across all programs through disaggregated gender data and norms and standards in project formulation (fao, b). • ifad-ifad's gender strategy implemented in was articulated around three objectives: promote women's economic empowerment, ensure equal participation and influence within institutions and rural organizations and guarantee equity in workloads and in the share of extension services and economic value (ifad, ) . • in the cfs produced gender and nutrition policy recommendations (cfs, ), which included: affirmative action for women. enhancing women's role in food security decision making. enacting legislation to guarantee women's access to resources and services. • in october , fao, ifad, un women and wfp launched their joint initiative on accelerating progress toward the economic empowerment of rural women (un women, ) . it seeks greater leadership opportunities, better food security and higher incomes for women, as well as to foster greater gender awareness. in the face of inaction by governments, the un has taken a step further in legislating around gender inequalities in rural and agricultural sectors over the past years: the committee on the elimination of discrimination against women (cedaw) recognized the myriad challenges facing rural women in , noting that in many cases, the situation has worsened. the committee also indicated that states should therefore ensure, among other things, that macroeconomic policies, including trade, fiscal and investment policies, as well as bilateral and multilateral agreements, are responsive to the needs of rural women and strengthen the productive and investing capacities of small-scale women producers. they should address the negative and differential impacts of economic policies, including agricultural and general trade liberalization, privatization and the commodification of land, water and natural resources, on the lives of rural women and the fulfillment of their rights. the cfs forum on women's empowerment has pointed to significant gaps in policy implementation: countries have at least one law restricting women's economic opportunities, countries exclude women altogether from certain jobs and leave it to husbands to determine if their wives can work. this forum has urged states to uphold their commitments to rural women's rights under the convention on the elimination of all forms of discrimination against women (fao, c) . in , the cfs began work on a set of voluntary guidelines on gender equality and women's empowerment in the context of food security and nutrition. the un declaration on the rights of peasants and other people living in rural areas, adopted by the general assembly in , calls on states to take all appropriate measures to eliminate all forms of discrimination against peasant women and other women working in rural areas and to promote their empowerment in order to ensure, on the basis of equality between men and women, that they fully and equally enjoy all human rights and fundamental freedoms and that they are able to freely pursue, participate in and benefit from rural economic, social, political and cultural development. the world bank's world development report : agriculture for development recognized the importance of smallholder farmers, and especially women. it emphasized the significance of investment in smallholder-led agricultural development for poverty reduction after decades of development processes bypassing small-scale farmers, particularly women cultivators (world bank, ) . in the ensuing years, two broad agendas have emerged, with tools that call for more responsible investment in agriculture and tackling gender inequalities: the voluntary sustainability standards (vss), targeting mainly the private sector, and the responsible investment frameworks in agriculture (rifs), targeting mainly governments. important gaps remain in addressing gender inequality and empowering women farmers, and these tools have to be used in the appropriate context so that they work (sexsmith et al., ) . also in , the bill & melinda gates foundation established a gender policy for the agricultural projects that it supports. this seeks to ensure that women benefit and to track project impacts on women and their children and communities (coon, ) . however, since the food price crisis, there is scant evidence that policy responses have taken gender differentials into account, and research in this area is still patchy. decades of rhetoric about the greater vulnerability of women have borne limited results in policy action. this neglect is reflected in aid expenditures. oecd data show that overall bilateral aid targeting gender equality and women's empowerment as either a significant (secondary) or principal (primary) objective in all sectors combined was higher than ever before in - , corresponding to % of total aid. however, the aid activities marked with the principal objective remained consistently below a total of $ bn per year, representing only % of total bilateral allocable aid from development assistance committee (dac) members in - . dedicated support focused on gender equality and women's empowerment as the principal objective in the economic and productive sectors-which encompass agriculture and rural development-decreased from $ m on average annually in - to only $ m on average in - , representing less than % of aid to these sectors (oecd, b) . nevertheless, it is worth noting that out of that $ m, more than half ($ m) was committed to agriculture and rural development. even though agriculture is the main economic and productive sector for targeting gender equality, making gender a principal objective of aid to agriculture and rural development is still not high on donors' agendas. furthermore, it is important to bear in mind that even when donors tag their aid projects with the oecd gender equality markers, this does not necessarily mean that the projects advance gender equality or empower women. grabowski and essick examined aid projects carrying the markers and found that only two of them actually met all of the oecd's minimum criteria for using the gender equality project marker (grabowski and essick, ) . also, although strong women's rights organizations and movements are recognized as being particularly effective actors in bringing about sustained changes toward gender equality, aid going to these organizations remains extremely modest. in - , an annual average of $ m went specifically to women's nongovernmental organizations (ngos), and women's organizations in developing countries received just $ m of this (oecd, b). in agriculture in - , there was little attention to the gender-disaggregated effects of the food price crisis, including its nutritional impact, coping strategies such as withdrawing girls from school and worsening poverty among female-headed households. the work of agnes quisumbing and ruth meinzen-dick and their colleagues at ifpri (quisumbing et al., ) and fao's ( ) sofi are major exceptions. there is still no access to sex-disaggregated data in food security programs (see box ) (un women, ) . of fao's indicators on food security determinants and outcomes, just one is gender related (anemia among pregnant women) (un women, ) . lack of sex-disaggregated data on rural populations also hampers implementation of cedaw's provisions on the rights of rural women. data are also lacking in terms of donors' actual funding to support women in farming and adapting to climate change, and not all donors systematically report to the oecd creditor reporting system. moreover, oecd gender equality markers only indicate if a project targets gender equality and whether it is a mainstreamed objective or fundamental to a project's design and expected results. the markers do not distinguish the nuances between projects that target resources to women and those that aim to transform gender relations (grabowski and essick, ) . as pearl-martinez notes, because aid recipient countries fail to gather sexdisaggregated data, it is impossible to track whether oda reaches women box collecting high-quality, sex-disaggregated data for better prevention tools: the case of the harmonized framework. l since , the permanent interstate committee for drought control in the sahel (comit e permanent inter-etats de lutte contre la s echeresse dans le sahel, or cilss) has been developing and refining its harmonized framework (cadre harmonis e) for the analysis and identification of risk areas and vulnerable groups in the sahel and west africa. the framework is a tool for food crisis prevention and management, and can identify and analyze zones with populations at high risk of food and nutrition insecurity. the results of these analyses allow the classification of food insecurity on a severity scale and estimates of the most affected populations, as well as projections for lean periods. this tool, targeted at decision makers, could be more qualitative with the inclusion of gender analysis, for example by systematically collecting sex-disaggregated data and evidence. this first step could help characterize food insecurity through a gender lens, and thereby help to better target vulnerable populations. farmers (pearl-martinez, ) . tools exist that can be used to measure gender empowerment, e.g., the women's empowerment in agriculture index, which the us ftf initiative helped create. m such empowerment is essential for transforming rural women's roles in agriculture and food security, as well as for addressing the structural causes of hunger (coon, ) . more investments in agricultural development, even if they target small family farms, do not automatically benefit women and food security. the key questions related to whether agricultural development promotes gender equality include whether women are able to access resources, whether they actually can make decisions about the fruits of productivity and income gains and whether development efforts help them to meet their needs and aspirations (huyer, ) . the international institute for sustainable development (iisd) showed in that men and women do not benefit equally from foreign investments in agriculture (sexsmith et al., ) . though its analysis looks at private investments, some of the faults detailed are also found in publicly funded development programs: • foreign investors tend to reinforce existing inequality in land ownership and control by working only with men who have formal land rights. this can reduce rural women's ability to use common lands to meet household needs. • women frequently have difficulties accessing credit and extension services, and so may be excluded from contract farming schemes. these factors also prevent them from benefitting from agricultural innovations. • investors tend to overlook women's needs and thereby increase their workload, including their unpaid labor. foreign investments can increase household incomes, helping women to ensure that their families are food-secure, but if this requires producing export crops instead of food crops for the household's own consumption, it entails new food security risks, e.g., greater vulnerability to volatile global commodity prices and increased competition. • investment projects reinforce rather than transform gender divisions of labor, with women remaining in insecure and often informal jobs. m for further detail, the weai resource center at http://weai.ifpri.info/. • projects also tend to fail to change women's under-representation in cooperatives and agricultural worker organizations, and particularly in leadership roles in these groups. gender integration in agricultural development and food security policies and programs requires ex ante impact assessment to ensure respect for the "do no harm" principle, considering local social and cultural contexts and how these shape women's ability to participate in development activities. in particular, projects must consider who controls assets within the household and seek to redress inequities. failing to do so will simply reinforce existing gender norms and inequalities (quisumbing et al., ) . poorly designed agricultural development interventions can lead to the increased marginalization of women in decision making. too often, projects require beneficiaries to have minimum levels of education and access to credit, for example, prerequisites that wind up excluding women (dury et al., ) . a gender strategy can help project staff better understand the potential gendered impacts of their interventions, and who is likely to benefit (quisumbing et al., ) . boxes and discuss gender integration efforts in rural development projects in haiti and nigeria. haiti is the poorest country in the western hemisphere and has one of the most unequal income distributions on the planet. agriculture remains central to development in the country, accounting for % of employment and % of gdp. yet poverty pervades the haitian countryside, with % of the population living below the poverty line (compared with an overall national poverty rate of %) (ifad, n.d.; world bank, ). hunger and malnutrition go hand in hand with low incomes: % of all haitian households experience food insecurity and % of pre-school children are chronically malnourished (usaid-haiti, ) . rural women in haiti are especially vulnerable. according to a study for usaid, % of all haitian women are anemic. women are percentage points more likely than men to be unemployed, and on average they earn more than % less than men. in the countryside, rural women have inadequate access to land and participate less than men in high-value agricultural activities. box case study-food insecurity among rural haitian women. n -cont'd this affects the quantity and quality of the food that they are able to consume. in addition, nearly half of rural haitian women should be considered "not empowered," due to their heavy workloads (including many unpaid household responsibilities), lack of ability to make decisions related to agriculture and lack of membership in groups such as farmers' associations or cooperatives (rames et al., ) . in , the us government made haiti one of its ftf "focus countries." according to an assessment of avanse, the feed the future north project in haiti, the project provided women with %- % of the benefits (anglade et al., ) . so avanse can be characterized as "gender-sensitive," in that project staff explicitly sought to mainstream gender and include women and their organizations in activities (avanse, ). however, the project was not gender-transformative, as it did not challenge traditional gender roles in rural northern haiti. it engaged women in what is locally considered "women's work," e.g., small-scale, wholesale marketing of farm produce and the heavy manual labor of building soil and water conservation structures such as terraces and retaining walls. participating farmers at various project sites told the assessment team that "kek grenn fanm" (just a few women) were engaged in growing rice through avanse. the assessment recommended that agricultural development efforts in rural haiti such as avanse make more concerted efforts to consult with women farmers about their needs and priorities, and give them the opportunity to participate in all project activities, including production of all kinds of crops and livestock. box increasing disposable income for women's food security and empowerment in nigeria. food prices in nigeria have trended upwards since (samuels et al., ) , reaching a peak in that negatively affected poor consumers' access to food. in a country very dependent on imports of commodities, the agriculture sector represents a large part of the economy, employing % of working nigerians, mainly as smallholders with below poverty line incomes (matemilola and elegbede, ) . women farmers have less access than male cultivators to land, inputs, paid labor and extension services, and this means that they tend to grow and earn less. in response, many national and international programs have been implemented in nigeria (matemilola and elegbede, ) , but not many have targeted smallholder farmers and women. at a national level, nigeria is far from the % caadp target for agriculture's share of the national budget, with the figure remaining below % as of (mwanzia, ) . very little attention is given box increasing disposable income for women's food security and empowerment in nigeria.-cont'd to specific budget lines for women, youth and marginalized segments of communities. in , gender and youth were lumped together in the budget and only % of proposed projects for them were funded (mwanzia, ) . international initiatives have not tackled this issue either, but some programs, like the one described below, have tried to recognize the productive capacity of female small-scale producers and empower them to significantly reduce food insecurity. since , oxfam has led a village savings and loans (vsl) o program in nigeria, allowing small groups of - villagers to create a common savings fund from which all group members can take loans. one of the main goals of these groups is to increase women's access to financial resources, and eventually to empower women economically, socially and politically. women represent % of program participants. a - baseline study examined the vsl program's impacts on women's empowerment. one of the direct impacts is on community food security. in , some of the respondents, mostly women, reported having fewer than three meals per day in some villages, but in all respondents in all villages reported three meals per day. this improvement can be directly linked to the increased financial capacities of women participants. the following assertion from a woman beneficiary in the village of kebbi shows that vsl allowed her to diversify her household's sources of income, and gave her more choices in buying food to ensure household food security: "before joining the vsl group, i needed to seek permission to buy even soup condiments because the money comes from my husband. but after joining vsl, i am empowered and don't need to seek permission before making little purchases." the program has indeed had a positive impact on joint decision making at the household level because women now contribute fully to expenditures. "i now contribute with money to support my husband, and this is possible because i joined vsl," said a woman from adamawa state. another, from guyuk village, added: "when my husband sells a goat, we discuss how to spend that money. i am very happy, everything has changed." vsl has also contributed to a change of perceptions on women's social role and has reinforced their participation in community political decision making. a woman from kebbi reported: "since i joined vsl, i am being respected by all. often times, i am being included as an executive member of most committees constituted in my community." o the vsl is a methodology invented by care international in . since then, the vsl methodology has been implemented worldwide by several ngos, including oxfam. the authors are grateful to oxfam in nigeria for providing information on the program used here. a study analyzing policy documents in uganda found that the rhetoric of "gender mainstreaming" was well integrated, but that this was insufficient to advance gender equality, given the lack of concrete implementation efforts. the study also found that the documents used mainstreaming in a way that tended to depoliticize gender (acosta et al., ) . multiple food supply and demand factors triggered the food price crisis of - . price spikes also revealed how the structural evolution of the global food system has fomented inequalities in accessing food. the food price crisis denied the right to adequate food to whole categories of people who have suffered long-term impacts. women have experienced disproportionate effects because they face discrimination at both the societal level and within their own households, with profound effects on their right to food. the global response to the crisis has been very visible, with many actors involved and numerous commitments, new initiatives and instruments launched by intergovernmental bodies, countries, global donors and private stakeholders. however, funding has been insufficient and the policy response has mainly targeted production issues instead of focusing on the right to food, especially of women. after years, global food security governance is highly fragmented, with the power of a small number of actors increasing dramatically. those actors include major multinational corporations, the world bank and the imf and the g governments. the voices of the people who have been left food-insecure are seldom heard in policy discussions. funding targeted at women in agriculture is insignificant compared with other official funding, and this public disinvestment opens the door to other actors, such as multinational companies, which have taken a "business as usual" approach and make gender equality in agriculture a low priority at best. especially in light of climate change and increased conflicts, failing to address the structural causes of the food price crisis has put women even more at risk on all dimensions of food security. in order to start tackling these challenges, we offer the following recommendations: • developing country governments and donors should support inclusive agricultural transformation and create an enabling environment for both female and male farmers to exercise their rights. this should include reducing power imbalances and supporting national-level land reforms. • governments and donors must make women's economic empowerment in agriculture a high priority. actions should include greater support for women farmers' organizations and for developing markets for crops that women tend to produce. p • local communities, farmer organizations, rural women's organizations and other relevant civil society actors should be involved in the design of food and agricultural policies. governments and donors need to take a rights-based approach, including ex ante target group identification, ex ante gender analyses and affirmative action addressing the needs of women (e.g., extension services reaching out to them and employing female extension agents). special attention should be paid to ensuring that women participate in decision making at all levels. • policies and funding should support and promote women smallholder farmers in achieving sdg by facilitating the self-organization of women and women's organizations. • donors should encourage multilateral agencies, such as the world bank and ifad, to increase the share of their agricultural spending that supports gender equality. • development aid providers should increase the quantity and quality of aid and support to focus on women smallholders, promoting low-input, climate-resilient practices, particularly soil restoration, crop diversification and water conservation and management. • investments in small-scale agriculture should be combined with and complementary to other initiatives that seek to restore the rights and decision-making power of women smallholder farmers, including initiatives that seek to increase women's access to education and encourage families to share the responsibilities of unpaid care work, as well as legal efforts to give women the same rights as men. • developing country governments should increase public investment in agriculture, with a focus on both women and men smallholder farmers and sustainable, climate-resilient approaches to agricultural p for more on this recommendation, see willoughby ( ) . development, and should include specific line items in their agriculture budgets to support women farmers. • governments should ensure that women farmers' associations and women's rights organizations are able to participate in budget decision making. • african governments should make meeting and then exceeding their caadp pledges on allocating % of national budgets to agriculture a top priority. these budgets should emphasize public investment rather than recurrent spending such as salaries for public officials. • developing country governments should adopt national policies that prioritize food production and discourage the diversion of farmland to large-scale production of crops for export and biofuels. q • governments should create public databases on land ownership and the terms and conditions of large-scale land transactions. • donors should help strengthen developing country governments' capacity to negotiate with investors in large-scale land transactions. • governments should facilitate the participation of civil society, farmers' organizations and women's organizations in the development and governance of food reserves. bilateral and multilateral donors should provide financial and technical assistance to establishment of reserves. • agriculture policies should facilitate women's access to inputs, resources and services. • governments should develop accountability mechanisms to ensure that national and transnational companies do not violate land rights and should ensure gender equality in land governance. • governments should enact or enforce existing competition or antitrust legislation to regulate excessive private power in markets. governments should cooperate on a regional and global basis to enforce competition policies. • national seed policies and legislation on plant breeders' rights should ensure the right of women and men smallholder farmers to save, reuse, exchange and sell seeds. q for more detail, see bernabe ( ) . • developed country governments should increase climate change adaptation financing. • donors should increase efforts to promote gender equality through their bilateral climate adaptation finance by significantly increasing the share of adaptation projects that have gender equality as a principal (dac marker ) or significant (marker ) objective. collect sex-disaggregated data to assess gender inequalities in agriculture • research institutions and agrarian and economic policy forums should seek quality sex-disaggregated data, with strong gender indicators, from all actors, and especially from governments and donors 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partnerships in african agriculture ripe for change: ending human suffering in supermarket supply chains institute for agriculture and trade policy and the global development and environment institute (gdae) world bank framework document for a global agriculture and food security program (gafsp) food price hike drives million people into poverty global food crisis response program from billions to trillions: transforming development finance post- , financing for development: multilateral development finance the world bank in haiti world bank databank the authors wish to acknowledge the assistance of ranu key: cord- -l r hl x authors: eftimov, tome; popovski, gorjan; petković, matej; seljak, barbara koroušić; kocev, dragi title: covid- pandemic changes the food consumption patterns date: - - journal: trends food sci technol doi: . /j.tifs. . . sha: doc_id: cord_uid: l r hl x background: the covid- pandemic affects all aspects of human life including their food consumption. the changes in the food production and supply processes introduce changes to the global dietary patterns. scope and approach: to study the covid- impact on food consumption process, we have analyzed two data sets that consist of food preparation recipes published before ( , ) and during the quarantine ( , ) period. since working with large data sets is a time-consuming task, we have applied a recently proposed artificial intelligence approach called diethub. the approach uses the recipe preparation description (i.e. text) and automatically provides a list of main ingredients annotated using the hansard semantic tags. after extracting the semantic tags of the ingredients for every recipe, we have compared the food consumption patterns between the two data sets by comparing the relative frequency of the ingredients that compose the recipes. key findings and conclusions: using the ai methodology, the changes in the food consumption patterns before and during the covid- pandemic are obvious. the highest positive difference in the food consumption can be found in foods such as “pulses/ plants producing pulses”, “pancake/tortilla/outcake”, and “soup/pottage”, which increase by %, %, and %, respectively. conversely, the largest decrease in consumption can be food for food such as “order perciformes (type of fish)”, “corn/cereals/grain”, and “wine-making”, with a reduction of %, %, and %, respectively. this kind of analysis is valuable in times of crisis and emergencies, which is a very good example of the scientific support that regulators require in order to take quick and appropriate response. the covid- pandemic affects all aspects of human life including their food consumption. the changes in the food production and supply processes introduce changes to the global dietary patterns. to study the covid- impact on food consumption process, we have analyzed two data sets that consist of food preparation recipes published before ( , ) and during the quarantine ( , ) period. since working with large data sets is a time-consuming task, we have applied a recently proposed artificial intelligence approach called diethub. the approach uses the recipe preparation description (i.e. text) and automatically provides a list of main ingredients annotated using the hansard semantic tags. after extracting the the united nations's food and agriculture organisation (fao) has al- ready discussed the impact of the covid- pandemic to the world's food and agriculture systems. they point out that, based on the highly global- ized nature of today's food production and supply, commodities need to move from the world's source of grain supply to where they are consumed (food furthermore, restrictions on shipments have lead to potential shortages of some food products, especially related to fresh fruits and vegetables, fish and fish products, and other food products of similar perishable nature. this furthermore affects seasonal workers, like those working on farms. conse- quently, this further affects and decelerates the food production process. another economic factor is that during the pandemic, many people are ex- concepts (such as names of food ingredients and cooking procedures) speci- ter), and then using the tags on a higher level leaf (i.e., to more general food concepts, e.g. diary produce). the results are presented in figures and . acting on their behalf may be held responsible for the use that may be made of the information contained herein. the hansard corpus - allrecipes, . amazing allrecipes facts and statistics espen expert statements and practical guidance for nutritional management of individuals with sars-cov- infection covid- information on nutritional support food and agriculture organization (fao) of the united nations who director-general's opening remarks at the media briefing on covid- . world health organization the continuing -ncov epidemic threat of novel coronaviruses to global health-the latest novel coronavirus outbreak in wuhan, china. international tree ensembles for pre- dicting structured outputs feature ranking for hierarchical multi-label classification with tree ensemble methods hungarica accepted for publication dietary habits analysis through understanding recipe's content. under review foodbase corpus: a new resource of annotated food entities key: cord- -thgxxz d authors: elsahoryi, nour; al-sayyed, hiba; odeh, mohanad; mcgrattan, andrea; hammad, fwziah title: effect of covid- on food security y: a cross-sectional survey date: - - journal: clin nutr espen doi: . /j.clnesp. . . sha: doc_id: cord_uid: thgxxz d background: novel coronavirus (covid- ) and subsequent quarantine could raise the risk of food inadequacy and nutrition deficiency crises. objectives: this study aimed to assess the impacts of covid- on household food security in jordan, determined the percentage of food security and the levels of food insecurity during the quarantine, determined the associated factor with food insecurity, and determined main food groups associated with fins during the quarantine. design: a cross-sectional study was conducted using a web-based validated questionnaire. the food insecurity experience scale was used to measure the food insecurity during the first four weeks of the quarantine, and a modified food consumption score was used to determine the number of times the household consumes each food group. univariate and multiple logistic regression models were used to describe, explore, and predict risk factors correlated with food insecurity among jordanians, during the first four weeks of the quarantine. results: a total of jordanians had responded to the assessment and fully answered the questionnaire. . % of the total participants were severe food insecure, while . % were moderate food insecure, . % were food secure. the regression model demonstrated the monthly income per capita below the poverty line and a number of the family member ( – and – ) associated significantly with moderate food insecurity (or: . ; % ci: . – . , or: . ; % ci: . – . , or: . ; % ci: . – . , respectively). as well as with the severe food insecurity (or: . ; % ci: . – . , or: . ; % ci: . – . , . ; % ci: . – . , respectively). age – years old (or: . ; % ci: . – . ) and living in a rented house (or: . ; % ci: . – . ) were associated significantly with severe food insecurity. carbohydrates and the meat group were significantly related to food insecurity (p-value was < . for both groups). conclusion: covid- and its subsequent quarantine have a tangible impact on food security levels for the populations. awareness and strategies to support individuals at higher risks should be guided not only by the income but also by other risk factors identified in the present study as the number of persons in the family, younger adults ( – years old), and those who do not own their houses). the coronavirus (covid- ) pandemic is a global health crisis caused by a newly discovered coronavirus [ ] . covid- is far more than an infectious disease; it is affecting the socioeconomic and food security (fs) worldwide. the impact of the virus on fs is not clear. the united nation's framework for the immediate socioeconomic response reported that the virus would most likely increase poverty, food insecurity (fins), and inequalities on a global scale. therefore, achieving sustainable development goals (sdg) is perceived as a top priority [ , ] . other international organizations have supported this concept, as; the food and agriculture organization of the united nations (fao) [ ] and the international food policy research institute (ifpri) [ ] . fao defined fs as the situation in which all people have physical and economic access to sufficient, safe, and nutritious food to meet their dietary needs and food preferences for an active and healthy life all the time [ ] . the four domains of fs described widely in the encyclopedia of fs and sustainability [ ] ; availability, accessibility, utilization, and stability, along with food safety and sanitation concepts considerations. fins is defined as the limited or uncertain availability of access to adequate and culturally appropriate food for lack of money or other resources [ e ] . poverty, poor health of household member(s), as well as suboptimal livelihood and household management strategies could lead to fins. the severity and classification of fins depend on the perception of the household member towards food and foodrelated budget [ ] . consequences and threats of fins include a negative impact on mental, social, and psycho-emotional status [ , ] . fins could be mild food insecurity, moderate food insecurity (mfins), and severe food insecurity (sfins). the classification depends on the severity of uncertainty, anxiety regarding food access, unbalanced diet, and changes in the quality of the diet [ , ] . several scales are available to measure fins. the food insecurity experience scale (fies), that designed by fao, is one of the four experience-based fins scales: the household hunger scale (hhs); the household food insecurity access scale (hfias); the latin american and caribbean fs scale (elcsa) and fies [ ] . it is a dynamic, reciprocal, and time-dependent scale. number of recent literature reviews were discussed the effect of covid- lockdown (or quarantine) on the fins [ e ]. a systematic review of fs and the coronavirus disease concluded that the pandamic affected negatively on the food supply and demand, and decreases the purchasing power and the capacity to produce and distribute food [ ] . in jordan, the rate of fins has kept rising, despite the prevalence of undernutrition was decreased from . % to . % within years (fao, ifadz, unicef ). the turmoil that has happened around jordan over the last decade has proven that fins can contribute to conflict, especially when it coupled with poverty, low income, ambiguous economic status, and unemployment. challenges as hosting syrian refugees [ ] and increasing difficulties of agriculture production [ ] make the situation even harder and challengeable. the report of world food bank (wfb) of the state of fs in jordan ( e ) indicated that fs households were . % while the insecure households and households vulnerable towards fins were . % and . %, respectively [ ] . the distribution of fins between the governates indicated that balqa and zarqa had the highest percentage of fins . % and . %, respectively [ ] . moreover, a recent report from the united nations international children's education fund (unicef) describes the food price in jordan with high food prices, and there was no prevalence determined for fins among the overall population [ ] . limited researches were found on fins in jordan. a crosssectional survey among women in northern jordan indicated that more half the sample ( . %) was fs households, and only . % were fins households [ ] . bawadi et al., concluded that women who have low education levels, low income (less than the poverty line), and rent houses were more likely to have fins [ ] . under recent circumstances, jordan announced the incidence of the first case of covid on march nd, . the prime minister's office announced the details of quarantining procedure and lockdown operations, which described in detail by the national defense law [ ] . the quarantine was all the time within the first four weeks. it was predicted that the quarantine would probably affect the household fins of jordanians. thus, the present research aimed to [ ] determine the resultant effects of covid- on fins in jordan during the quarantine [ ] . assessing the population prevalence of fs and fins (levels) in jordan during the subsequent quarantine of covid- [ ] . identifying risk factors that could associated with fins [ ] . identifying main food groups associated with fins during the quarantine [ ] . shed light on the key impact and differential impacts of the pandemic [ ] . suggest recommendations for the future based on the results. it is a cross-sectional survey conducted among all jordanian population (aged more than years) during quarantine caused by covid- and followed by carrying out a prediction model to identify variables associated with fins. data were collected from all governates of the jordan kingdome. data collection took place from the first day of the quarantine along four weeks. considering that the total jordanian population (> years) is about , , . in ( % female and % male) [ ] . the required sample size based on calculations and the expected response rate would be respondents. assuming that confidence interval (ci) %, and the margin of error is % [ , ] . a web-based questionnaire was used in this study. it includes three parts. the first part included socioeconomic and sociodemographic details. the second part was fies, which was used to measure the individual experience of fins. this scale consists of eight questions capturing a range of fins severity [ e ]. fies is a valid and reliable scale [ e ]. fies categories were classified as food secured (fs), moderate food insecure (mfins), and severe food insecure (sfins) [ , ] . the third part was modified food consumption score (fcs) [ ] , which included questions regarding the number of times for each household food group consumed during the first four weeks of the quarantine. the questionnaire was pretested, responses discussed amongst authors, and modified to ensure standardization. the questionnaire was translated from english to arabic by two bilingual researchers (arabic, english). to ensure the exactitude of translation, another bilingual researcher retranslated the questionnaire back from arabic to english. the two english versions (original, translatedback translated) were compared to assure that the meaning of the items in the two versions did not change. three expert panels reviewed, examined and approved the arabic version of the questionnaire for content and construct validity. age categories based on commerce economics and statistics administration [ ] , place of living (address) based on the formal administrative divisions in jordan [ ] . two income categories were generated based on the jordanian national poverty line cut point [ ] . education, marital status, family numbers, employees within the household, house status (owned or rented), presence of chronic disease(s) within the family, type of health insurance also added. an online questionnaire was published on the first day ( march. ) of the quarantine to april. ). it was accessible to responders only for four weeks, i.e., during the complete lockdown quarantine in jordan. the questionnaire was endorsed by the official web sites of the following bodies: the crown prince foundation (cpf), ministry of health (moh), ministry of higher education (mohe) mainly, hashemite university, and the university of petra. descriptive statistics, including frequencies, percentages, and univariate analysis (cross-tabulations), were used to measure the distribution of fins according to the different social and demographic factors. odds ratios (ors) and subsequent % confidence intervals were obtained to identify factors responsible for increasing the odds of fins. multinomial logistic regressions were used for getting ors. chi-square test was conducted to examine the distribution of individuals with different levels of fins on the weekly consumption of each food-group. the p-value of < . was considered significant. spss software for windows (version ) (spss inc., chicago, il, usa) was used. ethical approval for this study was secured through the university of petra internal review board (irb); decision number: q/ / . a total of jordanian individuals participated in this national questionnaire within the first four weeks of the quarantine ( % male and % females). as shown in table , the majority of the participants were between and years old. more than threefourths of the participants were from first territories. more than half of the participants were single ( . %). approximately % of the participants had a diploma or bachelor's certificates. the monthly income per capita was . $ monthly for . % of the participants. most families ( . %) consist of e persons. employee numbers (within the household) were around half ( . %) of the study sample. around one-third of the participants had their own homes ( . %). almost half of the participants had chronic diseases within the family ( . %), and . % had no health insurance. the results of fins in jordan during the quarantine indicated that . % of the total population were fs while . % were mfins and . % were sfins as shown in fig. . most categories of the sociodemographic characteristics distributed almost in equal proportion within the fs and fins. for example, . % and . % of females and males respectively were fs as shown in table . based on the monthly income per capita, the results indicated that more than half of participates who have monthly income more than the poverty line ( . %) were fs. while . % of the participants who have personal monthly income, less than the poverty line were fins ( . % mfins and . % sfins) as shown in (tables and ). the chi-squared test indicated that there was a significant difference in fins categories related to education level, monthly income per capita, and the house status (p-values were . , . , and . , respectively). the ors of being fins were estimated for each variable. fins (moderate and severe) were not associated with the governate, gender, social status, education, number of employees per family, chronic diseases within the family, and health insurance. nevertheless, age, number of family members, income per head, and house status were associated significantly with fins compared with fs. age was associated with the fins status; participants aged e years were . ( % ci: . e . ) times more likely to be in severe fins status. monthly income per capita was associated with an increased risk of mfins and sfins. participants with the monthly income of less than the poverty-line were five times more likely to be mfins and seven times more likely to be sfins ( % ci: . e . ) and ( % ci: . e . ) respectively. participants who rented houses had . times higher odds of being severely fins when compared with those who owned houses ( % ci: . e . ). increasing family members was associated with an increased likelihood of both mfins and sfins. the chi-square goodness-of-fit test indicated that the fruits group, vegetable group, milk and dairy products group, oil group, and sweets group consumption were similarly distributed among the fs, mfins and sfins (p-value > . ). the carbohydrates group and meat group consumption per week were statistically significantly different (p-value . ). the results of the current study indicated that less than half of the participants were fs during the quarantine obligated by covid- . the other participants were distributed within fins categories: a higher percentage of mfins. leading variables associated with fins were monthly income per capita, house status, age, and the number of family members. the calculated sample size based on the jordanian target population was respondents. surprisingly, full responses were received. many factors may drive the unexpected higher response rate: first is the channels to circulate it, i.e., large governmental bodies (cpf and moh) and local universities. second is the timing of the survey, at the time of circulating survey, the internet coverage in jordan was excellent, and the country was in a complete lockdown state. finally, the topic of the survey might be perceived as relevant to the population during the covid- pandemic; accordingly, many participants realized the value of their participation. the distribution of responders in the present research showed inline results with the overall population. for example, . % of the responders were from the middle region (which have the capital, amman and the second largest governate (zarqa), in addition to many other governorates). age structure for responders to the survey is in line with the jordanian population; in the present study, only . % of responders were older than years old. many baselines result in the current work matched well with the overall jordanian population; for example, the jordanian households' average members, single vs. married ratios, and health insurance coverage [ ] in addition to education levels [ ] . more females ( %) have responded vs % males compared with the ratio in the population ( % female and % male). a higher level of education compared to the general population was also noticed. nevertheless, the education level in the present study is comparable with the urban areas in the overall community [ ]. to our knowledge, this is the first published paper of fins during the quarantine, alongside the covid- pandemic in jordan. accordingly, there was no published data with which to compare the results. these data compare favorably with a report and studies published earlier during the regular, non-pandemic period in jordan and other countries. in general review, it was reported that lower-and middleincome countries (including jordan) had a percentage of . % for fins and . % for sfins. upper-and middle-income countries had portions of . % and . %, respectively. it was not unexpected that higher percentages would be reported during the quarantine, as our data indicated. regards to jordan classification, the word bank stated that "on july st, , the world bank classified jordan as an upper-middle-income country. based on new data, on july st, , the world bank classified jordan as a lower middle-income country'' [ ] . the results of fins percentage in our research could refer to many reasons; for example; unavailability of the food especially for long time, limitation on migrant workers who work on the food sectors, the lockdowns and movement control during the quarantine were restricting the physical ability of people to access food and is creating food deserts in most areas, reduced wages and loss of income affecting the most vulnerable, the global price of all products increased as well as in jordan. as mentioned by, middle east and east africa is the regions of conflict and crisis that covid- threatened fs and it was increased the obstacles to food access that created by political and military pressures [ ] . compared with previous researches conducted on the normal situations (in jordan); cross-sectional research in northern jordan reported that . % of the women were fs, and ( . %) were fins [ ] . however, the sample of bawadi et al. (n ¼ ) was only females who attended outpatient clinics and fins assessment was carried out by using the short form of the usfs survey module. our [ ] . it is agreed that epidemics (like hiv/aids, ebola, and the middle east respiratory syndrome) usually increase risks related to fins [ ] . moreover, the official jordanian efforts are more directed to identify and investigate areas of fins at the district level. furthermore, its target was both rural and urban areas [ ] . our study did not target jordanians within the poverty reduction program, and refugees. such group (n ¼ , ) reported higher percentages for fins; vulnerable to fins ( %) and fins ( %) [ ] . while jordan is already struggling with significant poverty, inequality, and considered within the middle-income country, a further economic crisis brought about by the covid- pandemic is likely to be disastrous, resulting in the denial of access to diverse and food supply nutritious diet among the adult population (roberton et al., ). the a accumulative effect of the pandemic combined with existing food supply problem first and then nutrition and health problem problems. thus, this percentage of fi could weaken the efforts to achieving sustainable development goals (sdgs) , which emphasizes ending hunger, achieving fs and improving nutrition, and promoting sustainable agriculture. whatever the percentage of fin before the pandamic, most references in low and middle income country indicated that this pandamic increase hunger and reduce the fs [ , , , , ] . despite differences in the prevalence of fins populations between the research and the official reports, there has been an agreement that financial status is perceived as the most reliable predictor and a risk factor for fins. bawadi et al. ( ) calculated that the odds ratio for people with income less than the poverty line to be . ( % ci: . e . ) [ ] . similarly, official reports confirmed that the annual income of % of fins households was less than jd [ ] . such collective results are in agreement with a recent review, which stated that around % of the population in low-income countries suffer from fins [ ] . similar results had been widely demonstrated by many global researchers [ , , e ] . focusing on the fins during the quarantine, a surveys published in nigeriacomparing fs outcomes of households before and after the outbreak of the pandemic concluded that the that lockdowns increase fins and reduced the probability of participation in nonfarm business activities [ ] . a second widely agreed factor that kept its influence even during the quarantine was renting a house (compared to owning a house). our results, during quarantine, are in line with published research, badawi et al., reported odds ratio for such variable . ( % ci: . e . ), other researchers had also documented similar results [ , , ] . the third variable was the number of family members, which somehow in line with other research results [ , , , ] . in the present study, the correlation with fins for many variables had been attenuated when adjusted with other variables, examples of such variables that used to demonstrate correlations in typical situations, but not during quarantine: educational level [ , , , e ] , and gender [ , , , ] . surprisingly, the age kept its statistically significant relation with fins despite adjustment. due to different study designs and methodologies, the age variable did not demonstrate a marked correlation with fins. however, studies that specifically target the older population have had the age in their final results as a factor related to fins despite adjustment [ , , ] . however, this study suggests strength the cooperation between the government sectors by adopting a common strategies to strengthen the food supply system in jordan through appropriate policy measures, to protect the disadvantaged people at all the times, not only during the pandemic crisis in addition to special policy measures during covid- pandamica to limit the increase of hunger, based on the understanding of the gravity of the moment. the current results indicated that food groups are not related to fs and fins except for the carbohydrate and meat group. one of the fs dimensions focuses on diet quality, food safety, and adequate nutrition supply. most works of literature considered fs is the physical, social, and economic to access to sufficient and safe amount of food. in addition, food should meet the recommended dietary needs and the preference of the consumers [ ] . therefore, table the association between fs and fis, and the socio-demographic characteristics of the participants in jordan during the quarantine. the term fs advanced to "nutrition security" and "food and nutrition security," which means that the fs is considered as a subset of "food security and nutrition" [ ] . in a similar concept, nutrients deficiency and malnutrition are the most serious consequence of fins which are related to the quality of food, not only the quantity [ ] . in the first four weeks of the quarantine, almost all people worried about not having enough amount of the main food items such as the carbohydrates, dairy products (mainly the milk) and meat (mainly poultry in jordan). carbohydrates and meat groups are significantly related to fs and fins status in quarantine time. higher weekly carbohydrates intake was among sfins participants. in contrast, higher weekly intake of the meat, poultry, and fish was among fs participants. there are several explanations for this result. the first point may refer to the variation prices of these food items in the jordanian market. carbohydrates, mainly rice and bread are among the highest consumption rates among the jordanians, and they attributed by a very low price compared with the meat group [ , , , ] . in addition, the government co-pays the price of bread in jordan, which make it available for most individuals [ ] . second, during the first four weeks of the quarantine, the jordanian government allowed the bakeries to work for h to provide the citizens through delivery only. moreover, the jordanian government distributed bread during quarantine by the reasonable price ( . usd/kg). third, large number of the population could make bread at home. due to its high price compared with all other food groups in the jordanian market, many participants could replace this group with cheaper food group, but similar nutritional value such as legumes. further, the absence of meat from nearby grocery stores should be pointed out. the analytical report of wfb [ , ] reported that the cereals group was the highest intake among all fs and fins categories, equally, but higher intake of meat group was among the fs group [ ] . however, the current study includes all populations during covid- pandemic and quarantine while bawadi et al. ( ) [ ] and wfb ( ) have different aims and study designs. the insignificant relationship between the other food groups (fruits, vegetables, milk and milk products, oils, and sweets) and fs/fins during the quarantine period means that the study sample experienced the same consumption frequency during and before the quarantine. this is not surprising due to many reasons. first: the jordanian government prohibited raising the prices of food commodities. second: during the quarantine period, the jordanian government allowed shopping from small nearby grocery stores and supermarkets on the condition that the access to shops is by walking not by cars for few limited hours. therefore, quarantine did not affect the intake of these groups. having a piece of evidence exploring the impact of pandemic (covid- ) quarantine on fins in jordan is the main strength in the concept of the present study. subsequently, the current findings add to a growing body of literature on both fins and pandemic impact on the population. having a large sample size with almost % more than the minimum is another strength in conducting the present study. using the fies has driven inherited strengths linked to its advantages [ ] whereas most published researches were reviews. despite the ease and reasonable cost of using a selfreporting survey, it has some limitations. it is a subjective measure, and it represents the perception of fins. also, the current research didn't include refugees. due to the quarantine circumstances, the used food consumption score (fcs) focused on the meal's number consumed by household members during quarantine, the source from which the household secured food was beyond the concern in the present study. table distribution food group intake per week within food security and food insecurity (moderate and sever) among the participants in jordan during the quarantine. n (%). this research concluded that food security is a critical aspect that affected the social and environmental status in jordan. quarantine that adopted as protection was against spreading covid- virus should trigger awareness toward individuals at higher risk for food insecurity. the lockdowns may be the only way to halt the spread of the virus, but where social protection is lacking they may have disastrous economic, social, and nutritional consequences and food chain mainly. in such circumstances, around % of the population were considered as secured, one-third of the population was moderate food secured, and less than one quarter was severe food insecure. the risk of the severe food insecure was strongly correlated with many factors as monthly income per capita, the number of family members, individuals younger between and years old, and those who lived in rented houses. regarding the time number of food categories intake per week, carbohydrates and the meat group were the only groups that have significant relation with food insecurity. overall, covid- affected many food chain in jordan mainly; food production, trade, commerce, and the supply chain which produce adverse consequences on the food security during the pandamic. this predict negative effect on the dietary pattern and nutrient intake of the adult people on the short and long term. if proper precautionary measures are not assumed to address the issues of food supply by taking into consideration the individual economic status (such as the individual income) and the sociodemographic properties such as (education level), this will effect on th poverty level in jordan, inequality, education, health status, which will threaten the achievement of sdgs in . this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. the lead author affirms that this manuscript is an honest, accurate and transparent account of the study being reported. the reporting of this work is compliant with strobe guidelines. the lead author affirms that no important aspects of the study have been omitted and that any discrepancies from the study as planned have been explained. nour a. elsahoryi designed the study, collect and analyze the data and writing the manuscript. hiba al-sayyed contributed in designing the study, data collection and writing the manuscript. mohanad m. odeh contributed in designing the study, data collection and writing the manuscript. . andrea mcgrattan contributed in writing the manuscript. fwziah j hammad designed the study, collect and analyze the data and writing the manuscript. all authors read and approved the final manuscript. there are no conflicts of interest. we would thank all of the participants who took part in the study. the state of food security and nutrition in the world e building resilience for peace and food security a un framework for the immediate socio-economic response to food security and the e sustainable development goals: from human to planetary health covid- ) -addressing the impacts of covid- in food crises preventing global food security crisis under covid- emergency. ifpri; 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[food insecurity: associated variables and issues for public policy factors associated with child hunger among food insecure households in bangladesh food insecurity in older adults: results from the epidemiology of chronic diseases cohort study the association between intimate partner domestic violence and the food security status of poor families in brazil prevalence and risk factors of food insecurity among a cohort of older australians leavened apprehensions: bread subsidies and moral economies in hashemite jordan food and nutrition profile nutrition in jordan: a review of the current nutritional trends and major strategic directions of the national food and nutrition policy the state of food security in jordan world food programme regional market survey for the middle east. amman key: cord- -v onclcc authors: woertz, eckart title: wither the self-sufficiency illusion? food security in arab gulf states and the impact of covid- date: - - journal: food secur doi: . /s - - - sha: doc_id: cord_uid: v onclcc past approaches to food security in the countries of the gulf cooperation council (gcc) were informed by concerns about food availability. they aimed at domestic self-sufficiency and self-sufficiency by proxy (via farmland investments abroad). these strategies have failed. water scarcity at home increasingly compromises agricultural production. farmland investments abroad have not matched ambitious related announcements due to a complex mixture of commercial, socio-economic and political factors. they do not contribute meaningful quantities to the gulf countries’ food imports. the failure of such strategies has prompted a shift of focus instead towards value chain management as a means to secure food availability. rather than trying to fight food import dependence, the gulf countries now accept and manage it. however, malnutrition that leads to high levels of obesity and diabetes constitutes a risk factor in the face of covid- . food accessibility for vulnerable population segments such as migrant labour is another issue that requires yet further policy measures, such as safety nets – whose expansion would be politically controversial if not impossible, however. the middle east and north africa (mena) region is the largest importer of cereals globally. its imports of poultry and dairy products are extensive as well. only with regard to fruit and vegetables do some countries of the region have a meaningful degree of self-sufficiency, or are even net exporterssuch as turkey and morocco. the vulnerability to import disruptions is most acutely felt in the arid gulf region that is rich in oil but poor in water and agricultural potential. to alleviate such fears, saudi arabia and the united arab emirates (uae) expanded local food production with the help of unsustainable mining of fossil water after the world food crisis of [ ] [ ] [ ] [ ] . by the time of the global food crisis of / this strategy had run its course, as aquifers ran dry. this time, the gulf countries rushed to secure privileged bilateral access to food production abroad. large farmland investments were announced, often in food-insecure countries such as ethiopia and sudan. the covid- crisis and its impact on global food systems is an opportunity to revisit these past approaches to food security. the gulf countries have barked up the wrong tree. neither domestic self-sufficiency nor self-sufficiency by proxy (i.e. farmland abroad) are the main challenges, rather the management of value chains, food diplomacy to ensure the functionality of multilateral frameworks, tackling malnutrition and its consequences (e.g. obesity) and ensuring food accessibility for vulnerable segments of the populationsuch as migrant labour and people with insecure residency statuses. the mena region lost its ability to grow its required amounts of food from domestic renewable water resources in the s already and has increasingly come to rely on food trade (allan ) . there is unease with this growing dependency, which can be explained by a number of negative historic experiences: the difficult food supply situation in world war ii, the politicisation of food trade by the united states in the s and s when it used subsidised public law food exports for political leverage, the same country's threat of a food embargo in retaliation for the arab oil boycott and, more recently, sanction regimes like that of the united nations in iraq from to that wreaked havoc on food security in the latter country. there are also intellectual arguments for a degree of selfsufficiency that run counter to the trade-based approach to food security that is advocated by economic liberalism and international organisations such as the world bank. countries that have limited purchasing power, rely on volatile export earnings, depend on a main staple food that is controlled by only a few suppliers (e.g. rice), or are at risk of sanctions, war and/or geopolitical supply disruptions might benefit from reducing their exposure to volatile international markets. finally, heavy reliance on imported calories is simply not an option for vast countries such as china and india because of their sheer size in comparison to exportable surpluses elsewhere (clapp ) . gulf self-sufficiency aspirations are understandable, but have clashed with the realities of resource constraints and population growth. agricultural subsidies made saudi arabia the world's sixth-largest exporter of wheat in the s, but it had to phase out production between and for lack of water. domestic agricultural aspirations nowadays confine themselves to the water-efficient cultivation of fruit and vegetables in greenhouses and vertical farms as well as livestock-raising with imported foddernot the grandiose self-sufficiency visions of yesteryears. farmland investment abroad, the self-sufficiency by proxy strategy, has failed as well. announcements were grandiose and quickly became part of a media narrative about the gulf countries buying up africa and other developing countries. but implementation lagged behind, mimicking the failure of a similar plan in the s to develop sudan into an arab bread basket (woertz ) . lack of infrastructure, a challenging local business environment, missing expertise on the part of the gulf countries, resistance by disenfranchised holders of customary land rights and reduced fiscal space to invest as a result of falling oil prices all took their toll. the farmland-investment wave has not made its mark in the foodtrade statistics over a decade after its launch: the gulf countries continue to receive the vast majority of their imported food from established agro exporters, among them a growing number from tropical regions such as brazil. major target countries of land investments in the developing world such as sudan hardly figure meanwhile (international trade center ; woertz and keulertz ) . if the gulf countries did actually put money on the table it was mostly in developed agro markets and investments were in food-trade value chains rather than further upstream in farmland. saudi state-owned salic, for example, teamed up with international grain-trader bunge to purchase a majority stake in the privatised canadian wheat board. the gulf countries themselves are home to modern value chains in food processing and distribution. gulf capitalists play an influential role in such modern value chains in other mena countries, too, operating via large conglomerates such as kuwait-based americana and saudi arabia-based savola (hanieh ) . the impact of covid- will most likely be most severe in traditional and transitional food value chains, such as household microenterprises on the one hand and small and medium-sized enterprises and wet markets on the other (reardon et al. ) . informal and labour-intensive, they bring together large numbers of workers in crowded spacesat considerable risk of contagion and with ensuing shutdowns and labour shortages. the capital-intensive farming of staple crops will be less affected in comparison. the labour-intensive cultivation of fruit and vegetables will likely fare better as well, as it is subject to less labour density than the traditional and transitional downstream value chains. this all means that the gulf countries find themselves in a relatively privileged position: their global supplies of agricultural products are unlikely to dry up in the foreseeable future, while their modern food value chains that are dominated by supermarkets and capital-intensive processing plants are less vulnerable to covid- -related disruptions. much of their reaction has already focussed on the management of value chains and their international linkages. they have increased storage to bridge supply shortfalls, diversified providers, streamlined sanitation measures and eased import flows by changing the requirement for all goods to be labelled in arabic. internationally, stocks of staple foods are higher and markets better supplied than during the global food crisis of / . some food exporters such as ukraine and vietnam have announced quotas, but price spikes and outright export restrictions have not occurred so far. political awareness about the detrimental effects of such restrictions has grown meanwhile. multilateral initiatives such as the agricultural markets information system (amis) have sought to increase market transparency and dampen food-price volatility. such initiatives could also help to limit national rushes to beef-up physical storage, which might create the very problem that they wish to address: illiquid food markets (von braun et al. ). the gulf countries may consider raising their concerns as well in multilateral bodies such as the world trade organization and the g , not unlike the group of the net food-importing developing countries (nfidc) that formed an interest group within the general agreement on tariffs and trade negotiations during the uruguay round to lobby for affordable food imports (narlikar ) . in contrast to the global food crisis, a renewed wave of announced land investments is not likely. the strategy has not brought benefits and plummeting oil prices mean that there is less capital available for adventurous investment deals. securing food focusses now on the management of value chains, where the gulf countries are in a relatively privileged position as a result of their modern food systems. as before, food availability is not the primary issuehaving proven to be manageable. however, covid- has turned the spotlight onto issues of food accessibility and malnutrition. the gulf countries have one of the largest per capita shares worldwide of people suffering from diabetes and obesity, two groups particularly at risk of succumbing to covid- . authorities have been reluctant to address underlying issues more forcefully, such as sedentary lifestyles and diets rich in sugar, fat and carbohydrates (alnohair ). the obesity epidemic, which is particularly prevalent among females, highlights that food security is rarely an issue of lacking calories, rather of insufficient micronutrients. this also shows in other phenomena related to nutrition insecurity. the percentage of children in the gulf with stunted growth is smaller than elsewhere in the mena region, but still in the higher single digits in saudi arabia, bahrain and oman (breisinger et al. ) . food accessibility can also be compromised for vulnerable segments of the population, namely migrant workers and those with insecure residency statuses. migrants make up the vast majority of the population in the uae ( %), qatar ( %) and kuwait ( %). in saudi arabia and oman, they form substantial minoritiesbeing % and % of the population, respectively. in bahrain, their population share is % (world bank ). additionally, there are long-term residents with unclear residency statusthe so-called bidoon ("without"). in kuwait and the uae, they often hail from local bedouin populations that were not awarded citizenship status at the time of independence. in saudi arabia, large shantytowns exist around mecca, medina and jeddah that are home to descendants of migrants from africa and southeast asia who came to the country decades ago and overstayed their visas. like migrant workers, they form a permanent underclass with limited social and legal rights. covid- is not the great leveller that will affect everybody equally. the poor are more at risk than the affluent. they can ill afford to shelter in place, their blue-collar occupations cannot be conducted from the safety of the home and they do not have meaningful savings to bridge longer periods of time without employment and income. their cramped living quarters constitute an increased risk of contagion and they have less access to healthcare if they contract the disease. covid- has brought long-standing grievances in the gulf labour sector into sharp relief, such as non-or late payment of wages, limited rights under the kafala sponsorship system and poor working conditions (kamrava and babar ; rajan ). migrant workers suffer most from the economic havoc that covid- is wreaking. current circumstances undermine their ability to purchase nutritious food in adequate quantities. national labour still works predominantly in the public sector, where it enjoys a degree of protection or receives relief aid from the government that is only available for nationals. in the private sector nationals also enjoy more protection. saudi arabia, for example, has decided to pay % of the private sector wages of saudi nationals for up to three months as part of its unemployment insurance scheme (saned). in comparison, the economic impact of covid- is far more severe for migrant workers. they suffer most from restrictive measures like quarantines and their access to relief aid and healthcare is limited. the recent decision by the saudi government to open up the healthcare system to everybody for covid- treatment regardless of their legal residency status is an implicit acknowledgement that such lack of access can be a public health risk. maintaining food security under covid- will require safety nets that go beyond random charity transfers. the necessary formalisation that goes with that will likely raise concerns. the issue of migration was a sensitive one even before covid- and tied to debates on demographic imbalances and political stability. already there are calls in kuwait, saudi arabia and oman to take the covid- crisis as an opportunity to permanently reduce the share of migrants in the overall population. the uae and qatar have relaxed their flight bans, allowing outgoing flights to repatriate migrant workers. many migrant workers are suffering with regard to food accessibility, as they find themselves caught between a rock and a hard place. either they stay in the host state with no or reduced pay or they return prematurely to their home countries, with their limited savings gone and struggling to repay the fees of the agencies that facilitated their temporary labour migration in the first place. the food systems of the arab gulf countries have so far performed well during the covid- crisis in terms of ensuring food availability. their modern value chains are more resilient than the traditional and transitional ones that dominate in developing countries. the improvement of such value chains deserves the attention of policymakers and researchers alike. hydroponics, aquaponics, vertical farming and other modern production technologies might allow the gulf countries to meet some of their requirements regarding fruit, vegetables and fish without depleting groundwater resources at unsustainable rates. however, the vast majority of food supplies will continue to come from global markets. multilateral frameworks such as the wto and g could help in making international food trade more dependable, yet the gulf countries have not paid enough attention to corresponding food diplomacy at the respective bodies. the covid- crisis has also highlighted that food security is nutrition security above all else. it could provide an opportunity for the gulf countries to tackle food-related epidemics such as obesity and diabetes more forcefully. policy interventions could range from taxation on and declaration requirements for carbohydrates and sugar-rich foods to school meals and awareness campaigns. food accessibility for migrant workers and other vulnerable segments of the population is another priority area of concern. it would require improvement of existing labour regulations, assistance programmes and safety nets. as such, it points to the fraught debates around long-standing grievances in the labour sector that intersect with concerns about demographic imbalances and workforce nationalisationpolitical concerns that dim prospects of reform significantly. funding information open access funding provided by projekt deal. this article is not part of a specific project funding line. conflict of interest/ competing interest no conflicts of interest exist. open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/ . /. the middle east water question beyond the arab awakening. policies and investments for poverty reduction and food security food self-sufficiency: making sense of it and when it makes sense money, markets and monarchies: the gulf cooperation council and the political economy of the contemporary migrant labor in the persian gulf international trade and developing countries : bargaining coalitions in the gatt and wto (ripe series in global political economy) the oxford handbook of migration crises how covid- may disrupt food supply chains in developing countries eliminating drastic food price spikes -a three pronged approach for reserves oil for food. the global food crisis and the middle east food trade relations of the middle east and north africa with tropical countries international migrant stock (% of population besides academic publications he has contributed to numerous consultancy and policy reports for clients in the middle east and at international organizations. previously he held positions at the barcelona centre for international affairs (cidob) key: cord- -t yioyl authors: rohr, jason r.; barrett, christopher b.; civitello, david j.; craft, meggan e.; delius, bryan; deleo, giulio a.; hudson, peter j.; jouanard, nicolas; nguyen, karena h.; ostfeld, richard s.; remais, justin v.; riveau, gilles; sokolow, susanne h.; tilman, david title: emerging human infectious diseases and the links to global food production date: - - journal: nat sustain doi: . /s - - - sha: doc_id: cord_uid: t yioyl infectious diseases are emerging globally at an unprecedented rate while global food demand is projected to increase sharply by . here, we synthesize the pathways by which projected agricultural expansion and intensification will influence human infectious diseases and how human infectious diseases might likewise affect food production and distribution. feeding billion people will require substantial increases in crop and animal production that will expand agricultural use of antibiotics, water, pesticides and fertilizer, and contact rates between humans and both wild and domestic animals, all with consequences for the emergence and spread of infectious agents. indeed, our synthesis of the literature suggests that, since , agricultural drivers were associated with > % of all — and > % of zoonotic — infectious diseases that emerged in humans, proportions that will likely increase as agriculture expands and intensifies. we identify agricultural and disease management and policy actions, and additional research, needed to address the public health challenge posed by feeding billion people. i nfectious diseases are emerging at an unprecedented rate with significant impacts on global economies and public health . the social and environmental conditions that give rise to disease emergence are thus of particular interest, as are management approaches that might reduce the risk of emergence or re-emergence . at the same time, undernutrition -the insufficient intake of one or more nutrients -remains a major source of global ill health [ ] [ ] [ ] [ ] . together, the unprecedented rate of infectious disease emergence and the need to sustainably feed the global population represent two of the most formidable ecological and public health challenges of the twentyfirst century [ ] [ ] [ ] [ ] [ ] (fig. ) , and they interact in complex ways (fig. ) . although modern agricultural technologies have reduced hunger, improved nutrition and spared some natural ecosystems from conversion to agriculture, current global agricultural production and distribution infrastructure still leaves billions of people's diets deficient in one or more crucial nutrients, with major consequences for global morbidity and mortality , and these deficiencies are expected to worsen with climate change [ ] [ ] [ ] [ ] . credible estimates are available for specific nutrient shortfalls -for example, . billion people suffering iron-or vitamin b -deficiency anemia , . billion people with insufficient dietary energy (that is, calorie) intake , % of pre-school age children and % of pregnant women at risk of vitamin a deficiency -but the world still lacks a rigorous, recent assessment of the population suffering shortfalls of any one or more nutrients, although the number is surely in the billions. by , the united nations projects that the global population will grow by nearly billion, to exceed billion people . meeting the united nations' sustainable development goal, to "eradicate hunger" (https://sustainabledevelopment.un.org/) for this expanding human population will necessitate a large increase in food supplies, with major changes to agricultural production and distribution systems, infrastructure and social protection programmes (fig. ) . despite large and, in many cases, growing inequalities, the global population is on average expected to become richer, and historically, with greater affluence has come greater consumption of food products in general and more animal-sourced foods in particular, both of which further increase food demand and thus the requirement for agricultural expansion and/or intensification . agriculture already occupies about half of the world's land and uses more than two-thirds of the world's fresh water , and recent studies have suggested that agricultural production might need to double or triple by to keep pace with projected population growth and food demand [ ] [ ] [ ] (fig. ) . meeting this demand using present agricultural production systems could require replacing > hectares of natural ecosystems with agricultural production, approximately % of the global land area, which is larger than the continental united states, although continuous efficiency improvements in agriculture will compel re-evaluation of these estimates. in turn, this agricultural expansion could result in an estimated ~ -fold increase in irrigation, ~ . -fold increase in fertilizer , , and -fold increase in pesticide use (fig. ) . the challenges of feeding > billion people and managing infectious diseases intersect in several ways ( figs. and ) . first, the expansion and intensification of agriculture are disproportionately occurring in tropical, developing countries , , , where % of deaths are attributable to infectious diseases , where the risk of disease emergence might be greatest, and where disease surveillance and access to health care, particularly for those infections that accompany extreme poverty, are most limited , . second, agricultural expansion and intensification have historically come with massive habitat conversion, contamination with animal waste and increasing use of agricultural inputs, such as pesticides and antibiotic growth promoters. beyond their direct adverse effects on human health , , agricultural biochemical inputs are known to have direct effects on emerging human infectious diseases, and can also serve as indirect drivers by contributing to the emergence of wildlife diseases that constitute important sources of emerging infections in humans , . however, the strengthening of agricultural production systems can also improve nutrition, which has pronounced benefits for combating many infectious diseases at the individual and population levels , . although concerns have been raised regarding the environmental impact of agricultural expansion and intensification , - , , , their effects on infectious disease risk have not been synthesized. here, we review both the beneficial and adverse effects of agricultural expansion and intensification on the transmission of human infectious diseases. we synthesize the pathways through which agricultural practices influence human infectious diseases, and vice versa, and identify opportunities to minimize the adverse consequences of agricultural growth while maximizing the human health benefits of agricultural development (fig. ). agricultural development can yield direct improvements to nutrition, and through several mechanisms, nutrition can be a critical determinant of infectious disease susceptibility and progression , (figs. and ). for example, immune responses are energetically costly and thus undernutrition often reduces the development and effectiveness of immune responses that can limit or clear infections. the relationship between infectious disease and nutritional agricultural production can improve human health by reducing food prices and enhancing nutrition, which can increase resistance to infectious diseases. however, freshwater habitats established for irrigation, as well as other agricultural inputs, often increase the risk of vector-borne diseases, such as malaria and schistosomiasis. in general, rural residents are most vulnerable to these increases in infectious disease, whereas consumers some distance away derive most of the benefits from increased food production. to maximize human health given the impending billion humans projected on the planet by , society must minimize the adverse consequences of agricultural growth while maximizing the health benefits. images by kate marx. status can function in reverse as well, because many parasitic infections place direct demands on host nutrition, causing undernutrition when food is limited . in fact, some parasites, such as helminths, can even cause eating disorders, such as geophagy (desire to eat soil), bulimia and anorexia . enduring infections often require rapid and effective repair of tissue damage caused by parasites, which is also costly. hence, certain infections can cause undernutrition, which itself can compromise both resistance and tolerance to infections , . by improving nutrition, agricultural development should facilitate combating many infectious diseases. for example, death rates from acute respiratory infections, diarrhoea, malaria and measles, diseases that on average kill more than a child every seconds ( million per year) , are much higher in children who suffer undernutrition than in those that do not , . in addition, poor maternal nutrition and associated impaired fetal growth are strongly associated with neonatal death from sepsis, pneumonia and diarrhoea ; undernourishment is a well-understood risk factor for . although the traditional green revolution approach to food production has succeeded in reducing undernourishment arising from insufficient calorie and protein intake, it has been very slow in reducing micronutrient deficiencies , which can be have significant effects on defence against disease. to make matters worse, where violence, unrest and terrorism impede access to food, such as in parts of africa and central asia, morbidity and mortality attributed to communicable diseases can be further exacerbated . although research suggests that improving nutrition will generally improve responses to infectious diseases, there may be important exceptions. for certain diseases, such as schistosomiasis and many respiratory infections, pathogenesis is a product of host immunity, often from hyperinflammation , . thus, undernutrition can actually decrease symptoms by reducing the strength and pathogenicity of immune responses . in addition, as nutrition improves, some parasites might proliferate faster than immunity can increase , resulting in more, rather than less, morbidity, with the classic example that dietary intake of iron can increase malariainduced mortality . in this section, we review the links between rural economy, infrastructure and infectious disease. , phosphorous (c), fertilizer and pesticide use (d), cropland area (e), and irrigated land area (f) and associated % prediction bands (light blue bands). 'nitrogen' refers to the normalized estimated global amount of nitrogen nutrients in fertilizers produced (originally reported in thousands of tonnes, now in metric tonnes). 'phosphorous' refers to the normalized estimated global amount of p o nutrients in fertilizers produced (originally reported in thousands of tonnes, now in metric tonnes). for a, data were collected from the world bank. for b-f, data were collected from the food and agriculture organization of the united nations and statistical models were developed based on the relationships between these variables and global human population density. after the best model was identified, year was substituted for human population density based on the fit in a. these projections should be evaluated with considerable caution because the models assume that human population size is the only factor that affects fertilizer and pesticide use and the amount of arable and irrigated cropland, when in reality, many factors affect these responses (for example, climate, diets, type of crops grown and so on). they merely illustrate that even an extremely parsimonious model seems to track past patterns tolerably well and thus could serve as a basis for coarse projections. see supplementary methods for details of the statistical models used to generate these figures and supplementary table for coefficients and statistics for the best-fitting models. economic development. economic development, especially agricultural development, has historically driven reductions in both infectious diseases and poverty across many settings. in fact, the poor financially benefit more from economic growth in the agricultural sector than in industrial or service sectors , . the early stages of economic development often involve the construction of infrastructure to facilitate food production and distribution, including roads, dams and irrigation networks , . more recently, the early stages of rural development often include rapid expansion of telecommunication, and to a lesser degree, electrification, both of which are promising but underutilized resources for disease monitoring and control in the developing world . other rural infrastructure that is more crucial to infectious disease prevention, such as safe water, sanitation and energy supplies, often follows or is developed concurrently , . in developing countries, rural infrastructure that provided access to sanitation and safe water explained % and % of the difference in the prevalence of malnutrition and child mortality rates between the poorest and richest quintiles, respectively . moreover, clean water, sanitation and electricity can also facilitate the construction of schools and health clinics that can help to further reduce disease through education, prevention and treatment. hence, if the history of the developed world repeats itself in the developing world, then it seems plausible that agricultural development necessary to feed billion people might help to reduce infectious diseases by promoting economic development and rural infrastructure. there are several important assumptions to this hypothesis, however, such as: ( ) it is possible to feed billion people; ( ) the rate of economic development will match or exceed the pace of human population growth; and ( ) developing countries are not in an infectious disease-driven 'poverty trap' , which is the notion that poverty increases the chances of acquiring and succumbing to disease, and chronic disease traps humans in poverty [ ] [ ] [ ] [ ] [ ] . if agricultural development lags behind population growth or if clean water supplies, sanitation and electricity do not immediately follow road, dam and irrigation construction, then the prevalence of many infectious diseases could remain unchanged or even increase as human populations grow . agricultural irrigation and freshwater redistribution. one major change in rural infrastructure that often accompanies agricultural development is the redistribution of fresh water, which has well-known consequences for the transmission of infectious diseases. for example, because % of crop production comes from only the % of agricultural land that is irrigated, and irrigated lands accounted for much of the increased yields experienced during the green revolution , the potential for increased irrigation infrastructure to exacerbate infectious diseases is a critical concern (fig. ) . importantly, agricultural development has caused both declines of certain types of fresh water, such as wetlands, and increases of others, such as dams, reservoirs and irrigation schemes. one of the largest drivers of global wetland losses has been conversion to agriculture , which has led to declines in diseases that rely on wetland habitats. for example, japan's successful eradication of schistosomiasis during the mid-twentieth century relied in part on conversion of wetlands to orchards in schistosomiasis-endemic areas , although replacing oxen with horses, which are less susceptible to schistosoma japonicum, as draft animals is also thought to have contributed substantially . similarly, some of the earliest successes in malaria control at the turn of the twentieth century occurred in the southern united states, where wetland drainageincluding for agricultural conversion -was one of a suite of antitransmission strategies used by the rockefeller foundation in its landmark malaria control efforts . although wetlands often decline with agriculture, dams, reservoirs and irrigation networks often increase, and this redistribution of fresh water has been widely associated with increases in some vectors and hosts of human pathogens . for example, construction of the aswan high dam in egypt and the accompanying irrigation network was associated with a rise in mosquito vectors and the disfiguring mosquito-borne disease lymphatic filariasis, commonly known as human elephantiasis . likewise, dam and irrigation construction resulted in increases in malaria in sri lanka and india , , and a sevenfold increase in malaria in ethiopia . a meta-analysis of studies revealed that humans living near irrigation schemes or in close proximity to large dam reservoirs had significantly higher risk of schistosome infections than humans that did not live near these water resources , at least partly because of increased freshwater habitat for intermediate snail hosts. similarly, a recent analysis of schistosomiasis case data from the past years across sub-saharan africa showed far-reaching effects of dams and irrigation schemes, with increases in schistosomiasis risk extending up to hundreds of kilometres upstream from the dams themselves . hence, dams, reservoirs and irrigation networks related to agricultural expansion are likely to increase vector-borne and waterborne diseases unless water resources are developed in deliberate and coordinated ways to mitigate these risks . urbanization, globalization and the movement of agricultural products. the world's population became majority urban in and urbanization continues to outpace population growth, especially in developing countries. urbanization necessarily extends food supply chains, as consumers reside further from farms and fisheries. although only % of the food produced globally for human consumption is traded across international borders , globalization is likewise elongating food supply chains. furthermore, as the costs of international travel have declined over time, the movement of people across borders has likewise increased. the expanded spatial scope and increased frequency, speed and volume of people and agricultural products moving within and among countries necessarily facilitates the spread of pathogens. for example, in ecuador, there is evidence that the construction of new roads has affected the epidemiology of diarrheal diseases by changing contact rates among people as well as between people and contaminated water sources . each year in the united states, there are already an estimated million people with illnesses, , hospitalizations and , deaths from food-borne infections , and imported foods -especially from developing countries with poor sanitation infrastructure and weak food safety enforcement -have been associated with a rise in food-borne illness . in addition, globalization is already thought to be a factor in the spread of human influenza viruses that spillover from poultry and swine , . although modernization of food supply chains, especially those linking farms in developing countries to high-income consumers in cities and high-income countries, has typically accelerated the diffusion of stricter food safety and quality standards , , as urbanization and globalization further extend food supply chains, enhanced monitoring for the spread of pathogens across transportation networks and strengthened food safety regulations will be needed. in this section, we review the effects of agricultural industrialization. anti-parasitic and antibiotic drug use. as the global human population increases, there will almost certainly be an increase in high density, industrialized livestock and aquaculture operations. currently, such livestock operations are vulnerable to devastating losses of animals to disease. for instance, in just the last years, an influenza a virus (h n ) and a foot-and-mouth outbreak led to the destruction of more than . million chickens and million livestock in china and great britain , respectively, and a 'mad cow disease' epizootic led to the slaughter of million cattle worldwide . similar scenarios have occurred in aquaculture. in the past three decades, there has been more than fourfold growth in industrial aquaculture worldwide , which should continue to increase as food demand grows and wild fish and shellfish captures push the limits of renewable production . bacterial outbreaks in aquaculture are common, especially in developing countries where there are sanitary shortcomings . in an effort to prevent these catastrophic disease-associated losses and improve animal growth, the agricultural industry uses a larger proportion of global antibiotic and anthelmintic production than human medicine, and most of the antibiotics are provided at non-therapeutic doses in the absence of any known disease , . in fact, although estimates are lacking for most countries in the world, in the united states, nearly nine times more antibiotics are given to animals than humans and, of the antibiotics given to animals, more than times as many are used nontherapeutically as therapeutically . this widespread use of antibiotics and anti-parasitic drugs (for example, anthelmintics) in industrialized agriculture and aquaculture could have important implications for human infectious diseases because it seems to be driving microbial resistance to these drugs, some of which are also used in human medicine , , . for example, livestock are a primary source of antibiotic-resistant salmonella, campylobacter and escherichia coli strains that are pathogenic to humans . there is evidence that antibiotic-resistance genes acquired from aquaculture are being transferred to human systems and these pathogens have subsequently caused outbreaks . anthelmintic resistance is also rife among parasitic worms of livestock and is strongly implied for parasitic worms of humans . as livestock and aquaculture production expand to address growing food demands, it is likely that current antibiotics and anthelmintics will become less effective because of evolved resistance, and thus infectious diseases of domesticated animals and humans will be more difficult to treat . pesticides, fertilizers and disease. pesticides, particularly insecticides, have shared value for suppression of agricultural pest populations and disease-carrying insect vectors, such as mosquitoes and other flies. because of the anticipated sharp increase in pesticide use by (fig. ) , insecticide resistance is also expected to increase, with important implications for the control of diseases carried by insect vectors. insecticides with widespread shared use for both crop protection and vector control include pyrethroid, organophosphate and organochlorine insecticides . several mosquito vectors of human and livestock pathogens have already evolved some resistance to these compounds . if agricultural expansion and intensification is accompanied by an increased use of insecticides, vector resistance may become more common and the control of vectorborne diseases more challenging. in addition to potentially driving vector resistance, increased pesticide use is likely to cause numerous other effects on host-parasite interactions. pesticides can alter disease risk by modifying host susceptibility to parasites [ ] [ ] [ ] . for example, many pesticides are immunomodulators that can increase infectious diseases of wildlife and humans , , or are endocrine disruptors of humans with potential downstream effects on immunity . even if pesticides do not directly affect immunity, detoxification of pesticides is energetically 'expensive' for the host, and thus pesticide exposure can reduce available energy resources for humans and zoonotic hosts to invest into parasite defences , . pesticides can also affect human disease risk by altering the densities of hosts or parasites or their natural enemies or mutualists , . several pesticides can alter host behaviours or be directly toxic to hosts and parasites, which in turn can modify contact rates between parasites and human hosts. in addition, pesticides can alter community composition, which can indirectly affect behaviours or densities of intermediate and zoonotic hosts and parasites. although chemical contaminants can be deadly to many free-living stages of parasites, both empirical trends and theoretical models suggest that stress associated with pesticide exposure can increase non-specific or generalist pathogens , , . in addition to the impacts that pesticides can have on infectious diseases, they can also contribute to non-infectious diseases, such as cancers, birth defects, miscarriages and impaired childhood development , which can further strengthen the poverty-infectious disease trap. indeed, among african agricultural households, there is evidence of an association between increased pesticide use and increased time lost from work due to sickness . in addition to an increase in pesticides, nitrogen-and phosphorous-based fertilizers are expected to increase threefold by to boost food production, and most of this increase will occur in tropical regions already rich with pathogens , , . although the effects of environmental nutrient enrichment on disease are indirect and complex, with some infections increasing and others decreasing, two reviews on the subject suggest that elevated nutrient levels more often than not exacerbate the impact of infectious disease , . for example, phosphorous enrichment can benefit mosquitoes that transmit malaria and west nile virus , . in addition, nitrogen-and phosphorous-based fertilizer use can increase the number of snails that transmit flatworms that cause human schistosomiasis , . conversion of natural habitat to agriculture can increase the abundance of ecotones (boundaries between ecological systems), change species composition and reduce native biodiversity , . ecotones play an important role in a number of important emerging infectious diseases , , and reduced biodiversity that accompanies agricultural intensification can increase zoonotic disease emergence and can worsen already endemic diseases [ ] [ ] [ ] . a recent global meta-analysis suggests that, based on the available literature, such biodiversity losses generally increase infections of wildlife and zoonotic infections of humans . however, studies of the relationship between biodiversity change and infectious disease risk tend to focus on a single parasite or disease, often of non-human animals, which limits the ability to determine more broadly the effects of agricultural intensification on the overall burden of infectious disease in human populations . recent studies have found that the local loss of dense forests, largely from agricultural expansion, affected diarrheal diseases, acute respiratory infections and general fever in cambodian children and infectious disease incidence in nigerian children over a decade , . proximate causes probably included reduced regulation of microbial contaminants in surface and ground waters, increased smoke from biomass burning, shifts in the ranges of insect vectors and decreased access to forest ecosystem services. a major concern is the potential for positive feedbacks between poverty, biodiversity loss, soil degradation and infectious disease , . several mechanisms can underpin these reinforcing relationships. the first arises as a result of poor rural peoples' reliance on limited biophysical assets for their livelihoods. as households clear forests, deplete soils or overharvest biota to meet near-term consumption needs, this resource degradation can compromise future economic productivity and increase disease risk. in addition, poverty, environmental degradation, biodiversity loss and disease can quickly become mutually reinforcing responses to natural shocks, such as droughts or floods, or to protracted conflict in a region. there are also more direct examples. for instance, global net losses of tropical forests remained unchanged during the s and s (at approximately million ha yr − or . % annually ; also see https://glad.umd.edu/projects/global-forest-watch and https:// www.globalforestwatch.org) and forest clearing can lead to transmission of zoonotic disease by increasing contact with wild animals. conversely, encroachment of people and domesticated animals into natural areas can introduce diseases to wildlife that can devastate wild populations and create reservoirs for the disease to be transmitted back to domesticated animals (see next section for further discussion and citations). especially as the agricultural frontier expands, considerable attention must be paid to monitoring and managing these biodiversity-poverty-disease feedbacks . a central tenet of epidemiology is that the incidence of many infectious diseases should increase proportionally with host density because of increased contact rates and thus transmission among hosts . hence, increasing human and livestock densities could cause increases in infectious diseases unless investments in disease prevention are sufficient to prevent these increases. given that most of the increase in human and livestock densities are expected to occur in developing countries where disease surveillance, pest control, sanitation, and medical and veterinary care are limited, there is little reason to expect that control efforts will keep up with the expected increases in infectious diseases associated with increasing densities of these hosts. as host densities and thus transmission increase, theory suggests that parasite virulence should also increase under some circumstances . when virulence of a pathogen is tied to its propagule generation within the body (such as occurs with many viral infections), the intermediate virulence hypothesis posits that an intermediate level of virulence maximizes parasite transmission because it balances producing many parasite offspring (increasing parasite fitness) with detriments to host survival due to pathology (decreasing parasite fitness). the balance in this trade-off determines parasite persistence. hence, as host densities increase and transmission becomes more frequent, the cost of increased virulence declines, shifting the optimum towards higher virulence . consequently, for pathogens that experience this virulence trade-off, increases in human, crop and livestock densities have the potential to augment both the incidence and severity of infectious diseases. feeding billion people -and the associated increase of land converted to agricultural production and livestock grazing -is expected to cause a surge in human-livestock, human-wild animal and livestock-wild animal contact rates, increasing the likelihood of 'spillover' events, which are defined as pathogen transmission from a reservoir host population to a novel host population , . as natural ecosystems are converted to crop land or range land, interactions among humans, and domesticated and wild animals, could increase . furthermore, if developing countries follow a trajectory similar to developed countries, then their demand for meat will increase, further increasing human-livestock, human-wild animal and livestock-wild animal contact rates . these interactions are crucial because % of livestock pathogens are capable of infecting multiple host species, including wildlife and humans , and based on published estimates from the s, over half of all recognized human pathogens are currently or originally zoonotic , , , as are - % of recent emerging infectious disease events , , (fig. ) . examples of recent zoonotic disease emergences with enormous impacts on either livestock, humans or both, many of which might have agricultural drivers, include avian influenza, salmonellosis (poultry and humans), newcastle disease (poultry), swine flu, nipah virus (pigs and humans), middle east respiratory syndrome (camels and humans), bovine tuberculosis, brucellosis (mostly cattle and humans), rabies (dogs and humans), west nile virus, severe acute respiratory syndrome (sars) and ebola (humans) , . to quantify the relationship between agricultural factors and disease emergence in humans through time, we used the human disease emergence database of jones et al. . we classified land-use change, food industry and agricultural industry as agricultural drivers of human disease emergence (see supplementary methods) . these analyses revealed that agricultural drivers were associated with % of all diseases and nearly % of zoonotic diseases that emerged in humans since (fig. ) . these values are even higher if we include the use of antimicrobial agents as an agricultural driver of human disease emergence, given that agricultural uses of antibiotics outpace medical uses in the developed world nearly nine to one , . several factors have materialized that facilitate spillover events associated with disease emergence . spillover appears to be a function of the frequency, duration and intimacy of interactions between a reservoir and novel host population . for example, influenza is believed to have jumped from horses to humans soon after domesticating horses and then made additional jumps to humans from other domesticated animals, such as poultry and swine . similarly, when free-range turkeys were prevented from interacting with wild birds and when interactions between domesticated pigs and wild fruit bats were reduced, influenza and nipah virus incidence , human pathogens that are currently or originally zoonotic , , and recent emerging pathogens that are zoonotic , . dropped, respectively, suggesting wild-animal sources of these infections , . in sub-saharan africa, the high frequency and duration of environmental interactions between different species of schistosoma worms infecting humans and cattle has undoubtedly facilitated their hybridization, and these hybrid schistosomes are more virulent to humans than their non-hybrid counterparts . these factors associated with spillover and disease emergence could be targeted to reduce transmission potential as human populations and agricultural productivity increase. given that most human population growth is expected to occur in developing, tropical countries, hunting, fishing and gathering pressures will almost certainly rise in subsistence economies , . the consequences of these pressures might initially increase contact rates between humans and wildlife. this could increase disease risk as bushmeat hunting is already thought to be responsible for several emerging human infectious diseases . to make matters worse, bushmeat hunting is the second biggest threat to biodiversity behind habitat loss, and biodiversity losses can contribute to disease emergence . however, if humans overexploit these natural resources, then human-wildlife interactions could eventually decline as species go extinct, which could reduce spillover events. changes in the composition of biodiversity associated with overhunting and overfishing can also have complex indirect effects on disease risk mediated by species interactions. for example, empirical evidence supports the notion that defaunation of large vertebrates in africa should increase zoonotic disease risk by reducing the predators and competitors (large herbivores) of rodents, a common reservoir of human pathogens . similarly, overfishing of snail-eating cichlids in lake malawi in africa seems to have been a causal factor in snail population and human schistosomiasis increases there . investigations of the effects of overexploitation on infectious diseases remain in their infancy, but the consequences for human populations could be profound. up to this point, we have focused on the effects of feeding billion people on infectious diseases, but the relationship is bidirectional. that is, human infectious diseases can also impact the agricultural and economic development necessary to feed the growing human population (fig. ) . for example, the overuse of antibiotics, anthelmintics and pesticides to prevent diseases is driving resistance to these chemicals that will compromise future crop, livestock and aquaculture production. in sub-saharan africa, areas with higher historical tsetse-fly abundance, the vector of the parasite (trypanosoma brucei) that causes african sleeping sickness in humans and cattle, experienced greater lags in the adoption of animal husbandry practices (for fertilizer and labour in agricultural enterprise) that hindered agricultural development and prosperity in africa long before and after europeans colonized . in rural subsistence communities, any source of ill health can significantly impact people's productivity, yields and agricultural output [ ] [ ] [ ] . for example, human immunodeficiency virus/aids has reduced average life expectancy in sub-saharan africa by years since , and a kenyan study found that crop production by rural subsistence-farming families dropped % after the death of a male head of household . many neglected tropical diseases (ntds) impose devastating productivity losses for affected people that can impede agricultural development from local to national to regional scales . some low-income communities appear mired in this poverty-disease trap, and thus might require substantial investment in health systems to promote the necessary agricultural and economic growth to pull them out of the povertydisease cycle [ ] [ ] [ ] [ ] [ ] . the goal of identifying potential changes to infectious disease risk associated with feeding the growing human population is not only to draw attention to this important current and future problem but to also encourage preparation for these changes by stimulating agricultural-and disease-related research, management and policy that could maximize the human health benefits of agricultural development . one urgent challenge is the problem of antibiotic, anthelmintic and pesticide resistance. analyses demonstrate that, in some cases, improvements in growth and feed consumption can be achieved by improved hygiene instead of antibiotics . indeed, all antibiotics as growth promoters were banned in the european union in . to curb antimicrobial consumption in food animal production, van boeckel et al. suggest: ( ) enforcing global regulations to cap antimicrobial use, ( ) adhering to nutritional guidelines leading to reduced meat consumption, and ( ) imposing a global user fee on veterinary antimicrobial use. in addition, as recommended by the world health organization, international organization for epizootics, and food and agriculture organization, national and international policies based on best management practices should be developed and implemented that document when and how antibiotics should be used, and agencies should be established to monitor their use, mandate reporting and enforce these policies . finally, given that host genetic variability can reduce disease risk , large-scale industrial livestock operations could add genetic variability into their artificially selected food animals in an effort to reduce epidemics and epizootics. these changes promise to secure the long-term viability of antibiotics and anthelmintics for curing diseases of humans and non-human animals. another challenge that seems surmountable is to enhance education and health literacy. not surprisingly, education has been documented as a major contributing factor to reducing infectious diseases, especially ntds, and reducing ntds can have reinforcing positive effects on the ability of humans to fight more deadly diseases, such as aids, malaria and tuberculosis . limiting ntds could also have knock-on effects for education and health literacy because ntds impede cognition, learning and school attendance . indeed, an investment of just us$ . per child for ntd control can result in the equivalent of an extra school year of education . this is likely an underestimate because of unaccounted for indirect effects of deworming on learning. a recent study revealed large cognitive gains among children who were not dewormed but had older siblings who were . thus, enhanced education and ntd control have the potential to synergistically fuel agricultural and economic development and facilitate escape from the poverty-disease trap. national and international shifts in investments could also potentially pay large dividends for nutrition, infectious disease control and poverty reduction. there is considerable evidence that the developing world will struggle to feed its growing human population because of the poverty trap of infectious disease . however, evidence also suggests that this trap might be broken through investments in health infrastructure and preventive chemotherapy [ ] [ ] [ ] . curing worm diseases has the potential added benefit of reducing nutritional needs of cured individuals by ceasing the feeding of their parasites. by reducing food demand, these drugs could also protect the environment by reducing the conversion rate of natural areas to agriculture. this, in turn, might help to curb climate change, which is one of the greatest threats to global food security and might also increase disease risk , . understanding the economic relationships among infectious disease treatment and prevention, food production, poverty and climate change in the developing world are important areas of future research. as human populations increase, there might be more pathogen spillover events that could result in new emerging human infectious diseases. historically, humans have combated emerging diseases through early detection followed by coordinated quarantine, as demonstrated by the sars outbreak in and the ebola outbreak in . we recommend continued and improved coordinated international disease surveillance, but this approach reacts to rather than prevents disease. we recommend a shift in both research and disease management efforts towards proactive management approaches. one proactive approach that has promise for preventing zoonotic disease emergence is biodiversity conservation , , but more research is needed to evaluate its effectiveness across various types of zoonotic diseases and its costs and benefits relative to more proven reactive public health interventions. ultimately, science needs a better understanding of pathogen spillover, the origins of disease emergence and post-spillover evolution so that human disease emergence can be better predicted and prevented , , . improved and diversified plant and animal genetic material could also help to simultaneously reduce hunger and disease. many efforts are already well underway; for example, introducing c traits into rice to enhance higher photosynthetic capacity in a warming world, and breeding drought-and flood-tolerant cereals, pulses and vegetables better suited to increased frequency of extreme weather events that can help sustainably enhance productivity. crops and livestock genetically adapted to resist more pests can reduce pesticide and antibiotic use. in addition, given that micronutrient deficiencies are now the most widespread source of undernutrition globally, commodity research must diversify beyond merely boosting productivity of staple cereals. far greater attention is needed on approaches that add mineral and vitamin content to foods . other, perhaps more challenging, interventions also merit attention. closing 'yield gaps' on underperforming lands, increasing cropping efficiency, eating less meat and excess per capita food consumption -which also have adverse health impacts on noninfectious diseases, such as high blood pressure, diabetes and heart disease -and reducing food waste and loss have the potential of doubling global food supplies , , , , while simultaneously allowing financial savings to be redirected towards health infrastructure to control disease. in addition, family planning, promoting female education and job market prospects, and enhancing early childhood survival have proved very effective at reducing human population growth . finally, producing food in more urban and suburban environments through vertical farming (the practice of growing produce in vertically stacked layers) also has potential to enhance food production locally, and might have reduced agrochemical and transportation costs and non-target effects relative to more traditional farming . investments into predictive models could also pay dividends. agricultural environments are complicated, multi-species systems that exhibit interactions at many levels. the complexity further increases from the tensions that arise in balancing expanding agricultural systems, social benefits and infectious disease risk. all of this complexity can overwhelm many analytical tools and experiments, which makes advances in mathematical modelling especially crucial to addressing these issues. box describes several examples of advances in mathematical modelling that illustrate their promise for analysing the links between agricultural practices and the dynamics of infectious diseases, projecting risks to future decades, influencing risks through either intentional (policies and interventions) or unintentional (continued habitat box | modelling tools for quantitative analysis of agriculture-infectious disease systems mathematical models facilitate the investigation of a complex web of interactions between agricultural systems, social dynamics and infectious diseases in the presence of the substantial nonlinearities inherent in these disparate processes. a notable example is a body of theory and analyses that have emerged to examine the links between agricultural systems and the dynamics of infectious diseases in the context of global development . the approach combines ecological and economic theory to model population subsistence and health, with the goal of examining the conditions under which subsistence and health needs of populations are met. the fundamental consumer-resource relationships that underlie the biological generation of capital via agricultural production can be formalized in ordinary differential equation models, which can be coupled with similarly structured models that estimate the gains and losses in human capital associated with population health and the increasing risk of acquiring and succumbing to infectious diseases associated with poverty. key insights emerge from such integrated models. high prevalence of infectious diseases among populations that rely heavily on subsistence, labour-intensive agriculture can reduce agricultural productivity, degrade human capital, undermine economic growth and generate conditions that systematically reinforce poverty . poverty, in turn, increases disease transmission as the lack of access to clean water and preventive care often associated with the lifestyle of the poor make them continuously exposed to parasites and pathogens embedded in the environment . malnutrition, a common consequence of poverty, may weaken immune response and increase susceptibility to disease. poor education and lack of resources lead to further reduction of health-seeking behaviour. modelling shows that the reinforcing feedback between poor health, labour productivity and capital formation triggers a cycle of increasing poverty and disease, known as disease-driven 'poverty trap' . it also shows that poverty traps are reinforced by the asymmetry between the slow pace of investment in disease protection associated with increasing capital due to agricultural development, and the relatively faster ecological changes in transformed landscape that foster disease transmission . modelling can also reveal the impact of temporary versus lasting structural interventions in changing the development trajectories of poor populations. these intrinsically quantitative and mechanistic investigations can indicate specific conditions for economic growth or resilience that can inform development strategies, via, for instance, targeted investments in agricultural development, human health or ecological conservation that may reinforce globally stable development equilibria . a final major contribution of such models is to encourage primary data collection in support of deeper understanding of system dynamics, and greater inference of underlying determinants of health and wealth. because there are strong traditions of primary data collection in population biology, epidemiology and other disciplines wherein mathematical modelling is being advanced, the expansion of model-based research on coupled agricultural-health systems is likely to yield new field data collection efforts and direct the design of experiments, which, in turn, will yield greater opportunities for model parameterization and validation. these new empirical field data are what are desperately needed to explore whether the predictions of highly stylized models are supported in settings far more complex than modelled. simulation modelling, in turn, can also permit exploration of the uncertainty intrinsic to field experiments that generate data in a specific place and time, advancing understanding of system performance under a range of feasible weather, market and other conditions not realized during the period of data collection. conversion and antibiotic use) actions, and incorporating economic and social costs of various public health or agricultural interventions. these models should help direct field experiments, which are desperately needed to parameterize and validate these models and to quantify key sources of uncertainty. ultimately, we believe 'win-win' scenarios for controlling infectious diseases, increasing agricultural productivity and improving nutrition are attainable. although this sort of integrative thinking has been historically rare because agriculture and public health have been perceived as disparate disciplines, it is beginning to slowly penetrate these distinct fields of study. for example, several agrochemicals seem to increase the risk of human schistosomiasis and agriculturally derived zoonotic pathogens, and thus researchers are actively attempting to identify agrochemicals that might 'kill two birds with one stone' , reducing crop pests and thus increasing food production while not increasing or even decreasing human pathogens [ ] [ ] [ ] . similarly, researchers are beginning to consider the introduction of prawns as biological control agents of schistosomiasis, which could simultaneously decrease disease and increase nutrition -because restored prawns can be fished, harvested and consumed without compromising their diseasecontrolling benefits , . we believe 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institutional affiliations. key: cord- - l gw sk authors: avgoustaki, dafni despoina; xydis, george title: how energy innovation in indoor vertical farming can improve food security, sustainability, and food safety? date: - - journal: nan doi: . /bs.af s. . . sha: doc_id: cord_uid: l gw sk food safety is an important scientific field, but at the same time a discussion topic of modern society that occupies more and more space of our every day time, dealing with the preparation of food, with its nutritious value, and various transportation and storage ways aiming at preventing food-related sickness. this work compares traditional farming with greenhouses and indoor vertical farming focusing on the challenges and the opportunities for each category. the scope of this work was to stress the role of indoor vertical farming towards this direction. indoor vertical farms can produce high quality and virus-free products that can be locally distributed, inside the urban environment that such investments take place, saving annually millions of tons co emissions. beyond that, in this work it was pointed out how energy plays a role in food safety in such systems. it was stressed that indoor vertical farms can act as a demand response aggregator. in large scale units it could play a role to adjust their production according to different electricity prices offered in different time zones throughout the day. this way, the owners under a multi-value business model will create the opportunity to the vertical farm owners not only to improve their production but at the same time absorb inexpensive electricity offered, by creating an additional profit mechanism (multiple revenue streams) under such an approach by entering into contracts with companies in a utility electric region. sustainability of resources and safety in the food production line is a major issue globally. by , it is expected that the global population will reach the . billion people, . billion people more that need to be fed (united nations, department of economic and social affairs, ) . today, agriculture occupies land equal to the size of south america in order to cover the demand of the global population. based on the assumption that the minimum daily demand of a single person is minimum kcal, if we maintain the same agricultural practices, we will need additional land equal advances in food security and sustainability # elsevier inc. issn - all rights reserved. https://doi.org/ . /bs.af s. . . to the size of brazil ( . billion acres) to cover the global food demand (despommier, ). on the other hand, according to lotze-campen et al. ( ) , the land used for agriculture is projected to be transformed for other purposes such as urbanization, energy production, or infrastructure growth. it is worth to mention, that another crucial challenge that will significantly affect agricultural production in the upcoming years is the rapid increase of the global temperature, as per each degree of temperature rise, % of existing agricultural land will be lost (despommier, ) . nowadays, climate change is a huge issue since it is expected that the upcoming years will outstandingly affect the agricultural process. the significant increase of the carbon dioxide emission levels from a global perspective-since it constitutes an important impact factor of agricultural productivity-can influence the global economy via the effects on the agriculture's total production rate. in specific, based on mulatu's et al. ( ) research conducted for ethiopia, indicates that the impact of co emissions will decrease . % to . % the real agricultural gdp since it will lead to lower the agricultural productivity and subsequently reduce the amount of traded and non-traded crops. such population increase certainly indicates a significant rise in the required food production, raising concerns on the deficiency, the quantity, and the quality of future food products. we should also take into account the fact that nowadays food travels daily thousands of miles from the production areas to the urban consumers, in order to meet the demand, releasing huge amounts of co . less developed countries such as ethiopia that were mentioned above, apart from global climate change will have to face and other enlarged problems concerning food safety. for example, human excrements that are used as fertilizers (estimation of % of the global farming) can cause diseases such as cholera, typhoid fever and numerous parasitic infections (despommier, ) . nowadays, even the more developed counties have to face food safety and security problems even if this kind of infectious diseases have been eliminated. it is worth to mention the pandemic of our age, covid- caused by virus sars-cov- that was initially reported in the province of hubei, wuhan in china. the disease is estimated to have originated from a seafood market in wuhan where wild animals were traded such as marmots, bats, snakes and birds (zhou et al., ) . the specific family of viruses, coronaviruses, are known to be transferred from animal to humans. according to zhou et al., , it is mentioned that % of the genetic makeup of covid- is matched with the coronavirus found in bats. the uncertainty that is caused globally via covid- has caused apart from multiple deaths and lockdowns to most of the european countries, will affect significantly the economy and will cost trillions of dollars in the global economy, during and beyond (unctad, ) . food safety is a major issue of our era, as there are multiple reports of cases worldwide over the last years that have caused food recalls due to bacterial infectious diseases leading to loss of billion dollars. why do we seem to have so many outbreaks concerning food production these days? only in the us, despite the attempts to provide a safe food supply, every year are recorded million foodborne illnesses, , hospitalizations and deaths (cdc, ) . in - , e.coli o : h outbreak in the us caused sudden eruption linked to consumption of leafy greens and the romaine lettuce. the pathogen was mainly reported in the regions yuma, az and salinas, california, where greenhouse installations that produce more than % of the leafy vegetables and greens in the united states are based. e.coli contamination in the production line almost all of the times originates from the irrigation water used in the fields. additionally, further risk in the contamination process from various bacteria and pathogens comes from the washing of field-grown products after they are harvested, while this step can spread contamination to the whole production. the most regular technique that outdoor farming applies after harvest is to dunk lettuce heads in water tanks from rainfall or irrigation, while most greenhouses apply triple washes with running water from the local network. vertical farms are a novel type of farming in a controlled-environment with a total replacement of solar radiation with artificial lighting that provides the necessary nanometers of the spectrum for the growth and development of plants. in vertical farms, plants grow in soilless cultivation systems such as hydroponic (roots are immersed in multiple substrates, i.e., perlite, rockwool enriched water with nutrient solution), aeroponic (soilless air/ mist solution) or even aquaponic (co-cultivation of fish and hydroponic plants) systems that allow stacking multiple layers or columns of plants horizontally or vertically. vertical farms are located in completely isolated spaces from outdoor environment with thermally insulated installations (especially when at the top floor of the building) and airtight structures that give the opportunity to the farmers to control the environment in terms of temperature, humidity and co (avgoustaki and xydis, ) . since vertical farms can theoretically be placed anywhere in the urban network, they allow local, nutritious and fresh consumption for consumers. in specific, a study conducted by jill ( ) , mentioned that food sourced from conventional farming uses to times more fuel compared to locally grown food and emits to times more co . meanwhile, vertical farms may be able to increase the productivity rate in highly urbanized areas that can lead to improvements in the food security of the community. the purpose of the following subchapter is to compare the different farming techniques of outdoor farming, greenhouses and vertical farms in between them in terms of input of resources, the final product in terms of safety and the shelve life of the products in terms of nutrient status and freshness. additionally, we will examine the above criteria for lettuce, which is one of the most important cultivated species in vertical farms and will give us access to multiple data. lettuce belongs to the basic daily diet products; its nature is fragile and can be easily contaminated and spread diseases among the population. in order to make more understandable the concept of resource use efficiency, in fig. the essential resources for growing plants under various farming types are shown. the most vital for plant growth is water, co , light, nutrients, electricity (for ventilation purposes) and heating. as shown in fig. , the definition of resource use efficiency (rue) is given by the ratio of the final plants production to the total input. in order to calculate the total input of a system, we have to summarize the input of resources, the environmental pollutants and the production system. in order to evaluate the sustainability and efficiency of a production system in the food industry, we have to assess three key directions of the system. • rue: the amount of necessary resources to produce. • the cost performance: the ratio of the sales amount to the production cost. • the vulnerability of the system, meaning the deviation of the yield production per year and the quality value per product unit. water is absolutely necessary for all food production such as vegetables, fruits, grains, meat etc. based on nederhoff and stanghellini ( ) , the water use for the global food production reaches at km and has a rapid increasing rate. the irrigation water-use efficiency can be researched under different scopes and multiple concepts such as storage, delivery distribution of the water to the farm or out of the farm. additional systems that can affect water use efficiency is the ratio of water that is delivered for irrigation and the water that supplies the system. there are various ways we can calculate water use efficiency as one of the major resource inputs in food production that can be accomplished with agronomic ways, engineering or even economic approaches. more analytically, irrigation efficiency estimates the ratio between the diverted water and the consumed by the cultivation, thus it provides water-use measurements that estimate the performance of the irrigation system. on the other hand, water use efficiency is considered an economic concept that in practice evaluates the farm, as it is calculated by the crop yield unit of water diverted (kg/m ). in terms of energy consumption, it is one of the reasons that causes greenhouse gas emissions (ghgs) contributing at the rising global warming. the main gases released by agricultural production are carbon dioxide (co ), methane (ch ) and nitrous oxide (n o). since the global policy makers, organizations, researchers, retailers and producers try to propose and implement novel techniques that identify and reduce ghgs, it is necessary that we will focus and refer to the status of emissions under each farming type and propose mitigation measures in the sector. in order to describe sustainability in agriculture, it is not enough to relate sustainability with the field only from the resources perspective. understanding and evaluating what constitutes a sustainable farming system, it is of vital importance, to furthermore understand the economic and social terms that influence the contemporary issues, values and perspectives of a unique system. economic efficiency reflects to the value that is relative to the cost. in order a resource to reflect an economic value, has to be rare and difficult to obtain, for the market prices to allocate the use of this resource for competitive purposes. for example, even if air and water are essential resources for life giving them high "intrinsic" value, nevertheless under most circumstances they have no economic value due to their sufficiency levels in the environment (ikert, ) . they only obtain an economic value in cases of scarcity due to, e.g., high levels of pollution or drought. even if is the most ancient way that people use land, over the last decades with the technological breakthroughs and the numerous innovations introduced, outdoor farming has changed. sensors, satellites and advanced machinery allow farmers to apply more targeted (and precision) agriculture to treat the fields individually according to the needs of the crop and the soil, by dividing it in smaller parts in order to take into consideration the variability level of each unit. to complete the whole picture of climate change issues, an additional evolution process that crucially reduce the growth rate of plants is soil degradation due to excessive floods and droughts. traditional food production systems offer food solutions for people from the beginning of human history. over time, additional innovative techniques were applied in traditional farming in order to rise the productivity rate and reduce the cost and the crops overall footprint. in terms of resources, conventional farming seems to have an increase demand for water use (table ) as traditional agriculture uses almost % of the available fresh water globally. furthermore, a very common problem in terms of sustainability in water use efficiency of conventional farming is the limited soil water-holding capacity that results from the limited mulching of the soil and the consistency in the same fertilizers/soil-preparation practices. scientific results (pimentel et al., ) have shown that this maintenance of these practices lead to low soil moisture status and low conservation levels of conventional farming systems. the most used approach for conventional farms is the irrigation efficiency and the water use efficiency. it is worth to mention that the more water applications are applied in a crop, the higher the water delivery losses are. in order to improve the water use efficiency, many farmers apply a combination of hydroponic systems with drip irrigation and smart scheduling of water distribution. hydroponics successfully address the challenge of soil drought and salinity that reduces both yield and crop quality. it should be noted that a decisive factor for the selection of hydroponic systems is the high irrigation water needs that renders the requirement for recirculating water. it becomes apparent that combination of water-saving technologies with limited-water application technologies (such as close-loop hydroponics, drip irrigation, mulching and smart scheduling of water supply) are the most effective solutions for optimizing water use efficiency. regarding land use, growing and producing food to respond to the expanding demand of the world has led agriculture production and food scarcity that can be difficulty bridged. today's farmlands, occupy almost % of the global habitable land (ourworldindata.org). we gathered the footprint of the various resources that meet the demand for lettuce production via traditional farming techniques. worth noticing that deforestation is a major problem, since forests are continuously sacrificed against farmland that leads to climate change acceleration and soil inability to maintain water at lower levels. depending on the cultivated variety, the techniques and the season, traditional farmed lettuce has a cultivation cycle between . and . months. therefore, farmers have the ability to grow multiple successive crops in the same field throughout a yearly cultivation period in order to increase their yield and income. additional techniques that open-field farmers follow in order to increase their yield and income per hectare (ha) of cultivated land is the density of planting, fertigation (combination of fertilization with irrigation) application and the use of healthy transplants grown in nurseries. assuming that romaine lettuce growing in the mediterranean is planted in distances of - cm between the rows and - cm between the plants, then the resulted yield reaches at , - , plants per ha (savvas et al., ) . by increasing the planting distance per row by cm, it can lead to a % reduction of the total production. harvest period vary depending on the type or the variety of the cultivated crop. for the romaine lettuce grown outdoors, the harvest period is between and days with a typical yield of - tons/ha. the energy use in outdoor farming is mainly linked to fossil fuels for operations such as soil plowing, sowing, fertilization, harvesting etc. additionally, further electricity is required for pumping (water irrigation), which in developed countries can reach up to % of the total fossil fuel usage (despommier, ) . conventional farming, unfortunately, is associated to higher emissions in comparison to other types of farming. the majority of the emissions is directly linked to the transportation of the products, also known as food miles. the amount of miles that is required in order for food to travel from the producer to the consumers could release between to kg of co emission depending on the location of the farm (gerecsey, ) . since farmlands are often located many kilometers away from the urban centers, where the majority of the end-user is located. food miles emissions represent on average % of the total emissions released throughout traditional farming. another important source of co emissions that is linked to traditional farming is the significant amounts of food waste. even if food waste is not only linked to traditional farming, maladministration and mismanagement on-farm losses, and non-marketable crops put traditional farming under the spotlight of high shares of carbon footprint. for the estimation and assessment of the economic efficiency of farming, significant role in the calculation, the resources that bear an "economic" value have played a role. in traditional farming, there is limited motivation to protect and evaluate the quality, use and water maintenance, air, solar radiation and in some cases even soil fertility and productivity. the costs of a farm can vary between two main categories: the variable costs (operational expenses-opex) and the fix costs (capital expenses-capex). in the category of variable costs, all the expenses that cover particular farming actions in a specific period of time such as seeds, fertilizers, chemicals, labor are included. on the other hand, in the fix cost category, all the expenses that will be incurred regardless the process and status of production, building expenses (rent, installations, land) and equipment (irrigation system, machinery) are included. thus, the economic efficiency consists from a combination of technical and other components. based on aurangzeb et al. ( ) and a research that conducted to compare the economic efficiency between traditional farming and mechanized farming systems, it is pointed out that the net income in mechanized farms is significantly higher due to the higher yields/ha than the one of traditional farms. this effect of traditional farms could be explained by the longer time periods in soil preparation, limited tillage practices as well as the high cost requirements of labor expenses (specifically in seasonal workers during harvesting and sowing) in comparison to the high technology and mechanization farming systems. last, another factor that highly affects the final quantity of production is biodiversity. for this reason, the selection and maintenance of mono-cropping techniques that provide a uniformity in the applied practices, can reduce the labor costs and make harvesting easier. however, by cultivating only onespecies crops in the entire field, it can highly influence the biodiversity and make crops more susceptible to pathogen infections. to avoid this effect, traditional farmers apply chemicals and genetically modified organisms to maintain a simple farming system. this practice, though, requires a lot of continuous input of resources and energy (cost). the innovative and high quality mechanization and technological innovation can lead to the increase of production and hence income. multiple practices become more and more vital in traditional farming, as they improve the efficiency of resources use in general and can overall enhance sustainability. concerning the water usage, there are several approaches that new farms bring along in the field and can optimize the existing severe water waste situation. common agronomic measures such as improved crop husbandry and changed crop mix driven by the crop selection, can have a huge impact in improvement of water usage. furthermore, there are various cultivation techniques such as modification of the irrigation infrastructure, which can also influence positively the water use efficiency. last, management actions such as optimal irrigation planning and frequent maintenance irrigation system scheduled maintenance can also influence positively the system's efficiency (wheeler et al., ) . due to the growing population, farming has shifted to technologies that enhance significant scale-up of the production via innovative technologies. greenhouses are types of installations, designed to protect and enlarge the cultivation season of various crops. plants growing under greenhouses can grow protected from severe weather conditions such as hail, snow, extreme low temperatures or excessive heat, while at the same time can allow cultivations of out-of-season species. greenhouses first introduced in the th century but only on the th century were commercially applied in the global market. according to their installed area, greenhouses can be presented with various coverage materials such as plastic, glass, polyethylene and rigid that protect crops from the variability of the outdoor conditions, diffuses solar radiation and traps moisture, which contributes to increased plant growth. the coverage system allows farmers to control the cultivation environment according to each crop preference, as they can apply different techniques that will maintain the heating and the cooling requirements to the desired levels. this way, inside the greenhouses, farmers can develop and maintain the desired microclimate and create a more predictable environment that enhances the final plant yield, achieving higher quality and reduced water consumption compared to open field crops. there are different greenhouse systems that are diversified according to the energy flow inside the greenhouse and the resources flow in the production line. in more details, open greenhouses refer to the structure of the irrigation system, meaning that they do not collect the drained water of the crops for reuse (usually have soil-based crops). these systems seem to have low level of water usage efficiency as they are affected by water losses due to soil depletion and constant water drainage, which drains the excess amount of water with fertilizers. this waste of resources cause significant problems to the environment. usually growers can control the amount of drain as part of the management strategy of resources they follow. the percentage of drain can number between % and % of the water supply, but can be improved by reusing this drain in the irrigation system. additionally, open greenhouses use window openings as the only mean of dehumidification and cooling technique. there are also the semi-closed systems of greenhouses that have a smaller cooling capacity and window openings, combined with mechanical ventilation air-cooling systems. the combination use of mechanical systems and window openings depending on the cooling demand. concerning the irrigation systems, semi-closed greenhouses reuse the drained nutrient solution by collecting it to a tank that is constantly topped-up with fresh water. in some cases is followed water disinfection in order the collected drain water to be purified for avoiding diseases spread in the crop. to avoid imbalances in the nutrient solution, farmers use various techniques such as bleeding or dumping. in specific, bleeding techniques remove constantly % of the drain water, while in the dumping technique the mixing tank gets completely emptied and refilled with fresh water enriched with nutrient solution. finally, closed-systems refer to absolute mechanical support of the cooling and dehumidification system by air treatment units. the air treatment unit consists of a heat exchanger that is connected to a ventilator. the purpose of the ventilator is to withdraw air from the interior of the greenhouse, cool it, dehumidify it, and then distribute it back into the greenhouse. furthermore, in closed-systems water usually follows a close loop that allows the collection, recycle and re-distribution of the irrigation water both for irrigation purposes but also for cooling and heating purposes from inside the distribution pipes between the plant lines (qian, ) . concerning the irrigation system in closed-systems of greenhouses, the water does not follow the procedures of bleeding or dumping that are followed in semi-closed systems. on the other hand, the water is constantly recirculated in the mixed tank as it is automatically topped up with the correct and precise amounts of fresh water and each nutrient element. the growers are aware of the status of each nutrient element and are able to adjust it precisely in order not to disrupt the nutrient balance. this process becomes possible because of the high evolvement of automations, sensoring and programming in close greenhouse systems and achieve a - % better water use compared with open greenhouse systems (nederhoff and stanghellini, ) . greenhouses have different techniques for irrigation and water collection and highly depend on if greenhouses use soil based techniques or soilless for crop production. another factor that highly influences the final water use and water use efficiency is the type of the system, meaning it is an open system, a semi-open system or a closed-system. however, as can be retrieved from tables and the big difference in water use efficiency can be explained primarily because of the higher production accomplished in greenhouses compared to traditional farming but also because of the lower transpiration in greenhouses. transpiration is the most important factor that influences the water uptake by %, thus the control and reduction of transpiration rate can have a huge impact on the water use. transpiration is highly affected by the status of humidity and the irradiation levels inside the greenhouse. the higher the humidity inside the greenhouse the lower the transpiration levels are. if growers manage to control these two factors in the optimal levels for each crop, then there is reduced transpiration level per m , which means lower water usage and therefore better water efficiency. the selection of the applied irrigation system, has also a significant influence. drip irrigation is one of the most popular irrigation techniques in greenhouses. water is located at the foot of each plant with the use of a pipe. drip irrigation has the advantage of saving large water amounts and also can control and maintain the humidity levels of the soil or the hydroponic substrate in constant levels. in that way, water stagnation and puddling of the ( ) food miles - km selected substrate mean can easily be avoided. finally, drip irrigation allows the targeted and limited fertilization being dissolved, in the watering system. other irrigation systems are the micro sprinklers that spray water in a range around two meters according to the pressure of the selected nozzle type. this system is mainly used in soil-based greenhouses with sandy soil texture. another very commonly used system is the irrigation with diffusers and is mainly used in narrower areas and the pressure of the diffuser depends on the nozzle that regulates the water supply and flow. finally, other irrigation systems applied in greenhouses are irrigation with hose and underground irrigation mainly found in soil-based greenhouses and present low level of water efficiency. most of the modern greenhouses apply hydroponic solutions that allow plant to grow without soil. in more detail, the word hydroponic comes from the greek words "Ύδωρ + Πονέω" translated as "water + cultivate," meaning that plants do not grow in soil but in mineral nutrient solutions in water solvent. various substrates in the market replace soil such as perlite, rockwool and zeolite. because of the nature of this technology, plants are permitted to dip directly in their roots into the nutrient-rich solution and subsequently plants can absorb faster the nutrients and in an easier way in comparison with soil-based crops. because of this process, plants grown in hydroponics form smaller root system and can divert more energy for growing their leaves and stems. additionally, smaller root allows more plants in the same area to be grown and harvest higher quantities in comparison to the outdoor farming. the above-described capacity of hydroponic systems, boosts the ability of growing food in limited areas as greenhouses can be. hydroponics consist of a total automated system that pumps water, and pipe-system can be completely auto-controlled. under various handlings and monitoring of every aspect that can be practiced in hydroponic systems, the growers can result into optimal food production results. more specifically, this process gives the opportunity to farmers to control the whole irrigation process of the crops according to the demand of each species and the seasonality. in addition, they can have access to data that can optimize the development rate and the resource footprint of the plants such as (a) the quantity of water that is distributed in each plant, and (b) the amount of nutrient solution that was given to the plants. hydroponics offer a big advantage as they are usually installed in close or semi-close loops that return the excessive water with the enriched nutrient solution back to a collective tank in order to re-distribute it back to the cultivation area. in contrast to the hydroponic solutions, traditional farming experiences huge amounts of resource and water waste as farmlands face the negative effects of soil degradation and the harmful effect of eutrophication (when nutrients from agricultural land create massive increase of phytoplankton populations leading to reduction of oxygen and nutrient reduction of from water and suffocation of multicellular water organisms). unfortunately, in traditional agriculture, excess supply of phosphates and nitrates in the soil can cause nutrient run/off and leaches. furthermore, the close or semi-closed loop of hydroponics categorizes them as more efficient in terms of sustainability process for water efficiency in comparison with traditional farming where most of the water is drained to lower levels of soil that plants cannot access. greenhouses consist of air-sealed cultivation rooms where are installed various automations and technologies that can control and provide the optimal environmental conditions for each crop. according to factors such as location, size of installation, height, outdoor climate conditions, greenhouses use different technologies that can properly adjust the indoor environment to the ideal air conditions. heating is one of the most important processes for space heating inside the growing room, when the outdoor conditions and too hostile for the plants' growth. for heating purposes, the technologies that are usually used vary according to the demand of each case. in general, heating systems use the interior hot air of the greenhouse to transfer heat through a heat exchanger to the stored water that is used as a thermal storage medium. a very common and cheap technique is using water heating systems that consist from plastic bags and ground tubes filled with water placed inside and between the rows of the plants. during daytime, this system absorbs and traps the solar irradiation and during nighttime, the stored heat is transferred in the interior of the greenhouse by releasing heat (sethi and sharma, ) . there are electric heaters operated via a thermostat or an automatic timer in order to rise the inside temperature to the desired levels. additional techniques used for heating are rock bed storages, movable insulation and ground air collectors. cooling is a technique of similar importance with heating as it enables to reduce the thermal energy inside a greenhouse and maintain the optimum temperature in each growing stage of the crop. various techniques are used around the world according to the specific climatic conditions, the size and the demand of each case. such techniques can be natural or forced ventilation, fogging and misting, roof cooling and fan-pad systems, as well as shading and reflection systems. the most successful systems are the composite systems since they are giving the opportunity for both heating during the winter period and cooling during the summer period. according to sethi and sharma ( ) , the most promising composite system is the earth-toair-heat exchanger system (eahes) that operates with the underground constant temperature of earth mass and utilize it to transfer or dissipate heat from or to the greenhouse. according to botanists plants are diversified to "long day" plants and "short day" plants based on the photoperiodism needs-meaning on how many hours of light they have to be exposed during the day in order to grow. artificial lighting is a technique that provides greenhouses supplementary lighting in case that the solar radiation does not completely meet the photosynthetic demand of each plant species for optimal growth and development. efficient and proper use of lights in horticulture and with additional boost of reflectors can provide apart from the optimal levels that are required for photosynthesis also can benefit the greenhouses with additional heating (fig. ). heat and energy loss is a common issue in greenhouse and artificial lighting. the latter can become an effective solution that mitigates these losses and add an additional value on the required lighting solutions. the most common types of lamps that are used in greenhouses are high pressure sodium lamps, lighting emitting diodes (led) lamps and ceramic metal halide lamps. energy use into a hydroponic production line is mainly meeting the demand of artificial lighting, heating and cooling loads as well as water pumps. the energy that meets the water pumping needs in a hydroponic system for lettuce is estimated by the average pumping time that is needed to irrigate the plants and the corresponding nominal power of the pump. based on the calculations of kublic et al. ( ) it was estimated that the average irrigation duration for lettuce is four and a half hours of total pumping daily. the energy related to the heating and the cooling loads in a lettuce production greenhouse is estimated by using the following equation the heat transfer coefficient depends on the coverage material of each greenhouse, while the efficiency of cooling and heating systems depends on the height of the greenhouse ceiling. the loss of heat depends on the external climatic conditions and it is a decisive factor of the air technique modification to be used. artificial lighting usage depends on the photoperiod necessary for each species and the active hours of sunlight that plants can absorb for photosynthesis purposes. the active time that lamps have to operate is highly relevant with the location of the greenhouse, meaning that greenhouse areas with limited solar irradiation hours (north part of europe, i.e., netherlands, denmark) have higher demand on artificial lighting in comparison with areas under sunshine (southern part of europe, i.e., spain, greece, italy). furthermore, the duration of the supplementary lighting depends on the nature of the cultivated plants in photoperiodism (if they belong to "long day" or "short day" plants as we mentioned before) . this characteristic can differentiate the need of the plants in total daily radiation and according to the outdoor sunlight, the extra hours that artificial lamps need to operate should be estimated. the ultimate purpose of artificial radiation is to provide to the crop the indispensable photosynthetic active radiation (par) in mol/m /day for optimal yield production. in order to calculate the energy of a mole of photons that reach the canopy the following equation is used: the result value of the above calculation of the energy demand of artificial lighting in the greenhouse is in [kj/kg/year]. food production and consumption is constantly rising, having a significant environmental impact making the implementation of more sustainable practices in food production necessary. in order consumers to satisfy their demand for off-season vegetables and fruits, the necessity of heated greenhouses for production is continually increasing. as it is mentioned in the traditional farming section, food transportation causes huge amounts of ghg emissions. however, this number is lower in comparison to the ghg emissions corresponding to heating hydroponic greenhouses in cold climate areas (ntinas et al., ) that try to meet high yields in order to meet customers demand. when heating of greenhouses is achieved with the use of natural gas, the consumed energy can reach the . mj with . kg of co for the production of kg of tomatoes. since the majority of greenhouses use fossil fuels to meet their heating demand such as natural gas, diesel, fossil fuel and liquid petroleum gas, it is of vital importance to strongly limit the greenhouses heat losses, upgrade the heating systems and to shift in utilization of renewable energy sources . heat losses can be minimized with the use of double glazing coverage material or with the use of multiple screens. the upper goal of these measures is to increase the environmental sustainability of greenhouse production lines. as it has already been mentioned, greenhouses combine different energy technologies, automations and digitalization for plants' monitoring, controlling and harvesting. greenhouses is a type of farming that can provide the option to connect with renewable energy resources in order to increase the sustainability of such systems and the energy efficiency of the various treatments that are necessary for mass food production (manos and xydis, ) . different types of renewable energy sources such as solar, wind, geothermal, hydroelectric, biofuels, biomass etc., are found all over the world bringing the possibility to greenhouse plants to produce yields under a more sustainable, economical and cost-efficient way (xydis, a) . energy policy strategies in a national and a global level, have as a high priority the support of electricity generation and heating from renewable energy and biofuels (xydis, b) . over the last decades significant improvements in a big variety of significant renewable energy systems, which are ground source-based, solar-based energy systems and wind-based energy systems have been made (koroneos et al., (koroneos et al., , . these can be for example electricity-driven heat pumps instead of traditional combustion-based heating systems consumes - % less energy in comparison to a conventional fuel heater (avgoustaki and xydis, ) . another advantage that heat pumps present . - . times higher energy efficiency compared to fossil fuel heaters as also % - % reduced co emissions in the cultivation area in comparison with the conventional. there are also examples of greenhouses that use several solar systems that store energy or other photovoltaic systems (pv) that undertake the conversion of solar energy to electricity that meets the heating and cooling needs of greenhouses. based on research conducted by ntinas et al. ( ) , greenhouses that utilize renewable biofuel (wood pellet) present - times lower global warming potential in comparison with a greenhouse that use fossil fuels for heating purposes ( . - . kg of co per kg of harvested tomatoes), even when the required energy is the same for both cases. greenhouses in the netherlands use complex technology for production of various cultivars that gather multiple operation during the production such are nurseries, growing bedding plants and transplants. these systems are highly automated and occupy land approximately ha or more (kozai et al., ) . even if these machineries occupy a lot of potential cultivated space, they reduce the labor cost and therefore the production cost. without the use of highly automated technology, the average work force required in greenhouses for cultivating purposes is estimated at approximately workers per a m production area. according to penissi et al. ( ) greenhouses produce g of fresh weight of romaine lettuce per m daily while traditional farming produce g of fresh weight of romaine lettuce per m per day. as it can be retrieved from table , the required land use for obtaining kg of fresh romaine lettuce daily is m presenting almost % of decreased land usage in comparison to traditional farming. in greenhouses there are different variables that based on their priority can offer different benefits to the farmers. these could be the location of the greenhouse, the product type, the access to capital, the required work force and other requirements. high significance in the cost efficiency is also the upfront cost and the ongoing growing cost of the greenhouse that can also lead to higher cost depreciation and development rates of the production unit. based on a comparative study conducted by , a greenhouse farm consisting of a semi-closed system of m of growing space in denmark, the opex and capex related with the farm were analyzed. their results showed that by assuming that the wholesale price of greenhouse produced greeneries reached at . €/kg, the annual yield production of harvested products reaches at , kg/year. it is also presented that the capital expenses for the installation of the greenhouses was calculated at , € including the hydroponic system and grow unit racks, natural gas, heating and ventilation system, light connection (for supplementary radiation), and electricity distribution. additionally, for the operational expenses the total amount of expenses rises to an annual cost of , €, including the leasing costs, the electricity demand costs (lighting, ventilation), the natural gas heating cost, the water demand, the labor requirements, the packaging expenses and finally the use of organic material (seeds and nutrients). different greenhouse scenarios were presented and a cash flow analysis in a -year projection, indicated that the cumulative gross profit increased in parallel with the increasing wholesale price of greeneries. more specifically, the payback period was calculated much longer than the operational period of the years resulting in negative prices of the net present value (npv), unless the wholesale price of greens increases to . €/kg or more. indoor vertical farming is an innovative type of closed plant production system that provides the opportunity of a controlled-environment agriculture, which can be controlled according to the crop regardless of the weather conditions. indoor vertical farms use artificial lighting as radiation source in order to cover the demand of plants for growth and development via photosynthesis. vertical farms are based in soilless cultivation techniques such as hydroponics, aeroponics or aquaponics. in addition to the hydroponic systems that recirculate the nutrient solution and benefit greenhouse cultivations, vertical farms use systems that condense and collect the water that is transpired by plants at the cooling panel of the air conditioners and continuously recycle and reuse it for irrigation. some principles concerning the structure elements permeate closedsystems of vertical farms. more specifically, vertical farms are thermally well-insulated and nearly airtight structures that are covered with opaque walls. this characteristic makes the farms capable to totally protect the inside crops from the outdoor climatic conditions and make them able to maintain the indoor conditions to the desired levels without having thermal losses. another characteristic that differentiate vertical farms from greenhouses is the multiple layers of stacked plants in the vertical racks or horizontal columns. this way, the construction provides maximization on the possible yield per unit of land in comparison to both greenhouses and outdoor farming. more specifically, vertical farms, according to the size on the installation, have a multilayer system mostly between and rows or columns with approximately cm of distance between the layers (can slightly vary according to the selected cultivated crop). inside vertical farms airconditioners or heat pumps, which principally are used to reduce the heat generated from the lamps and provide cooling and dehumidification for the crop are installed. furthermore, air-conditioners help to eliminate the water vapor that plants transpire in the cultivation area. fans are installed in order to circulate the air in the culture room; at first to achieve a constant and stable spatial air distribution and secondly to improve the photosynthesis and transpiration status of the plants. key factor in the optimal operation of vertical farms is the co delivery units that stabilize the co levels in the cultivation area at around ppm during photoperiod (when lamps are on) in order to increase the level that plants photosynthesize. an important characteristic of vertical farms is the nutrient solution unit that distributes the nutrients to the crops, the electrical conductivity control unit (ec) and the ph controller that monitors the level of the nutrient solution. last, it is very important to analyze the radiation systems inside vertical farms as part of the total structure essentials. as mentioned above, vertical farms are equipped with artificial lighting due to absolute lack of solar radiation. lighting is a key factor in plants development and depending on the selected lighting solution, plants can present differentiations in morphology, flowering and biomass production. light is electromagnetic energy that includes visible as also invisible wavelengths. sunlight is a free resource input that provides plants the whole spectrum of several wavelengths, % of it is within the range of - nm (kozai et al., ) . however, according to a number of researchers over the last decades (hogewoning et al., ; kim et al., ; lin et al., ; liu et al., ) , it is reported that the most important wavelengths for photosynthesis, morphology of plants and flowering are the wavelengths in the visible ( - nm) and the infrared ( - nm) spectrum. lighting emitting diodes (leds) offer advantages in comparison with other types of lamps such as fluorescent, incandescent, high-pressure sodium or high-intensity discharge (hid) lamps. these advantages are the robustness, they produce, a stable output that is immediately activated after the electric current flow, have long life (approximately , h), the opportunity of controlling the light output etc. for this reason, vertical farms focus on applying lighting recipes that combine different nanometers and can promote plants' growth. apart from the spectrum selection of the lamps crucial factors for plants are the dimensions of light, meaning the intensity of light during photoperiod and the duration that lights operate. what has literally been neglected is the potential of indoor vertical farms to act as a demand response provider (aggregators). it may sound weird, but indoor vertical farms could under a multi-value business models create the opportunity to the vertical farm owners to focus on their crop production and at the same time absorb inexpensive electricity offered. usually plants require some hours daylight and fewer darkness. it has been proven that by selecting the hours throughout the day that are not expensive to give the required light, and "give darkness" when electricity price is expensive, has not a significant impact on plants' growth and development. under a mass deployment scenario of such units in major urban environments (xydis, ) , the owners and operators of the indoor vertical farms could create an additional profit under such an approach by entering into contracts with companies in a utility electric region. the opportunity to earn (or at least save) significant amounts will or course be related to the size of the indoor farms and create multiple revenue streams. indoor vertical farms have thermally insulated walls and high level of airtightness that allows a better cooling by air-conditioners during the time that lights operate. this process is functioning even during cold winter nights, as the interior temperature can be increased due to the operating lamps that constantly generate heat in the cultivation rooms. the ultimate goal of air-conditioners is to maintain the indoor temperature at the desired levels. however, during the cooling process, a lot of the water portion is lost due to evaporation of plants or evapotranspiration. indoor vertical farms have heat pumps with cooling panels, which can condense and collect this water, recycle it and via the close irrigation loop, reuse it for watering the plants. according to kozai et al. ( ) , only a small part of the irrigated mass water is getting lost to the outside because of the high level of airtightness inside the vertical farm. it is also pointed out in this research, that the airtightness level of vertical farms should not exceed the . h À . this is suggested because this level of airtightness helps to reduce the co losses to the outside environment and at the same time to maintain the sanitize level inside the farm by preventing pathogens, bacteria, dust or insects to enter the area of cultivation. greenhouses compared to indoor vertical farms, do not provide the opportunity of collection, reuse and recycle of the water masses that evapotranspired from plants, because the majority of the water is lost via the ventilation process to the outside area and furthermore most of the water vapor of greenhouses is mainly condensed at the inner walls, making impossible its collection process. another remarkable point that influences the resulted transpiration in indoor vertical farms is the operation of the artificial lighting. more specifically, when lamps do not function, the relative humidity of the room can reach up to % (little transpiration in the culture room), and cause physiological and morphological disorders to the plants. in order to solve this issue, farmers operate the lamps in rotation after dividing them in groups (two or three) and each group operates for - h per day. with this action, a constant heat generation during the day from the lamps that aligns with the -h function of the heat pumps that dehumidificate and cool the air in the culture room can be achieved. in order to calculate the water use efficiency in indoor vertical farms the following equation is used: where -wc is the water mass (or weight) that is collected in the cooling panel of the air conditioners for recycling purposes (kg*m À *h À ), -wp is the alteration in the water mass that is detained by plants and hydroponic substrates (kg*m À *h À ) and -ws is the irrigated (or supplied) water mass to the indoor vertical farm. in general, co use efficiency in indoor vertical farms is around . - . (when the level of airtightness is between . and . h À ) and the concertation is around ppm-unlike greenhouses which achieve approximately a . cue with closed ventilation system and airtightness level of . h À and co concentration level at ppm (yoshinaga et al., ) . based on these data we can estimate that the cue of indoor vertical farms is . / . ¼ . times higher compared to the greenhouses that do not operate the ventilators and provide co enrichment in the culture room. this phenomenon can be explained because of the amount of co that is released to the outside area from the culture room and keeps increasing with the level of airtightness but also with the difference between the co levels inside and outside. the fact that the co concentration for enrichment in an indoor vertical farm is usually around - ppm in comparison to the greenhouses that have around - ppm can be explained based on that. in order to calculate the cue the following equation is used: where -cp is the net photosynthetic rate (μmol m- h À ), -cs is the enrichment rate of co (μmol m À h À ) and -cr is the rate of respiration of the workers (if there are) in the culture room (μmol m À h À ) the light energy of the lamps that is send in the canopy aims to provide the necessary energy that plants need to grow and photosynthesize. however, the salable part of plants can only fix maximum - % of the electrical energy as chemical energy. the remaining - % of the electrical energy that is not absorbed by plants is converted to heat energy into the culture room and the remaining is removed by air-conditioners to the outside area (avgoustaki, ). the above-described effect can also explain the negligible heating costs in well thermally insulated indoor vertical farms even in the winter cold nights. nevertheless, indoor vertical farms are based in automations and precision agriculture and all the input resources are measured and validated in order to provide the optimal results in the cultivated crop. for this reason, all farms focus on measurements and optimization of the light energy use efficiency both of the lamps and the plant community. what is important for these measurements in the definition and estimation of the par, which in other words, is the wavelengths of light that are in the visible spectrum of the - nm and are the ones that drive photosynthesis. par is not a measurement of light; rather it defines the type of light that is necessary for plants to photosynthesize. apart from the type of light, farmers need to know and further metrics of light such as the amount and the spectral quality of par. in order to estimate the light energy use efficiency of lamps (lue l ) we use the following equation: where f is the convention factor from dry mass to chemical energy that is fixed in dry mass (around mj kg À ) -d is the increase rate of dry mass of the whole unit of plants or only the salable part of plants in the indoor vertical farm (kg m À h À ) and -par l is the photosynthetic active radiation emitted by the lamps (mj m À h À ) respectively, in order to estimate the light energy use efficiency of the plant community (lue p ) is provided by the following equation: where: -par p is the photosynthetic active radiation that is received at the surface area of the cultivation. based on the calculations and experiments conducted by yokoi et al., , it is shown that indoor vertical farms have . to . times higher lue p in comparison to the greenhouses. only % of the light energy is actually converted into salable portion of plants. nevertheless, there are different techniques which can be applied and can improve the conversion factor to % or a little higher. a simple technique that can be followed is the application of interplant lighting, upward lighting, and use of reflectors (fig. ) . traditional lighting that is located only on top of the crop can cause undesirable shading in dense crops by uneven light distribution and lead to senescence of the leaves that are in lower levels. on the contrary, the application of interplant lighting can provide access of light also in the lower levels of the plants, improve the distribution of light and therefore improve the photosynthetic rate of the crop. according to dueck et al. ( ) , the photosynthetic rate of leaves in low levels is usually negative or nearly zero, but the application of interplant light can increase it in positive values. welldesigned reflectors can significantly enhance the lue l as they can reduce the vertical distance between the canopy and the lamps and increase the distance between the plants or the density, since plants constantly grow. same positive results by interplant lighting have been reported also in greenhouse canopies. the most suitable lamp selection for interplant lighting technique is leds as they have small volume and they perform lower surface temperatures in comparison to fluorescent and other types of light sources. leds have been proven beneficial for reducing the eue l also due to the higher conversion coefficient from electrical energy ( . ) compared to the fluorescent lamps ( . ). although the capital cost of leds is generally higher than the cost of fluorescent lamps, leds have longer operational life and the prices have considerably decreased over the last couple of decades and is expected to continue decreasing. apart from the lighting adjustments, other modifications can improve the lue l such as the control of the environmental conditions. the environment of plants and the ecophysiological status of plants can be enhanced by the optimal selection of air temperature, co concentration, water vapor pressure deficit (vpd), air current speed as well as the combination of ph, electric conductivity (ec) of nutrient solution. these parameters have to be set according to the selected cultivated species. another way to improve the lue l as well as the eue l of the salable part of plants, is to reduce the dry mass of the nonsalable parts of the plants. in indoor vertical farms, the most frequently selected crops for cultivation are leafy vegetables such as lettuce, small fruits and herbs and it is important to limit the percentage of the root mass into less than % of the total mass of the plant (kozai et al., ) . due to of the cultivation technologies used in indoor vertical farms this is an achievable measure only by minimizing the water stress of plants by controlling the water vapor pressure deficit of the room. if the selected crop is root species, then we can significantly increase the salable portion by harvesting earlier than usual in order to have an edible aerial part. finally, other factors that can also help in increasing the relative annual production capacity (per unit land area) of indoor vertical farms are: • limitation of the culture period between transplanting and harvesting by optimal monitoring and controlling of the environmental conditions • increase of the ratio of cultivation area under each farming type (field, tier, floor, culture bed) • increase of the salable part of plants as also the percentage of salable plants. according to kozai et al. ( ) , it is stated that by applying the abovedescribed techniques, the relative production capacity per land area unit in an indoor vertical farm of layers can rise up to - times higher compared to outdoor farming, considering that indoor vertical farms already produce - times more yield than traditional farming (table ). in practice, those techniques could double the efficiency of the whole system. indoor vertical farms use culture beds that are isolated from soil usage and the nutrient solution that enriches the irrigation water is distributed through pumping to the plants. because of the high-automated process of irrigation, the nutrient solution is drained from the culture beds that plants are growing and it follows a close loop by returning to the central nutrient solution tank for recycle and reuse. in order this process to be achieved, nutrient solution is rarely removed to the outside area. this process usually takes place once or twice per year when the level of certain ions such as na + and cl-are not well absorbed by plants and the percentage in the culture beds exceeds the normal levels, requiring discharge. in order this measure to be implemented, the supply of fertilization closes for some days and plants already planted can absorb the nutrient elements existing in the culture beds (kozai et al., ) . on the contrary, the fertilizer use efficiency of greenhouses and of fields in traditional farming is relatively low and occasionally can cause on the soil, surface salt accumulation. in order to calculate the fertilizer use efficiency (fue) the following equation is followed: where: -i u is the absorption rate of plants of ion element i that are in the organic fertilizer and -i s is the supply rate of ion element i into the indoor vertical farm. it is worth to be mentioned that the ion element includes the basic elements of fertilization solutions such as nitrogen (no À and no + ), phosphorus (po À ) and potassium (k + ). artificial lighting apart from a key element in the growth of plants indoor, it does increase the energy consumption of vertical farms. shamshiri et al. ( ) , noted that three major operational expenses in a vertical farm are the electricity cost with - % of the total cost, the operational costs (opex) with % of the total cost and the capital expenditures (capex) with - % of the total cost. indeed, energy consumption is a significant cost of indoor vertical farms and can be used as an measure for their sustainability levels. many research groups and institutes focus on developing innovative technologies and optimizing the lighting recipes in order to reduce the energy footprint of vertical farms and create a more sustainable and cost efficient type of farming. even if the demand for purchased energy is much higher in indoor vertical farms than in greenhouses, the energy efficiency of the former is significantly higher (graamans et al., ) . indoor vertical farms, since are in absolute controlled systems face high efficiency when operating with renewable energy . there are multiple examples of vertical farms that are operating under smart grid systems that generate energy for the demands of the farm via wind turbines or solar panels or even geothermal energy. additional roles in the vertical farm systems towards increasing their efficiency have the connectivity with resourceful batteries that provide the opportunity for smart use of cheap stored electricity from the hours that the electricity prices are lower. an approach gaining constantly more and more attention also under the dynamic pricing concept, where also accurate forecasting plays a crucial role (karabiber and xydis, ) . in order to calculate the energy use efficiency for the lamps (eue l ) is followed the below equation where: h is the conversion coefficient of electrical energy to energy of photosynthetic active radiation that is emitted by lamps. for the latest technology of leds this number reaches the . - . (kozai et al., ) . apart from the energy that is consumed in order to meet the lighting demands, the energy demand of the heat pumps for the cooling (or heating) processes in the indoor vertical farms should be added to the equation. this type of efficiency is often referred in literature as coefficient of performance of heat pumps for cooling purposes. the coefficient of performance of the heat pumps, in a specific room, increases when the outside temperature decreases. the electrical energy use efficiency for cooling by heat pumps (eue c ) is calculated by the following type: where: -h is the heat energy that the heat pumps remove from the cultivation area (mj*m À *h À ) and -a is the consumption of electrical energy by the heat pumps (air conditioners) (mj*m À *h À ). it is worth to mention that the total energy consumption of indoor vertical farms is defined by the sum of the energy consumption of the lamps, the heat pumps/air-conditioners and the electricity demand of other equipment used for the optimal function of the farms such as nutrient solution pumps and air circulation fans. if we focus only in the electricity cost demand of indoor vertical farms, lighting accounts to approx. % of the annual electricity energy use (assuming fluorescent lamps of w), while the electricity cost demand for air conditioning is around % and % the electricity demand of the auxiliary electrical equipment (kozai et al., ) . table presents the estimated representative values of resource use efficiencies in an indoor vertical farm that use artificial lighting. it could be concluded (from table ) in comparison to table , that the relative production capacity per land area unit in an indoor vertical farm of layers is to times higher compared to traditional farming and to times higher compared to greenhouse production. indoor vertical farming is a type of farming which by definition is developed to provide enough production in order to meet the local demand in urban areas with continuous increased demand for fresh and nutritious fruits, vegetables and herbs. in general, the most frequently cultivated species are plants that have higher profitability and have a relatively high price. a significant factor on crop selection is the crop to have a short production cycle in order to reduce the required electricity costs for lighting, heating and cooling of the crop and therefore can be harvested as early as possible. additionally, growers prefer plants that have high harvested yield, meaning a high portion of the crop that can be harvested and sold. for example in crops like lettuce and herbs, growers can harvest and sell the whole unit of the plant, while in tomatoes or peppers they can sell only the harvested fruit but at the same time. therefore the electricity used for the rest of the plant, could be considered as a product waste. another key issue in crop selection is the height of the plants, meaning that it is way more preferable the crop to have a compact status in order to be able to reduce the growing distance between multiple plants and grow more at the same available area. plants are also selected according to the perishability level that they present after harvesting and reaching the market. since indoor vertical farms are mainly located in urban or suburban areas, their goal is to produce crops that can increase their self-life (even of perishable crops), by shortening the harvesting and delivery time to the market. another parameter taken into account when selecting crops is the situation in the local market. if, for instance, tomatoes are missing for some reason from the market, then depending on the price they can get, they could be preferred against of another fruit or herb that is in abundance and its price cannot climb up. finally, most suitable crops are those that have year-round productivity in order to be affordable for the farmers to have a year-round market demand that can be profitable despite the continuous operational expenses. the constant production in a yearly basis of the same crop selection, allows also maintenance of the same, specific engineering settings of the crop, avoiding the modifications in the automations' selection that could cause abnormalities from a horticultural perspective. due to the concept of indoor vertical farming and the technology used in the cultivation areas, growing in an urban environment do not advantage the crops due to possible shading of the building, non-fertile soils or dormant soils. this fact can also be considered as one of the major drawbacks as the land price in urban areas is relatively high. concerning this approach, indoor vertical farms are often installed in large warehouses, industrial factories or even abandoned buildings, where the prices are low. according to kozai et al. ( ) , it is stated that indoor vertical farms can produce the same yield of lettuce heads and other leafy greens in only % of the land required by traditional farming and % compared to a greenhouse construction. based on tables - , it can be retrieved that the land use efficiency of indoor vertical farms ( . m ) required for obtaining kg of fresh romaine lettuce per day is almost % reduced compared to greenhouses and % compared to traditional farming. an indoor vertical farm of layers can produce g of fresh weight of romaine lettuce per m per day ( g fw/m /d for greenhouses and g fw/m /day for traditional farming). adenaeuer ( ) mentions that the increase in yield between indoor vertical farms and traditional farming can be increased by . due to the technology and by due to the technology combined with the stacking ability of the plants. depending on the stacking area and the volume of harvest, cultivation care and crop preparation techniques, the work force can highly vary. , propose that . workers are necessary per , kg of yield, resulting in % of the annual operational expenses of the farm (depending on the labor cost in each country). the same work force is required for a greenhouse production and approximately half of it for an open field farm. more analytically, according to savvas et al. ( ) , in soil-based crops the labor numbers , €/ha while a hydroponic greenhouse or indoor vertical farm requires around , €/ha as production cost. this demand is met by both permanent and by seasonal workers that will be hired for specific labor-intensive operations of the farm (like pruning and harvesting) throughout the year. indoor vertical farms have the advantage that allows them to generate bio-waste as bio-product during the process of edible biomass production. according to the cultivation system that plants grow in (hydroponic, aeroponic or aquaponic), the opportunity to farmers to collect easily all the by-products after the harvest period such as leaves, roots with fibers, stems, or even damaged vegetable and fruits and use it as well waste is offered. based on adenaeuer ( ) , the bio-waste that is collected and used in indoor vertical farms can be metric tons per year and with daily plant wastes that are collected for the indoor farms of roughly . tons. since indoor vertical farms use advanced close loop systems, present also the possibility to convert the daily amounts of biowaste and after careful processing to useful resources material for the crop as liquid fertilizer or biofuel (nikas et al., ) . the are several cases of installation of indoor vertical farms that have designed specific lines of biowaste management in their production line that only serve this specific purpose. it should be stressed that indoor vertical farms have the option to implement high tech equipment for conversion of food waste into energy production via anaerobic digestion. more specifically, this technology is a biogas recovery system that captures methane from food waste and convert it to heat, steam and electricity to meet the energy demands of the farm. this process requires a close-loop system, which creates biogas from organic material by piping it into the turbine generator. the electricity that is finally produced meets the high-energy demand of indoor vertical farms such as the operation of the lamps. anaerobic digestions is also compatible with aquaponic systems by receiving the organic waste of both fish and plants to produce electricity (agstar, ; united states environmental protection agency, ). one of the key factors that influences the selection of the farm system is the selling price of the products. according to tasgal ( ) , traditional farming products are to times cheaper in comparison to greenhouse an indoor vertical farming products. more specifically, traditional farming lettuce price usually costs less than €/head, while greenhouses lettuce and indoor vertical farm lettuce cost - €/head. additionally, based on the same study, the significant upfront capital requirements of indoor vertical farms can highly limit the pool of market participants. this happens because both the land prices, rents and acquisition of high-technology equipment are significantly higher in comparison with the leasing cost of farmland. on the other hand, , by conducting a comparative analysis between indoor urban farms and greenhouses presented slightly different results. in more detail, they assumed an indoor vertical farm with the same growing space and wholesale price of the greeneries as in the greenhouse facility, of m and . €/kg respectively. an interesting point is the massively increased production yield that can be achieved in an indoor vertical farm compared to greenhouses, reaching at , kg of fresh greeneries being annually harvested. the operational expenses of indoor vertical farms according to the examined case reached at , €/year resulting in almost similar numbers with the greenhouse facility. however, the biggest cost of indoor vertical farms noticed were the capital expenditures reaching at , € per grow unit, with the most costly equipment the lamps and integral connection of lamps, installation of growing unit racks and the electric distribution of electricity. subsequently, based on their model and the different cash flow analysis, indoor vertical farms present profitable investment opportunities with a high internal rate of return (irr) and a payback period between and years with a wholesale price equal or more than . €/kg. another research conducted by liaros et al. ( ) , a case scenario of a small iuvf of m growing area inside an apartment was presented, showing profitability to smallholders under various scenarios. worth to mention at this point, micro indoor farming in small growing spaces such as containers, garages or even simple rooms can be profitable depending on the demand and the flexibility to rearrange different cultivation parameters aiming for the optimum result. similar findings were also supported by ucal and xydis ( ) . on the other hand, based on a report conducted by agrilyst ( ) indoor micro-farms can be very costly, nevertheless, there are multiple marketing strategies for optimizing the results. according to the united nations (un) projections, the global population will exceed . billion until , all requiring to meet their food demand. additionally, un estimate that % of the global population will be located in urban areas by that time. in order all this increased food demand to be met, it is necessary to produce % more nutritious and fresh food. however, at the same time, land experts such as agronomists and ecologists, already warn of the growing shortages in agricultural land, necessary for sufficient food production (al-kodmary, ). when it comes to high quality food, the fact that already food prices are climbing high also due to limited agricultural resource inputs such as water and energy is a matter of great concern. over the last decade, the increase demand for more farmland in order to meet global food demand it becomes more and more obvious. as an immediate effect a lot forest areas are substituted by new farmlands in order to supply this demand. at the same time, since cities constantly grow in terms of area they occupy, a lot of farmland is lost due to this expansive urban development. it is important to convert the global production line to a greener form for both human beings but also for the planet. this implies that food production will not sacrifice the attention for the human health against the commercial profit. according to world health organization, more than half of the farms globally, still use for fertilization purposes of their crops raw animal waste that can attract insect as flies or contain weed seeds or even diseases which can contaminate the cultivated crops. subsequently, these techniques can highly affect people's health and can cause diseases. nowadays, the majority of the food is produced in large, industrialized farms and is transported, distributed and sold in supermarkets, grocery stores or multinational food outlets. agronomists, engineers and farmers in order to reduce the production cost and resource footprint of food production and at the same time increase the variety of the available food species for the consumers have developed various techniques. the high centralization level of food supply can allow the possibility of infection from foodborne pathogens and toxins that can poison large numbers of consumers. food usually travels thousands of miles every day leaving huge possibilities for contamination threats as it can be infected in one country and develop pollutant populations in another. because of the high logistic complexity of food supply, it is worth to mention the advantages and drawbacks of each farming type during the whole supply chain. what follows is an exploration of the three subjected farming types, including outdoor farming, greenhouses and indoor vertical farming. we will compare and evaluate products and growing process under the scope of food safety practices. outdoor farming is applied for thousands of years, allowing an unprecedented human development. however, over the past years the continuously increasing demand of the population has led farmers to apply chemical inputs for nourishing of plants, fighting pests, insects and improving soil quality. however, because of its nature, crops growing in the open field are facing all the difficulties from severe weather conditions and the danger of infection from various insects and pathogens. traditional farming is a type of agriculture that allows to multiple plant pathogens, bacteria and insect pests to affect crops, causing scalable losses in global crop production. after heavily tilled farming applications, severe irrigations and monocropped selections, soil has been seriously affected causing depletion of its nutrients, highly requiring additional nutrient solutions that can improve its fertile condition, making it appropriate for cultivation. once crops are harvested, a big after-harvest process and logistic supply has to be followed in order food to be transported from the farmer to customers' table. when we are talking about vegetables and greeneries there is a high level of perishability that needs to be confronted. crops have to keep cool in order to maintain the high fresh and nutritious status. in order farmers to retain a high value for their products, after harvesting, food is transported from the field to processing facilities that are responsible for the cutting, washing of plants in cold water applying centrifugation methods in order to remove the excess water from the products. after removing the roots and fulfilling the described procedure, products begin to decompose. an often procedure that farmers follow is to treat their production with chlorine compounds and/or antioxidants that expand preservation during and after washing. continuously, food is usually packaged and stored in refrigerators and very low temperatures in order to remain in inertia status. however, outdoor farmers are not able to perform refrigeration between harvest and transport of the products for water processing, making it more uncertain in pathogens infection. in order groceries to arrive from the processing facilities to the shelves of the markets, they require on average to km, resulting to - days in transportation. according to kublic et al. ( ) , every three days, products lose % of their nutritious value after being harvested and roots' removal, meaning that consumers finally receive severely influenced vegetables in terms of nutritional value. according to the centers for disease control and prevention, each year, "roughly million people ( in )" are food poisoned in the united states. in terms of food safety what products of outdoor farming face is the severe contamination from improper use of manure, either from human fecal that is used as fertilization mainly in developing countries or from contaminated concentrated animal feeding operations (cafos). even if it has been proven by various researchers as a great nutritious source for the crops after proper compostable process, on the other hand the absence of carefulness, targeted application and lack of sanitation can lead to transmission of various types of parasites. a serious parasite that is worth to be mentioned is geohelminths (hookworm, ascaris and whipworm), that can survive their eggs in soil for years when they find the right climate conditions, causing diarrheal diseases as well as permanent learning deficit to children (hotez and pecoul, ) . e.coli was a foodborne illness that took high publicity after infecting approximately , people and causing about deaths, after severe pollution of agricultural water reservoirs in farms of california. to summarize, even if there are multiple technological automations, innovations and outbreaks in outdoor farming over the last decades, the nature of this agricultural type is very open to foodborne illnesses, illnesses extremely difficult to be traced rising the total risks. because of the importance of food safety and in order to avoid further foodborne illnesses, there are several rules that force outdoor farmers to enhance the safety status of their production for the overall benefit of the population. the strictest and most widely recognized organization of food control audits is the global food safety initiatives (gfsi), which was established in to reduce and control the risks associated with food production as also to streamline and improve the overall food safety while reducing the operating costs. various certifications are provided to farmers including the safe quality food (sqf) and hazard analysis critical control points (haccp) that set the necessary rules and prerequisites of a high-level food safety status. this includes some of the following rules: • it is of significant importance the control and validation of the agricultural water. to be more specific, there are rules that prerequisite the testing of the water quality that is applied via irrigation to the crops, but also the water related to the tangential purposes such as hand-washing of the workers during or after harvest, the ice that refrigerates food and the surfaces that food contacts with. • biological adjustments are often applied in soil for or particular nutritional uses that replace chemical fertilization. it is of vital importance that farmers who follow these techniques to follow specific guidelines for the use of raw manure (such as animal and human feces) as also for the use of stabilization compost in order to maintain a high level of sanitation. • there are rules concerning the compliance of domestic and wild animals either they are working in the farm, invade in the farm or graze. • finally, there are high requirements in workers' health and hygiene that need to be followed in order to prevent the contamination that may source by humans. . . food safety status of greenhouses as has already analyzed, there are greenhouses that are soil-based and the more advanced use hydroponic solutions. in hydroponic greenhouses, plants are transported several times according to the growing stage and are monitored throughout the different growing cycles. that give the opportunity to apply the exact resource requirements in every stage, in comparison with soil-based greenhouses and outdoor farms, where the plants remain in the same position until their harvest. another significant advantage of greenhouses in relation with outdoor farming is the high geographical flexibility of installation as it allows a significant reduction of the transit time of the products from the harvesting and processing point to the final consumers. greenhouse plants in an industry that constantly growing, with today's list accounting half of the tomato production and / of the global pepper production that are distributed in the fresh market (brauther, ) . greenhouses are a significant driver of national economies of the agricultural sector because of the high profit margin as also the opportunities for high added-value products. unlike traditional farming products, greenhouse production is highly protected from dangerous elements and various contaminants. however, the technologies that are applied for monitoring and controlling of the environmental conditions do not guarantee crops free of microbes and pathogens. the management practices applied in greenhouses are these that can conduct to growth, survival and spread of foodborne pathogens. a severe contamination thread could be spread by processing equipment since crates and baskets that are used for transportation of products, from propagation tools or even for surfaces that food contacts with. irrigation water is one of the most important food safety risks even in greenhouses as it can be drawn from a wide variety of uncertain sources such as municipality supply, rainwater, underground aquifer, reservoirs or surface water. greenhouses that use untreated surface water as irrigation source face high contamination risks. for example, in , salmonela saintpaul (cdc, found to have infected cucumber greenhouses in us that caused the infection of individuals across the country as they consumed imported vegetables with questionable irrigation water status. because of the high risk of infection of consumers, even from more controlled agricultural systems (compared to outdoor farming), regulations for food safety have become stricter by establishing new standards for food production (produce rules). the four areas that these standards focus on are the followings: • health and hygiene this practice targets in maintaining hygienic conditions of the personnel that is occupied in the greenhouse factories, involving criteria for personnel cleanliness, handwashing and use of appropriate gloves. even if handwashing is considered one of the simplest and cost-efficient practices, it has been reported that only % of greenhouses practice handwashing before the harvesting process. • irrigation water quality and management since water quality is one of the most crucial and contentious factors, it seems absolutely necessary the mandatory establishment of rules that control the water baseline quality profile. greenhouses withdraw water from a bog variety of sources such as municipality supply, wells, reservoirs and surface ponds. by checking and understanding the quality of the quality of various water sources can provide important information and reduce the risk of contamination. by regulation, greenhouses have to determine frequently microbiological testing on the water sources. furthermore, greenhouses that apply hydroponic solutions in semi-close or closed loops that circulate, recycle and reuse water, have to include filtering treatments that remove possible pathogens before re-applying it. methods that are effective and efficient in water recycling is uv light or disinfectants. • animals and waste significant measure for the protection of crops from foodborne pathogens is also to eliminate the restriction of domestic and wild animals at growing activities inside the greenhouses as well as in the outside area of the buildings. practices that contribute in discouraging animal intrusions can be for example the rapid weeding that will minimize rodents attraction and protection. • sanitation of equipment, tools and greenhouse surfaces foodborne pathogens are usually found all over the greenhouse environment such as harvesting bins and boxes and tarp floor covers of the greenhouse (ilic et al., ) . according to produce rule, all the tools and equipment that used in the production line should be inspected, cleaned, sanitized and maintain in this condition throughout the whole production, harvesting and post-harvesting process, in order to prevent contamination. greenhouses in comparison with traditional farming have the advantage of the three-key elements application that can eliminate contamination risk: innovations, automations and control. in specific, innovations provide to greenhouse farms a more secure food safety support such as water filtration systems, integrated pest management and higher quality control systems. automations can reduce the danger of contamination or cross contamination as they minimize or decrease the introduction of foreign specimens. finally, biometric systems provide to growers the ability to detect tracking information concerning the plants. after harvesting, the produce is set up in a traceability system from the greenhouse plant to the customer delivery service. . . food safety status of indoor vertical farms leafy greens, vegetables and herbs are considered of high-risk crops since they are usually not cooked but eaten raw. the usual process of consumers is to rinse their purchased greeneries after purchasing them from their grocery store and then consume them. this is not a particularly effective and protective procedure, since harmful pathogens need interference of chemicals to be detached from plants. outdoor farming and most of the greenhouses perform triple-wash on the harvested plants in order to mitigate the contamination risk, as a post-harvest process. this process consists of the pre-washing, a saline wash and the final bathing of greeneries in sanitizing, choline base solutions. unfortunately, this method cause quality reduction to greeneries, as is observed loss of flavor and texture along with the concurrent risk of contamination existing and spreading under the possibility of incorrect application. greens that grow outdoors follow the triple-wash procedure as a postharvest measure for increasing their health status. harvested crops are transported in the processing facility and sorted, rinsed, put in spinners, apply a second rinse, spinner again, third rinse, sorted (again), packed, and then at the end they get delivered at the grocery market. crops that follow the above washing method bear usually on the packaging labels such as "triple-washed" or "pre-washed". even if this method can provide sufficient results in harvested outdoor crops, if the water used for the triplewashing process is polluted with pathogens, then this can spread rapidly to the rest of the harvested crop. for this reason, triple washing cannot categorized as the most effective and guaranteed process. indoor vertical farms apply only nutrient elements in the irrigation system and completely avoid the use any chemicals during the growing period of plants, excluding all the types of pesticides, herbicides and chemical spaying for fertilization. the philosophy of indoor farming depends on monitoring and constant controlling of the crops as also of all the resources that come in and out from the farm and they are isolated from mother nature where many threats and contamination sources may appear. for this reason, indoor farmers suggest that their products do not need to be washed before consumption, as they are already clean by a protected and purified growing process and a quick delivery to local grocery stores. hermetically sealed environments, inside highly controlled spaces that are designed to offer the highest possible level of food safety particularly for the growing period, surround the cultivation rooms of indoor vertical farms. since there are no seasons to be followed as in outdoor farming neither humidity, temperature fluctuations nor long gaps on post-harvesting processes and packaging, indoor farmers can dramatically reduce a potential contamination with precise systems. in addition, the hermetically sealed environment protects crops from being exposed to outside elements such as harmful pests, insects, fungi and bacteria. in one of other type of such systems, aquaponics, co-cultivation of fish with plants is done. this method of cultivation uses very innovative water filtration systems, which extract solids from the fish tanks. continuously, solid break down to beneficial bacteria that transforms them into nitrates. then, the nitrate-rich water circulates to the plant culture area where plants absorb the nutrients and purify the water. since the aquaponic system follows a close-loop, the clean water is circulated and reused into the fish tank. plants that grow in soilless systems can travel along their production process giving the opportunity to be inspected for health status. for example, after sowings, seeds are moved to germination rooms with high humidity that boosts their sprouting. then, seedling is moved to propagation room with controlled climatic conditions that promote their development. next, young plants usually located in the main part of the cultivated room in floating rafts, receiving a nutrient-rich water. after finishing their development and reaching their mature stage, they are daily harvested and shipped. between every translocation of plants, there is intensive quality check to prevent crops' contamination. high precision irrigation systems are used in order to monitor the water that travels throughout the crops. innovative hydroponic or aeroponic methods usually draw water from filtered and drinkable sources and distribute it at each crop often without even touching the salable part of the plants. this is achieved either by the use of water in liquid form, mist or fog that sprays it only into the root section of the plants and not in the parts consumed. extensive sterilization and supplier are also applied methodologies of indoor vertical farms that control and assure the input resources of the farms such as seeds, nutrients that need to be absolutely safe and clean. because of control and monitor mechanisms that are carried out indoor, there is clear advantage of indoor farms. they are aware of the cleaning status of plants and maintain it with further regulations during the cultivation period and finally harvest and deliver a healthy and fresh product. even if indoor vertical farms produce food safer to consume than the open field grown products, bottlenecks and hazards can still be introduced during the growing process of crops. such threats can be dirt and bacteria transferred from the workers and dangerous threats in the nutrient medium that include chemical sources, cleanliness and water safety. further risks can also detected at the post-harvest activities such as trimming, sorting and delivery of the products. thus, it is of vital importance even for indoor farmers to perform high status and certified systems for detection, monitoring, testing and evaluation as in outdoor farming and greenhouses. a study conducted by purdue university (wang et al., ) , found that there is also high risk of crops contamination due to pathogen pollution in vegetables grown in hydroponic or aquaponic systems. more specifically, they reported that e.coli o :h was found in fish feces and because of the circulation that close loops systems, it caused water contamination of the plant root surfaces that were in the aquaponic and the hydroponic systems. since fish probably were contaminated by the bacteria, it is important to follow a proper and certified handling, cleaning and sanitizing process in order to reduce the contamination risk in hydroponic and aquaponics. it is a very difficult, time consuming and α costly process to control all the plants even in an indoor vertical farm for having a % safe food product. indoor vertical farms use controlled environment of humidity and temperature in order to provide plants the most suitable conditions. however, in the case that unpredictable production errors occur, e.g., technical malfunctions with the engineering equipment, temperature and humidity can get out bounds to unwanted levels and create fertile environment for bacteria growth. this incident could be possibly avoided in the case of traditional farming, as the constant natural air circulation and the sunlight could smooth out some of these errors. bacteria population are not biased, meaning they do not grow or prefer targeted geographic locations, but they are transported to different locations by human activities as they can be brought by clothes, shoes or skin. furthermore, it should be noted that even if indoor farms consist a safer environment compared to other farming types, if a controlled environment develops for some reason bacterial infection, it will be extremely difficult to eliminate the contamination and protect the rest of the growing crop. for this reason, indoor farms follow high sanity level protocols to avoid the possibility of crops' contamination by human contact that involves all the workers involved with various cultivation processes of the plants. that include strict control by imposing the use of facemasks, hair and beard net, footbaths and clean or single-use suits, which can diminish the risk of contamination. another solution for further risk elimination from potential contamination, is the application of innovative technologies that operate extensive integrated pest monitoring. this can be achieved with the use of ultraviolet light outside of the farms that detect possible threats as also air curtains that are installed in every door and can control air that enters the cultivation room protecting it from the danger of contamination. additional solution that can increase the sanitation levels of indoor crops, is the application of certified hvac filters, in order to perform an extensive pest monitoring. indoor vertical farms belong to a novel type of farming cooperating with innovative technologies in order to provide the safest, higher quality and most fresh and nutritious groceries. both advocates and critics of this technology seem to recognize that indoor vertical farms under suitable circumstances (mainly of the high demand on electricity loads), could offer a solution to the safety and sustainability problems faced in traditional farming. however, consumers seem to be more skeptical and critical on this technology. potential explanation of the consumers' skepticism is the uncertainty and lack of trust in other food innovations such as genetically modified crops, food nanotechnology and artificial irradiation that struggled to find acceptance in the market. nevertheless, the subjective knowledge and awareness level of consumers on the indoor vertical farming is still limited, even with the excessive spread of technology and information globally, it is of vital importance to increase the education of people on this new technology by informing them on the actual growing properties and impugn the unjustified myths and dangers. because of the increasing demand of indoor vertical farms and their establishment in the market, many researchers have focused on designing and addressing customer surveys and other research methodologies in order to define the public opinion on this technology and the status of their trust and preference on already existing agricultural production systems. significant angle on these researches is to explore the existing knowledge and perception of customers between the three different farming systems; traditional farming, greenhouses and indoor vertical farms, in respect of the cultivation techniques, safety, resource sustainability, quality and their willingness to buy products from each category. for this reason, primarily it was of high importance to validate that consumers are able to recognize the different agricultural systems between them in order to provide valid, clarify and comprehensive results. different customer studies that investigated customers' opinion on different agricultural methods show a more skeptical belief concerning novel technologies on food production. more specifically, peoples' perception with technological innovations in agriculture are associated with high risks for food production presenting low expectations on the provided benefits of technology used (sparks et al., ) . in another research (coyle and ellison, ) participants rated higher the greenhouses facilities and the outdoor farms compared to the indoor vertical farms in terms of naturalness in the production process and the final product. concerning the quality status of the final product people also seem to present higher levels of confidence and trust on the greenhouse products and subsequently indoor vertical farms and finally in outdoor farming products. naturalness seems to be a high influencing indicator for consumers' selection globally as also a critical significant factor on the usefulness of the agricultural system. according to j€ urkenbeck et al. ( ) , customers replied that led lighting is not considered a too artificial tool for horticulture and slightly agreed that they do not consider indoor vertical farming too artificial concerning the overall production system. even if consumers in general prefer naturally and traditionally produced food, nevertheless the fact that food of indoor vertical farms grow without chemical additives is highly considered. on the other hand, under a customer research conducted by j€ urkenbeck et al. ( ), it is noticed that consumers seem to present a high acceptance on indoor vertical farming concerning the offering sustainability and the high ecological footprint. people seem to select their purchased food based on their concerns on the naturalness, ethics and environmental status. in more details, % of the respondents in that research declare that they put an extra effort to select and buy locally grown food because of its high level in freshness, nutrition and reduced food mile emissions compared to traditional farming methods. on the other hand, a significant share of the consumers evaluates indoor vertical farming as an artificial agricultural process in order to trust their footprint outcome. for this reason, it is pointed out that knowledge, information and nutritional awareness can become a solid solution for the higher acceptance of indoor farming and irradiated food products. respondents of the specific survey showed a strong willing on buying products that were produced in an indoor vertical farm with . % of the total sample, . % partly agreed on that statement, and finally only . % were not willing to purchase these products. however, it should be noted that the perceived behavioral control does not influence the customers' willingness to buy, but it has some influence on the behavioral intension of willingness to purchase the product. overall, the behavioral intention of customers to purchase products from indoor vertical farms is highly dependent on sustainability. under a different analysis, it has become very clear that perceived sustainability of indoor vertical farming is the main reason of acceptance. it has been observed that the more positive the resulted sustainability status of the system is, the higher and the customers' acceptance and willingness to purchase the product is. furthermore, based on the perceived sustainability level of indoor vertical farms it seems that customers increase and their acceptance of this innovative technological food production system. based on these results, we could indicate that the growing involvement and concern of consumers to select products from agricultural systems that present high environmental performance. indoor vertical farming can be very advantageous in terms of resources sustainability since because of the high technology and the soilless cultivation systems it consumes way less on natural resources (e.g., water and nutrients). additionally, indoor vertical farms significantly decrease the co emissions that are correlated to food transportation from the producers and the processing facilities. in specific, indoor vertical farms can provide times higher productivity per year per unit land area compared to traditional farming due to the zero dependence on weather conditions, seasonality and possible infections from insects, pests and bacteria. due to the evolution of technology it is not anymore a prerequisite holding a large area of land for sufficient fresh food production, but the use of multiple layers, optimally controlled (environmental conditions and physiological parameters of the crops and minimum possible loss from crop threats). significant characteristic of indoor vertical farms in terms of sustainability is the minimization food delivered losses. in addition, significant reductions can be observed in the cooling fuel demand, necessary to cool the production in order to be transported in long distances. this can be achieved since indoor vertical farms are usually installed in the urban or suburban areas in shaded and/or abandoned buildings (or even basements) due to the soilless farming techniques and the artificial lighting, providing access to fresh and nutritious greeneries to citizens. finally, one of the significant benefits that indoor vertical farms provide is the ability after proper processing of the use of waste water, crop wastes and excessive co produced in urban areas, as input resources of water, nutrients and co in the culture area. to summarize some of the basic improvements in resource savings provided by indoor vertical farms compared to the immediately following high technology cultivation system, the greenhouses are the following: • indoor vertical farms save % of the pesticide use in their interior by maintaining the culture area clean and insect-free. • because of the application of close loop irrigation systems and of the collection, recycle and reuse of the water vapor that plant leaves transpire, indoor vertical farms can reduce up to % the water consumption. furthermore, the use of closed loops can decrease up to % the fertilizer usage since it is feasible to recirculate and reuse the nutrient solution. • significant land reduction up to % can be achieved with the application of indoor vertical farming, due to the important increase (more than times) of the annual productivity of crops per unit land area. • yield variation can also reduced by % because of the constant monitoring and control of the crops and the lack of influence from the outdoor environmental conditions. food safety and traceability of products is another important factor highly relevant to indoor vertical farming. even if it does not provide a % safety for consumers, despite the fact that crops grow in a controlled environment protected by wildlife, animals, birds and insects, it upgrades the safety and security feeling of the products than those that grow in open field. the majority of the selected cultivated crops of indoor vertical farms are among the species with the higher contamination risk when they grow outdoors or unprotected, because they grow very close to the ground level. furthermore, one of the most crucial factors that greatly affect the possibility of contamination is the water quality that involves during the whole production process, including the irrigation water as also the washing water at the post-harvest processing techniques. farmers of all categories should follow high standards and criteria for the water sources that channel water into the farms as also frequent control and monitor of the crops for potential threats of contamination. it is now clear, that indoor vertical farms are a high necessity for tackling the challenges concerning the conservation of their resources. nevertheless, in order to enhance the environmental sustainability and improve the efficiency and sufficiency of food production supplies for our society, it is necessary to develop more diverse, effective and ecological agricultural systems including both the traditional farms and the greenhouses. further research and experimentation it is absolutely necessary in order both to improve the efficiency of resources in an indoor vertical farm but also to possibly eliminate the possibilities for contamination threats and constantly provide the outmost safe, fresh and nutritious fresh fruits and vegetables to the human population. notwithstanding the promising benefits that are linked with indoor vertical farming, there are also important challenges in the further implementation of this farming system in the future. it is of vital importance further improvements on the efficiency and effectiveness of the equipment that will lead to a significant decrease of the energy demand of the systems. by achieving the reduction of energy demand, it will add extra value in the environmental sustainability of the system but also it would also make it more appealing for the public, the investors and the industry and will increase the viability and profitability. however, it is pointed out by despommier ( ) that there is the opportunity for energy recovery from the non-salable crops' parts and capture of renewable sources of energy that can create zero energy building for hosting indoor vertical farms. at the same time, the whole system of indoor farming can synchronize and manipulate huge amounts of carbon and simultaneously release into the atmosphere oxygen from plants' respiration. significant is also the start-up costs that are associated with indoor vertical farms as it is clear that it is more expensive to develop a vertical greenhouse than a normal greenhouse (fletcher, ) . as it has been highlighted by many studies one also key barrier that indoor vertical farmers have to confront is the public resistance to these type of products as social masses face difficulty in accepting indoor vertical farms instead if traditional farming ones because of the natural way that food is produced. additionally, as indoor vertical farms serve the concept of local, fresh food production and they are mainly installed in urban or peri urban areas, they have also to salient the issue of affordability because of the expensive land and space use. for this reason, key factor is the productivity rate of indoor vertical farms that can maintain them profitable and keep them prevailed in the future. more specifically, if indoor vertical farms achieve to produce up to times more yield compared to traditional farming, then they can offset the capital expenditures and the expensive land use. previous research conducted by , presented that indoor urban vertical farms regardless the financing scheme, are much more profitable in comparison to greenhouse constructions. in the specific work, different investment scenarios are presented based on the cash flow analyses and show that iuvf can present high irr (investment return rate) as also a payback period between and years. finally, another drawback that is linked with indoor farming production is the limited variety of crops that can be produced with this technology, such as lettuce, herbs, tomatoes and berries. even if theoretically, all types of crops could be cultivated indoors, that would not be economically feasible due to the highly increased energy demand. thus, low-value agricultural crops such as wheat and barley will continue to grow under economically and environmentally unviable conditions. under these circumstances, the indoor vertical farms have to face a limited production compared to the "limitless" hectares of traditional farming and a reconsideration of scaling up would be particularly costly and complicated. the last years that indoor vertical farming gained more recognition and research interest, a plethora of new studies, prototypes and innovation designs have been presented under the academic and industrial scope. indoor vertical farming presents a high interest and potential to play a critical role in the demanded sustainability in food of urban areas. this becomes even more important by the multiple studies that estimate and analyze the significant increased food demand in urban areas. indoor vertical farming presents important advantages compared to traditional farming, concerning the required sustainability in our times by focusing in three main categories: environmental, economic and social. there is a high demand for further development in automation. this will 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balance discovery of a novel coronavirus associated with the recent pneumonia outbreak in humans and its potential bat origin key: cord- -zpzncgiv authors: galimberti, andrea; cena, hellas; campone, luca; ferri, emanuele; dell'agli, mario; sangiovanni, enrico; belingheri, michael; riva, michele augusto; casiraghi, maurizio; labra, massimo title: rethinking urban and food policies to improve citizens safety after covid- pandemic date: - - journal: front nutr doi: . /fnut. . sha: doc_id: cord_uid: zpzncgiv the ongoing pandemic caused by the coronavirus disease (covid- ) is literally changing the world. from december to date, more than million cases have been reported worldwide and global health institutions are acting to slow down the virus transmission and are looking for possible prevention strategies in case of a new outbreak. as in other endemic or pandemic phenomena, the issues mostly covered by scientific and media attention are related to the diagnostic and therapeutic approach of covid- . however, a still neglected issue regards the adoption of a more systemic approach considering the close connection among the infection, the environment, and human behaviors, including the role of diet and urban management. to shed light on this issue, we brought together a faculty group involving experts in environment and biodiversity, food safety, human nutrition, and behavior, bioprospecting, as well as medical doctors having a deep knowledge of the complex historical relationship between humanity and vector-borne infections. two main aspects emerged from the integrative overview of the current covid- pandemic: (i) the scientific community should start sharing social actions and policy advocacy based on the assumption that human health strongly depends upon a sustainable exploitation of natural resources in populated areas; (ii) the specific strategic role of the cities in developing sustainable food systems and promoting healthy dietary patterns. definitely, some priority issues should be addressed to achieve these goals, such as global efforts to increase food safety and security, which would benefit from urban and peri-urban agriculture enhancement, smallholder food producers support, and ecosystem services and local biodiversity maintenance. the ongoing pandemic caused by the coronavirus disease (covid- ) is literally changing the world. from december to date, more than million cases have been reported worldwide and global health institutions are acting to slow down the virus transmission and are looking for possible prevention strategies in case of a new outbreak. as in other endemic or pandemic phenomena, the issues mostly covered by scientific and media attention are related to the diagnostic and therapeutic approach of covid- . however, a still neglected issue regards the adoption of a more systemic approach considering the close connection among the infection, the environment, and human behaviors, including the role of diet and urban management. to shed light on this issue, we brought together a faculty group involving experts in environment and biodiversity, food safety, human nutrition, and behavior, bioprospecting, as well as medical doctors having a deep knowledge of the complex historical relationship between humanity and vector-borne infections. two main aspects emerged from the integrative overview of the current covid- pandemic: (i) the scientific community should start sharing social actions and policy advocacy based on the assumption that human health strongly depends upon a sustainable exploitation of natural resources in populated areas; (ii) the specific strategic role of the cities in developing sustainable food systems and promoting healthy dietary patterns. definitely, some priority issues should be addressed to achieve these goals, such as global efforts to increase food safety and security, which would benefit from urban and peri-urban agriculture enhancement, smallholder food producers support, and ecosystem services and local biodiversity maintenance. the ongoing pandemic caused by the coronavirus disease (covid- ) is literally changing the world ( , ) . from the first documented human patient in wuhan (hubei, people's republic of china) in december , on august , more than million cases have been reported worldwide, of which more than six million still active ( % in serious or critical conditions) and almost k deaths. who and other authorities soon realized that it was no longer possible to contain the virus spread, but only to slow down its transmission and try, at least, to reduce "pressure" on national health systems. as in other endemic or pandemic outbreaks, the issues mostly covered by scientific and media attention are related to the diagnostic and therapeutic approach of covid- contagion. however, greater consideration should be given to a systemic approach considering the close connection between this disease, the environment and human behaviors, in a framework of building a safer, more sustainable and healthier world ( ) . how is it possible that a virus from a chinese market has spread to other continents so quickly, penetrating the heart of cities and killing the weakest citizens? to shed light on this issue, we brought together a faculty group involving experts in environment and biodiversity, food safety, human nutrition, and behavior, biological activity of natural products as well as medical doctors having a deep knowledge of the complex historical relationship between humanity and vector-borne infections. we believe that unlike the pandemics of the past, the factors triggering the current spread of covid- outbreak, should be analyzed not only by scientists and politicians but also by societal stakeholders. many european countries most afflicted with covid- have started thinking ahead are now facing with the "phase two" of the covid- situation by operating the recovery of industrial and social activities keeping, at the same time, the infection spread as low as possible. in such a context, the linear science, which analyzes those biological variables dealing with the pathogen and its infectivity to find possible solutions [e.g., a vaccine or a therapy ( )], clashes with the "post-normal science" (psn) approach, for which, societal values (e.g., the right to freedom, economic needs, and relational aspects) claim their importance ( ) . pns is designed to deal with situations of uncertain facts, values in dispute, high stake and urgent decisions [( ); figure ]. pns should be operated together with responsible research and innovation (rri) tools (https://www.rri-tools.eu/aboutrri) that offer a broad set of strategies to address global challenges throughout the analysis of "real-world complexities' considering new scientific knowledge and technologies, but also the needs of different stakeholder categories. the contrast between these approaches to science is exerting some pressure on governments that even proposed solving the problem of covid- with autonomous strategies or hypothesized to reach a sort of herd immunity by sacrificing an entire generation of older people ( , ) . this situation demonstrates the lack of organization by the modern society to address complex global issues. our contribution aims at supporting the adoption of a pns response to covid- pandemic, also considering the geopolitical and social aspects which caused the dramatic susceptibility to such infection. for this reason, we aimed at better addressing two main concepts regarding covid- "effect" on cities and citizen-led community responses, to prevent future pandemic events. the first point to discuss is the unexpected permeability of cities to this virus and hypothesize how the spillover from wildlife of such a kind of pathogens can reach urban centers. this evaluation is of primary concern to better define suitable prevention strategies for limiting or blocking the current one and other future pandemic spreads. what characterizes covid- contagion, is that it fully took advantage of globalization facilities, enabling rapid spread of the virus across the world. generally, accurate controls are performed on goods transported worldwide but in case of novel pathogens (e.g., the covid- ) diagnostic options are very limited. moreover, when human mobility is a major factor in the spread of infectious diseases, we should acknowledge that screening measures adopted at airports or customs should be implemented ( ) . temperature screening alone may not be very effective as it may miss travelers incubating the disease or concealing fever during travel, or it may yield false positives (e.g., having fever of a different cause), therefore it should be accompanied by other health messages, questionnaires and data collection ( ) . a different scenario occurs for the trading of food commodities for which strict regulations about quality and safety impose the adoption of analytical tools and innovation technologies to prevent the spread of foodborne pathogens or other contaminants ( , ) . in most cases, food quality evaluation is based on bioindicators, both at chemical and microbiological level ( , ) . most diagnostic techniques allow to characterize the internal microbiome and virome ( ) ( ) ( ) ( ) . considering covid- , what can be said with certainty is that such controls did not occur in the wuhan market where the virus started its incredible global spread. this situation further remarks the concept that pandemics are strictly linked to insufficient or absent food safety assessment and disease prevention protocols (e.g., as happening every time ebola viruses outbreak in central africa). it is necessary to remark that the food regulations across countries vary and the quality standards of the same food items produced in different countries are not the same ( , ). the current covid- pandemic, perhaps more than others, highlights that it is necessary to align food security protocols on a global scale since country specific inadequacies may cause serious global consequences. therefore, we believe that to prevent future pandemic outbreaks it is more and more important to consider issues arising from the establishment of supranational risk-governance systems. these typically operate in a framework of compromise between the local governance and local producers needs and the global safety for human health. safety is a priority for all the stakeholders associated with the entire food supply-chain. moreover, after the covid- emergency, it is desirable that citizens enhance its awareness toward the topic of food control and the concept of food safety will acquire a stronger social meaning based on "shared values, beliefs and norms that affect human mindset and behavior" ( ) . consumers' behavior and choices will help modify food supply-chains safety to prevent zoonoses and reduce other risks for humans. ( )] provides a framework to map systems uncertainty against decision stakes. global citizenship is based on rights to be actively involved in debates, responsibility, shared decisions (following careful risk evaluation), and actions to control and implement shared strategies. with regard to covid- , we know that a bat species and/or the malayan pangolin have been found to be likely reservoir hosts for the virus; however, the definitive identity of any intermediate host that might have facilitated spillover to humans is still unknown ( , ) . overall, the identification of the vector has a relatively important value. the central point is that the unceasing exploitation of wildlife and habitat has dramatically increased the risk of exposure to zoonotic diseases, as already and sadly demonstrated for example by hiv, ebola and h n ( ) . but how calculating the risk of these phenomena? are stakeholders and citizens aware of the risks? these elements are fundamental for a pns discussion that is necessary to drive the path of food safety. it is time to realize that food safety cannot rely only on the production chain but potential risks to human health and the environment should be considered as well. the increasing advances in scientific and technological tools have now been adopted to assess such risks, thus opening a new era of "prediction" rather than "reaction" to reduce pathogen contamination and foodborne outbreaks ( ) . for example, the current trends in food safety research rely on the application of (i) genomic analyses for foodborne pathogen identification and traceability, (ii) geographic information systems (gis) to prevent and predict the spatial spread of pathogens outbreak, (iii) tools adapted from landscape ecology (species distribution and niche modeling) and social network analysis for predicting patterns of disease outbreaks, as well as guidance for interventions, and (iv) meta-analysis tools to confer an overall summary of available study findings, providing generalizable estimates and generating strategic highlights to be used by policymakers and decision makers ( ) . overall, risk prevention remains the key factor. the history of pandemics teaches us that almost all recent human pandemics and most of the emerging infectious diseases originated from animals (mainly in wildlife). it is known that species more resistant to human pressure are likely to become the new competent hosts of vector-borne diseases and then to become the most probable spillover agents toward human hosts ( , ) . furthermore, we must remember that biodiversity perturbation and its trivialization is the main trigger of virus spillover events ( ) , as probably happened for covid- (figure ) . given these assumptions, the international food policies concerning food safety should consider biodiversity and ecological interventions to prevent zoonotic spillover events. this would be especially urgent in rural areas, where farming and livestocking often overlap with wildlife species ranges and it has been documented that livestock species usually act as figure | list of the principal pandemic and emerging zoonotic viruses showing human-to-human transmission after the spillover is occurred. summarized host and spillover interface data are provided as in ( ) (mouse: directly from wildlife; swine: directly from domestic animals; mosquito: transmission by vector involving wildlife or domestic host respectively; u: unknown). detailed references for each listed virus are provided in ( ) . frontiers in nutrition | www.frontiersin.org intermediate hosts of spillover events (e.g., influenza a and sars coronavirus, figure ). for this reason, it is also time to rethink urban areas by projecting proximity buffer zones to prevent direct contact between agricultural/zootechnic activities and natural habitats. finally, the conservation of natural biodiversity and its related species interactions are essential conditions to reduce the risk of spillover events ( ) . on the whole, a cooperative work (rri-driven) involving human-health agencies, agricultural authorities, farmers, and natural resource managing institutions, could be essential to promote the global ecological management to avoid the spread of a new putative pandemic "covid- " or other risky vector-borne pathogens that may adversely affect human health, the environment and economy. our second consideration regards the fragility of citizens, especially the weakest ones such as the elderly, and their sensitivity to diseases. it is now clear that these social categories are the most susceptible to severe covid- outcomes, particularly if they already suffer from multiple pathologies. diabetes is the most common comorbidity observed in infected deceased patients in italy, after hypertension ( ) . furthermore, recent data showed a high prevalence of obesity ( %) and overweight ( %) in italian patients, median age years, from different italian icus, confirming evidence available so far in the literature supporting impaired immune response to viral infections ( ) . therefore, beyond the infectious capacity of this virus, it is important to focus on those elements of modern society which could increase citizens' vulnerability, including diet, lifestyle and environmental factors, strictly linked to morbidity and mortality for all non-communicable diseases (ncds) ( , ) . although this concept is well-established, today, the global average consumption of healthy foods is substantially lower than the reference dietary intake, whereas overconsumption of highly processed, energy dense, and nutrient-poor foods is increasing ( ) . the mediterranean diet is considered by unesco as one of the "intangible cultural heritage of humanity" with multiple health benefits, including fortification of immune defenses. however, epidemiological data on covid- would seem to contradict this belief since mediterranean countries (e.g., italy and spain) have the highest number of confirmed covid- cases in the world. five years after the expo , dedicated to the theme "feeding the planet, energy for life, " the city of milan, which hosted the event, is under siege by covid- pandemic. recent dietary changes within the mediterranean basin, with a decreased consumption of plant foods, increased consumption of fast meals and junk food, and negative health consequences such as rise in obesity rates and in ncds incidence (e.g., diabetes, cardiovascular diseases, and cancer) are partially responsible of this burden ( ) . the modern-day change in food choices is the results of lifestyle standardization, enhanced technologies in food production and processing and limited time for culinary activities. this caused for example the progressive erosion of mediterranean food cultures ( , ) . moreover, environmental emergence, such as water scarcity in most mediterranean countries and land wasting also has deleterious consequences on mediterranean food production. global climate changes have also produced the failure of several crops, fisheries, and livestock productions, and the declining of mediterranean biodiversity and agrobiodiversity does not allow the selection of new varieties and resistant breeds. so, once again the erosion of the environment and biodiversity is closely connected to health risks ( ) . how to react to these social and environmental changes showing serious health consequences? the sustainability of the food supply chain is certainly essential ( ) . kinnunen et al. showed that less than one-third of the world's population can meet their food demand within a -km radius ( ) . we should also change our view of food and diet which should no longer, or rather not only, considered an energy source but a reservoir of bioactive molecules beneficial to human health. greater consumption of health-promoting foods and limited intake of unhealthier options are intrinsic to the eating habits of certain regional diets such as the mediterranean diet ( ) . healthy dietary patterns positively influence health and promotes the prevention of common non-communicable diseases (ncds), strengthening host community defenses ( , ) . this concept assumes a particular importance since the over years old citizens could be more at risk of being infected by covid- , not only for intrinsic conditions due to natural aging processes and comorbidities development, but also for inadequate nutritional status and related inadequate intake of macronutrients (e.g., proteins and healthy fatty acids, like omega- ), micronutrients (e.g., vitamins a, b , b , c, d, e, and folate), trace elements (e.g., zinc, iron, selenium, magnesium, and copper) and phytochemicals which are pillars in preventing many chronic degenerative diseases and supporting the immune system ( ) . this would seem to be true even for younger patients with metabolic and cardiovascular diseases, showing severe acute respiratory distress syndrome (ards) caused by covid- ( ) . these considerations are also well-known for past pandemics. a recent retrospective data analysis from the pandemic flu, showed that nutrition played a consistent role in the severity of the disease and was related to mortality also in younger age groups ( ) . more recently, chronic malnutrition has been correlated to high morbidity and mortality during the influenza pandemic ( ) . similarly, malnourished children appear to be at increased risk for viral pneumonia ( ) . in dietary recommendation, fat quality has to be addressed ( ) , since evidence shows the need to achieve a balance between dietary intake of omega- and omega- for optimal nutrition ( ) , especially in those subjects more vulnerable to malnutrition and "silent inflammation" which disposes to a greater propensity to viral infections ( , ) . certainly, the presence of an unbalance between pro-and anti-inflammatory lipid mediators has been reported in literature ( ) and it is important to remark that science has already given solutions ( ) which are not adopted in new diagnostic policies for primary and secondary prevention. moreover, food supplements such as vitamins c and d might also be considered to help both innate and adaptive immune cells ( ) ( ) ( ) ( ) . studies on human coronaviruses (hcovs), including severe acute respiratory syndrome coronavirus (sars-cov), have highlighted that secondary metabolites of some plant species seem to inhibit virus proteins, cellular infection, and intracellular replication ( ) . extracts of spontaneous plants such as root tubers from rheum officinale baill. (rhubarb), root tubers or vines from polygonum multiflorum thunb., (polygonaceae) showed an inhibitory activity against the interaction of sars-cov s protein with ace ( ). procyanidins and other secondary metabolites extracted from cinnamomi cortex (cinnamomum cassia j. presl) can reduce the virus infection by interfering with endocytosis ( ) . the extract of cimicifuga rhizoma, meliae cortex, coptidis rhizoma, phellodendron cortex, and sophora subprostrata radix showed an ability to inhibit of rna-dependent rna polymerase and/or proteases crucial for coronavirus rna replication ( ) . finally, the antiviral activity of licorice (glycyrrhiza glabra l.), containing glycyrrhizin, inhibits replication, absorption and penetration of the sars-cov acting on the early steps of the replicative cycle ( ) . in this field, traditional chinese medicine is working actively to identify dedicated compounds to specifically contrast covid- infection ( ) . this practice relying on biodiversity and known as "bioprospecting, " may be a good strategy to find compounds having a positive effect on human health as well as to find new raw materials to produce novel and fortified foods for modern citizens. recently, di marco et al. ( ) suggested that the risk of emerging infectious diseases (eids) is a key aspect for developing suitable policy strategies at the global scale. within this framework, the conservation of biodiversity and food production are two additional pillars that should be considered to prevent drastic environmental changes and the risks of zoonoses, and virus spread. in figure we aimed at further remarking this concept including additional factors strictly related to covid- pandemic. from a nutritional point of view, addressing subclinical micronutrient deficiencies is one of the first steps that must be considered to improve resistance to infectious diseases like covid- (and other pathogens) ( ) . it is therefore recommended that micronutrient testing, such as vitamin d measurement, should be applied in the annual check up of selected individuals at high risk of deficiency ( ) . a nutritional approach, ensuring a long-term sustainability, is essential to improve micronutrient status by increasing the availability and consumption of micronutrient-rich foods ( ) . besides lifestyle changes, including diet has been shown to positively affect metabolic and cardiovascular diseases, which are the most frequent comorbidities associated to severe covid- disease. the spread of inappropriate eating habits and inactivity in western societies, particularly among the younger, "comfortably off " generations, has led to the development of chronic degenerative diseases defined as "comfort" diseases ( ) early in life, leading to an increase in premature deaths for ncds. food is readily available in developed countries but there is an evident split-up between scientific evidence, food choices, and dietary patterns of consumers. this, over time has favored the spread of the obesity epidemic and other diet-related diseases. it is time to acknowledge that environmental factors exert a major influence on dietary behavior, primarily by facilitating meals consumption away from home and by minimizing time dedicated to meal preparation and consumption and secondly, making food of poor nutritional quality available on the market and appealing for appearance, taste and price. this burden is exerted by market rules that affect behavior and food choices with scarce public awareness of the potential negative impact on health. it is necessary that science, technology, education, legislation, and community policies combine to create the urban structures and environment required to encourage healthy lifestyle including dietary choices, not just for few, but for everyone ( ) . more efforts must be addressed to reduce exposure to ambient air pollution, strongly associated with population density ( ), promoting chronic inflammatory state and affecting resilience to infectious diseases not last covid- ( ) . finally, western medicine generally tends to identify pharmacological molecules that act on specific disease mechanisms; however, human body complexity and individual answers are sometimes underestimated. thus, it could happen that infected patients die more due to comorbidities associated to infection with covid- than for covid- per se. the time has come to apply a systems biology approach where drugs, foods and lifestyle work in synergy to promote patient healing and prevent further infections, gaining a holistic approach to community health ( ) to support the further personalization of health and social care ( ) . for these reasons, in our scheme, we stressed the impact of environment and food system of therapeutic approaches. this integrative framework demands both an increased attitude of sharing by the scientific and technical community as well as a social participation since we believe that, as previously anticipated, food safety and human health should be regarded more as a social issue. our final suggestion is to start a frank and open scientific discussion on covid- issues and future risks for new pandemic outbreaks, continuing the legacy of expo , declared in the milan urban food policy pact, signed by more than cities in the world ( ) . in this document, the strategic role of the cities in developing sustainable food systems and promoting healthy diets is stated, yet acknowledging all the differences in their natural and policy endowments, including economic background and cultural innovation, managing vast public resources, infrastructure, investments, and expertise. these issues will be fundamental especially for those countries that are coming out of covid- lockdown restrictions and where it is more expected that political and social contrast will emerge if different stakeholders needs and opinions will not be analyzed and considered for planning the recovery after the pandemic event. we would like to undermine and integrate this overview with few take-home messages that arise from the teachings of this dramatic situation we are experiencing firsthand: (i) food safety is a global issue. the unsafety of local food markets, like the wuhan's one, can exert severe and global impact. (ii) smallholder food producers play a key role in feeding cities, by helping to maintain resilient, equitable, culturally appropriate food systems, and promote sustainable diets. in cities with a high percentage of elderly, local food production should be tailored for specific targets to maintain adequate nutritional status, including fortification of immune system. similarly, in developing countries, smallholder farms should improve the production of local crops rich in macro and micronutrients to improve food security and health of local populations ( ) . (iii) acknowledgment that urban and peri-urban agriculture may offer opportunities to protect and integrate biodiversity into urban landscapes and food systems, thereby contributing to synergies across food security, ecosystem services, and human wellbeing. this is very important to prevent the spillover of viruses but also to offer better efficacy of new drugs synthesized to fight future diseases. a unified approach to nutritional screening and assessment is recommended guiding toward integrated panels of biomarkers to investigate the nutritional status and predict future health outcomes of the individual and moving from stratified to personalized to precision nutrition ( ) . the whole scientific community should start sharing directions, social actions and policy advocacy recognizing that the health of people is closely connected to the health of biodiversity and ecosystems where they live. in this context, the "one health" approach (https://www. cdc.gov/onehealth/basics/index.html) represent a good starting point for successful public health interventions by fostering collaboration across all sectors, taking the right steps to promote health not for the few but for the whole planet. the original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author/s. this opinion paper was conceived by ml, ag, and hc. all authors contributed to its execution and write up with ml leading on the manuscript structure, biodiversity-related aspects were contributed ag and mc, nutrition aspects by hc, botanic and phytochemistry aspects by md, es, ef, and lc, and medical aspects by mr and mb. covid- : what is next for public health? 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oxford covid- evidence service team centre for evidence-based medicine ( ) putting the patient back together-social medicine, network medicine, and the limits of reductionism developing the power of strong, inclusive communities. a framework for health and wellbeing boards office for public management potential role of neglected and underutilized plant species in improving women's empowerment and nutrition in areas of sub-saharan africa the authors are grateful to davide magnani for artworks support. the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.the reviewer ml declared a past co-authorship with one of the author mr to the handling editor.copyright © galimberti, cena, campone, ferri, dell'agli, sangiovanni, belingheri, riva, casiraghi and labra. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord- - wvo fs authors: bajželj, bojana; quested, thomas e.; röös, elin; swannell, richard p.j. title: the role of reducing food waste for resilient food systems date: - - journal: ecosyst serv doi: . /j.ecoser. . sha: doc_id: cord_uid: wvo fs food waste undermines long-term resilience of the global food system by aggravating ecosystem damage. the global community must therefore work to reduce the amount of food that gets wasted. however, we should be mindful of some potential conflicts between food waste reduction and food system resilience. over-production and over-supply are a contributing cause of waste, yet they also provide resilience in the form of redundancy. in this paper, we examine individual interventions designed to minimise food waste by scoring their impact on different aspects of resilience. we find that there are strong synergistic elements and interventions that support short- and long-term resilience, such as improved storage, which reduces the need to provide a constant flow of ‘surplus food’ and replaces it with a stock of ‘spare’ food. some interventions carry a risk of trade-offs due to possible losses of redundancy, and investment lock-in that may reduce the ability of farmers to adapt by changing what and where they farm. trade-offs do not mean that those interventions should not be pursuit, but they should be recognised so that can be adequately addressed with complimentary actions. this review underlines the necessity of food-systems thinking and joined-up policy. food systems around the world face multiple challenges, and multiple objectives as response to those challenges. two of such separate objectives are (i) to increase the resilience of food system -the ability of the food system to withstand and to recover from shocks, (sustainable development goal . ), and (ii) to reduce food waste in the food system (sustainable development goal . ). the underlying reason for improving resilience is to ensure disturbances do not reduce food security, and the underlying reason for reducing food waste is to improve the environmental sustainability of food production. there are a few possible interpretations of the relationship between 'sustainability' and 'resilience' (roostaie et al., ) . the two concepts can be seen as one and the same, or largely overlapping (maleksaeidi and karami, ) . tendall et al. ( ) see food system resilience as a pre-requisite to its sustainability, as food systems cannot 'sustainably' continue provisioning food unless they are able to overcome disturbances. however, due to the magnitude of the impacts that food systems have on the environment and ecosystem services that support the food production itself (foley et al., , costanza et al., we argue that food system sustainability (aimed at reducing those impacts) is also a prerequisite for long-term food system resilience. this paper therefore takes the view that sustainability and resilience are separate concepts, but the achievement of one is largely required to achieve the other. but herein lies a tension: while food sustainability and resilience are pre-requisites of each-other, some of their building blocks are opposing. the concept of redundancy for example, which is considered as one of key principles of resilience (biggs et al., ; tendall et al., ) , can in some manifestations be in conflict with increasing efficiency, including reductions of waste, which are key strategies to achieve food sustainability (godfray and garnett, ; bajželj et al., ) . how can we still achieve the goals of resilience and sustainability simultaneously? are there food waste reduction interventions that are synergetic with resilience that we could prioritise, and others that are opposing and that we should therefore de-prioritise or re-consider? what trade-offs should we be mindful of? to answer these questions, this papers sets out to analyse linkages between food waste reductions and food system resilience. t food waste reduction, impacts on other areas of concern -in this case the resilience of the overall food system. with this paper, we aim to cover all major stages of the supply chain, and develop concepts broad and universal enough to cover different geographies, traditional and modern food systems, low income and high-income settings. often, food systems span across different geographies and income settings and modes of production (for example, farmers in kenya growing green beans for markets in the european union along with subsistence crops). while the need for more resilient food system is most acutely felt in the low-income setting, the opportunities to improve both food waste and resilience exist across all types of food system, its stages and geographies. while the challenges of some actors in the food supply chains, e.g. small-holder farmers, are unique, many concepts apply to several stages of supply chain. for example, both a farmer and a household provider may struggle with matching food 'supply and demand'. for a farmer this may mean planting just the right amount to meet his contract without wasting seeds, fertiliser, time and energy. for a provider this may mean buying just the right amount to feed the family for the next week. food system resilience, the ability of the food system to withstand and to recover from shocks, is of increasing interest due to the increase in climatic and price variability, political instability. adding to this it the recent experience of the threats to the food system from pandemics, threatening to further increase the increasing number of undernourished people globally (fao, ifad, unicef, wfp and who, ) . existing definitions of food system resilience (schipanski et al., ; tendall et al., ; urruty et al., ; biggs et al., ) refer to the ability to withstand shocks and external pressures while maintaining the system's basic structure, processes, and functions, through buffering capacity, adaptability and ability to recover from disturbances. food system resilience is closely related to ecosystem services, as the production related disturbances we worry about (crop failures due to e.g. floods, droughts and disease) are often related to the failure or insufficient provision of supporting and regulating ecosystem services. the stocks of natural capital that provide these services continue to shrink (costanza et al., (costanza et al., , , driven by anthropogenic climate and global environmental change. there are multiple causes of this, but one of the largest driver is actually food production and its expansion itself (foley et al., ) . meaning that food production activities undermine their own resilience, which is exacerbated by over-production of food caused by much of the food being wasted. threats to food system resilience are compounded by a number of other factors, including the increasing homogenization of crops and agricultural landscapes. food resilience is also related to food security (adequate access to safe and nutritious food by all people), but here we treat them as separate concepts. for the purpose of this paper, we consider the stability and recovery from disturbances as main attributes of resilience, which is one of the important conditions to achieving stable food supply and therefore food security. other conditions, most notably sufficient social security and income levels, are additional factors needed to ensure food security. in this paper we use the term 'food waste' as a general term to refer to material which was produced with the intention to be consumed by people, but ultimately exited the food supply chain. we do not separate the terms 'food loss' (often used to describe losses earlier in the supply chain, or those related mostly to the lack of infrastructure and access to market), and the term 'food waste' (often used to describe losses later in the supply chain, or those related to the behaviour of different actors) (chaboud and daviron, ) , as often multiple factors -a combination of structural and behavioural ones -are at play regardless of where in the supply chain food is lost. the intervention to address food loss and food waste are often hard to distinguish as well; however, the consequences of the interventions may be different (see the discussion). the un fao estimated that roughly one-third, or about . billion tonnes per year, of the edible parts of food produced globally for human consumption is lost or wasted (gustavsson et al., ) . this global estimate is based on extrapolation and is in need of an update, but while it is possible that the wastage is somewhat higher or lower, it is undoubtedly significant. food waste across supply chain has been more robustly measured by a small number of individual countries, roughly arriving at similar estimates (wrap, ). the causes of food waste are complex and varied. in this paper, we put forward the following framework on causes of food waste. as a simplification, each instance of food waste could be explained as a 'rational' economic decision based on comparing the cost of time and materials (infrastructure, appropriate storage etc.) needed to prevent wasting food, with the value of food at risk of waste. this decisionmaking process by actors in the supply chain is however further complicated by the following issues: . in low-income settings, access to capital and infrastructure present barriers, for example a farmer in kenya may be aware that investing in a cooler would pay back quickly through all the milk saved from spoilage, but they may still not be able to afford to buy a cooler in the first place; see (gromko and abdurasulova, ) . . issues related to these decisions are being made on the basis of perceived costs (of both time and resources needed on one side and food on the other side), which are often different to market costs (value of food on the market), which themselves are different to true costs (costs also including externalities). people are often unaware of the cumulative financial value of the food that they waste (this is true for both consumers, as well as factory managers and even farmers (wrap, )). furthermore, the financial cost of food is typically much below its true cost, i.e. one that would price in all externalities such as ghg emissions, the cost of pollution generated, the economic losses associated with biodiversity losses etc. (chen et al., ; national research council, ) . the market therefore tends to under-price and under-value food (benton and bailey, ) . as a consequence, the decisions that lead to food waste may be rational for that individual and the market, but are not rational at all from a societal or whole-system perspective. . many decisions leading to food waste may not be rational at all, as we are not very good at rationally considering everyday decisions, which are often done habitually on a subconscious level (kahneman, ) . it has been suggested that an oversupply of % over the nutritional need is desired to ensure adequate food supply (papargyropoulou et al., ; smil, ) . it has therefore been suggested, that only waste over % (as is likely the case in most high income countries, but not low income countries) is excessive -the rest is a natural result of the overproduction needed for food security, in other words, short-term resilience. on the other hand, a significant food waste reduction has been suggested as one of several key systemic changes that could significantly reduce the unsustainable use of ecosystem services and natural capital, including a significant reduction in ghg emission from the food system, which are key for long-term resilience. kummu et al. ( ) show the total land, water and fertiliser footprint of global food loss and waste are significant. bajželj et al. ( ) , röös et al. ( ) and springmann et al. ( ) have all shown, on the basis of modelling approaches, that low-waste food systems (food systems where current wastage rates are halved) would require significantly less land, water and reduce ghg emissions associated with the food system in the future in scenarios for . according to these studies, food sustainability goals seem out of reach without a significant reduction of food waste; such findings has also led to the formulation of sdg . of halving food loss and waste. stopping the unsustainable use of natural capital is important for food system resilience in the long term, as food system resilience is already at risk from climate change and increasing scarcity of suitable agricultural land and water reserves and decline in many ecosystem services crucial for food production. however, as the concept of the % safety margin exemplifies, food waste reduction may run contrary to some aspects of resilience. the complex direct and indirect, shortterm and long-term relationships between resilience and food waste reduction have not yet been explored. in this paper we examine the main linkages, positive and negative, between low waste and high resilience food systems. a significant reduction of food waste seems essential to establish long-term resilience, but could lead to short-term trade-offs. we therefore also examine individual interventions aimed at food waste reduction through the lens of food system resilience. we discuss in more detail the interventions that appeared most synergistic for both food system objectives, and suggest how policy could benefit. we studied the literature that describe the principles, policies, strategies and characteristics to achieve either food waste reduction or increased resilience, and mapped reinforcing and opposing linkages between these two food system objectives. the literature describes different 'characteristics' or 'principles' of a resilient food system. for food waste, the literature mostly discusses 'policies' (e.g. food waste measurements and reporting), and environmental and social 'costs' of the current food waste levels. in this paper, we suggest a novel approach to group and differentiate these concepts in a way that facilitates identifying linkages between the two objectives. we propose a separation between: . interventions, which are defined as concrete, practical mechanisms to achieve fostering conditions. for example, putting irrigation in place is a resilience intervention that provides stability. provision of dryers improves overall storage capacity and is an example of a food waste reduction intervention. . fostering conditions are conditions that will make reaching desired food system objectives more likely (some of which we can directly influence by policy or interventions); . objectives are key characteristics that describe the status of the food system that were the overall goal of the interventions; and . other outcomes are those that are also likely to occur as a consequence of the reaching the objective that are of concern for sustainability or resilience (desired or undesired). we reviewed a wide range of academic and grey literature to characterise food waste reduction interventions, fostering conditions, objectives and outcomes, all described below. food waste reduction interventions were defined as specific activities and changes to the food system that lead to less food being lost or wasted across the supply chain. these include changes to infrastructure and operations alongside changes that target human behaviour (e.g. through training or campaigns) along the supply chain. these need to be specific enough to have a clear mechanism through which they work. to ensure we were comprehensive, we searched in scopus using the following combinations of terms: either "food waste" or "food loss" and either "intervention" or "behaviour change" for any year. a range of articles related to food waste policy were also reviewed. the majority of articles related to the household consumption stage. we augmented the academic literature review with case studies from grey literature and media. fostering conditions were one of the following: broader system characteristics that multiple interventions aimed to achieve; broader policy context; or a reversal of the key drivers for waste, drawn from the same literature as above, most importantly from the following papers and reports: parfitt et al., ( ) , quested et al. ( ) , papargyropoulou et al. ( ) , hlpe ( ), schanes et al. ( ) , wrap ( ) and flanagan et al. ( ) . these agree that higher awareness of food waste as an issue and widespread measurement and reporting are the basic condition to reduce the levels of food waste across all stages of the supply chain. some of these authors and organisation however also emphasise that this in itself in not enough. better storage capacity/infrastructure as well as reduced rate of spoilage (either through improved conditions or skills) of food when it is either in storage and transit, are commonly mentioned. matching of supply (production) and demand, both in quantity, quality and time is another broad condition that would prevent waste in most stages of supply chain (either through planning, forecasting or communication). increasing the value of food (e.g. with priced-in externalities) or cost of wasting is highlighted by fao ( ) and benton and bailey ( ) . the objectives of a low waste food system were defined as a significant reduction in the flow of food material leaving the food system, and a significant increase in the ratio between food consumed and food grown. other outcomes. according to economic theory (rutten, ) , reducing food waste may lead to two outcomes (providing we avoid shifting waste from one stage of supply chain to another): (i) increase food consumption or (ii) reduced food production. in the absence of other changes in the food system, the occurrence of one over the other depends on the elasticity of supply and demand, through a downward pressure on food prices. a combination of both may also occur. policy can be used to encourage one of these outcomes over the other. both of these outcomes have consequences for resilience, through different mechanisms. where food security is an issue, increased consumption of (nutritious) foods can be a positive development and directly improve resilience. elsewhere, and when it comes to less nutritious foods, it would be more beneficial from a sustainability perspective to steer the system towards reducing over-production (rather than increasing consumption) and therefore reducing the use of resources including land, water, fertiliser, pesticides and seeds, reducing ghg emissions and pollution and maximising ecosystem services. an additional reduction in ghg emissions and pollutions comes from reduced waste management requirements (e.g. less waste in landfill). however, reduced overproduction also means that there is a reduced surplus flow of food in the system. we characterised food system resilience based on the following literature: biggs et al., ; ingram, ; schipanski et al., ; tendall et al., ; urruty et al., ; . from these papers, we pooled together what authors described as characteristics, principles or mechanisms of food system resilience, and categorised them according to the conceptual framework designed here. resilience interventions -concrete and specific activities implemented to improve food production that recovers quickly from disruptions -were taken as examples from the literature listed above. unlike for food waste we did not attempt to provide an exhaustive list of the interventions, as the main focus of this paper is to examine the role of food waste reduction on resilience (not vice-versa; although we also touch on that in the initial step -conceptual mapping). as fostering conditions for resilience we considered: • stability, mainly reduced likelihood and magnitude of disruption events themselves, such as extreme weather events leading to crop failures, and the ongoing increase in mean temperatures affecting crops, livestock, pest and pollinators in various ways, water scarcity, pest and disease outbreaks (ipcc, ), and also shocks to supply chains including disrupted access to labour and markets, as the ongoing ( ) disruptions to the food systems due to the new corona virus epidemic exemplifies. • diversity of crops, livestock, production systems, inputs, landscapes, income streams, customers and suppliers increases resilience according to biggs et al., and schipanski et al., ) . the principle of resilience in diversity is that individual crops, communities or products will carry different responses to the disruptive condition. diversity of crops and landscape may also for example prevent or slow down the spread of pest and disease outbreaks (schipanski et al., ). • redundancy, which can mean either interchangeability (according to biggs et al. ( ) , however we will consider this under flexibility) or spare capacity (of food itself, but also land, water, income, inputs (e.g. fertilisers and fuels), supporting and regulating ecosystem services), according to tendall et al. ( ) . spare food capacity emerges as a critical issue with apparent trade-offs between resilience and low waste/efficiency. • flexibility and interchangeability, being able to use the food that you have for several purposes (biggs et al., ) , swap one food for another, or derive income in different ways from different sources. e.g. pigs were traditionally valued as domestic animals that could take a variety of different feeds, but modern livestock systems use breeds and systems that are specialised, increasing efficiency at the expense of flexibility. today food supply chains are quite inflexible through pursuit of efficiency. inflexibility (e.g. strict cosmetic specification, strict contracting in time and quantity) can also lead to waste on farm levels. • adaptability is related to flexibility, but refers to the relative ease of making significant changes, i.e. adaptation to the way food is produced and procured. for example, farmers changing crops, calendars, locations. transformational (i.e. abrupt) adaptation may be needed due to the pace of climate change and change in weather patterns -not just step-wise adaptation to the signals as they come, but a pre-emptive, fundamental shift in practices and locations . adaptation also includes technical innovations such as more resilient breeds. • connectivity in food system includes trade, communication along the supply chain, as well as the connection between different kinds b. bajželj, et al. ecosystem services ( ) of ecosystem services, for example the proximity of pollinator habitats to crops requiring pollination (biggs et al., ) . the downside of high connectivity is that diseases and other disturbances can spread faster. the objectives are defined as stable supply in the face of disruption and quick recovery from disruption. other outcomes. improved food security and stable food prices are two of the outcomes that are desired from a resilient food system. however, redundancy, flexibility and diversity may lead to reduced efficiency. diversity typically reduces economies of scale associated with specialisation (compare a large farm growing few crops in rotation with specialised equipment to a farm that grow many crops), while redundancy may lead to not all food produced being eaten. we mapped the interlinkages between the objectives, outcomes, and fostering conditions of the two desired system states on a long-term food systems level, by laying them out and examining where the causes and interactions (both synergetic and opposing) might occur between the systems, and represented them graphically on fig. using a similar technique also used to produce causal loop diagrams (e.g. foresight, ) . to further untangle potential synergies and trade-offs, and move from abstract to concrete examples, we assessed how individual food waste interventions influence short-term resilience, as represented by fostering condition of the resilience (as described above in conceptual framework). the list of food waste interventions and resilience conditions were obtained from the literature as explained above. we grouped the interventions by different stages of the supply chain in three tables: primary production, then grouping together processing, manufacturing, distribution, retail and food service, and finally the consumer stage. in the tables we considered how a large-scale implementation of each intervention would impact on food system resilience, looking at each fostering condition at the time. three of the four co-authors, giving a good spread of expertise across food waste along the supply chain, and food system resilience, scored the influences individually and independently, by posing themselves the question: would the system be more or less resilient after the intervention in question, and through what mechanisms. scores were there compared, and we had a discussion, focusing particularly on any scores that diverged, agreeing the final scores. we scored the impact with a '+' if the intervention would impact positively on that fostering condition for resilience, a '-' if it was negative, a ' ′ if it had little or no effect and a '+/−' if it had an mixed effect. if we all felt that the effect was unclear, we marked it with a '?'. in regard to stability, as we have already established that successful food waste prevention will have positive effects on climate stability, and the supply of ecosystem goods and services including water, we have focused on more short-term aspects such as their effect on stable supply and demand (otherwise all interventions would be scored positively for stability). . . linkages between food waste reduction and food system resilience on a system level fig. shows the interlinkages between the objectives, outcomes, and fostering conditions of the two desired system states. solid lines show reinforcing interactions, and dashed lines show opposing interactions. the magnitudes of the links are difficult to quantify, although it is clear that some of the links are more significant and more direct than others. one link that has been quantified in the literature is between the reduced over-production and reduced ghg emissions, land and water use. bajželj et al. ( ) and springmann et al. ( ) for example quantified these for hypothetical, global future scenarios, and most recently by philippidis et al. ( ) for current situation in the european union. through this analysis we concluded that food waste reduction is essential for long-term food system resilience (through substantial reduction of resource use and ghg emissions, both of which are critical for long-term resilience), but that the issue of 'redundancy' was a hotspot where both trade-offs and synergies between food waste reduction and resilience in the short-term may occur. this is further illustrated with fig. . actors in the food chain cannot exactly predict how much food they will produce and/or require. under-supply typically has graver shortterm consequences compared to over-supply, leading to actors, who want to achieve resilience, systemically over-producing and over-supplying. high levels of waste are, in part, a symptom of such resiliencemotivated over-production, at the expense of long-term resilience, as it depletes natural capital, reduces supply of ecosystem services and contributes to de-stabilisation of climate. another direct link between food waste reduction and resilience occurs when increased food consumption is needed and positively affects consumers, directly increasing food security. in these cases, food waste reduction (most often through prevention of spoilage) directly improves resilience. food waste reduction can also help with food affordability if prices rise. this is partially what we understand happened in the uk between and , when the food waste reduction information campaign (love food hate waste) in combination with economic downturn and rising food prices, helped reduce household food waste by estimated % whilst also helping people to save money and maintain the quality of their food purchases (britton et al., ; wrap, ) . we can assume a similar effect in low-income settings as it follows from economic theory (rutten, ) . however, we lack empirical data to test this hypothesis. table shows the result of assessing individual interventions in primary production, focused mostly on farms with some interventions that also apply to other types of primary production, e.g. fishing. primary production is a hotspot for both waste and resilience, as it is exposed to two sources of variability and uncertainty: ) the variability of natural systems and growing conditions and therefore yields and timing, and ) the variability of the social system, reflected in dashed line signifies that over-production is often a result of seeking resilience. b. bajželj, et al. ecosystem services ( ) table the interactions between food waste reduction interventions and resilience at primary production level. for definitions and description of the resilience conditions, see the methodology section. '+' marks positive impact of the intervention on that fostering condition for resilience, '-' a negative impact, ' ′ little or no effect, '+/−' mixed effect, and '?' if effects are unclear (bradford et al., ; cbi, ; gitonga et al., ; morante et al., ; neff et al., ; springer et al., ) . fluctuations in the demand quantities, prices on the market and demand timing. some of the interventions are aimed at reducing the variability (e.g. robust varieties), or help farmers match the levels of production and demand (forecasting) or bridge them in time (storage). these interventions generally help reduce both food waste and improve resilience, provided that they are done well and are resilient themselves (for example, storage could be sensitive to disturbances e.g. floods or disruptions in energy supply). overall, we have found that even in the short-term, most food waste interventions at primary production level have positive, synergetic influences on various aspects of resilience, particularly stability and flexibility, and a few also for connectivity. the implementation of these farm-level interventions, particularly if aimed at small-holders, will require provision of financing, equipment and training. as expected, redundancy was one aspect for which the scores were mixed. some interventions, mostly those directly or indirectly related to storage and food longevity, were scored as positive, while others that reduce the amount of surplus without increasing longevity scored negatively. interventions that reduce over-production without compensating for redundancy in another way may pose some risk in reducing short-term resilience, but may still be worthwhile doing to improve long term resilience. for farmers, losses of crops due to something unexpected can be catastrophic for their business and livelihood. the surplus has comparatively small effect, even if wasted (feeback, ; johnson et al. ) . it is therefore farmer's need for resilience that leads to this type of 'systemic over-production' and waste. however, this 'need for redundancy' could be reduced if the risks associated with variability were more evenly distributed along the supply chain (e.g. by wholesalers and retailers giving more flexibility to their suppliers), though improved insurance, forecasting and storage. interventions that directly target resilience, such as increasing income diversity and improving water supply, can also remove some of the farmer's need to over-plant and therefore reduce waste. adaptability was the other aspect that could be negatively affected by food waste interventions, when the intervention created a lock-in to certain location and crop. for example, a construction of silo or an immobile drying unit can further lock the farmer to a specific crop and location, depending on how crop-specific and mobile the intervention is. we have found that the food waste interventions seemed neutral for the diversity of crops, breeds and foods (and only linked to landscape diversity in the long-term through land resource savings). we grouped the intermediate stages in the supply chain because some of the interventions are common, for example those that refer to a seller and buyer relationship. another reason is that, compared to primary production and the end-consumer, the rest of supply chain receives relatively little coverage in the academic literature and grey literature, and therefore the number of suggested interventions and case studies is relatively low. similarly, existing food resilience literature mainly considers primary production as the stage that is most exposed to natural variability, or consumers and their availability to access safe and nutritious food. many interactions were given a neutral score, especially for diversity and adaptability. we did not find as much synergistic potential with improving stability as we did for the primary production. however, connectivity stood out as the resilience condition that would benefit from many food waste interventions in the middle of the supply chain. similar to primary production, some food waste interventions were scored as positive, some negative and some as mixed for redundancy. interventions targeted at household waste have the highest potential when it comes to freeing-up resources and reducing food waste related ghg emissions, and therefore, long-term resilience through stability, for two reasons: in high and middle-income settings, the volume of waste is the largest at the consumption stage, and secondly, this food has accumulated more impact as it processed through the supply chain (for example, it has been transported, stored, perhaps processed and pre-prepared). there are many different interventions targeted at households. they broadly fall in two categories: a) behavioural interventions -promoting behaviours that lead to lower wastage of food; aimed at householders themselves, such as storing and using up leftover food, including incentives to reduce overbuying, improved understanding of date labels, correct portioning when cooking, use of leftovers, optimal storage (including keeping fridges at a temperature below degrees celsius), freezing of food that will not be used in time, and use of long shelf life products (canned and dried foods) (quested and luzecka, ; reynolds et al., ; schanes et al., ) b) technical interventions -changes to products themselves, for example a change in packaging that increases shelf-life and therefore increases the likelihood that the food will get eaten before it spoils, including changes in pack-sizes and pricing structures to discourage over-buying; increasing shelf-life and open-life through innovative packing, changes to food itself (e.g. using different bacteria cultures in cheese or yoghurt), or reducing the time it takes to get food to market (lee et al., ) ; changing the date labelling to avoid overly-cautious discarding of food; improving storage and freezing guidance on packs (wrap et al., ) . consumer behaviour can affect the stability of demand and cause spikes and dips in food demand. in the uk for example, foods such as burgers, strawberries and lettuce are typical foods that will sell very well in sunny weather and spike around sporting events, whilst demand plummets in rainy weather. growers and producers aim to meet surges in demand, however if expected demand does not materialize produce remains in the field (wrap, ) or is wasted elsewhere. some of this waste could be prevented with better forecasting, however the consumption habits could also adapt; for example, by aiming to match consumption to the growing season. most interventions investigated were scored positively for improving stability. the scores were mixed again for redundancy and also more mixed for flexibility and adaptability, with some interventions potentially reducing the number of options households have in any given moment when it comes to food. there were more links with diversity than in other stages of supply chain -as some interventions promote specific types of foods, typically long-life products, which either add or reduce diversity, but very little identified impact on connectivity. key interventions that emerged as synergistic for food waste and are improved storage, transport, surplus valorisation, increased shelf life, and promotion of long shelf life products. food storage can take place in many stages of the supply chain and can take many forms, for example grain stores, which can be operated from national to village or individual farm scales. food is stored in many other ways as well (not necessarily labelled as storage): on farms, in warehouses, cold stores and industrial freezers, in supermarkets, while in transport on ships and trucks, and also individual households' cupboards, fridges and freezers. each one of these stages adds up to the overall storage capacity of the food system, and each could potentially be improved. (see tables - for examples) . preparing and storing food optimally creates a buffering capacity different to a continuous surplus production by creating a reserve. in systems dynamics terminology, better storage replaces a need for a constant additional 'flow' with increasing the 'stock' (from which occasionally an additional flow can be drawn). for example, families could rely more on having well-stocked cupboards with long-life cupboard essentials that can also be made into a nutritious meal, rather than constantly buy more perishable foods than they use. surplus production could be diverted to become a reserve by extending shelf life through canning and dehydration of fruit, meat, dairy and vegetable products, to be used in times of scarcity and disruptions in food supply due to a variety of different reasons from droughts to epidemics. this would be a much more resource-efficient way of providing resilience compared to over-production year on year. improved storage is not necessarily about only the size of storage (warehouse, fridge etc.), but table the interactions between food waste reduction interventions and resilience at intermediate steps in the food supply chain (blanke, ; wrap, a; cohen et al., ; dora et al., ; freedman and brochado, ; kallbekken and saelen, ; parfitt et al., ; refed, ; stöckli et al., ; wansink and van ittersum, ; williamson et al., ; wrap, b) . the interactions between food waste reduction interventions and resilience at consumer level (devaney and davies, ; fisher and whittaker, ; ganglbauer et al., ) . conditions (e.g. temperature, air moisture) and preparation of food stored (drying, pre-cooling, mould-free) . it should be noted that there are some challenges associated with having a higher proportion of food as reserves. stock management in both the supply chain and in homes may need to be improved to ensure that the food in storage is circulated correctly. secondly, on a foodsystem basis, having a larger proportion of overall food in storage may mean that on average, the time between harvest and consumption increases, highlighting the need to monitor not only food safety, but also food quality and nutritional value. thirdly, there are trade-offs between increasing some types of storage capacity, especially cooling and freezing, and energy use -increased energy use leading to increases in ghg emissions and cost. and lastly, the resilience of storage against same of different kinds of disturbances that effect food production should also be considered (e.g. energy supply, susceptibility to pests etc.). improved storage should reduce price volatility. at harvest time, especially in good years, the price of produce (e.g. grains, vegetables) on the market is low, but farmers without safe storage options are forced to sell despite the low prices they receive. similarly, consumers without storage or access to food with longer shelf-life cannot bulk-buy and store foods when prices are low. if neither producers of consumers can store, prices are more likely to spike outside main harvest seasons. higher prices in one year can attract many newcomer producers in the next season, leading to over-production the next year, therefore low prices and high waste when price does not even justify harvest costs (which are significant, johnson et al. ) perpetuating a boom and bust cycle. price volatility is therefore not only a sign of a system with low resilience, but it can also lead to waste. in a market economy, changing prices are unavoidable, and are valuable signals about scarcity and over-production, and distorting them through some market mechanism may lead to unintended consequences. however improved storage, preparation of food for storage, diversification into longer-life products and innovation in insurance could reduce some of the high demand volatility and make optimal production decisions easier for farmers and other actors in the food supply chain. reducing food waste in most cases leads to a good return on investment (wrap, ; hanson and mitchell, ; gromko and abdurasulova, ) , improving the profitability and income of the people involved in the point of the stage of supply chain where food waste is being reduced. as such, food waste reduction leads to increased resilience of that actor in the chain, say a farmer or manufacturer. this also applies to consumers. for example, data in the uk (britton et al., ) suggests that in the context of reducing disposable income and rising food prices, people that reduced the food that they wasted were able to continue buying the same quality of food they were buying before. reduced food waste can also present an opportunity to increase added value in the supply chain. when customers save money but not over-buying in quantity, they are often happy to spend more on 'quality' (britton et al., ) . however, assuming food waste reduction at consumer level does lead to financial savings, these could result in rebound effects if they are spent on other polluting activities, diminishing some of the environmental gains (martinez-sanchez et al., ; salemdeeb et al., ) . in this paper we focused on reducing food waste 'at source' (i.e. food waste prevention). however, there are other mitigating actions that also count as food waste reduction: for example, feeding the surplus food material or food scraps to livestock (zu ermgassen et al., ) and using it as feedstocks in bio-economy, for example extracting limonene from waste orange peel (wrap, ) . these 'surplus valorisation activities' too can lead to significant resource savings, although typically less than prevention. zu ermgassen et al. ( ) for example calculated that feeding food scraps to pigs through advanced centralised swill operations similar to those operating in japan and south korea could also lead to significant land-use savings of . million hectares in europe, compared to . million hectares calculated for food waste prevention by philippidis et al. ( ) . they can also potentially contribute to increased resilience if the flows of material out of the food system can be used to feed humans during times of crisis, and should be pursued in addition to food waste prevention to reduce pressure on resources. some surprising linkages between food waste and resilience emerged through our investigation. some food waste can be seen as a consequence of actors wanting to achieve resilience through redundancy: over-production and over-purchasing, so that they call on this surplus if something unexpected happens; these 'unexpected events' could be a grave issue such as a farmer experiencing a low yield, or relatively small things like consumers entertaining unexpected guests or not finding the time to go do your weekly shop at the regular time. however, some wasted food did not provide resilience at any point in time. generally, if the 'food at risk of becoming waste' can be tapped into relatively quickly (for example, by relaxing cosmetic standards), then that quantity does provide redundancy and therefore some shortterm resilience. but if there are no means of preventing the spoilage and waste, then waste food never provided any resilience. some of the types of food waste that provide short-term resilience are also some of the easiest to address to reduce over-production. interventions such as relaxing cosmetic standards and reducing overpurchasing through better planning are examples of changes that can be implemented fairly easily, and therefore also get implemented when something unexpected occurs, i.e. in time of scarcity. for example, in untypical weather resulted in poor yields of fruits and vegetables, in response to which uk's supermarkets relaxed their rules on their cosmetic appearance (vidal, ) , evening the supply. the relative ease of intervention implementation provided redundancy. however 'saving' these interventions for times of scarcity comes with cost a of diminishing natural capital and contribution to climate change from over-production. therefore, the recommendation of the authors is not that the interventions that reduce redundancy are not pursued (they could be considered as a priority due to their ease of implementation), but that they are balanced with complementary interventions that compensate for lost redundancy, most notably improved storage. this investigation of food waste and resilience led us to a new proposal to conceptualise wasted food, depending on whether it represents mainly a) a loss of needed nutrition (a direct loss of food security) or b) a loss of resources used to produce it (leading to indirect, long-term loss of resilience). in practice it may be difficult to allocate a loss of an individual item of wasted food between the two, as the mechanisms and causes of loss may be identical, but the consequences are not. they also depend on the context, particularly the socio-economic status of the actor. as actors improve their socio-economic status, they often seek to improve their food security through increasing over-production, rather than through reducing food loss though interventions, for a variety of different reasons. therefore, the nutrition loss shifts to resource loss, even though the causes and mechanisms (the actual process of food becoming inedible) may remain unchanged. the short-term resilience of the actor improves, but the long-term resilience of the whole food systems diminishes through increased depletion of natural capital and reduced stability. as progress is made towards halving food waste, it would be helpful to track the nutrition loss and the resource loss (over-production) separately at a large/global scale. for this, better production and consumption statistics would be needed. to complement food waste reduction, and also to encourage it, policy should carefully consider which of the two outcomes of reduced food waste are preferable for the circumstances: reduced production or increased consumption. at national food policy levels, food waste reduction targets are rarely linked to other outcomes. (if anything, they are vaguely linked to improving import-export balance). this lack of systemic food policy represents a missed opportunity to strengthen other desirable food system transitions, including increased short-term or long-term resilience. long-term resilience could be doubly-encouraged for example, by gradual internalisation of externalities so that food price would be stable despite downwards pressure from food waste reduction (benton and bailey, ; rutten, ) . this should lead to reduction of over-production, and therefore reduction of ghg emissions and increase in other ecosystem services that can be provided by spared land. the delivery of specific ecosystem services, many of which can again be conductive to long-term resilience, can be then further encouraged with compatible financial incentives, and would, through competition for resources, further reduce food over-production. the opportunities include: farmers being able to build in more resilienceinducing features that protect soils, pollinators and other resources on the spared land (for example: buffer zones, hedgerows, stony habitats, pollinator habitat enhancement and lagoons, see gardner et al., ) ; reduced use of fertiliser (and its negative impacts) not only through reduced production but also reduced fertiliser subsidies; water reservoirs and aquifers re-filling (or being used less intensely), increasing the resilience of water supply in the future; healthier ecosystems on and surrounding the agricultural lands. reduction in food loss and waste combined with an ecosystem services approach can therefore steer the food system to a more resilient and sustainable future. on the other hand, in circumstance where an increase in consumption is preferred to directly improve food security, prices can be allowed to decrease through food waste reduction interventions. this is particularly appropriate for highly nutritious foods that are underconsumed in the population. however, an increase in consumption is not helpful in all circumstances and for all types of food. particularly for food with high energy and poor nutrient values amongst populations with an obesity problem, without taking a systemic approach pursuing food waste reduction in isolation may contribute to exacerbating the problems. the lack of systemic approach also reduces the chances of food waste reduction incentives succeeding. the first signal from a significant reduction of food waste at one point in the supply chain at either demand or supply side is bound to be a reduction in price (rutten, ) . this can encourage waste at another stage in supply chain, or at another geography. for this reason, it is important that food waste reduction is being pursued on a global scale and in all stages of supply chain. good monitoring systems are needed to be put in place to ensure that waste is not pushed from one end of the supply chain to another, and from one place to another. global monitoring frameworks are currently being set up by un fao and unep, but the challenges associated with the monitoring of food waste should not be underestimated. in the future, however, it would be beneficial to monitor other separate indices at critical points in transition to high-resilience, low waste system, particularly the total storage capacity and overproduction as indicators of food system resilience and efficiency. this could mean for example an introduction of food reserves targets and monitoring on national, business or even household level (% of total food reserves, % of households with access to safe food storage options in kg/capita). the discourse on food waste for the past ten years have been quite simplistic: food waste is big, bad, and it must be reduced. this was justifiable given the low awareness surrounding food waste, its scale and missed opportunities it embodies. now that awareness has increased, at least amongst policy makers, researchers and businesses (flanagan et al., ) , it is time we enter the next stage in food waste policy and discourse: one that is more nuanced and realistic, and tackles both synergies and trade-offs with other food system sustainability goals more explicitly, achieving better outcomes for all goals. in the eu, food waste reduction measures on farm are currently not considered as a part of circular economy package (european commission, ), however it could be something that is encouraged through the common agricultural policy. common agricultural policy has a potential to increase farm resilience by encouraging resource efficiency, establishment of resilience features and encourage supporting and regulating ecosystem services. the parallel pursuit of food waste reduction should help free up the resources needed to do this, without sacrificing productivity. in this paper, we used a theoretical approach to try to structure and characterise complex interactions between different parts of and changes to the food system, focusing interactions between interventions aimed at food waste and resilience. this approach was largely based on the experiences and knowledge of the experts involved. where possible we tried to base the judgements on potential causes and effects on observed data; however, this was not possible for all identified linkages. furthermore, while we strived to be comprehensive by taking a systemic approach, it is possible that some important linkages were missed entirely, which could be improved in the future by involving a wider range of stakeholders in the system mapping process. nonetheless, we believe this approach and its conclusions have value, and will hopefully provide a basis for future research on these questions fundamental to food sustainability. there are strong linkages between reducing food waste and food system resilience, that through the analysis in this paper we separated into: a) long-term linkages: food waste prevention interventions influence long-term resilience of the food system though its sustainability, by reducing ghg emissions and therefore climate change and variability, and potential to increase natural capital and improve supporting and regulating ecosystem services. these interactions are overwhelmingly positive for resilience and significant in strength and scale. b) short term-linkages where food waste interventions interact with stability, diversity, redundancy, flexibility, adaptability and connectivity of the system through interventions that lead to changes in livelihoods, storage capacities, variability in supply and demand etc. these interactions can be positive or negative. they form two clusters: one around redundancy -where trade-offs are most apparent, and one around stability and reduced volatility (of supply, demand and price), where synergies are most apparent. the scale and strength of these linkages are not yet known. individual food waste prevention interventions that focus on reducing over-production, for example the relaxation of cosmetic standards, do reduce redundancy and therefore short-term resilience. however, these interventions should not be discouraged as they present a vital opportunity to improve resilience in the long-term. the trade-offs should be recognised so that they can be adequately addressed and compensated for. one example is by improved storage, which by reducing the variability of supply and demand, smoothing prices provides redundancy not in the form of surplus, but a reserve. policy recommendations and implications of this work are the following: . replace surplus with reserves. current approach to food resilience relies on over-production. this is exemplified by a notion that % of food over-supply is required for adequate food supply and security. however, such reliance on over-production undermines food system resilience in the long-term. the approach to food system resilience needs to shift from over-production to reserves (storage and extension of shelf life e.g. though dehydration), with accompanying storage-related incentives and targets. food waste reduction should be easier to achieve when it is recognised that for many actors, the need to provide resilience is the driver for over-production and therefore waste. the actors need to be reassured that the food waste reduction activity is going to improve rather than reduce their resilience. . increasing resilience can indirectly reduce food waste. overproduction for the sake of resilience can be replaced through other resilience conditions, e.g. through increased diversity, by installing irrigation or alternative producer income opportunities related to other ecosystem services. for that purpose, it is important to have an understanding of ways to support resilience alternative to redundancy. . approach food policy systemically. food waste reduction policy should consider two of its possible outcomes: reduced production and increased consumption, and actively steer towards the one that is considered more desirable depending a range of circumstances ranging from food resilience, security, public health, state of the environment and ecosystem services. food waste reduction would both facilitate and be facilitated by pricing-in of externalities into food production as well as diversifying the income from other ecosystem services. reducing food waste on its own is less likely to succeed and result in positive food system changes, but such combination of strategies can steer the food system to a more resilient and sustainable future. food and agricultural policy should not overlook this opportunity. the covid- epidemic (ongoing at the time of writing) highlights the importance of food system resilience, as it is disrupting food supply chains in many different ways though e.g. order cancelations by the entire hospitality sector, creation of supply chain choke-points (such as the closure of slaughter-houses in the us), harvest-labour shortages (in india and europe). all of this seems to be leading to a large increase in waste food -so not only does waste lead to lower resilience, low resilience may also leads to waste. the amount of food that is wasted instead of being supplied to people is particularly tragic, as at the same time, people are also becoming increasingly food insecure primarily due to slumps in incomes (world food programme, ). the interventions that we recommended in this paper, such as improved storage options and strategic well-managed stocks of long-life foods at household, business and regional/national level would help to alleviate such pressures. tom quested, richard swannell and bojana bajzelj are associated with wrap, a uk-based charity with a longstanding history of working on food waste reduction. no other potential conflict of interest is declared. importance of food-demand management for climate mitigation the paradox of productivity: agricultural productivity promotes food system inefficiency toward principles for enhancing the resilience of ecosystem 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consumption norms and win-win solutions for reducing food intake and waste of waste and waists: the effect of plate material on food consumption and waste covid- will double number of people facing food crises unless swift action is taken understanding out of home consumer food waste food waste in primary production -a preliminary study on strawberries and lettuces. banbury, uk. wrap, . food surplus and waste in the uk. banbury, uk. wrap, fsa, defra, . labelling guidance key: cord- -bjv biop authors: smith, michael d; wesselbaum, dennis title: covid- , food insecurity, and migration date: - - journal: j nutr doi: . /jn/nxaa sha: doc_id: cord_uid: bjv biop in this policy piece, we investigate the coronavirus disease (covid- )–food-insecurity migration channel and develop a policy agenda. the interaction between covid- and the drop in economic activity will lead to increased food insecurity within and across countries. higher food insecurity may act as a multiplier for the epidemic due to its negative health effects and increased migration. research has shown that food insecurity affects within-country and cross-border migration. besides the mean prevalence rate, the distribution of food insecurity affects the migration decision. the impacts of covid- are particularly strong for people in the lower tail of the food-insecurity distribution. in the current context, the effect of food insecurity therefore could be increased migration, including both rural–urban migration and international migration. importantly, the crisis might lead to a structural break in migration patterns. people might avoid heavily affected covid- destination countries (e.g., united states, italy, or spain) and move to other countries. due to the persistent nature of migration flows, this could have long-lasting effects. the coronavirus disease (covid- ) pandemic and the global recession it has induced is the most serious crisis in the world economy since the end of the second world war. most countries in the world have imported the sars-cov- (severe acute respiratory syndrome coronavirus ) virus and are now beginning to deal with the societal and economic effects. the policy response, including lockdown and socialdistancing measures, have large, negative effects on economic activity. in its april world economic outlook ( ) the international monetary fund predicts a decrease in the world economy of %, which is larger than the output loss of the global financial crisis. they also predict the drop in gross domestic product to be larger in advanced countries (− . %) than in developing countries (− %). world trade volume is predicted to fall by % and consumer prices are predicted to increase by . % in advanced economies and . % in developing economies. this situation is likely to be especially severe in countries with weak institutions and countries that are already dealing with crises, such as conflicts and weather-related disasters. an important channel through which covid- affects people is the food and agriculture sector. food insecurity is an increasing concern around the world, with > billion people affected by nutrient deficiencies ( ) . according to recent data, the total the authors reported no funding received for this work. author disclosures: the authors report no conflicts of interest. the findings and conclusions in this publication are those of the authors and should not be construed to represent any official national oceanic and atmospheric administration or us government determination or policy. address correspondence to dw (e-mail: dennis.wesselbaum@otago.ac.nz). number of food-insecure individuals has increased for several years, with . % of the world's population (∼ million people) experiencing undernourishment in ( ). david beasley, director of the un's world food program (wfp), said that the world was "on the brink of a hunger pandemic." the wfp predicts an additional million people will be pushed into starvation by the end of . further, we already observe large increases in food prices in some countries. according to fao data, food prices since february have, for example, increased by > % in belarus, bolivia, ghana, and myanmar and by > % in guyana, sudan, and zambia. in this context, the effect of food insecurity could lead to increased migration, as individuals migrate to diversify household income and smooth consumption to withstand exogenous shocks to food access ( ). food insecurity is likely to increase both rural-urban migration and international migration. the covid- crisis might also lead to a structural break in migration patterns as people avoid heavily affected covid- destination countries (e.g., the united states, italy, or spain) and move to other countries. in this policy piece, we investigate the covid- food-insecurity migration channel and develop policy recommendations. according to the fao ( ), food insecurity is a multidimensional concept that includes availability, access, utilization, and stability. the recent covid- crisis and the associated policy responses are likely to affect each of these components ( ) . what does history teach us about the link between epidemics, migration, and food insecurity? the last global pandemic like covid- , arguably, is the spanish flu ( ) ( ) ( ) , which had up to million cases and million deaths. comparisons with the spanish flu and other pandemics allow us to derive upper bounds on the economic effects, to understand key factors in how the pandemic spread, and which policy measures were effective. these insights will be important to inform policy makers today, given the great deal of uncertainty around covid- , even if economies are vastly different y after the spanish flu. history suggests that hunger can worsen disease. for example, some scholars argue that bad quality of food contributed to the spread of the spanish flu ( ) . further, famines in europe from to increased rural-urban mobility ( ) , which, in turn, increased the epidemics raging in cities (these epidemics included, for example, typhus and the plague in the early th century and smallpox in the late th and th centuries). a discussion of early th-century famines identifies other interactive effects ( ) . data suggest that famines adversely affect health, which lowers the ability to resist a viral infection and, hence, make epidemics more severe. in addition, the increased mobility of people suffering from malnutrition increased population densities, which, in turn, increased the likelihood of infection. a similar argument is made for th century india ( ) . famines increased food prices and led to mass unemployment, which increased rural-urban migration. increased migration toward cities and unsafe water caused a cholera epidemic ( - ). in the current crisis, food supply will suffer from disruptions to the food supply chain. these disruptions, for example, are generated by ) producers themselves contracting the virus, ) policy responses affecting markets, and ) transport restrictions. food distribution will be affected as well: transport limitations and restrictions put in place to limit the spread of the virus (e.g., social distancing, quarantine, restaurant closing). food utilization will be adversely affected, particularly for those living in high-density areas, where conditions are already unsafe and could become worse due to lockdown measures. for example, limited access to health services, sanitation facilities, and clean water may impact food storage, processing, and sanitation ( ) . moreover, we expect behavioral responses (panic buying, hoarding) to affect food prices and the availability of food. lockdowns and increased uncertainty might lead to overeating, as stress is known to increase food consumption ( ) . policy responses implemented in many countries will have severe implications, especially in developing countries. people in developing countries rely heavily on informal labor, have low savings, and face a high population density at home. according to gallup world poll data from , the average household in a low-income country has . adults and . children. in comparison, in high-income countries the numbers are . adults and . children. further, lockdowns will likely affect the institutions providing help to the poor and lead to short-term rural-urban migration flows. the looming global recession will reduce remittances flowing toward low-income countries. according to gallup world poll data from , % of households in low-income countries reported having received remittances. the world bank ( ) predicts for a % ($ billion) decline in remittances toward low-and middleincome countries. overall, lockdowns might quickly lead to an increase in food insecurity and a further spread of the virus in low-income countries. in the united states, nutrition and obesity, which correlate with racial and ethnic inequalities, have been found to increase covid- hospitalization rates ( ) . simulation results for low-and middle-income countries indicate that, due to disruptions in health care and access to food, child and maternal deaths could increase dramatically (up to , , extra child deaths and , maternal deaths over mo) ( ) . underlying health conditions or comorbidities have been found to increase hospital admission rates and mortality from covid- ( ) . research in the united states shows that food insecurity is strongly correlated with these chronic health conditions, such as hypertension, coronary heart disease, stroke, cancer, asthma, diabetes, chronic obstructive pulmonary disease, and kidney disease ( , ) . currently, data are still lacking to determine with certainty whether or not covid- health outcomes are worse among the food insecure. however, since food insecurity has been shown to worsen covid- comorbidities, it is likely that food insecurity also affects the severity of covid- outcomes. the interaction between covid- and the drop in economic activity will lead to increased food insecurity within and across countries. higher food insecurity may act as a multiplier for the epidemic due to its negative health effects and increased migration. the effects of food insecurity are likely to be heterogeneous within and across countries. according to the fao ( ), the consequences will be largest for the unemployed, workers in the informal sector, and other vulnerable groups (e.g., women and children). the poor are more likely to suffer from increased food insecurity due to, for example, binding liquidity constraints ( ) and lower adaptive capabilities ( ) . in this context, migration is a response from a utility maximization ( ) and from a riskmanagement perspective ( ) ( ) ( ) . domestic migratory movements are mainly from rural to urban areas or from small towns to larger cities. rural populations and smallholder farmers make up most of the food insecure in developing countries ( ). in these areas, domestic migrants often end up working in the urban informal sector (with precarious jobs and highly variable earnings). for those who are severely food insecure, rural to urban migration may be more common than international migration, since they may not be able to afford the international migration costs. rural migrants also use migration to the city as a first step towards eventually migrating internationally. additionally, due to economic hardship, we expect increased flows from urban to rural areas. poor urban residents are likely to return to rural areas, which could further spread the virus ( , ) . food insecurity is also likely to lead to increased international migration. for example, frongillo et al. ( ) found that food insecurity was strongly and negatively associated with subjective well-being, especially in relatively more-developed countries ( ) . in cai et al. ( ) , it was shown that individuals with lower subjective well-being have higher international migration desires, with subjective well-being playing a bigger role in determining migration than income. returns to international migration are potentially greater than domestic migration, but it typically has greater fixed costs and associated risks ( , ) . households with better networks and more resources to meet migration costs are more likely to select international destinations and thus receive international remittances. moreover, international migrant jobs are typically neither seasonal nor temporary and therefore more reliable than domestic migrant jobs. people will also have to manage the risk of moving to a destination where covid- might be more prevalent. this holds particularly true for rural-urban migration, where cities with a higher population density might increase the risk of infection. this negative health effect could reduce migration. recent research shows that food insecurity can have a large effect on migration behavior ( ) . a study of countries shows that individual-level food insecurity is an important determinant of migration behavior ( ) . likewise, in a cross-section of countries, warner and afifi ( ) found that households use migration as a risk-management strategy to deal with changes in rainfall variability and food insecurity. climatic conditions in guatemala affected food security while also decreasing migration opportunities ( ) , and adverse climatic conditions in senegal depressed international migration in regions with high undernutrition ( ) . based on a survey of people in african cities, crush ( ) showed that urban food insecurity has a greater impact on international migration than rural food insecurity. the effect of the mean prevalence rate and within country distribution of food insecurity on migration behavior in lowand middle-income countries is studied in an unpublished paper by smith and wesselbaum ( ) , which showed that food insecurity increases international migration flows toward oecd (organization for economic co-operation and development) countries and higher within-country dispersion of food insecurity reduces migration. for people below the mean country prevalence rate, the effect of food insecurity on migration is stronger than the effect for people above the mean. the impacts of covid- are particularly strong for people in the lower tail of the food-insecurity distribution, which is likely to magnify the effect of food insecurity on migration patterns. our discussion suggests the need for immediate coordination between the international food security and migration policy agendas. in order to reduce the hardship of unemployment and reduced incomes, countries rely on monetary and fiscal policies. fiscal spending should be targeted toward health and supporting all components of food security ( ) . automatic fiscal stabilizers (e.g., unemployment benefits and food-assistance programs) should limit the effect of the recession, but additional measures, such as cash transfers and wage subsidies, are needed ( , ) . resources that have addressed food crises in the past could disappear. supporting the food distribution system is paramount ( , ) . reducing disruptions to global and local trade flows requires international coordination. the - food crisis led to food price spikes that increased food insecurity ( ) . avoiding such disruptions could involve reviewing existing tax and trade policies as well as supporting transportation systems (e.g., increasing efficiency and labor supply). a group of countries (including new zealand, chile, and canada) have responded to this need by removing trade-restrictive measures on essential goods, including food ( ) . export restrictions have reduced the ability of exporting and importing countries to stabilize domestic food price volatility ( , ) . thus, protectionist measures (e.g., export and import barriers) implemented by food-exporting countries to increase domestic food stocks should be avoided ( , ) . in contrast, multilateral agreements to limit protectionist measures can limit price spikes and reduce the negative effects of beggar-thy-neighbor policies ( , ) . finally, support systems need to be implemented for vulnerable groups (e.g., the elderly and other groups at high risk of covid- infection and death) and state and civil society agencies should provide health information (e.g., about nutritious diets and accessing food assistance) ( ) . we expect covid- to prompt structural changes to seasonal and permanent migration flows. this holds for ruralurban as well as cross-border migration. further, covid- will have different economic effects across countries (e.g., due to different policies). this could lead to a changing pattern of global migration flows. italy, spain, and the united states have been prime destinations for migrants, but they are among the worst-hit countries in the world ( ) . on the one hand, higher food insecurity in africa and asia due to the global recession could increase migration towards europe and the united states. on the other hand, severe recession in traditional destination countries will reduce their desirability, potentially forcing migrants towards other, less affected countries ( ) . this implies that countries that currently do not receive large migration flows should prepare for increased migration (e.g., by updating immigration laws and migrant support policies). even as some countries face increased migration, others might face problems due to lower, mainly seasonal, migration ( , ) . for example, due to outbreaks, migration may decrease in continental european countries where harvesting or planting often requires seasonal workers (e.g., from eastern europe). easing immigration and labor-market policies in these countries might reduce the shortage induced by the crisis ( ) . finally, while the crisis has many negative effects, it may also lead to innovative ideas and should encourage policy makers to use unexploited technologies. for example, it could increase efficiency by reducing food waste ( ) . further, this crisis should lead to a re-thinking of immigration policies and encourage a global approach to managing migration flows. in conclusion, food insecurity could act as a multiplier for the epidemic due to its negative effects on health and its push effect on migration. we expect covid- will affect the level and inequality of food insecurity within and across countries. both the level and inequality of food insecurity will also affect the decision to migrate. we therefore expect food insecurity to lead to increased migration: rural-urban and international. importantly, the crisis might lead to a structural break in migration patterns. people might avoid heavily affected covid- destination countries (e.g., italy, spain, or the united states) and move to other countries. due to the persistent nature of migration flows, this could have long-lasting effects. measuring food insecurity food and agriculture organization; international fund for agricultural development; unicef; world food program; who. the state of food security and nutrition in the world . rome: food and agriculture organization rome declaration on world food security and world food summit plan of action, w orld food summit. rome: food and agriculture organization impact of covid- on food security and nutrition. draft paper by the high-level panel of experts on food security and nutrition. brussels: food and agriculture organization the spanish influenza pandemic: a lesson from history years after epidemics and famine in the little ice age famine, mortality, and epidemic disease in the process of modernization social crisis and epidemic disease in the famines of nineteenthcentury india food systems and covid- . fao policy brief; rome: food and agricultural organization stress, overeating, and obesity: insights from human studies and preclinical models covid- crisis through a migration lens covid- and disparities in nutrition and obesity early estimates of the indirect effects of covid- pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study covid- ) food insecurity, chronic disease, and health among working-age adults. no. food insecurity, acculturation and diagnosis of chd and related health outcomes among immigrant adults in the usa impact of covid- on informal workers. fao policy brief the migration response to increasing temperatures climate vulnerability and human migration in global perspective self-selection and the earnings of migrants rural-to-urban migration in ldc's: a relative deprivation approach does relative deprivation induce migration? evidence from sub-saharan afri ca . fao; internatonal fund for agricultural development; world food program. the state of food insecurity in the world . strengthening the enabling environment for food security and nutrition food insecurity is associated with subjective well-being among individuals from countries in the gallup world poll food insecurity was more strongly associated with poor subjective well-being in more-developed countries than in less-developed countries international migration desires related to subjective well-being remittances, household expenditure and investment in guatemala domestic and international migration from rural mexico: disaggregating the effects of network structure and composition linkages between migration, agriculture, food security and rural development where the rain falls: evidence from countries on how vulnerable households use migration to manage the risk of rainfall variability and food insecurity rainfall variability, food insecurity and migration in cabrican climate, migration, and the local food security context: introducing terra populus linking food security, migration and development assessing the effects of food insecurity on international migration. unpublished manuscript actions now can curb food systems fallout from covid- us unemployment insurance replacement rate s during the pandemic. nber working paper cambridge ma: nber; the determinants of fiscal and monetary policies during the covid- crisis vulnerability of the united kingdom's food supply chains exposed by covid- trade policies and global food security the republic of the union of myanmar government trade restrictions and international price volatility agricultural trade distortions during the global financial crisis gone with the wind: international migration migrant workers and the covid- pandemic. fao policy brief. rome: food agriculture organization the state of food and agriculture: moving forward on food loss and waste reduction. rome: food agriculture organization the authors' responsibilities were as follows-both authors: contributed equally to and share responsibility for the design and writing of this manuscript and read and approved the final manuscript. key: cord- -hjxph jm authors: petrović, t.; d'agostino, m. title: viral contamination of food date: - - journal: antimicrobial food packaging doi: . /b - - - - . -x sha: doc_id: cord_uid: hjxph jm a review of the relevant foodborne viruses is presented. published data from scientific journals as well as the data presented in official reports and published on the internet were used for this review. in the review, information is given for the main foodborne viruses, implicated virus species, and food matrices involved, some history data are given, as well as modes of transmission, and sources of the virus presence in food. results of surveys on the presence of viruses in different kind of foods commodities (fresh produces and shellfish) and in some cases connections to caused outbreaks are presented. also, possible zoonotic infection and implicated viruses that could be transmitted through food are given. human norovirus followed by hepatitis a virus are the most common foodborne viruses, which are transmitted by food consumed raw, such as shellfish, fresh vegetables, and berry fruit. in developed countries, hepatitis e virus is increasingly being recognized as an emerging viral foodborne pathogen that includes zoonotic transmission via pork products. the existing knowledge gaps and the major future expectations in the detection and surveillance of foodborne viruses are mentioned. , and over persons in japan contracted foodborne gastroenteritis due to astv (oishi et al., ) . more recently, there was an outbreak in germany, predominantly in schools and childcare settings, linked to nov in frozen strawberries that were imported from china (mäde et al., ) . outbreaks have been documented to be caused by different kind of food items (e.g., deli meat, vegetables, berries, shellfish, and a great variety of rte foods like sandwiches, bread rolls, bakery products, cold meat, pastries, and ice cubes) (efsa, ) . the food types that are at highest risk of contamination are foods requiring either intensive manual handling, including manual handling under poor hygienic conditions, or close-to-fork and final-product manual handling. dishes containing fresh (or freshly frozen) fruits and vegetables have been the source of numerous outbreaks of foodborne illness (koopmans and duizer, ; efsa, ) . filter-feeding shellfish are a particular risk, as they concentrate viruses present in water during their growth, and numerous outbreaks linked to the consumption of shellfish have been reported (koopmans and duizer, ; efsa, ) . foods at greatest risk of virus contamination at the preharvest stage are shellfish, soft berry fruits, herbs, and salad vegetables. preharvest contamination of fruits and vegetables, including strawberries (niu et al., ) , raspberries (reid and robinson, ; ramsay and upton, ) , blueberries (calder et al., ) , lettuce (pebody et al., ) , and green onions (cdc, ) were reported and have resulted in outbreaks of disease in countries such as finland and new zealand, where populations have low or no immunity to the disease (pebody et al., ; calder et al., ) . the source of contamination in these outbreaks was reported to be either infected fruitpickers or contaminated irrigation waters (greening, ) . postharvest contamination of raw food may occur as a result of human handling by workers and consumers, contaminated harvesting equipment, transport boxes, contaminated aerosols, wash and rinsing water, or cross-contamination during transportation and storage (harris et al., ) . recontamination after cooking or processing and inadequate sanitation has also been associated with outbreaks of enteric virus infections (richards, ) . foods at risk from contamination by food handlers include a wide range of foods that are subjected to too much handling and are subsequently consumed cold or uncooked. these include bread and bakery goods (kuritsky et al., ) , lightly cooked or raw shellfish, delicatessen meats, sandwiches (parashar et al., ; daniels et al., ) , salads, herbs, fresh fruits, and cold desserts. poor food handling was shown to be a key risk factor in the transmission of noroviruses and rotaviruses in the netherlands (de wit et al., ) . an expert meeting convened under the auspices of the food and agriculture organization (fao) of the united nations and the world health organization (who) reviewed available evidence and grouped viruses according to their ability to cause high morbidity, severe disease, or a significant ability to cause foodborne outbreaks (fao/who, ) . in the fao/who document, the common pathogens such as nov, group a hrv, and hav were ranked as priority hazards. in the category of emerging hazards, hev, nipah viruses, h n avian influenza viruses, and sars coronavirus were considered to be of greatest concern. the meeting discussion resulted in several virus-commodity combinations for which prevention and control measures should be considered. those combinations are: for nov and hav in bivalve molluscan shellfish; for nov and hav in fresh produce; for nov and hav in prepared foods; for rotaviruses in water for food preparation; and emerging viruses in selected commodities. nov is one of the most widely recognized viral agents associated with foodborne outbreaks of nonbacterial and often epidemic gastroenteritis and is considered to be the most common cause of foodborne disease worldwide (greening, ; efsa, ) . nov is shed in huge quantities in the stool and vomit of infected persons, and it has been estimated that the infectious dose may be as few as virus particles (teunis et al., ) . novs are primarily transmitted through the fecaloral route, by consumption of fecally contaminated food or water, or by direct person-to-person spread that is still the major mode for nov transmission. secondary spread is person-to-person spread, but may also occur by airborne transmission. according to efsa ( ) caliciviruses (including nov) cause approximately % of epidemic nonbacterial outbreaks of gastroenteritis around the world and are responsible for many foodborne outbreaks of gastroenteritis. the majority of viral gastroenteritis outbreaks in europe have been attributed to novs, where they were reported to be responsible for more than % of nonbacterial gastroenteritis outbreaks between and koopmans et al., ) . estimations based upon analysis of questionnaire data suggested that in the netherlands approximately - % of community cases of nov gastroenteritis were attributed to foodborne consumption (efsa, ) . also, european data from the beginning of this century show that about % of the nov outbreaks are foodborne (ecdc, ) . this makes nov as common a cause of foodborne gastroenteritis as campylobacter and a more common cause than salmonella (de wit et al., ) . a european-wide surveillance network for nov outbreaks, divine-net, has noted that europe has been faced with an increased nov activity during the second half of the first decade of the twenty-first century. the new nov variants of gii. - had most likely been the dominating circulating strains. the role of foods, such as oysters and imported raspberries, as vectors for nov transmission, had been stressed, because both food commodities have been associated in several nov outbreaks in many countries (petrović, ) . hav is the etiological agent of one of the most common types of hepatitis worldwide, and hav as a serious foodborne infection is a notifiable disease in most developed countries. approximately . million people worldwide become infected with hav annually (issa and mourad, ) . the incidence of infection varies among regions of the world, with the highest rate in developing countries where sewage treatment and hygiene practices are poor and where more than % of children have been reported to be infected, usually asymptomatically, by years of age (cliver, ; greening, ) . conversely, the number of reported cases of hav infection has declined substantially in countries with effective vaccination. the major mode of transmission for hav is directly or indirectly from the human reservoir, mainly as a consequence of traveling to endemic regions, engaging in risky sexual practices, or consuming contaminated water or food (efsa, ). food (pebody et al., ; lees, ; greening, ) and drinking water (tallon et al., ) are considered major vehicles of hav transmission to humans. hav can, via sewage discharge, contaminate watercourses, soil, and consequently food crops (bosch, ; cook and rzeźutka, ) . the other main source of produce-associated hav infection is from food handlers and food processors. hav is distinguished from other viral agents by its prolonged ( - -week) incubation period. since hav is shed before symptoms become apparent and there are often more than infectious virus particles excreted per gram of feces, hav-infected produce harvesters and food handlers can become a source of contamination without their knowledge. in areas with poor hygiene practices, this can present a high risk to human health. foodborne outbreaks of hav are relatively uncommon in developing countries where there are high levels of immunity in the local population, but foreigners in these regions can be susceptible if they are not vaccinated (greening, ) . hev is usually the result of a waterborne infection in developing countries and is suspected to be spread zoonotically in industrialized countries (bosch et al., ) . the disease is endemic in many parts of the world, mostly in the indian subcontinent, northwest china, and central asia. in these regions, hev is transmitted mainly through the fecal-oral route, especially by the consumption of fecally contaminated drinking water, and sewage is a major source for contamination of surface water (greening, ; fao/who, ) . foodborne outbreaks of hev are most common in developing countries as a consequence of inadequate environmental sanitation (greening, ) . hev is unusually reported in industrialized countries and when it is reported, it is mostly as sporadic cases in humans who have traveled to endemic countries. recently, some human hev infection in nonendemic countries could not be explained by the contact of those patients with the virus in the endemic regions. although originally it was believed that hev did not occur in industrialized countries, in recent years it has been identified in europe, asia, australia, and the united states; however, it rarely is a cause of overt disease in these countries (clemente-casares et al., ; emerson and purcell, ) . in contrast to nov and hav, hev has been identified also as a zoonosis (efsa, ) . hev has been detected in the feces of a wide range of domestic animals (meng et al., ; vasickova et al., ; greening, ; petrović et al., ) . it has been found to be highly prevalent in pigs in several countries where hev in humans is rare, including spain, new zealand, the netherlands, serbia, japan, and canada (emerson and purcell, ; lupulović et al., ; petrović et al., ) . also, recent studies have revealed quite variable seroprevalence rates among europe's population and a possible porcine zoonotic transmission has been postulated (meng, ; petrović et al., ) . moreover, the human hev strains described in industrialized countries appear to be closely related to the swine hev strains found in the same countries. although rare, the importance of hev transmission via food is increasingly being recognized in the european union (eu) (efsa, ) . hrv is the leading cause of severe diarrhea among infants and young children. in adults, the disease caused by hrv is considered to be mild (greening, ) . it is estimated that hrv causes more than million cases of diarrhea in children less than years of age annually worldwide (glass and kilgore, ) . hrv infection is a particularly serious problem in developing countries where up to , deaths occur annually among children. in the united states, hrv had been estimated to cause about four million infections per year, resulting in almost , hospitalizations and more than deaths annually . it was estimated that only % of hrv cases was foodborne (mead et al., ) . hrv causes disease in both humans and animals, especially domestic animals (greening, ) . outbreaks associated with food and water have been reported in a number of countries . in countries with a seasonal climate change, hrv is more common during the winter months. in tropical regions, outbreaks can occur both in the cooler and drier months and throughout the year, especially where transmission is related to contaminated water supplies and where no sewage treatment systems exist (ansari et al., ) . hrv is stable in the environment, so infection can occur through consumption of contaminated water or food and contact with contaminated surfaces (greening, ) . evs of concern for water and foodborne spread include polioviruses, coxsackie a and b viruses, and echo (enteric cytopathic human orphan) viruses. they are transmitted by the fecal-oral route and are excreted in feces, but generally do not cause gastroenteritis. they can cause a range of other diseases, including viral meningitis, myocarditis and poliomyelitis (greening, ) . polioviruses were the first viruses that have been confirmed to be foodborne (jubb, ; , but virulent wild-type strains are now very rare because of global immunization campaigns. outbreaks of foodborne illness associated with coxsackie viruses and echo viruses have been reported (cliver, ; . enteroviral infection is most common in summer and early autumn, and many infections are asymptomatic. although evs are regularly detected in the environment, there have been very few recorded foodborne outbreaks associated with these viruses. evs, including echo viruses and coxsackie a and b viruses, have been isolated from shellfish, but no outbreaks associated with the consumption of shellfish have been reported (greening, ) . astvs are distributed worldwide and they have been isolated from different animal species like cats, dogs, pigs, sheep, cattle, and birds, as well as from humans. the main feature of astv infection in both humans and animals is a self-limiting gastroenteritis (greening, ) . astvs are a common cause of human gastroenteritis, with most cases of infection detected in young children less than year of age . although astvs cause a mild infection in adults, they have been associated with gastroenteritis in immunocompromised persons. transmission is through the fecal-oral route via water, food, and person-to-person contact . hadvs are widespread within nature, infecting birds and mammals, including humans. they commonly cause respiratory disease but may also cause other illnesses such as gastroenteritis and conjunctivitis. in children under years of age, the enteric hadvs are the second most prevalent cause of gastroenteritis (after hrv) (allard et al., ) . hadvs can be transmitted from person to person by direct contact, or via fecal-oral, respiratory, or environmental routes. most hadv infections in normally healthy individuals are mild or subclinical, but can be associated with respiratory, ocular, and gastrointestinal disease. all virus serotypes are shed enterically in feces, but of the many types of hadvs, only hadv serotypes and are generally associated with fecal-oral spread and cause gastroenteritis (greening, ) . the virus is shed in large numbers in feces and respiratory secretions for long period, even for months or years after the infection. enteric hadv infections are common all year round. these viruses have been identified in a variety of environmental samples, including wastewater, sludge, in marine, surface, and drinking waters, and shellfish, but no foodborne or waterborne outbreaks associated with the enteric hadv have been reported (greening, ) . food may be contaminated by viruses during all stages of the food supply chain. the presence of viruses in food can be the result and consequence of the environmental contamination during primary production-contaminated irrigation waters by sewage as well as manure, which in turn contaminate produce on the field, during the processing and storage phases-by water contaminated with viruses, and from contact virus transmission from humans, such as infected food handlers (involving fecal-oral and aerosol spread of fecal material and vomit). transmission of zoonotic viruses (e.g., hev) can also occur by consumption of products of animal origin (efsa, ). the relative contribution of different sources (shellfish, fresh produce, food handler including asymptomatic shedders, food-handling environment) to foodborne illness has not yet been determined (efsa, ) . food handlers are very often the reason for virus transmission. transmission could occur via infected food handlers with clinical symptoms, but also from infected food handlers who have recovered from illness and no longer display any symptoms, but may still be shedding high numbers of nov. in addition, transmission could occur via infected food handlers with asymptomatic infections and food handlers who come in contact with sick people (koopmans and duizer, ) . although most outbreaks can be traced to infected food handlers at the end of the food chain, the food contamination could occur anywhere (e.g., seasonal workers during berry harvesting or people on recreational boats near shellfish harvesting areas). fresh fruits and vegetables can become contaminated by enteric viruses, possibly through the use of contaminated fertilizers or irrigation water supplies (grohmann and lee, ) . an increased number of foodborne viral outbreaks are being recorded in several countries. reasons for this include the improved diagnostic methods for virus detection and the increased marketing of fresh and frozen foods that have led to a worldwide availability of high-risk foods (efsa, ) . in , a total of foodborne outbreaks were reported in the eu, and it was at the same level as in . overall, , human cases, hospitalizations, and deaths were recorded. the largest number of reported foodborne outbreaks was caused by salmonella ( . % of all outbreaks), followed by viruses ( . %), bacterial toxins ( . %), and campylobacter ( . %). during , eu member states reported a total of foodborne outbreaks caused by viruses (efsa and ecdc, ) . overall, the number of reported viral foodborne outbreaks increased by more than % compared to and . only a few ( . %) reported viral outbreaks were verified (efsa and ecdc, ); however, the number of verified viral outbreaks also increased by . %, from outbreaks in to in . for out of the total of verified foodborne virus outbreaks, the implicated foods were fruit/berries and juices, and products thereof. these outbreaks were reported by finland and sweden and involved human cases (efsa and ecdc, ) . the panel on biological hazards (biohaz) identified nov, hav, and hev as viruses of significance for foodborne transmission (efsa, ) . data from systemic virus surveillance in foods are missing mainly because there are no systemic surveillances on national or wider levels, and the existing data were collected partly from research projectbased studies and mainly from studies after the outbreak occasions. in the european rapid alert system for food and feed (rasff) online database (http://ec.europa.eu/food/food/rapidalert/rasff_portal_database_en.htm) up to december , , presence of enteric viruses in fruit and vegetables were found in a total of cases (alerts). mostly nov was detected ( / ; . %) in fruit ( / ), most often frozen raspberries ( / ), and just in one case in lettuce (from france). out of alerts of hav presence in different kind of fruits, hav-positive fruit (dates) cases from to originated from algeria, and hav fruit (different kinds of berries) alert cases from until april originated from different, mostly european countries. nov-positive raspberries originated from serbia ( / ), poland ( / ), china ( / ), and chile ( / ). nov outbreaks linked to fresh soft red fruits and leafy greens have been reported. between and , foodborne outbreaks of infectious enteric disease were reported in england and wales. from that number, ( . %) were associated with the consumption of salad vegetables or fruit. the pathogens most frequently reported were salmonellas ( . %) and nov ( . %) (long et al., ) . in denmark, at least linked outbreaks of gastroenteritis with a total of cases were reported in january . lettuce of the lollo bionda type grown in france was found to be the vehicle of virus transmission (ethelberg et al., ) . baert et al. ( ) reported that during from a total of reported foodborne outbreaks in belgium, were caused by nov, affecting persons. the major implicated foods were sandwiches ( / ). furthermore, baert et al. ( ) summarized the data collected from international outbreaks between and reported by eurosurveillance, morbidity and mortality weekly reports and from internationally available peer-reviewed scientific journals. as a result, foodborne and waterborne outbreak events due to nov, epidemiological and/or laboratory confirmed, from to have been reported. further analysis revealed that in . % of the cases, the food handler was responsible for the outbreak, followed by water ( . %), bivalve shellfish ( . %), and raspberries ( . %). maunula et al. ( ) the nov detected in patients' stool samples from six outbreaks were sequenced and epidemiologically linked to the single batch of frozen raspberries originating from serbia. these molecular investigations showed that the apparently independent outbreaks were the result of one contamination event of frozen raspberries (müller et al., ) . out of examined fruit products, despite a good bacteriological quality, stals et al. ( ) found nov gi and/or gii in / , / , / , and / of the tested raspberries, cherry tomatoes, strawberries, and fruit salad samples, respectively. the level of detected nov genomic copies ranged between . and . log per g. baert et al. ( ) reported the results of the study where in total, samples of leafy greens, samples of fresh soft red fruits, and samples of other types of fresh produce (tomatoes, cucumber, and fruit salads) were analyzed in those three countries. nov was detected in . % (n = ), . % (n = ), and % (n = ) of leafy greens tested in canada, belgium, and france, respectively. soft red fruits were found positive in . % (n = ) of the samples tested in belgium and in . % (n = ) of the samples tested in france. also, . % (n = ) of the other fresh produce types, analyzed in belgium, were found to be nov-positive. hav has often been associated with the consumption of contaminated fresh-cut vegetables and fruit (efsa, ). at the beginning of , cases of hav were reported in and around jefferson county, kentucky (rosenblum et al., ) . a case-control study found that eating green salad was strongly associated with acquiring hepatitis. rosenblum et al. ( ) concluded that this outbreak of hav was the first recorded outbreak in the united states apparently associated with fresh produce contaminated before distribution to restaurants. in , a total of cases of hav were reported from schools in michigan and cases from schools in maine. most of the patients ate lunch in schools, and preliminary analysis established a strong association between illness and consumption of food items containing frozen strawberries originating from mexico (hutin et al., ) . forty-three cases of serologically confirmed hav occurred among individuals who ate at a restaurant in ohio in . a case-control study was conducted that determined foods containing green onions, which were eaten by ( %) of case patients were associated with illness (dentinger et al., ) . in , a large hav outbreak connected to one restaurant in pennsylvania was described by wheeler et al. ( ) . out of identified patients, died and at least were hospitalized. identical sequences of hav strains from all tested patients were identified. mild salsa, which contained green onions grown in mexico, was identified as the source of the hav (wheeler et al., ) . petrignani et al. ( ) reported the connection between hav infection with cases in the netherlands at the beginning of , and that semi-dried tomatoes in oil was the source of the outbreak. all the examined patients were infected by an identical hav strain not previously detected in the netherlands. in october , semi-dried tomatoes originating from turkey were identified as the source of several hav outbreaks in australia (more than cases) and france ( cases) (efsa, ). gillesberg lassen et al. ( ) described a foodborne outbreak of hav in denmark from october to april . a case-control study identified frozen berries eaten in smoothies as the potential vehicle. in the following weeks, finland, norway, and sweden also identified an increased number of hav patients without travel history. most cases reported having eaten frozen berries at the time of exposure. in total, cases were notified in the four countries. according to information obtained in the case-control study, different kinds of berries were suspected to be the source of hav, but no specific type of berry, brand, or origin of berries was identified. during , more than cases of hav were reported by eu member states as potentially linked to an ongoing outbreak (wenzel et al., ; ecdc, ) . epidemiological, microbiological, and environmental investigations indicate frozen berries as the vehicle of infection for this outbreak and suggested that it could be linked to a single source (ecdc, ) . frequent zoonotic transmission of hev has been suspected. norder et al. ( ) sequenced the orf genome region of hev strains originating from human blood sera collected between and and found that patients infected in europe were infected by genotype . in order to find the connection between human and swine hev, norder et al. ( ) additionally sequenced the hev strains originating from piglets from herds in sweden and denmark. phylogenetic analyses of the genotype strains showed geographical clades and high similarity between strains from patients and pigs from the same area, so the authors concluded that autochthonous hev cases are present in scandinavia. also, bouquet et al. ( ) assessed the genetic identity of hev strains found in humans and pigs in france. hev sequences identified in patients with autochthonous hev infection were compared with sequences amplified from pig livers collected in slaughterhouses. a similarity of > % was found between hev sequences of human and swine origins, indicating that consumption of some pork products, such as raw liver, is a major source of exposure for autochthonous hev infection (bouquet et al., ) . recently, there has been increasing evidence of foodborne transmission of hev. tei et al. ( ) concluded that consumption of uncooked deer meat was a major epidemiological risk factor for hev infection in the city of kasai in japan. in their study, from the total of examined volunteer subjects with experience of eating raw deer meat, ( . %) of the subjects and only ( . %) of the controls had measurable serum anti-hev igg levels. in addition, the studies of yazaki et al. ( ) and tamada et al. ( ) suggest that consumption of undercooked pig liver and undercooked wild boar meat may have been the cause of some cases of hev in japan. wild boar liver is often eaten raw in japan, and this has also been linked to some hev cases (matsuda et al., ) . numerous survey studies have estimated the prevalence of hev rna in marketed livers. hev rna was detected in . % of livers from supermarkets in japan (yazaki et al., ) , and in % of packages in the netherlands (bouwknegt et al., ) . feagins et al. ( ) examined packages of commercial pig liver sold in local grocery stores in the united states for the presence of hev rna, and found ( %) positive for hev rna. subsequent experimental infection of pigs inoculated with positive pig livers homogenates demonstrated that hev in pig livers was infective. leblanc et al. ( ) examined the presence of hev in the tissues of adult pigs, randomly selected from an experimental herd at slaughter in canada. hev rna was detected in out of the animals tested. even although no hev rna was detected in any of the muscle tested, . % of liver samples obtained at the slaughterhouse tested positive for hev rna. in a chinese abattoir, li et al. ( ) found that . % of liver samples tested were positive for hev rna. during , the centre for food safety in honk kong obtained a total of fresh pig liver samples from pigs slaughtered in a local slaughterhouse. among the collected samples, out of ( %) roaster liver samples were found positive for hev, while none of the pork liver samples were found positive. partial orf sequences of some hev isolates from roaster pigs were found to be the same as those from seven local human cases from , as well as local cases recorded in the past. this study suggests the possibility that, apart from contaminated water or food such as raw or undercooked shellfish, pigs also could be one of the sources of human hev in endemic regions (anon, ) . available data suggests that the consumption of raw/undercooked sausage meat is a potential route of hev transmission. in the united kingdom, grierson et al. ( ) detected hev in out of ( . %) tested sausages, and the presence of hev was found at all three points of the pork food supply chain: production, processing, and point of sale. in another study in the united kingdom, berto et al. ( ) detected hev in out of ( . %) and in ( %) of tested sausages and livers. hev rna was also detected at each of three sites (production, processing, and point of sale) in the pork food supply chain. an autochthonous hev infection was recently described in portugal in a patient who recalled eating traditional homemade pork sausages made of raw meat about weeks prior to the development of the clinical manifestations of acute hepatitis (duque et al., ) . renou et al. ( ) presented the case of the direct evidence of foodborne transmission of hev after consumption of uncooked "figatellu" sausage in france, with % identity between the sequences from the patient and the food product. di evaluated the prevalence of hev in the pork production chain in the czech republic, italy, and spain during . hev rna was detected in at least one of the samples (feces, liver, or meat) from ( %) out of examined slaughtered pigs at slaughterhouses. pig feces showed highest hev rna presence ( %), followed by liver ( %) and meat ( %). out of sausages sampled at the processing and point of sale (supermarkets) stages, hev was detected only in spain ( %, / ). hev sequencing confirmed only g hev strains. the efsa biohaz has published a scientific opinion urging for measures to prevent hev from entering the food chain (efsa, ). the biohaz opinion states that in contrast to nov and hav, hev has been identified as a zoonotic virus that can be very effectively transmitted between pigs, and can be transmitted to humans through consumption of products of animal origin, especially through consumption of meat; however, there are no measures in place to control the spread of the virus (efsa, ). eleven foodborne outbreaks consisting of cases of rotaviral gastroenteritis were reported in new york between and (greening, ) . from that number, seven outbreaks have been associated with food-service premises, and the foods included salad, cold foods, shepherd's pie, and water or ice . large-scale outbreaks of rotaviral gastroenteritis have been reported in japanese primary schools with more than cases recorded for one outbreak (matsumoto et al., ) . school lunches prepared at a central facility were suspected as the vehicle of infection, but no hrv was isolated from food or water. lettuce at a market was found to be contaminated with hrv and hav at a time when there was a high incidence of rotaviral diarrhea in the costa rican community (hernandez et al., ) . recently, mayr et al. ( ) described an hrv outbreak in a mother-and-child sanatorium. in total, food samples from the sanatorium kitchen were taken and tested for hrv. hrv particles were isolated from potato stew. out of samples of packaged leafy greens, tested by mattison et al. ( ) , ( %) were found and confirmed to be positive for nov, and only ( . %) was found positive for hrv group a. additionally, brassard et al. ( ) described the presence of hrv as one of the detected pathogenic human and zoonotic viruses on strawberries. probably one of the most recognized routes of foodborne transmission of enteric viral infections is through the consumption of shellfish grown in sewage-polluted marine environments (okoh et al., ) . the most common route for transmission is accidental contamination after heavy rainfall, when extra loads cause an overflow and there is a release of untreated sewage into the aquatic environment. current water treatment practices are unable to provide virus-free wastewater effluents. consequently, human pathogenic viruses are routinely introduced into marine and estuarine waters (bosch and le guyader, ) . shellfish, which includes mollusks such as oysters, mussels, cockles, clams, and crustaceans such as crabs, shrimps, and prawns are filter-feeders that result in the bioconcentration of environmentally stable, positive-stranded rna viruses, such as nov, hav, and ev in their edible tissues, digestive glands, and gills . shellfish can filter some - l of water per hour and in that process, they concentrate infectious agents that are present in the marine environment (grohmann and lee, ) . by this process, oysters can concentrate viruses up to times compared to the surrounding water (burkhardt and calci, ) . a major public health concern posed by virus-contaminated bivalves is that shellfish are often eaten raw, like oysters and clams, or lightly cooked, like most other molluscan shellfish, just steamed for a few minutes (bosch and le guyader, ) . hav has contributed to numerous foodborne outbreaks that are often associated with raw or lightly cooked shellfish (richards, ) . contamination generally occurs either preharvest or during food handling. the first recorded outbreak of shellfish-associated viral disease resulted from storing clean oysters in a fecally contaminated harbor while awaiting sale (gard, ) . that hav outbreak resulted in more than cases. the largest foodborne outbreak of hav occurred in china in when approximately , people were infected during a -month period after consumption of partially cooked, hav-contaminated clams harvested from a growing area contaminated by raw sewage (halliday et al., ) . a few of the documented shellfish-associated outbreaks include oysters in australia (conaty et al., ) , oysters in brazil (coelho et al., ) , mussels in italy (croci et al., ) , and clams in spain (bosch et al., ) . sewage was generally the source of pollution in most of these outbreaks. contamination of shellfish with hav is still common in italy, spain, and other european countries (greening, ) . foodborne nov outbreaks often result from preharvest contamination of foods such as shellfish (christensen et al., ) . berg et al. ( ) described three oyster-related gastroenteritis outbreaks attributed to nov that occurred in louisiana between and . traceback and environmental investigations revealed that the overboard disposal of sewage by oyster harvesters into oysterbed waters was the most likely source of contamination in at least two of the outbreaks. christensen et al. ( ) described the outbreak in which more than people in denmark became ill from consumption of imported oysters during the new year of / . nov and ev were identified from both oyster and patients' fecal samples. bosch et al. ( ) provide examples of large outbreaks (with more than cases) described in literature connected to the viruses in shellfish. in presented outbreaks from to , mostly nov in oysters, cockles, and clams ( / ) was the causative agent followed by hav in cockles and clams ( / ). in recently conducted studies, nov has been detected in - % of oyster samples collected from europe and the united states by random sampling at market places and oyster farms (boxman et al., ; costantini et al., ) . boxman ( ) published a detailed review about human enteric virus presence and prevalence in bivalve mollusks that were collected from european waters or markets from to . rna of enteric viruses have been detected in shellfish from commercial and noncommercial harvesting areas, as well as in products available on the market for direct consumption and in shellfish associated with disease outbreaks. the presented data suggest a high prevalence of different human enteric viruses, but mostly nov, hav, ev, hadv, and hrv were found in shellfish samples collected from growing areas, as well as from the market in different countries. the viruses were present in shellfish from polluted areas, in depurated shellfish and even in shellfish classified in category class a, as well as those ready for human consumption. the relation with the e. coli most probable number (mpn) that is in use for classification of growing areas and to determine whether shellfish products can be presented for human consumption could not be confirmed in this study. up to february , , in rasff online database notifications of enteric viruses in shellfish on the european market (http://ec.europa.eu/food/food/rapidalert/rasff_portal_database_en.htm), boxman ( ) found alerts on the (suspected) presence of viruses. twenty-eight alerts have been reported on nov in food notified by different eu countries between and , and alerts have been reported on the (suspected) presence of hav in food between and . the majority of these alerts on nov in food concerned oysters ( times), followed by scallops (one report). half of the notified batches of oysters were of french origin, followed by oysters derived from the united kingdom, and ireland. all alerts on the (suspected) presence of hav in food were reported by italy and spain and were only involving shellfish: oysters (five reports), small bivalve animals (four reports), and scallops (one report). half these products were of french origin, whereas the other half was shellfish from peru (boxman, ) . after this period and the data described by boxman ( ) until december , , new nov-positive shellfish alerts were published in the rasff online database. analyzing the alert reports on shellfish, nov presence was mostly connected to oysters ( / ; . % cases) from france ( / ), ireland ( / ), the netherlands ( / ), and spain ( / ); in three cases connected to mussels from the netherlands ( / ) and spain ( / ); in three cases connected to clams from portugal, united kingdom, and vietnam; and in one case connected to raw shell scallops from chile. in the efsa report ( ), from a total of foodborne outbreaks reported in eu member states during , crustaceans, shellfish, mollusks, and products thereof were the most frequently implicated food items. for those outbreaks that were verified, nov was the most frequent cause, followed by hav (efsa, ). in the recent united kingdom food safety authority project-based study, nov was detected in . % oyster samples ( / ), with similar prevalence in the two species of oysters tested ( . % ( / ) for crassostrea gigas and . % ( / ) for ostrea edulis). clear seasonality was observed with a positivity rate of . % ( / ) for samples taken between october and march compared with . % ( / ) for samples taken between april and september (anon, ) . in the first report on the presence of human enteric viruses in shellfish from portugal, approximately different kinds of shellfish, organized in batches, were collected between march and february (mesquita et al., ) . viral contamination was detected throughout the year in all shellfish species and in all collection areas, independently of classification of their harvesting areas. nov was detected in % of the batches, followed by ev in %, and hav in %. overall, % of all analyzed batches were found to be contaminated by at least one of the studied viruses, while the simultaneous presence of two and three viruses was detected in % and % batches, respectively. the special problem was the fact that viruses were detected in six of the eight shellfish batches from the a-class harvesting areas (one nov, three ev, and two hav) (mesquita et al., examined the prevalence of different enteric viruses in commercial mussels at the retail level in three european countries (finland, greece, and spain). a total of mussel samples from different origins were analyzed for virus presence. samples were positive in % of cases. hadv was found to be the most prevalent virus detected ( %), and the prevalence of nov gg ii, hev, and nov gg i were %, %, and . %, respectively. presence of hav was not detected. epidemiological evidence of astv transmission by foods is limited, but infections via contaminated seafood like shellfish and water have been reported (oishi et al., ; . one large outbreak of acute gastroenteritis was reported in japan involving thousands of children and adults from different schools in (oishi et al., ) . the outbreak was traced to food prepared by a common supplier for school lunches and astv type was identified as causative agent. there are several japanese reports of astv genomes identified in shellfish with the evidence of their contribution in foodborne outbreaks of gastroenteritis, mainly after the consumption of contaminated oysters (kitahashi et al., ) . hadvs have been identified in a variety of environmental samples, including wastewater, sludge, and in marine, surface, and drinking waters, as well as in shellfish, but no foodborne nor waterborne outbreaks associated with the enteric hadvs have been reported (greening, ) . swine manure could be a source of hev contamination of coastal waters with subsequent contamination of shellfish (smith, ) . said et al. ( ) reported that the small genotype hev outbreak on a cruise ship returning to the united kingdom in was connected to the consumed shellfish. zoonotic viral infections are generally not transmitted by food; however, there are a few reports on transmission of some emerging viruses via food. this transmission is likely to be rare, relative to other transmission routes, and will probably be restricted to a few food products or items and occasions. for example, highly pathogenic avian influenza (hpai) virus in undercooked poultry or eggs, hev in porcine organs, or muscle tissue and nipah virus in date palm sap are postulated to be foodborne. another emerging virus for which this mode of transmission may be relevant is severe acute respiratory syndrome coronavirus (sars-cov) (fao/who, ; newell et al., ) . all mentioned viruses are zoonotic, and limited epidemiological data exist that support their transmission by the consumption of contaminated foods. each of these viruses is capable of causing significant illness and mortality in humans. they are present in the intestinal tracts of infected humans and animals, and are shed into the environment through feces that can contain high levels of virus (newell et al., ) . sars-cov was spread into the human population through the preparation and consumption of food animals that appear to be infected from another reservoir, probably bats (lau et al., ) . infectious h n avian influenza virus has been found in duck meat, and the consumption of duck blood has resulted in the infection of humans (tumpe et al., ) . almost all reported cases of avian influenza (ai) virus infection in humans that have been recently caused by hpai viruses belonging to the h or h subtypes were transmitted directly from infected birds to humans. other routes of infection, such as consumption of edible tissues from infected avian species or contact with contaminated water, have been suggested as possible sources of infection, but have not yet been proven (efsa, ). transmission of hev through food of animal origin is already documented (yazaki et al., ; tei et al., ; li et al., ; meng, ; said et al., ) and explained in detail previously. nipah virus was shown to affect people slaughtering pigs. whether eating produce from infected pigs can transmit the nipah virus is not known (fao/who, ) . nipah virus was shown to affect children eating fruits contaminated with urine from bats shedding the virus, and three outbreaks in bangladesh have been linked to consumption of fresh local sweet delicacy, which had been contaminated by bats (luby et al., ) . besides those mentioned, there is evidence of transmission of the ebola virus through bushmeat mainly by ingesting the meat of fruit bats. this mode of ebola virus transmission has been found as a route of virus transmission from wildlife to human population (leroy et al., ) . it is important to stress that, for most of the aforementioned emerging foodborne pathogens, contaminated foods is not a usual or even a likely vehicle of transmission, but the potential for foodborne transmission should be considered in epidemiological studies (fao/who, ; newell et al., ) . recently, the european food safety authority (efsa) biohaz stressed that except for tick-borne encephalitis virus, which can be shed by infected dairy animals and subsequently infect humans via milk; and hev, which can be transmitted through consumption of undercooked meat, viral foodborne infections are limited to the recycling of human viruses back to humans (efsa, ). food and environmental virology is a relatively young scientific discipline and consequently there is little published data on virus presence and prevalence in different matrices. there are just a few existing data on virus presence and prevalence in different foods. the data available originates mainly from research project-based studies, and in most cases were from studies conducted after the outbreak occurred. data from systemic virus surveillance in foods are missing mainly because there is no systemic surveillance either on a national or wider level (petrović, ) . another important data gap relates to the lack of knowledge regarding the prevalence of disease caused by viruses in foods in comparison with other possible transmission routes. also, the relative contribution of different sources (shellfish, fresh produce, food handler including asymptomatic shedders, and food handling environment) to foodborne illness has not been determined. most countries have some level of reporting of foodborne illness outbreaks, but few of these systems include viral foodborne illness (greening, ; newell et al., ) . due to the high rate of secondary transmissions, small initial foodborne events may rapidly present person-to-person outbreaks, if the initial introduction event was not recognized (efsa, ). some case-based surveillance exists for hav and evs, but usually it is not focused on detecting foodborne transmission as a source of the infection (newell et al., ; efsa, ) . as a result, national statistics on foodborne viral disease are not readily available and, where present, it likely reflects significant underreporting (mead et al., ; greening, ; fao/who, ) . routine harmonized surveillance of viral outbreaks and of virus occurrence in different foods would be recommended to aid source attribution studies. estimates of the proportion of illness caused by foodborne viruses that can be connected to consumption of contaminated food are based upon very few studies, and according to the efsa biohaz (efsa, ) would require the addition of systematic strain typing to routine surveillance, or more systematic studies to provide more reliable data for burden estimates. testing for viruses in food products is difficult, and there is considerable debate over interpretation of findings. as a consequence, data from food-product monitoring are at the least inconsistent (efsa, ). a problem for the detection, study, as well as for the control of most of the foodborne viruses is that some enteric viruses replicate poorly (hav) or not at all (nov) in cultured cells (atmar and estes, ). in addition, there are no laboratory animal models available for experimental studies of virus inactivation. for these reasons, detection methods currently rely on virus genome detection by molecular techniques such as reverse transcription polymerase chain reaction (rt-pcr). the application of molecular techniques such as real-time (rt)-pcr has enabled relatively rapid, sensitive, and specific detection of viral genome sequences. the problem of this methodology is the fact that the positive signal does not provide information on virus infectivity; rather it indicates the presence of the viral genomic segment. so, inactivated virus particles that pose no threat to public health may still contain intact rna and give a positive result (koopmans and duizer, ; stals et al., ) . the positive results of nov presence in food are of special concern in the absence of linked outbreaks. consequently, a potential risk for infection cannot be excluded, but the actual risk from rt-pcr nov-positive produce remains unknown. for this reason, studies should be designed determining the probability of infection related to the presence or levels of nov genomic copies . a lack of appropriate detection methods for confirmation of viruses as the etiological agent in food is also the reason for underreporting of foodborne virus outbreaks (baert et al., ) . although protocols are available for the detection of hav and nov as the viruses that are most frequently associated with foodborne outbreaks, few laboratories use them when investigating the causes of foodborne diseases, because the methods are considered to be too expensive and too time-consuming for the routine screening of foods (lopman et al., ) . from , an international organization for standardization (iso) methods (technical specifications) for the detection of hav and nov in foods exists: "horizontal methods for determination of hepatitis a virus and norovirus in food using real-time rt-pcr (iso ts - , and iso ts - , )," but still they are very expensive and time-consuming and not adequate for wide surveillance studies. currently, methods used for monitoring of foods using e. coli as microbiological criteria do not correlate consistently with presence or absence of viruses in foods. also, current safety standards for determining food quality typically do not specify what level of viruses should be considered acceptable (okoh et al., ) . as a consequence, the food industry and food safety authorities, at present, lack the tools that enable them to monitor virological quality control in contrast with the situation that exists for bacteriological contamination (efsa, ) . despite the fact that viruses are one of the most common pathogens transmitted via food, no systematic inspection and legislation exist regarding the presence of viruses in the food chain that would set up virological criteria for food safety (koopmans and duizer, ; okoh et al., ) . accordingly, the education of food-industry managers, producers, distributors, and consumers about hygienic regulations and conditions of food production and processing are essential (vasickova et al., ) . commission regulation (ec) / on microbiological criteria for foodstuffs lays down food safety criteria; however, no specific criteria are set for viruses. at the time of this writing, no routine monitoring of viruses in foodstuffs is performed; however, it would be highly beneficial to have such surveillance, including a system where data from food and environmental monitoring could be epidemiologically compared with data from outbreaks in the population (petrović, ) . molecular epidemiology and surveillance of food samples are necessary to elucidate the public health hazards associated with exposure to foodborne viruses and for the estimation of the true size of food-related cases (ecdc, 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associated with the consumption of processed pork products multiple norovirus outbreaks linked to imported frozen raspberries other food-borne viruses rotavirus a review, foodborne viruses and fresh produce a review of hepatitis e virus screening of fruit products for norovirus and the difficulty of interpreting positive pcr results recovery and sequence analysis of hepatitis a virus from spring water implicated in an outbreak of acute viral hepatitis consumption of wild boar linked to cases of hepatitis e zoonotic transmission of hepatitis e virus from deer to human beings consumption of uncooked deer meat as a risk factor for hepatitis e virus infection: an age-and sex-matched case-control study norwalk virus: how infectious is it? characterization of a highly pathogenic h n avian influenza a virus isolated from duck meat viruses as a cause of food-borne diseases: a review of the literature hepatitis a outbreak in europe: imported frozen berry mix suspected to be the source of at least one infection in austria in an outbreak of hepatitis a associated with green onions enteric viruses in the aquatic environment sporadic acute or fulminant hepatitis e in hokkaido, japan, maybe food-borne, as suggested by the presence of hepatitis e virus in pig liver as food the authors would like to acknowledge funding from the project no. tr of ministry of education, science, and technological development of the republic of serbia. special thanks go to dr. nigel cook, fera, united kingdom, who introduced the research interest for food and environmental virology to the authors of this book chapter. key: cord- -cve mqd authors: adhikari, jagannath; timsina, jagadish; khadka, sarba raj; ghale, yamuna; ojha, hemant title: covid- impacts on agriculture and food systems in nepal: implications for sdgs date: - - journal: agric syst doi: . /j.agsy. . sha: doc_id: cord_uid: cve mqd the objective of this study was to understand the impacts of covid- crisis in agriculture and food systems in nepal and assess the effectiveness of measures to deal with this crisis. the study draws policy implications, especially for farming systems resilience and the achievement of sdgs and . the findings are based on (i) three panel discussions over six months with policy makers and experts working at grassroots to understand and manage the crisis, (ii) key informants' interviews, and (iii) an extensive literature review. results revealed that the lockdown and transport restrictions have had severe consequences, raising questions on the achievement of sdgs and , especially in the already vulnerable regions dependent on food-aid. this crisis has also exposed the strengths and limitations of both subsistence and commercial farming systems in terms of resiliency, offering important lessons for policy makers. traditional subsistence farming appears to be somewhat resilient, with a potential to contribute to key pillars of food security, especially access and stability, though with limited contributions to food availability because of low productivity. on the other hand, commercial farming - limited to the periphery of market centres, cities, and emerging towns and in the accessible areas - was more impacted due to the lack of resilient supply networks to reach even the local market. lower resiliency of commercial farming was also evident because of its growing dependence on inputs (mainly seeds and fertilizer) on distant markets located in foreign countries. the observation of crisis over eight months unleashed by the pandemic clearly revealed that wage labourers, indigenous people, and women from marginalized groups and regions already vulnerable in food security and malnutrition suffered more due to covid- as they lost both external support and the coping mechanisms. the findings have implications for policies to improve both subsistence and commercial farming systems – in particular the former by improving the productivity through quality inputs and by diversifying, promoting and protecting the indigenous food system, while the latter through sustainable intensification by building reliant supply network linking farming with markets and guarantying the supply of inputs. the novel coronavirus pandemic has revealed how the global food systems can become vulnerable and lead to increase in food insecurity, malnutrition and poverty especially among marginalized groups (world bank, a; wfp, ; nguyen, ; stephens et al., ; fore et al., ) . nepal, a landlocked and least developed country located in south asia (fig. ) , has also been witnessing various adverse impacts of covid- in terms of human casualties and physical and mental health and on country"s diverse farming systems and food security. as of nd november, , total cases of infection with , active cases and total deaths were reported (worldometer, ) . nepal imposed a lockdown to control the spread of the coronavirus since march and partially opened since the first week of september . the lockdown has affected the overall physical, mental, social and spiritual health of the people and posed unique challenges with vulnerable populations and limited resources to respond to the pandemic (poudel and subedi, ) . it has also negatively impacted on education, especially for the agricultural students who should be conducting the practical fieldwork that will not be possible through online classes or videoconferencing . like in other developing countries, nepal also faced a question as to whether the real crisis from covid- would come from health or from hunger, or to what degree the crisis could setback in the achievement of the sustainable development goals (sdgs) by (un, ) . however, nepal"s farming systems also have some resilience that helps to cope with and adapt to the crisis. for example, diversification of crops and income generating activities within the farming system in the hills and mountains was considered as adaptation to face the crisis brought by severe earthquake in (epstein et al., ) . government and other actors in nepal have also implemented new ways to deal with the disruption caused by covid- in food production and food security, and some of them have helped farmers and the broader population. the objective of this study was to assess the immediate impacts of covid- on different farming and food systems as well as their consequences on sdgs (no poverty) and (zero hunger) in nepal. this paper looks into: how local farming systems are being affected and which systems are likely to be resilient; how food security has been impaired; and how effective are the current measures taken by the government and the community to deal with the impact of covid- on farming systems and food security. we also aim to offer some insights into appropriate responses required to deal with the crisis in nepal. the paper is based on a series of three virtual panel discussions organized by the nepalese association of agriculture, forestry and environment in australia as a part of its continuous conversation on this topic the first one was organized on april and the last one on october , which led to an understanding on how the crisis and its impacts progressed over time and how the government"s and community"s responses worked. these virtual discussions were open in which authors participated as discussants and presented the information and data they collected. two of the authors have been working at the grassroots levels in nepal to observe the impact, provide help to people, and influence policy changes to deal with the crisis. other authors collected data and information through secondary sources. researchers and students (ranging from - in each of the virtual panel discussions) based in different countries and interested in this research theme participated in these discussions and provided comments. these discussions were supplemented by findings from key informants" interviews with selected government and non-government agriculture officers and farmers and literature review. ten government officers and fifteen civil society and ngo officials working at different administrative levels were interviewed through telephone once in mid-april and again on mid-october (see table for details on checklists and questions used in panel discussions and interviewing the key informants). nepal has now become a net importer of food. its ability to produce enough food has been hampered by several factors, some of which are small farm sizes, remoteness of farms, insufficient support to general spread of covid- ; general impact on the lives of peoplehealth, food, social, psychological and economic impact across the country; impact on farmers and farm production, distribution of food or farm products through trade/transportation; ground reality in terms of access to food, various safety nets implemented, how people suffered, who suffered; media reports and reality observed; forecasting as to what will happen in coming months in terms of food production, marketing, access to food, and health services; people"s (farmer"s) response to cope with the crisis on their own initiative and how is it helping; what should be done to improve food security. key informants -government policy makers ( ) ) mid-april ( ) ) mid-oct ( ) government policies to deal with such crisis; what supports are provided, how and to whom; policy gaps in agricultural sector in general and food security in particular as exposed by the crisis; experience/idea with regard to resiliency of prevailing farming systems to cope with such crisis; role of indigenous food systems in such crisis; what new initiatives taken at different government levels to deal with the crisis and continue with food production, marketing, distribution through trade/transportation, supply of inputs, new incentive structures; effectiveness of these new initiatives and which seem to work effectively; what could be the policies options for the future to deal with the crisis. key informants-ngos and civil society organizations (csos) ( ) ) mid-april ( ) ) mid-oct ( ) ngos provide emergency services, food provision; livelihood support; agricultural knowledge; and support services. checklists and questions used: effects on people in general, especially to marginalized groups and women; practical measures taken by csos/ngos, communities to deal with the crisis and support people in problems; gaps in such support mechanisms; kind of emergency services required; how the work of csos/ngos affected by the crisis and how this, in turn, affected people/farmers; supports available for farm production, marketing, storage, supply of inputs and the like; effectiveness of various measures taken to support farmers and other people; role of indigenous food systems in such crisis; measures to be taken make safety net, food production and marketing effective so that overall food security is ensured for all. farmers in terms of access to inputs like seed, fertilizer, irrigation, and technical know-how (adhikari, a) . the farming systems have largely been oriented towards subsistence living. indigenous food systems have also been obliterated, and regions where indigenous populations dominate have largely been food insecure, and where malnutrition is widespread (singh, ) . only in the peri-urban areas and in terai plains, there is some commercial farming, where farmers grow crops and keep animals mainly for the market. nepal"s farm products generally cannot compete with cheaper products coming from india (nepal and india have open border and free trade policy), where cost of production is low due to subsidies in fertilizers, irrigation, machineries and services like technical help, and guaranteed marketing through minimum support price (sunam and adhikari, ) . on the other hand, since the s, opportunities to work in foreign countries expanded with globalization that also coincided with nepal government"s openness in letting its people go out for work. slowly labor migrationwithin and outside the country -emerged as a major source of livelihood contributing equivalent to about % of gdp (about usd . billion in - ) (world bank, c) with remittances entering to % households (cbs, ) . many poorer people including marginalized indigenous groups go to india or to cities within nepal for work, whereas lower and upper middle class generally seek jobs in malaysia, gulf, and other wealthier countries. it is mainly because of migration of youths and use of remittance to purchase food from the market that a significant proportion ( %) of cultivated land, especially in the hills and mountains, has been abandoned from farming (upadhyay, ) . nevertheless, nepal still produces about % of the basic required cereals in the country, even though there are annual fluctuations as farming is mainly dependent on monsoon rain for irrigation (moad, ) . nepal also made some significant improvements in poverty reduction (people living under the line of poverty came down from % in to . % in ) and food security and nutrition in the past two and a half decades (gon-npc, ) thanks mainly to increase in remittances and non-farm income contributing about one-third to one-half of the poverty reduction (world bank, b). government has developed plans for sdgs with the aim that it would be able to achieve most of the goals by (un, ; gon-npc, ) fig. . map of nepal showing seven provinces and districts (province no. is named as "karnali", no. as "gandaki", no. as "bagmati", no. as "lumbini", and no. as "sudur pacchim"). the country runs from east to west with high altitude northern areas covering high hills and mountains, mid-altitude middle areas with mid-hills, and low altitude southern areas with plain lands called terai (map source: http://nepalsbuzzpage.com/new-map-of-nepal-with- -province/). impact of covid- on farming systems and food security, and sdgs - a rapid assessment of socio-economic impact of covid- in nepal revealed that the virus will seriously derail the achievement of sdgs if external donor supports are not made available on scale needed to fight the disease and its impact (undp, ). our analysis from the current study reveals that the consequences will spill over to multiple sdgs with an immediate threat to two intricately interrelated goals (goal : no poverty; goal : zero hunger) and negative effects on all pillars of the food security (i.e., availability, access, utilization, and stability). of the four pillars, the profound impact in short-term is seen in availability and access to food and in long term, it will impact all the four pillars of food security. similarly, different farming systems are also being affected differently. farming systems resilience and impacts on farming there are around . million landholdings (family farms) in nepal, % of which are ownercultivated (fao, ) . average size of a farm family is of only . ha. these smallholders produce a wide range of foods, using mainly family labour and consume a main part of the production in-house. they sell just % of their production in the market and generate just % of their total income due to low productivity, limited surplus to sell and lack of access to market and infrastructures like road and transportation networks (fao, ) . on the other hand, these smallholder farms were found to be somewhat resilient in the face of covid- as they depended on local inputs -local indigenous seeds, compost, and family and community labour exchange (personal communication with bakhat khadka, agriculture development office, ministry of agriculture, karnali province and with amrit gurung, gandaki province) and did not need market as the products were consumed at home or locally. these smallholder farms also had potential to initially absorb about half a million youths who returned to their villages from cities from nepal or from india and other countries because of covid- pandemic (undp, ). some of these returnee migrants already started cultivating some of their abandoned fallow land. for instance, in dailekh, a mid-hill district in the karnali province, these returnee migrants have now started ginger and turmeric farming in the traditional fallow lands employing themselves (dhamaka daily, ) . the strong community that is built around this type of farming is also useful in sharing the resources like seeds and labour. for example, it is seen that community seed banks maintained by such communities played an important role in this pandemic as these ensured local seeds, conserved biodiversity, and contributed to a diversified food system (de falcis, ) . the resiliency of such farms (measured by robustness and recovery of system productivity) was also observed during the great earthquake of when nepal was hit by -rector scale earthquake causing over , deaths and widespread damage of infrastructures (epstein et al., ) . resilience can also play a major role in the survival and expansion of many agricultural systems and great empires and strengthen the resilience of nations against future pandemics and other shocks (haldon et al., ) . in other countries (e.g. spain) too, family farms are seen to provide cushion against the pandemic (fao, ). on the other hand, the limitations of such subsistence farms were also realized when, despite potential, they could not fully engage these returnee migrants, and so a reverse migration has started to nepal"s cities and to india (see also ayer, ) . low productivity and inadequate ability to provide full livelihood security is a limitation of such farming systems despite the fact that they are somewhat resilient. moreover, these smallholder subsistence farms have also been neglected by government, and hence their potentials have not yet been realized. the land consolidation, use of fallow/barren land, irrigation, improvement in indigenous landraces, and promotion of market for niche products would have helped increased production. for example, meuwissen et al. ( ) j o u r n a l p r e -p r o o f journal pre-proof developed a conceptual framework to assess the resilience of farming systems and presented a methodology to operationalize the framework with a view to diverse farming systems of europe. such learning could have been useful in developing contextualized concept in case of nepal as well as in other countries of south asia. commercial or semi-commercial farms in nepal, which are generally located near the urban centres especially in downstream terai plains and produce mainly cash crops such as perishable fruits and vegetables, and eggs and milk, faced greater problems in this pandemic as they were neither able to sell their farm products to or purchase farm inputs (seeds, fertilizers, etc.) from markets on time due to lockdown and transport restrictions. situation of chitwan valley, a breadbasket for nepal and a centre of commercial and modern farming, clearly illustrates the plight of market-driven farming in such pandemic when marketing practices are not made resilient. its production of eggs and chicken has made the country more or less self-reliant in poultry production. in addition, it produces vegetables, fruits and milk to meet the significant market demand in cities like pokhara and kathmandu. it produced around . million litres of milk per day prior to covid- , but then due to lockdown and unavailability of feed (mostly imported from india), production declined and that too did not get the market (onlinekhabar, a) . immediately after the covid- , farmers had to throw their milk, eggs and vegetables and on the street, as they did not have any plans for such immediate breakdown in market channel (timilsina and ghimire, ) and to show wrath to government for not helping in the marketing of the products. banana did not sell and so were left rotten on the plants. lack of onfarm processing and cold storage facilities aggravated these problems for the commercial farmers. because of higher incomes, farmers even in high hill districts of province and province with accessibility to roads had slowly converted to commercial vegetable production prior to the pandemic. but these farms had to incur losses due to marketing problems triggered by covid- (adhikari, b; adhikari and hussain, ) . a survey of , households conducted in april -about a month after lockdown-revealed that covid- increased food insecurity by percentage points, pushing the proportion of food insecure households to % and deterioration of the dietary diversity by % affecting mainly children. the survey also showed that % households lost livelihood source altogether, and % faced a reduction in income (subedi, ) . vulnerability of karnali province, which had been suffering from food insecurity for a long time and was getting support from food-aid programmes, was most affected. by september , the vulnerability to food security had deepened, especially in karnali. for example, there were reports that all the food depots responsible for the distribution of food to people in mugu district in karnali had become empty of food stocks, and people could not buy food at all (shahi and gautam, ) . a second large survey conducted in august revealed that there is slight decrease in food insecurity overall in the country because of resumption of some supply networks. there was slight increase in loss of income (by . %), but more households faced severe and moderate loss of income (by %). for more than % households increases in food price was a major concern during the covid- crisis. lost income and increase in food price created a precarious food security situation (reliefweb, ) . covid- also exposed nepal"s vulnerability to dependency on other countries for inputs required in production of crops, livestock and poultry. as nepal has started modern farming methods, demand of these inputs is met through imports. however, this year, there was a serious shortage of chemical fertilizer for rice because of transportation restrictions and lack of preparedness from the government (prasain and giri, ) . the annual demand of chemical fertilizer is about . million tonnes and in most years the government imports about half of this. but this year, supply was delayed due to trade restrictions. as a result, farmers were distributed with only kg of urea per household during the j o u r n a l p r e -p r o o f journal pre-proof peak season of fertilizer use in rice, which will result in lower productivity. in the same line, productions of other crops and livestock and poultry are also expected to decline. as the prolonged lockdown started to impact food production and distribution, government allowed people to carry out their farming activities like harvesting of wheat and planting of maize and rice, respecting its covid- related precautionary health guidelines. nevertheless, the lockdown has continued to adversely impact food availability through production as well as trade/distribution as the supply chains of inputs and farm products were disrupted. on the other hand, the pandemic has now made the country and the people realize the problem when a country depends on others for food. this has now triggered a policy debate on the necessity to become self-sufficient in food production (adhikari, a) . covid- has also revealed the importance of federal political and administrative governance structure, which was created only in . the federal ministry of agriculture and livestock development created "rapid response teams" at different administrative levels (moald, a) to provide services to farmers to tackle their immediate problems in marketing and input supply, though they have not been as effective as planned because of lack of vertical and horizontal coordination with other related ministries, especially the ministry of health and population and the ministry of home affairs. the devolvement of power and resources at sub-national governments has however made it easier to make quick decisions to solve contextualized problems. for example, in the karnali province, a perennially food insecure region, the federal government responded by providing nrs . billion ( us$= nrs . ) for the agricultural sector including production of off-season potato and the local governments in the province responded by announcing minimum support price for wheat and timely supply of threshers for wheat harvest. likewise, a few best practices have also emerged from the actions of local governments across the country during this pandemic. these include, as observed by authors while working in the field, free threshers for wheat harvesting (e.g., saptari district in eastern terai); a system of buying vegetables from farmers and distributing them free to the affected people (e.g., khotang district in eastern hills); a program to pay four months" interest for loan taken by the affected people (e.g., province government); "agriculture ambulance service" for transport of farmers" products (e.g., province government), and cash grant to farmers if they use existing fallow lands for farming (e.g., gulmi district in western hills). now, the questions have arisen as to how these best practices are to be institutionalized and scaled-up, which could support farmers and produce more food locally in future. this pandemic and food insecurity caused thereby led to the realization that indigenous/local food systems are also important. in the past, these indigenous foods and local farming systems were overlooked and, in many cases, discarded, which in fact adversely affected indigenous populations. this has also been emphasized in a wider context in a recent article in lancet (zavaleta-cortijo et al., ) . support to increase production of food from such systems strengthen resiliency in food security with other positive consequences like self-reliance and mitigation of micronutrient deficiency and overall malnutrition especially among children and women. this would also help to conserve local agricultural biodiversity and a local food-culture. initiatives launched by government of sikkim, india to make the whole state "organic" through the promotion of organic farming based on indigenous farming systems could also be an alternative in the hills and mountain environments . as a silver lining of the covid- crisis, there is, thus, an opportunity to promote local foods and increase food availability locally (iied, ) . realizing this, provincial and j o u r n a l p r e -p r o o f journal pre-proof local governments in nepal are now more focused to increase availability of food locally, and so have placed priority in bringing fallow land (estimated to be %) under cultivation by engaging the returnee migrants from both within the country and overseas. for example, gandaki province has announced that it would provide nrs , per ropani ( ha = ropani) of fallow land, if the same is brought into cultivation. besides, covid- has also forced people to engage in backyard, balcony, and rooftop farming, which could increase food production, and government has initiated a policy of giving free seed and fertilizer to people interested in such farming. other measures of the government that came after the incidence of covid- include: policy intervention to support insurance of selected crops and livestock; minimum support prices of major crops; providing extension and advisory services; providing easy and cheap loans; and providing subsidy on improved/hybrid seed, fertilizers, and machines (moald, b). in terms of technology, it is now felt necessary to introduce labour saving technologies because of shortage of labour, especially male labour, because of their out-migration and to reduce work burden on women and elderly, who now carry the farm work. further participatory research is needed to find out context specific and scaleappropriate mechanization and other labour-saving techniques such as zero or reduced tillage, and direct seeding of rice (basnyat, ; paudel et al., ) . in the same line, key informants which were government officials identified measures that are essential to increase food availability, which include: establishment of agro-processing industries, agri-businesses and post-harvest facilities, development of cold storage and grain storage facilities, and expansion of irrigation facilities especially in the currently rainfed lands in hills. impact on access to food covid- reduced people"s access to food through the loss of livelihoods and income. according to a survey conducted in april , access to food and vulnerability to shocks has further deteriorated among daily wage laborers and female-headed households. about % non-agriculture daily wage laborer and % farm related daily wage earners were reported to have lost their jobs because of the covid- , and % of wage laborers experienced reduced income. income reduction was most common among traders ( %) and remittance receivers ( %) (subedi, ) . however, wage labourers were most vulnerable to food insecurity as they had no food stocks and reserve funds as there was no social safety-net as such, except for a temporary distribution of food that would last only for a few days. lack of this safety net was a major reason why there was exodus of wage workers from cities like kathmandu, who walked for weeks to reach home despite the restrictions to move out during lockdown. most of these migrant workers in cities (almost %) were involved in informal sector (spotlight, ) , which faced major loss in jobs. a study has revealed that % job losses in small and medium enterprises and % in informal daily wage job markets made many people unable to sustain their lives smoothly (spotlight, ) . for many families, remittances had been propping up the food security. at the national level, nepal received usd . billion remittances, equivalent of . % of gdp, in (world bank, c). covid- has two major consequencesreturn of migrants leading to further demand in food, and reduction in income. remittance in nepal is estimated to decline by % in highest decline in asia (adb, ). between , and , migrant nepalis entered nepal from india via land borders, and this migration had been the main coping mechanism, especially for the food-deficit and food-insecure households in karnali and sudur pacchim province. nepal government estimated that of about . million nepalis working in gulf and malaysia, about . million migrants are estimated to return due to covid- (acaps, ) . by september, however many migrants who had returned from india started going back to india again despite the increasing threat of covid- there (ayer, ) . these migrants, which were mainly from karnali and sudur pacchim province, reported j o u r n a l p r e -p r o o f that they could not sustain their livelihoods in their villages. this clearly showed that poorer people are more worried about food and livelihood than the covid- infection itself. gender dimension has emerged as a crucial issue in the analysis of vulnerability and safety net. this pandemic brought to light various unseen dimensions of the gender issues that made women further vulnerable in such crisis, for instance increase in women"s workload at home and decline in their income from wage work or sale of vegetables and milk. digital illiteracy and lack of driving skills also made them more vulnerable (barooah et al., ; ghale, ) . in quarantine/isolation too, women were not given food that is nutritious to their specific requirements, suffering badly the health of pregnant and lactating women and weaning children. domestic violence against women has increased rapidly (by %) since this pandemic started (ghale, ) . in dang district in province , women reported higher income losses leading to more often having insufficient food, eating less, skipping meals and going hungrier than their male counterparts during the pandemic (barooah et al., ) . the main coping mechanisms for income losses were the reliance on savings ( % of respondents) and borrowing funds ( %). another issue regarding the access to food was related to its distribution. whatever small relief the government provided was confined mainly in cities, and was marred by lack of information as to who is vulnerable and who is entitled or not. as a result, conflicts were witnessed among the people and between poorer people and relief agencies. a lesson was learned that it is wise to support everyone who comes to line for taking the minimum basic food. during the pandemic, a few issues about the sanitation of food, and contamination and decaying of food emerged. for example, people were confused about how to sanitize the food that was obtained from the market or touched by many people. availability of and access to vegetables, fruits and other nutrient-dense foods were limited, and whatever came to the market, it was sold without cleaning following safety and sanitization standards. harris et. al. ( ) report similar situation in india. foods distributed as relief package consisted only rice and pulse, and, as reported by authors working at the grassroots, it was often found to be contaminated, decayed, or of sub-standard quality. the chronic problem of malnutrition among children and women was exacerbated by covid- . children"s immunization and safe birth in hospital was compromised, leading to health problems in these groups (singh et al., ) , impacting food utilization. the pandemic has given a lesson to the policy makers that preparations are to be made for the unexpected events of vulnerabilities, especially about the need to keep higher amount of food stock. the immediate action of the government has, of course, been focused on supporting the people and in increasing food production in the next cropping season. a major issue that emerged from discussions and key informants in this regard was the small amount of buffer "food stock" that government maintained, and whatever was there was just meant for regular food-aid to some food insecure regions, mainly the karnali province. j o u r n a l p r e -p r o o f aside from undp ( ), there is still no systematic impact assessment of covid- on poverty, food security, and wellbeing in the country. our study pointed to some important directions as to what should be the policy choices and institutional mechanisms to deal with such problems based on the panel discussions, field observation, and information obtained from key informants and secondary sources. nepal has several active policies for agriculture and food security that emphasize right to food. key informants and discussants emphasized that these policies have not anticipated disasters like covid- pandemic, and so there were no preparations to deal with such crisis. the right to food and food sovereignty act and zero hunger policy provide strong support for the achievement of sdgs - , but they lack concrete action plans to improve food availability, access and utilization, and strategies to deal with crises like epidemics or pandemics. apart from strengthening safety net, nepal needs to increase food production in the smallholders through provision of appropriate inputs and build marketing networks that work even during such crisis. lack of this support mechanism had led to abandonment of cultivation from about % of the cultivated land. key informants indicated that some of these lands are already being utilized by returnee migrants in the recent rice season. with appropriate policies and support, remaining fallow lands could be brought back into cultivation, which would also help in conserving traditional and indigenous food system with positive consequences on food diversity, biodiversity and maintenance of food culture. immediately after the lock down, there was a shortage of food in the market. government did not have enough food-stock for food distribution to so many people in urban areas, especially to daily wageworkers. in addition, food had to be supplied to food dependent regions like karnali. as a policy option, the panel discussions, especially the last one, emphasized a much larger amount of food to be kept as "buffer stock" for the emergencies like this. nepal food corporation that maintains the buffer stock for public distribution and for emergencies has been keeping around thousand tons of food against a minimum required thousand tons. but emergencies like a drought and pandemic would mean such stock should be around to thousand tons (himalayan news service, ). moreover, a diversified mixture of food has to be kept in food reserve. as of now, it is only rice that is being kept as reserve with a small amount of lentil. as a result, food obtained from public distribution, as was the case in this pandemic, is generally of low nutritional value. a large stock would also make the food price more stable, and safety net wider and strong. it is also one of main indicators highlighted for monitoring food system disruption caused by covid- in bangladesh (amjath-babu et al. ). the covid- pandemic also revealed that it is important to identify, collect, conserve and research the indigenous species of crops, animals and other useful plants and promote the resilience aspects of subsistence farming especially in the hills and mountains to achieve resiliency at the time of future shocks due to climate or pandemics while also promoting commercial or semi-commercial farming to achieve food sufficiency. among the innovations made during the pandemic for increasing production, it is helpful to continue three innovations, which were found to be effective. the first innovation is providing support for mechanization that is suitable to the terrainlike larger machines (tractors and harvesters) in terai and small machines for seeding, plowing and threshing in the hills (paudel et al., ) . because of migration of young people, there is labour shortage in farming, and such mechanization helps in coping with such shortages, and makes farming less drudgery, especially taking into women"s heavy involvement in farming. the second innovation of cash support for bringing fallow lands into cultivation was found to be promising, which called for more funds j o u r n a l p r e -p r o o f allocation to local governments for this purpose. as a matter of fact these two polices would help in bringing abandoned farmland into cultivation. if the currently abandoned land is brought under cultivation and the rest of the farmland is intensively cultivated, nepal"s desire to become selfsufficient in food could be achieved. the third innovation in relation to digital marketing that connects local producers and consumers as implemented in few sites deserve further developments and up-scaling (see kumar et al., in case of india). sincere implementation of these policies is also equally important, as many good policies have not been implemented in the past. accordingly, good institutional infrastructures and governance structures are to be set-up so that these policies are effectively implemented and would enable nepal to achieve sdgs and by maintaining all four pillars of food security even during crisis times like covid- pandemic. migrant vulnerability in bangladesh, india and nepal. covid- and labour migration a future in farming. the record nepal vegetables worth millions rotting in farms amid lockdown in dhading covid- : why nepal"s farmers should have sustained cereal production key indicators for monitoring food system disruptions caused by the covid- pandemic: insights from bangladesh towards effective response nepali migrant workers start returning to india amid covid- threat in lack of job at home covid- challenges to equity: insights from rural nepal and senegal what is the role of community seed banks: lessons from the covid- epidemic coping strategies of smallholder farming communities after the nepal earthquake: insights into post-disaster resilience and social-ecological change national sample census of agriculture the economic lives of smallholder farmers: an analysis based on household data from nine countries the resilience of valencia"s "l"horta" in times of covid- child malnutrition and covid- : the time to act is now . i am saving vegetables in kitchen fifteenth plan nepal sustainable development goals: status and roadmap lessons from the past, policies for the future: resilience and sustainability in past crises food system disruption: initial livelihood and dietary effects of covid- on vegetable producers in india diversify food buffer stock to tame inflation will a hunger pandemic follow in the mountains? curbing-impacts-covid- -nepals-small-scale-farmers-seizing-oportunities-for-foodsystem-reform how indian agriculture should change after covid a framework to assess the resilience of farming systems formation of rapid response team food security policy ministry of agriculture and livestock development state of food security and nutrition in the world report: rising hunger and covid- present formidable challenges lockdown leaves chitawan dairy farmers lamenting scale-appropriate mechanization impacts on productivity among smallholders: evidence from rice systems in the midhills of nepal impact of covid- pandemic on socioeconomic and mental health aspects in nepal nepal"s fertiliser conundrum-governments ponder over it every paddy season and then forget after harvest. the kathmandu post the impact of covid- on households in nepal: second round of mvam household livelihoods, food security and vulnerability survey nepali farmers fight to save indigenous seeds food shortage looming large in mugu, dolpa districts of karnali province nepal covid- : food security and vulnerability update the perils of covid- in nepal: implications for population health and nutritional status covid- -nepal-where-are-we-after- -weeks-lockdown editorial: impacts of covid- on agricultural and food systems worldwide and on progress to the sustainable development goals food insecurity increased to percent; karnali most vulnerable how does transnational labour migration shape food security and food sovereignty? evidence from nepal impact of covid- lockdown on agriculture education in nepal: an online survey impact-of-covid- -on-nepal"s-agriculture-the-road-ahead envision : goals to transform the world for persons with disabilities rapid assessment of socioeconomic impact of covid- in nepal covid- : number of children living in household poverty to soar by up to million by end of year young country, fallow lands. the kathmandu post against-all-odds-what-driving-poverty-reduction-nepal covid- will double number of people facing food crises unless swift action is taken covid- coronavirus pandemic berrang-ford, l., the indigenous health climate change and covid- : reinforcing indigenous food systems we acknowledge nepalese association of agriculture, forestry and environment in australia (nepafe) for hosting the panel discussions and the institute for study and development worldwide (ifsd), sydney for in-kind support in literature review, virtual discussions, and interviews. we thank all participants from various countries for their participation and contribution in the discussions. we especially thank hom pant for his substantive inputs during and after the panel discussions. key: cord- -g i b authors: niles, meredith t.; bertmann, farryl; belarmino, emily h.; wentworth, thomas; biehl, erin; neff, roni title: the early food insecurity impacts of covid- date: - - journal: nutrients doi: . /nu sha: doc_id: cord_uid: g i b covid- has disrupted food access and impacted food insecurity, which is associated with numerous adverse individual and public health outcomes. to assess these challenges and understand their impact on food security, we conducted a statewide population-level survey using a convenience sample in vermont from march to april , during the beginning of a statewide stay-at-home order. we utilized the united states department of agriculture six-item validated food security module to measure food insecurity before covid- and since covid- . we assessed food insecurity prevalence and reported food access challenges, coping strategies, and perceived helpful interventions among food secure, consistently food insecure (pre-and post-covid- ), and newly food insecure (post covid- ) respondents. among respondents, there was nearly a one-third increase ( . %) in household food insecurity since covid- (p < . ), with . % of food insecure households classified as newly food insecure. respondents experiencing a job loss were at higher odds of experiencing food insecurity (or . ; % ci, . – . ). we report multiple physical and economic barriers, as well as concerns related to food access during covid- . respondents experiencing household food insecurity had higher odds of facing access challenges and utilizing coping strategies, including two-thirds of households eating less since covid- (p < . ). significant differences in coping strategies were documented between respondents in newly food insecure vs. consistently insecure households. these findings have important potential impacts on individual health, including mental health and malnutrition, as well as on future healthcare costs. we suggest proactive strategies to address food insecurity during this crisis. the global covid- pandemic, and social distancing efforts implemented to slow its spread [ ] , have disrupted economies and food systems globally and locally, with extensive food security ramifications. food insecurity-the lack of consistent physical, social, and economic access to adequate and nutritious food that meets dietary needs and food preferences [ ]-can lead to serious public health consequences. in , . % of american households were considered food insecure at some very low food security ( to affirmative answers) can be combined and referred to as having food insecurity [ ] . in addition to measuring food security status, the survey also included additional questions related to food access challenges, use of food assistance programs, food purchasing behaviors, concerns about food access and availability, covid- perceptions, and behaviors and demographics. table a details the specific questions utilized in this analysis, which are primarily focused on understanding the relationship of food security status to food access challenges, use of food assistance programs, and concerns about food access and availability. future analyses will explore other questions in the survey. to examine differences in household food insecurity during the first weeks of the covid- pandemic, we created three categories of respondents: ( ) households with food security (n = , including households food secure before and since covid- and households who were food insecure at some point in the year before covid- , but were no longer food insecure during covid- ); ( ) households with consistent food insecurity (n = , both food insecure before covid- and remaining food insecure since covid- ); ( ) households with new food insecurity (n = , categorized as food secure before covid- , but food insecure since . in some cases, we refer to food insecure households, which encompass both consistently food insecure households and newly food insecure households. to determine statistically significant differences between groups we utilized stata [ ] , to run kruskal-wallis tests, wilcoxon rank sum tests, t-tests, and one-way analysis of variance (anova) tests, depending on the distribution of the dependent variable. we used a logistical regression model to determine the factors correlated with food insecurity during the covid- pandemic, with coefficients reported in odds ratios. in this model, we estimate food insecurity outcomes during covid- , including respondents who were classified as either consistently food insecure or newly food insecure. we used all available data to estimate effect sizes and interactions and assumed any missing data were missing at random. reflecting the demographic composition of vermont [ , , ] , the majority of respondents identified as non-hispanic white, lived in rural areas, and had a household income below $ , ( table , table a ). women encompassed % of our sample, which may be reflective of the fact that women are the dominant food shoppers in households [ ] . we found a nearly one-third increase ( . %) in food insecurity prevalence (p < . ) between the year preceding the covid- outbreak, when . % of households ( % ci . - . %) reported experiencing food insecurity at some point, and since the covid- outbreak when the percentage rose to . % ( % ci . - . %) (table a ). among those experiencing food insecurity since the outbreak, . % also experienced food insecurity at some point in the year prior to covid- , and were also food insecure since covid- ; in comparison, . % were newly food insecure. in consistently food insecure households, . % exhibited very low food security since covid- (marked by disrupted eating patterns and reduced intake), while . % had low food security. in newly food insecure households . % exhibited very low food security, while . % had low food security (table a ) since covid- (p < . ). multivariable logit models predicted the factors contributing to higher odds of food insecurity during covid- (e.g., both consistently food insecure respondents and newly food insecure respondents) ( table ). note that we also ran a multinomial logit model to examine whether there were statistically significant differences in newly versus consistently food insecure respondents, which there were not (table a ) . respondents experiencing a job loss had three times greater odds of living in a household experiencing food insecurity (or . ; % ci, . - . ), and those experiencing a furlough (or . ; %ci, . - . ), or a loss of hours (or . ; % ci, . - . ) also had significantly greater odds of being in a household experiencing food insecurity (p < . ). the odds of experiencing food insecurity since the covid- outbreak were higher among households with children (or . ; % ci, . - . ), while households with higher incomes had reduced odds (or . ; % ci, . -. ) (p < . ). finally, women were % more likely to experience household food insecurity during covid- , compared to men (p < . ) (or . ; % ci . - . ), while a college degree (or . , % ci . - . ) was associated with reduced odds of household food insecurity (p < . ). respondents indicated multiple physical and economic barriers to food access during covid- , with respondents experiencing household food insecurity significantly more likely to express greater access, availability, and utilization challenges than respondents in food secure households (p < . ) ( figure , table a ). these challenges included not finding as much or the kinds of food that someone wanted, going to more places than usual to find food, and not being able to afford the food a household wanted. challenges also included those related to food assistance, including at food pantries and through school food programs. consistently food insecure households had a higher average prevalence of food access challenges, as compared to those in newly food insecure households including trouble affording food (p < . ), getting food through a food pantry (p = . ), and knowing where to find help for getting food (p < . ). households with children (or . ; % ci, . - . ), while households with higher incomes had reduced odds (or . ; % ci, . -. ) (p < . ). finally, women were % more likely to experience household food insecurity during covid- , compared to men (p < . ) (or . ; % ci . - . ), while a college degree (or . , % ci . - . ) was associated with reduced odds of household food insecurity (p < . ). respondents indicated multiple physical and economic barriers to food access during covid- , with respondents experiencing household food insecurity significantly more likely to express greater access, availability, and utilization challenges than respondents in food secure households (p < . ) ( figure , table a ). these challenges included not finding as much or the kinds of food that someone wanted, going to more places than usual to find food, and not being able to afford the food a household wanted. challenges also included those related to food assistance, including at food pantries and through school food programs. consistently food insecure households had a higher average prevalence of food access challenges, as compared to those in newly food insecure households including trouble affording food (p < . ), getting food through a food pantry (p = . ), and knowing where to find help for getting food (p < . ). average frequency of challenging food access situations since covid- among respondents with household food security and food insecurity in a survey of vermont households, march-april, (p < . for comparison among all groups). standard errors shown with brackets. differences between newly and consistently food insecure shown through stars (*** p < . ), ** p < . ) and in table a . respondents experiencing household food insecurity during covid- (both newly and consistently food insecure) were significantly more likely (p < . comparison across all groups) to express higher levels of concern and worry about a variety of potential situations related to food access and covid- ( figure , table a ). these situations included potential for food to become more expensive and for households to have a decrease in income, not enough food, loss of access to food programs, and food availability and safety. as compared to newly food insecure households, consistently food insecure households were also significantly more likely to have higher levels of concern and worry about food access for all situations except for food becoming unsafe (p < . , table a ). nutrients , , x for peer review of march-april, (p < . for comparison among all groups). standard errors shown with brackets. differences between newly and consistently food insecure shown through stars (*** p < . ), ** p < . ) and in table a . respondents experiencing household food insecurity during covid- (both newly and consistently food insecure) were significantly more likely (p < . comparison across all groups) to express higher levels of concern and worry about a variety of potential situations related to food access and covid- ( figure , table a ). these situations included potential for food to become more expensive and for households to have a decrease in income, not enough food, loss of access to food programs, and food availability and safety. as compared to newly food insecure households, consistently food insecure households were also significantly more likely to have higher levels of concern and worry about food access for all situations except for food becoming unsafe (p < . , table a ). average level of concern for potential food access situations during covid- among respondents with household food security and food insecurity in a survey of vermont households, march-april, (p < . for comparison among all groups). standard errors shown with brackets. statistically significant differences were also found between newly and consistently food insecure in all cases except for "food will become unsafe" (shown through stars, *** p < . ), ** p < . , * p < . ) and in table a . households newly and consistently experiencing food insecurity were significantly more likely (p < . ) to be implementing coping strategies related to obtaining food as compared to respondents in food secure households. these strategies included those related to disrupted eating patterns (i.e., eating less), buying different, cheaper foods, accepting food from friends and family, and utilizing government programs, credit or food pantries ( figure , table a ). consistently food insecure households, as compared to those newly experiencing food insecurity, were also significantly more likely to currently accept food (p = . ) or borrow money from friends or family (p = . ), use a food pantry (p < . ) and use government assistance programs (p = . ), especially the supplemental nutrition assistance program (snap) (p < . ) (tables a and a ). average level of concern for potential food access situations during covid- among respondents with household food security and food insecurity in a survey of vermont households, march-april, (p < . for comparison among all groups). standard errors shown with brackets. statistically significant differences were also found between newly and consistently food insecure in all cases except for "food will become unsafe" (shown through stars, *** p < . ), ** p < . , * p < . ) and in table a . households newly and consistently experiencing food insecurity were significantly more likely (p < . ) to be implementing coping strategies related to obtaining food as compared to respondents in food secure households. these strategies included those related to disrupted eating patterns (i.e., eating less), buying different, cheaper foods, accepting food from friends and family, and utilizing government programs, credit or food pantries ( figure , table a ). consistently food insecure households, as compared to those newly experiencing food insecurity, were also significantly more likely to currently accept food (p = . ) or borrow money from friends or family (p = . ), use a food pantry (p < . ) and use government assistance programs (p = . ), especially the supplemental nutrition assistance program (snap) (p < . ) (tables a and a ) . households newly and consistently experiencing food insecurity were also significantly more likely (p < . across all group comparisons) to report an intention to implement these same coping strategies in the future for assistance with obtaining food during covid- . among food insecure households, those with consistent food insecurity were more likely to indicate that in the future they would accept food from friends or family (p = . ), use food pantries (p < . ), government assistance programs (p < . ), and to stretch the food they have by eating less (p = . ), as compared to newly food insecure households (table a ) . compared to food secure households, new and consistently food insecure households were significantly more likely (p < . ) to find strategies to address physical or economic food access challenges helpful during covid- (table a ) . these helpful strategies included extra money to help pay for food or bills, an increase in benefits of existing food assistance programs, greater trust in the safety of going to stores and food delivery, support for food delivery costs, more or different food in stores, and information about and help with food assistance programs, among others. consistently food insecure households were also significantly more likely than those in newly food insecure households to find access to public transit, extra money for food or bills, increased benefits of food assistance programs, information about food assistance programs (all p < . ), help with administrative food assistance problems (p = . ), and support for food delivery costs (p = . ) more helpful (table a ) . nutrients , , x for peer review of figure . prevalence of current coping strategies utilized by households with food security and with food insecurity during covid- in a survey of vermont households, march-april, (statistical differences among all groups p < . ). statistical differences between newly and consistently food insecure shown through stars (*** p < . ); ** p < . , * p < . ) and in table a . households newly and consistently experiencing food insecurity were also significantly more likely (p < . across all group comparisons) to report an intention to implement these same coping strategies in the future for assistance with obtaining food during covid- . among food insecure households, those with consistent food insecurity were more likely to indicate that in the future they would accept food from friends or family (p = . ), use food pantries (p < . ), government assistance programs (p < . ), and to stretch the food they have by eating less (p = . ), as compared to newly food insecure households (table a ) . compared to food secure households, new and consistently food insecure households were significantly more likely (p < . ) to find strategies to address physical or economic food access challenges helpful during covid- (table a ) . these helpful strategies included extra money to help pay for food or bills, an increase in benefits of existing food assistance programs, greater trust in the safety of going to stores and food delivery, support for food delivery costs, more or different food in stores, and information about and help with food assistance programs, among others. consistently food insecure households were also significantly more likely than those in newly food insecure households to find access to public transit, extra money for food or bills, increased benefits of food assistance programs, information about food assistance programs (all p < . ), help with administrative food assistance problems (p = . ), and support for food delivery costs (p = . ) more helpful (table a ). this statewide survey in vermont documented a statistically significant increase in food insecurity since the state's first reported case of covid- and the stay-at-home executive order (which began march , ). we demonstrate a nearly one-third increase in household food figure . prevalence of current coping strategies utilized by households with food security and with food insecurity during covid- in a survey of vermont households, march-april, (statistical differences among all groups p < . ). statistical differences between newly and consistently food insecure shown through stars (*** p < . ); ** p < . , * p < . ) and in table a . this statewide survey in vermont documented a statistically significant increase in food insecurity since the state's first reported case of covid- and the stay-at-home executive order (which began march , ). we demonstrate a nearly one-third increase in household food insecurity among respondents, with individuals experiencing job loss or disruption at significantly greater odds of experiencing household food insecurity since covid- , as compared to other demographic controls. further, we find that the majority of consistently food insecure households and nearly one-third of newly food insecure households were classified as having very low food security, marked by disrupted eating and cutting meals or going hungry. fully, two-thirds of vermont respondent households with food insecurity during covid- are already eating less to stretch their food. the findings indicate challenges to all food security dimensions, including economic and physical access, availability, utilization, and stability, and may have profound potential health impacts. we further demonstrate physical and economic barriers to food access during covid- and the respondents' coping strategies in food insecure households. previous research [ , ] suggests links between job loss and food insecurity, indicating that the profound increase in americans experiencing job loss and disruption [ ] will present acute and large-scale impacts across the population. since vermont unemployment claims reflect the national trend, these results likely reflect a broader u.s. phenomenon of rising food insecurity rates, evidenced by early non-peer reviewed studies [ , ] . in addition to these new economic barriers, the pandemic presents many new physical barriers for food access, reductions in public transportation, and new distribution models, and in a rural state like vermont, a lack of income for transportation costs including fuel. in rural areas where food assistance programs, such as food pantries, are limited, closures due to illness, social distancing, or lack of volunteers may be particularly challenging. this presents opportunities to expand food pantries and support mobile pantry units, as well as encourage the expansion of programs such as fruit and vegetable prescription programs, shown to positively affect food security [ ] and improve health outcomes [ ] . ultimately, this research demonstrates a need to increase food assistance programs and provide resources to remove food access barriers now, and likely in the future, during state and national economic and health emergencies. this rise in food insecurity presents many potential health impacts. food insecurity is negatively associated with health outcomes [ , ] and some evidence indicates it is positively associated with poor diet quality [ , ] . further, higher rates of anxiety and mental health disorders among children and adults have been documented in food insecure households [ , ] . indeed, survey respondents in this study experiencing household food insecurity demonstrated significantly higher rates of concern and worry about food. disrupted eating, found in two-thirds of respondent households with food insecurity, is associated with decreased immune function and can negatively impact mental and emotional health [ ] . further research is needed to understand how food insecurity during the covid- pandemic relates to diet quality, particularly if disrupted eating patterns persist and increase. healthcare providers can address food insecurity through simple interventions. screening for food insecurity and providing resources now may reduce short-and long-term consequences, including the potential long-term impacts on child health outcomes associated with the duration of household food insecurity [ ] and higher health care expenditures associated with food insecurity [ ] . the hunger vital sign, a validated two-question food insecurity screening tool based on the usda household food security survey module [ ] , can quickly determine risk for food insecurity in clinical and community settings. this tool is widely utilized, especially in pediatrics [ , ] , and could be made standard in health care and other service settings during covid- and beyond. providers could refer families in need to locally available resources or to united way, which aggregates these resources locally. however, during this heightened time of unemployment, there is also potential for government agencies, particularly those distributing unemployment benefits, to help connect families in need to available resources as well. importantly, this research demonstrates there are still a significant number of food insecure households which, even if aware of food assistance programs, may not use them. low rates of seeking assistance in our results, especially among newly food insecure households, may be partly related to the stigma associated with assistance programs [ , ] . prior research suggests that populations living outside major metropolitan areas may be more likely to use friends and family for support [ ] and to see government assistance programs as a "last resort" [ ] . however, with social distancing and widespread financial challenges, such personal safety nets may be eroded, and these households may be particularly vulnerable. additional research is needed to understand the barriers to using food assistance programs, especially among those that may be newly food insecure since covid- . this study suggests some of the first population-level impacts of covid- and social distancing policies on food insecurity. the limitations are partly rooted in the need to rapidly administer this survey in the early days of the pandemic, to provide data that can be tracked over time. though our respondent population matches statewide census statistics closely on many metrics, this was a convenience sample; further research is expanding these results using similar questions with representative samples across states and populations. it is worth noting that our observed overall rate of food insecurity prior to covid- ( . %) is above the most recently available state figure ( . %) in . there are potentially multiple reasons for this. first, this is likely to be due, in part, to a higher than average number of female respondents and respondents in households with children; both groups have been documented, in vermont and elsewhere, to have elevated rates of food insecurity [ ] . second, our measurement instrument for documenting food security, the usda -item food security module, includes a subjective experience domain that measures concern about household food supplies. according to the local media [ ] , anxiety about household food supplies nutrients , , of preceded the stay home/stay safe order and may explain the higher than expected level of food insecurity prior to covid- . further, we used an internet-based survey, given the necessity of social distancing during covid- and the need for a rapid response, which may limit the capacity of some people to participate, although % of vermonters do have internet plans [ ] . the study's strengths include its large sample size, early administration, population-based assessment, and survey instrument addressing the multiple dimensions of food security. we implemented this survey in the beginning of a stay at home order and covid- economic impacts. as such, it is likely that many respondents experiencing job loss or disruption had not yet received unemployment benefits and federal stimulus checks were not distributed. future research will examine the evolution of food security impacts, and how various interventions, including the care act and unemployment benefits, as well as food assistance expansion and health care screenings, may affect food insecurity outcomes as covid- unfolds. since the coronavirus outbreak (march th), how often did these happen to your household? = never, = sometimes, = usually, = always, not applicable could not afford the amount or kind of food my household wanted to buy could not find as much food as i wanted to buy (e.g., food not in store) could not find the kinds of food my household prefers to eat delivered food to a friend, neighbor, or family member had challenges getting food through a food pantry had challenges getting food through a school food program had challenges knowing where to find help for getting food had to go to more places than usual in order to find the food my household wanted had to stand "too close for safety" to other people, when getting food (less than six feet) table a . cont. on a scale from (not at all worried) to (extremely worried), what is your level of worry for your household about the following as it relates to coronavirus. = not at all worried, = extremely worried, not applicable there will not be enough food in the store food will become more expensive for my household food will become unsafe my household will lose access to programs that provide free food or money for food my household will have a decrease in income and won't be able to afford enough food my household won't have enough food if we have to stay at home and can't go out at all what, if anything, would make it easier for your household to meet its food needs during the coronavirus pandemic? = not helpful, = somewhat helpful, = helpful, = very helpful, not applicable access to public transit or rides different hours in meal programs or stores extra money to help pay for food or bills help with administrative problems (like applying for food assistance) increase benefits of existing food assistance programs (like snap or wic) information about food assistance programs or food pantries more (or different) food in stores more trust in safety of food delivery more trust in safety of going to stores support for the cost of food delivery the base outcome comparison is food secure households. we find no significantly differences between the factors predicting food insecurity since covid- for newly or consistently food insecure households, so report the combined results of a multivariable logit model in the main results of both newly and consistently food insecure households together. interventions to mitigate early spread of sars-cov- in singapore: a modelling study. lancet infect. dis. . 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shelves empty we would like to thank those who assisted in the dissemination of the survey including key: cord- -rc epbnn authors: xie, jingyi; xu, yan; li, haixiao title: environmental impact of express food delivery in china: the role of personal consumption choice date: - - journal: environ dev sustain doi: . /s - - - sha: doc_id: cord_uid: rc epbnn the online food ordering business in china is developing rapidly in recent years with considerable environmental impacts. however, the impacts caused by the express food delivery and the differences between the regions with different economic levels have seldom been quantified. changing personal consumption behavior might help to reduce such impacts. but to what extent personal consumption changing could alter the environmental impacts caused by express food delivery remained uncertain. thus, we have conducted a quantitative study based on the data collected from a -persons survey to determine the environmental impacts caused by the express food delivery in the different regions of china. additionally, the reducible environmental impacts were estimated by establishing a scenario of personal consumption behavior changing. the results showed that each express food delivery order would generate . g co( ) emission equivalent on average. most ( %) of the co( ) equivalent of the express food delivery came from the food packages. compared to the orders in the second-class and third-class cities, the orders in the first-class cities had a significantly higher co( ) equivalent due to the greater use of food packages. the results also demonstrated that by walking to take the food in the restaurants nearby (< km), % of the co( ) equivalent derived from the express food delivery could be reduced. people’s willingness to change consumption behavior plays an important role to achieve the environmental impact reduction. in the year of , the environmental writer colin beavan has published his book "no impact man" in which the author has shared the experience of how his family passed one-year eco-friendly living. one of their efforts was to consume locally on foot for food products in order to reduce the environment impact caused by the transportation and packages of goods. however, after eight years it has been difficult to achieve buying locally on foot in china. global and regional food trade has made our markets full of unlocal foods. according to the data of from wits (world integrated trade solution), china spent million, million, and million dollars for the global trade for food products, animals, and vegetables, respectively. thus, a great amount of food in our markets comes from the import with long-distance transportation. in addition, the client's demand for food inside country also requires a number of logistics transportation. based on the chinese national logistics operation report for , the total expenditure of agricultural product logistics was billion yuan, viz. billion dollars. even so, clients could still go to markets or groceries and choose to buy the foods produced in the regions closed to their cities and counties. but with e-commerce development soaring by the days, it seems clients in china are also losing their "mobility" on foot to consume foods. instead, people prefer to order express food delivery using some apps (e.g., meituan and eleme) on the cell phones (liu & chen ) . the results of daxue consulting on the chinese market in have demonstrated that the worth of china's delivery food market was estimated to be over billion dollars with a quarter of chinese clients ( million) ordering food on the cell phones. the huge economic benefits in the food transportation and the delivery market would lead to considerable environmental impacts (eis). distant food transport is a major contributor to fuel using pollution and greenhouse gas emission (norberghodge et al. ) . in the usa, transporting food within the nation's borders accounts for over % of all commodity transport, and results in at least million tonnes of co emissions every year (norberghodge et al. ) . considering the greater population in china, the amounts of co emissions caused by distant food transport could reasonably be greater than that of the usa. in addition to fuel using pollution, food delivery is also proved to have other huge environmental costs, like package material cost. in , the chinese express delivery industry, including food delivery, accomplished a total of . billion express delivery orders and consumed approximately . billion package boxes, . billion plastic bags, . billion woven bags, . billion envelopes, and . billion meters of tape accounting for . × kg co emission with other pollutants . it was reported that takeaway food consumption can generate tonnes of food wastes and approximately . billion wasted meal boxes and plastic bags per day in china (liu & chen ) . moreover, gallego-schmid et al. ( ) mentioned that the single-use food containers are quite environment influencing, by considering environmental impacts, including element cycles, fossil resources, global warming, human toxicity, ecotoxicity, etc. many technical strategies are being taken to reduce the eis of global and regional food transport, such as the optimization of food logistics (guo et al. ) . the efforts are also made in management strategies, such as the implementation of green supply chain management (wang et al. ) and sustainable supply chain management (rajesh a) . those technical and management strategies would confront several barriers to overcome, including the lack of adequate training and progress monitoring, poor customer awareness, and lack of pressure for widespread adoption. therefore, those approaches would take a long time to have considerable effects on the reduction in eis caused by global food trade and transport and would not be a personal work. on the other hand, individual efforts should not be ignored in reducing the eis of food transportation and delivery. urien and kilbourne ( ) mentioned that consumption in industrial countries is the main cause of environmental problems. thus, a change in consumption behaviors in our daily life might be possible to create sustainability of the food market, especially when ordering express food delivery is now becoming the lifestyle of chinese people. if they reduce the frequence of ordering express food, it will definitely have a positive effect on reducing the eis caused by food delivery and packages. the willingness to change personal consumption would be the key to accomplish such an effort. prothero et al. ( ) mentioned that only % of consumers who said they were willing to consume greenly would actually fulfill their willingness. in that case, understanding the potential of reducing the eis of express food delivery via changing personal consumption and whether it is worthy to conduct the consumption behavior changing might help people to fulfill their willingness of consuming greenly. therefore, this study aims firstly to conduct a quantitative analysis to show the magnitude of eis of express food delivery could be reduced by changing consumption behavior. the data for the quantitative analysis were collected by a -persons survey on the information in their cell phone food ordering apps. then, whether the scenario of consumption behavior changing and the reduction in eis are possible and worth being conducted is discussed by considering people's preference over environment quality and other material welfares. at the macro-scale, the eis of consumption and production could be assessed by the methodologies of environmentally extended input-output tables, process-based life cycle assessment, and hybrid methods (lorenzo et al. ) . those methods have been successfully applied to estimate the different categories of eis of consumption and production in multi-regions. for example, ivanova et al. ( ) had used the exiobase . multiregional input-output database to estimated four eis of carbon footprint, land footprint, material footprint, and water footprint for countries in the world. while beylot et al. ( ) added the elementary flow to the exiobase to estimate eis of consumption in countries of eu, including acidification, terrestrial eutrophication, marine eutrophication, freshwater eutrophication, land use, water use, non-cancer human toxicity, cancer human toxicity, freshwater ecotoxicity, particulate matter, photochemical ozone formation, climate change, fossil resource use, mineral and metal resource use. however, the ei estimation of the express food delivery could be simplified. the local express food delivery does not need to take the multi-region effects into consideration. in addition, there is no need to consider the various categories of environmental impacts for the express food delivery. it is because that the only input-output flows of materials for the consumption demand of express food delivery are the energy used for delivery transport and the materials for food containers, while both of them could be easily converted into carbon footprint or material footprint. the details of the methods are described in the following sections. the data collection was conducted via an enquiry invitation on the social software wechat during a period of two weeks from june to july, . in total, persons from chinese cities (tianjin, haikou, xiaogan, wuhan, hangzhou, beijing, changsha, ningbo, shanghai, shenzhen, zhuhai, nanjing, fuzhou, yanglin, xi'an, suizhong, ha'erbin, qingdao, huhehaote, taiyuan, guilin, lipu, zhenjiang) have responded to the enquire. the participants were asked to provide their express food delivery data by sending us the captured figures of food orders from the food ordering apps (ele.me and meituan) containing the information of restaurant location, delivery destination, and order contents. at most ten recent express food orders were collected from each person, and in total sets of data were recorded. for each data set, the delivery distance between the restaurant location and the delivery destination was deemed on the site of amap (https ://www.amap.com). the information of food package materials and amounts was figured out via the food order contents and the description of the participants. the eis of express food delivery mainly consists of fuel consumption during delivery and the usage of food packages . the fuel consumption is calculated from a delivery distance. the usage of food packages is first figured out by the order contents, and the eis of each sort of material is calculated separately. to facilitate the calculation, the environmental impact equivalent used in this study was the co emissions equivalent (co -eq). the express food is mainly delivered by electric motorcycles. the common bands of electric motorcycles in china are tailing (https ://www.tailg .com.cn/), yadea (https ://www. yadea .com.cn/), and aima (https ://www.aimat ech.com/). according to the parameters of electric motorcycles on their sites, most motorcycles equipped with the v ah battery (total power about . kwh). in general, the travel distance for those motorcycles is - km. therefore, the electric motorcycle would consume . - . kwh of electricity per kilometer. although electric motorcycle may not generate co emission by not using mineral fuel as power, the generation of electricity could cause co emission. according to ang and su ( ) , the average co emission of electricity production over the world in was g co per kwh. the electricity production from coal power plants would cause a great proportion of co emission. in , about % of total electricity was produced by thermal power generation over the world (ang & su ) . they had a low generation efficiency of % and a high co emission of g per kwh. several technologies have been applied to reduce the co emission for electricity generated from coal. for instance, the approaches of pulverized fuel combined with flue gas desulphurization and integrated gasification combined cycle could reduce the co emission of coal-generated electricity to g and g co per kwh (sims et al. ) . those technologies as well as the other electricity sources of nuclear power, hydropower, eolien power, and solar energy contributed to reducing the average co emission to g co per kwh. since in , . % of total electricity was produced by thermal power generation in china (data from china electricity council), which was similar to the global situation in . so, in this study, the co emission per kwh could be deemed at g for the electricity consumption impact calculation of the food delivery. in terms of the transport distance, it firstly depends on the delivery distance, viz. the distance between the restaurant and the delivery destination. in general, the delivery rider would stay close to the commercial center where the restaurants located. so, for a single order, the transport distance could be simply calculated as twice as the delivery distance. however, several orders could share the same routing due to the uncertainty of the coming orders, which could decrease or increase the transport distance. according to the survey of delivery riders conducted by liu et al. ( a, b) , . % of the total orders could share delivery and . % of the total orders would need a single delivery. in general, there might be - orders for sharing. thus, the transport distance for each order could be estimated as follows: where d is the transport distance; d is the delivery distance; α is the proportion of orders sharing a delivery; β is the proportion of orders taking a single delivery; n is the average number of orders sharing a delivery. in this study, α, β, and n are deemed at . %, . %, and . %, respectively. hence, the environmental impact (co -eq) caused by fuel consumption of delivery is calculated as follows: where e delivery is the environmental impact caused by fuel consumption of delivery; d is the delivery distance; e is the electricity used by electric motorcycle per km; c electricity is the co emission caused by electricity generation of kwh. in this study, e and c electricity are deemed at . kwh km − and g co kwh − , respectively. another part of the eis caused by express food delivery come from the food packages. those impacts were generated by raw material fabrication, package production, transportation, and use . during the life time of food packages, a lot of harmful compounds, such as heavy metals, co , fluoride, no , so , methane, pm . , and radioactive emission, will be emitted to the environment. among these harmful compounds, the amount of co is at least two magnitudes higher than any of the other compounds . therefore, the co emission could approximately represent the eis of the express food packaging. in order to deliver the food steadily, the restaurants usually chose plastic bags, plastic boxes/bowls, paper bags, and paper boxes as food containers. barrett et al. ( ) have listed the carbon footprint for the consumption of different types of plastics by considering its production and transportation: . kg co per kg plastic film, . kg co per kg plastic drink bottles (pet), . kg co per kg food packaging (ldpe), and . kg co per kg dense plastic (hdpe). the co -eq of plastic usage has been reduced in recent years. according to the study of muthu et al. ( ) in china, the co -eq of plastic bags is . kg co per kg plastic. whereas, the co -eq of paper bags is . kg co per kg paper. those values were used for the calculation of food package eis in this study. the total amounts of plastics and papers used for each order were first figured out based on the order contents, and then, their co -eqs were calculated. the average weights of the plastic bag, plastic box/bowl/cup, paper bag, and paper box/bowl are deemed at g, g, g, and g per each, respectively, according to the data offered by the merchants on alibaba (https ://www.aliba ba.com). besides food packaging, disposable chopsticks should be taken into account to calculate the eis of the express food packages. china's annual consumption of disposable chopsticks is billion pairs, which brings carbon emissions for . million kg (chen ) , viz. . g co per pair of disposable chopsticks. in addition, a part of the packages could be recycled. for instance, in the european union, % of the express food containers made of pp were recycled, while % went to incineration and % went to landfilling (gallego-schmid et al. ). the recycling rate of papers could be higher than that of plastics. the recycling process could contribute to reducing the eis caused by the raw materials of plastics and papers, such as oil extracts for plastic production. however, the recycling of plastics and papers also generates co emission. so, it is difficult to quantify precisely the effects of recycling on the eis of plastic and paper food packages. thus, in this study, we did not take the recycling of plastics and papers into account. the environmental impact of the food package was calculated as follows: where e package is the environmental impacts caused by food package; m plastic and m paper are the amounts of plastics and papers used for one order on gram; c plastic and c paper are the co -eqs caused by production, transportation, and use of plastics and papers; p is the pairs of disposable chopsticks used in one order; c chopsticks is the co -eq caused by production, transportation, and use of chopsticks. in this study, c plastic , c paper and c chopsticks are deemed at . g co g − plastic, . g co g − paper, and . g co per pair of chopsticks, respectively. in this study, we shall not discuss thoroughly replacing the express food delivery by homemade dishes for the sake of reducing its eis, since it is difficult to fulfill. we considered that the food delivery activity could be replaced by walking to the restaurant to have the same or similar food in place. in that case, the eis of food delivery and food packages might be reduced. in terms of consumers' willingness to walk for consumption, yang and diez-roux ( ) have conducted a study showing that % of clients willed to a walking trip of . miles ( . km), % of walking trips were more than . miles ( . km), and % of walking trips were more than mile ( . km). on average, the distance of walking trips for consumption might be at least . km. we assumed that the walking trips for the restaurant could probably not be stout of line compared to other purposes. accordingly, in this study, we have created a scenario that the consumers are willing to walk about km to have the food rather than ordering express food delivery. for each order, we searched the area within km away from the delivery destination in gaode map (https ://ditu.amap.com) to find whether there was a restaurant offering the similar foods as the order. if there was such a restaurant, the environmental impact caused by food delivering and packaging could be reduced via walking to have food in place. but e package = m plastic * c plastic + m paper * c paper + p * c chopsticks for the fast foods, the environmental impacts from packages cannot be reduced even when eating in place. the reduction in eis was calculated by the methods mentioned in sect. . . the average values of delivery distance, plastic package amount, paper package amount, disposable chopstick pairs, co -eqs of express food delivery order (including those of food delivery, food package, and the total value), and possibly reducible co -eqs (including those of food delivery, food package, and the total value) by walking to restaurant and having food in place were calculated for all the orders. additionally, in order to compare the different situations of express food ordering in the areas with different economic development levels, the data were categorized into three groups, which were the orders from first-class cities (beijing, shanghai, and shenzhen as the new first-tier cities in china), second-class cities (tianjin, wuhan, hangzhou, changsha, ningbo, nanjing, xi'an, qingdao as the new first-tier cities), and third-class cities (haikou, xiaogan, changsha, zhuhai, fuzhou, yanglin, suizhong, ha'erbin, huhehaote, taiyuan, guilin, lipu, zhenjiang as other cities), respectively. the anova was conducted using the mixed procedure in sas . (sas institute inc., usa) to study the effects of city groups on the variables of express food delivery eis. the effects of city groups were the fixed effects, and the effects of survey participants were considered as the random effects. city groups' effects were deemed significant when p < . . differences of each variable among the city groups were identified by multiple comparisons with test tukey using the lsmeans statement in sas . . the differences between variables of different city groups were significant when p < . . according to the results, one express food delivery order on average required a delivery distance of . km and generated . g co -eq for the food delivery (table ) . taking different classes of cities into consideration, there was no significant difference between the average delivery distances for first-class cities ( . km), second-class cities ( . km), and third-class cities ( . km) (table ) . thus, co -eqs for the food delivery between three city groups shared similar patterns with no significant difference observed. overall, . % of the orders had a delivery distance shorter than km, while . %, . %, . %, . %, and . % of the orders had a delivery distance of - km, - km, - km, - km, and over km, respectively (fig. ) . it should be noted that even having the smallest average delivery distance, third-class cities had a smaller proportion ( . %) of orders with delivery distance inferior to km in contrast with those of first-class cities ( . %) and second-class cities ( . %). whereas for second-class cities, there was a higher proportion of orders with delivery distance over km ( . %) than those of firstclass cities and third-class cities ( . % and . %, respectively). average values of delivery distance, plastic package amount, paper package amount, disposable chopstick pairs, co equivalents of express food delivery order (including those of food delivery, food package, and the total value), and possibly reducible co equivalents (including those of food delivery, food package, and the total value) by walking to restaurant and having food in place for all the orders, and the orders from first-class cities, second-class cities, and third-class cities *the value after ± is the standard error different letters after the values indicate the significant difference (p < . ) between the different classes of cities delivery distance (km) in terms of food package, each order costed . g of the plastic package, . g of the paper package, and . pairs of chopsticks (table ). the usage of those packages could generate . g co -eq per order. the orders in the first-class cities used significantly higher amounts of plastic and paper packages ( . g and . g per order, respectively) than those in second-class cities and third-class cities (table ). in addition, . % and . % of the express food packages were made of paper in the first-class cities and the second-class cities, respectively, and the value of the third-class cities was only . % (fig. ) . but there was no significant difference observed on the use of disposable chopsticks, although orders in first-class cities also tended to use relatively more chopsticks per order (table ) . because of using a greater amount of food packages, express food delivery orders in the first-class cities had significantly greater the co -eq caused by food package ( . g per order) than those of the second-class and third-class cities ( . and . g per order, respectively) ( table ) . proportions of orders with the delivery distances of < km, - km, - km, - km, - km, and > km for all the food orders, and the orders in the first-class, second-class, and third-class cities accordingly, each delivery order could generate . g co -eq (table ). the orders in the first-class cities had significantly greater total co -eq. ( . g per order) than those of the second-class and third-class cities ( . and . g per order, respectively). on average, . % of total co -eq came from food delivery and . % of total co -eq came from food packages (fig. ) . different cities had a similar pattern with . %, . %, and . % of total co -eq were caused by food packages for the orders in first-class cities, second-class cities, and third-class cities, respectively. based on our assumption, by walking to the restaurant within km away and taking the similar food in place, . g co -eq could be reduced per order (table ) , taking up . % of the total co -eq (fig. ) . significantly more reducible co -eq. ( . g) was found for the orders in the first-class cities. while the orders in the second-class cities had the smallest possibly reducible co -eq. ( . g) (table ) . it was because the orders in the first-class cities had significantly more reducible co -eq caused by food package fig. average proportions of paper package and plastic package usages for all the food orders, and the orders in the first-class, second-class, and third-class cities ( . g), whereas the second-class cities had the smallest possibly reducible co -eq caused by food package ( . g). in terms of the proportion for reducible co -eq, orders in the first-class cities had the highest proportion of . % followed by . % in the third-class cities and only . % in the second-class cities (fig. ) . moreover, as shown in fig. , across all the orders . % of the possibly reducible co -eq came from the food package. the proportion of reducible co -eq of food package was highest for the orders in first-class cities ( . %) followed by those of the third-class cities ( . %) and the second-class cities ( . %). the results showed that on average an express food delivery order would generate . g co -eq. this amount is about half of the co emission caused by -km driving of internal combustion vehicles (onat et al. ) . considering that there will be more than million express food orders per day (iimedia report: - china online take-out industry analysis report), the amount of co -eq caused by express food delivery is considerable. fig. average proportions of co equivalents caused by food delivery and food package for all the food orders, and the orders in the first-class, second-class, and third-class cities but it was assumed that . % of the eis could be reduced by taking the foods in the restaurant nearby (< km). firstly, walking to restaurants to have food will certainly contribute to reducing the co -eq caused by food delivery. for each order, . g co -eq of food delivery could be possibly reduced. different economic development levels of cities did not bring significant difference to the food delivery distance and the food delivery derived co -eq. however, the clients in the first-class and second-class cities seemed to be "lazier" than the clients in the third-class cities with more orders within km away (fig. ) . thus, the clients in the first-class and second-class cities have more potential to conduct the efforts to reduce food delivery derived co -eq. in addition, other efforts, such as optimizing the delivery routing to shorten delivery distance and time (zhao ; liu et al. a, b) , could also contribute to mitigating the co emission caused by food delivery. however, it should be pointed out that the food delivery derived co -eq only possessed a small part of the total co -eq of express food delivery. the co -eq of food delivery only took up . % of the total co -eq (fig. ) , and the possibly reducible co -eq of food delivery took up . % of the total possibly reducible co -eq (fig. ) . thus, reducing food delivery transportation would have limited effects on ei reduction. more attention should be paid on the co -eq derived from food package. according to song et al. ( ) , the waste food packages from food delivery surged from . million tons in to . million tons in . the authors pointed out that fig. average proportions of possibly reducible and non-reducible co equivalents for all the food orders, and the orders in the first-class, second-class, and third-class cities because of the food residues the food delivery packages had low recycling value with % disposed by sanitary landfilling, % for incineration and % treated by illegal dumping and open burning. our results demonstrated that the co -eq derived from food package occupied % of the total co -eq, which was more than six times of the food delivery derived co -eq. the usage of food packages per order was site-specific. the orders in the first-class cities had the highest proportion of food package-derived co -eq with significantly higher use of food packages per order (table ). this might be first due to that clients in the first-class cities tended to order food together, especially the company staff. it was proved by the use of disposable chopsticks as clients in first-class cities used more pairs of chopsticks per order (table ) . another likely reason could be that in the high economic development areas, clients are more willing to consume the food with nicer packages as described by silayoi and speece ( ) and chandon ( ) . hence, the restaurants tended to use more and nicer food packages to improve their sales. this theory was partly confirmed by the use of package materials. the food orders in the first-class and second-class cities would use more paper for food packages compared to those in the third-class cities (fig. ) since the paper packages would feel more textured and comfortable than plastic packages. it should also be mentioned that although paper had a smaller carbon footprint than plastic for the same weight, the packages made of paper would be heavier than the same-size plastic packages. thus, using paper food packages instead of fig. average proportions of possibly reducible co equivalents caused by food delivery and food package for all the food orders, and the orders in the first-class, second-class, and third-class cities plastic packages would not help to reduce the eis (muthu et al. ; roach ) , which is shown in our results. on the other hand, the orders in the second-class cities had the smallest proportion of possibly reducible co -eq (fig. ) . it could be strongly related to the orders of fast foods including chips, hamburgers, fried chicken, milk tea, and other soft serves. according to the data, . % of the total orders in the second-class cities were the fast food, while there were only . % and . % for the first-class cities and third-class cities, respectively (data not shown as results). since most of the fast-food packages are made of paper, that is why the orders in the second-class cities had a higher proportion of paper package use than the others (fig. ) . in our assumption, fast food packages could not be replaced and their eis could not be reduced even when eating in the restaurants. in china, most private restaurants use non-disposable dishes for the clients eating in place or accept clients to take away their foods even with the clients' own containers. however, in terms of the fast-food restaurants which are generally managed in a chain store mode, the use of the disposable dishes is strictly demanded for the sake of food security. we had tried to use our own containers to take away foods from mcdonald's and kfc in china, and hfc in france, but were refused for food security reasons. therefore, if clients are willing to order fast foods by cellphones, its environmental impact caused by food packages will be the least reducible. in short, on average . % of the eis of express food delivery could be reduced by walking to take food in the restaurant nearby (< km). compared to shortening the food delivery, more eis could be potentially reduced by saving food packages. it would be easier for the clients in the first-class and second-class cities to reduce the food delivery derived co -eq as they ordered more foods from the restaurants nearby (< km). moreover, it will be difficult for the clients in the second-class cities to reduce the co -eq caused by food packages since the co -eq caused by the food packages for fast foods can seldomly be reduced. ideally, more than half of the eis of express food delivery could be mitigated by walking to have similar food in the restaurants within km. however, whether it is possible in practice to achieve such a reduction is questionable. firstly, although we have created the scenario that people are willing to walk km to have food according to the study of yang and diez-roux ( ) , many other factors would influence the willingness to walk. in the study of sumalee et al. ( ) on people's transport under adverse weather, they have pointed out that people are less willing to travel by public transport or walk under adverse weather. it is a similar case for people's willingness to walk for food. in general, the peak seasons of food ordering in china are the months of july to september (summer) and december to february (winter) (https ://www.can-dao.com/news/ .html & https ://www.waima iwanj ia.com/?p= ). because during those seasons, the weather is either too hot or too cold so that more people are willing to order foods on the cellphones rather than walking out for foods. the second factor influencing the willingness to walk could be the time. a round walking trip of km commonly requires about - min, and taking food in place takes - min including the waiting time. in total, it might take more than one hour to have food in the restaurant nearby. it would be a little urgent for some people to do so. for instance, the staff in chinese enterprises usually have - . h of resting time at noon. as most staff will choose to take a nap of - min to keep energetic in the afternoon, using more than one hour to take food could be a luxury for them. in contrast, ordering food online beforehand could be a better choice for them to save time. whereas, agrawal et al. ( ) reported that the density, diversity, and design of the route will also influence people's decision to walk. we shall not discuss much on the esthetics of urbanization, but it will be commonly accepted that people prefer to walk with the presence of greenery, attractive buildings, smooth, and wide sidewalks compared to the presence of heavy traffic (agrawal et al. ) . in addition to the walking willingness, people's compromise to take similar foods in the restaurants nearby is also questionable. cho et al. ( ) have conducted a survey of people's perceptions about food delivery apps. the results showed that among five-dimensional attributes of food delivery app quality: convenience, design, trustworthiness, price, and various food choices, the trustworthiness were the most significant attribute for the implementation of the online food delivery business. even though similar foods might be found in the restaurants nearby, people still tend to order the foods from the restaurants with high trustworthiness, viz. high reputation, more sales, or high purchase frequency in the restaurants. on the other hand, in this study, the environmental impacts of express food delivery were estimated for the delivery transport and food packages. but, liu and chen ( ) mentioned that the food waste and the overconsumption should also be taken into account for the eis. the food practice recognizes both material and social contexts, especially in the mianzi culture of china. when several people eating in the restaurant in china, the hosts would order more dishes than they need to show their kind hospitality. it would lead to either food wastes or extra food packages for the dishes left. whereas, the surveys conducted by liu and chen ( ) showed that the express food delivery also caused the problem of food wastes when some light eaters complained that usually, they could not eat up the foods they ordered. thus, more information on food waste is necessary in order to estimate the eis of express food delivery. therefore, although % of the total environmental impact of express food delivery orders could be potentially reducible, we have to make a discount for the reduction as it is questionable in practice to fulfill the reduction potential. people's awareness of the environmental problem and willingness to behave is indispensable to conduct the reduction. in terms of environment protection, it is no doubt that people should sacrifice some convenience and comfort to reduce the eis of express food delivery orders. however, in environmental economics, there exists a preference function over environment quality and other valued goods, which captures the trade-off people are willing to make between material well-being and the quality of the natural environment (welsch ) . thus, it is clear that we should protect a good environment for a comfortable life, not use a comfortable life to trade for a good environment unless it could bring us a better life. welsch ( ) mentioned that it is possible to identify appropriate levels of environmental protection only when we could quantify the trade-off of happiness and comfort of life. for example, levinson ( ) has shown that people were willing to sacrifice about $ for a one-standarddeviation improvement in air quality, like . μg m − of pm , with a happiness model. hofstetter et al. ( ) also suggested happiness as a unit to quantify sustainable consumption. they use the indicator chap to describe the relationship between happiness and co emission, as follows: where Δhappiness i is the increase/decrease in happiness due to consumption activity i; and Δco , i is the increase/decrease in co -emissions due to activity i. taking the express food delivery order for the case, the convenient food ordering could contribute to save time and avoid adverse weather, whereas walking to have food in place could contribute to do sports and perhaps enhance the social relationships. the difference between happiness and the difference of co emission between the two activity choices could both be figured out with some measurements. thus, once there is a standard chap adapted to the current era, national circumstances, environmental requirements, and, etc., we could simply tell whether it is worthy to change the consumption behavior to reduce the environmental impacts. the chap calculation would help people to make consumption decision at a personal level, there is also the indicator calculation considering eis for the organization. for instance, rajesh and rajendran ( ) induced the environmental, social, and governance (esg) scores as an indicator for the sustainability performance of organizations. it contributed to investigating the potential negative impacts of economic activities on environments. they also mentioned that good performance on esg of firms could improve their financial performances and hence be beneficial to investors, managers, and decision-makers. additionally, rajesh ( b) reported that the resource use, the environmental innovation, and the corporate social responsibility emerge as the most important indicators contributing to esg scores indicating the great attention on environmental impacts in the economic activities. if there are more enterprises with good environmental performance, it will be easier for clients to make the decision to consume greenly. moreover, the choice over environment quality and material welfare should have a low priority in some emergencies. during the explosion of coronavirus (covid- ) pandemic in the city of wuhan from january to april , the citizens were confined at home, while the foods were only supplied by the express food delivery organized by the government. according to our study that activity would no doubt lead to more environmental impacts and less feeling of happiness, but it effectively ensured the control of the epidemic. therefore, the conclusions of our research should only apply to daily life conditions and not to social emergencies. in this study, we have shown how much environmental impact would be produced for each express food delivery order in china, and how much of the impact could be potentially reducible. we also found that the potential reduction in express food delivery environmental impacts are site-specific. more impacts are potentially reducible in the first-class cities. as we know that from the beginning of , the food ordering apps (ele.me and meituan) started to make efforts to reduce express food delivery environmental impacts by rewarding the consumers who do not command tablewares in their orders. however, only a part of disposable chopsticks, forks, spoons, and napkins could be saved in that way while most food packaging would be still needed. according to the results in the study, even more than half of the environmental impacts could be reduced by changing the consumption behavior of express food delivery, in practice, it is difficult to conduct the ideal reduction because of chap i = Δhappiness i Δco ,i various reasons such as people's work patterns, food quality, and weather condition. thus, more efforts might be made to help people to enjoy taking food on foot. right now many grand companies in china have their own canteens to provide high-quality foods for their staffs instead of making them ordering express foods. in addition, the enterprises could also change their time-table to give people more flexible time for taking meal comfortably. of course, the government could use regulations to guide people's consumption. for example, according to the new regulation of ministry of ecology and environment, china, by the end of , the use of non-degradable disposable plastic straws are prohibited in the catering industry. but after all, people's willing to alter the consumption choice is the key to reduce the environmental impacts. in addition, before changing consumption behavior people should understand if it is worthy to reduce the environmental impact. a quantifying function for the trade-off between environmental quality and material well-being could be defined based on the collection of more data in the express food delivery business to help people make the choice of consumption. however, it should be noted that this approach should only apply to daily life conditions and not to social emergencies. 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research on optimization of delivery route of online orders publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations in this study, we thank tao xia, zhe wang, jiayin zhou, xue li, xiaoxin zhang, yuxin li, xin zhang, and other participants for the collection of data. key: cord- - jx h y authors: murphy, madhuvanti m.; guariguatax, leonor; samuels, t. alafia title: a covid- opportunity: applying a systems approach to food security and noncommunicable diseases date: - - journal: rev panam salud publica doi: . /rpsp. . sha: doc_id: cord_uid: jx h y nan small island developing states (sids) are highly dependent on food imports from larger nations, with the caribbean community (caricom) and pacific islands combined importing almost $ billion in food in , and more than half of sids countries importing more than % of their food, much of it nutritionally poor and highly processed ( ) . this has been an important driver of high levels of obesity (> % of adults), food insecurity, and noncommunicable diseases (ncds) (between - % of adults) in these countries ( ) . the susceptibility of the sids food system to shocks in the supply chain of imported foods has been dramatically exposed in recent weeks through the growing covid- pandemic with discussions focused on food security and vulnerability to climate change ( ). the current crisis has accelerated the discourse on increasing food security, particularly in the caricom, as the region-which consists of nations with a combined population of over million-braces for a disruption in food imports from larger economies, and also due to border closures. food security in the context on covid- was high on the agenda at the ninth special emergency meeting of the conference of heads of government of caricom on april , , focusing on a regional approach instead of individual country approaches ( , ) . in october , the caricom published the regional food and nutrition security policy, which has goals of promoting increased production and access to safe and nutritious value-added food products in order to reduce the region's vulnerability to ncds, natural disasters, and socioeconomic shocks ( ) . implementation of the policy, however, has been slow. like the rest of the world, sids are already seeing the dire and challenging consequences of covid- on supply chains. however, there is a window of opportunity to enhance food sovereignty in sids focused on increasing the availability and consumption of local and regionally produced healthy foods. it is not enough, though, to just increase agricultural production. the policies and plans developed and implemented during this critical time must align with goals set in health, development, and climate sustainability ( ) . in january , the lancet commission report on "the global syndemic of obesity, undernutrition, and climate change" made explicit the need to not only coordinate policies, but target them in such a way that they create lasting systemic change across goals for sustainable develop, health, and climate change ( ). one ongoing project in the caricom, the "improving household nutrition security and public health in the car-icom" has taken a systems approach to examine the drivers of unhealthy eating in the context of low agricultural production and food importation ( ) . stakeholders across the food, health, and development sectors involved in the project have highlighted the need to shift the ways in which the sids populations interact with local foods. currently, local agricultural production is dependent on the fluctuating willingness of retailers to buy local, which is further dependent on availability and affordability of healthy local agricultural foods. there must be a prioritization and protection of those foods by the government and producers, and an accompanying infrastructure to ensure storage, safety, and processing capacity. policies must be coordinated from the local to national and regional levels with buy-in across sectors. key to success is increasing the demand by the private sector, such as manufacturers, as well as the public, which will need strong marketing components to compete with unhealthy, affordable products. perhaps unrecognized in the current discussions is the need to limit the reach of the nutritionally poor, highly processed foods that make up the bulk of diets in many sids. in terms of health, the best hope for reducing the ncd burden and improving food sovereignty in caricom is to continue to enhance consumer demand, availability and competitive pricing of healthy local foods, while taxing unhealthy foods such as sugar sweetened beverages and ultra-processed foods and also banning transfats. governments at the national and regional levels can ensure a better future with these systemic issues in mind. what cannot be lost as we try to implement quick solutions to address the potential food security issues in sids, as a response to covid- , is the ability to evaluate which diets and food production practices together will achieve the necessary goals for a healthier, more sustainable future. fao's work with small island developing states transforming food systems, sustaining small islands study on the state of agriculture in the caribbean the covid- pandemic and agriculture -short and long run implications for international trade relations caricom agri ministers meet to craft covid- food security position ninth special emergency meeting of the conference of heads of government of the caribbean community, via videoconference the helsinki statement on health in all policies the global syndemic of obesity, undernutrition, and climate change: the lancet commission report using group model building to describe the system driving unhealthy eating and identify intervention points: a participatory, stakeholder engagement approach in the caribbean key: cord- - hbegx authors: harris, jody; depenbusch, lutz; pal, arshad ahmad; nair, ramakrishnan madhavan; ramasamy, srinivasan title: food system disruption: initial livelihood and dietary effects of covid- on vegetable producers in india date: - - journal: food secur doi: . /s - - - sha: doc_id: cord_uid: hbegx disruption to food systems and impacts on livelihoods and diets have been brought into sharp focus by the covid- pandemic. we aimed to investigate effects of this multi-layered shock on production, sales, prices, incomes and diets for vegetable farmers in india as both producers and consumers of nutrient-dense foods. we undertook a rapid telephone survey with farmers in states, in one of the first studies to document the early impacts of the pandemic and policy responses on farming households. we find that a majority of farmers report negative impacts on production, sales, prices and incomes. over % of farms reported some decline in sales, and over % of farms reported devastating declines (sold almost nothing). price reductions were reported by over % of farmers, and reductions by more than half for % of farmers. similarly, farm income reportedly dropped for % of farms, and by more than half for %. of surveyed households, % reported disruptions to their diets. a majority of farm households reported reduced ability to access the most nutrient-dense foods. around % of households reported ability to protect their staple food consumption, and the largest falls in consumption were in fruit and animal source foods other than dairy, in around half of households. reported vegetable consumption fell in almost % of households, but vegetables were also the only food group where consumption increased for some, in around % of households. our data suggest higher vulnerability of female farmers in terms of both livelihoods and diet, and differential effects on smaller and larger farms, meaning different farms may require different types of support in order to continue to function. farms reported diverse coping strategies to maintain sales, though often with negative implications for reported incomes. the ability to consume one’s own produce may be somewhat protective of diets when other routes to food access fail. the impacts of covid- and subsequent policy responses on both livelihoods and diets in horticultural households risk rolling back the impressive economic and nutrition gains india has seen over the past decade. food systems, and particularly those making available the most nutrient-dense foods, must be considered in ongoing and future government responses. disruption to food systems has been brought into sharp focus by the covid- pandemic, but such disruptions are a persistent feature of these complex systems, so it is important that we learn from the current crisis to be better prepared for the next one. this paper uses novel empirical data to understand disruptions to production, livelihoods and diets in agricultural households in india, to draw lessons from covid- and particularly its effects on nutrient-dense perishable food items for making food systems more resilient. the objective is to gain a better understanding of how food system disruption affects the various roles of vegetables in food systems, and we draw on food systems theory and frameworks, and research on food system effects of previous shocks, to frame our study in the indian context. food systems have been defined as "all the elements [...] and activities that relate to the production, processing, distribution, preparation and consumption of food, and the output of these activities" (hlpe ) . key outputs are the diets that people can access through the food system; the livelihoods of those involved across the food system; and the environmental effects of the food system. these complex and spontaneous systems are shaped by a range of drivers, from the biophysical and technological to the political and socio-cultural (hlpe ) . when there are disruptions to these drivers, there is potential disruption to food systems. importantly, different foods are likely to be affected differently by food system shocks. four months into the covid- pandemic, the un food and agriculture organisation (fao ) stresses that global stocks of staple food crops such as rice and wheat are adequate and looks set for a good harvest, depending on how long the pandemic and restrictions last. perishable foods howeversuch as dairy, meat, fruit and vegetablescannot be easily transported and stored and are more vulnerable to food system disruption. restrictions to movementwhether of people, trucks or shipshave significant potential to disrupt production and trade in vegetables and their inputs, and their perishability means this may result in vastly increased food waste at a time when production is uncertain. it is precisely these perishable foods that are the most nutritious (having the most nutrients per calorie) (beal et al. ) so concerns about food system disruptions also play out in concerns over reductions in diet quality. some of these hypothesised impacts from food systems theory have been studied in previous shocks, and signal some areas of the food system that will be important to understand in the current crisis. in terms of production, a study using a system dynamics model suggested that a severe pandemic with > % reduction in labour availability can create widespread food shortages even in developed nations (huff et al. ) . this prediction was in fact witnessed during the ebola epidemic in west africa that began in , where movement and labour were severely curtained and production volume of staple crops was reduced by % (huber et al. ). in contexts where shocks lead to food gluts or shortages, a second key area is effects on food prices. often the most nutritious foods increase most: in indonesia a drought and financial shock in - led to a % increase in the price of leafy greens alongside smaller rises in other food prices, for instance (block et al. ) . a % rise in staple food prices during the food price crisis led to a % increase in total food expenditure across low-and middle-income countries, putting pressure on household food baskets (darnton-hill and cogill ) . healthy diets based on diverse plant foods are already too expensive for over . billion people in the world (hirvonen et al. ) , and shocks such as covid- that reduce incomes or increase prices will only exacerbate this situation. reductions in diet quality (even while maintaining sufficient calories) has been seen in other significant food system shocks, with households tending to protect staple food consumption over the consumption of more expensive but more nutrient-dense foods (darnton-hill and cogill ). in the indonesia example, consumption of eggs fell by over half, and of green leafy vegetables by up to % (block et al. ) , severely limiting diet quality. different populations are also affected differently: while covid- does not distinguish between rich and poor, the diets of the most marginalized in society will be most affected and the least able to adapt. the coping strategies employed by farming households during shocks (such as borrowing and relying on social networks) are likely to have broader welfare implications in the longer term that need to be captured and understood (galiano and vera-hernández ) . overall, the type of shock matters: a biophysical shock affects food production and availability, and thereafter perhaps prices (béné et al. ). an economic shock affects farmers' ability to procure inputs and labour, but also consumers' ability to afford food and therefore demand (block et al. ) . a health shock experienced directly by a household leads to changes in health expenditures and reductions in labour, either in the short term or longer term depending on the type of pandemic (hiv being chronic, ebola being acute, for instance) (harris ; gillespie ) . the covid- pandemic (an acute health shock) and its associated social and policy responses (broader production and economic shocks) are exceptional in that they potentially affect multiple food system drivers at the same time; affect the food system from inputs and production to trade and marketing to price and affordability to consumer demand; and affect almost every scale, from local to global. in this crisis, it is important to understand how farmers experience the shock of covid- as both producers and consumers of food. the produce of vegetable farmers in particular is likely to be among the most disrupted, as outlined above. our hypothesis based on previous research is that production might be disrupted and sales might fall for these farmers, impacting livelihoods; reduced incomes are likely to lead to less diverse and healthy diets in these households; and these impacts will be different for different types of farmers across socio-economic groups. we therefore aimed to understand impacts on the livelihoods and diets of vegetable farmers in india through the multi-layered shock of covid- . india reported its first case of covid- on january th , and early response measures related to the limiting of international travel and health system preparedness. it was only with increasing cases in late march that individual states ordered lockdowns, and on march th a full national lockdown was ordered, extended several times and still in place at the time of writing, though with relaxations applied according to the severity of covid- in different zones. the lockdown coincided with peak harvest (rabi) season for certain fruits and vegetables in many parts of india (fao ), and agricultural work was largely allowed to continue, with agricultural operations remaining out of the purview of the covid- lockdown restrictions (padhee and pingali ) except in active containment zone areas. public and private transport restrictions however limited the domestic movement of seasonal workers and agricultural inputs, especially crop protection products, and significant negative impact was realized in terms of accessing markets for sales. sudden closure of outlets left vegetable producers with reduced customer base, with street food vendors, restaurants and supermarkets mandated to close, though small food shops and open-air markets were allowed to open with time restrictions (gain ). the current study was undertaken with farmers engaged in existing, forthcoming, and recently concluded projects with the world vegetable center (worldveg) in four indian states (table ) . data were collected between may th- th , six weeks into the national lockdown and in the early stages of various government relief packages. in jharkhand, about % of the vegetable produce was procured by the project itself during the lockdown; about % of the farmers we interviewed in jharkhand were part of this initiative, and the johar project was explicitly working with women farmers. in andhra pradesh, about % of the tomatoes produced were supplied to a processing factory through the project and its partners; about % of the farmers we interviewed in andhra pradesh were part of this initiative. the study used a phone-based survey method to elicit information about how vegetable farmers in four indian states were affected by the lockdown measures imposed to contain covid- . phone-based interviews were necessary because it was not possible to visit farmers in person. worldveg staff identified farmers from their projects with whom they worked directly and for whom they had phone numbers, and purposively selected farmers to call until they reached their sample size quota of farmers. as only one single staff member was available in the projects in andhra pradesh and karnataka, their quota was raised to . the quota followed a rule-ofthumb as we did not have information available for the appropriate power calculations. responses were recorded by the staff members in real time using a customized smartphone application which reported and aggregated the data. informed consent was sought and recorded before each interview. the study was virtually risk free for participants and the study plan was therefore exempted from ethical review by the institutional biosafety and research ethics committee of worldveg before implementation. we aimed to limit the interviews to min and therefore included only questions in the survey. these covered questions on production and wastage (vegetables produced, changes in production, reasons, and mitigation strategies); questions on prices, sales, and farm income (changes in each, reasons, and mitigation strategies); and questions on diets (changes in consumption of different food groups, reasons, and mitigation strategies). change in diets was asked as a binary question ('has your household diet changed as a result of covid- ') and we also looked at changes in the balance of the individual food groups consumed. importantly, each of the questions relied on farmers' perceptions of change since covid- ; we did not define a timescale but rather let the respondents attribute change to covid- as they viewed it. change within each of the quantitative questions was captured as a likert scale (for instance: increased a lot (more than doubled)|increased a little (less than doubled)|no change| decreased a little (not to half)|decreased a lot (less than half)) sometimes presented with a percentage range (for instance: sold nothing at all (> %)|lost most of sales ( %- %)|lost half of sales ( %- %)|lost some sales ( %- %)|lost little to no sales (< %)|increased sales). qualitative questions (such as reasons and coping strategies) were asked without pre-defined responses, with enumerators instructed to probe for multiple answers and select the most appropriate responses from a multiple-choice list. we also collected some basic farm and household data in order to compare farms and households on proxies for key socio-economic issues (gender of the farmer, as a proxy for gender differences; and farm size, as a proxy for income/economic status). of the initial sample of farmers contacted for this study, rejected the interview, had not produced vegetables, and provided incomplete information, therefore the analytical sample had observations for farmers. descriptive analyses were undertaken for each topic, with particular sections also analysed by gender and farm size (larger or smaller than ha (ha)) to understand heterogeneous effects. ordered logit models were used to estimate the influence of farm and household characteristics on selected outcomes. we use ordered logit regressions to analyse associations between the intensity of self-reported changes in vegetable livelihoods (quantity sold, prices, income) and diets (change in consumption per food group) due to covid- and major household characteristics (farm size, gender of the farmer, and the number of produced vegetables). the dependent variables are on to -point likert scales. where necessary we invert the order of the variables, so that higher values always reflect a worse situation of the household. to control for differences between the projects and their context, we add a set of state dummies to the list of independent variables. across our survey a quarter of farmers were women (table ). this was driven by the project in jharkhand where half of the respondents were women, while in all other states very few farmers were women ( - %). jharkhand also had much smaller farm sizes (average . ha) compared to the . to ha farms in the other three states. in disaggregated analyses (not shown here) female farmers had slightly smaller farms on average than their male counterparts. overall, % of farmers reported disruptions to production; % to sales; and % to diets. farmers produced a diverse range of vegetables. the median number of vegetables produced was , the mean , and % of households produced five or more types of vegetable. this varied by state, with farmers in andhra pradesh mainly producing tomatoes, but farmers in other states producing - vegetables on average. figure shows the main vegetables produced by each farmer (self-reported), to which questions on production, sales and prices related. the 'other' vegetable category included several cucurbit species, beans, radish, beetroot and cauliflower, each of which was produced by less than % of farmers and combined into one collective category for visualization. of all types and locations of farms with interruptions to their production, most reported that prices were too low to continue with production ( %) or that they could not find buyers ( %). of problems associated with production, most cited lack of transport ( %), many cited lack of inputs ( %), lack of harvest labour ( %), and some cited lack of storage ( %). again this varied by state, though transport was cited in every state. women farmers were less likely to suffer from lack of labour (but had smaller farms on average) but were more likely to see prices as too low. large farms were more likely to lack labour and storage, and smaller farms had difficulty accessing inputs, in particular. farmers who experienced reduction in sales due to covid- sold their produce through multiple marketing channels, from selling directly to consumers through fresh markets, to selling through collectors/middlemen (table ) . only two farmers sold directly to institutions, and another two to exporters or supermarkets. more female farmers sold directly to consumers and did not have supply contracts, and more male farmers sold through collectors and had a higher diversity of sales channels. the average number of marketing channels among smaller farms (< ha) was . less than among larger farms. a vast majority of farmers saw declines in vegetable sales, prices and farm incomes (fig. ) . over % of farms saw some decline in sales, and over % of farms saw devastating losses of sales (sold almost nothing), slightly higher among female farmers, and double among small farms compared to large (data not shown here). prices reduced for over % of farmers, and by more than half for % of farmers. similarly, farm income dropped by for % of farms, and by more than half for %. we estimated an ordered logit model to assess the association of farm size, gender of the farmer, and the number of produced vegetables with covid- related shocks (table ). the results show that a higher diversity of produced vegetables is significantly associated with a better development of sales but worse changes in prices and income. women experienced a stronger disruption to the price of their vegetables. farm size was not significantly associated with any of the variables. of surveyed households, % reported disruptions to their diets. a majority of farm households reported ability to protect their staple food consumption, meaning their food security in terms of calories (fig. ) , though % of households did report a fall in ability to procure staple foods. the largest falls in consumption were in fruit and animal source foods other than dairy, in around half of households. pulse, dairy and vegetable consumption fell in - % of households. vegetables were the only food group where consumption reportedly increased in a significant proportion of households, with around % reporting an increase. the major reason for increases in vegetable intakes was eating the farm's own production, while reasons reported for reductions in vegetable consumption were mostly due to reduced physical availability and affordability. women farmers were significantly more likely than men to report a stronger reduction in consumption of vegetables, fruits, and dairy, controlling for other factors (p < . in separate ordered logit regressions), and were much less likely to be able to afford vegetables than men ( % of women versus % of men specifically quoting price changes; % of women versus % of men quoting changes in general affordability; data not shown here). we asked about coping strategies used by farm households to mitigate the impacts of covid- on sales, income and diets. in terms of farm income (table ) , the most common strategies have been to find new markets (including selling door-todoor), reduce prices, and eat the farm's own production. all of these are practiced more by female than male farmers. women were only half as likely as men to apply no coping strategy for production. to deal with reduction in sales, most were leaving harvest in the field, feeding vegetables to livestock, and sharing vegetables with others. smaller farms were generally less likely to reduce their production or destroy the harvest (plant less, leave vegetables in the field, compost vegetables, or feed to livestock). to mitigate the effects on farm incomes, most are finding new markets and reducing prices, with female farmers reducing prices more than men, and small farms more than large farms. in total % of farmers plan to produce less, fig. major vegetables produced in the study areas during the survey in terms of dietary coping strategies, the most common were reducing household expenses and eating more own- note: the number of supply channels is tested for equality of means (t-test), all others comparison test for equality of proportions (z-test), sample are all households that have been unable to sell some of their vegetables due to covid- , n = * p < . , ** p < . , *** p < . produced food (table ). other households relied on financial coping strategies, such as buying cheaper food, and borrowing money. most coping strategies were used more by households in which the farmer is female, particularly the financial strategies; and these households were almost twice as likely to have received food aid or other formal support. this study has shown food system effects of covid- reported by farmers on production, livelihoods, food environments and diets in households involved in vegetable production in four indian states. our data is limited by its convenience sample and moderate sample sizes across different states, limiting the generalizability of the findings. as with all surveys, the findings rely on the accuracy of the data portrayed by the respondents, and we asked specifically about the perceptions of farmers on changes since covid- rather than use independently verifiable data. our focus on vegetable farmers was deliberate, because we wanted to understand the impacts on a sector providing nutritious foods, but of course our findings cannot necessarily be generalized to farmers of other crops, or to households relying on other livelihoods. nonetheless, this is one of the first studies to document the early impacts of the pandemic and policy responses on farming households, and provides an important snapshot of impacts on a sector that provides both decent livelihoods and healthy diets in india. while we did not investigate the direct effects of sickness in farming households, the subsequent lockdown policy was perceived by farmers to have affected production (through lack of labour, storage and inputs); sales (through drops in demand and lack of transport); prices and income (with reductions due to lack of demand); and diets (in terms of ability to access the most nutrient-dense foods). these core findings largely mirror the findings of previous research on food system disruptions (jaacks et al. ) . a survey of vegetable value chains in ethiopia similarly found increased farm losses alongside shortage of inputs and labour; reduced producer prices for vegetables, though retail prices so far unchanged; and both vegetable trade and consumption reduced (tamru et al. ) . these studies therefore concur broadly with what we saw in india. a study on retail prices in india found that these had increased and then stabilised in india on a national level, but that this varied by the particular type of vegetable (pingali and mittra ) , an issue we were not able to address in this study. indian newspapers have similarly reported issues with finding harvest labour, transport to market, reduced demand by buyers and retailers, and increased retail prices for vegetables in different states (pothan et al. ) . we look forward to further covid- food system studies to compare our results further. in addition to the core findings, sub-analyses of our data suggest that female farmers reported higher vulnerability in terms of both livelihood and diet. women farmers claim to use more mitigation strategies to first secure their income, and then to secure their diet. the reasons women cite for changes in vegetable consumption show that they perceived themselves to be particularly affected by changes in food prices and affordability. so, the mitigation strategies available to them are not sufficient to protect their livelihoods and diets from income and price shocks. our findings suggest that farming households in general find it hard to mitigate the worst of these shocks in the short term, accepting lower prices to maintain sales, but still with interruptions to the flow of vegetables to consumers, thereby affecting diets more broadly in the country. producing a variety of different vegetables appears to mitigate impact on sales (perhaps through diverse sales routes) but not on incomes (as prices are hit). the ability to consume one's own produce is somewhat protective of diets when other routes to food access fail: due to the inability to sell their own produce, many households consumed more of their own vegetables and a proportion increased their consumption note: test for equality of proportions of the two group applying each strategy (z-test), respondents were able to quote more than one coping mechanism, * p < . , ** p < . , *** p < . note: test for equality of proportions of the two group applying each strategy (z-test), respondents were able to quote more than one coping mechanism * p < . , ** p < . , *** p < . above previous levels. this route to dietary resilience is particular to the sample (horticultural households) but it does suggest that producing vegetables provides some resilience to dietary shocks for some households. so far, the major responses of the indian government to ensure livelihoods of farmers have been making loans more available and providing tax relief and direct farmer payments. in our work, smaller and larger farms see differences in the impacts of covid- , and therefore implement different coping strategies and require different types of support from the government in order to continue to function. government response to ensure food security has been to double allocations under the public distribution system (pds) and provide cash payments to out-of-work labourers (but not self-employed farmers). female farmers in particular report accessing food aid according to our data, but it should be noted that the pds system provides grain and pulses but not vegetables or other nutrient-dense foods that are seen to be badly hit in our data. understanding farmers' real-time coping strategies and limitations through studies such as this might help policy-makers to prepare strategies that take into account the lived experiences of farming households. the challenge is to carefully weigh the remaining direct epidemiological risks of the virus against the livelihood and dietary hazard to both consumers and farmers. the impacts of covid- and subsequent policy responses on both livelihoods and diets in horticultural households risk rolling back impressive economic and nutrition gains india has seen over the past decade. india's right to food legislation commits the government to action in this area, and suggests that food systems, and particularly those making available the most nutrient-dense foods, must be considered in ongoing and future government responses. impact of climate-related shocks and stresses on nutrition and food security in selected areas of rural bangladesh macro shocks and micro outcomes: child nutrition during indonesia's crisis maternal and 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health and population lessons from a pandemic to repurpose india's agricultural policy how did covid- impact india's food prices? tata-cornell institute for agriculture and nutrition blog local food systems and covid- : a glimpse on india's responses. rome: fao available from impacts of the covid- crisis on vegetable value chains in ethiopia. ifpri covid blog acknowledgments the willingness of vegetable farmers to contribute to this study at short notice is greatly acknowledged. we also acknowledge the support of ms. funding information no specific funding was used in the research reported here. all authors and field officers used their time funded under world vegetable center budgets to undertake this work. conflict of interest the authors declare no conflict of interest in the preparation of this paper.open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/ . /. jody harris is lead specialist in food systems at the world vegetable center, bringing a food systems and policy focus to work on healthy diets, and undertaking research to further understand the role of vegetables in complex food and social systems. she is an applied researcher with a particular interest in the policy and social drivers of healthy diets and nutrition. her phd in development policy is from soas, university of london. she has p r e v i o u s l y w o r k e d a t t h e international food policy research institute (ifpri) and the institute of development studies (ids) as well as several universities and international ngos, conducting research and designing programmes in various contexts in asia and africa, particularly vietnam and zambia.lutz depenbusch joined the world vegetable center in november to work in its impact evaluation team. his research focuses on the effectiveness, efficiency, and distributional effects of the center's research and development projects. currently he works on projects related to home gardens, farm mechanization, plant breeding, plant protection, and scaling techniques. he has implemented research projects in bangladesh, cambodia, india, kenya, and myanmar. lutz obtained his phd in economics as part of the global food research training program at the university of goettingen, germany.arshad ahmad pal is a scientist in post-harvest technology at the world vegetable center in india, specialising in horticulture, postharvest management of fruits and vegetables, postharvest physiology and technology, value chains and project management. he plans and manages research and development for different projects within the region, providing technical and administrative leadership to the national project team. his phd in horticulture science is from charan singh university, india, and he has previously worked for the central institute of temperate horticulture (icar) in india.ramakrishnan madhavan nair was appointed regional director for the world vegetable center south and central asia in march . he also leads the worldveg global legume breedi n g p r o g r a m a n d t h e i n t e r n a t i o n a l m u n g b e a n improvement network (imin). ram has over years of experience in managing and leading national and international projects, and his extensive academic publication record includes peerreviewed journal articles, conference papers and, book chapters. he received his phd with a specialization in plant breeding from kerala agricultural university, india. in , he won the sardi breakthrough innovation award and in , ram and his team won the worldveg science of excellence award for their work on mungbean. key: cord- -sj ypr c authors: parks, courtney a; nugent, nadine budd; fleischhacker, sheila e; yaroch, amy l title: food system workers are the unexpected but under protected covid heroes date: - - journal: j nutr doi: . /jn/nxaa sha: doc_id: cord_uid: sj ypr c coronavirus disease (covid- ) poses an occupational health risk to food system workers including farmers/producers, grocery store workers, emergency food system staff and volunteers (e.g., food pantry workers), and others. these food system workers have been pushed to the front-line of this pandemic, providing essential services that support food consumption for all americans. food system workers are some of the most economically vulnerable populations and are at risk of further financial disparities and contraction of covid- during this pandemic. as we continue to grapple with the best strategies to support the food system and mitigate concerns around the spread of covid- , appropriate measures must be considered to better protect and support front-line food system workers that safeguard food access for all americans. the coronavirus outbreak of sars-cov- and cases of coronavirus disease (covid- ) that began in china in late december has spread worldwide ( ) . in the wake of this pandemic the usa should turn its attention to our most economically vulnerable populations. with shelterin-place mandates and social distancing guidelines, day-today life across the usa has shifted quickly. anxiety remains high with populations living below the federal poverty level disproportionately bearing the brunt of the pandemic and experiencing new levels of stress and accompanying negative consequences with workplace health and safety implications ( ) . food insecurity impacted . % of us households in ( ) , and with unprecedented job loss and economic downturn during and after this pandemic, this number has increased rapidly. recent analyses from the covid impact survey, week ( - april, ) have shown that % of all respondents and % of those with children reported worrying about food running out ( ) . health care practitioners have surfaced as front-line workers addressing the urgent needs of the covid- pandemic, and there remains much ground to gain in terms of providing adequate support and protection for these groups ( ) . although risks are potentially inherent in this line of work, the level of risk has exponentially increased. concurrently, other unlikely groups have now become tantamount to "essential" workers, including those working within multiple levels of our food system. the need to protect and support food system workers is paramount, given that these groups are unexpectedly, and in many cases, unpreparedly, being pushed to the front-line of this pandemic. food system workers did not knowingly "sign-up" to be serving on the front-line of a pandemic and are often not prepared with adequate knowledge and safety measures to ensure their health and wellbeing, and are not compensated accordingly. to date, there have been ∼ , covid- cases and ≥ deaths among workers in meat and poultry processing facilities ( ) . factors that affect risk of infection include difficulties with workplace physical distancing and hygiene, and crowded living and transportation conditions ( ) . in terms of production, fruit and vegetable (fv) producers are subject to negative externalities of the pandemic, including a drastic drop in demand for food service (e.g., restaurants), accompanied by a simultaneous spike in demand for food retail (e.g., grocery, emergency food). this pendulating demand is already wreaking havoc on the food supply chain ( ) . for instance, farmers are currently being forced to throw out entire fields of crops as they are not equipped with the resources to make this shift from food service to food retail ( ) . this applies to smaller fv producers that typically sell direct to consumers [e.g., farmers' markets, community supported agriculture (csa) boxes] and larger commodity crop producers. many communities across the usa are advocating for farmers' markets to remain open and be categorized as essential since they distribute fresh fvs, which are often limited in grocery stores located in low-income communities ( ) . however, some producers are finding innovative ways to distribute fvs that limit social contact, such as csa boxes and preordering. for example, a group of university students have started an online site, farmlink, seeking to connect farmers with food banks ( ) . in brick and mortar retail, grocers are struggling to meet sudden increases in consumer demand, while simultaneously experiencing unprecedented disruptions in distribution systems due to covid- . food retailers strain to keep up, as many consumers buy in bulk and stockpile food and supplies, leading to empty shelves. grocers are currently limiting bulk purchases of more than a dozen popular food items ( ) , and although these measures may address panic buying and unnecessary stockpiling, these restrictions may also pose a threat to foodinsecure households that may not have transportation for food shopping on a more regular basis and may be limited to purchases of specific lower cost items that also tend to be less nutritious. in addition, grocery store employees have become front-line workers during covid- , often working with limited personal protective equipment, interacting with the public on a regular basis, and putting their lives at risk. recent newspaper articles reported that ≥ front-line grocery workers have already succumbed to the virus, while many others have tested positive ( ) . increasingly, grocery chains have introduced measures to protect their employees, such as adopting more stringent customer capacity limits, adding plexiglass partitions at the register, and informational floor decals and -way aisles to promote social distancing. some grocery chains have also pushed to have their employees considered as first responders, giving them access and priority to testing and protective gear. many municipalities have put in place executive orders to prohibit restaurants, cafes, food trucks, and other similar businesses to serve food and beverages for consumption on premises. food service operations have also adapted. the fda has relaxed rules on food labeling to allow restaurants and food manufacturers to sell food that may not be labeled for retail sale during this pandemic ( ) . restaurants are slowly starting to open in many states, and many have transitioned to these types of sales and other "no contact" ways to help feed americans while also trying to keep their business afloat. these no contact ways -often cash-free approaches -negatively impact low-income customers who might not have credit cards. finally, as a result of new restaurant social distancing regulations, an estimated - million restaurant workers will be laid off by june ( ), many of which already live paycheck to paycheck. the working poor -including many that make up the frontlines of the food system -may lack the financial resources to meet basic nutritional needs or ability to buy food in bulk. many individuals also have new added childcare responsibilities, further hindering lower income households' ability to earn a living wage. this challenge is compounded when the nearly million children participating in school and childcare-based federal food assistance no longer have access to these programs as many locations remain closed, and not all of these individuals will be eligible for federal nutrition assistance or want to risk applying due to the chilling effect of the public charge rule [allowing immigration inadmissibility based on public benefits use including the usda department supplemental nutrition assistance program (snap)] ( ) . food-insecure households often engage in tradeoff behaviors in order to put food on their tables (e.g., not paying bills like utilities in order to buy food) ( ) . thus far, the federal government has enacted . stimulus packages in response to covid- (p.l. - ; p.l. - ; p.l. - ; p.l. - ). some of these stimulus funds are appropriated to various industries and individuals with ∼$ . billion to assist farmers, most of which is designated for soy and corn producers (e.g., commodity crops), leaving out producers of "specialty crops" which include fvs. these measures may widen the nutrition gap in the usa, further deteriorating a limited food system to support healthy eating. other covid- stimulus package nutrition provisions allow significant flexibilities and additional appropriations for certain federal nutrition assistance programs ( ) . this includes the suspension of the time limit for able-bodied adults without dependents (abawd) participation in snap and gives states the flexibility to suspend work requirements during the pandemic ( ) . emergency food systems (e.g., food banks, pantries) are also experiencing a rapid increase in demand and are attempting to provide services for existing clients, as well as new families not previously food insecure and who are now seeking services due to covid- . many food banks/pantries rely on older adult volunteers, which is not safe or viable during this crisis, creating a demand for assistance from younger individuals in good health. a recent solution-oriented partnership between the farm bureau and feeding america seeks to allow farmers to work directly with food banks to shorten the supply chain and find a much-needed home for the american-grown food that would otherwise be wasted ( ) . in conjunction with emergency food systems, there will be extra stressors put on federal nutrition assistance programs, as americans apply to receive needed benefits. it is imperative to continue to protect these programs and consider additional approaches, such as snap benefit adequacy, to better leverage federal nutrition assistance to reduce food insecurity and stimulate the economy by subsidizing food consumption ( ) . nutrition incentive programs, as authorized through the farm bill and operationalized through the gus schumacher nutrition incentive program (gusnip) grants includes snap incentive and produce prescription programs. these innovative programs aim to increase fv purchases through point-of-sale incentives, including farmers' markets and grocery stores ( ) . gusnip programs are now able to leverage pandemic-snap and disaster-snap and could potentially reallocate fv incentives from site to another to better assist the food-insecure population affected by covid- and as outlined by usda's national institute of food and agriculture (nifa). as congress considers additional covid stimulus packages, appropriate workplace health and safety measures must be considered to better protect and support front-line food system workers; otherwise, there most likely will be longlasting, adverse effects on our food system and nation's health. communities, public authorities, and organizations are working to curb the crisis and plug the gaps in food systems to be more resilient in an accelerated fashion. perhaps americans will surface at the end of this pandemic with a greater appreciation for local foods and will have rediscovered home cooking and healthier food habits ( ) . some high-level considerations for action are outlined below. • develop system-wide strategies to respond appropriately to food insecurity during covid- , considering multiple levels of the food system, such as mobilizing innovative direct-toconsumer federal nutrition assistance approaches to support adequate nutrition for all. • develop and disseminate innovative consumer education about food procurement, safety, storage, and consumption to promote high dietary quality, particularly among vulnerable populations. • mobilize allied health and workplace health and safety professionals and other social services to monitor food insecurity and the impact on existing, as well as newly affected groups. food insecurity is an important threat to supporting nutrition among low-income populations, a group that has seen recent spikes with covid- . • provide support and protection for front-line workers, including covid- protective resources, paid leave, and targeted outreach regarding nutrition assistance. these frontline food system workers are vital for everyone to access safe, nutritious foods and beverages during this pandemic, and adequate protection and support should be provided. • develop strategies to assist working parents with childcare given school/childcare facility closures. • offer paid sick time and paid family and medical leave for all workers. world health organization declares global emergency: a review of the novel coronavirus (covid- ) why inequality could spread covid- household food security in the united states estimates of food insecurity during the covid- crisis: results from the covid impact survey supporting the health care workforce during the covid- global epidemic almost , meatpacking and food plant workers have reportedly contracted covid- . at least have died food goes to waste amid coronavirus crisis reestablishing healthy food retail: changing the landscape of food deserts we had to do something': trying to prevent massive food waste. the new york times grocers limit food purchases, urge shoppers not to hoard as panic buying continues. kroger ramps up hiring. cnbc at least grocery store workers have died from covid- , union president says fda provides temporary flexibility regarding nutrition labeling of certain packaged food in response to the covid- pandemic to million restaurant workers could lose their jobs by june -business insider feeding lowincome children during the covid- pandemic auxiliary measures to assess factors related to food insecurity: preliminary testing and baseline characteristics of newly designed hunger-coping scales covid- updates who stands to lose if the final snap work requirement rule takes effect? brookings joint letter from american farm bureau federation and feeding america: covid emergency food response the impact of increasing snap benefits on stabilizing the economy, reducing poverty and food insecurity amid covid- pandemic. durham, nc: healthy eating research effectiveness of subsidies in promoting healthy food purchases and consumption: a review of field experiments health and social determinants and outcomes of home cooking: a systematic review of observational studies the authors' contributions were as follows-all authors: conceptualized the manuscript; cp: developed the first draft; cp had primary responsibility for final content: and all authors: have provided edits, and read and approved the final manuscript. key: cord- -zupocnuf authors: li, junxiong; hallsworth, alan g.; coca‐stefaniak, j. andres title: changing grocery shopping behaviours among chinese consumers at the outset of the covid‐ outbreak date: - - journal: tijdschr econ soc geogr doi: . /tesg. sha: doc_id: cord_uid: zupocnuf this study focuses on the embryonic stages of the covid‐ pandemic in china, where most people affected opted to abide by the chinese government’s national self‐quarantine campaign. this resulted in major disruptions to one of the most common market processes in retail: food retailing. the research adopts the theory of planned behaviour to provide early empirical insights into changes in consumer behaviour related to food purchases during the initial stages of the covid‐ outbreak in china. data from the online survey carried out suggest that the outbreak triggered considerable levels of switching behaviours among customers, with farmers’ markets losing most of their customers, while local small independent retailers experienced the highest levels of resilience in terms of customer retention. this study suggests avenues for further scholarly research and policy making related to the impact this behaviour may be having around the world on society’s more vulnerable groups, particularly the elderly. since its outbreak in wuhan (china) in early january , the covid- strain of the novel coronavirus spread rapidly across china and beyond to affect countries with tragic consequences -over million cases (over . million in europe alone) of reported infections with in excess of , people dead by the end of april of (who ) . this has had a major impact on consumers and the retail sector across europe and further afield (feng and fay ; evans ) . as a response to the initial outbreak, china was the first country in the world to impose a mandatory nation-wide self-quarantine between january and february (bloomberg news ). since then, many other countries in europe and further afield have followed suit by issuing restrictions to their citizens' movements in order to stem the spread of the virus (chinazzi et al. ; hedgecoe et al. ) . although the full impact of this crisis on the retail sector will only emerge once it has been brought under control, early indications show that retail outlet closures ordered by governments around the world as well as changes in consumer behaviours associated with this pandemic are having a detrimental impact on the sector already, to the point that up to , high street retail outlets have been forecast to close in the uk alone as a result of this pandemic (munbodth ) . indeed, earlier research has shown that major pandemics, such as the severe acute respiratory syndrome (sars) outbreak in or the middle eastern respiratory syndrome (mers) outbreak in , can have major impacts on supply chains (cavinato ; oke & gopalakrishnan ) and consumer behaviour in retail with a specific focus on online food shopping even if most of this research has been carried out primarily from a hospitality (alan et al. ; chien and law ; jayawardena et al. ) or tourism perspective (wen et al. ; kuo et al. ; jamal & budke ) with the majority of studies focusing on asia (mckercher & chon ; kuo et al. ) due to the prevailing geography of earlier pandemics. this study seeks to contribute to current knowledge of customer behaviour in retail within the context of a major public health crisis, which has been somewhat dominated by research related to supermarkets and online purchases (e.g. forster & tang ) and largely ignored other retail formats, including small independent retailers and traditional markets. for this purpose, the theory of planned behaviour first posited by ajzen ( ) is adopted to explore planned changes to consumer food shopping behaviours at the early stages of the covid- outbreak in china. due to the geographical origin of the covid- pandemic, the data was collected in china with a focus on eliciting early insights from food and grocery shopping behaviours during the embryonic stages of the pandemic when it was still classified as a mere outbreak. during this difficult time, the supply and demand of food was unbalanced due to the shortage of supply and potentially by panic buying behaviours (cachero ) , which have since been replicated in much of the rest of the world. as such, this study presents a customer-centred enquiry of supply versus demand to grocery retailing at the outset of the covid- pandemic. as part of this study, insights were sought on prior shopping patterns -familiar sources of food shoppingas well as evidence of how switching took place. the implications of the findings are discussed later against the backdrop of similar issues emerging in leading western economies currently facing the fallout of this growing pandemic. initially, a number of possible theoretical frameworks were considered for this study, including the technology acceptance model (tam) and ajzen's ( ) theory of planned behaviour, when seeking to characterise how consumers tried to purchase food and groceries before and during the covid- outbreak. building on earlier retail studies with a similar theoretical framework (e.g. spence & townsend ; lobb et al. ; hansen ) , the theory of planned behaviour (tpb) was adopted for this study to analyse planned changes in consumers' food shopping behaviour during the early stages of the covid- outbreak in china, in line with research published recently on the impacts of this pandemic on food supply chains, where authors speculated with major potential changes to consumer behaviour in grocery retailing in canada and elsewhere (richards & rickard ) . first, food availability was investigated among different retailers, including online retailers, local independent small shops, supermarket chains and farmers markets. food was categorised broadly as fresh, packed and canned, cooked and ready to eat, and frozen. data for this study was collected using a selfadministrated online questionnaire launched during the chinese government's mandatory national 'self-quarantine' campaign adopting a non-probability snowball sampling strategy. the survey was distributed using china's most popular social media platform -wechat. in order to avoid repeat responses, wechat account login was required in each case. response rates were boosted by means of a survey panel provided by tencent group. the survey was closed on february -the last day of the mandatory national self-quarantine campaign. a total of respondents participated in the survey, with an average survey completion time of minutes. an outline of the survey respondents' profile is shown in table . respondents were asked to what extent they could buy food from those channels ( = very difficult, = very easy). overall, customers found it difficult to buy all categories of food across all shopping channels (mean = . ). supermarkets had the greatest availability of food across all categories (mean = . ), while farmers markets (mean = . ) were the most difficult place to find food during the outbreak (table ) . although there were a number of food categories the ministry of commerce of china had to take control over to ensure supply chain safety (china news service ), this study investigated the food categories most in demand by chinese consumers during the early stages of the covid- outbreak. for this purpose, each respondent was asked to indicate his/ her most wanted food categories at this early stage in the covid- outbreak. the result ( figure ) shows that vegetables, rice (with rice-related products) and meat were the most wanted food categories during the early stages of this fast-evolving pandemic. a preliminary, first-cut, principal component analysis (pca) indicated the presence of four distinct factors: perceived usefulness, perceived ease of use, trust in retailer (q: retailer will ensure food hygiene and safety), trust in government (q: local government will ensure food hygiene and safety) (kmo = . , cronbach's alpha = . ). we quickly concluded that the overriding factor in a time of great change and crisis was, understandably, perceived usefulness (see below). this construct characterised online shopping as a means of reducing the risk of getting infected, as well as the helpfulness of online shopping in one's daily life during the outbreak. it explained per cent of variances of online shopping intention (p = . vif < . ), while other variables were insignificant. there was a mild level of anxiety on food supply (q: "i am worried that there is a food shortage in my local area" = strongly disagree, = strongly agree; mean = . std. dev. = . ). anova and subsequent post hoc tests were applied to various demographic variables (including age, gender, household size, income, etc.). the results suggested that respondents with a masters degree or a higher level of educational attainment (p < . ), were less worried about food shortages, while the fear of running out of food showed no difference within other demographic categories. clearly these patterns require further research, particularly in the context of western economies. before the outbreak, as many as per cent of the survey's respondents bought their food and groceries from supermarkets. however, while supermarkets remained a popular choice during the outbreak, the proportion of consumers choosing supermarkets dropped to per cent. there was also a sharp decline in purchases from farmers markets, with the proportion of people shopping from this channel dropping from per cent to per cent. in contrast, there was a surge in online shopping, with the percentage of consumers buying food and groceries online increasing from per cent before the outbreak to per cent, with online food shopping becoming the most popular channel during the outbreak. local independent small shops also saw an increase during the outbreak from per cent to per cent, as shown in figure . in line with this, consumers' switching behaviour (table ) unveils that per cent of online shoppers remained online, the rest moved to local independently owned small shops ( %) and supermarkets ( %). we do not have the detail to know if any switching from the internet was due to inability to arrange a delivery in time. however, small independent shops demonstrated a high level of customer retention. among consumers who used to do their food shopping primarily in small independent shops, per cent remained buying from their local independent small shops during the outbreak, with per cent moving to online shopping. on the other hand, among supermarket shoppers, per cent moved to shop online while per cent continued using the supermarket for their food and grocery shopping during the pandemic. farmers markets experienced the highest levels of customer churn, which may be attributable to the outbreak being identified initially in a wet market in wuhan -only per cent of consumers continued buying from this channel, per cent of consumers moved online, per cent moved to local privately-owned small independent shops, while per cent switched their food shopping to supermarkets. however, the nation-wide governmentimposed lockdown, which coincided with the chinese new year national holiday, resulted in a general shortage in food supply (cachero ; rosner ) . largely as a result of this nation-wide lockdown, per cent of respondents reported that the retail outlets where they previously bought their food had closed. while respondents based in larger cities (e.g. beijing, shanghai, shenzhen and guangzhou) only reported a food retail outlet closure rate of per cent, respondents from smaller cities and towns (kim ; kim & hallsworth ) and particularly in china (goldman ; tacconelli & wrigley ) has undoubtedly brought new formats into the system and left local communities with an enhanced range of possible purchase opportunities. this study has focused on how such changes played out in a short but turbulent time, namely a major pandemic. a particular characteristic of supermarkets and yet larger outlets is their capacity to process large numbers of shoppers in a short space of time. that focus on high volume and rapid turnover was in dramatic opposition in this particular instance to the need for isolation and quarantine. figure and table both provide similar evidence of a move away from close contact, mass formats to smaller retail formats or online purchases, though further research is required to explore the longer-term implications of this behavioural change and whether it will remain in place once the covid- crisis is over. as in south korea with its world-leading fast broadband, china facilitated online shopping well before the present covid- crisis. it is, therefore, likely that online retail will go from strength to strength globally as a result with early movers most likely to benefit. this could offer a tentative explanation for the lower expressions of stress displayed by survey respondents with a higher level of educational attainment, though further research is required on this front to establish whether job security and expendable income may not be key here instead of the respondents' level of educational attainment. what, then, does this tell us about the relevance of competing theoretical approaches towards understanding (rapid) retail change? building on the work of ajzen ( ) , the theory of planned behaviour attempted to understand the interface between the individual and the choices presented by a rapidly retail environment in the context of a major public health crisis. in common with similar approaches, the underlying initial proposition was that people would make broadly rational decisions given the known choices available. in the context of switching behaviours to online shopping, earlier studies have investigated this (e.g. elms et al. ) . underpinning this, by implication, is an ongoing assessment of the available options that themselves slowly and steadily evolve through time. if we look at the evolution of the work of leading retail researchers, timmermans ( ) , for instance, rapidly moved from rational choice models to cognitive/ behavioural approaches. in recent decades, building on the work of kahneman and tversky ( ) and their successors (see thaler & sunstein ), there has been a growing acceptance of behavioural economics including the importance of routine, habit, heuristics and so on. at the consumer/structure interface, clarke et al. ( ) argued that local shopping behaviour was fitted into complex lifestyles rather than consumers exerting free choices, unhindered by their time-juggling complex lifestyles. perfect information, time availability, utility maximisation functions, human (ir)rationality, consumer preferences, willingness and ability to know and compare, are everyday underpinnings to routinised food shopping behaviour. all such approaches, it would seem, inherently struggle with rapid, sudden and dramatic change. for instance, behavioural approaches founded in game theory (gt) place special emphasis (again see kahnemann & tversky) on how individuals respond when they do not, or cannot, know how others will act, namely, decision making under uncertainty. however, government-imposed restrictions in china and elsewhere have effectively contributed a fundamental element of certainty even if only by removing certain shopping options. if events surrounding the early days of the covid- outbreak in china are to be understood through a retail prism, the fundamental challenge for local residents was to find an available format (or formats) that (still) worked in a rapidly changed environment. in line with this, it could be posited that what emerged was in effect a variant on the technology acceptance model (tam). although with tam it is possible to add variables such as trust (in government or retailer/supplier), the perceived usefulness dimension of tam over-rides other considerations. online shopping is a tam-based 'fix' that pretty much explained all the variances of intention to use in this study. ease of use, conversely -always popular in times of stability -was surely not a factor because it was often difficult for customers to rely on online channels due to unusually high traffic volumes. in china, retailers often had to close down their sites and this seems to have recurred in the uk and elsewhere less than two months since the survey was carried out. at root, online (like downsizing to use smaller, quieter outlets) was effectively a functional choice and one that appears to have worked for many hard-pressed consumers in china consulted in this study. transparently, there will be specific local factors in other countries. italy, for instance, has a notably low penetration rate for internet grocery shopping (some times lower than that of the uk). in contrast as noted above, internet grocery shopping has grown rapidly in china -and especially so in south korea, also affected by this pandemic, with its fast internet and high population densities as key structural facilitators. overall, this study has attempted to offer a retail-focused insight to the early development stages of the covid- outbreak in china. many people -most of whom would not go on to be affected by the pathogenwere advised to self-quarantine but without any clear behavioural precedents on which to work. as in venice, milan, madrid, paris, new york and other major cities affected by the coronavirus, this involved a sudden, immediate and major disruption to one of the most common market processes: food retailing. this research note, albeit not in a conclusive manner, attempts to nevertheless shed some light on how such a large number of people initially sought to find food supplies under unusual, difficult and rapidly changing circumstances. what has emerged since our data gathering is that countries, and their citizens, have varied in their preparedness and responsiveness. it is alleged that in the british government felt able to ignore warnings of a potential future shortage of ventilators and protective equipment: the very shortage it now faces. surely similar errors cannot be repeated in the future. nevertheless, our focus is on consumer responses to covid- . our data relate to the first time-period when residents faced the rapid removal of options to buy food. they had no precedents on which to rely on aside from the sars pandemic of - , which was far less virulent due to the specific characteristics of the pathogen's strain involved. in the case of the covid- outbreak and subsequent global pandemic, a large proportion of governments around the world, including the chinese government, acted to close down retail outlets on which many relied for food -including restaurants, cafes, bars and, in the uk, the traditional 'pub' -with a dramatic impact on the service sector and, more specifically, catering, hospitality, food retail and their wider supply chains. similarly, in china and elsewhere social distancing and self-quarantine measures were introduced by governments, which varied considerably from one country to another in terms of their severity. the still-functioning food system, however, is and remained a free market operation, even when it has long been known that home delivery is not cost-effective for retailers. on occasions of food stockpiling or instances of buying excessive amounts of food, as experienced in much of europe, australia and other western economies, it was the decision of retailers -not national governments -that this should be curbed. one of the key findings of this study is that a significant response from consumers was to switch their food shopping to online channels; a trend copied in several other countries where internet shopping and home deliveries were available options. in the case of the united kingdom, as kirby-hawkins et al. ( ) revealed, consumer take-up of internet shopping was exhibiting clear trends well before the covid- crisis. none of those trends particularly favoured the older, less mobile, less wealthy, less tech-savvy shoppers who have been the ones most affected by government 'lock-down' policies related to the covid- crisis only to compound the fact that many of these groups, certainly more elderly consumers, remain particularly vulnerable to this pandemic physically and mentally. given that the heaviest internet users tend to be younger, wealthier, but time-pressed, home deliveries of food purchases made online have become difficult due the lack of availability of delivery slots. this is often affecting particularly the more vulnerable groups discussed here. however, further research is required to analyse how these dynamics are affecting consumers, including whether more elderly consumers have had little option but to come out of self-isolation to buy their food in supermarkets, markets or local shops and, in doing so, increasing their risk of contracting the virus. the same issue applies to ethnic minorities and socio-economically disadvantaged groups, as there is a growing body of evidence showing that they have been disproportionately affected by this pandemic in the united states, the united kingdom and other european countries. future policy research must surely address how those most affected can reliably obtain basic food under future pandemic conditions. overall, this study has attempted to offer a retail-focused insight to the implications of the early development stages of the covid- outbreak in china. as we have stressed, many people -most of whom would not go on to be affected by the pathogen -were advised to self-quarantine but without any clear behavioural precedents on which to work. as in venice, milan, madrid, paris, new york and other major cities affected by the coronavirus, this involved a sudden, immediate and major disruption to one of the most common market processes: food retailing. this research note, albeit not in a conclusive manner, attempts to nevertheless shed some light on how such a large number of people initially sought to find food supplies under unusual, difficult and rapidly changing circumstances. the theory of planned behavior crisis management and recovery: how restaurants in hong kong responded to sars european food cultures: an exploratory analysis of food related preferences and behaviour in european regions the internationalisation of grocery retailing wuhan residents on coronavirus lockdown are facing food shortages. business insider supply chain logistics risks: from the back room to the board room the impact of the severe acute respiratory syndrome on hotels: a case study of hong kong ministry of commerce: increase the supply of rice, oil, meat, eggs, vegetables, etc". (商务部:切实增加 粮油、肉类、蛋、蔬菜等市场供应) novel coronavirus (covid- ) outbreak market rules and territorial outcomes: the case of the united states retail restructuring and consumer choice : long-term local changes in consumer behaviour internet or store? an ethnographic study of consumers' internet and store-based grocery shopping practices socio-economic impacts of novel coronavirus: the policy solutions store closings and retailer profitability: a contingency perspective the role of online shopping and fulfilment in the hong kong sars crisis the transfer of retail formats into developing economies: the example of china food retailing consumer values, the theory of planned behaviour and online grocery shopping coronavirus capital by capital: how are europeans coping with shutdown? bbc news tourism in a world with pandemics: local-global responsibility and action sars: lessons in strategic pplanning for hoteliers and destination marketers prospect theory: an analysis of decision under risk korean consumers' patronage of discount stores: domestic vs multinational discount store shoppers' profiles wal-mart korea: challenges of entering a foreign market the influence of structural changes in a local commercial district on local consumer consumption behavior in south korea: using the multinomial logit model tesco in korea: regulation and retail change an investigation into the geography of corporate e-commerce sales in the uk grocery market estimating the impact of avian flu on international tourism demand using panel data assessing impacts of sars and avian flu on international tourism demand to asia modelling risk perception and trust in food safety information within the theory of planned behaviour the overreaction to sars and the collapse of asian tourism coronavirus: , high street shops that have closed during lockdown will never reopen. the mirror managing disruptions in supply chains: a case study of a retail supply chain covid- impact on fruit and vegetable markets a couple in china on living and cooking under coronavirus lockdown the grocers: the rise and rise of the supermarket chains examining consumer behavior toward genetically modified (gm) food in britain organizational challenges and strategic responses of retail tncs in post-wto-entry china nudge: improving decisions about health, wealth, and happiness unidimensional conjoint measurement models and consumer decisionmaking retail structure of beijing the impacts of sars on the consumer behaviour of chinese domestic tourists food scares: a comprehensive categorisation available at <https://covid .who.int/>. accessed on aldi and the german model: structural change in german grocery retailing and the success of grocery discounters the deadly coronaviruses: the sars pandemic and the novel coronavirus epidemic in china key: cord- - pp spjw authors: gundersen, craig; hake, monica; dewey, adam; engelhard, emily title: food insecurity during covid‐ date: - - journal: appl econ perspect policy doi: . /aepp. sha: doc_id: cord_uid: pp spjw for a decade, feeding america's map the meal gap (mmg) has provided sub‐state‐level estimates of food insecurity for both the full‐population and for children. along with being extensively used by food banks, it is widely used by state‐ and local‐governments to help plan responses to food insecurity in their communities. in this paper, we describe the methods underpinning mmg, detail the approach feeding america has used to make projections about the geography of food insecurity in , and how food insecurity rates may have changed due to covid‐ since . we project an increase of million americans who are food insecure in but this aggregate increase masks substantial geographic variation found in mmg. this year represents the tenth anniversary of feeding america's map the meal gap (mmg). on an annual basis, mmg provides county-and congressional district-level estimates of food insecurity for both the full-population and for children and, upon request, sub-county-level results at, for example, the zip-code level. along with being extensively used by food banks to direct scarce resources to those most-in-need, it is now widely used by state-and localgovernments to help plan responses to food insecurity in their communities. for mmg, food insecurity rates are calculated with an imputation method that uses information from the current population survey (cps) and the american community survey (acs). since the core food security module (csfm) is in the december cps and the resulting data isn't publicly released until september of the following year and the acs isn't released until december, this has meant that mmg, released in the spring, is based on data that is roughly months old. given that post-great recession, rates have remained relatively stable from year-to-year as have geographical differences within and across states, this release schedule has not produced issues regarding timeliness. of course, covid- has changed all of this and, given the sharp projected increases in unemployment (and, hence, food insecurity) the levels of food insecurity across the united states are likely to be far higher in than in . in this article, after describing the methods underpinning mmg, we detail the approach feeding america has used to make projections about the geography of food insecurity in and how this may differ from . central to these projections is that the methods used in mmg allow for us to do this when information about predictions of the underlying variables are available. we then turn to a description of multiple aspects of this changed geography of food insecurity. this article is protected by copyright. all rights reserved. the official measure of food insecurity in the u.s. as established by the usda uses responses to questions about food hardships due to financial constraints experienced by households ( for households without children and for households with children). examples of survey questions include: did you or the other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money for food?). were you ever hungry but did not eat because you couldn't afford enough food? and did a child in the household ever not eat for a full day because you couldn't afford enough food? (the most severe question). (for the complete set of questions, see coleman-jensen et al. .) the responses for these questions are sometimes, yes or no. in other cases, respondents are asked if something happened never, sometimes, or often. a response of sometimes or often is counted as an affirmative response. other questions ask respondents if something happened almost every month, some months but not every month, or in only or months. a response of almost every month or some months but not every month is counted as an affirmative response. based on these responses, households are delineated into three categories: a household is said to be food secure if they respond affirmatively to two or fewer questions; low food secure if they respond affirmatively to three to seven questions (three to five questions for households without children); and very low food secure if they respond affirmatively to eight or more questions (six or more questions for households without children). food insecure households are those without access at all times to enough food for an active, healthy life for all household. the questions employed in mmg to define food insecurity are the same as those used by the usda since to define food insecurity. we proceed in two steps to estimate the extent of food insecurity in each county (congressional district). step ( ) where s is a state, t is year, un is the unemployment rate, pov is the non-undergraduate student poverty rate, mi is median income, hisp is the percent hispanic, black is the percent african-american, own is the percent of individuals who are homeowners, dsbl is the percent of individuals who report a disability, μ t is a year fixed effect, υ s is a state fixed effect, and ε st is an error term. this model is estimated using weights defined as the state population. in previous iterations of mmg we used data back to but the disability variable is only available since and, hence, why the model is estimated from to . our choice of variables was first guided by the literature on the determinants of food insecurity. we included variables that have been found in prior research to influence the probability of a household being food insecure. (for an overview of that literature in this context see gundersen and ziliak, .) while the food insecurity measure is defined at the household level, we assume all members of a food insecure household are food insecure consistent with the this article is protected by copyright. all rights reserved. accepted article approach found in, e.g., table of coleman-jensen et al. ( ) . next, we chose variables that are available both in the cps and the acs. step : we use the coefficient estimates from step plus information on the same variables defined at the county level to generate estimated food-insecurity rates for individuals defined at the county level. this can be expressed in the following equation: where c denotes a county. this is because the true resources available to undergraduates are, on average, not reflected in the poverty rate. consistent with this are the much lower food insecurity rates among college students in comparison to non-college students of similar ages (gundersen, ) . the above methods allow us to establish a base measure of food insecurity for all counties for the full population and for children. using this base measure, we establish what we believe will happen to food insecurity in the u.s. in because of the covid- pandemic. to do so, we consider what will occur if two of the variables in the model above, the unemployment rate and the poverty rate, increase along the lines predicted by expert opinions. (the other variables in our model are unlikely to change due to covid- .) in our most recent estimates of the upper-bound impact (as of july , ), we have assumed that the annual this article is protected by copyright. all rights reserved. accepted article average unemployment rate will increase to . % (up . percentage points compared to ) and the poverty rate will increase to . % (up . percentage points compared to ). when we wrote the first version of this paper, there had not been expert projections of changes in poverty rates due to covid- so we assumed that the proportional change in the poverty rate viz. the unemployment rate would be roughly the same as during the great recession. to put this into terms of equation ( ), we assume the value of un c will increase (on average) by . and the value of pov c will increase by . . this increase in the unemployment rate, though, is unlikely to be uniform across all counties in the u.s. instead, certain industries and occupations will be disproportionately affected by covid- . so, we further adjust the county-level and cd-level unemployment projections for the proportion of the population that is likely to lose their jobs, combining data from the american community survey with estimates established in hatzius et al. ( ) . at the national level, we project million food insecure americans in , approximately million higher than in . for children, the food insecurity rates are projected to increase to million, up nearly million from . these national estimates, though, mask substantial heterogeneity across the country in terms of the projected impacts of covid- . this is not unexpected given the geographic diversity in the base models for both the full population ( figure ) and children (figure ). looking at states, the highest five states are the same whether or not covid- occurred -mississippi, arkansas, alabama, louisiana, and new mexico. however, there are some states that will see much higher food insecurity rates. nevada stands outpre-covid- it would this article is protected by copyright. all rights reserved. accepted article have been th but post-covid- it is projected to be th . for children, louisiana and new mexico are first and second with or without covid- but nevada is now third (ninth without covid- ). the substantially higher projected rates for nevada is primarily due to their reliance on service sector jobs which have been disproportionately affected by covid- . one of the key contributions from mmg is its portrayal of the substantial heterogeneity in local food insecurity that is seen in figures and . the responses to covid- will also vary based on geography albeit, consistent with the state results, there is likely to be some similarities in terms of county rankings. for the full population (table ) , we display, first, the counties with the highest rates of food insecurity in the base case and due to our projections. in the base case, the counties are all in the south or counties with indian reservations. the highest is jefferson county, mississippi ( . %) and the th is harlan county, kentucky ( . %). without the adjustments for county-level differences in unemployment rates described above, these would be the same orderings after covid- but, due to these adjustments, there are some differences. the five highest remain the same but, for example, washington county, mississippi and wolfe county, kentucky are now in the top . in the final two columns of table we display the projected percent increases in food insecurity for the highest counties. these are all counties with base rates that are relatively low and, hence, this is the reason for the dramatic increases. the increases range from . % in the highest (burke county, north dakota) to . % in the th highest (daggett county, utah). these dramatic increases may be one reason for why some food banks reported being especially strained in response to covid- . the proceeding discussionand the full set of results with updates as needed at http://map.feedingamerica.org/ -provides an overview of the geographic diversity in food insecurity rates across the u.s. and what may happen due to covid- . we conclude with three main points. first, while these projections of increased food insecurity rates are of great concern, they would have been for worse were it not for the resiliency of the agricultural supply measuring food insecurity during the covid- pandemic of spring food insufficiency and children with special healthcare needs food insecurity across the adult life span for persons with disabilities household food security in the united states do walmart supercenters improve food security? do high food prices increase food insecurity in the united states? are college students more likely to be food insecure than non-college students of similar ages? applied economic perspectives and policy. forthcoming food insecurity research in the united states: where we have been and where we need to go the sudden stop: a deeper trough, a bigger rebound key: cord- -d kqobp authors: dewitt, emily; gillespie, rachel; norman-burgdolf, heather; cardarelli, kathryn m.; slone, stacey; gustafson, alison title: rural snap participants and food insecurity: how can communities leverage resources to meet the growing food insecurity status of rural and low-income residents? date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: d kqobp the burden of obesity disproportionately influences poor health outcomes in rural communities in the united states. various social and environmental factors contribute to inadequate food access and availability in rural areas, influencing dietary intakes and food insecurity rates. this study aims to identify patterns related to food insecurity and fruit and vegetable consumption within a snap-eligible and low-income, highly obese rural appalachian community. a prospective cohort was implemented to identify gaps in resources addressing obesity and food insecurity challenges. sas . software was used to examine differences in dietary intakes and shopping practices among snap participants. among participants (n = ), most reported an annual household income less than usd , (n = , . %), . % reported food insecurity, and . % reported receiving snap benefits within the last month. the overall mean fv intake was . daily servings ( % ci: . – . ) among all participants. snap participation was associated with food insecurity (p = . ) and those participating in snap were two times more likely to report being food insecure (or = . , % ci: . , . ), relative to non-participants. these findings further depict the need for intervention, as the burden of food insecurity persists. tailoring health-promoting initiatives to consider rurality and snap participation is vital for sustainable success among these populations. the burden of obesity and related chronic diseases disproportionately affects rural communities in the united states (u.s.) more so than their urban counterparts [ ] . theories of social disorganization suggest that the intersection between community structure, such as poverty, socioeconomic status (ses), and residential instability, can result in a void of health promoting culture, infrastructure, and efficacy [ , ] . previous insights have shown disparaging differences between urban and rural areas on mortality, chronic disease, and screening rates [ , ] . residents' limited knowledge of health promoting behaviors may lead to poor health literacy and unhealthy lifestyle behaviors, including poor dietary intakes and sedentary physical activity levels [ ] [ ] [ ] . thus, the degree of rurality among geographic areas throughout the u.s. influences the numerous barriers rural communities face and, consequently, their morbidity and mortality rates. among rural populations, myriad factors affect obesity rates, though fruit and vegetable (fv) intakes are of great influence and few u.s. adults are meeting recommended amounts [ ] . this is particularly true in rural communities, where adults exhibit higher obesity prevalence and are less likely to meet daily fv recommendations due to various social and environmental factors [ , ] relative to their urban counterparts. in addition to individual level factors associated with poor dietary intake, rural residents also face greater rates of food insecurity [ ] . a depleted or limited food landscape can predispose residents' dietary consumption and shopping patterns thereby further influencing their health status, as diet is a contributing factor in several chronic illnesses [ ] . while agriculture and food production are prominent in many rural landscapes across the u.s., it is not the case for all rural communities. rurality does not equate to farmland or local food production, which many would think support food security within these communities. further, the census of agriculture revealed a decline in number of farms and farmers and in acres of farmland and farmland production [ ] . at the local level, there are numerous factors that dictate food production, including geography, terrain, and inadequate resources such as economic hardship or lack of farmers. those who do operate small farms rely on additional off-farm sources for household income [ ] . these factors can also influence the household food environment in rural areas. among low income rural populations, the household food environment, including food security and income concerns, are key factors controlling food choice [ ] . rural communities continue to face higher rates of food insecurity, compared with their urban counterparts [ ] , and food insecurity has been associated with obesity and greater cardiometabolic risk [ ] . the supplemental nutrition assistance program (snap) is the largest federally funded nutrition program in the u.s., serving as a household-supporting infrastructure for individuals facing food insecurity. snap assists eligible, low-income individuals and families in need throughout the u.s. [ ] . while eligibility varies by state, those whose income and resources fall below certain thresholds are able to supplement their food budgets using snap benefits [ ] . thus, snap is often considered a vital resource for those living in rural communities, as the perpetual ses divide continues between rural and urban settings [ ] . at the national level, approximately % of those living in rural communities live below the federal poverty line, compared with % in urban areas [ ] . due to these income gaps, snap participation is higher in rural areas, with % of households participating, compared with % in urban areas [ ] . additionally, most recent federal data from indicate that of those eligible for snap, participation is higher in rural areas ( %) compared to urban areas ( %), and this participation gap continues to climb [ ] . rural areas account for % of counties in the u.s., and % of counties with the highest rates of food insecurity [ ] . furthermore, a report from indicates that . % of those living in rural areas faced food insecurity, compared with . % in urban areas [ ] . resources, such as snap benefits, and other programs for those of low ses, are imperative for those in rural communities, as many in these areas are at risk of being food insecure. thus, initiatives like snap can aid in alleviating food insecurity among vulnerable households and improve dietary intakes, when adequate access to nutritious choices are available [ ] . community-based efforts have emphasized the importance of looking at social and physical environments when striving to improve food access [ ] [ ] [ ] . therefore, community-based efforts focused on addressing the local food system are necessary to alleviate the barriers related to the procurement of nutritious foods in rural areas. prioritizing engagement with key stakeholders and community members is vital to consider how to best approach food access initiatives in rural communities. conceptually, community-based efforts can be successful in rural communities, as the multifaceted community setting plays a vital role in influencing the food environment and, ultimately, diet choice in these communities. improving health outcomes pose unique challenges, as resources are sparse and healthcare infrastructure is limited; however, modifying or improving the existing food environment encourages nutritious food choices and shopping behaviors. nonetheless, environmental triggers and product availability affect the dietary choices individuals make, influencing overall health and obesity status [ ] . given the unique limitations rural communities face, exploring frequented destinations to assess availability can be beneficial to mitigating the barriers that exist [ ] . knowing one's food environment, snap participation, and food insecurity status can influence diet quality, an understanding of the interrelationship among these factors can provide guidance for intervention. this study aims to identify patterns related to fv consumption and food access within a snap-eligible and low-income, highly obese rural appalachian county in kentucky. these findings will serve as a baseline to provide context for addressing food insecurity in a remote rural region of the u.s. baseline findings will guide points of intercept, design future programming to explore the impact rurality has on obesity status, and address the barriers related to accessing nutritious foods within this community and those similar. the present study is part of a multi-year high obesity program (hop) project through the centers for disease control and prevention (cdc) to reduce rural obesity prevalence and decrease the risk of chronic disease and preventable mortality. this paper describes one component of the hop project aimed at providing increased geographic or financial access to nutritious foods. efforts to improve food access will address food insecurity. this work was completed by leveraging existing cooperative extension (ces) infrastructure, with an emphasis placed on community partnership and empowerment, thus enforcing action via established community infrastructure. the cdc funding announcement identified eligible counties across the u.s. based on their obesity prevalence. the setting for this funded project was one eligible appalachian county in kentucky with an adult obesity prevalence greater than % per the cdc. the appalachian region of the u.s. has continued to experience significant decline in life expectancy [ ] , lack of economic development, and stark out-migration, leaving once fervent and thriving communities destitute, impoverished, and struggling to prosper [ ] . this community is reflective of the region, experiencing a persistently high rate of poverty and unemployment, low educational attainment, and food insecurity. the cdc's social vulnerability index, comprised of social and economic indicators, designates the county as "highly vulnerable." [ ] the county population is approximately , , and declining, with a median household income of usd $ , and an estimated % of the population living in poverty [ ] . the estimated food insecurity rate is %, and approximately % of households participate in snap [ , ] . in order to assure broad community input into all program activities, a health coalition was formed, comprised of key stakeholders including local officials (mayor, magistrates), school representatives (food service director, family resource coordinators), library director, concerned citizens, health department representatives, faith-based organization representatives, and community advocates. the health coalition has been pivotal in establishing partnerships to improve health outcomes within the community. it continues to provide input and direction for all aspects of the current project to identify and implement nutrition-related strategies to address the issue of obesity in the county. the current study aims to identify gaps in community resources to establish new partnerships that address obesity and food insecurity challenges. therefore, a formative food system assessment was conducted at baseline to identify potential areas for intervention to enhance healthier food procurement options. figure outlines the community's primary food access points identified through the food systems assessment. findings from the assessment were shared with the coalition to identify potential programmatic efforts to reduce food insecurity within the community. in alignment with the aim of this study, and to complement community efforts, a prospective cohort was enrolled at baseline for a longitudinal study. the prospective cohort study included a face-to-face survey that occurred in year and will again at years and . the university of kentucky institutional review board (irb) approved the research, promotional materials, consent forms, and survey instrument. in summer , messages on the county's ces facebook page recruited community residents interested in participating in the cohort study. the ces office, a local food pantry, several faith-based organizations, and grocery stores in the county distributed recruitment materials. furthermore, recruitment occurred through current community programs offered at the ces office. recruitment messaging continued until enough individuals enrolled to meet the required sample size, which allowed for attrition. participants were excluded if they were under years of age, lived outside the county, were non-english speaking, reported plans to move within the next three years, had lived in the county for less than one year, or if they had been diagnosed with cancer. invited study participants completed the survey via a face-to-face meeting. prior to survey administration, interviewers verbally reviewed key points of the consent form with participants, who then reviewed the full consent form independently, and provided an opportunity to ask questions or to decline participation. once deemed eligible, and agreeable to participation, the participant signed the informed consent form and enrolled in the study. a statistical power analysis was performed for sample size estimation and a proposed sample size of adults were recruited to allow for expected attrition. the prospective cohort study surveys were administered at three locations in the county on various days in fall : the ces office, a local food pantry, and the senior citizens center. the initial date of administration had greater turnout than anticipated by study personnel; several surveys were self-administered as a result (n = ). moving forward, study personnel modified recruitment processes to schedule appointments for each eligible participant to partake in a verbally administered survey. those interested contacted study personnel or the county's ces office to schedule a day and time to participate. this resulted in fewer ineligible participants and complete survey responses. the in alignment with the aim of this study, and to complement community efforts, a prospective cohort was enrolled at baseline for a longitudinal study. the prospective cohort study included a face-to-face survey that occurred in year and will again at years and . the university of kentucky institutional review board (irb) approved the research, promotional materials, consent forms, and survey instrument. in summer , messages on the county's ces facebook page recruited community residents interested in participating in the cohort study. the ces office, a local food pantry, several faith-based organizations, and grocery stores in the county distributed recruitment materials. furthermore, recruitment occurred through current community programs offered at the ces office. recruitment messaging continued until enough individuals enrolled to meet the required sample size, which allowed for attrition. participants were excluded if they were under years of age, lived outside the county, were non-english speaking, reported plans to move within the next three years, had lived in the county for less than one year, or if they had been diagnosed with cancer. invited study participants completed the survey via a face-to-face meeting. prior to survey administration, interviewers verbally reviewed key points of the consent form with participants, who then reviewed the full consent form independently, and provided an opportunity to ask questions or to decline participation. once deemed eligible, and agreeable to participation, the participant signed the informed consent form and enrolled in the study. a statistical power analysis was performed for sample size estimation and a proposed sample size of adults were recruited to allow for expected attrition. the prospective cohort study surveys were administered at three locations in the county on various days in fall : the ces office, a local food pantry, and the senior citizens center. the initial date of administration had greater turnout than anticipated by study personnel; several surveys were self-administered as a result (n = ). moving forward, study personnel modified recruitment processes to schedule appointments for each eligible participant to partake in a verbally administered survey. those interested contacted study personnel or the county's ces office to schedule a day and time to participate. this resulted in fewer ineligible participants and complete survey responses. the administered survey took approximately - min to complete. participants received a usd $ incentive to be used a local grocery store as compensation for completing the survey. the survey instrument utilized for this cohort comprised a variety of items to measure fv intake, household environmental measures, food purchasing practices, and demographic characteristics. demographic items in this analysis included age (in years), gender, preferred language, residential status, highest attained education level, race, and annual household income. snap participation was assessed by asking: "in the past month, did you or any member of your household receive snap benefits or food stamps?" response options included 'yes' or 'no'. questions from the national cancer institute (nci) fruit and vegetable intake screener [ , ] assessed fv intake. the nci screener asks respondents about usual intake of various fv, ranging from never to ≥ times per day, and portion sizes for every item (e.g., "over the last month, how many times per month, week, or day did you eat fruit?" and "each time you ate fruit, how much did you usually eat?"). items include % fruit juice, fruit, lettuce salad, french fries or fried potatoes, other white potatoes, cooked dried beans, other vegetables, tomato sauce, vegetable soup, and the survey instrument utilized for this cohort comprised a variety of items to measure fv intake, household environmental measures, food purchasing practices, and demographic characteristics. demographic items in this analysis included age (in years), gender, preferred language, residential status, highest attained education level, race, and annual household income. snap participation was assessed by asking: "in the past month, did you or any member of your household receive snap benefits or food stamps?" response options included 'yes' or 'no'. questions from the national cancer institute (nci) fruit and vegetable intake screener [ , ] assessed fv intake. the nci screener asks respondents about usual intake of various fv, ranging from never to ≥ times per day, and portion sizes for every item (e.g., "over the last month, how many times per month, week, or day did you eat fruit?" and "each time you ate fruit, how much did you usually eat?"). items include % fruit juice, fruit, lettuce salad, french fries or fried potatoes, other white potatoes, cooked dried beans, other vegetables, tomato sauce, vegetable soup, and mixtures that included vegetables. summed items created an overall measure of fv intakes among the sample. this measure served as the primary dependent variable for analysis because increased fv intake is a primary goal of the cdc hop project. the secondary dependent variable, food insecurity, was assessed by asking "which of the following statements best describes the amount of food eaten in your household in the last days?"-enough food to eat, sometimes not enough to eat, or often not enough to eat [ ] . "sometimes not enough to eat" and "often not enough to eat" were collapsed into "not enough food to eat" to create a dichotomous assessment of food insecurity. potential covariates of interest included gender, income, education, and years of residency. to minimize skewedness, income, education level, and residential status categories were collapsed: income was dichotomized as <usd $ , /year or ≥usd $ , /year; education categorized as less than high school degree or high school degree or more; and years of residency was dichotomized into < years or ≥ years. data were entered into redcap (vanderbilt university, nashville, tn, usa) by trained study personnel and were double-checked to minimize data entry errors. data were then exported, and analyses were conducted using sas . (sas institute, cary, nc, usa). for all analyses, significance was set at p < . . descriptive statistics, including frequencies and medians, were used to characterize survey responses. the nci food frequency scores were calculated using the published algorithms [ ] . to test comparisons across groups, wilcoxon rank sum tests were used for continuous measures (age, fv consumption patterns) and chi-square and fishers exact were utilized, as appropriate, for categorical measures. logistic regression models were fit to assess the predictors of food insecurity. since fv servings per day were skewed, the data were log transformed and fit with a generalized linear model. models were adjusted for age, gender, snap participation, residency, and income. table details the characteristics of the cohort study population and those of the martin county population. of those who registered, there were participants consented and enrolled in the baseline cohort. participants (n = ) had a mean age of years, with the majority (n = , . %) identifying as female. most participants reported an annual household income less than usd $ , (n = , . %) and . % report receiving snap benefits within the last month. table outlines household shopping practices. respondents shop at grocery stores ( %) or supercenters ( %) and primarily shop there due to price ( %) and location ( %). these practices were not significant when stratified by snap participation. participation in snap was associated with an awareness of the farmers' market (p = . ), yet not with regularly shopping at this venue (p = . ). findings from the regression analyses are in table . among all participants, the overall mean fv intake was . daily servings ( % ci: . - . ). males not participating in snap ( . servings; % ci: . - . ) and females participating in snap ( . servings; % ci: . - . ) reported highest fv intakes within the sample. there is no significant effect for daily fv intake by residency or education. among all participants, . % reported food insecurity, with a greater percentage of snap participants reporting being food insecure ( . %) than non-participants ( . %). logistic regression models indicate that snap participation was associated with food insecurity (p = . ) compared to those not participating in snap. those participating in snap were two times more likely to report being food insecure relative to non-participants (or = . , % ci: . , . ). when examining food insecurity and dietary intake by snap participation stratified by gender (table ), the effect of snap participation on food insecurity was stronger for females (or = . , % ci: . - . ), but not significant for males. it is clear among the literature that numerous factors contribute to high obesity prevalence, including poor nutrition, absence or lack of physical activity practices, and the environment [ , , ] . residents of rural communities experience greater obesity prevalence and limited access to healthy choices related to the environments in which they live [ ] . these factors shape rural residents' behaviors, and are well understood as influencing obesity prevalence. additionally, attention to the food environment is imperative in order to increase consumption of healthier foods within rural communities. access to healthy foods, such as fv, must be a grounding consideration of obesity prevention efforts within disadvantaged communities such as those found in rural appalachia. rural communities typically face greater financial burden compared with urban communities, particularly in the south, [ ] and low household income augments obesity prevalence [ , ] . we did not specifically investigate income within this sample because of collinearity between income and snap participation. therefore, we used snap participation as our independent variable to measure ses, given that nearly two-thirds of the current population report an annual income less than usd $ , and nearly half receives snap assistance. our findings illuminate a growing trend between rural residency, snap participation and food insecurity. it is interesting to note that snap participants were more likely to report being food insecure, suggesting immediate intervention is necessary within this population living in an impoverished community. previous studies have found snap participation to improve food security [ ] ; however, our data suggest that those in snap are currently experiencing high rates of food insecurity. this paradox reveals high rates of reported food insecurity despite snap participation, leading to questions of adequate parameters or potential pitfalls. perhaps snap alone is not sufficient to reduce food insecurity, yet is a necessary factor to help prevent higher rates among those who are eligible for snap participation. some suggest that snap participants have lower fv intakes due to unobserved preferences [ ] while others have found snap participants would be more food insecure if benefits were not available [ ] . thus, improving diet quality while simultaneously combating food insecurity requires nuance. although snap participation provides an avenue to food security, it is clear that when compounded by additional factors, such as the economic disparities this rural appalachian community experiences, it does not equate to consistent nutritional nourishment for these areas. furthermore, rurality and geographic location are important factors to consider when it comes to food security and snap participation. previous studies have even shown that rural geography contributes to differences in food perceptions and purchasing patterns, due to differences in access and availability [ ] [ ] [ ] . this could explain, at least in part, the barriers in the appalachian region. the appalachian region includes all or parts of states where % of the population is rural, compared with only % throughout the u.s. [ ] . appalachian communities experience a high propensity for food insecurity and poverty. across the appalachian region, the median household income is approximately usd $ , , compared to usd $ , across the u.s. [ ] . further, the central appalachian region, which includes all of the appalachian counties in kentucky, maintains an annual household income of usd $ , [ ] , which may mean these communities are more disadvantaged than other rural and appalachian communities across the u.s. our findings further identify martin county as representative of a geographically isolated and persistently impoverished area in central appalachia with exacerbated food insecurity. snap participation could be a mitigating factor to improve diet quality and food security among food insecure individuals [ , , ] . thus, food access initiatives must also consider affordability and snap participation with obesity prevention efforts focused on improving diet quality. our study also reveals that gender may influence food insecurity and would be valuable to examine in future investigations. gender was the only covariate that had a significant effect within our sample, suggesting it may be more salient in terms of food insecurity among rural residents. the effect being stronger for females could have occurred for various reasons, including differences in other constraints for food insecurity between men and women, though we did not explore this relationship in the present study. examining the relationship between gender and food insecurity will aid in understanding why individuals in rural communities are able or unable to access healthy foods. although increasing access to nutritious foods, including fv, may be challenging in a community with limited income, it is possible [ ] [ ] [ ] . rural communities continue to struggle with food accessibility within the retail food landscape, and in a particularly impoverished community, such as the one of this study, addressing the mechanisms and avenues that support food access is imperative. recently, covid- incidence has shed light on the disparities that exist between low-income and higher income households [ ] . rates of food insecurity have risen dramatically in the u.s., given a host of factors related to covid- virus [ ] . thus, current programmatic and intervention efforts are critical to assist communities in dire need. further, as figure depicts, much of the existing food system is heavily reliant on food assistance programs such as food pantries, usda subsidized commodity foods, and small-scale church assistance [ ] . therefore, a mode of improving health status and dietary consumption would be to target these outlets and enhance offerings to individuals that utilize this network of need-based food assistance. while environmental modifications are pivotal for sustained change, so too are policy considerations. the implications of these baseline findings align with the opportunities laid out for federal nutrition research within the u.s. [ ] . this work allows us to grasp the influence of the food environment and other environmental determinants on health disparities, as well as potential relevant solutions. it is evident that policies that dictate federal nutrition program funding and allocation must consider social determinants of health within vulnerable populations. these findings also illuminate the broader systemic issues that underpin the growing rates of food insecurity within these regions exacerbated by the covid- pandemic. currently, snap is the only federal nutrition support offered during covid- , in the form of emergency allotments, adjusted verification requirements, and expanded benefits to children [ , ] . while these policy changes are temporary, they highlight larger issues and provide a platform to build upon for future research and policy development. our findings demonstrate that providing snap benefits alone is not sufficient to eliminate food insecurity in rural populations. thus, we need stronger policies that improve how we reach all vulnerable populations with improved food access. collectively, these findings elucidate the need for intervention, as the burden of obesity and food insecurity are major public health concerns that frequently coexist within rural communities. however, tailoring interventions to rural appalachian communities, and other communities with unique needs such as these, is vital to implement sustainable solutions successfully. thus, these factors should be considered together in order to construct an understanding of the intricate interrelationship between them. in rural appalachian communities with fewer resources, using existing assets and infrastructure are critical for community-based efforts related to food system enhancements [ ] . while we are not directly influencing individual behavior with future interventions, traditional ces programing encompasses direct education focused on food procurement, preparation, preservation, and nutrition. researchers cannot neglect these concepts when implementing community-level systems or environmental changes. obesity prevention efforts must be multifaceted to address all levels of the socio-ecological model. these data create a critical baseline for a prospective cohort study that will allow us to measure the ongoing work of the cdc hop project in martin county. since the time of survey administration, several strategies have been implemented, or will be considered for implementation, to encourage healthy eating and active living as a well-rounded approach for obesity reduction and prevention. these strategies include nutrition and environmental audits of gas stations and grocery stores [ , ] , a community garden [ ] , an in-store marketing initiative [ , ] , a community-wide walking challenge [ , ] , and enhancements to existing walking trails in partnership with the public library [ ] . these approaches have led to the formation of additional partnerships within the community emphasizing healthy lifestyle behaviors. collectively, these projects and partnerships further augment healthy eating and active living initiatives aimed at reducing obesity in this highly obese community. the generalization of the study findings is limited due to the study's sample of participants from one rural appalachian county in kentucky, which may not be representative of all rural communities in kentucky, or in other states. while verbally administered by a trained interviewer, self-reported survey responses may include social desirability or recall bias and other errors. we aimed to minimize bias by including validated survey instruments. furthermore, researchers verbally administered the survey to reduce concerns of participants with low literacy and to reduce the likelihood of missing data due to skipping questions or not following question instructions. this format also aided in reducing survey fatigue, as the survey was pages long. a portion of surveys were self-administered; however, sensitivity analyses conducted between self-administered and verbally administered surveys revealed no significant differences in findings. results of the analyses are available upon request. because our survey was cross-sectional, we are unable to determine causality with these results. moreover, these are baseline data used to understand the priority population. thus, we are not powered on interactions and results should be interpreted with caution. however, these data represent the baseline findings of a longitudinal study, which will eventually allow us to estimate causal relationships. the findings of this study support continued collaboration with community networks to identify and implement strategies to address accessibility of nutritious foods. while obesity prevention efforts continue in rural areas, this community's high obesity prevalence, coupled with low fv intakes and high food insecurity, suggests community-based efforts aimed at improving healthy food access would prove beneficial. furthermore, tailored health-promoting initiatives that consider rurality and snap participation may have the greatest impact. therefore, important next steps include leveraging existing relationships with local food providers to encourage healthier choices via food pricing and marketing strategies at their venues. additional collaboration with local partners, such as a community health coalition and the ces, is vital to appropriately design and implement programs that consider these specific identifiers and enhance access to venues offering healthy foods. prevalence of obesity among adults from rural and urban areas of the united states: findings from nhanes the relationship between rural status, individual characteristics, and self-rated health in the behavioral risk factor surveillance system rural/urban differences in self-rated health: examining the roles of county size and metropolitan adjacency spatial patterns of rural mortality. in 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american community survey the supplemental nutrition assistance program, food insecurity, dietary quality, and obesity among us adults implementing a healthy food distribution program: a supply chain strategy to increase fruit and vegetable access in underserved areas introduction of farm stands in low-income communities increases fruit and vegetable among community residents multilevel approaches to increase fruit and vegetable intake in low-income housing communities: final results of the 'live well, viva bien' cluster-randomized trial feeding low-income children during the covid- pandemic the impact of the coronavirus on food insecurity community adaptations to an impending food desert in rural appalachia, usa. rural remote health strengthening national nutrition research: rationale and options for a new coordinated federal research effort and authority snap covid- waivers covid- and food insecurity: an uneven patchwork of responses using relationships as resources in social impact investing: examining a local food movement in appalachia nutrition environment measures survey in stores (nems-s) development and evaluation measurement of nutrition environments in grocery stores, convenience stores, and restaurants in the lower mississippi delta association between community garden participation and fruit and vegetable consumption in rural missouri in-store marketing of inexpensive foods with good nutritional quality in disadvantaged neighborhoods: increased awareness, understanding, and purchasing assessment of a healthy corner store program (fit store) in low-income, urban, and ethnically diverse neighborhoods in michigan how to get a nation walking: reach, retention, participant characteristics and program implications of heart foundation walking, a nationwide australian community-based walking program community weight loss to combat obesity and disability in at-risk older adults public libraries and walkable neighborhoods this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we gratefully acknowledge the contributions to this study by jennifer hunter and would like to acknowledge the martin county cooperative extension office and the martin county health coalition for their ongoing support of this project. we would like to thank grace anderson (uk undergraduate student), haley copeland, caroline blincoe, and cora teets (uk graduate students) for their assistance with data collection and data entry. this research utilized the center for clinical and translational science redcap tool, supported by the nih national center for advancing translational sciences through grant number ul tr . the content is solely the responsibility of the authors and does not necessarily represent the official views of the nih. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord- - ynmn ua authors: lipinski, brian title: why does animal-based food loss and waste matter? date: - - journal: anim front doi: . /af/vfaa sha: doc_id: cord_uid: ynmn ua nan it matter? food loss and waste, defined most simply, refers to food and/ or associated inedible parts that are removed from the food supply chain (food loss and waste protocol, ) . (some sources make a distinction between "food loss," which occurs in the early parts of the supply chain, and "food waste" which occurs at the retail and household stages of the food supply chain. for this article, the author does not make a distinction between food loss and food waste and instead uses the phrase "food loss and waste" to encompass the entire food supply chain.) the impacts of that loss and waste are significant. according to fao estimates, this level of inefficiency results in approximately us$ billion per year in economic losses. it also results in significant environmental impacts. for example, food loss and waste is responsible for % of the world's greenhouse gas emissions (fao, ) . in fact, if food loss and waste were contained to one country, that country would be the world's third-largest emitter after the united states and china. although food loss and waste occur across the entire food supply chain, the extent and details of where that loss and waste occur vary by region and economy. figure shows the percentage of food loss and waste occurring in each stage of the food supply chain for seven key regions. in more developed regions such as north america, industrialized asia and europe, most of the loss and waste occurs toward the end of the food supply chain, at the retail and consumer levels. conversely, in developing regions, most of the loss and waste occurs at the production and storage levels. therefore, although food loss and waste is a significant problem across all countries, the solutions for addressing it differ greatly depending on the region and circumstances where it is occurring. the extent of food loss and waste also varies greatly across different types of commodities, as seen in figure . when examined by weight, fruits, and vegetables make up the largest share of global food loss and waste, due in large part to the high amount of water content. when examined by caloric content, cereals and grains make up the largest share due to their high-energy density compared with other food groups. how much animal-based food is lost or wasted? compared to other commodities, animal-based foods (e.g., meat, milk/dairy, and fish/seafood) are lost or wasted to a implications • food loss and waste is an increasingly important issue for companies and governments to address, with implications for the economy, the environment, and general human well-being. • although the amount of animal-based food that is lost or wasted is low compared with other commodities, the higher impact associated with producing animal-based food is still worth addressing. • additionally, covid- may be causing higher levels of food loss and waste in animal-based food industries. • companies within the food industry can address food loss and waste through measurement and action in their own supply chains, partnership with other businesses and through creative re-uses of food that would otherwise go to waste. much smaller degree. as in figure , animal-based foods only comprise about % of global food loss and waste. typically, animal-based foods have a higher economic value than other commodity types. this may lead to this lower rate of loss and waste since the economic effect of that loss or waste is more significant than it can be with other commodity types. the covid- pandemic may change this trend, however, due to unforeseen consequences within the animal-based food industry. although comprehensive data on how covid- have affected food loss and waste will likely not be available until , there are numerous reports of increased food loss and waste due to the closure of meat processing facilities as well as due to the closure of restaurants and other facilities where the food would otherwise be sold (corkery and yaffe-bellany, ) . although animal-based products have historically been lost or wasted less than other commodities, the effects of that lost and waste are more significant than with other types of food (university of missouri-columbia, ). one reason, as mentioned above, is the higher economic value of animal-based products. another reason is the significantly higher level of environmental inputs required to produce animal-based products. for example, when it comes to food-related greenhouse gas emissions, meat has the highest level of emissions per kilogram of food, followed by dairy (ranganathan et al., ) . reducing or preventing the loss or waste of animal-related foods, therefore, has a higher impact than other commodities and should be seen as an opportunity to achieve greater economic gains while reducing environmental costs. loss and waste? there is no single cause of animal-based food loss and waste. food is lost and wasted throughout the entire supply chain, due to a wide variety of causes and drivers. one frequent cause of loss or waste in the animal-based food industry is spoilage during storage or transport. since most animal-based foods require to be kept at cold temperatures, any disruption of a cold storage environment can lead to spoilage. another cause unique to the animal-based food industry is animal sickness, which can spread quickly through livestock and lead to unnecessary animal deaths, resulting in great loss. a third such cause is discoloration of meat that can occur not necessarily due to spoilage but merely due to oxidation. because consumers heavily rely on surface meat color when making a purchase, small spots of browning can cause consumers to reject even slightly discolored meat, which leads to waste at the retail level. on the consumer side of the supply chain, animal-based food loss and waste tends to be due to mishandling at the household level. this can be due to improper storage (such as not keeping animal-based products at a significantly cold temperature) or failure to freeze food before it spoils. the other significant cause at the household level is insufficient knowledge about how to prepare food, which can lead to food being burnt or inedible if cooked incorrectly. additionally, if consumers are not experienced preparing a meal in their own kitchen, they may unknowingly discard edible portions of food. an additional cause of animal-based food loss and waste at the consumer end of the supply chain is due to misunderstandings of the meaning of food date labels. food date labels appear in numerous forms (e.g., "best before," "sell by," and "use by") and may refer to either food quality or food safety, leading to confusion for consumers. additionally, in a recent survey, more than half of participants incorrectly believed date labeling to be federally regulated, when in fact the dates are set by manufacturers for the vast majority of products (neff et al., ) . waste by governments? food loss and waste is being addressed by governments around the world. at the international level, the most significant step has been the adoption of sustainable development goals (sdgs) by the united nations general assembly, with sdg seeking to "ensure sustainable consumption and production patterns." more specifically, the third target under this goal (target . ) calls for halving per capita global food waste at the retail and consumer levels and reducing food losses along production and supply chains (including postharvest losses) by . this target has focused attention on the issue of food loss and waste reduction and led to numerous initiatives and actions. the group champions . (named for sdg target . ) is one such initiative and describes itself as "a unique coalition of executives from governments, businesses, international organizations, research institutions, and civil society dedicated to inspiring ambition, mobilizing action, and accelerating progress toward achieving sdg target . ." members include the ceos of such prominent global food companies as nestle, unilever, sodexo, and olam international. among other activities, champions . publishes an annual report showing the progress the world has made toward achieving sdg . while also detailing what steps still need to be taken (champions . , ). national-level strategies have also been effective in addressing food loss and waste. for example, in december , the fao launched a project to help albania, armenia, the republic of north macedonia, and the republic of moldova develop strategies for food loss and waste reduction (fao, ) . the project will also develop a regional awareness-raising campaign, establish and coordinate a partnership network, and conduct training programs in postharvest handling practices and food and waste reduction. uganda, which experiences the highest amount of loss near the production side of the food supply chain, also has begun developing a national strategy to tackle postharvest losses in grains. the strategy will aim to increase general awareness, enhance postharvest management skills, and increase the availability of postharvest loss reducing technologies. countries-such as the united states, united kingdom, the netherlands, and indonesia-have also found success in forming national-level partnerships to fight food waste. this has been a successful approach because it establishes relationships between sectors and entities that often do not work together and allows them to work creatively toward a common goal. the private sector members generally share best practices and innovations across the entire food supply chain, while the more prominent public figures keep food loss and waste on the national agenda by sharing success stories with media outlets and discussing the issue at events and in the media. many countries are also enacting legislation to incentivize food loss and waste reduction. for example, in april , argentina's national plan for the reduction of food losses and waste became law. the plan includes a provision through which businesses that redistribute surplus food are protected from prosecution if someone who eats the food becomes ill, as long as the business has respected relevant laws regarding food safety and expiration dates. the new law also encourages businesses to donate food products that are near to their expiration date. in july , the food safety and standards authority of india passed a series of regulations to encourage individuals and organizations to donate food. the new regulations, which come into force in , would protect those who donate food in good faith. companies at all stages of the food supply chain have begun to realize the economic benefits of reducing food loss and waste. for most companies, the journey to food loss and waste reduction begins with measurement to understand the extent and causes of food loss and waste within their operations. the data obtained through measurement then allows for targeted interventions in the company's operation to address the most significant sources of the wastage. then, companies continue to measure and report that data over time to understand their own progress and impacts. one example comes from the company nestlé, which published a detailed case study about dairy losses across farms in countries (charad et al., ) . nestlé conducted a multiyear measurement study to understand how much milk was being lost during transportation to their factories. they found that across the countries, between % and . % of milk was being lost during transportation. although relatively small, the amount of loss totaled up to over , tonnes of milk loss across the countries. as a result, the company undertook a series of reforms to reduce these losses, including decreasing spillage, improving training and handling procedures, and applying a strict cutoff time between milking, chilling, and processing. these measures reduced the milk waste by about one-third and generated $ . million in savings for farmers and nestlé. in addition to individual action, companies have begun to work together to address food loss and waste collectively. companies from multiple sectors have formed partnerships and initiatives within their sector to encourage collective action among companies that might otherwise be competitors. for example, the sustainable rice platform, a global multistakeholder alliance of some of the world's largest rice producers and buyers, called upon its members last year to commit to halving postharvest rice losses by . the courtauld commitment, a voluntary agreement among members of the uk retail sector, has reduced food and associated packaging waste by several million tonnes since its first phase in . this sort of commitment by animal-based food businesses would be a powerful step toward reducing the impacts associated with food loss and waste by the industry. food companies have also taken steps to address downstream causes of food loss and waste as well. for example, in , grocery manufacturers and retailers within the united states announced a voluntary initiative to simplify date labels to attempt to reduce consumer confusion and reduce associated food loss and waste (food industry association, ) . the board of directors for the consumer goods forum, a network of of the biggest consumer goods companies across countries, adopted a similar initiative that same year (consumer goods forum, ). the most effective approach to addressing food loss and waste is the "target-measure-act" approach, which leads users through three steps: ( ) target: targets set ambition, and ambition motivates action. by setting a strong target (such as the % reduction by target), a business sends a clear message about its intentions and has a tangible goal to work toward. ( ) measure: as seen in the nestlé example, measurement is a powerful tool for businesses that are beginning to address food loss and waste. by understanding the extent and causes of food loss and waste within a set of circumstances, plans can then be tailored to specifically address the root causes that emerge from the measurement activity. guidance on measurement of food loss and waste can be found in the food loss and waste accounting and reporting standard, available at www. flwprotocol.org. ( ) act: what ultimately matters is action. companies, farmers, governments, and actors across all food types and all stages of the food supply chain have a part to play in food loss and waste reduction. although the needed actions differ greatly across different commodities and sectors, the champions . annual progress report, mentioned earlier, is an excellent resource to learn about different types of action that have been occurring to reduce food loss and waste. although addressing food loss and waste can seem like a daunting task, the benefits are numerous. reducing the amount of wasted food leads to economic savings, improved food availability, and reduced environmental impacts. these benefits are even larger in the animal-based food sector than for other foods, due to the higher cost and higher impacts associated with animal-based food. with numerous governments and food companies acting to reduce food loss and waste already, the issue of food loss and waste is likely to only grow in stature in the coming years. conflict of interest statement. none declared. during his time with world resources institute, brian lipinski has worked extensively on the topic of food loss and waste, having served as the lead author on the paper "reducing food loss and waste" and the recent guide "how and why to measure food loss and waste." he is also a coauthor of the food loss and waste accounting and reporting standard, the world's first global standard of requirements and guidance for quantifying and reporting on food loss and waste. he holds a master of science degree from the university of michigan school of natural resources. sdg target . on food loss and waste: progress report nestlé's milk losses from farm gate to factory in countries companies commit to simplify food date labels worldwide by , reducing food waste we had to do something': trying to prevent massive food waste global food losses and food waste-extent, causes and prevention food wastage footprint and climate change fao supports the reduction of food loss and waste in southeastern europe reducing food loss and waste: setting a global action agenda grocery industry launches new initiative to reduce consumer confusion on product date labels food loss and waste accounting and reporting standard: version . misunderstood food date labels and reported food discards: a survey of u.s. consumer attitudes and behaviors shifting diets for a sustainable food future. working paper. installment of creating a sustainable food future key: cord- -ulvnn we authors: perdana, tomy; chaerani, diah; achmad, audi luqmanul hakim; hermiatin, fernianda rahayu title: scenarios for handling the impact of covid- based on food supply network through regional food hubs under uncertainty date: - - journal: heliyon doi: . /j.heliyon. .e sha: doc_id: cord_uid: ulvnn we this paper discusses an optimization model for handling the impact of the covid- pandemic based on food supply network through regional food hubs (rfhs) under uncertainty. to this end, uncertainty is assumed in the demand and production data. during the pandemic covid- period, uncertainty has increased and the food supply chain system has changed. thus, a new configuration of the food supply network requires analysis. in this paper, the concept of rfh is introduced to connect producers in rural areas and customers in urban areas. this paper determines the location and capacity of rfhs, the food supply network, the sum of maximum food supplies, and minimum logistics cost. this is done via a multi-objective many-to-many location-routing problem model. furthermore, since the conditions of the covid- pandemic is uncertain, robust optimization is employed to handle uncertainties. during the current pandemic, red zones are defined to indicate the severity of the pandemic in a region. in this paper, the numerical experiment is considered for three scenarios: when a region is in large-scale social distancing, partial social distancing, or normal conditions. this social distancing situation is based on the defined red zones. the optimal food supply network is obtained for the three scenarios and the best scenario among the three is identified. the indonesian government's initial attempt to minimize the covid- pandemic's seriousness by taking early preventative measures has resulted in it forfeiting the opportunity to keep the covid- pandemic under control in the short phase of the outbreak. according to statistics indonesia ( ), approximately . % of indonesia's population is in urban areas, and most covid- cases in the country have been concentrated in these areas. furthermore, the pandemic is having several effects on environmental, social, and economic aspects, as well as on food security. one result of the covid- pandemic is the bullwhip effect of food supply, which has caused uncertainty in demand and supply and increased the complexity of the food supply chain (mitchell et al., ; chen et al., ) . as a result, the consumption of food in urban areas will be more volatile, which the distribution system will need to accommodate. during the pandemic, the emerging stockpile of staple food must gain significant attention as a government concern, specifically for areas designated as red zones . thus, in the red zone, large-scale social distancing and restrictions are imposed, which impacts the distribution of some food products from the production areas. large-scale social distancing also affects economic growth, changes consumer behavior, and results in the decrease in purchasing power parity for food products (hobbs, ; mukhamedjanova, ; gregorioa and ancog, ) . this situation is also exacerbated by the closure of several public facilities, such as restaurants, caf es, schools, offices, and shopping centers. public discourse in indonesia is predictable focused on how the community can survive in the middle of large-scale social distancing and how people can get food supply (rizou et al., ; hobbs, ; pulighe and lupia, ) . these conditions have implications for the availability of food, hampered access to food for the community, restrictions on interaction between red zones and other areas, and the affordability of supplies (pulighe and lupia, ) . the food distribution system is the foundation to decrease hunger, malnutrition, and food insecurity (galanakis, ; devereux et al., ) . in recent times, food access has impacts on social, economic, and sustainability factors (black et al., ; hilmers et al., ; walker et al., ) . therefore, understanding the complex system of food security is essential for social development (b en e, ; devereux et al., ) . several actions and policies have been implemented to address food security (ge et al., ; blay-palmer et al., ; johnson et al., ) . affordability, availability, and food accessibility for the communities has been the focus for the government, the private sector, and other stakeholders. food security during the pandemic should be ensured by using technology such as e-commerce and the internet of things (iot), not only to improve food security but to also help enhance food safety (deng et al., ) . recovering downstream processing could help with adopting the latest technology (galanakis, ) , which can assist in providing food for the community and improving the value of the products (galanakis, ; hobbs, ; barba et al., ) . however, innovation, technology, and regulations are not keeping pace with the food consumption needs. various problem in this regard have been apparent in recent time, such as uncertainty of food demand and supply, the high cost and inefficiency of logistics and delivery services, the high volume of losses and waste, the powerless of the upstream actors, and food safety (mitchell et al., ; chen et al., ; rizou et al., ) . the covid- pandemic has led to the emergence of a new era of the food supply network (rizou et al., ) where food safety has become one of the focus components (galanakis, ) . to minimize the transmission of the coronavirus, the main concern must be product and worker hygiene to achieve food safety (who, ; galanakis, ; rizou et al., ) . during the distribution process, the transportation system becomes an essential element to protect customers and food supply services providers (gray, ) . attention to macromolecules and micromolecules could be given for the application of food safety and food hygiene protocols (galanakis, ) . the pandemic has also changed consumer behavior in choosing food. consumers seek to protect themselves and improve their immune system, and are concerned about changing their food consumption habits, bioactive ingredients, and nutritional content (galanakis, ; rizou et al., ; zinoviadou et al., ) . therefore, the food system should develop structured managerial systems, adequate infrastructure, facilities, and sustainable food supply (galanakis, (galanakis, , rizou et al., ; gray, ; mitchell et al., ) . an effective strategy to ensure food supply is to develop food hubs. a food hub is a business organization that supports local and regional producers, principally as an aggregator, distributor, manager of food security, and marketing operator for smallholder distributors, as well as to satisfy the wholesaler, supermarket, horeca (hotel, restaurant, and catering) , and other marketplaces (levkoe et al., ; fischer et al., ) . the conceptual model of food hubs is evolving, and hubs have widely adopted innovation to support locales and their goals (ballantyne-brodie and telalbasic, ) . in recent decades, regional food supply chains have become an essential issue, and food hubs are emerging as principal factors for developing viable local and regional food systems (sharpe et al., ; blay-palmer et al., ) . besides being a principal factor of the food system, regional food hubs (rfhs) have a role in regulating and guaranteeing food supply, in ensuring food security and access in some regions, and will likely have a positive impact in the development of the regional economy (sharpe et al., ; etemadnia et al., ; farmer and betz, ; kotani et al., ) . for food security issues, the rfh becomes a critical facility to optimize food supply to consumers, as well as pay attention to sustainability aspect as a part of food security (sharpe et al., ; sonnino et al., ; etemadnia et al., ; farmer and betz, ) . rfh is a centralized facility with a business process management that aims to ensure food supplies and connect the various actors to strengthen food security and food safety through coverage of specific areas. rfh plays an essential role in developing local food systems and promotes entrepreneurship, develops local jobs, and fights food insecurity (o'hara, ; silver et al., ; rose, ) . the rfh has become a network to collaborate with local producers and customers, forming local food networks by adopting socio-technical processes to address socio-economic and political tensions and support a fairer, more sustainable, and socially just food system (prost et al., ) . rfhs should develop through a mutually beneficial collaboration network by involving the local food hub (lfh) to provide a source of the food supply. the lfh acts as a local aggregator hub for some local sources and specialty food distributors. it serves high-quality and locally grown products from small and mid-sized farms, and aims to meet the demands of its customer base (barham et al., ) . meanwhile, supermarkets, restaurants, caf es, and catering services partner with the rfh to sell products to the customers and other food service providers. rfh uses design-driven innovations to approach daily challenges, such as maintaining the constant balance of food availability in a region. rfh used as a continuous cycle of a strategy to change the sustainable local food supply networks system (ballantyne-brodie and telalbasic, ). the food supply network system is a strategically interconnected network that improves the optimization, efficiency, and effectiveness of the food production and delivery process (robinson et al., ). in the system, transparent edges between producers and consumers are a critical aspect to meet the sustainability goals (brinkley, ; le velly and dufeu, ) . the food supply network system must be prepared for various conditions, and must function not only under regular conditions but also during the pandemic. the rfh makes an essential contribution to the disaster relief supply by providing essential food for the communities during disasters and post disasters. in the time of pandemics, such as today, rfh could also function as a food resilience network (frn) to make food available, affordable, accessible, and hygienic for communities affected by the pandemic (brand et al., ; berno, ; dasaklis et al., ) . the pandemic might raise food deficiency due to the obstruction of the food supply chain. the locations for the development of rfhs and optimal logistics for the food network must be determined based on various general conditions and, at the time of a pandemic, by considering the entire community as victims affected by it. the covid- pandemic will have a longlasting effect on the food supply network, including the development of e-commerce and customer preference toward local food (hobbs, ; galanakis, ) . research on rfh logistics optimization is largely underway in europe, the united states, canada, and mexico (mittal et al., ). the conceptual model of rfh is still emerging and is increasingly applied to the development of logistics systems for agriculture (mittal and krejci, ; fischer et al., ) . the rfh movement embraces a bank of locally adapted food networks, food traceability, inventory, and warehouse operation management (mittal and krejci, ; prost et al., ) . further, rfh has been developed for the sustainability of the local food system (cleveland et al., ) . sharpe et al. ( ) notes the importance of providing access to healthy food for all levels of society by optimizing the role of food hubs. other research has developed conceptual models for optimizing food supply networks during the pandemic (liu et al., ; tang and lau, ; dasaklis et al., ) . however, studies have not considered the location for the development of rfh and the food network in all conditions, especially during the pandemic. this paper aims to determine the optimal location of rfh and food supply networks connecting producers in rural areas and customers in urban areas. it focuses on food security to ensure that food is available, affordable, accessible, and safe at all times, including in the new era food supply network. the many-to-many location-routing problem (mmlrp) is used in this paper to examine the location and capacity of rfh, the food supply network, the sum of maximum food supplies, and minimum logistics costs. several pervious works have attempted to solve the food supply network problem using mmlrp. wang et al. ( ) discuss mmlrp for cold chain logistics. the scheme proposed in their model consists of supply point, distribution center (dc), and demand point. in their model, mmlrp is used to determine dc location and the network distribution. another work of mmlrp in the food supply network problem is hiassat et al. ( ) , who use the mmlrp model for perishable products and propose a scheme that consists of warehouse and customer. mmlrp is used in their model to determine the warehouse location and food distribution network. however, neither model considers uncertainties, such as demand or production capacity uncertainties. they also do not consider multi-item products in their mmlrp model. therefore, an mmlrp model that considers multi-item (multi-commodity) products is developed in this paper. this model also addressed several uncertainties, such as food demand, food production, and distribution cost uncertainties using robust optimization (ro) that assumes that the uncertain parameters lie in an uncertainty set (ben-tal et al., ; gorissen et al., ; yanıko glu et al., ) . ro aims to remove all the uncertain parameters from the uncertain problem and obtain a robust reformulation of the uncertain problem called a robust counterpart (rc). furthermore, a two-objective mmlrp is proposed in this paper: ( ) maximize food supply, and ( ) minimize logistics cost. the latter includes food handling costs under several health protocols to guarantee food safety. to solve this multi-objective mmlrp (mommlrp), the lexicographic method is applied. the lexicographic method is a way to handle multi-objective optimization problems, by priority-ordering the objectives and solving them iteratively (stanimirovic, ) . the rest of this paper is organized as follows: section paper discusses the problem statement related to this paper, followed by the methodology employed in this research. it is followed by a case study that explains the research location. the results and discussion sections describe three alternative simulation scenarios in the covid- situation. the conclusion focuses on the result of the paper that answer the problems discussed in the next section. this paper addresses the problem of determining the optimal location of rfh by considering aspects of sustainability and food security for all conditions, including during pandemics. by connecting the local producer and customers through rfh, the food supply network could be developed to maintain food security. this paper discusses three alternative scenarios to tackle rfh during the pandemic. it aims to identify the best alternative rfh location and capacity and food distribution network; the maximum product fulfillment of each region; and the minimum logistic costs in red zones, defined as an area at the epicenter covid- infection. scenario represents the large-scale social distancing condition in red zone areas. food supply from the green zone is not allowed in the red zone. the red zone must survive by relying on the food products of its region. this condition is intended to minimize the spread of the covid- pandemic and to determine if the red zone can fulfill food demand. further, this condition is designed to determine if the green areas can meet food demand without any supplies from the red zones. the food distribution problem in scenario is illustrated in figure . in scenario , the partial social distancing condition was applied in the red zone. these areas are forbidden from delivering food products to other regions. however, other regions can supply food to red zones. these conditions are meant to decrease the spreading of covid- from the red zone to other areas, and other regions can support the red zones. this scenario problem is illustrated in figure . alternative scenario is used in the new era condition in which a food supply network is allowed to function as usual. however, security protocols are applied following health standards for the prevention of covid- due to the transformations in the food supply chain during this covid- pandemic (rizou et al., ) . this scenario considers the function of rfh after the covid- pandemic condition. this condition is intended to compare the results of the two preceding alternative scenarios. figure illustrates the problem in scenario . an optimization model with mommlrp can describe the best alternative solution for complex problems. variables, objective functions, constraints, and coefficients are used as the central concept of optimization models. the assumptions for the three alternative scenarios are determined using several parameters: food demand, production capacity, and operational costs. in this paper, the food in question is the commodity of rice as the staple food of indonesians, chicken eggs as an alternative source of animal protein consumed, and vegetables as a source of fiber. in this study, vegetable commodities are limited to the most common vegetables consumed by indonesians, shallots, red chilies, beans, potatoes, carrots, tomatoes, spinach, and water spinach. furthermore, each scenario's mommlrp model involves several uncertain parameters, that is, food demand, food production, and distribution cost, which makes the mommlrp model uncertain. ro is applied to solve the uncertain mommlrp by removing all uncertain parameters from the uncertain problem and to obtain a robust reformulation of the uncertain problem called the rc, which is used to give a robust alternative scenario. the rc of each scenario is solved by numerical simulation to find a robust solution that is feasible under all possible disruptions. general optimization problems often involve uncertain parameters. the uncertain parameters are likely caused by measurement error, such as temperature or size measurements. the uncertain parameters could also be caused by mistakes in estimating the data, for instance in estimating demand, profit, selling price, or travel time. in this paper, ro is used to handle the uncertain parameters, that is, food demand, production capacity, and distribution cost. ro is a method to handle uncertain parameters that are assumed to be part of an uncertainty set (ben-tal and nemirovski, ) . the method's primary purpose is to achieve an optimal solution that is robust to uncertain data. the mathematical formulation for the general uncertain linear programming as proposed by ben-tal et al. ( ) and discussed by gorissen et al. ( ) is given by ( ). where c;x r n ;a m mÂn ðrÞ, b r m , and u is primitive uncertainty set (an uncertainty set that has not yet been determined). the aim of ro is to remove all the uncertain parameters in uncertain problem ( ) and obtain a robust reformulation of it, called the rc. to solve the uncertain problem ( ), several assumptions are necessary, as discussed by ben-tal et al. ( ), gorissen et al. ( , and yanıko glu et al. ( ): (a ) the objective function is certain, (a ) the right-hand side vector is certain, and (a ) the uncertainty is constraint wise. under assumptions (a ) and (a )-that is, assume that c r n and b r m are certain-the uncertain problem ( ) can be rewritten as ( ). now, since c r n and b r m are certain, the robust reformulation of ( ), which is generally referred to as the rc problem, is given by ( ): where z ⊂r l . the constraint in ( ) can be rewritten constraint wise. denoting a i as the i-th column in matrix a, ( ) becomes ( ): where a i r n ; d i m nÂl ðrÞ, and b i r; i f ; ; ⋯; mg. in this paper, a box uncertainty set is used, with uncertainty parameters as discussed by ben-tal et al. ( ) and gorissen et al. ( ) . the box uncertainty set is defined by z box ¼ fζ : ζ j ∞ g (gorissen et al., ) . thus, ( ) can be written as ( ): ða i þ d i ζÞ t x b i ; i f ; ; ⋯; mg; ζ z box : by using the concept of the best worst-case reformulation as discussed by gorissen et al. ( ) thus: take ζ as the unit vector: thus, ( ) can be rewritten as follows: in the case of box uncertainty, the rc of ( ) is given by ( ): by repeating this step for all other uncertain constraints, rc for the uncertain problem ( ), where ζ z box , is given by ( ): i f ; ; :::; mg É : ( ) this section describes the experimental mommlrp model for optimal rfh locations and food networks based on the three scenarios described in the problem statement section. it also discusses the robust mommlrp model to handle food demand, production capacity, and distribution cost uncertainties. the mommlrp models are designed based on the three scenarios to describe the development of an rfh location and network in west java province. this subsection discussed the mommlrp model developed in this study for the three scenarios. first, the mommlrp model for large-scale social distancing is discussed. then, the mommlrp model for partial social distancing and for normal conditions are discussed based on the differences from the large-scale social distancing model. the mommlrp model of the three scenarios is then summarized. to solve the problems in scenario , a mommlrp model seeks the maximum demand fulfillment and minimum total cost of logistics. the sets that are used in this model are i, which represents the demand zone, j, which represents rfh, k, which represents the production zone, c, which represents commodity, and r, which represents the red zone or the epicenter of covid- infection. the parameters used in scenario are d ci , which represents the demand for food c from district i (kilotonne/day); v ci , which represents the selling price of commodity c in district i (rp/kilotonne); f ck , which represents the production capacity of commodity c on central production district k (kilotonne/day); b ji , which represents distribution cost between district j and district i for transporting the food (rp/kilotonne); q which represents food handling cost under several health protocols (rp/kilotonne); and h which represents the rfh-building cost (rp/hub). the decision variables used in this model are x j , which decides if the rfh will be built on district j, which takes if the rfh will not be built on district j, and otherwise; p cj , which decides the rfh capacity for commodity c in district j (kilotonne/day); y ckj , which decides how much of the commodity c produced on district k is sent to the rfh in district j in proportion to production capacity f ck ; and w cji which decides how much commodity demand c on district i is fulfilled by the rfh in district j, in proportion to demand d ci . the decision variables x j are binary (x j ; ; j j). the decision variables p cj are real numbers (p cj r; c c;j j). the decision variables y ckj are real numbers between and (y ckj ½ ; ; c c; k k; j j). decision variables w cji are real numbers between and (w cji ½ ; ; c c; j j; i i). this model has two objectives, maximizing demand fulfillment and minimizing logistics cost. the source of the logistics cost is the operational costs for distributing the food between segments (production area-rfh-customer). the logistics cost also includes the operational costs of the rfh building and food handling under the pandemic with several precautions to maintain food safety. the objective function to maximize the demand fulfillment is given by ( ): the objective function to minimize the logistics costs as explained above is given by ( ): the constraints that guarantee the determined rfh capacity of all commodities are determined based on the demand and the production capacity are given by ( ): the constraint that guarantees that the commodities delivered from the production area to the rfh will not exceed the production capacity for those commodities is given by ( ): x j j y ckj ; c c; k k the constraint that guarantees that the demand fulfilled by the rfh will not exceed the demand is given by ( ): x j j w cji ; c c; i i the following constraint guarantees that no commodities will be delivered to the red zone if the rfh is not built in that zone: the constraint that guarantees that no zone's demand will be fulfilled if the rfh will not be built in that zone is given by ( ): the constraint given below guarantees that there will be no food distribution to an rfh in the red zone from the production area in other zones: the following constraint guarantees that there will be no food distribution to the customer in the red zone from an rfh outside the red zone: the constraint that guarantees that there will be no food distribution from a production area in the red zone to an rfh in other zones is given by ( ): the following constraint guarantees that there will be no food distribution from an rfh in the red zone to customers in other zones: the difference between the first and second scenarios is that in the second, the production areas would distribute food to the rfhs in red zones. this is considered so that the food demand in the red zones can be fulfilled, aiming to decrease food insecurity. however, the quantity of food distributed to the red zone is limited by the maximum transportation capacity for food per delivery period. accordingly, parameter n c has been added, which represents the maximum amount of commodity c that could be distributed in one-way distribution (tonne/ distribution). also, two new decision variables are introduced, m r and m r . decision variable m r decides how many times the distribution should be done to the rfh in red zone r. decision variable m r decides how many times the distribution should be done to the consumer in red zone r. constraint ( ) in scenario is changed to constraint ( ) below, which guarantees that the food distribution to the rfh in red zone is allowed. constraint ( ) also calculates how many times the distribution should be done, as follows: x k kÀfrg y ckr f ck m r n c ; c c; r r constraint ( ) in scenario is modified into constraint ( ) below, which ensures that the food distribution to consumers in the red zone is allowed. constraint ( ) also calculate how many times the distribution should be done, as follows: x j jÀfrg w cjr d cr m r n c ; c c; r r ( ) scenario adopts a typical food supply network, in which there are no constraints on the distribution process of each zone aiming to fulfill the food demand. the limit on scenario is the maximum capacity of food supply delivery in one distribution period, noted by n c (tonne/ distribution). corresponding to the statement above, two new decision variables are added, m r and m r . decision variable m r decides how many times the distribution should be done from the red zone r. decision variable m r decides how many times the distribution should be done from the rfh in red zone r. constraint ( ) in scenario was modified into constraint ( ). constraint ( ) guarantees that the food distribution from the red zone is allowed. constraint ( ) also calculates how many times the distribution should be done as follows: x j jÀfrg y crj f cr m r n c ; c c; r r constraint ( ) in scenario was modified into constraint ( ), which guarantees that the food distribution from rfhs in red zones is allowed. constraint ( ) also calculate how many times the distribution should be done as follows: x i iÀfrg w cri d ci m r n c ; c c; r r the differences between the models in the three scenarios are measured based on the maximum, minimum, and constraints used in each scenario. the differences between the mommlrp model of the three scenarios are summarized in table . in this study, we assume that the uncertain parameters are demand for the commodities d ci , production capacity for commodity f ck , and transportation costs between locations b kj and b ji .the multiplication of the uncertain parameters b ji d ci in objective function ( ) is considered as a single uncertain parameter m cji , which represents the maximum travelling cost to fulfill the demand for commodity c in district i from the rfh in district j. besides, the multiplication of the uncertain parameters b kj f ck in objective function ( ) is considered as a single uncertain parameter n ckj , which represents the maximum travelling cost to deliver all the commodity c that was produced in district k to the rfh in district j. the transformation is given as follows: thus, the uncertain parameters considered in this model are d ci ; f ck ; m cji ; n ckj , as in ( ): by substituting ( ) into objective function ( ), the objective function ( ) a new objective function ( ) is obtained: constraints ( ), ( ), ( ), ( ), ( ), ( ) constraints ( ), ( ), ( ), ( ), ( ), ( ), the objective function ( ) is replaced with ( ). the uncertain mommlrp model for each scenario is presented in table . ro is employed to handle the uncertain problem. this can be done by removing all uncertain parameters from the uncertain problem to obtain a robust reformulation of the uncertain problem called the rc, as discussed in the methodology section. by using the assumption (a ), the uncertain objective function ( ) becomes ( ): with a new decision variable z added and defined in a new constraint: all the uncertain parameters are on the left-hand side of constraints. the uncertain constraints in the uncertain mommlrp model for all scenarios are ( ) and ( ). by using assumption (a ), the uncertain mommlrp can be used for every single uncertain constraint ( ) and ( ). the single uncertain constraint ( ) and ( ) can be written in vector as given in ( ) and ( ): where f r jkj ; d r jij ; m r jcjþjjjþjij ; n r jcjþjkjþjjj and p; z r. as it is assumed that the parameter f; d; m and n are contained in a box uncertainty set, the constraints ( ) and ( ) can be rewritten as ( ) and ( ): then, the rc of ( ) and ( ) are given by ( ) and ( ): in this case, d ;d ;d , and d are diagonal matrices. thus, the terms of d t y;d t w;d t w, and d t y are vectors as presented in ( ) and ( ): since the ℓ -norm of those vectors are the summation of its elements, constraint ( ) and ( ) can be rewritten in the form of a summation as given in ( ) and ( ): where f ck is the average production capacity for commodity c in production area k; d ci is the average demand for commodity c in district i; m cji is the average distribution cost to fulfill the demand for commodity c in district i from the rfh in district j; n ckj is the average distribution cost to deliver all the commodity c that was produced in district i to the rfh in district j; and s ck ; t ci ; u cji ; v ckj is the uncertain part of f ck ;d ci ;m cji ;n ckj . in this paper, all the uncertain parts are set based on the average. by repeating the same step for all other uncertain constraints, the rc of uncertain constraint ( ) and ( ) is given in ( ) and ( ): the rc of the uncertain mommlrp for each scenario is presented in table . the rc model of all scenarios in table is then called the robust mommlrp model (rmommlrp), which is robust against the uncertain food demand, production capacity, and distribution cost. the rmommlrp models have two objectives as seen in table , which maximizing demand fulfillment and minimizing logistics cost. therefore, the lexicographic method is used to solve the problem. the lexicographic method is a way to handle multi-objective optimization problem (stanimirovic, ) . it orders the objectives based on priority (rao, ) . the multi-objective problem is then solved iteratively from the first objective and substituted back to the problem as a new constraint with the following objective. case studies are carried out in west java, the most populous province in indonesia. according to statistics indonesia ( ), west java is the third leading agricultural producer in indonesia after east java and central java, as well as a strategic marketing area because . % of indonesia's population is in west java province. in this study, the commodities analyzed are the strategic commodities of the people of west java, that is, rice, chicken eggs (particular chicken eggs), and vegetables. rice as a staple food for indonesia as a complex carbohydrate source. chicken eggs (layer) are the most consumed protein due to the low price and availability. moreover, vegetables are considered a high-value commodity, that is, shallots, red chilies, beans, potatoes, carrots, tomatoes, spinach, and water spinach. the demand and production capacity of each commodity are assumed to be uncertain. accordingly, ten-year consumption and production capacity data from west java were analyzed for each commodity over the period - (statistics of jawa barat, barat, , barat, , barat, , barat, , barat, , barat, , barat, , barat, , barat, , . the logistics costs for each region are assumed to be uncertain and calculated based on the price of commodities and diesel fuel price. in this model, diesel fuel prices are the benchmark for calculating logistics cost because these types of fuel are widely used by mini trucks, which distribute food commodities (pertamina, b,c,a) . other logistics costs that are calculated in this model are operational cost and cost of investment. data on the selling price of each commodity was obtained the rfh location is also determined for the red zones, as presented in figure . as claimed by pikobar, as of may , . % of patients exposed to covid- were in west java, placing west java in the third position for the highest number of covid- cases in indonesia after dki jakarta and east java. some red zones in west java are urban areas with high population density and are far from food supply sources. moreover, west java province does not yet have an rfh to manage food supply sources for the community, and thus faces a severe food security problem. according to pikobar, districts or cities in west java province have patients who tested positive for covid- . in the scenarios constructed, eight districts are considered red zones in case (based on data from march , ) and thirteen red zones are identified in case (based on data on may , ). all red zones are in urban areas and are the focus of the central and regional governments' monitoring activities. none of the districts in the red zone have a robust food supply network yet, and the government thus gives high priority to the issue of food security. in this paper, the rfh model was also designed based on the governor of west java's flagship program, "jabar juara" (west java champion). rfh development in west java province emphasizes the concept of the smart supply chain for agricultural development. it aims to provide a stable food supply network and focus on the optimization of local production levels. the west java provincial government also aimed to meet the nutritional needs of the community, reduce food loss and waste, and adopt sustainable agriculture by developing rfhs. therefore, presidential directives have a significant point of working related to food security (djalante et al., ) . this subsection discusses the results of the numerical simulation for the three scenarios. first, the result for each scenario is discussed, which are then compared at the end of the subsection. the optimal location for the rfh in scenario is developed based on case (eight red zones) presented in table , and case (thirteen red zones), as shown in table . there are eleven alternative rfh locations in case , eight in red zones and three outside. in this scenario, large-scale social distancing is applied as protection aimed to limit space in the red zone. the rfh development area in scenario is at high risk for deficiency of food supply. further, hunger will continue to increase in the red zone as it cannot depend on the other production areas. the total logistics cost for scenario in case is rp , . /kg production. in case , seventeen optimal rfhs must be built, thirteen in the red zone and the rest from other zones. the implementation of large-scale social distancing reduces food distribution from other districts. in scenario , there is a change in the amount of rfhs that must be built. as more red zones and locations change, the need for rfh development will continue to increase. it can affect the availability of food in areas affected by large-scale social distancing. the total logistics cost for scenario in case is rp , . /kg. as discussed before, the greater the number of red zones, the higher is the need for rfh development. this is due to the restriction of the food supply network in the red zones. rfhs should be built in every red zone to maximize demand fulfillment in those areas to avoid an increase in hunger. in terms of the complexity of the problems, case in scenario has , decision variables and parameters, which are involved in , constraint functions. meanwhile, case in scenario has the same decision variables and parameters, which are involved in , constraint functions. the greater the number of red zones involved in the case, the more complex the model will be. in this scenario, the rice demand of urban areas that become the epicenter of covid- could not be fulfilled, as presented in table . the area's capacity to produce rice cannot match its total rice needs. the rfhs in four red zones could not import rice from the production areas outside the red zones, due to the policies that forbid distribution from or to the red zones. thus, more than million citizens in four red zone are in food insecurity. changes in the classification of red zones affect rice demand fulfillment. depok and bandung city, whose production capacity cannot fulfill their demand, were classified as red zones in case . however, in case , they are no longer classified as red zones, and so their demand could be fulfilled by other districts, resulting in an increase in the rice fulfillment in those districts. in contrast, cimahi city was classified as a green zone in case , and other districts could fulfill its demand. however, in case , cimahi city became a red zone that could not fulfill its demand, resulting in a decrease in rice fulfillment in cimahi city. although there are other red-zone status changes in several districts, their demand fulfillment was figure . food supply network from production zone to rfh for case in scenario . t. perdana et al. heliyon ( ) e not affected, e.g., tasikmalaya, indramayu, sukabumi, bogor, cianjur, purwakarta, and karawang. their capacity to produce rice can meet their demand, so the demand fulfillment in those districts will not change if they become red zones. overall, the rice fulfillment increase in depok and bandung is higher than the rice fulfillment decrease in cimahi. at the same time, other changes in red zones did not affect rice demand fulfillment. this makes rice fulfillment in case is higher than in case . unlike rice commodities, demand for chicken eggs can be met by all areas, as presented in table . the districts/cities in west java can produce chicken eggs without depending on other production areas. the classification of the red zone thus does not affect the fulfillment of chicken egg needs. however, chicken eggs are insufficient to reduce the risk of hunger and the issue of immunity during the covid- pandemic. changes in the classification of red zones did not affect the fulfillment of the egg demand. when green zones in case become red zones in case , their egg demand could not be supported by other districts. however, their own capacity to produce eggs could fulfill their demand, and so the demand fulfillment in those districts could be maintained. when a green zone in case became a red zone in case , the eggs produced there could no longer be distributed to other districts. however, other districts produced sufficient eggs, and so the egg demand in green zones was still fulfilled, thus maintaining the overall fulfillment of egg demand. when the red zone in case became a green zone in case , the egg produced could be distributed to another green zone. further, their demand could be fulfilled by another green zone, which makes for a better and more productive food supply network. about eight districts/cities in case and nine red zones in case could not meet vegetable demand, as presented in table . this was because these zones are not the main vegetable-producing area. the main production areas were restricted from distributing the vegetable yields to the red zones, which makes the vegetable fulfillment in this scenario even worse. based on the rate of vegetable consumption in each district, it is estimated that more than million people in west java could not fulfill their vegetable needs. changes in the classification of red zone affect vegetable fulfillment. the fulfillment ratio of a red zone in case that changed into a green zone in case will remain the same or increase. whenever a red zone becomes a green zone, its demand can be fulfilled by other districts, and so its demand fulfillment increased or at least remains the same. in contrast, the fulfillment ratio of a green zone in case that changed in a red zone in case will remain the same or decrease. whenever a green zone becomes a red zone, its demand cannot be fulfilled by other districts anymore, and so their demand fulfillment decreases or at least remains the same. the green zones in case that changed into red zones in case figure . food supply network from rfh to consumer for case in scenario . are predominantly in suburban areas, with sufficient production capacity to fulfill their own demand. the red zones in case that changed into the green zone in case are predominantly urban, with a high population density, resulting in more people requiring vegetable supply. this makes the vegetable fulfillment in case higher than in case . scenario restricted the food supply network from the production area to the rfhs in the red zones, who are then forced to produce food. the scenario creates a significant rfh development cost because every time an additional red zone comes up, the government must build an rfh. limited movement causes shortage of some food commodities. this scenario cannot optimize the rfh function as an aggregator between food production and consumer areas. these conditions result in food insecurity and malnutrition. scenario is not compatible when applied in the long term. it would cause certain areas to be isolated from production areas and reduce the fulfillment of food demand. although rfhs are required to serve all consumers, the supply does not match the consumption needs. in figures and , the rfh is not optimistic about providing food for the community. the optimal location for the rfh in scenario is developed based on case (eight red zones) in table , and case (thirteen red zones) in table . scenario was built, in which partial social distancing conditions were applied in the red zone areas. although the production center can supply food to the rfhs in the red zone, the addition of the red zone still affects the number of rfhs that must be built. the total rfhs built is eleven in case , eight in the red zones, and the rest outside. the total logistics cost for scenario in case is rp , . /kg, and the fulfillment ratio of rice and chicken egg reaches %; only the demand for vegetables could not be fulfilled. if the vegetables produced in west java is sufficient to fulfill the overall demand, rfh development will not be affected by the changes in the classification of red zones. however, since this is not the case, rfhs should be built in the red zones so that the vegetables produced in the red zones could be distributed to fulfill their demand. this condition makes the number of rfhs increase in case , in which sixteen rfhs are built. the total logistic cost for scenario in case is rp , . /kg. in terms of the complexity of the problems, case in scenario has , decision variables and parameters, which are involved in , constraint functions. meanwhile, case in scenario has , decision variables and parameters involved in , constraint functions. the greater the number of red zones involved in the case, the more complex the model will be. in this scenario, rfhs become crucial to maximize the supply of products. according to table , all areas in cases and could fulfill rice demand, as rice production in every area in west java is sufficient to satisfy their demand. the application of partial social distancing helps rfhs to provide for the rice needs in each rfh. further, hygiene and food safety standards must be implemented in the case of partial social distancing in food distribution. the changes in the classification of red zones did not affect the rice demand fulfillment in scenario . this is because when a green zone in case became red zone in case , their produced rice could no longer be distributed to other districts but there other districts produced sufficient rice, which maintains the fulfillment of rice demand. when a red zone in case became a green zone in case , fulfillment of rice demand improved because the rice produced in those districts is no longer restricted, which provides additional rice supplies from those districts, resulting in a the better and more effective food supply network. the chicken egg requirement in scenario can be fulfilled % in each district of west java province, as presented in table . the partial social distancing for some commodities could build customer confidence to reduce risk exposure and guarantee universal health coverage. these results carry obvious implications for household food security and nutrition, particularly for those in the red zone. the changes in the classification of red zones did not affect the egg demand fulfillment in scenario . this is because when the green zone in case becomes a red zone in case , the egg produced there could no longer be distributed to other districts. however, other districts could produce sufficient eggs, which helps maintain the fulfillment of egg demand. when the red zone in case became a green zone in case , the egg demand fulfillment improved because the eggs produced in those districts is no longer restricted, which increases egg supply from those districts. in this scenario, partial social distancing cannot meet the needs of vegetable consumption, as presented in table . therefore, vegetable needs can be substituted with other vegetable commodities to meet daily food fiber needs. there are about . million people in west java whose figure . food supply network from production zone to rfh for case in scenario . changes in the classification of red zones affect vegetable demand fulfillment. this is because the vegetables produced in west java are less than the demand for them. when the red zones in case become green zones in case , the vegetable produced there could be distributed to other districts, which strengthens the food supply network. however, when a green zone in case becomes a red zone in case , the produced vegetable could no longer be distributed to other districts anymore. meanwhile, the vegetable produced in other districts is insufficient to fulfill the overall demand. thus, the greater the number of red zones, the lower the vegetable supply, which results in a decrease in vegetable fulfillment. this condition could worsen if the green zones that change into red zones are predominantly in suburban areas with high vegetable production capacity. in case , the vegetable fulfillment reached maximum with all the vegetable produced. all vegetable produced are distributed in case . however, as the number of red zones increased in case , vegetable fulfillment decreased. cianjur is one of the suburban areas with high vegetable production capacity. when cianjur becomes a red zone in case , west java loses one of its main vegetable production sources, which makes the vegetable fulfillment in case lower than case in . although rfhs can receive supplies from several nearby production areas, the red zones are restricted from supplying food to other districts, as shown in figures and . this distribution model is still safe if the area affected by the pandemic is an urban area. however, if the pandemic extends to areas of food production centers in west java, food shortages is likely to occur in various districts. the food supply network of rfhs can only serve consumers who are in the red zone. this scenario is safe if the red zones are confined to urban areas-this model is designed to ensure that customers in the red zone have food security. however, the large number of rfhs has caused high rfh development costs. the optimal location for the rfh in scenario is developed based on case (eight red zones) in table , and case (thirteen red zones) is shown in table . unlike scenarios and , in scenario , rfh development is not affected by the change in the classification and increase of red zones. the number of rfh that must be built does not change in scenario , which has implications for the cheaper rfh development. the rfh is built near central production areas, and can optimized to supply food to a broad range of consumers. the total logistics cost in model is thus lower than in scenario and , at rp , . /kg. the demand fulfillment of all food commodities reaches its maximum in this scenario. the number of rfhs built in this scenario is less than in scenarios and , whereas, the total capacity of all rfhs is higher. the food supply network in this scenario is more effective than in scenarios and . in terms of the complexity of the problem, case in scenario has , decision variables and parameters, which are involved in , constraint functions. meanwhile, case in scenario has , decision variables and parameters, which are involved in , constraint functions. the greater the number of red zones involved in the case, the more complex the model will be. in scenario , the rfh development can optimize food security for the whole community. the food supply network that carries out normal conditions could impact the economic circulation. food security in the covid- pandemic is vital for the survival and health of society. for the people of west java, rice supplies are crucial, especially when there is social distancing. the needs of rice in west java can be fulfilled, as presented in table . the needs of the chicken egg in west java province can also be fulfilled, as presented in table . six districts control up to . % of the total production of chicken eggs in west java province. this scenario can guarantee the sustainability and availability of egg supply in each customer area in west java province. two cities could not meet vegetable demand, and one district cannot fulfill % of the vegetable needs in the area, as presented in table . around . million people are threatened with a shortage of vegetable supplies. as stated earlier, the lack of fulfillment of vegetables can be substituted with other commodities that are not considered in this model. therefore, vegetable consumption fulfillment can be reconsidered by adding consumption and production components of other vegetable commodities produced locally. each production area can supply crops to the nearest rfh with due consideration to hygiene protocols as a preventive measure for covid- transmission. the food supply network with a system based on normal conditions ensures the availability of food for the communities, as presented in figure . this condition can have implications for social and economic factors of the communities in urban and rural areas. in distributing food from rfhs to consumers, rfh services cover all areas within a certain distance, as presented in figure . food distribution from rfhs is done through traditional markets, modern markets, caf es, restaurants, catering services, hospitals, hotels, and online market places. the distribution system guarantees the availability and traceability of food, making it easy to control food security in each consumer area. as a result of the covid- pandemic, the issue of the food system has emerged. the food system includes all aspects of providing food. the implementation of the large-scale social distancing impacted the uncertainty of food demand and supply. therefore, it is essential to develop a food system to tackle the uncertainty of food supply. in this paper, a model was developed that focuses on the rfh location and network. it determined the improvement of food security for society by considering aspects of sustainability, food safety, and effectiveness of the food supply network. a set of rules were applied to each situation to arrive at the best scenario for food supply during the pandemic. the three scenarios are compared and summarized in table . scenario implements large-scale social distancing so that areas designated as red zones cannot deliver or receive food supplies from other regions and vice versa. the limitation in this scenario aims to minimize the spread of the disease. this scenario becomes a problem if the red zone only falls in urban areas that do not have sufficient capacity for food production. the number of rfhs in scenario is higher than in both scenarios and . the results for this scenario will also worsen when the number of areas classified as red zones increases, as each location will need to build rfhs and fulfill food needs independently. a change in the number of red zones also affects the total cost of rfh development. the application of large-scale social distancing on the food supply network inhibits economic circulation and social activities. this condition is not in line with the principle of food security and sustainability (sharpe et al., ) . scenario applies partial social distancing; other zones support the food needs of the red zone and are predicted to decrease hunger. food distribution activities from the other areas are also carried out by implementing food and health safety protocols recommended by the government as a way to minimize the spread of the disease. food security should consider the spreading of the virus between producers, retailers, and customers and avoid massive food insecurity. scenario aims at keeping the food supply network functioning to be able fulfill food needs. however, this scenario will only work well if all red zones are in urban areas. the situation would be different if the red zone extends into the production center, causing a shortage of food supply in several areas. it is feared that this situation will worsen the community's physical and mental health (highlander and singley, ) . moreover, the costs required for rfh development are not much different from scenario . in scenario , food delivery is carried out under the new era in the food supply chain, which involves the implementation of health and food safety protocols. each production area can supply the crops to the nearest rfh, and rfhs can serve the entire area based on their range and capacity. the vegetable needs can be fulfilled by substituting other vegetable commodities not included in this model's calculation. rfh development in scenario is not affected by the increase in the number of red zones and location changes. therefore, the costs required for rfh development is lower than in scenarios and . the rfh could be the optimal form of food supply network as it can ensure the supply of food for the entire region, and also has implications for reducing carbon emissions (galanakis, ; hobbs, ; sharpe et al., ) . the determination of the scenario takes into account aspects of the food system, sustainability, and health regulations (hobbs, ; sharpe et al., ; djalante et al., ; brand et al., ; mittal et al., ; brinkley, ; ge et al., ; levkoe et al., ; dasaklis et al., ). the food system should be developed with consideration of food security and food safety (galanakis, ; rizou et al., ) . in scenario , rfh is designed to benefit all levels of society from the availability of sufficient food. upstream actors can minimize overproduction to increase production efficiency and value addition (kharisma and perdana, ; barba et al., ) . downstream actors are becoming interested in local foods, including perceptions about sustainability, hygiene, and health benefits (hobbs, ; galanakis, ; rizou et al., ) . food security during the pandemic must be ensured. maintaining hygiene during production and logistics, as well as the hygiene of food and workers are important considerations while ensuring food security to the whole community during a pandemic (who, ; rizou et al., ; galanakis, ) . therefore, rfhs could be used as a resilient food network to ensure the availability and safety of food (b en e, ; galanakis, ; rizou et al., ) . from the perspective of sustainability, food delivery can reduce carbon emissions from efficient use of vehicle fuel, decreased food loss during distribution and post-harvest, and reduction of food waste during the selling process (hakovirta and denuwara, ; nagarajan et al., ; galanakis et al., ) . rfhs are designed based on the locality of agricultural products and aim to improve the social and economic condition of communities affected by the pandemic (nicola et al., ; phillipson et al., ) . therefore, the development of rfhs needs to be strengthened by the development of efficient and interconnected food chain networks (galanakis, ; handayati et al., ) . to reduce the spread of covid- and support physical distancing, digital food services could be adopted to optimize the rfh services. such services will have a longer-term effect on the food supply chain, including the increase of e-commerce and customer preference on the local food supply network (hobbs, ; keesara et al., ) . digital food services could also reduce food loss and waste, make a traceability system possible, fulfill the nutrition requirements of the customer, as well as provide a fast response to imminent economic crises in the era of the covid- pandemic (sarfarazi et al., ) . functional local food can fortify health and improve the consumer's immunity system (galanakis, ) . the conception of the model also considers the policies that apply both in west java province and the central government (manganelli et al., ). an alternative model of rfh development in west java province can be a reference for the government to build a food supply network that emphasizes aspects of food safety and health based on the specific conditions in west java province. the best scenario is scenario , as it illustrates ideal conditions during typical situations. this scenario is chosen because none of the rfhs have territorial boundaries (red and green zones) during the procurement. the food supply network's delivery should conform to health and safety protocols to minimize the spread of disease. the number of rfh that should build is fixed, that is, six rfhs, and so the investment cost of rfh development is lower than in scenarios and . the rfhs and food supply network are in a strategic location, food is supplied from the nearest rfh region, and rfh serves the closest coverage area. this scenario has an impact on the efficiency of distance and the use of diesel fuel, which leads to an increase in farmers' income and customers' access to local food. a possible topic for future research is minimizing the spread of disease by developing digital services. digital food services could be an alternative technology to decrease human interaction, reduce the time spent in product purchase, decrease carbon emissions, reduce food loss and waste, and maximize warehouse capacity. some food processing technologies to process food waste from the supply chain could also be considered. digitalization is useful in obtaining bioactive ingredients to strengthen the consumer's immune system and minimize food waste for a more sustainable food supply chain. the model scenario presented here could be used as a reference for the provincial government to build rfh during the covid- pandemic and as a recommended strategy to develop food security in 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review of food deserts literature optimization of location-routing problem for cold chain logistics considering carbon footprint fruit juice sonication: implications on food safety and physicochemical and nutritional properties the authors thank the west java development planning agency and universitas padjadjaran, which supported this study by providing research data. red zone ( figure . food supply network from production zone to rfh for case in scenario . this research was funded by indonesian the ministry of research and technology/national research and innovation agency ( /un . . / lt/ ). the authors declare no conflict of interest. no additional information is available for this paper. key: cord- -tz jajeb authors: deaton, b. james; deaton, brady j. title: food security and canada's agricultural system challenged by covid‐ date: - - journal: nan doi: . /cjag. sha: doc_id: cord_uid: tz jajeb the effect of covid‐ on canadian food security is examined from two different perspectives. covid‐ creates a unique “income shock” that is expected to increase the prevalence of household food insecurity. this food insecurity can be measured by utilizing the canadian community health survey (cchs). more fundamentally, covid‐ heightens household concern about the capacity of the canadian food system to ensure food availability. despite surges in demand and supply chain disruptions, we currently do not observe broad, rapid appreciation in food prices. this suggests that there is an adequate supply of food for the near term. there is less certainty over intermediate and longer time periods because so many factors are in flux, particularly the rate of increases in sicknesses and deaths across the country and globally. data on these health factors and elements of the food supply chain are needed to predict beyond a short time frame. in this regard, we discuss three ongoing considerations—ease of capital flows, international exchange, and maintaining transportation—that will help ensure food availability in the longer run. this paper examines the effect of the covid- pandemic on canadian food security. the loss of income to canadian households and challenges to the food supply chain are our primary focus, as those are the only factors that we can readily speak to with any degree of confidence. the loss of income associated with covid- is expected to increase measures of food insecurity as derived from the household food security survey module (hfssm) of the canadian community health survey (cchs), conducted by statistics canada. importantly, by this measure, the income shock associated with covid- will likely increase the prevalence of households identified as food insecure. beyond the effects captured in the food security module, households across canada are now concerned about the capacity of the food system to ensure food availability, both now and in the future, at relatively stable food prices. the private and public sectors working in tandem must address this more fundamental issue of food security, and it is our conviction, based on the ready response of supportive public policy at all levels of government, that this will occur. consequently, our assessment is that food availability will be relatively stable over the coming months. longer-term challenges to food security in reality and in the realm of public perception depend on a number of factors that cannot be fully anticipated. that said, we identify and briefly discuss three critical factors to monitor and analyze: international exchange, farm financial stability, and transportation. covid- is recognized as a health threat that poses a challenge to food security, from both an actual and a perceptual basis. section describes the expected effect of covid- on household income and subsequent levels of food insecurity. in this context, the measure employed to determine food insecurity will be clarified, so that the substantive meaning is understood regarding the basis of our expectation that the prevalence and intensity of food insecurity may increase. section examines the threat that covid- poses to more fundamental aspects of food security: society-wide expectations that food availability and food prices will be adequate to meet national needs and remain relatively stable. covid- has had immediate consequences on household income and future expectations thereof, as public and private workplaces and businesses closed principally to enforce "social distancing." workers also left jobs for health concerns for themselves and their families. in one week in mid-march, as the events described above unfolded, there were over , applications for unemployment insurance, compared to , applications that same week in the previous year (breen, ) . the canadian economy is expected to contract in the second quarter; some estimate by more than % (deloitte, ) . the u.s. economy is expected to contract by % (goldman sachs, ) . this last measure is comparable to contractions associated with the great depression (inman, ) . the u.s. contraction (and strength of its eventual rebound) is a critical consideration for canada, as canadian provinces do more north-south trade than east-west trade (deloitte, ) . the economic effects of covid- , like many income shocks, will have a depressing effect on the global economy for some time. covid- has some important characteristics that make its deleterious effects on employment and income generation unique and different from previous income shocks like the financial crisis of . first, covid- impairs the health and vitality of the work force, both directly, through illness, and indirectly, as some workers stay home to avoid carrying the virus back to their families and friends. another unique aspect of covid- is that the policies of social distancing significantly limit the range of public agency, university, organizational, and entrepreneurial responses that might accompany other recoveries and serve to stabilize household income-thereby reducing food insecurity. even before the pandemic, approximately . % of canadian households experienced some level of food insecurity according to results from the cchs (tarasuk & mitchell, ) . the first nations regional health survey (rhs), employing a similar survey approach to the cchs, found that . % of first nations adults living in first nations communities reported their households as food insecure (first nations information governance centre, ). income is a key factor influencing both whether a household identifies as food insecure and self-reports on the intensity of food insecurity. to better understand the relationship between household income and food insecurity, and build an appreciation of the potential effect that covid- social distancing refers to the practice of leaving space (often m) between people so as to limit the spread of covid- . in addition, the number of people (not already living together) that can gather in one place at the same time is restricted, and those exposed to covid- are expected to isolate themselves for a period of time (typically weeks). social distancing is more than a best practice; at the time of our writing, governments across canada have implemented a host of specific rules regarding social distancing. f i g u r e food insecurity by household income. source of figure: tarasuk ( ) will have on food insecurity, we briefly describe the most common method of determining food insecurity as measured and reported in canada. a similar food security module is used in the united states and administered by usda. the household food security survey module (hfssm) of the cchs (canadian community health survey) conducted by statistics canada (statistics canada, ) is a standardized survey that poses up to questions designed to probe the degree of food insecurity in the respondent's household. for example, an initial question asks respondents to assess whether they worried if food would run out before they had money to buy more. later questions in the survey identify more severe situations. for example, one question asks the respondent if they believe they lost weight due to a lack of money to buy food. answering affirmative to the initial question only, for example, identifies a "marginal" degree of food insecurity, while answering affirmative to questions along the lines of the latter example indicates more "severe" food insecurity. depending on the number of affirmative responses to the survey questions, households can be categorized as marginally food insecure, moderately food insecure, and severely food insecure. using this classification scheme and cchs results from and , . % of canadian households were classified as "food insecure" (tarasuk & mitchell, ) . of these, % were defined as marginally food insecure, . % were moderately food insecure, and % were considered to be severely food insecure. these categories imply considerable differences in what it means to be food insecure. statistics canada ( ) provides definitions of each of these categories as follows: • marginally food insecure: at times during the previous year, these households had indications of worry about running out of food and/or limited food selection due to a lack of money for food. • moderately food insecure: at times during the previous year, these households had indications of compromise in quality and/or quantity of food consumed. • severely food insecure: at times during the previous year, these households had indications of reduced food intake and disrupted eating patterns. with respect to these measures of food insecurity, a couple of points merit consideration. first, food insecurity is associated with a lower income. that said, food insecurity is complex, and, unsurprisingly, there are observations of relatively high-income households that are food insecure and low-income households that are food secure. nonetheless, figure reinforces an important association between household income and food insecurity. as incomes increase, the prevalence of food insecurity declines. in the context of first nations, deaton, scholz, and lipka ( ) find that individuals in the low-income category-$ - , are approximately times as likely to be food insecure as individuals with an income of $ , or more. covid- ′ s negative influence on employment levels, subsequent incomes, and future economic growth is expected to increase the prevalence of food security by this measure. a loss of household income is expected to influence the quantity of food consumed as well as the type of goods purchased. generally, food is considered income inelastic so the percentage change in consumption levels are expected to be less than the percentage change in income. additionally, the loss of income will lead households to increase their consumption of f i g u r e food insecurity by main source of income, . data are from canadian community health survey, statistics canada. figure retrieved from proof attributed to https://proof.utoronto.ca/wpcontent/uploads/ / /public-policy-factsheet.pdf, attributed to tarasuk, michell, and dachner ( ) so-called "income inferior goods." in the future, the change in consumption associated with income and price volatility caused by covid- can be more rigorously analyzed using income and price elasticities. as discussed above, the income shock triggered by covid- is expected to increase the prevalence of household food insecurity. but an important additional consideration is how the distribution of food insecurity changes across the three categories: marginal, moderate, and severe. the severely food insecure category (presently % of canadian households) is the most concerning. given that covid- is expected to lead to both losses as well as shifts in employment, the likely effect will be to skew the distribution of food insecurity towards the relatively more harmful experiences of "moderate" and "severe." a recent study by tarasuk, fafard st-germain, and mitchell ( ) finds that every $ , increase in income (before tax) reduces the odds of marginal food insecurity by %, the odds of moderate food insecurity by %, and the odds of severe food insecurity by %. this indicates that moderate and severe food insecurity may be more sensitive to changes in income. figure demonstrates how the experience of food insecurity varies by sources of income (i.e., employment income versus unemployment, social assistance, workers compensation, etc.). importantly, from the perspective of this discussion, a lack of employment income is associated with a higher prevalence of moderately and severely food insecure households. the health considerations associated with covid- add additional complications that may influence both the prevalence and intensity of household food insecurity. additionally, covid- might have debilitating health effects that persist after economic recovery. by contrast, the income shock associated with the financial crisis of was not accompanied by sickness or death. from a financial standpoint, the debilitating health effects or deaths associated with covid- further endanger the capacity of the household to recover. ameliorative policy measures are being undertaken in rapid fashion by the government and non-governmental groups throughout canada. these measures include government efforts to provide support for families-for example, mortgage support and increased child care benefit payments; assistance to people facing unemployment-for example, direct payments of $ , a month to eligible workers, improved access to employment insurance; and financial backing to business to support continued employment-for example, the canadian emergency wage subsidy covers % of salaries for qualifying businesses (government of canada, ). the government has expanded support to non-governmental groups addressing the challenge of food insecurity. many of these groups have been at the fore of addressing food insecurity for some time. food banks, for example, are presently challenged to maintain and expand their capacity to address food insecurity. food banks are particularly important to the most food insecure households. indeed, households that use food banks have been found to be relatively lower income and relatively more likely to be moderately or severely food insecure (tarasuk, fafard st-germain, & loopostra, ) . any comparisons with past events must recognize the additional challenges that covid- ′ s health effects place on the response, and this is an important distinction from past income shocks. food banks and home delivery to the elderly, for example, rely heavily on volunteers, many of whom fear the potential health effects of covid- . social distancing and health concerns complicate all efforts to respond to the pandemic. this is particularly concerning because many support services, like food banks, administer services to those who experience food insecurity most severely. recent surges in demand (and hoarding behavior) reflect household responses to public health requests for people to stock up on food, in order to comply with social distancing, and reflect public fear that covid- could limit food availability. such demand surges might, at times, lead to temporary shortages on grocery store shelves. observations of these shortages by consumers may also reinforce the notion that food availability was under immediate threat. however, these surges will likely be tempered by the fact that shelves will be restocked, and shoppers will not empty them at the same rate, having already stored up on the high demand items. if this be the case, then food shortages and/or a rapid upswing in food prices are unlikely in the short term. the relative stability of food prices in the later weeks of march is a signal that expectations regarding the demand and supply of food are relatively stable. over a longer-term period (i.e., months- year) in which we could even experience a second wave of the virus, being able to prevent food shortages and a rapid upswing in prices are key to determining whether the necessary and sufficient supply of food (in terms of nutrition and quantity, respectively) are available and affordable at the point of consumer purchase. with this in mind, we identify and examine three factors that impact food shortages and price increases, specifically impacted by covid- , which could undermine the food supply chain. these are: (a) challenges to international exchange; (b) farm financial stability; and (c) transportation. though % of what is purchased in grocery stores is "produced" in canada (statistics canada, ) , continued exchange among countries remains paramount to ensuring diversity in both production and consumption. key to this exchange is the health stability of the labor force, which includes temporary foreign labor. the importance of temporary foreign labor to ontario's fruit and vegetable production was underscored after trudeau announced the closing of the borders to foreigners (with the exception of u.s. citizens) on march , . this action alarmed key sectors because this foreign labor was viewed as essential to vegetable production. so, very quickly, the restrictions were relaxed and temporary foreign labor was given an exception (hughes, ). yet, as we write, there are reports of uncertainty about the availability of cross-border laborers, presumably because of logistic challenges and their own covid- related health conditions (grant, ) . with respect to the food industry, the importance of borders will differ depending on the particular industry. some industries like animal production are less dependent on foreign inputs than others like sugar and confection processing. should the border "thicken" in the longer-run, this effect will differ across industries and alter relative prices. accordingly, the consumption basket for food will adapt, depending on cross-price elasticities among choices available, and while consumers will adapt, some nutritional consequences could occur as well. though our focus is on examining food security from a canadian standpoint, we would parenthetically note that, from a global perspective, the rise of protectionist policies could ultimately entail deleterious export/import constraints-such as those now taking place in kazakhstan and viet nam, and threatened by russia. protectionist policies may be particularly harmful, from a global perspective, to the world's most severely food insecure populations (glauber, laborde, martin, & vos, ) . given the economic ties between the united states and canada, the spread of protectionist policies is concerning and worthy of careful assessment and scrutiny. achieving a balance of trade and domestic production in food systems is an ongoing challenge determined by economic efficiency, consumer choices, and social and political preferences. conditions that generate increased fear or uncertainty about food availability spark new debates about how best to achieve societal goals and meet food needs. this pandemic will continue to fuel such debate in canada about the appropriate balance of domestic production and international trade. some commentators have already raised concern about our current reliance on trade. fraser ( ) argues that the dialogue regarding regional selfsufficiency "could spark a reinvestment in canadian farms, food processors, and our rural economies that have been declining for decades" (fraser, ) . the relationship among the components of the rural economy of canada deserves continuing attention, especially to determine the components relationship to a "robust balance of domestic production and global trade" (fraser, ) . whether that robust system will lead to more or less regional self-sufficiency can be more fully evaluated after this crisis. at the moment, two issues are worth noting. over the course of the past month, the food supply chain has adjusted relatively well to an extraordinarily challenging situation. it is not clear to us, at least as of the writing of this article, that a more regionally selfsufficient system would have adjusted more quickly to the challenge. many of the challenges associated with social distancing would apply to a more "regionally self-sufficient" system as well. second, "self-sufficient" regional agricultural systems, even in the best of times, are threatened by challenges like weather. in the extreme, regional self-sufficiency in production can become regional dependency in consumption in situations of drought or plague, severely restricting the quantity and quality of available goods. some farm families will suffer along with others from sickness and loss of productivity from covid- illness. more to the point of this section is concern about the capacity of capital to flow smoothly to farmers and to supportive businesses along the supply chain. this was addressed by efforts of the bank of canada to dampen interest rates and the federal government's increased enhancement base to farm credit canada, which provides more flexible extension of credit to farmers. many farmers have multiple loans and policies that enable deferments of interest payments, and flex was provided to allow farmers to manage loans and financial burdens to ensure stability in production. similar steps to strengthen small business concerns will offer further protection. these policies will likely require extension if the crisis persists for a longer period of time (i.e., beyond months). covid- has the potential to influence the smooth function of transportation at nearly every step along the food supply chain. illnesses related to covid- could limit the availability of skilled personnel in the transportation sector all along the food supply chain. this complex supply chain includes inputs to the field, to storage, to processors and manufacturers, and to distributors and retailers. remote and food insecure areas like nunavut are particularly susceptible to transportation challenges. in these areas, the majority of food in grocery stores is flown into the communities. indeed, naylor, deaton, and ker (forthcoming) note that none of the communities in nunavut are connected by road and rely heavily on food flown in by air, at an average distance of , km. given the high rates of food insecurity in these areas, maintaining air transportation is critical. the authors provide evidence that the primary program of addressing food security in these remote areas-that is, the nutrition north program-successfully lowers prices to households, but depends on air transportation. the effect of covid- on food security is examined from two different perspectives. from the perspective of food insecurity as measured by the canadian community health survey, covid- is a unique "income shock" that is expected to increase the prevalence of household food insecurity. moreover, because this income shock is associated with unique detrimental health effects, covid- has the potential to increase the proportion of households identified as "moderately" and "severely"' food insecure. unfortunately, covid- has threatened canadian food security in more fundamental ways than the cchs is designed to assess. specifically, canadians worry that covid- might limit the capacity of our food supply chain to ensure adequate food availability. despite short-term surges in demand and the challenges of ensuring worker safety, we expect that food availability will be stable over the course of the next months. nonetheless, temporary shortfalls in food supply and increased prices for certain foods might still occur. this cannot be determined due to the unprecedented nature of this global tragedy. what we do know is that the magnitude of the covid- tragedy demands that it be studied in great detail in terms of key variables that impact food security, the comparative weight of variables impacting food security, and how amenable they are to policy interventions. finally, we look with great expectation to the regional, and country, specific data and global meta data analysis that will certainly follow in the aftermath of covid- to provide a more confident basis for responding to comparable tragedies in the future. we thank bethany lipka, elsie richmond, and alex scholz for helpful comments and edits. we also appreciate insights from discussions with pat westhoff. that said, any opinions expressed and all errors should be attributed to the authors. coronavirus: , canadians have filed for ei this week. global news an empirical assessment of food security on first nations in canada predicting the post-pandemic recovery. deloitte economic-insights the covid- pandemic and canada's food system. ipolitics covid- : trade restrictions are worst possible response to safeguard food security. ifpri blog: issue post us daily: a sudden stop for the us economy crops in peril as temporary foreign workers yet to arrive ottawa to exempt temporary foreign workers from some covid- travel rules. the globe and mail a hundred years on, will there be another great depression?the guardian assessing the effect of food retail subsidies on the price of food in remote indigenous communities: a case study of nutrition north canada section : food in canada canadian community health survey-annual component (cchs)- determining food security status household food insecurity in canada geographic and socio-demographic predictors of household food insecurity in canada the relationship between food banks and food security: insights from canada. voluntas household food insecurity in canada implications of a basic income guarantee for household food insecurity key: cord- - c kq w authors: lin, paohui; tsai, hsientang; ho, tzuya title: food safety gaps between consumers’ expectations and perceptions: development and verification of a gap-assessment tool date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: c kq w in recent decades, food safety has become a major concern due to frequent food safety incidents in many countries. this may lead to increased health risks associated with low quality food consumption, thereby reducing consumer trust in food safety. a better understanding of consumer perceptions of food safety can improve indicators that do not meet consumer expectations. we propose a food safety gap model with four gap-construct based on consumer expectations and perceptions. the model was empirically tested through a survey of items, and then assessed for gaps through the importance–performance analysis (ipa). from a sample of taiwanese consumers, we found a huge gap between consumer expectations and perceptions related to food safety. more importantly, the results of the ipa indicate that most items must be immediately improved, which is vital in order to mitigate the risk of food safety. food safety has become an important public health concern, so it is controlled and regulated by the government. governments have taken measures to manage issues, and many previous studies have also explored these mechanisms, including governmental policies and regulations on organic farming [ ] , the impact of foodborne poisoning caused by food contamination [ ] , a novel coronavirus caused by microbial contaminants in game meat [ ] , concerning the risk of animal diseases such as avian flu, swine flu, mad cow virus [ , ] , safety assessment of meat products [ ] , and food inspection standards, such as instrumental detection methods based on the nuclear magnet resonance [ ] or low field nuclear magnetic resonance [ ] to assess the adulteration of oils and fats. it is hoped that these approaches can be used to ensure a baseline level of food safety. in academia, various researchers have studied complex food safety issues, each with its own terminology and classification, for example, wu and hsiao [ ] used a failure mode and effect analysis (fmea) method to evaluate risk in food cold chains for chilled or frozen food companies in taiwan; lai et al. [ ] estimated on disease burden from foodborne illnesses in taiwan from to ; wu, lin, and chen [ ] investigated food safety risks in china; whitworth, druckman, and woodward [ ] proposed the categorization of food scares; jespersen, maclaurin, and vlerick [ ] developed the food safety desirability response scale; park, kim, and bahk [ ] analyzed south korean food safety incidents between and ; nayak and waterson [ ] studied the food safety culture of a group of industry stakeholders in the uk; wongprawmas and canavari [ ] provided food safety label categories that are indicators of thailand consumers' willingness to pay. despite the increased academic interest in food safety issues in recent years, food safety incidents remain problematic and have not declined significantly over the past decade. food safety incidents cause economic losses, social disruption, and also have environmental impact, so manufacturers involved in the food supply chain and associated governmental departments are striving to reduce both the frequency and severity of their occurrence. however, many of these incidents can be traced back to food manufacturers and their non-compliance with food hygiene and/or food safety procedures. for example, sun et al. [ ] pointed out that street food vending in the night markets presents public health challenges, with evidence of diarrheal diseases. park et al. [ ] found that between and , south korea had an average of . food safety incidents per month, which had both local and international impacts. according to peng et al. [ ] , taiwan has also faced food safety incidents in recent years, with adulteration involving illegal additives being the most common: black tea with coumarin, emulsifiers with plasticizer, edible oils with cu-chlorophyll, lard with recycled cooking oil, and antibiotics (tetracycline) in honey. it is worth noting that the taiwan food and drug administration (tfda) has established official regulations and analytical methods to assess food quality and determine whether food is adulterated. however, many food safety incidents still occur, although the cause of each event may vary by product, time, and geographic distribution, but a pattern can be seen between certain events. therefore, it is useful to classify consumers' similar perception gaps when developing strategies to reduce food safety scares. parasuraman, zeithaml, and berry [ ] noted that the consumer expectations will be influenced by past experiences, personal needs, and word-of-mouth. indeed, there are various attributes of safety food. with the improvement of food safety awareness, more consumers are willing to pay higher prices to buy safe foods. for example, products with food traceability, food certification mark, and labeling of product ingredients. parasuraman, zeithaml, and berry [ ] studied consumer perception models (called pzb model), which is the most cited literature on service quality gaps. the original pzb model proposed five gaps to describe the service quality model by conducting in-depth interviews with fourteen executives from four service companies and service users. the pzb model is very attractive because it can reasonably explain the gap between perception and expectation. however, the model concerned the perceived discrepancy between management and customer. the gap is strongly managers-oriented and not particularly applicable in the context of food safety. thus, we propose a food safety gap model that uses the concept of the pzb to describe the food safety gap between consumer perceptions and expectations, and develops a multiple-item instrument to measure these gaps. prior research focused on consumer perceptions of food safety risks [ ] , food-related hazards [ ] , trust of food [ , ] , and consumer acceptance of food safety incidents [ , ] . recent studies have developed several instruments to measure perceptions of food safety in food-related organizations, such as food safety climate [ ] , and food safety culture [ ] . nonetheless, based on the consumer-oriented context, the concepts of food safety gaps are still ambiguous and no unanimous definition has been found. drawing on food safety related literature and expert views, we have developed a conceptual model of psychological activity of food consumers to explicate the key determinants of food safety gaps, and define the main concepts which are present in this study. the psychological activity of food safety perceptions includes three stages: evaluation, confirmation, and action. we called this the eca model and depicted this conceptually in figure . the evaluation stage is subdivided into four gaps between consumers' expectations and perceptions. this process is derived from the gap concept of the pzb model [ ] . confirmation and action stages can be divided into the expectation of confirmation or not as the antecedent of subsequent perceptions. the upper part of the framework refers to related concepts of the expectation confirmation theory (ect; [ , ] ). this explains how consumers evaluate their food safety experience and how this evaluation affects their decision to continue purchasing (e.g., expectation confirmation → satisfaction → continuance trust). the lower part depicts the psychological contract breach [ ] . reneging and incongruence are two root causes of perceived psychological contract breach. for example, an obligation exists but knowingly fails to meet that obligation, or made an explicit promise and then failed to uphold that promise. however, the perception of contract breach will not necessarily lead to intense emotional reactions. whether this cognitive perception of breach will lead to an emotional response, and the intensity of this reaction, depends on the interpretation and persuasion process of the defaulter, whereby the consumers attaches meaning to the perceived breach (e.g., expectation disconfirmation → expectation trust breach → emotion regulation ← interpretation/persuasion). the definition of the eca model in our study includes the gap of expected and perceived, which then affects cognition attitude and subsequent behavior intention. after experiencing the first-stage of the evaluation and finding a perceived gap, if consumers' perceptions of food safety are much lower than expected, consumers are exposed to food safety gaps and vulnerabilities. that is, the importance of food safety and gaps are the main reasons for this study. study the expectations versus the actual perceived disparities at the consumer's level and unravelling human perceptions in the context of food safety is important as both might affect the validity of the evaluation stage. this study emphasizes a consumers' perspective on food safety being subjective and experiential. this approach aims to explore gaps on how consumers actually perceive food safety in terms of an evaluation of its expected trust. therefore, we will not only give a brief overview of prior research on food safety but also discuss the food safety gap model, and assessment tool. food safety is defined as a necessary condition to guarantee the health of consumers [ ] , which is considered as the basic rights of consumers. food safety specifications and laws are among the instruments used from manufacturers and governments to discuss safety issues in the food supply chain [ ] . governments often set food-related regulations or standards to figure out the baseline level in food safety, which can protect consumers from food safety issues [ ] , this includes a number of routines that should be followed to avoid potential health hazards. nelson [ ] argued the food has credence-attributes in the consumption market and may face the asymmetry of product information because consumers cannot see or verify, either before or after purchase. if this is not a priority, this can cause serious damage in food safety. however, giving credence-attributes can be costly, and firms can also incur fixed costs associated with providing accurate information [ ] , so reducing credence-attributes can be one of the means to improve performance. the tracks within this line of thought are safety between the government and industry, and then between industry and the market, and then between the market and the consumer. specifically, a lack of food safety can be the main reason for the gaps in perceptions that consumers have. therefore, gap to gap illustrates the difference between consumers' actual perceptions and expectations concerning food safety in the first-stage of the eca model. the gap model further constitutes a theoretical explanation for the mentality of food safety, which is the main focus of this study. among these four gaps of food safety trust, 'gap' stands for the expected difference between consumers, manufacturers, and government. gap shows the difference between consumers' actual perceived and expected trust towards manufacturers. before selling food, a company's management essential to understand the characteristic of food safety to fill consumers' needs, due to the affected consumers' evaluation of food safety. gap describes the consistency of trust between consumers and the government in food safety, which in turn forms food safety regulations to protect consumers. it is because the commitment and policies communications by government can affect consumers' perceptions regarding food safety. gap is the discrepancy between food manufacturers and what is promised via external regulations put in place by the government. various situations, such as legal conditions and regulatory constraints, may lead to differences between expected trust from manufacturers and governments by consumers and what they perceive these established regulations for food safety. gap is the difference between consumers' perceptions and expectations of food safety. the gap is concept-oriented, especially for food safety. gap may also be affected by gaps , , and . the means that the direction and size of each gap will have an influence on food safety. the reasons for the gap include (a) unrealistic food information, (b) public anxiety over food safety incidents, and (c) poor enforcement of food safety regulations. hence, further research is needed to help consumers understand their gaps of food safety. in order to develop the food safety gap scale (fsgs) to measure the gap between consumer expectations and food safety-related concepts, we collected items related to the basic attributes of food quality from previous studies. we divided these measurement items into four dimensions, which include assurance, commitment, regulation, and assessment. the explanation of each dimension is as follows. assurance-this is related to measuring the objectivity or clear evidence of food, such as food label information, appearances being kept intact, food certification marks, labeling of product ingredients, and food traceability [ ] . these items which were classified as "food manufacturers have the control, honest, and sufficiently open about the safety of food" (a - ) are based on the consumers for confidence-in-food manufacturers questionnaire [ ] . for consumers, manufacturers must prove that food safety and hygiene are more important than productivity and cost savings. although this notion already is ingrained in the consumers' perception, food safety goals often are in conflict with the financial performance of a manufacturer [ ] . therefore, if the manufacturers' ethical beliefs and values of food safety align with consumers, they will be more motivated and exceed expectations. this will then decrease negative perceptions of food safety for consumers such as item a "absence of a code of ethics in enterprises makes you suspect the safety of the food with additives." [ ] , and item a "alert and attentive to potential problems and risks related to hygiene and food safety" [ ] . in addition, according to taylor's survey items, where framed in the context of food safety: "the food product is labelled with all necessary information" (a ) as well as " the food producer (a )/shop or retailer (a ) maintains control over the hygiene" [ ] , these items were adopted. another indicator that manufacturers face with food safety issues is the assurance of trust. as argued by morgan and hunt [ ] , trust and confidence plays an important role in the business/consumer relationship, yet this trust appears only when the supplier satisfies the needs of the consumer [ ] . this sense can bring about increased motivation on the part of the consumer, and it also means that people "trust taiwanese food manufacturers to produce safe foods" (a ) and "trust processors to honestly convey the country of origin and the product's ingredients" (a ) [ ] . as described above, items of the food safety gap between consumers and manufacturers are integrated into the first version of the self-assessment scale in table . the food product is labelled with all necessary information. the food producer maintains control over the hygiene. a the shop or retailer maintains control over the hygiene. a i trust taiwanese food manufacturers to produce safe foods. i trust processors to honestly convey the country of origin and the product's ingredients. absence of a code of ethics in enterprises makes you suspect the safety of the food with additives. wu et al. [ ] a my acquaintances (e.g., family, friends, or colleagues) are alert and attentive to potential problems and risks related to hygiene and food safety. griffith et al. [ ] . the commitment to food safety through government is a measure which consumers consider regarding their own values and beliefs about food safety, and if they are aligned with those of their own government. previous research has identified the relationships between the positive and negative effects of organizational commitment across a wide range of different contexts [ , ] . nevertheless, the extent of the changes brought upon by the commitment of government is yet to be explored. in this case, the component commitment of this study is to identify the impact of government commitment on consumers, and to assess the expectation gap between consumers and government. based on the leader-member exchange (lmx), the commitment in an environment of food safety is affected by the government-consumer exchange (gcx). this notion is inferred from the quality of the social exchanges between government and consumers. regarding gcx, a high gcx can result in better engagement in commitment concerning regulation and policies. the term "commitment" is used to describe food safety, the purpose is to reduce the social panic that may be caused by contaminated food, and how to effectively promote policies to attract consumers [ ] . for example, item c "government's regulation on additives is a lack of effectiveness" [ ] , item c "government set clear objectives", and item c "government strive for continuous improvement" [ ] . every time the government participates in critical food issues, it must prove the significance of their regulations and how they impact food safety. therefore, we introduced item c "government clearly considers food safety and hygiene to be of great importance" and item c "government acts quickly to correct problems/issues" [ ] . we argued that a high gcx also means that communication from government to consumers is a major factor. generally, consumers expect that food will not harm their health or the environment. consumers' trust in regulators is vital in building and maintaining confidence in food safety [ ] . therefore, griffith et al. [ ] conceptualized that consumers' confidence in food safety is influenced by their trust in government, food safety risks and food risk controls, such as items c , c , and c . when consumers cannot maintain the control of food quality they are consuming, the trustworthy relationship with government is considered a good deputy for controllability [ ] . the choices associated with the assessments of food risks result in a very time-consuming process. so, people need to delegate control with certain situations and let other trusted characters act on their behalf [ ] . in this sense, the level of food safety control handing as a determinant of food quality is based on government regulations, specifically, the safety controls required by law for public hygiene, risks related to manufacturers' food production, and certifying bodies' indirect controllability. for these reasons, it is important to know how much trust the public has in the government's food regulations to cope with food risks, such as development items c [ ] , c [ ] , c and c [ ] (see table ). the government strives for continuous improvement of food safety and hygiene. the government clearly considers food safety and hygiene to be of great importance. hall et al. [ ] c the government acts quickly to correct problems/issues that affect food safety and hygiene. c the government sets a good example concerning food safety and hygiene. in our government, the risks related to food safety and hygiene are known. in our government, the risks related to food safety and hygiene are under control. in our government, good policies and procedures concerning food safety and hygiene are in place. yiannas [ ] c i think that the food safety level of market product is very poor/very good. berry the government should design regulations and standards related to hygiene and food safety, and ensure that manufacturers know their roles and responsibilities. at the regulatory level, taiwanese laws abide with the strict regulatory framework established by the united states and the european union (e.g., hazard analysis and critical control points (haccp), genetically modified organisms (gmos), and regulation (ec) no. / ) to trace food safety. for this reason, item r "taiwanese authorities enforce strict hygienic standards for food" [ ] was retained. in addition, the nature of trust is very complex [ ] , such as the recognized qualities of taiwanese local gastronomic products, but taiwanese may also have doubts regarding the safety of food. specifically, over the various food safety incidents which may have led to lower consumer confidence and an increase in food scares. on the one hand, food scares can be interpreted with more and more people having anxiety over food safety incidents, and this anxiety is closely correlated with media attention given to such events [ ] . on the other hand, media information about the relationship between food safety and consumers is often highly distrustful compared to other sources, but it is also a primary source of information for many consumers [ ] . in general, if government authorities appear willing to disseminate relevant regulatory information regarding food safety, consumers will be have more "trust in imported food, and feel it is safe" (r ), "trust the food inspection schemes adopted" (r ), and "trust the food safety standards adopted" (r ) [ ] . if "governments communicate regularly with the public (r ) and food manufacturers (r ) about hygiene and food safety" [ ] , this process creates a short-term positive impact upon consumer consumption behavior. additionally, whether these violations of public health will be corrected immediately have also caused significant consumers concern. therefore, guchait, neal, and simons [ ] proposed a causal sequence illustrating the importance of serious (r ) and substantial (r ) food safety violations. each of the above these items are included in table . i trust the food inspection schemes adopted by the taiwan government. r i trust the food safety standards adopted in taiwan. the government communicates regularly with the public about hygiene and food safety. yiannas [ ] r the government communicates in a clear way with the food manufacturers about food safety and hygiene. if health violations have a direct impact on public health and must be corrected immediately. serious items may, as a group, lead to the closure of a food establishment if not corrected (e.g., food additive, filthy food contact surfaces, temperature problems, food from unapproved sources, adulterated food). guchait et al. [ ] r these are violations of such a direct and substantial impact to public health that the violation must be immediately corrected or the health officer will require the closure of the food establishment (i.e., no water; no hot water; no ability to sanitize; sewage back up; power outage; pest infestation; no/expired food dealer's permit). expectation-disconfirmation theory (edt) [ ] has been utilized by researchers to understand consumer satisfaction, intention to purchase again in the future, and complaining behaviors, and is an extension of cognitive dissonance theory (cdt) [ ] . cdt explains how discrepancies between one's cognition and reality change the individual's later cognition and behavior. in the context of food safety, cognition refers to one's food risk opinions [ ] , food consumption values [ ] , affective attitudes of food [ ] , and food safety knowledge [ ] , while behavior refers to actions started in response to this cognition or individual's evaluation of such behavior [ ] . food safety is a social risk associated with human factors, therefore, the relationship between expectations and actual perception is complex. using edt to depict a psychological process of individual behavior whereby consumers generate initial expectations about a food product, experience its usage over time, and then form actual perceptions of the food product itself. although earlier research explained the gap between food safety attitudes and behavior [ , ] , it did not measure the consumers' observed expectations of change in terms of cognitive dissonance. the gap between consumers' original expectations and actual perceived existed in the disconfirmation construct. cognitive dissonance may be positive or negative depending on whether the actual perception is above or below initial expectations, and is viewed as a deviation of initial expectations. indeed, some contend that the gap is ambiguous, and the effect appears to be mixed, or inconclusive. both the actual perceptions and expectations play a factor in determining consumer satisfaction or dissatisfaction with food safety, and explain the continued intention among food purchases. in line with this conception, among these food safety incidents in taiwan, adulterations involving illegal food additives were the most frequent [ ] . items e to e explain the observed expectation changes in terms of food additives [ ] . food safety and any possible risks related to it, should be known by the consumers, so they can take this information into account in their purchase decisions. consumers may be aware of the "attention given to the risks of consuming certain foods in taiwan" (e ) [ ] , "responsible for food safety after purchase" (e ) [ ] , or "know where the food originates from" (e ) [ ] . in line with these conceptions, consumers may not just blindly trust the system, item e "as a result of the occurrence of food safety incidents, i am suspicious about certain food products" is measured for the over-confidence of consumers concerning food safety and public health issues [ ] . each of the above these items are included in table . table . indicators of food safety gap between consumers' expectation and actual perceived. i usually put attention on risks of food in taiwan. sparks and shepherd [ ] e influence from information regarding the presence or absence of quality and safety certification of food with additives. wu et al. [ ] e doubt about the food safety of domestic food market. e influence from information regarding additives on the package labels. e unwilling to buy food with additives due to the experience of family. e abuse of food additive became a major potential food risk. e lose confidence in the domestic food market. e consumer is responsible for food safety after purchase. drawing upon the aforementioned literature regarding food safety, previous research has centralized on improving food safety quality to promote the consumer trust. however, this did not significantly increase consumer confidence in buying foods, mainly because many foods on the market still do not satisfy the consumers' expectations. three experts interviewed during this elicitation stage consisted of a member from food manufacturer administration, a senior staff of the government's health department, and a professor in the field of food safety. next, a pretest for food consumers to evaluate the comprehension of this closed questionnaire. the participants were recruited from a range of food markets for supermarket, organic stores, and traditional taiwanese markets. after conducting this pretest, we revised the tested fsgs into the first version for this study. the first version of the fsgs was distributed during a preliminary and test stage which lasted from december to january . a total of questionnaires were returned, and only were used for data analysis to evaluate the reliability and validity of each dimension, and we apply confirmatory factor analysis (cfa) to purify the structure of fsgs. the number of indicators were confirmed using the factor loading values greater than . criterion. items that did not meet this criterion were removed one at a time to ensure utmost accuracy. after iterative rounds of cfa, we excluded items to constitute the final version. the final version of the fsg self-assessment questionnaire is divided into four parts, including subjective perceptions of food safety, the importance and performance of food safety, along with basic demographic information of the respondent. all items were scored by using -point likert scale, ranging from = "strong disagree" to = "strong agree", except for personal information. the data collected were over a period of approximately three months (february -may ). a total of valid responses were collected and then included in reliability and validity, and importance-performance analysis (ipa) to understand the food safety gaps of consumers. the profiles of participants were shown in table . note. cfa = confirmatory factor analysis, ipa = importance-performance analysis. using the data of subjective perception for reliability and validity analysis. among the participants in the final version of fsgs (n = ), the convergent validity was assessed by determining the significance of item to factor loadings [ ] , and further the internal consistency. the calculated cronbach's alpha values ranged from . to . (cutoff value > . ), and displayed in table . convergent validity was measured by composite reliability (cr), which should be greater than average variance extracted (ave), which in turn should be greater than . [ ] . the cr values of this study range from . to . , and ave value range from . to . . thus, good internal consistency among the attributes within each dimension was confirmed. in addition, these thresholds also tested the discriminate validity of the assumption that the ave square root of each variable exceeds the related coefficients of these variables [ ] . additionally, a pairwise correlation less than . indicates discriminant validity between two factors [ ] . in summary, the -item measurement fsg exhibited a considerable construct which was deemed valid and reliable (see tables and ) . note. items on the diagonal in boldface represent the ave square root; ** p < . . importance-performance analysis (ipa) developed by martilla and james [ ] , and marketing research techniques helped provide insights to management in order to identify the strengths and weaknesses of service attributes [ ] . more importantly, ipa is able to determine the most important attributes that have the highest impact on consumer satisfaction, and understanding that the lowest performance attributes that need to be improved immediately [ ] . therefore, to date, the application of ipa extends to a wide range of fields, including manufacturing [ ] , tourism [ , ] , hospitality [ ] , food [ ] , health care [ ] , transportation [ ] and other industries. in this study, ipa involves two dimensions and four quadrants that measure the performance/perceived (x-axis) and importance/expectation (y-axis) of food safety attributes. according to their position on the matrix, the following improvement gap of food safety can be recommended. quadrant i: "keep up the good work", are viewed as the opportunities to achieve or maintain competitiveness; quadrant ii: "concentrate here", high importance, but low performance is considered as a major weakness for food safety gaps. therefore, immediate improvement is required; quadrant iii: "low priority", the attributes in this quadrant are not considered crucial and do not require additional efforts; quadrant iv: "possible overkill", low importance but high performance, customers do not particularly value these attributes in this quadrant, which indicated that the resources committed are excessive. table shows the mean importance (i), mean performance (p), gaps score, paired t-value between importance and performance, and quadrants of each item gained through the analysis of data. the paired sample t-test shows that significant differences exist between the respective expectation mean and perception mean for all items. moreover, these gap scores between the importance/expectation and performance/actual perceptions are negative which indicates that the quality of food safety is generally less than what consumers think it actually is. from a gap analysis perspective, all items must be improved, as well as the order of their improvement priorities based on the results of the ipa. looking at the different aspects among score gaps, the items a ( . ), a ( . ), and e ( . ) have a smaller gap score, while items a ( . ) and e ( . ) have a larger gap score. specifically, these items mostly belong to the "assurance" and "assessment" constructs in the fsf-scale. as revealed in the above results, the data were then transferred to the ipa matrix presentation in figure . the practical implication based on the result diagram of expectation and perception is that food safety should pay more attention to these items to decrease the gap. note. i = importance, p = performance, quad. = quadrant, no item in quadrant iv, *** p < . significance levels. our findings have revealed that gaps in food safety have highest importance and performance in quadrant i, such as items a , a , e , and e . therefore, at least the performance level should be continued and then narrow the gap. in quadrant ii, where 'performance/actual' perception is lower than 'importance/expectation', there are many items that fall into the "concentrate here" quadrant (a , a , c , c , c , c , r , r , r , r , r , r , e , e , e ) . in short, government and manufacturers must focus on improving these attributes. it is worth noting that all items related to the "regulation" construct fall within this quadrant. the gap analysis results illustrate that these items with a gap less than . fall into the "low priority" quadrant (iii) in the ipa matrix, implying low importance and low performance. therefore, these items may not be prioritized when government or manufacturers make improvement plans. in quadrant iv, the consumers are satisfied with the performance but they assess less important food safety attributes. however, not any particular item falls into this quadrant. the above results indicate that the gap scores were able to successfully evaluate the magnitude of the gap between consumers' expectations and actual perceptions of food safety. the evaluation of all items based on expectations and actual perceptions of consumers' food safety has generated a conflicted consequent with a lower perception and rather higher expectation. this overwhelmingly verifies that a gap exists between consumers' expectations and actual perceptions of food safety in all indicators, and that the improvement of these indicators needs to be promoted because they fail to satisfy customers' expectations [ ] . previous studies have argued the gap exists between food safety attitudes and behaviors of respective food vendors [ , , ] . our results indicate a gap between consumer expectations and actual perception of food safety, which is one of the enduring challenges for dealing with food safety. figure represent the magnitude of the gaps within each indicator ranging within the four constructs. from the magnitude in each gap, we found that there is a wide gap existing between expectations and actual perceptions of food safety. despite most food vendors complying with governmental regulations and standards, it is likely that they cannot truly satisfy the expectations of the consumer. moreover, in order to increase the sales within the food economy, the government has inadvertently ignored the actual perception of food safety by consumers and has not yet provided any approach to address consumers' perceptions of food safety after recurring incidents of food safety. though recognizing that incident of food safety was an extremely important issue for the future at the consumer level, if manufacturers and governments were unwilling to expand any additional effort in the environment of food, these problems threaten to permanently diminish their quality of food safety. while food production is becoming increasingly more complex, no matter how different in terms of risk characteristics and the degree of threat to public health, successive food scares may lower consumer confidence. as a result, consumers tend to rely heavily on government and manufacturers to ensure the quality of the products they consume. however, less research has focused on the level of importance consumers place upon aspects of expectation and gap concerns regarding food safety perceptions. the eca model is viewed as a three-stage model where first-stage "evaluation" is caused by the gaps between expectations and actual perceptions of food safety, and to confirm the size of the gap. given this background, the purpose of this paper is to describe the application of a gap model and how it affects and relates to food safety. more specifically, this study was undertaken in order to understand consumers' gap of food safety, and to suggest some theoretical as well as practical implications of this process. the results show that taiwanese consumers have large gaps in the food safety environment. a larger gap between expectations and perceptions means that consumers are less confident about food safety in the market, or their lack of confidence in mandatory regulation has led to the current level of food safety that may not meet the need or expectation of consumers. for instance, ipa suggests the "regulation" performs poorly with all indicators that fall into quadrant ii. therefore, we argue that the government should still be a key actor. although the taiwanese food and drug administration (tfda) ensures food safety and the quality of food, developed official regulations and analytical methods to assess food quality are used to determine whether food has been adulterated. even in situations where tfda affects practice, these influences appear not to be more valid over time. that is, the weak enforcement of food safety regulations, which at best create a favorable attitude. in addition, the consumers from our survey are generally concerned about food safety, they are considered with one of the most important sources, 'the food labelled with full product information', since this indicator (a ) has the highest importance score ( . ) and the largest gap score ( . ) . the possible reason is that in the initial period of purchasing food, this information can only be obtained through labels seen on the packaging. therefore, we argue that manufacturers should clearly label food information to reduce potential issues of transparency between consumers and manufacturers. even though taiwan is presently improving its food safety standards, consumer concerns about food safety are also increasing. indeed, there is a public demand for improving food quality by food providers, the food safety environment is a much more significant factor affecting their decision-making process when they decide to purchase food. in conclusion, food safety has become a priority for many countries, citizens, and the food industry. as food manufacturers place more concern on the strategic importance of food safety, consumers will have a positive view of the governmental regulations, and this is important for consumers. additionally, consumers are seeking added reassurance and are willing to pay a higher price for a safer food environment. the findings of this research should lead to a food safety gap taxonomy which will allow us to study the psychological mechanisms involved when a food safety message is expressed in a consumer environment, versus what is actually communicated from the manufacturer themselves. they could also be applied to improve the importance-performance analysis in food safety, as well as consumer behavior. in general, they will be useful for improving evaluative indicators and in particular, to unify evaluation criteria among the consumer of the food and safety hazards. furthermore, since food manufacturers are ubiquitous figures in the food market worldwide and are one of the main causes of food safety incidents outbreak, identifying the potential gaps in consumers' expectations and perceptions is imperative to building upon interventional strategies to promote food safety. the fsg scale allows quantification of this tendency by evaluating the extent of consumers' expectations themselves by asserting how they are actually perceived. this research is significant as a new validated scale can now be applied to the measurement of food safety gaps. however, whether this will also apply to food safety contexts in other parts of the world cannot be determined based on this study. further research is therefore warranted in different cultural and geographical contexts. finally, this study has some potential limitations. due to its convenience sampling in taiwan, the data presented here may not be representative of other regions worldwide. in addition, since this is a cross-sectional survey, we recommend a longitudinal study to obtain more contextual relationships between food safety incidents. despite these limitations, this study has considerable potential for food safety. governmental policies and regulations including fsma on organic farming in the united states and around the globe. in safety and practice for organic food cognitive biases of consumers' risk perception of foodborne 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gadhoke, preety title: addressing food insecurity through a health equity lens: a case study of large urban school districts during the covid- pandemic date: - - journal: j urban health doi: . /s - - - sha: doc_id: cord_uid: odct kt reduced access to school meals during public health emergencies can accelerate food insecurity and nutritional status, particularly for low-income children in urban areas. to prevent the exacerbation of health disparities, there is a need to understand the implementation of meal distribution among large urban school districts during emergencies and to what degree these strategies provide equitable meal access. our case study of four large urban school districts during the covid- pandemic aims to address these knowledge gaps. guided by the getting to equity (gte) framework, we conducted a mixed-methods study evaluating emergency meal distribution and strategy implementation in four large urban school districts (chicago public schools, houston independent school district, los angeles unified school district, and new york city department of education). we gathered data from school district websites on ( ) meal service and delivery sites and ( ) district documents, policies, communication, and resources. using qualitative coding approaches, we identified unique and shared district strategies to address meal distribution and communications during the pandemic according to the four components of the gte framework: increase healthy options, reduce deterrents, build on community capacity, and increase social and economic resources. we matched district census tract boundaries to demographic data from the american community survey and united states department of agriculture food desert data, and used geographic information systems (gis) software to identify meal site locations relative to student population, areas of high poverty and high minority populations, and food deserts. we found that all districts developed strategies to optimize meal provision, which varied across case site. strategies to increase healthy options included serving adults and other members of the general public, providing timely information on meal site locations, and promoting consumption of a balanced diet. the quantity and frequency of meals served varied, and the degree to which districts promoted high-quality nutrition was limited. reducing deterrents related to using inclusive language and images and providing safety information on social distancing practices in multiple languages. districts built community capacity through partnering with first responder, relief, and other community organizations. increased social and economic resources were illustrated by providing technology assistance to families, childcare referrals for essential workers, and other wellness resources. geospatial analysis suggests that service locations across cities varied to some degree by demographics and food environment, with potential gaps in reach. this study identifies strategies that have the potential to increase equitable access to nutrition assistance programs. our findings can support ( ) ongoing efforts to address child food insecurity during the pandemic and ( ) future meal provision through programs like the summer food service program and seamless summer option. future research should further examine the rationale behind meal site placement and how site availability changed over time. the novel coronavirus (covid- ) pandemic has brought unprecedented challenges to schools that were forced to close to prevent further exacerbation of infection. however, students' needs pertaining to nutritional supplementation through school meals persisted despite not attending school in-person. ensuring access to food during these critical times is of paramount importance to meeting the public health needs of vulnerable populations at greatest risk for food insecurity. further, as schools contemplate reopening plans, a greater emphasis is placed on ways to maintain practices developed over the closure period, protecting access to supplemental nutrition. federal nutrition assistance programs like the school breakfast program (sbp) and national school lunch program (nslp) help address child food insecurity [ ] [ ] [ ] and improve access to healthy foods [ ] . nearly million students participate in sbp and nslp daily [ ] , and % of sbp and % of nslp participants receive free or reduced priced meals based on household income, meaning their families do not have adequate means to purchase food in absence of safety net programs. for many students, school meals make up onethird to one-half of their caloric intake in a day [ ] . regular consumption of school meals can improve dietary intake; students who eat school meals every day consume more fruits and vegetables, fiber, and whole grains compared with those who do not [ , ] . accordingly, school meals provide a unique and rich source of nutrition for youth and may offset risk for overweight and obesity through mitigating food insecurity [ ] . children who are food insecure are at increased risk for obesity and diabetes [ , ] , two of the most common comorbidities associated with covid- hospitalizations [ ] . before the pandemic, one in three children and adolescents were diagnosed with overweight or obesity [ ] ; current school closures could exacerbate risk of obesity in childhood and increase disparities [ ] . ensuring the continuity of school meal programs during a national emergency [ ] is critical. in response to school closures and the ensuing threat of child food insecurity, us congress authorized support for school meal providers in covid- federal relief packages in march of . the united states department of agriculture (usda) responded by granting nationwide waivers allowing school districts to ( ) provide grab-and-go and home-delivered meals [ ] , ( ) expand the hours when they serve food [ ] , ( ) deviate from nutrition standards in the case of a supply chain disruption [ ] , and ( ) allow guardians to pick up meals without children present [ ] . the agency also waived the "area eligibility" requirement for the summer food service program (sfsp)/seamless summer option (sso) for states including california [ ] , illinois [ ] , new york [ ] , and texas [ ] , enabling districts to serve meals to low-income students where poverty was not as concentrated. under normal circumstances, usda only allows such meal provision where more than % of students qualify for free or reduced-price meals. with these waivers properly implemented, large urban school districts were in a position to effectively distribute emergency meals given that their operations already required complex food distribution, communication, and technology systems, and economies of scale can drive down costs in higher density populations. however, large urban districts typically serve predominantly ethnically, economically diverse populations in dense geographic areas. this creates distinct challenges given current social distancing recommendations. access is an important factor in establishing healthy dietary patterns. lower income and racial/ethnic minority children, who are more likely to live in areas with limited food access, may be particularly vulnerable to changes in access during disasters, including the covid- pandemic. an equitable emergency school meal system considers critical factors including availability (adequacy of the healthy food supply), accessibility (location and ease of getting to the food supply), affordability (food prices and perceptions of worth relative to cost), acceptability (attitudes about attributes of the food environment), and accommodation (how well local food sources accept and adapt to residents' needs) [ ] . there is limited research of these factors when schools are closed-during emergencies or during summer meal service-and more research is therefore needed. furthermore, the pressure on schools to re-open in the fall of is increasing, adding to the precarious state of school nutrition programs and meal service during the pandemic. data regarding how school districts implemented emergency school meal programming will provide a better understanding of "gaps in the food safety net" [ ] and help address areas for future improvement for schools as they consider reopening or continuing their emergency food service programming. accordingly, we sought to address two aims in this case study: . investigate the emergency school meal service strategies adopted by four of the largest school districts in the usa at the beginning of the covid- pandemic. . evaluate the degree to which districts promoted equitable access to emergency nutrition programming during the pandemic through a health equity lens. this case study focused on four of the largest urban school districts in the usa [ ] : chicago public schools (cps), houston independent school district (hisd), los angeles unified school district (lausd), and new york city department of education (nycdoe). these sites were selected based on ( ) location of the investigators' institutions (nycdoe), ( ) size of the school district (cps, lausd, and nycdoe are the three largest districts in the country), and ( ) seeking district case sites from diverse geographic locations (northeast, midwest, west, south) in the usa. furthermore, our ongoing collaboration with the urban school food alliance yielded information that houston was undergoing a reconstruction of their emergency school food response, warranting further study and investigation. table illustrates the demographic characteristics of these case study sites. to direct our assessment of each school district's meal distribution system, we developed an evidence-based set of guidelines for establishing an equitable emergency meal distribution system during a pandemic. since the onset of covid- in the usa, entities such as no kid hungry [ , ] have published information on best practices for providing meal service during school closures. furthermore, prior research on how emergency food supplies are deployed to address food insecurity during natural disasters [ , ] offers insight into this important issue. to our knowledge, there are no guidelines for evaluating equity in an emergency meal distribution system during a pandemic. we endeavored to address this need by developing guidelines that can inform future actions of urban school districts. this study was grounded in the getting to equity (gte) in obesity prevention theoretical framework to inform guideline development [ ] . the gte framework was designed to provide practitioners and researchers with strategies to increase the equity impact of policy, system, and environmental (pse) change interventions that aim to decrease obesity. the framework identifies opportunities for four key opportunities for intervention and action research that emphasize equity: ( ) increase healthy options (e.g., increase access to healthy food retailers), ( ) reduce deterrents (e.g., address threats to personal safety), ( ) improve social and economic resources (e.g., offer nutrition assistance programs), and ( ) build on community capacity (e.g., build strategic partnerships). using the gte framework [ ] , relevant scientific literature [ , [ ] [ ] [ ] [ ] [ ] [ ] , and information from various health-focused organizations (e.g., no kid hungry, feeding america, cdc, fda) [ , , , ] , we drafted evidence-based guidelines for increasing the equity impact of an emergency meal distribution system during a pandemic. guidelines were organized into four areas of action, similarly to the gte framework (see fig. ), and were used to direct a detailed evaluation of documents and media that describe each school district's meal distribution strategies. for the increasing healthy options domain, it was important to understand how meals were being distributed and promoted as a means to facilitate participation [ , ] , providing information on menu items and prioritizing healthy foods as an integral part of service [ ] , and providing as many meals as possible/feasible per collection period (i.e., breakfast and lunch, several days of food) [ ] . further, ensuring health and safety of children, families, and food service staff is an important component to maintaining access to emergency school meals [ , ] . in relation to reducing deterrents, literature and guidance points to the need to address barriers to accessing meals such as discrimination/stigma, language barriers, and safe access [ ] [ ] [ ] ] . as such, we were interested in the degree to which districts empowered children and families through inclusivity and attempted to reduce fears of discrimination through communication and outreach. the third quadrant, building on community capacity, was of particular interest, and through consultation of the literature, we sought to understand how districts collaborated with other organizations and networks to facilitate reach to children and families and promoted emergency school meals through these networks [ , , , ] . finally, we sought to understand how social and economic resources may be leveraged to facilitate access to school meals for those in greater need, such as provision of financial and logistical support to families [ , ] . high poverty is linked with greater food insecurity [ , ] , thus providing greater resources to families may help offset other costs, potentially mitigating the effect of covid- on food insecurity. we recognize that the sso and sfsp initiatives are developed with the sole purpose to offset food insecurity and thus are grounded following a health equity approach. the covid- pandemic has presented additional challenges, however, which warrant further study and thus our findings can be used to inform current and ongoing meal distribution during the pandemic. for this evaluation, we completed a comprehensive document analysis to characterize each district's emergency meal distribution system and to identify promotion strategies. we gathered information about emergency meal provision practices from each district website and social media pages, including press releases, food service policies and guidance, meal site information, and images between mid-march and mid-may . through such a process, we also were able to gather the number of meals served by each district over this time period. all documents were stored in a shared google drive folder to facilitate open coding. to capture overarching themes from documents and images, initial analysis was inductive, which allowed us to develop emergent open codes that were overarching concepts related to emergency school meal service [ ] . four members of the research team open-coded school districts' documentation separately and then met as a team to review open codes and discuss convergence/divergence. we then agreed upon an iterative coding strategy where one member led the initial document analysis and three members provided thorough member checking. using open coding, four research team members independently identified health and nutrition information for each school district's documentation. based on this independent document analysis of all four urban school districts, a research team member developed a list of open codes across the four domains of the gte framework. then, team members met to review all open codes and all school district documentation and reviewed and revised this list of codes [ , ] . this list was finalized to codes among the four domains (see table ). this iterative, team-based process facilitated a nuanced understanding of the factors that may impact emergency school meal service, and the degree to which district-level strategies could ensure equitable access to school meals. this approach enhanced integrity of the coding process but facilitated clear synergies to be identified to gte framework. the aim of the geospatial analysis was to understand the availability and accessibility of meal sites by census tracts. we reviewed school district homepages for covid- -related district location information. all districts included dynamic, searchable data on meal sites on one of these two pages. three districts included a link to a publicly available, interactive online map (lausd, hisd, cps) and one (nycdoe) included a drop-down menu of site locations. we used python code to download publicly available data (e.g., site name, address, hours of operation) from each district daily between april and april . meal site locations were triangulated using district documentation (e.g., press releases). for the spatial analyses, we either transferred meal site locations from mapped datasets or processed address information with the google maps application programming interface (api) through the batchgeo website and geocoded sites (mapped location from a physical address) to the highest level of positional accuracy possible. we decided to use food deserts as an important metric of food access because children living in these areas may have greater problems accessing healthier foods compared with non-food desert dwellers, and have a greater need for access to safety net programs like school meal programs in order to meet dietary recommendations. we joined the usda food desert locator dataset to a census tract boundary map file for food desert data. usda defines "food deserts" in urban areas as low-income census tracts where a significant number or share of residents is more than / mile from the nearest supermarket [ ] . we joined the food desert polygon data to meal site location point data. to identify meal sites relative to high poverty areas, racial minorities, and youth population (age - ), we used the american community survey, - , year estimates at the census tract level. we extracted census tract-level variables of "percent minority" (all non-white, including hispanic) and "percent poverty level" (income in the past months below poverty level, divided by total households) and joined these data to census tract boundary map files. we extracted the total population of children ages - in each census tract and used school district boundary files to select only the census tracts that fell within the school district perimeter. we joined the census sociodemographic data to the meal site location data and determined the number of meal sites per census tract. finally, we used univariate statistics to determine the prevalence (count and proportion) of meal sites in census tracts above and below the median census tract measure for each characteristic described above (i.e., percent poverty, percent racial/ ethnic minority, population - years of age). normally, cps serves around , meals a day [ ] . in april, the district served between , and , meals a day ( - % of typical service). for the week of th april, the same week used for gis data collection, lausd served between , and , [ ] ( - % of typical service), and nycdoe served between , and , meals to children per day ( - % of typical numbers) from its food "hubs." hisd, which typically serves , meals a week [ ] , distributed between , and , pounds a week in food boxes [ ] . after piloting different service concepts and strategies before spring break, all districts committed to models that remained the rest of the scheduled school year (see table ). a visual representation of availability and accessibility for nycdoe can be found in fig. . site distribution across cities varied, with two distinct strategies emerging. hisd and lausd operated fewer overall sites, but appeared to strategically place central collection points throughout the district. nycdoe and cps emphasized more sites and more localized coverage across district areas. for example, in the first weeks of school closure, cps served days' worth of breakfast and lunches from all schools [ ] . during spring break, cps provided grab-and-go meals from school sites. starting april th, the district consolidated food service at the schools with the highest participation before spring break. families could pick up days' worth of meals every weekday from : a.m. to : p.m. [ ] . hisd originally distributed meals from school sites in partnership with the houston food bank school market program [ ] but halted operations when staff were exposed to covid- [ ] . the district relaunched food service on april th, after spring break, distributing -pound boxes of food [ ] instead of meals. hisd continued to distribute boxes, daily (including weekends), from four to five locations across the city, depending on the day of the week [ ] . distribution times varied from morning to afternoon, depending on the site. lausd initially proposed opening family resource centers where children could study and obtain warm meals [ ] , but abandoned the plan before implementation. instead, on th march, the district announced grab-and-go food centers, open monday through friday from : a.m. to : a.m. [ ] . (as of th april, centers were open from : a.m. to : a.m.). working with the red cross, volunteers, and school food staff, lausd provided breakfast and lunch to families at pick-up sites. for the first week of school closures in new york ( - march ), nycdoe provided grab-and-go breakfast and lunches from each of its plus schools. the following week, starting rd march, nycdoce began providing students grab-and-go breakfast, lunch, and dinner monday through friday from : a.m. to : p.m. outside schools deemed citywide "hubs." the district continued to provide hot meals at "regional enrichment centers" for children of essential workers [ ] and launched a partnership with doordash to deliver tailored meals to medically vulnerable students [ ] . nycdoe temporarily closed sites for cleaning when staff fell sick and permanently shuttered others due to low participation. however, the general trend was to open more service locations; nycdoe operated approximately sites at the beginning of may. according to the gte framework, the two domains for increasing health equity through policy and systems change interventions are: "increase healthy options" and "reduce deterrents" to health promotion and healthy behaviors [ ] . the two key domains for building individual, household, and community resources and capacity are: "increase social and economic resources" and "build community capacity." our findings for urban school districts' responses to the covid- pandemic appear in table matched to the gte framework and are depicted in an adapted gte framework in fig. [ ] . districts' efforts to increase healthy options during the covid- pandemic varied by addressing barriers to accessing meals; offering a breadth of geographic eligibility and distribution of free meals, the number and quality of meals offered, and choices to serve children and adults; emphasized "healthy, nutritious" meals; and providing menus and nutrition information. each district took advantage of federal waivers to offer free meals during school closures: cps and lausd offered two free meals, and nycdoe offered three free meals a day. in contrast, hisd offered a bag of free groceries a week, with no apparent limit on site visits for families. all districts specified that food was available to students, but only three of the four used language that made it clear adults could also pick up food. for example, when still providing grab-and-go meals, hisd restricted the program to adults with children present and did not provide menus for the food boxes. all districts offered social distancing guidelines, but lausd and nycdoe emphasized the topic with specific reference to social distancing and wearing masks, specifically for staff. to reduce deterrents to health promotion and health behaviors during the covid- pandemic, districts provided grab-and-go meal locators and maps, up-todate information on site closures and the number of active sites, links to partner sites (i.e., food banks), and meal options for special or restricted diets (e.g., religious restrictions), as a proxy for addressing the fear of discrimination. for example, hisd partnered with houston food bank to distribute meals from convenient community locations, and lausd offered free meal distribution at homeless shelters. while nycdoe promoted kosher, halal, and vegetarian options, hisd was the only district that did not offer special or restricted diet options; cps did not list partner sites or offer vegetarian and gluten-free options. one important distinction to draw from houston's approach to meal service is that, providing large boxes of food (i.e., pounds) may present a barrier/deterrent for individuals seeking emergency nutrition, particularly if they do not have access to a car or other convenient transportation. providing multilingual information and resources was another way district leadership reduced deterrents for the inclusivity of diverse households; again, cps was the exception. hisd offered resources and educational materials in spanish and english; lausd in spanish, vietnamese, and english; and nycdoe in arabic, bengali, chinese, english, french, haitian, creole, korean, russian, spanish, and urdu ( languages). between april and april, the four districts had between and meal sites open daily. figure illustrates geographic depictions of meal site locations across nycdoe, distributed across census tracts coded for each variable of interest. table shows the distribution of meal sites in each district above and below the median census tract measure for each variable of interest. meal sites appeared to be in areas with highminority populations, except for cps. districts also appeared to place most meal sites in areas above the median poverty level. hisd had the greatest percentage ( %) of sites in areas of higher poverty, and nycdoe had the greatest number ( ; %). the maps reflect the trends in table , except for hisd and nycdoe. in hisd, only one high poverty area ( . % and above) contained a meal site, and in nycdoe, a considerable number of high poverty tracts did not have meal sites. images on school district documents and social media platforms that evoked equity and empowerment were another strategy to reduce deterrents. lausd used cheerful cartoon images of ethnically diverse children dressed in colorful clothes holding fruits and vegetables. nycdoe displayed smiling children of diverse additional maps for cps, hisd, and lausd can be found in an online appendix (https://wustl.box.com/s/z bs saixs rm k z yjkfrmsh qdlug). all districts employed varying degrees of health equity and empowerment language. cps stated that "everyone deserves to lead a healthy life" [ ] ; hisd emphasized the importance of "nutritional services mobilizing food safely" [ ] ; lausd called attention to an "outpouring of community support"; and nycdoe stressed "commitment to health and safety." districts also employed empathetic language to acknowledge families' hardship during the pandemic. lausd used explicit phrases like "support families in need" [ ] and new york devoted a webpage to "messages to families," which included memos from the mayor discussing the difficult time, the need to "come together," and that "no one can be turned away" [ ] . together, these districts' images and language indicate a concerted effort to promote diversity and inclusion in communication. districts built on community capacity by building community partnerships [e.g., establishing programs to support first responders and their families, fundraising, partnering with community-based organizations, and distributing staple foods (hisd only)]. hisd partnered with the regional food bank and the police department to distribute free food in communities. in addition, lausd partnered with the red cross to help distribute meals, and promoted a list of local wellness centers/school clinics available on the resources website to enhance awareness of children/ families. nycdoe also provided information on local community resources, such as regional enrichment centers which were available specifically for children of first responders, healthcare workers, and vulnerable populations. cps also took this initiative and provided resources for parents who worked as first responders pertaining to childcare and emergency nutrition opportunities. all districts promoted healthy behaviors by placing a majority of meal sites in tracts with above-median juvenile populations. cps placed the highest proportion of meal sites in these areas (n = , %), whereas hisd had the lowest proportion with ( %) of their meal sites in census tracts above median juvenile population. placement of these sites has implications for reach and participation in emergency school food service programming. urban school districts offered a wide range of resources for families impacted by covid- , beyond nutritional cells represent count and (percent) of total meal sites either above or below the district median note: n, number of meal sites per district a corresponding median measure for each district supplementation. all clearly communicated weekday hours to access free meals, promoting visibility of the school meal programming. hisd also offered weekend hours for adults and nyc provided afternoon hours for adults who needed food. further, all school districts provided access to wellness programs or centers; wellness resources can reduce deterrents such as discrimination and social exclusion [ ] . moreover, although indirectly related to food service, all districts provided technology, such as ipads and chromebooks to students to facilitate distance learning, in addition to wi-fi through partnerships with local/national companies. this may therefore offset financial barriers experienced by families in the covid- pandemic and increase their ability to access up-to-date information about meal sites. in usda-defined food deserts, hisd placed the greatest proportion of meal sites (n = , . %), whereas nycdoe placed only five meal sites ( . %). meanwhile, both cps and lausd placed roughly a third of sites in food deserts. finally, other considerations for all school districts in light of global crises such as covid- are local policies and programs that can increase resources to low-income households, beyond the school system. these include the federal stimulus plan, access to food assistance programs, and local efforts such as raising the minimum wage. using an innovative mixed methods approach, this study investigated approaches to covid- pandemic school meal service among four of the nation's largest urban school districts, and how strategies could ensure equitable access to supplemental nutrition during the pandemic. nutrition assistance programs such as nslp and sbp can reduce food insecurity and help prevent child obesity [ ] . understanding strategies to assure program access during emergencies is critical to promoting equity. in relation to increasing healthy options, districts used multiple strategies to encourage participation, but meals reached only a portion of the normal student population. there were no clear patterns to suggest whether the number or kinds of meals served, location and number of distribution sites, or time of day affected participation. nycdoe had the lowest average participation rate, which may have more to do with covid- prevalence and larger structural barriers (a factor for future study), than with specific distribution practices, or both. moreover, it was the largest district and the most difficult to navigate without public transport compared with lausd or hisd where cars are more common. it is important to consider the nuanced challenges presented in the covid- pandemic that may have previously been considered as strengths, such as predominant use of public transport and dense populations of urban context. notably, all districts deviated from initial distribution plans, suggesting that districts have much to learn when it comes to meal distribution during school closures. all districts took steps to increase access to healthy options; they provided at least one meal per day for students, displayed food safety information, and advertised that all children could eat for free regardless of district enrollment. but there were differences in the number of free meals provided, populations served, and communication about menu options. during school closures, not all districts published menus, making nutritional quality of foods unclear. these differences may impact food security, given strong reliance on school food programs in urban contexts [ ] . to reduce deterrents to participating in emergency school meal programs, hunger and nutrition advocacy groups encourage districts to provide multiple days' meals, serve adults, and post menu information. given the strong links between food insecurity and child/ adolescent obesity [ , , ] , the importance of school meal nutritional quality cannot be understated. it is highly likely that some form of emergency meal service likely to continue in the - school year and districts should strive to provide nutritional information and promote consumption of high-quality foods. districts should also strive to provide more information in multiple languages representing all the relevant cultures and nationalities to reduce deterrents to health, particularly fear of discrimination and other inequities confronted by diverse households. all districts provided interactive maps to display meal locations and hours, potentially making it easier for families to access school meals. in regard to building community capacity and improving social and economic resources, all districts had some form of building community partnerships including collaborating with first responder programs and promoting relief fundraisers. developing an inclusive community culture and partnerships are methods national anti-hunger organizations such as share our strength no kid hungry campaign [ ] recommend to improve meal distribution and ensure equitable access to nutrition. partnerships not only build community capacity, they can also help improve social and economic resources. for example, hisd's partnership with houston food bank facilitated weekend meals and outreach efforts to families. weekend meals can increase children's and families' food security [ ] . given the economic crisis that resulted from the pandemic, additional weekend meals may be a more important factor than ever. moreover, due to the significant economic crises of the covid- pandemic, it would also be essential for researchers to consider factors beyond the school system, such as equitable access to federal stimulus checks and local policies to aid low-income households through raising the minimum wage, for instance. further research is needed to understand how these macro-level factors may play a greater role in health equity in the coming months, particularly as schools begin to re-open and changes to emergency meal distribution manifest. although our study is the first to look at the spatial distribution of pandemic school meal site locations in large urban areas during the covid- pandemic, our results could be interpreted in the context of previous work examining meal site placement during school closures. one previous study examined the placement of summer meal sites [ ] and found that urban summer meal sites were more prevalent in larger, higher poverty, and majority non-white high schools. we found similar patterns during the response covid- pandemic, with more sites in the larger, higher poverty and higher minority areas. unlike summer meal sites, which are required to operate in low-income areas, where at least half of resident families' income falls below % of the federal poverty level [ ] , meal sites opened and operated during the covid- pandemic were not required to meet this same criterion. in this case, we did expect to see some level of variation in meal sites across census tract income levels, compared with the placement of summer sites. meal site placement that remained consistent with placing sites in areas with higher economic need is promising and could be, at least partially, based on a site or school's previous experience as a summer meal site. future research should include evaluations of how districts used these variables of interest or other equitybased considerations in their decisions concerning meal site locations during covid- , especially as areas of high poverty appeared to be the most consistently prioritized across the four cities. such an approach for future studies could be based on the idea that lowincome populations often have lower access to healthy foods, which is supported by previous research [ ] . with regard to food access, we found that sites were more equitably distributed based on demographic characteristics rather than food desert status. focusing on demographic rather than food environment characteristics could leave children living in food deserts without adequate access to healthy food, so further consideration should be given to food assistance and food access data. in this research, we focused on the availability of meals sites, but other dimensions of food access may be influential [ ] and should be examined in future studies. this study uses a novel equity framework to classify elements of intervention design, delivery, and contextual factors influencing provision of emergency healthy meals during unplanned school closures. these districts represent multiple regions of the country: the east coast (nycdoe), midwest (cps), south (hisd), and west coast (lausd). this study also employs a rigorous mixed methodology for document analysis and geo-spatial mapping. it analyzes school districts' efforts while the usa is in the midst of an unprecedented pandemic. our findings are currently relevant for school meal and other nutrition assistance providers given the persistent threat of covid- . congress has mandated that states submit a report to usda describing districts' use of school meal waivers year after this emergency. paired with state reports, this study can inform future plans for public health emergencies and accelerate the implementation of school meal service. we must also acknowledge some limitations of this study. recommendations to social distance and the time constraints the public health emergency created for school meal providers limited data collection. we relied completely on publicly available data such as websites and social media, and did not recruit participants for primary data collection to avoid burdening food service management and other school staff and stakeholders during such a critical time. although we collected information over a prolonged period (i.e., weeks), we plan to conduct follow-up research in collaboration with other research teams to identify the ways in which school districts approached their emergency school meal programs and deviations from initial plans. finally, although we chose urban districts in each major region of the usa, findings are not generalizable to other diverse urban districts. instead, with the data available, we were able to identify and characterize each district's public efforts to provide meals during school closures. this case study highlights salient challenges and successes within four urban communities, but more work is needed to address school food practices. while this study focused on urban areas, suburban and rural districts' responses also warrant study. there is also a need to understand the current use of geospatial data to determine the location of meal sites, how the location of sites changed over time, and what opportunities there are to better integrate such data to improve reach of emergency school meal programming. future studies could also examine centralized versus more widespread site distribution; the way districts distributed sites suggests an intentional, although varying approach to address food access issues. due to how meal distributions differed (i.e., number of meals per day and days of food), we could not establish whether more sites led to better reach. therefore, it may be beneficial to study the differential impact on population accessibility to school meals, as well as the impact on pickup, district purchasing, and dietary patterns. our study focused on food deserts rather than other food environment conditions such as food swamps due to the potential exacerbation of food insecurity due to meal site location for vulnerable children living in areas of low access to healthy food, but the relation of meal sites to food swamps, particularly as a competition for school meal site usage, should be a focus of future work. finally, and most importantly, additional work should be conducted to contextualize stakeholder perspectives on the distribution of meal sites, both from the perspectives of decision makers (i.e., those individuals or groups responsible for identifying meal site locations and approaches, developing and disseminating information about sites, and evaluating the relative success or failure of approaches) and of community members, program recipients, program collaborators, and decisionmakers (e.g., anti-hunger organizations, youth empowerment organizations, and local economic policymaking). for urban school districts, one future direction may be to develop and maintain partnerships with community organizations to prevent food insecurity during school closures due not just to pandemics or natural disasters, but also weekend and holiday closures. research suggests community organizations like food banks are valuable stakeholders in preventing food insecurity and insecurity-related chronic disease [ , ] , so sustained partnerships between these two entities may help reduce food insecurity. as schools begin to reopen in the fall of following pressure from federal agencies [ ] , we strongly urge equity to be placed at the forefront of decisions pertaining to school emergency food services. given the detrimental impact of covid- on the economic landscape of the usa and subsequent surge in food insecurity prevalence [ ] , continuation of meal sites that serve meals to students and families may serve as a vital strategy to offset ongoing depravity. this will be especially important for families/children at a greater risk for contracting covid- who wish to remain at home and/or for parents who still cannot return to work through job loss or ongoing furlough. further, depending on the school schedule and whether schools opt for a rotation system to minimize attendance and asking students to be at school on certain days of the week, continued operation of walk-up and drive-up meal sites would facilitate equitable access to supplemental nutrition despite students not attending schools full-time. continuation of various waivers granted by the usda may therefore be necessary to combat rising food insecurity rates and ease the transition of going back to school amid the pandemic. the findings provide a unique perspective to promote equitable food access to students and families during a public health crisis. school meal, summer meal, and emergency food service providers can use the findings to promote participation, especially among nutritionally vulnerable populations. the need to address urban communities' food security challenges by providing equitable access to meals during a public health emergency cannot be understated, and our study is one of the first to address food security issues during covid- . findings provide valuable insights for future meal provision both during public health emergencies and ongoing federal interventions to combat food insecurity in children and households. household food security status of families with children attending schools that participate in the community eligibility provision (cep) and those with children attending schools that are cep-eligible, but not participating the relationship between the school breakfast program and food insecurity united states department of agriculture. food security in the us children's food security and usda child nutrition programs school nutrition and meal cost study, final report volume : school meal program operations and school nutrition environments schools and obesity prevention: creating school environments and policies to promote healthy eating and physical activity eating school meals daily is associated with healthier dietary 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nationwide waiver to allow meal pattern flexibility in the child nutrition programs mealpatternnationwidewaiver final.pdf &sa= d&ust= &usg=afqjcngcbxhd mpqpye v-arqkjp orw. accessed nationwide waiver to allow parents and guardians to pick up meals for children e a e l i g i b i l i t y -a p p r o v a l . p d f & s a = g = afqjcngrbocrlivjlbrg_c cgbwadyjcfw e a e l i g i b i l i t y -a p p r o v a l . p d f & s a = g = afqjcnfpyaxnlqug xkvvwqhotgf ars q o m / u r l ? q = h t t p s : / / f n s -p r o d e a e l i g i b i l i t y -a p p r o v a l . p d f & s a = g = afqjcnhaikuwghaksqcdjeakfimvdluzqg the local food environment and diet: a systematic review identifying gaps in the food security safety net: the characteristics and availability of summer nutrition programmes in california, usa. public health nutr top largest school districts by enrollment and per pupil current spending summer meals emerging strategies and tactics for meal service during school closures related to the coronavirus emergency food during natural disasters. today's dietician relevance and uses of the getting to equity in obesity prevention framework a framework for increasing equity impact in obesity prevention impact of covid- on clinical research and inclusion of diverse populations feeding low-income children during the covid- pandemic ensuring equitable access to school meals violent crime and park use in low-income urban neighborhoods longitudinal associations between change in neighborhood social disorder and change in food swamps in an urban setting complete eats: summer meals offered by the emergency department for food insecurity tisch center for food nutrition & and policy. serving students during the coronavirus: best practices best practices for retail food stores, restaurants, and food pick-up/delivery services during the covid- pandemic impact and implementation findings from an experimental evaluation of playworks: effects on school climate, academic learning, student social skills, and behavior severity of household food insecurity is sensitive to change in household income and employment status among low-income families document analysis as a qualitative research method demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development chicago public schools. cps stats and facts ashx?moduleinstanceid= &dataid= &filename= - factsfigures.pdf. accessed hisd to relaunch food distribution efforts on april with centralized packing hub all cps schools to offer free meals for pick up during closure beginning tuesday a special message from interim superintendent of schools grenita lathan community impact newspaper. houston isd abruptly halts food distribution program after suspected covid- case houston isd plans to restart food distribution at five campuses next week covid- : children, families & schools what to do while los angeles unified schools are closed in response to the coronavirus: grab & go food centers distribute free meals to students doordash partners with department of education to deliver food to medically homebound students. a m n e w y o r k new york city schools meal sites school closures during covid- : opportunities for innovation in meal service a reach, effectiveness, adoption, implementation, maintenance evaluation of weekend backpack food assistance programs united states department of agriculture neighborhood environments: disparities in access to healthy foods in the u.s operating school meal programs in rural districts: challenges and solut i o n s publications/ _the_journal_of_child_nutrition_and edsource. california food banks partner with schools to serve families of students where some of the country's biggest school districts stand on reopening schools country-driven' approach needed to limit covid- damage to food security acknowledgments we are grateful to both healthy eating research, a national program of the robert wood johnson foundation, and the united states department of health and human services centers for disease control and prevention-supported nutrition and obesity policy research and evaluation network (nopren) for their support of an ad hoc joint covid- school implications working group and to nopren for fellowship support (gm, cd). key: cord- - m on ct authors: xie, xiaoru; huang, liman; li, jun (justin); zhu, hong title: generational differences in perceptions of food health/risk and attitudes toward organic food and game meat: the case of the covid- crisis in china date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: m on ct in december , a novel laboratory-confirmed coronavirus ( -ncov) infection, which has caused clusters of severe illnesses, was first reported in wuhan, the capital of hubei province, china. this foodborne illness, which reportedly most likely originated in a seafood market where wild animals are sold illegally, has transmitted among humans through close contact, across the world. the aim of this study is to explore health/risk perceptions of and attitudes toward healthy/risky food in the immediate context of food crisis. more specifically, by using the data collected from respondents in january , the time when china was hit hard by the “corona virus disease ” (covid- ), this study investigates the overall and different generational respondents’ health/risk perceptions of and attitudes toward organic food and game meat. the results reveal that, firstly, based on their food health and risk perceptions of healthy and risky food, the respondents’ general attitudes are positive toward organic food but relatively negative toward game meat. secondly, older generations have a more positive attitude and are more committed to organic food. younger generations’ attitude toward game meat is more negative whereas older generations attach more importance to it because of its nutritional and medicinal values. in addition, this research also indicates that the covid- crisis influences the respondents’ perceptions of and attitudes toward organic food and game meat consumption. however, the likelihood of its impact on older generations’ future change in diets is smaller, which implies that older generations’ food beliefs are more stable. food choice and consumption are dynamic, situational, and complex, having resulted from the (non-)sensory characteristics of food and influenced by cultural and socio-affective factors as well as reliable information available about the food [ ] . it is a daily activity that can result in both good and bad consequences for our bodies. game consumption is complicated, interrelated with growth, prosperity, and consumption habits in economic, cultural, and social aspects. for example, with a growing market, game meat consumption has become a social status and fashionable lifestyle. the symbolic role of wildlife is obvious in china's developed cities. it has become a symbol of elite status and fashionable lifestyle for some people to buy and eat wildlife animals. despite being perceived as healthy based on its natural and nutritional characteristics, game meat consumption is also risky because of the potential microbiological contaminant. in december , a foodborne illness, which was caused by a novel coronavirus ( -ncov) and reportedly most likely originated from the wild animal pangolin, was first identified in wuhan, the capital of hubei province, china [ , ] . it has spread rapidly through human-to-human contact in the whole of china and hit the society hard, across the world. the covid- crisis has caused a food anxiety about game meat. given the possible microbiological contaminants in game meat, strategies have been conducted in response to the emergence of the covid- crisis to discourage the consumption of game meat. the chinese government has temporarily banned the trade in wild animals, including domestic transport and sales in markets, restaurants, and through online platforms [ ] . when the coronavirus crisis hit china's farms and food supply chain, the public moved to a high-value organic food for its safer characteristics such as lower microbiological risks and chemical contaminants. as research has demonstrated, food anxiety and health scares caused by food safety crises can change consumers' sensitivity and beliefs about food health, turn them to diets perceived as more natural, and make organic food more popular [ ] . however, owing to variegated ways of defining and standardizing organic food, the boundary between organic food and game meat is not clear. the "natural," "nutritional," and "tasty" attributes of game meat lead to a common cognition that game meat is organic. recent studies have revealed that game meat has high protein, low fat, and low calorie [ , ] . it can add a healthy alternative to the menus of meat lovers [ ] . however, being the origin of foodborne crisis, game meat is also regarded as a risky food with microbiological hazards. it constitutes one of the unique sources of foodborne illness in humans [ ] . considering the microbiological safety issues, handling, and/or consumption of game meat might expose humans to diverse microorganisms and result in novel diseases [ , ] . organic food and game meat consumption are complicated issues interrelated with different consumption habits. generational differences in food consumption do exist as age can influence the individual's attitudes and behavior and drive certain wants and needs [ ] . identifying a "generational effect" in organic food and game meat consumption is important because sharing historical and social life experiences of a generational cohort impacts the way people of that generation behave and distinguishes them from other generations [ ] . as it comes of age, each generation experiences a fresh interaction with traditional values and principles [ ] and is likely to develop distinct preferences, which distinguish their attitudes toward food. for example, the millennials, also known as generation y and mainly defined as the s and s generations, who grew up at a time of rapid economic and technological development [ ] , differ from previous generations in various ways. for example, they are characterized as being highly diverse, educated, and technology-natives, holding distinctive values and disparate views on food consumption [ ] . as turow argues [ ] , the younger generations are integrating food into their lives actively and purposefully, attaching more daily importance and value to it than any older generations. in addition, because of china's dramatic and rapid transformations in economy, politics, and culture, the gaps between the new and older generations are arguably larger than in western countries [ ] . these arguments enlighten us to explore whether differences in organic food and game meat consumption are linked to generational differences. this research aims to gain a general understanding of health/risk perceptions and attitudes toward healthy/risky food in the immediate context of food crisis as well as to understand the impact of generational difference on perceptions and attitudes. it provides an empirical survey to investigate the overall and different generational respondents' health/risk perceptions and attitudes toward organic food and game meat during the outbreak of the covid- crisis in china, utilizing data collected from respondents in january , when the crisis hit the whole society. food safety is one of the key areas of focus in public health. food safety incorporates hazardous factors such as animal disease-related safety issues and microbiological safety, and represents consumers' health concern regarding residues in food production, processing, and distribution. triggered by nutritional hazards in food crises, food safety issues have received increasing attention in nutritional studies [ , ] . in this regard, it is considered a priority to implement food safety assurance at the farm level [ , ] . organic food, generally believed to have higher nutritional content than conventionally grown food, such as higher vitamin c, higher dry matter, and lower nitrate content [ ] [ ] [ ] , is of growing interest due to food safety concerns. food safety is one of the main reasons for organic food purchasing [ ] . nowadays, the public is more concerned about food safety because of the extensive food scandals and intensively publicized debates on genetically modified organisms, which have led to increasing awareness and pursuit of safer alternatives [ , ] . scared of food hazards, many consumers choose organic food to avoid risks. consequently, further attention has been paid to the safety, nutrition, and health aspects of organic food [ ] . the definitions and standards of organic food, however, vary according to diverse situations and contexts. although food labeled as organic is commonly perceived to be healthier, tasty, and natural, without additional risk of food poisoning and free from contamination [ ] , the criteria are negotiated in the light of experience, practicalities, and moral considerations [ , ] . it is also claimed that the term "organic" refers to the situated production process instead of the product itself-the label is just a guarantee of a particular process [ ] [ ] [ ] . for example, in addition to their nutritional qualities, african wildlife meats are considered organic for they are reared as free-range and meet the general criteria of organic production [ ] . game consumption is a complicated issue interrelated with growth, prosperity, and consumption habits in economic, cultural, and social aspects. in keeping with population growth, increasing buyer power, and globalization, game trade, including skins, medicinal ingredients, and food has become a burgeoning business around the world [ , ] . it provides an income for some poor people and considerable revenue for the nation [ ] . in hainan, china, for instance, with the improvement in the town-dwellers' standard of living, people have become more interested and able to add wildlife to their daily menu, which offers the local villagers a commercial way to increase their income [ ] . southeast asia has been identified as a "wildlife trade hotspot" [ ] , where the consumption of wildlife for medical, superstitions, and nutritional reasons is culturally rooted [ ] . traditional chinese medicines (tcms), with some of the ingredients derived from wildlife, have become an integral part of chinese culture [ ] . the perceptions of therapeutic benefits of tcms are based largely on long-standing beliefs dating back thousands of years [ , ] . similarly, game meat in cambodia for use in traditional medicines is a practice with deep historical roots [ ] . in addition, with a growing market, game meat consumption has become a social status and fashionable lifestyle [ ] . in vietnam, for example, the majority of wild animals are now embedded in commercial networks to serve the growing urban middle class in provincial towns and cities [ ] . the symbolic role of wildlife is also obvious in china's developed cities, especially large cities in south china. it has become a symbol of elite status and fashionable lifestyle for some people to buy wildlife animals as crafts and souvenirs, eat game meats, and dress in animal furs [ ] . risk is "the probability that the potential of a hazard will be realized" and "a combination of the probability with the harm itself" [ , ] . before taking action to control, reduce, or eliminate risks, decisions must be made to estimate which risks are important and which can safely be ignored [ , ] . food health and risk perception are two vital factors concerning the acceptance of food, and the two are inversely and causally related [ ] . risk associated with food can be presented in various forms ranging from microbiological risks, nutritional deficiencies, physical and chemical contaminants to processing, handling, and eating risks [ , ] . contaminated food is risky since it poses threats to consumers' health and might cause illness and even death [ , ] . empirical research on food risk originated from debates on the genetic modification of food and considerable food scares in the s, especially the mad cow disease (bse) [ ] . with the development of the psychometric paradigm, scholarly attention has been paid to the perception of food risk [ ] . owing to several cases of food safety issues, food safety risk perception, which is a perception of the potential risk in food safety, has gained substantial attention in recent years [ ] . miles and frewer [ ] , for example, argue that food risk perception is multifaceted and results from risks associated with health, environment, economy, animals, and future generations. in terms of the socio-demographic characteristics, nardi et al. [ ] highlight that age can positively drive safety risk perception because it encourages consumers to think about life threats. food risk perception plays a significant role in attitudes [ ] . attitude is a psychological tendency that is expressed by evaluating things, the self, and others, involving the positive and negative aspects of being favorable or unfavorable, likable or unlikable, and good or bad [ , ] . it is "the predisposition toward a particular object, reflecting behavioral, normative, and control beliefs that are directly related to the consumer's intention and, consequently, his or her behavior" [ ] . attitudes can be judgments, memories, or both and stable or temporary, having resulted from relatively long-term processes such as socialization as well as short-term exposure to information [ ] . the construction of attitudes is often concerned with and reciprocally related to affects, beliefs, and (overt) behaviors that can serve as bases for attitudes [ , ] . albarracín, johnson, & zanna [ ] note that affect is the feeling that people experience; beliefs are cognitive thoughts about the perceived likelihood that an attribute is related to an object or event-the referent of a belief is a proposition and it can also refer to subjective experiences; and behaviors are conceptualized as the overt actions of an individual [ ] [ ] [ ] . in terms of feeling, clore & schnall [ ] argue that "decision-relevant feelings might come from vividly imagined consequences of a decision." affect is also associated with risk perception [ ] . sensory inputs can generate visceral reactions, which can automatically induce avoidance [ ] . emotions such as fear, guilt, and empathy are the strongest affective responses and fear, which is driven by uncertainty, appears more salient in food crises [ ] [ ] [ ] [ ] . this research is part of a bigger research project aimed to investigate mutual relations between organic food consumption, game meat consumption, and foodborne illness. the survey was conducted with a random sampling approach in january . wechat (the most used social media application in china) was employed to recruit questionnaire participants. the questionnaire was posted through a web-based link on wechat. this link was generated through a free chinese professional survey website wenjuanwang (https://www.wenjuan.com/, a website like surveymonkey), which designed the online questionnaire (in chinese). wenjuanwang also enables researchers to establish, distribute, collect, and manage their questionnaires online. potential respondents could fill in the questionnaires through wechat on their mobile phones, which accelerated the data collection during the outbreak of the covid- crisis. a total of usable responses were collected for data analysis. table shows the socio-demographic profiles of the respondents. in china, the generation is always described as "the post- s generation", "the post- s generation", etc. to investigate age differences, the respondents were divided into four age groups: aged below , - , - , and and above. data analysis was carried out with the statistic software spss, computed as means, standard deviations, and f-tests of differences. a structured four-section questionnaire was formulated based on a literature review involving perception, attitude, behavior, and intention of organic food and game meat consumption [ , , , , [ ] [ ] [ ] [ ] , as well as other projects conducted by the authors associated with research in organic food production and consumption. it included questions on the relation between game meat consumption and foodborne illness, perceptions of and attitudes toward organic food and game meat, and demographic profiles of the respondents. only part of the questionnaire that is related to this research is presented here. health/risk perception of and attitudes toward organic food and game meat were measured by means of the items of four measurements: "organic" consciousness and attitudes toward organic food, health/risk perception and attitudes toward game meat, perceived change in future diet: stability of attitudes toward organic food, and perceived change in future diet: stability of attitudes toward game meat. the statements were rated on a five-point likert scale. "organic" consciousness and attitudes toward organic food. the respondents' attitudes toward organic food was measured by their "organic" consciousness with questions about how they perceive organic food, in terms of both individual and societal cognitions. items to (see table ) were used to measure consumers' attitudes toward organic food associated with personal considerations, with questions about how they rate the overall liking, importance of organic food in a daily diet, necessity of shifting from traditional food to organic food, and how wise they think it is to buy organic food. the societal considerations of organic food were reified with items of environmental and animal ethics. health/risk perceptions and attitudes toward game meat. the respondents' health/risk perception and attitudes toward game meat, including the healthy and risky attributes of game meat, were assessed on a five-point scale. the assessment ranged from the overall liking, importance of game meat in daily diet, and food safety risk to health benefits (see table ). perceived change in future diet: stability of attitudes toward organic food. to measure the stability of attitudes toward organic food, respondents were asked to estimate their frequency of daily organic eating, future possibility of increasing organic food eating frequency, and extent of influence of the covid- crisis on future organic food eating (see table ). perceived change in future diet: stability of attitudes toward game meat. questions about the frequency of daily game meat-eating, future possibility of increasing game meat-eating frequency, and extent of influence of the covid- crisis on future game meat-eating were employed to measure the respondents' stability of attitudes toward game meat (see table ). ("of" as organic food; * significant at a . level; superscript "a" indicates the lowest score; superscript "b" indicates the highest score). table . the means, standard deviations, and f-tests of differences of the measurement "health/risk perceptions and attitudes toward game meat" across age. ("gm" as game meat; * significant at a . level; superscript "a" indicates the lowest score; superscript "b" indicates the highest score). ("of" as organic food; * significant at a . level; superscript "a" indicates the lowest score; superscript "b" indicates the highest score). ("gm" as game meat; * significant at a . level; superscript "a" indicates the lowest score; superscript "b" indicates the highest score). as table reveals, the respondents' attitudes toward organic food as health belief differs significantly among the four groups aged below , - , - , and and above. however, the items of the environmental and animal ethics of organic food are not statistically significant across age. all the mean scores are above , which means the respondents have positive consciousness about organic food. the respondents aged and above scored the highest among all four groups on "the extent of organic food favor," "the importance of organic food in a daily diet," and "the necessity of changing traditional food to organic food," while the respondents aged - scored the lowest on "the extent of organic food favor," "the importance of organic food in daily diet," and "buying organic food is wise." in general, the respondents aged and above have significantly more positive attitudes toward organic food than other age groups, while the - group shows the lowest perceptions. as shown in table , the respondents' attitudes toward game meat are significantly different among the four disparate generations. it indicates that the respondents have a relatively negative attitude toward game meat. however, the respondents aged and above showed a comparatively more positive attitude toward game meat than the other three age groups which expressed similar levels of concern about game meat hazards. the and above age group had the lowest perceptions of the food risk of game meat, which was reflected in items to . they had a more positive attitude toward game meat because of its nutritious and medicinal values. the - age group had the lowest perception of the nutritional and medicinal values of game meats. in general, the younger generations' attitudes toward game meat were more negative than that of the older ones. as shown in table , the respondents' eating frequencies of organic food are significantly different among the four disparate generations. respondents under the age of had the highest frequency of eating organic food in daily life-above the midpoint of -while the - group showed the lowest frequency. although the and above age group respondents also ate less organic food in their current daily life, they showed the highest willingness to increase their organic food eating in the future. in general, the covid- crisis has had a positive influence on future increase in organic food eating. however, its influence on the older generations is lesser than on the younger generations. as shown in table , the respondents' eating frequency of game meat is relatively low in their daily diet, and they show a very negative attitude on the future increase in game meat consumption. however, the factor "the future possibility of increasing gm eating frequency" is not statistically significant across age groups. as for the influencing extent of the covid- crisis to the future eating of game meat, table indicates that the crisis has an extremely significant impact. the younger generations, particularly the group aged below, are significantly more likely to decrease the amount of game meat in their future diets than the older respondents. thus, the covid- crisis has a considerable negative influence on the future eating of game meat. however, its impact on the older generations is smaller than the younger ones. attitudes toward organic food show that generally, respondents aged and above attached more importance on organic food than the other age groups, while the - age group respondents showed the lowest perceptions. this result is both consistent and contrary to some previous research. from the perspective of the influence of age on organic food consumption, research has been conducted within diverse situated contexts with different results. rimal, moon, & balasubramanian [ ] , for example, observed that older respondents are less likely to buy organic food than younger ones. on the contrary, geen and firth [ ] concluded that committed consumers of organic food tend to be older than the average population in the uk [ ] . however, despite the older respondents attaching more importance on organic food, the younger generations have a higher frequency of daily eating, especially the respondents aged under . this interesting result might be explained by the fact that in china, organic food consumption is still in the infant stage. although the amount of organic food consumption is increasing, the total quantity and frequency of organic food eating is still at a low level across the whole of china [ ] . parents who consider their children's health constitute the main consumers of organic food, and because of the previous "one-child" policy introduced in , most of them have only one child. however, as the authors were told in another research project by an organic farmer, because of economical consideration, some parents purchase organic food just for their children and seldom eat it themselves. therefore, the behaviors of "eating" and "buying," which both mean "consumption," might be different when the intention of "consumption" is considered. this might also be, at least in part, the reason why the and above age group generally attached more importance on organic food, while the respondents who ate more organic food tended to be younger, especially under . further research needs to verify this and investigate other possible explanations with more empirical examinations. this also implies that organic food perceptions of the older generations are based more on health characteristics. this implication is consistent with some previous research [ ] [ ] [ ] . healthfulness is a perceived short-term benefit of organic food [ ] . the elders' egoistic motives (health considerations) seem to come first rather than altruistic motives (ethical considerations). in the future, the older generations might become more committed to organic food. they appeared more willing to increase the proportion of organic food in their future diets. except for the considerations of their children's health, and, in this research, the impact of the covid- crisis, another explanation might lie in their own bodily needs. as noted by yiridoe, bonti-ankomah, & martin [ ] , consumers' preference for organic food is largely influenced by their concerns for health and safety, which is in line with their perceived deterioration in human health over time; therefore, it motivates them to purchase organic food as insurance and/or investment in health. as cullere & dalle zotte [ ] put it, health acts as a strong motivation for consumers to change eating habits. however, situated in a particular context, a previous research on the willingness to pay for the organic/green food in china shows a contrary result. it found that younger people are more willing to pay more as the older people are not willing to change their eating habits and pay a premium price for organic food [ ] . attitudes toward game meat indicate that the respondents have a relatively negative attitude toward game meat consumption, which signifies game meat as risky food. their negative attitudes are caused by perceptions of its food safety risk, as reflected in their high scores-a mean score of above . -on the statement "eating game meat is of health hazard" (see table ). their negative attitudes might also be enhanced by their anxiety during the severe outbreak of the covid- crisis. as research in the uk and european countries reveals, food panics generally spur initial disruption of attitudes and behavior but are also "followed by a gradual return to the previous consumption equilibrium" [ ] . this implies that the food crisis has an immediate effect on consumers. when situated in the particular context of the food crisis, humans' food anxiety is enhanced. on the other hand, respondents also attach game meat with somewhat "healthy" meanings, so they still sometimes "venture" to eat game meat, which might result from their perception of the nutritional and medicinal values of game meat. they are generally aware of the hazards of game meat. however, awareness does not necessarily indicate absolute avoidance. as martins and pliner [ ] argue, "humans must balance the necessity of obtaining a wide variety of nutrients (typically, through the ingestion of numerous food sources) with the perils accompanying the ingestion of unfamiliar edibles (i.e., the possibility that these foods may be harmful or toxic)." some studies also reveal that despite game meat being perceived as a health hazard with potential microorganisms and toxins and its consumption being far less than that of usual meat such as beef, pork, and fish, it still offers consumers a healthy meat alternative because of its nutritional value such as high protein, low cholesterol and fat, and an optimal ratio of unsaturated to saturated fatty acids [ , , , ] . tomasevic et al. [ ] , for example, conducted a study on perceptions of different game meat in european countries and pointed out that game meat is regarded as healthy and more organic than other types of meat. although being negative, the older respondents seem to have a significantly higher perception of game meat than the younger generations, which might be based more on its "health" benefits-being nutritious and medicinal-and they practice more "risky" behaviors. in game meat consumption, the eating frequency trend related to age is consistent with the trend of perceived risks. the older respondents eat more and have a lower risk perception of game meat than the younger respondents. this is partly consistent with previous research indicating that age has an impact on how respondents perceive health and food safety risks, but older respondents are more likely to have a higher perception of health and food safety issues as risks than younger respondents [ ] . the reason might be that when balancing the benefit and risk of game meat, the older respondents in this research attached more importance to the "medicinal" attributes of game meat, which could also be reflected in their higher scores on game meat's medicinal values. in china, except for its nutritional value, game meat is also perceived to have high medicinal value-as li et al. ( ) note [ ] , some consumers hold the belief that game meat has certain therapeutic effects. in addition, another belief rooted in the game meat consumers' mind might derive from the philosophy of medicine food homology, which is misunderstood as that "one is made of the supplements they eat" [ ] . considering the age difference, these cognitions are engrained more in the elders' minds. the impact of the covid- crisis on respondents' perceptions of health and risk is significant and would lead to the respondents' perceived future increase in the consumption of organic food and decrease in game meat consumption. this is in line with some studies revealing that food anxiety and health scares caused by food safety crises can change consumers' sensitivity and belief about food health, which turns them to diets perceived as more natural and makes organic food more popular [ , , , ] . for instance, the discovery of mad cow disease (bse) in canada and the us generated consumer scares about the safety of meat, besides rising the demand for naturally raised and organic meat [ , ] . in addition, the perceived extent of influence of the covid- crisis on future change in organic food and game meat-eating shows that the older generations' food belief is more stable. as this research reveals, the influences of the covid- crisis on future change in diets, both organic food and game meat, is smaller on the older than on the younger generations. the older generations have a more fixed view on food health and risk. this research aims to explore health/risk perceptions and attitudes toward healthy/risky food in the immediate context of food crisis, as well as to understand different generations' attitudes toward it. our findings reveal that a statistically significant "generational effect" is found in healthy and risky food consumption. the older generations have a more positive attitude toward organic food, and they have a higher willingness to increase their future eating frequency, which means they would be more committed to eating organic food than would the younger generations. the younger respondents have a more negative attitude toward game meat. the older generations attach more importance on game meat because of its healthy values of being nutritious and medicinal. as people become more affluent, they are able to choose organic food since it has more beneficial nutrients. thus, eating organic food is moving up more and more consumers' agenda. promoting production and trading opportunities for the certified organic food to meet sustainability goals should be a top priority of local government in the developing countries. this research maps a positive future for the organic food market, which might encourage more farmers to involve in organic agriculture. the covid- crisis has a positive impact on the respondents' attitude toward organic food and negative impact on their attitude toward game meat, which implies that food anxiety and health scares caused by food safety crises can change consumers' sensitivity and belief about food health and risk. the impact of the food crisis on the older generations' future change in diets is smaller, which means that the older generations' food belief is more stable. based on food health, they have a more solid belief on food than do the younger respondents. however, the covid- epidemic has created some opportunities for positive change in china. for example, the government prepares a ban on trade of wildlife to improve public awareness on the health risks of the consumption of non-aquatic wild animals for food. on the supply-side, incentives can be created to encourage more investment on building a healthier food system. in addition, this research also shows a positive future for organic food consumption, which might encourage more farmers to engage in organic food production. this study has a few limitations. firstly, the items used to measure the constructs in this study may not be the 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produced foodstuffs: a tentative comparison under belgian conditions manufacturing fear: the role of food processors and retailers in constructing alternative food geographies in toronto this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord- -cb j y s authors: farrell, penny; thow, anne marie; wate, jillian tutuo; nonga, nichol; vatucawaqa, penina; brewer, tom; sharp, michael k.; farmery, anna; trevena, helen; reeve, erica; eriksson, hampus; gonzalez, itziar; mulcahy, georgina; eurich, jacob g.; andrew, neil l. title: covid- and pacific food system resilience: opportunities to build a robust response date: - - journal: food secur doi: . /s - - -y sha: doc_id: cord_uid: cb j y s the unfolding covid- pandemic has exposed the vulnerability of the pacific food system to externalities and has had far-reaching impacts, despite the small number of covid- cases recorded thus far. measures adopted to mitigate risk from the pandemic have had severe impacts on tourism, remittances, and international trade, among other aspects of the political economy of the region, and are thus impacting on food systems, food security and livelihoods. of particular concern will be the interplay between loss of incomes and the availability and affordability of local and imported foods. in this paper, we examine some of the key pathways of impact on food systems, and identify opportunities to strengthen pacific food systems during these challenging times. the great diversity among pacific island countries and territories in their economies, societies, and agricultural potential will be an important guide to planning interventions and developing scenarios of alternative futures. bolstering regional production and intraregional trade in a currently import-dependent region could strengthen the regional economy, and provide the health benefits of consuming locally produced and harvested fresh foods – as well as decreasing reliance on global supply chains. however, significant production, processing, and storage challenges remain and would need to be consistently overcome to influence a move away from shelf-stable foods, particularly during periods when human movement is restricted and during post-disaster recovery. electronic supplementary material: the online version of this article ( . /s - - -y) contains supplementary material, which is available to authorized users. the unfolding covid- pandemic is a crisis with many faces. it has exposed the vulnerability of the pacific food system to externalities and has had far-reaching impacts, despite the small number of cases recorded thus far. in many respects, covid- has 'landed' in the countries and territories of the region, more as a suite of social, economic and food security issues than as a health crisis per se. although the pandemic has yet to fully reveal itself as a health crisis in the region, it has prompted national governments and regional development partners to develop mitigation and adaptation measures at a scale not previously experienced in the region. pacific island countries and territories (picts) are striving to ensure that covid- does not evolve into a health crisis. the measures adopted to mitigate this risknotably restrictions on the movement of people within and among countrieshave had severe impacts on tourism, remittances, and international trade, among other aspects of the political economy of the region. picts are food import-and remittance-dependent economies (connell ) , and many are heavily reliant on income from tourism (e.g. fiji, french polynesia, new caledonia, palau, samoa) (wood ) . the cessation of tourism is expected to result in substantial losses to economiesforecast scenarios in the range of us$ - billion regionally (pacific community ). such losses are realized across many parts of national economies, including unemployment, business failure, and changed patterns in the production and distribution of food. reliance on remittances is also high: across picts, funds transferred from overseas kin account for an average of . % of gdp (pacific community ). some countries have already experienced substantial falls in remittances since the covid- outbreak (graue ) . national food systems in the pacific region share attributes with those in other small island developing states (sids). much of their fragility is due to geographic remoteness, growing import dependence, and in many places, limited arable land and declining agriculture production (fig. ) . the region experienced a dramatic decline in per capita domestic crop production up to the mid- s, which has not been recovered. staple foods, particularly rice and wheat, account for much of the volume of food imported to the region, but nutrient dense and sugary food and beverages are also rising markedly. these trends in the availability of foods over the past half century (thaman ) are reflected in diets which have shifted from being high in locally grown fresh fruits and vegetables, seeds and nuts, lean meat and seafood, to diets high in processed and often imported foods (thow et al. ) . consequently, the triple burden of malnutrition is a large and growing issue in the region (global nutrition report ; hughes and lawrence ; sievert et al. ) and prevalence of diet-related non-communicable diseases are particularly high in picts (anderson ) . these trends and events highlight the complexity of addressing the food security dimensions of the covid- pandemic, in a landscape already challenged by processes and climate shocks that threaten economies and societies. in the last month, for example, tropical cyclone harold swept through solomon islands, vanuatu, tonga, and fiji in the midst of covid- mitigation preparations, destroying houses and crops. the confluence of the cyclone and covid- led to a tragic loss of life in the sea off the island of malaita in solomon islands, as people travelled to their home villages from the capital (kaukui ) . even in the much-desired scenario that the region remains largely free of widespread infection, its impacts will manifest in many different ways (table ). the range of potential and actual impacts for food systems and food security in the pacific region shown in table may be seen as a subset of those noted globally (haddad et al. a, b) . of particular concern will be the interplay between loss of incomes and the availability and affordability of local and imported foods. a disproportionate burden may fall on women and children as local availability and affordability of food is impacted through the closure of informal markets (table ) . in solomon islands, net imports (imports -exports) fig. comparison of trends in food (crop) production and food trade, in grams, per capita per day. domestic production data includes crops, excluding cash crops. trade data (net imports) includes foods relevant to food security, excluding cash crops; tuna was also excluded due to uncertainty in estimates. see supplementary materials for fig. for the list of: a foods included in the production and trade time series data and b) countries included in the presented annual mean production and trade estimates. note, fiji and papua new guinea were excluded due to their disproportionate influence on per capita estimates. trade data derived from the pacific food trade database (brewer et al. ) . crop production data downloaded from food and agriculture organization of the united nations ( a). population data sourced from food and agriculture organization of the united nations ( b) table summary of key potential food system impacts in the pacific region global analysis of potential covid- related impacts on food systems pacific-specific food system context potential food system, food security and nutrition impacts in pacific production access to inputs may be limited by restrictions on travel, reducing agricultural production, yields and income; access to services may be reduced (e.g. veterinary, extension services). decreased demand and purchasing power will reduce investment and technology, further reducing availability. seasonal impact needs to be considered. existing challenges in access to inputs, services, labour and finance; relatively long production cycles for root crops; data gaps in domestic production potential. increased demand for locally grown staples (e.g. root crops) if prices of imported commodities rise. potential for increased participation in home gardening/own account production; even if production increases still variability in capacity, especially by geography and access to technologies; challenges to access inputs, services, labour and finance exacerbated. little global commentary on fisheries to date. fish are the dominant animal-source food; beche de mer is an important source of income for many rural communities. demand and domestic catch of fish may increase; probable major disruptions to regionally important tuna industry will impact on national access to tuna and economies. restrictions on movement of people impacts seasonal agricultural workforce especially relevant for labour-intensive crops, such as fruits and vegetables. higher vulnerability to covid- for elderly farmers. decreased ability for companies to care for workers health and wellbeing (across global supply chain). many pacific island countries and territories (picts) are remittance-dependent; seasonal agricultural labour to australia and new zealand is significant. reduction in labour force mobility may contribute to declines in income, which can have direct implications for people's access to food; disease and limited health services will impair agricultural output in the instance of high disease rates. population flows from urban to rural areas, e.g. people returning to home villages, may influence availability of local rural labour for agriculture. increased levels of post-harvest losses due to reduced workforce. regionally produced foods subject to high losses. existing post-harvest losses potentially exacerbated due to supply chain disruptions; potential for investment in primary processing, local distribution. processing food companies (domestic and external) facing increased demand for processed staples may experience input shortages due to production and transport being affected. small and medium enterprises (smes) at risk of bankruptcy. limited domestic processing in picts and high dependence on imported inputs; village processing important for short distance/domestic distribution. reduced availability / increased prices for domestically produced staples and food that is usually processed in-country; local processing of tuna disrupted; shortages of imported processed and packaged foods possibleboth basic e.g. milk powder, tinned foods, and also highly processed foods (unhealthy discretionary foods). smes particularly affected. distribution restricted international trade, including exports from some countries; air freight and shipping likely to be reduced; price increase in export (non-pict) countries raising affordability concerns for picts; potential backlog at ports and airports during and post-crisis. all picts net-food-importers of staple (energy) foods. possible reductions in staple foods; shortages of imported processed and packaged foods possible (unhealthy discretionary foods); possibility to shorten supply chains including intra-regional trade. impacts on internal trade and distribution due to reduced travel and quarantine measures, including restricted internal borders. common to have food transported between and within islands domestically; some reliance on public transport for food transport; kin networks important for sharing of food. pacific is import-dependent for fuel. domestically produced food supply to urban centres reduced (e.g. root crops, fruit, vegetables); potential reductions in distribution of imported food to rural areas; likely differential impacts for producers (e.g. based on geographical location, own transport); home gardening won't be affected. any disruptions to fuel imports could impact stove fuels for cooking. food market fresh food markets reduced due to restrictions on gatherings; food safety concerns (hygiene). closure of farmers' markets and stalls for selling fresh fruit open markets major source fresh fruit and vegetables, meat etc.; hygiene and food safety may be an issue. access to and consumption of fresh food may be reduced in urban areas; if livelihoods affected, food security and/or ability to purchase different food may be for example, women comprise the majority of sellers in such markets now disrupted due to covid- related restrictions, with knock-on effects on household and village economies (eriksson et al. ) . as market places are changing, traditional practices of bartering and sharing are also on the rise (maclellan ) . the existing challenges of agricultural production and a high degree of food import dependence within the region have the potential to exacerbate the impacts of covid- responses. given the nature of imported foods, it is not axiomatic that covid- will lead to a reduction in the quality of diets. extreme necessity can be a time for positive policy innovation. our summary (table ) identifies some potential positive intersections that could prompt re-visioning of aspects of the food system in the region. the great diversity among picts in their economies, societies and environments will be an important guide to planning interventions and developing scenarios of alternative futures. papua new guinea, fiji, solomon islands, and other larger nations may envision futures with a resurgent agricultural base. in solomon islands, for example, growing conditions are favourable for a range of crops, and a majority of households are engaged in agriculture in some way on the estimated . million hectares of agricultural land in use (solomon islands national statistics office et al. ). such a future is less plausible for the atoll nations of micronesia where the production, trade, and consumption of fish, particularly tuna sourced through potentially very long supply chains, is more likely to be prominent. bolstering regional production and intraregional trade in a currently import-dependent region could strengthen the regional economy, and provide the health benefits of consuming locally produced fresh foodsas well as decreasing reliance on global supply chains. significant production, processing and storage challenges remain and would need to be consistently overcome to influence a move away from shelf-stable foods, particularly during periods when human movement is restricted and during post-disaster recovery. supply chains vary in complexity and vulnerability to disruption. their ability to respond quickly will depend on many factors including characteristics of the food itself, resilience of the distribution chains, and a preparedness to change. there is an opportunity to adapt supply chains in response to covid- by building affected; non-cash food economies likely to become more important in village economies; gendered impacts are evident from the restriction in informal marketing, with women and youths most commonly taking up economic activities for sale of subsistence produce in the margins of the formal economy. potential supply concerns for supermarkets, may be price gouging; commodity prices could also fall due to a lack of demand. types of foods consumed could change in response to change in prices. small stores a major source of food in region; supermarkets important source of food in urban areas. stores and supermarkets may be unable to source some stocks and prices may increase for goods in short supply. differential impacts rural/urban and differences between picts; price gouging may impact food security. declines in food eaten away from home with physical/social isolation public health measures. informal food service significant in economy. informal sector may be unable to access (physical/financial) food ingredients; smes likely to be particularly affected. dietary changes both positive (reduced 'fast' food), and negative (reduced dietary diversity). probable shift to long-shelf-life and staple foods with changed shopping behaviour due to physical distancing efforts; reduced consumption of fresh vegetables and other perishable products. limited storage capacities for fresh foods, particularly in low income areas. greater consumption of staple and processed foods may exacerbate diet transition, mediated by availability, accessibility, affordability of the substitute food and dietary habits. food substitution and access issues will differentially impact women and children. intra-household power dynamics very influential to food distribution in the pacific region. increase in domestic violence and conflict within households could increase food insecurity for vulnerable groups. on responses to climate change and natural disasters (cvitanovic et al. ) which will mean supply chains are more resilient in the long-term. these include increasing coordination and transparency of food trade within the region (steiner et al. ) , particularly for root crops; ensuring access to finance and inputs to increase local production; better integration of local food producers into local and regional value chains; and increased local processing and packaging to reduce food waste (table ) . enhancing storage, processing, and distribution of food commodities is vital in mitigating food and nutrition security impacts during the current crisis. for example, strengthening food storage and inter-and intra-island transport has been shown to increase consumption of fresh foods (and thus avert mortality and morbidity from diet-related non-communicable diseases) in fiji (snowdon et al. ). there may also be benefits to prioritising less perishable food (e.g. root crops) in pacific supply chains, which lack adequate storage for more perishable items such as fish. strengthening consumer demand has also been shown to enhance supply and demand systems and reduce post-harvest food waste (underhill et al. ) . education for behaviour change has the potential to increase demand for locally produced foods (cvitanovic et al. ; vermeulen et al. ) . working through covid- may strengthen the ability of sectors to work together in more integrated ways; discussions around food and food systems must intersect with health and the environment (bennett et al. ) . for example, recent analysis from the uk on the impact of covid- on food systems (sharpe et al. ) has shown that "… government reactions to food supply issues exposed how increased coordination could aid responses and build trust in times of crisis, both now and in the future." before covid- the pacific food system had become increasingly vulnerable to shocks and other disruptions to the production, distribution and acquisition of food. it had become that way for a multitude of historical and contemporary reasons and was already threatened by climate change and other external threats. like climate change, the pandemic was created somewhere else, but threatens the prosperity and wellbeing of pacific people in profound ways. unlike climate change, the resilient people of the pacific regio can influence how this crisis plays out: whether it will catalyse change in the functioning of national food systems and their reliance on imported foods will be a critical issue in the coming years. dr. penny farrell is a public health researcher and veterinarian with over seven years of experience in health, nutrition, and agriculture policy research in pacific island countries, asia, and africa. penny recently completed a phd on food security in the pacific region and has worked previously in the not-for-profit, university, and government sectors. penny currently holds a position as a research fellow at the university of sydney dedicated to researching how to build healthy and sustainable food systems globally, with a focus on low income settings. policy at the university of sydney. her research uses theories of public policy making to explore facilitators and barriers to best practice public health nutrition policy, with a particular focus on the interface between economic policy and nutrition. anne marie currently collaborates on research in asia, africa and the pacific, designed to strengthen nutrition policy making, and regularly consults with international agencies regarding nutrition policy, including the world health organization, food and agriculture organization and international food policy research institute. prior to her phd, anne marie worked for the governments of australia and fiji on nutrition policy issues. she trained in nutrition and has a masters in public policy and economics. dr. jillian tutuo wate is a nutritionist by profession with over years of experience in public health research and nutritionrelated policy intervention for the prevention of obesity and noncommunicable diseases in the pacific. she has led the assessment and monitoring work for food environments in the pacific under the pacific research center for prevention of obesity and non-communicable diseases (c-pond). she is currently a research fellow with worldfish, an international non-governmental organisation researching on ways to promote food and nutrition security in the pacific food system to address the double burden of malnutrition in solomon islands and vanuatu. she is based in honiara, solomon islands and has contributed to a range of multi-sectoral nutrition-related policies and research. ms. penina vatucawaqa is a national policy officer in food and nutrition security with the food and agriculture organisation (fao) working for the food and nutrition security, impact, resilience, sustainability and transformation (first) project in fiji. her work with fao first includes providing government with policy assistance and capacity development in support of improved food security, nutrition and sustainable agriculture in fiji. ms. vatucawaqa has also had a wide experience in conducting nutrition research such as national nutrition surveys and food balance sheets (a tool for assessing food availability) that has been used for developing policies in the country. dr. tom brewer is an interdisciplinary scientist with training in marine ecology and a ph d in environmental sociology. he has been working in the pacific for over a decade on natural resource management and human development challenges. his primary skill is in integration of diverse data sources to answer complex socialecological questions relating to resource sustainability and human wellbeing. tom is currently part of a team focused on improving food systems in the pacific (aciar fis- - ) . his primary role is in developing a database of food and beverage trade for the pacific to better understand the influence of food trade in macroscale food consumption patterns and non-communicable diseases such as obesity and diabetes. mr. michael k. sharp is an e c o n o m i c s t a t i s t i c s a n d microdata specialist at the pacific community (spc). mike has worked at spc for -years where he has supported pacific island countries and territories (picts) to collect, compile a n d a n a l y s e d e v e l o p m e n t microdata, which range from fisheries and agricultural to nationally representative census and survey data. his research interests mainly surround survey methodology to extend the use of household income and expenditure survey data to conduct poverty, food security and nutrition analysis in order to form an evidence base to address hardship and malnutrition in the pacific region. mike previously conducted fieldwork in vanuatu and guyana and he was employed in the australian financial sector. he holds a master's degree in economics and a bachelor's degree in agricultural economics. mike is an honorary fellow with the faculty of law, humanities and the arts, university of wollongong. chancellor 's post-doctoral r e s e a r c h f e l l o w a t t h e australian national centre for ocean resources and security (ancors) at the university of wollongong in australia. her research is focussed on the integration of food and nutrition security considerations in ocean and fisheries governance, and on ways to improve the overall contribution of seafood to food and nutrition security in terms of sustainable, equitable and rational resource use. she has published articles on issues of seafood sustainability and fisheries management, and on the integration of fish and food policies. anna has worked on aspects of sustainable food systems, in agriculture and fisheries, for over years and is currently investigating value chains and pacific food systems. dr. helen trevena has experience of working in the business, non-government, and government sectors in operational, consulting and policy roles. she is currently an early career research fellow at the menzies centre for health policy where her research interest is policy to deliver a healthier food supply. helen is supported by a co-funded national health and medical research council and heart foundation early career fellowship. ms. erica reeve is a phd candidate with globe at deakin university. she has over years of work experience in public health nutrition in the asia pacific region and remote australian indigenous communities which includes extensive experience working with and consulting to national governments and international organisations. she has experience in strategic policy development, stakeholder engagement, programme planning, health promotion and highlevel advocacy, particularly as applied to diets, ncds reduction, and maternal and child nutrition. dr. hampus eriksson is a systems ecologist. he is the senior scientist at worldfish, a cgiar centre, in solomon islands and an associate professor at the australian national centre for ocean resources and security (ancors) at the university of wollongong in australia. his research focuses on rural development through fish-based livelihoods; testing and evaluating innovations that enhance fish-based livelihoods in small-scale fisheries. the research is implemented through cross-disciplinary collaborations in the academic and fisheries sector in the pacific islands, southeast asia and africa. ms. itziar gonzalez joined fao in february as a policy officer for food security, nutrition and sustainable agriculture, working first in sri lanka and then in three pacific countries vanuatu, solomon islands and fiji. prior to this position, itziar spent over years implementing and providing technical advice to rural development initiatives in different countries of south and c e n t r a l a m e r i c a a n d t h e caribbean. during these years, she was involved in different development initiatives from the united nations, the spanish agency for international development cooperation, and some spanish ngos, amassing knowledge on different areas of expertise, as integral farming, food systems and nutrition sensitive agriculture, community forestry or artisanal fisheries and aquaculture. she is an agricultural engineer from the polytechnic university of madrid, spain and obtained an msc in management of agro-ecological knowledge and social change from the university of wageningen, the netherlands in . ms. georgina mulcahy is a r es ea r ch a ss is t an t a t t h e menzies centre for health policy, university of sydney, providing policy analysis and research support to food systems policy projects across sub-saharan africa, asia and the pacific. georgina holds a master of sustainability, university of sydney, and has years' experience working in health as an exercise physiologist, namely management of diet-related noncommunicable diseases. dr. jacob eurich is a postdoctoral scholar at the marine science i n s t i t u t e a t u n i v e r s i t y o f california, santa barbara. in he obtained his phd from james cook university and the australia research council centre of excellence for coral reef studies. he worked from papua new guinea to the great barrier reef studying reef fish population and community responses to changes in habitat structure and coral bleaching. his research now focuses on the interactions between coral reefs and human communities in the pacific region under the overarching themes of climate change, human use and resilience. specifically, how much coral reef-derived foods matter to human health and the effective reef management practices that lead to levels and types of seafood consumption that promote human nutrition. neil andrew is a professor at the australian national centre for australian national centre for ocean resources and security (ancors) at the university of wollongong. he has worked at the interface between fisheries and ecological research and policy for more than years in a wide range of contexts, including in australia, new zealand, zambia, malawi and in the pacific region. before joining ancors he worked as the global program leader in small-scale fisheries at the cgiar centre, worldfish, based in penang, malaysia. professor andrew is widely published in fisheries and ecology. the economic costs of non-communicable diseases in the pacific islands: a rapid stocktake of the situation in samoa covid- and its likely impact on the tuna industry in the pacific islands the covid- pandemic, small-scale fisheries and coastal fishing a method for cleaning trade data for regional analysis: the pacific food trade database version ( - ). pacific community working paper linking adaptation science to action to build food secure pacific island communities changes and adaptations in village food systems in solomon islands: a rapid appraisal during the early stages of the covid- pandemic appendix : countries with significant multiple forms of malnutrition families in samoa struggle as seasonal workers can't send money home the covid- crisis and food systems: addressing threats, creating opportunities covid- and pacific food system resilience: opportunities to build a robust response -crisisand-food-systems-probable-impacts-and-potential-mitigation-andadaptation-responses.pdf. accessed / / . high-level panel of experts on food security and nutrition (hlpe) review article: globalisation, food and health in pacific island countries a wfp analysis of the economic and food security implications of the pandemic mv taimareho: sea tragedy economic and social vulnerability to covid coordination must be key to how governments respond to covid- food impacts: a view from england. rethinking food governance guidance note modelling of potential food policy interventions in fiji and tonga and their impacts on noncommunicable disease mortality ministry of agriculture and livestock, & in collaboration with the food and agriculture organization of the united nations and the world bank blog : five covid- reflections from a food system perspectives-and how we could take action deterioration of traditional food systems, increasing malnutrition and food dependency in the pacific islands trade and the nutrition transition: strengthening policy for health in the pacific horticultural postharvest loss in municipal fruit and vegetable markets in samoa changing diets and transforming food systems what will covid- mean for the pacific: a problem in four parts acknowledgements supported by funding from the australian govern- key: cord- - o ffk y authors: veleva, vesela title: the role of entrepreneurs in advancing sustainable lifestyles: challenges, impacts, and future opportunities date: - - journal: j clean prod doi: . /j.jclepro. . sha: doc_id: cord_uid: o ffk y this paper examines the role of entrepreneurs in advancing sustainable lifestyles (sls) to address climate change and social inequity. it is based on empirical study of eight u.s.-based sustainable entrepreneurs, focused on reducing material consumption. while business has a key role to play, many large companies are unwilling to promote sls as this is contrary to their current business models which are focused on growing consumption and sales. this presents an opportunity for entrepreneurial companies with innovative business models who are passionate about sustainability and social impact, and better positioned to take risks and innovate. the research examined emerging business models for advancing sls, key success factors and challenges reported by the entrepreneurs, the social and environmental impacts of their actions, and the future opportunities for scaling up such practices. the study found that entrepreneurs are well positioned to address simultaneously environmental and social issues, however, they lack resources to effectively measure these impacts to demonstrate an overall positive benefit and strengthen their value proposition. promoting green attributes alone is not enough to change the behavior of most consumers. it is critically important to emphasize other benefits such as a product/service quality, time or cost savings, or social impact. social media, formal and informal sustainability networks, it, sustainability policies, and consumer awareness are key to developing viable business models and competitive strategies that are difficult to replicate. the study found that sustainable entrepreneurs often face “costly” sustainability actions and lack the power to change „the rules of the game“; for this they need to collaborate with other key stakeholders, including ngos, policy makers, and progressive companies. based on the research findings the author proposes a new framework for the role of sustainable entrepreneurs as civic and political actors who not only offer innovative products and services, but help educate and influence key stakeholders, develop informal sustainability ecosystem, and thus create momentum for policy changes. following the paris agreement in , many cities and nations globally have taken steps to achieve substantial cuts to their greenhouse gas (ghg) emissions by focusing on major sources of emissions: electricity, housing, and transportation. yet, global carbon emissions have continued to rise reaching a record of . billion tons in (mooney & dennis, ) , before sharply declining due to the covid- pandemic (le quere, ). one reason is that policymakers' ambitious plans do not account for indirect emissions closely aligned with lifestyles, such as the energy embodied in producing the food, buildings, or consumer goods and services made outside a city or a state's boundaries (so-called consumption-based emissions) (mont et. al. ; brown & cohen, ; southerton & welch, ) . a recent study in oregon, united states, showed that while sector-based ghg emissions in the state increased % between and , consumption-based emissions were up % over the same period (brown and cohen, ) . such outsourcing of emissions is not just creating the illusion of making progress, but it is also an issue of equity and justice, as more affluent households have greater carbon footprints. fifty percent of the world's ghg emissions have been attributed to the richest % (southerton & welch, ) . decarbonization and dematerialization of existing lifestyles and services, however, do not go fast and deep enough. research has shown that technological innovation alone cannot help addressing climate change (alfredsson et. al., ; cohen et. al. ) . there is an urgent need to lower the consumption of material goods, such as living in smaller homes, buying fewer disposable goods, consuming less read meat, and driving and flying less. to reach an % reduction of a city's ghg emissions or a carbon neutrality (such as the city of boston's goal for year ) will require more structural changes in the way people live and work. changing consumer lifestyles, however, is challenging as it requires to examine systemically the entire value chain and overcome a range of economic, institutional, cultural, and social barriers. business model innovation is increasingly seen as essential for advancing sustainable lifestyles (sls) such as using public transportation, renewable energy, adopting plant-based diets, reducing material consumption, and housing footprint (bocken and short, ) . such a transition will require a fundamental shift in the purpose of business and how value is defined by companies and society. it will require new innovative actors who can work with other key stakeholders to help solve environmental and social challenges (mont et. al. ; ghisellini et. al., ; murray et. al., ) . while business has a key role to play, many large companies are unwilling to promote sls as this is contrary to their current business models that are focused on growing consumption and sales (windsor, ) . further, logistical hurdles and risks associated with revamping of global supply chains, often prevent companies from adopting new strategies (york & venkataram, ) . these factors present an opportunity for entrepreneurial companies with innovative business models who are passionate about sustainability and social impact, and better positioned to take risks. entrepreneurs' niche experiments can provide valuable insights and social learning about the challenges and opportunities in advancing sls, as well as help build momentum towards enacting government policies that "change the rules of the game" to reward sustainable businesses mont et. al. ; windsor, ) . however, researchers have reported that majority of business model innovations fail and there is a need to better understand the challenges that entrepreneurs face (geissdoerfer et. al. ) , the impacts they create (horisch, ) and the role of sustainability networks in entrepreneurial success (davies & chambers, ) . more empirical research is needed to examine the different pathways towards sustainability transformation and how to translate customers aspirations into purchasing activities (schaltegger et. al. ) . this paper aims to address some of these research gaps and examine the role of sustainable entrepreneurs in advancing sustainable lifestyles by explore the following questions: what are some emerging business models for advancing sls and the role of value chain partners and social networks in ensuring success? what are the social and environmental impacts created by sustainable entrepreneurs and how do they measure and communicate these? what are the main challenges faced by sustainable entrepreneurs presently and how do they work to overcome these? what is the role of sustainable entrepreneurs in advancing sustainability transition? the paper is structured as follows: it begins with a literature review, illustrating the impact of personal consumption on climate change, current strategies to promote low carbon lifestyles and the role of sustainable entrepreneurs in such a transition. it then introduces the research method utilized and presents key findings from the cross-case analysis. the author then proposes a new framework for the role of sustainable entrepreneurs in advancing sls and concludes with discussion of the main lessons learned, research contribution, and implications for future policy, practice and research. despite the paris agreement to address climate change, signed by countries, global carbon emissions have continued to rise reaching a record of . billion tons in (mooney & dennis, ) . nineteen of the warmest years globally have been registered since , demonstrating a clear trend towards warming (nasa, ) . governments around the world have enacted a range of policies to address major sources of emissions: electricity, housing, and transportation. yet, such efforts will be insufficient to stop global climate change unless we address personal consumption and lifestyles (mont et. al. ; alfredsson et. al. ; brown & cohen, ; southerton & welch, ) . according to the u.s. environmental protection agency (epa) % of u.s. greenhouse gas (ghg) emissions are associated with the energy used to produce, process, transport, and dispose of products ( % of which are thrown away in months) (u.s. epa, ) . a recent analysis of major cities worldwide revealed a % increase of those cities' carbon footprints when using consumption as opposed to production-based accounting (c , ). while much of the world still needs further development and consumption to reduce poverty and hunger, developed countries must reduce their consumption to address climate change and social inequity. wealthier countries such as finland and japan, for example, have three to five times higher lifestyle carbon footprints compared to poorer countries like brazil and india (lettenmeier et. al., ) . in the european union, total material consumption is estimated at - tons per year, compared to a sustainable level of tons per capita per year (mont et. al. ) . the need to address individual consumption and unsustainable lifestyles was first recognized in in agenda but has received limited attention by policy makers and other stakeholders until recently (mont et. al. ) . sustainable lifestyles (sls) are seen as an alternative to the current consumption-centered lifestyles and defined as "a cluster of habits and patterns of behavior embedded in a society and facilitated by institutions, norms and infrastructures that frame individual choice, in order to minimize the use of natural resources and generation of wastes, while supporting fairness and prosperity for all" (unep, ) . a recent unep framework for sustainable living defined five core areas for taking actions at the consumer level: housing, mobility, food, consumer goods, and leisure (unep, ) . a shift toward more sls has the potential to drive greater economic equality, open new business opportunities, and improve quality of life. for instance, telework helps improve employees' wellbeing and engagement; plant-based diets improve health outcomes; preventing waste (from surplus food or consumer goods) is associated with financial and time savings; smaller houses are more affordable. three main types of strategies have been used to address personal consumption and advance sls: a) education and awareness about the impacts of individual actions on climate change; b) policies to reduce consumption and change consumer behavior, and c) innovative business models to reduce or modify consumption. while environmental awareness and concerns about climate change are growing , few people understand their personal contribution or what actions they can take. a recent study found that % of americans are willing to change their behavior to reduce environmental impacts (nielsen ) but % of people do not know their carbon footprint or how to lower it (grinstein et. al., ) . in a recent study cordero et. al. ( ) measured the impact of a year-long university course about climate change and found that participants reduced their individual carbon footprint by . tons of co per year five years later. the authors argue that if applied at scale such education programs "would be of similar magnitude to other large-scale mitigation strategies, such as rooftop solar or electric vehicles." other studies have found that education is necessary but not sufficient to change consumer behavior due to the gap between individuals' aspirations and actions. even in countries with strong culture for environmentalism, a small share of consumers buy sustainable products (vringer et. al. ) . often it is believed that consumers are "free" to make a choice, but research has identified a range of barriers, from simple (e.g., price, availability and quality) to more complex (social, institutional, and economic). for instance, public transportation may not always be available, or it could be inconvenient. while biking has been promoted as healthier alternative to driving, ensuring bike safety remains a challenge in many communities. telework can help reduce individuals' carbon footprint and is linked to increased well-being and productivity (gimenez-nadal et. al. ) but it requires adoption at an organizational level. consumers also face a range of social and moral dilemmas ; vringer et. al. ( ) found that people are often reluctant to impose constraints on others. addressing such economic, institutional, and moral barriers requires government interventions such as new taxes, subsidies, disclosure mandates, or bans. most research on sls to date has focused on policy initiatives. southerton and welch ( ) analyze different policy approaches for changing individual behavior -from pricing, to information (education), use of social marketing campaigns, and infrastructure development (e.g., for mobility). they argue that while there are many successful examples of effective policies, more must be done to address the social, cultural, economic, and material barriers for reducing consumption. they call for "radical policy experimentation" and an "open debate and dialogue at local, regional, national and international levels that directly tackle consumption and visions of future ways of life." such radical approaches include j o u r n a l p r e -p r o o f promoting "time affluence" (as alternative to material affluence) and reducing the working week. such an approach, however, is problematic for many working-class employees, who need overtime hours to meet their basic needs (lautsch and scully, ) . the literature on sustainability clusters has identified the importance of supporting infrastructure and other local factors in promoting productivity, innovation, and competitiveness (maskell and malmberg ; martin and mayer ; porter and kramer ) . resilient clusters include not only the local businesses but also institutions such as schools, universities, trade associations, and non-profit organizations. local governments can play an important role in promoting cluster development and firm competitiveness by setting clear and measurable social goals and enacting relevant policies to promote social development and business sustainability (deutz and gibbs, ; veleva et. al. ) . in their "shared value" framework porter and kramer ( ) emphasize the "profound effect" of a business location on a firm productivity and innovation, which remain understudied by researchers. they argue that "shared value helps uncover new needs to meet, new products to offer, new customers to serve and new ways to configure the value chain, where the resulting competitive advantage will often be more sustainable than conventional cost and quality improvements". other researchers have examined shifting to sustainable consumption through the lens of the social change theory (cohen et. al. ) . sustainable consumption is defined as "the use of goods and services that respond to basic needs and bring a better quality of life, while minimizing the use of natural resources, toxic materials and emissions of waste and pollutants over the life cycle, so as not to jeopardize the needs of future generations" (norwegian ministry of environment, ) . in the current capitalist economy where consumption is seen as key to economic success, changing the dominant "regime" is challenging and more likely to happen gradually through incremental changes "in the fractures of the dominant system, in niches where they do not seem to pose any immediate threat to dominant classes and institutions" (cohen et. al., ) . more generally, the literature on sustainability transitions, degrowth, and steady state economy, has called for national-level policies to overhaul our current economic system to ensure more sustainable production and consumption (jackson, ; cosme et. al. ; cohen et. al. ) . this approach, however, is outside the scope of the current study. new business models a business model is about how an organization creates, delivers, and captures value (or in simple words, how it makes money). in this paper, we define "business model" using three main elements: the value proposition, value creation and value capture. sustainable business models are distinct in their focus on analyzing and communicating a sustainable value proposition to customers, in how they create and deliver value, and how they capture value while also maintaining or regenerating natural, social and economic capital (schaltegger et. al. ) . business model innovation, on the other hand, is more challenging to define. it typically does not require inventing new products, technologies, or markets, but instead involves changing the revenue stream, synchronizing the time horizons, or integrating the incentives (girotra & netessine, ) . for instance, leasing instead of selling solar panels was a major business model innovation which enabled overcoming the upfront costs for customers and thus led to expansion of the market for solar energy. developing long-term relationships with suppliers, customers and other partners along the value chain, can help companies co-create value, and thus generate competitive advantage. recent empirical study of centers for urban remanufacture in europe found that majority of examined initiatives were dependent on external support, and were not financially viable (ordonez et.al., ) . the researchers concluded that entrepreneurial innovation was needed to make the business j o u r n a l p r e -p r o o f case, and recommended launching business incubators in the area of reuse and remanufacturing. companies are increasingly seen as playing an important role in changing consumer behavior "through marketing and branding, new business models and choice editing" (bocken, ) . bocken et. al. ( ) introduced eight sustainable business model archetypes, described as businesses that a) maximize material and energy efficiency, b) create value from waste, c) substitute with renewables and natural processes, d) deliver functionality rather than ownership e) adopt a stewardship role, f) encourage sufficiency, g) re-purpose the business for society/environment, and h) develop scale-up solutions. bocken and short ( ) introduce the concept of "sufficiency-based business models" where companies deliver sustainability by "reducing absolute material throughput and energy consumption associated with provision of goods and services by moderating end-user consumption and encouraging consumers to make do with less." key enablers for companies' success with such business models include: strong focus on customers, commitment to go against the business-as-usual trends, performance and incentive systems aligned with sustainability objectives of the firm, strong focus on quality and durability, and radically different marketing campaigns. freudenreich and schaltegger ( ) examine sufficiency-oriented business models in the clothing industry and report that innovations such as service-and sharing-oriented businesses can be successful and help address both social and environmental problems in the clothing sector. however, legislation and policy intervention are often needed to bring such niche practices to the mainstream (bocken & short, ) . this confirms previous findings by that besides b corporation and social entrepreneurs, most profit-oriented corporations "cannot be expected to solve climate change and other environmental problems without changes in government incentives for business. " geissdoerfer et. al. ( ) further report the designimplementation gap in sustainable business model innovation which leads to market failure. the role of sustainability entrepreneurs in advancing sls there is a growing body of research on the role of entrepreneurs in addressing sustainability challenges. thompson et. al. ( ) provide one of the most comprehensive analysis of the similarities and differences between social, environmental and sustainable entrepreneurs. while all three are similar in their mission-driven business strategies, they also differ. social entrepreneurs are primarily focused on their social mission related to helping people. environmental entrepreneurs focus "on environmentally-relevant market failures" and seek to deliver both economic and ecological benefits. sustainable entrepreneurs aim to deliver longterm benefits across a "triple bottom line" or create simultaneously environmental, social and economic benefits (thompson et. al. ) . for the purposes of this study we will focus on sustainable entrepreneurs with the recognition that there is an overlap between the three types and environmental entrepreneurs are a sub-category of sustainability entrepreneurs (thompson et. al. ) . according to york and venkataraman ( ) entrepreneurs are best positioned to solve complex problems and turn uncertainty into business opportunity with social and environmental benefits as they are willing to take risks and innovate. bocken and short ( ) demonstrate that while startup businesses may not be economically viable initially, this can change over time because of regulatory action or changes in the market. even though entrepreneurs have limited resources and reach, their ability to foster strategic partnerships with large players can stimulate disruptive innovation, leading to industry transformations in sustainable development. pacheco et. al. ( ) demonstrate how sustainable entrepreneurs are able to change the "rules of the game" or the competitive landscape, by "proactively devising and influencing the establishment of new industry norms, property rights, and government legislation that transform the payoffs of their competitive games". examples of such industry transformations include the fair-trade movement, leadership in environment and energy design (leed) for buildings, and benefits corporation (b-corp) certification. according to entrepreneurs are able to "escape the green prison" or the disadvantages they face when pursuing costly sustainable actions, by either identifying opportunities within the current market system or "creating new opportunities through institutional changes that improve the competitiveness of sustainable behavior. " schaltegger et. al. ( ) take a co-evolutionary view of sustainability transformation by examining how pioneering business models can be scaled or replicated by startups and large companies (incumbents), leading to sustainable mass markets. haigh and hoffman ( ) report how hybrid organizations, defined as organizations at the interface between for-profit and nonprofit sectors that address social and ecological issues, are able to successfully challenge "the notion of trade-offs between economic, ecological, and social systems and instead create business models that develop synergies between them." the result is creating opportunities for "for-profit activities to be undertaken in ways that address sustainability issues." the authors demonstrate how hybrids challenge a) the existing beliefs about the social, ecological and economic system, b) the competitive practices, and c) how sustainability is enacted. firms focused on new business models for sustainability, however, face many challenges. geissdoerfer et. al. ( ) report that numerous new business model innovations fail due to the inability to implement their ideas in practice. based on comprehensive literature review they identify seven categories of challenges: a) balancing a triple bottom line, b) mind-set challenges, c) lack of resources, d) difficulty integrating technology with business model innovation, e) engaging in external relations, and f) lack of effective sustainability-focused business modelling methods and tools. the authors call for additional research on the challenges that business model innovation faces and the reasons for the low success rates. future studies should help understand: a) the implementation of the business model innovation process, b) its tools, and c) its challenges (geissdoerfer et. al. ) . veleva and bodkin ( ) report that top challenges for both entrepreneurs and large companies focused on waste reduction and circular business models include the lack of regulation and incentives, the lack of data and indicators to measure and communicate impacts, and the cost of product or waste take-back. entrepreneurs face additional challenges such as lack of brand awareness and market demand, access to financing, mentorship, networks, and the complex product or packaging design that prevents proper repair or recycling. the economic viability of secondary supply chains (focused on product reuse or remanufacturing) can be a key challenge due to the cost of recovering products and materials (freudenreich & schaltegger, ) . entrepreneurs also face the challenge of effectively communicating their sustainability impacts (horisch, ; holt & littlewood, ) . more broadly, entrepreneurs focused on creating new opportunities "may be limited by the opposition of other interested parties' with powerful political influence who may "impair entrepreneurs' ability to promote new institutions" . overcoming these challenges often requires that entrepreneurs look beyond their industry peers to form relationships with environmental, economic development or other civil organizations . policy makers, are key for supporting the growth of start-ups by providing subsidized loans and other legal infrastructure to internalize existing externalities (horisch, ). being able to achieve positive environmental and social impacts is at the core of the business model for sustainability for entrepreneurs and how they differentiate from competitors. at the same time, holt & littlewood ( ) find that most entrepreneurs are not effectively measuring and capturing such impacts. to address this challenge, they offer a framework for identifying, mapping and building indicators of impact for hybrid organizations. the authors further acknowledge that both positive and negative impacts may arise from entrepreneurs' activities and these must be clearly identified and addressed. often there are trade-offs between the environmental and social impacts. measuring and reporting impacts is challenging due to its complexity and lack of resources, even though it is critically important for "fostering stronger relationships between hybrids and external stakeholders including customers, beneficiaries and communities, international donors and supporters, and managers in traditional businesses" (holt & littlewood, , p. ) . horisch ( ) also reports that "sustainable start-ups face the challenge to communicate the sustainability effect connected to their products and services." without communicating both the direct and indirect impacts, they are unable to put pressure on established competitors or standard-setting organizations in order to change consumer expectations and prevailing norms (horisch, ). more broadly, however, the assessment of social and environmental impacts is challenging because it is based on personal values, beliefs and priorities. in his analysis of the socio-technical transitions to sustainability, geels ( ) raises the question of who should choose between multiple "green" pathways and establish the criteria for the choice? one option is for government to do so with the assistance of technical experts; the second one includes a more inclusive group of stakeholders, society groups and the public. in both cases it is important for entrepreneurs to be part of this process to gain legitimacy and public support, since these are key for securing financial investments and supportive policies (geels ) . similarly, costa & pesci ( ) find that effective metrics must be defined and constructed in an open dialogue with all relevant stakeholders; that there is "no single "gold standard" of measurement but instead a variety of metrics which reflect local goals, needs and stakeholder demands. using social network theory, neumeyer et. al. ( ) demonstrate that entrepreneurs' degree of connectivity with key stakeholders and access to different types of networks is key for their success. oskam et. al. ( ) introduce the concept of "value shaping" which refers to the "mutually constitutive process in which on the one hand networking helps to refine and improve the overall business model and on the other hand an improved business model spurs expansion of the network." the authors identify five micro-level processes through which value shaping happens: ideation, conception, business start-up, early growth and continued growth. they report that redirecting value and extending value are influenced by network interaction and are a critically important step in creating value for multiple stakeholders. other researchers have also demonstrated that "transformation to sustainable practices is an incremental and co-evolutionary process requiring collective action among actors, including but not limited to sustainable entrepreneurs" (divito & bohnsack ; schaltegger et. al. ) . horisch ( ) uses the multi-level perspective (mlp) as theoretical framework to examine the role of entrepreneurs in sustainability transitions. according to the framework developed originally by geel ( ), societal transitions "result from interaction processes between three different socioeconomic levels, which build a nested hierarchy: micro level niches, meso-level regimes and macro-level landscape" (horisch, ). start-ups are important actors primarily at the niche level, although they can play a role at the mesolevel. their role, however is currently underexplored. based on literature review horisch ( ) identified two ways in which entrepreneurs can advance sustainability transitions: j o u r n a l p r e -p r o o f through their market impact and through their sustainability effect. sustainability entrepreneurs must first create products and services with positive societal impacts and then distribute these "as widely as possible to develop a large overall sustainability effect and a significant contribution to sustainability transitions." this, however is challenging as start-ups either have limited resources to expand or are restricting their growth to stay true to their mission. regardless, start-ups can influence other important actors at the meso-level, such as large companies (schaltegger et. al., ) , public authorities and standardizing bodies (e.g., the international organization for standardization) which are critically important for changing regimes and advancing a societal transition. our understanding of the sustainable entrepreneurial ecosystems and how it leads to change, however, is still limited, according to neumeyer et. al. ( ) , who call for further research into four areas: a) how environmental, social and economic value is created in a community or a region, and the role of key stakeholders; b) what are the formal and informal rules for being part of a sustainable entrepreneurial ecosystem; c) how can success be defined and measured, and d) what is the role of emerging online social networks in advancing sustainable business models. schaltegger et. al. ( ) call for more empirical research on the different pathways taken by sustainable niche pioneers and other market actors, and the challenges and opportunities they face. ludeke-freund ( ) integrates two major perspectives about the role of entrepreneurs -agency perspective and systems perspectiveand calls for more empirical research to examine "if and how sustainable entrepreneurs can unfold agency within given systems such as industries and markets" and "if and how sustainable entrepreneurs actually use their business models to benefit from public policies." this study aims to address some of these research gaps, by examining sustainable entrepreneurs' business models, created impacts, current challenges and how they work with key stakeholders to overcome these and advance a shift to more sls. this study is based on interviews with eight u.s.-based entrepreneurial companies focused on reducing material consumption and promoting sls. the sustainable entrepreneurs in the study included box save, fixit clinic newton, food for free, irn surplus, joro, preserve, project repat, and semi-new computers. they represent both for-profit and non-profit organizations from diverse sectors in different stages of development. data for each company was collected between december and may using two main sources: a) publicly available information from websites, case studies, and other publications, and b) in-depth, semistructured interviews with founders and senior managers. the interview protocol was developed based on a literature review. all interviews were audio-recorded and transcribed for accuracy. the empirical data was managed through cross-case analyses using methodology described in eisenhardt ( ) and eisenhardt & graebner ( ) . all collected data and information were aggregated and summarized in a table format to enable further analysis (see appendices a and b). to ensure validity and reliability of the qualitative analysis, as well as protect confidential information, each participating company was invited to review and provide feedback to the transcribed interviews and data analysis. the primary goal of the study design was to select a diverse group of companies in terms of maturity (measured by years in operation), type of business (for-profit or non-profit), and business model (selling products or services). all participating entrepreneurs were committed to delivering benefits across a "triple bottom line." the study focused primarily on business to consumer (b c) companies to gain insights about how participating entrepreneurs work to change consumer behavior and the key challenges they face in this process. the interview questions and case research explored the following: • what are some emerging business models for advancing sls and the role of value chain partners and social networks in ensuring success? • what are the social and environmental impacts created by sustainable entrepreneurs and how do they measure and communicate these? • what are the main challenges faced by the entrepreneurs and how do they work to overcome these? what is their role in the transition to sls? detailed descriptions of the cases are provided in appendix a and include each company story and current activities. appendix b summarizes the key findings for each participating company in four areas: a) business model and value proposition, b) social and environmental impacts, c) key challenges, and d) future opportunities for scaling up sustainable business models. study participants reported a range of factors behind their business success such as increasing awareness about climate change and other environmental and social problems, strategic partnerships along the supply chain, sustainability policies, it, and quality customer service, confirming previous findings (dean & mcmullen, ; bocken & short, ; veleva & bodkin, ) . growing consumer awareness and willingness to take action were reported as important enabler by food for free, joro, preserve, semi-new computers, and irn surplus, confirming findings by cordero et. al. ( ) . "people are paying more attention to sustainability. i see the momentum, especially in the last few years. some of it is related to culture, some to regulation," according to sasha purpura, executive director of food for free (veleva & smith, ) . sustainability-focused public policies directly or indirectly support their business models. for instance, the massachusetts organics ban in and the higher waste disposal fees have benefitted food for free, preserve and irn surplus. the city of newton's policies to reduce waste and increase reuse are key for the launch of fixit clinic newton. analysis of the eight cases revealed that strategic long-term partnerships along the value chain are a key part of each entrepreneur's business model (see table ). for instance, semi-new computers' partnership with harvard university and large corporations provides continuous source of surplus computers for refurbishing and resale/donation. joro's partnership with a carbon offset organization provides opportunities for revenue generation. for recycling company preserve, partnerships with materials processors ensure a continuous supply of raw material (post-consumer polypropylene), where its partnerships with retailers such as whole foods and target ensure a sales channel. food for free's partnerships with grocery stores and universities ensure access to fresh, healthy food, while its partnership with cities provides funding and access to people in need. furthermore, all participating entrepreneurs are part of an informal ecosystem of sustainable businesses and other stakeholders who act as suppliers, customers, or strategic partners (e.g., food for free and the town of cambridge, box save and monoflo, fixit clinic and green newton, preserve and stonyfield farm, plum organics and ocean plastics initiative). such networks, while informal and underdeveloped, provide competitive advantage and ensure entrepreneurs stay true to their sustainability mission. this finding is in line with neumeyer & santos' ( ) research about the importance of social capital and access to different types of network actors for launching a sustainable business model. the geographic location (massachusetts, usa) was also reported as key factor for entrepreneurial success, confirming previous research on the importance of a specific location for providing supportive culture, capital and other resources, as well as allowing to quickly respond to customer needs and gain trust and legitimacy (neumeyer et. al. ; porter & kramer, ) . in all cases technology enables companies to optimize logistics, reduce the costs of storing and shipping (e.g., box save, irn surplus), leverage low cost marketing (e.g., preserve, joro, box save, and project repat) and educate customers (joro, food for free). with exception of semi-new computers, all entrepreneurs use online social networks such as facebook, twitter, instagram, linkedin, you tube, and others (see table ), which they see as critical for their business success. this finding confirms previous research by correia et. al. ( ) on the role of social networks and mobile technologies in building competitive advantage by providing a new way to expand business, adapt to new consumers, turn fans into customers, and develop tacit organizational knowledge about virtual communities which is hard to replicate (correira et. al., ) . the research also confirmed previous findings about the importance of having a strong focus on customers, building long-term relationships, providing some incentives, and making it easy for consumers to act (bocken & short, ; bocken ( ) that entrepreneurs (and sustainability entrepreneurs in particular) are best positioned to solve complex problems and deliver social and environmental benefits. in addition to addressing waste and ghg emissions, participating entrepreneurs create positive social impacts such as developing new skills (fixit clinic, semi-new computers), reducing food insecurity (food for free), saving time (box save, irn surplus), and improving health (joro, food for free), in addition to creating local jobs. moreover, several participating entrepreneurs reported their social impacts as key for differentiating from competitors. while for companies like joro educating and empowering consumers to address climate change is at the core of their business model, other study participants emphasize cost or time savings, revenue generation, social impacts, and/or outstanding customer service. as one of the interviewees summed it up, "green attributes do not always lead to sales," confirming previous findings by esty & winston ( ) . all study participants reported lack of resources to more effectively measure the environmental and social impacts of their products and services. while some included specific indicators such as amount of products/waste repurposed or people served, these typically measured outcomes and not overall impacts such as greenhouse gas emissions prevented, skills developed, or time and dollar saved. for instance, irn surplus provides its customers with individualized reports which describe the outcomes and some impacts, but the latter are often qualitative or measure outputs, versus impacts. for example, for one of its customers -kent place school in summer, new jersey -irn surplus leveraged its network and partnership with steelcase to locate a nearby recipient -habitat for humanity restore in bucks county, pa, about miles away. the company reported several key impacts from the project: a) the school's ability to uphold its commitment to sustainability and reuse or recycle more than . tons of furniture without paying more than for disposal; b) steelcase's ability to uphold its commitment "to providing environmentally sustainable products and services throughout the lifecycle of steelcase products," and c) dozens of families who benefitted from obtaining "high-quality, low-cost furnishings through the habitat restore, or living in the habitat homes that restore revenues help to build." (irn surplus, ) . food for free measures the amount of surplus food repurposed (in pounds) and the number of meals distributed. in it helped rescue million pounds of food and feed over , people (veleva & smith, ) . the company, however, is unable to estimate the ghg gas emissions prevented from food rescue compared to composting or disposal, or the dollar savings and improved health outcomes for people having access to fresh, healthy food. similarly, fixit clinic newton measures the number of participants and products repaired but is unable to track and report the environmental and social impacts such as increased awareness of environmental problems, reduced ghg emissions and waste, new skills development, time to repair a product, or dollars saved. for many people the lack of time often leads to buying new products instead of repairing an old one, a sustainability challenge reported previously in the literature (southerton & welch, ) . better measurement would not only help strengthen entrepreneurs' value proposition among early adopters as reported by veleva & bodkin ( ) but is also crucial for evaluating potential trade-offs and demonstrating an overall positive impact. for instance, box save estimates that when comparing cardboard boxes to reusable crates for users, manufacturing of the former generates , % more co (not including shipping for landfill or recycling) (donovan, ) . this estimate, however, does not reflect the fact that cardboard is made of renewable resource, while polypropylene is derived from fossil fuel. preserve's move to compostable single use products could help reduce the ghg emissions from collecting and recycling post-consumer polypropylene. however, recent studies have warned about potential presence of highly toxic per-and polyfluoroalkyl substances (pfas) in compostable products, a class of over , fluorinated chemicals that persist in the environment for a long time, and are associated with cancer, developmental toxicity, immunotoxicity, and other health effects (cpa, ). furthermore, compostable containers require special facilities for handling (e.g., anaerobic digesters), which may not be available locally, potentially leading to landfill disposal or incineration, both associated with release of ghg emissions (veleva & smith, ) . while semi-new computers is committed to prevent waste and ghg emissions while closing the digital divide by sending refurbished computers to nigeria, ghana and sierra leone, they have been criticized for potentially contributing to the growing e-waste crisis in africa (clark & clark, ) . in addition, shipping computers to such far destinations contributes to climate change and air pollution. without proper life-cycle analysis and measurement of the overall social and environmental impacts of their business, it is not possible to confirm the overall positive impact. these findings illustrate the importance of developing and using effective indicators to measure and evaluate the social and environmental impacts at a company or product/service levels. previous research has found that even large companies within the same sector using standardized indicators, report inconsistent and vastly different measures focused on outputs rather than impacts (veleva et. al. ) . aggregating different measures to identify an overall impact is challenging as it reflects a variety of assumptions, local issues, and personal values, therefore must include other stakeholders affected by such practices. this confirms research by costa & pesci ( ) that effective metrics must be defined and constructed in an open dialogue with all relevant stakeholders; that there is "no single "gold standard" of measurement but instead a variety of metrics which reflect local goals, needs and stakeholder demands (costa & pesci, ; matzembacher et. al. ). deven's eco-industrial park provides one example of how a multi-stakeholder process can be leveraged to develop locallyrelevant sustainability indicators, which can serve as a valuable tool to raise awareness, promote transparency and accountability and guide local policies towards established goals and targets (veleva et. al. ) . despite their success to date, study participants reported numerous challenges in scaling up operations (see appendices a and b). while all of them offer competitive pricing, they often cannot compete with inexpensive imports from china based on cost alone (e.g., preserve, semi-new computers, project repat). to stay true to their mission, many face costly sustainable actions, such as using sustainable packaging, eco-friendly materials, or recycling waste instead of sending to landfill (e.g., project repat, food for free, box save, preserve, semi-new computers). this confirms previous findings that entrepreneurs are often at competitive disadvantage when pursuing new sustainable business models ludeke-freund, ) . all entrepreneurs report insufficient funding and other resources (space, transportation, storage, volunteers) as a key challenge. non-profit organizations such as food for free and fixit clinic rely on grants and volunteers to support their work; others such as box save, semi-new computers, project repat, joro, and preserve, capture value based on customers' willingness to pay for a product or service that is high quality, good value or socially and environmentally responsible. all entrepreneurs in the study reported not having the capacity to effectively measure and communicate the social and environmental impacts of their products and services which could strengthen their value proposition. these findings confirm previous research on the barriers faced by companies advancing new business models to reduce consumption bocken & short ; veleva & bodkin, ) . the lack of brand awareness was another challenge faced by most entrepreneurs, especially the "younger ventures" such as box save, joro, project repat and fixit clinic. some reported lack of consumer awareness about how to act to address sustainability challenges (joro, fixit clinic, box save), while others reported a gap between consumer aspirations and actions (preserve, semi-new computers). this confirms previous findings that consumer education is necessary (grinstein et. al. ) but not enough to change behavior (vringer et. al. ) . social media could be leveraged further to help consumers overcome some of the social and moral dilemmas reported in the literature (vringler et. al. ) . study participants also reported the need to raise awareness about the environmental and social impacts of reuse versus recycling and disposal in order to change the evaluation criteria used by customers, confirming previous research by veleva & bodkin ( ) . customers' lack of time was reported as a barrier by some participants (e.g., fixit clinic newton, preserve, joro) but was leveraged as opportunity by others (e.g., box save, food for free, irn surplus). the heightened awareness and interest by young people to take sustainability action and increasing local sourcing and zero waste commitments by cities and companies are expected to support future sustainable entrepreneurs. in addition, as reported by windsor ( ) "businesses, consumers and institutions (government and others) "are likely to face increasingly volatile, uncertain, complex, and ambiguous conditions in the future". the covid- pandemic, for instance, is expected to accelerate the shift towards more local and regional production and consumption, leading to reduced ghg emissions from transportation and new opportunities for sustainable entrepreneurs (mckinsey, ) . all sustainable entrepreneurs in the study see the lack of government policies such as carbon tax, bans on disposal of certain products, mandating design for repair, or a full-cost accounting, as the greatest barrier for scaling up their businesses but also the greatest opportunity in the future which confirms previous research (caldera et. al. ; veleva & bodkin, ) . for instance, a carbon tax (or a tax on raw materials) would make preserve products and box save services more price competitive. bans on landfill disposal of furniture and other products, would help create markets for reuse and recycling and support entrepreneurs such as irn surplus. the massachusetts organic waste ban for example, has led to significant growth in entrepreneurial companies focused on food rescue and composting, and measurable economic and social benefits (icf, ) . adopting laws mandating design for disassembly and repair, could help expand the secondary markets for many products and support entrepreneurs such as semi-new computers and fixit clinic. introducing reporting requirements for waste similar to the city of boston building energy and disclosure ordinance (city of boston, ) can increase transparency about the amount of waste generated and create incentives for large organizations to seek alternatives to landfill or incineration. although entrepreneurial players in the study have been able to identify opportunities within the current consumption-based economic system, scaling up such niche experiments requires involvement of other stakeholders and policy action (dean & mcmullen, ; bocken & short ; southerton and welch, ; cohen et. al. ; horisch, ; ludeke-freund, ) . for instance, the proliferation of fixit clinics in the u.s. has attracted the support of politically-active public advocacy groups which are working with citizens and progressive policy makers to adopt new "right to repair" mandates at state levels (u.s. pirg, ). as of december , at least u.s. states had put forward digital right to repair bills; these however, were opposed by the $ . billion electronic industry, demonstrating the push back by powerful incumbents and the challenges in changing current regimes (allendorf, ) . transitioning to more sustainable consumption systems requires creation and reinforcement of a new path, as well as "destabilization of the existing path," according to heiskanen et al. ( ) . path dependence is defined as the self-sustaining characteristics of existing systems, while path creation relates to creating new paths by engaging various stakeholders and generating momentum and respectively, change (heiskanen et al. ) . environmental entrepreneurs are often seen as "agents of change" and "a major force in the overall transition towards a more sustainable business paradigm" (schaper ) . while they are more likely to pursue path creation in sustainable consumption systems, the latter requires significant resources, including financial and political power, which they often lack, as demonstrated in the current study. what entrepreneurs are able to do, however, is to educate and influence other stakeholders, advance informal and formal sustainability networks and thus create momentum towards new policies, norms, and institutions. for instance, food for free is able to influence both policy makers and large companies to secure resources, reduce food waste and advance new policies to change food expiration labels. preserve's business model has attracted the attention of some large companies such as berry and vdl: "there's something about what preserve has been doing that makes the larger companies interested in us. one example is with berry, a $ billion sales and $ billion in market cap. they work with the gimme program every year and they make that preserve to go container. our partner in europe is vdl [they make the mini cooper]. they are an ecofriendly/socially responsible business and they are huge." transition to more sustainable lifestyles requires collective action and collaborations among various stakeholders, including users, ngos, progressive large companies and policy makers. a truly sustainable future "requires system-based thinking that involves in equal measure, society, environment and economics" (murray et. al., ) and calls for new policies that reward sustainable behavior. based on the study findings and analysis, the author proposes a new framework for the role of sustainable entrepreneurs in advancing sustainable lifestyles (see figure ), which demonstrates that they are not only innovators but also civic actors supporting this transition. in collaboration with a range of stakeholders such as other sustainable entrepreneurs, large companies, ngos and policy makers, sustainable entrepreneurs launch innovative business models to advance sls. most of their business model innovations include social rather than technical experiments which provide valuable insights and social learning about the challenges and opportunities in changing consumer behavior. to succeed, sustainable entrepreneurs leverage strategic partnerships, social media, it, the growing sustainability awareness, and public policies, which help them identify opportunities within the current economic system. their main value proposition for consumers is based on offering cost or time savings, social benefits, education and empowerment to act; they also provide strong customer focus and quality service. with their business model experiments, sustainable entrepreneurs help create informal and formal sustainability network and influence key stakeholders such as large companies, ngos and policy makers. thus, they act not just as innovators but also as civic actors helping create momentum towards enacting government policies that "change the rules of the game" to reward sustainable businesses that help address climate change and social inequity. the current study confirmed many findings from prior research about sustainable entrepreneurs' ability to launch innovative business models to address complex issues such as climate change and social inequity. it also identified some key lessons learned by first movers. first, entrepreneurs are well positioned to address simultaneously environmental and social issues. however, they lack the resources to effectively measure related impacts to strengthen their value proposition and demonstrate an overall positive impact. such measures require working with other stakeholders and developing locally-relevant indicators reflecting existing challenges, needs and goals. second, environmental awareness has significantly increased in recent years and a growing number of people are willing to take actions to reduce their carbon footprint. educating and empowering such early adopters could not only support new innovative business models, but also help change prevailing social norms, if effectively leveraging social networks and strategic partnerships. third, promoting green attributes alone is not enough to change the behavior of most consumers. it is critically important to emphasize other benefits such as a product/service quality, social impacts, time or cost savings. this confirms previous findings by esty & winston ( ) that sale of green goods is difficult and "green" should be promoted as the "third button" after quality and cost savings. fourth, formal and informal sustainability networks, social media, and sustainability policies, are key to developing viable business models and competitive strategies that are difficult to replicate. finally, to avoid "costly" sustainability actions and change the competitive landscape, entrepreneurs need to reach out and collaborate with other key stakeholders such as policy makers, ngos, and citizens coalitions, in order to change "the rules of the game," such as the laws, institutions and social norms. without such actions their market and sustainability impacts will be limited. the study demonstrates that policymakers have a key role to play in advancing sls by a) adopting consumption-based ghg emission inventory and raising awareness about the impact of individual lifestyles on climate change; b) enacting effective regulations or eliminating regulatory hurdles to sls; c) providing incentives to companies engaged in such practices through taxes, subsidies, disclosure mandates, or bans on certain products or practices in order to "level the playing field"; d) providing financial support, networking and mentorship opportunities for sustainable entrepreneurs, and e) supporting development of enabling infrastructure, new institutions and norms that promote sls. local zero waste goals or waste bans, for example, can increase demand for alternatives to landfill disposal and incineration and thus act as powerful drivers for entrepreneurial innovation. improved city planning could advance the use of public transportation, bicycling, and walking, supporting entrepreneurs focused on mobility solutions such as bike and shooter sharing. enacting regulations that ban toxic chemicals from products and packaging, and mandating design for disassembly and repair, are crucial for enabling reuse of products and materials. policy makers can utilize tax incentives or subsidies to reward companies advancing more durable, low-carbon choices such as the swedish tax break for repaired products (orange, ) and the european union "right to repair" laws (right to repair, ). providing financial support to entrepreneurs and other organizations in the form of grants, low interest loans, or business incubators, is critical for supporting smaller companies as previously reported in the literature (lowitt, ; rizos et. al., ; ludeke-freund, ). in addition, government agencies could partner with non-profit organizations to help raise awareness about the importance of waste prevention and reuse versus recycling, by launching carbon footprint labels, awards, benchmarking studies or networks promoting sls. such networks should include a variety of stakeholders, such as entrepreneurs, progressive corporations, non-profit organizations, academics, policy makers, and citizens' organizations. they could work to develop a locallyrelevant vision for sustainable living, indicators to measure progress, and actions to drive change. the present study demonstrates that a growing number of sustainability entrepreneurs are experimenting with new business models to promote sustainable lifestyles. they are able to overcome existing challenges by leveraging the growing consumer awareness, value chain partnerships, it, social networks and sustainability-focused policies, to launch innovative products or services which offer time or cost savings, quality service, and a range of social and environmental benefits. in this process they help educate and influence other important actors such as ngos, large companies, and policy makers, confirming previous research by geels ( ) and ludeke-freund ( ) . sustainability entrepreneurs, however, are unable to achieve a market effect and a shift to sls on their own, which requires political support and new regulations. their role is to experiment with innovative business models, help create sustainability networks, educate and influence key stakeholders, and empower them to act. in this process entrepreneurs provide valuable insights and social learning which has largely been missing in the sustainability transitions literature primarily focused on technological innovations and solutions. scaling up entrepreneurs' experiments to achieve a market impact (horisch, ) , however, requires the collaboration of various stakeholders in order to advance better measurement, bold policy interventions, enabling infrastructure, and new social norms to promote sustainable living. policy makers in particular have a key role to play to internalize existing externalities and ensure sustainable entrepreneurs are not at competitive disadvantage, which confirms previous findings by ludeke-freund ( ) . the study has several limitations. first, it only included eight entrepreneurial companies. a future study should consider including a larger number of entrepreneurs within each of the five domains of sls to examine emerging drivers, challenges and future opportunities as seen by the participants. research can also focus on a specific sector to explore in greater detail emerging business models and how entrepreneurs work with policy makers and other stakeholders to define key sustainability goals, indicators, and strategies to change existing norms and institutions. another limitation was that participating companies were based in massachusetts, a state with high public awareness and support for environmental and social initiatives. a future study could consider comparing two different regions to examine the impact of environmental awareness and culture on entrepreneurial success. in addition, future research could include a multi-stakeholder study for a specific region to examine the role of social and cultural norms and institutions on consumer behavior. the main contribution of this research is that it demonstrates that sustainable entrepreneurs act as civic and political actors who not only offer innovative products and services, but help educate and influence key stakeholders, develop informal sustainability ecosystem, and thus create momentum for civil and political changes. the study examines the main challenges faced by sustainable entrepreneurs presently and provides key lessons learned about how to overcome these. it illustrates the need for implementing effective indicators to measure the social and environmental impacts of sustainable products/services, in order to evaluate potential trade-offs and ensure overall positive impact. the research confirmed previous findings about the ability of entrepreneurs to identify opportunities within the current market system. however, it demonstrates that sustainable entrepreneurs cannot change "the rules of the game" on their own. scaling up their business models to achieve market and sustainability impacts requires collaborations among various stakeholders and bold policy actions to change the incentives for consumers and companies. company story and business model box save: promoting reusable moving boxes box save was founded in by two entrepreneurs, paul benoit and doran donovan, who worked for years in the finance and software industry, respectively. they launched box save after exploring many ideas such as used book shops and used sporting goods' shops (they also visited a company renting reusable moving boxes in washington d.c. to learn about their experience). the firm's core business is to rent reusable moving boxes to households, businesses, nonprofits and government agencies in the greater boston area. the co-founders run their business with minimal expenses; they have eight part-time employees and one part-time driver (they also deliver boxes themselves). the employees work mostly on cleaning the boxes which are sanitized with ecofriendly cleaner after each use. according to co-founder donovan there are about firms in united states with similar business, but they do not compete as each operates in a specific geographic area; instead they connect via facebook to share ideas. box save initially struggled to get exposure, but in emerged on the top of the search results for greater boston. for every $ invested in marketing they get $ in revenue (they use facebook, yelp, google, and real estate firms). in their first year of operations box save saw % growth; in their sales were up % compared to the prior year . the company's reusable boxes are made of polypropylene and can be used up to times (or years) and then recycled. they are also manufactured in the u.s. by monoflo, thus reducing transportation impacts. cardboard boxes on the other hand are used once or twice and even when recycled use % of the energy required to make a new box (box save, ) . despite these environmental benefits, the company's main messaging and value proposition for customers focuses on time and money savings (they offer drop off and pick up of the boxes, flexible schedules) and the outstanding customer service. fixit clinic-newton: helping people repair products fixit clinic is a non-profit organization launched in in the u.s. by entrepreneur peter mui with the main goal to help people repair broken products and thus extend their useful life and prevent waste. the company was modelled after the repair cafe movement in europe with one main difference -fixit clinic uses volunteers and teaches people about doing the repairs themselves (repair cafes, on the other hand, use specialists to repair consumer products). it aims to help people develop critical thinking and repair skills while saving them money and teaching them about sustainable consumption. the concept has grown quickly, and hundreds of events have been held recently across united states hosted by municipalities, local governments, ngos, colleges, and public libraries (gulf coast makercon, ) . since design constraints can make it challenging to repair many products, supporters of the idea have advanced new right to repair legislative proposals in numerous states in the u.s. (repair.org, ). following the steps of other massachusetts communities such as cambridge and belmont, the city of newton held its first fixit clinic in june at the newton free library. organized by the newton recycling committee, the event brought in volunteers who helped attendees repair a variety of products such as jewelry, textiles, lamps, and vacuum cleaners, among others. the success of the event led to scheduling two more events and discussions about making the fixit clinic a more regular event for residents. at the same time, organizers admitted that the lack of time, volunteers and ability to repair many products limit fixit clinic's impact. food for free: turning food waste into healthy meals food waste is a major problem around the world and especially in the united states where % of food is lost at the retail and consumer levels (contributing to waste generation and climate change), while . % of u.s. citizens face food insecurity (usda, ) . to address these two problems, food for free, a small nonprofit company in cambridge, massachusetts, began taking surplus food from grocery stores and other organizations (which would otherwise be thrown out), and creating healthy meals for people in need. the idea for the company emerged in when a group of friends realized that local meal programs were struggling to provide fresh food for people in need, while supermarkets were throwing away large amounts of food they could not sell. this led to launching an organization which can "bridge the gap between waste and want" (food for free, ). food for free's most innovative program is the family meals, which began in as a partnership with harvard university after the company leadership realized that it was legal to donate cooked food. in food for free had full-time equivalent employees and about volunteers helping to prepare the meals, which are sent to schools and community colleges. food for free takes all food for free and gives it out for free, therefore it relies on funding from individuals and small businesses, foundation grants, and state and city contributions to support its work (e.g., their backpack program) (veleva & smith, ) . irn surplus: promoting reuse instead of recycling irn was launched as recycling company in . in it decided to shift its core business to focus only on reuse. this led to the change in its name to irn surplus. the idea about reuse emerged in when co-founder mark lennon began getting calls from colleges unable to donate all of their surplus products locally (irn, ). as a result, "irn ended up with thousands of pieces of furniture that the local environment couldn't absorb," shared lennon. to address this problem, the co-founders developed a national and international network of recipients. presently irn surplus is a privately held, for-profit firm with employees, which works with companies and universities interested in donating surplus products. the transition to reuse was a result of "evaluating the business environment and deciding that it doesn't make sense to compete with the big names such as casella, waste management and el harvey, but instead focus on their niche market of repurposing, where there is very little competition," explains lennon . irn surplus has three core commitments: a) to handle everything, b) to make reuse simple, and c) to make reuse cost effective (irn, ) . to be competitive, the company charges %- % less than the cost of waste disposal. they operate in a very efficient way; the generators and recipients split the cost of transportation and all companies they work with use their own labor to move the products. irn surplus does not use warehouse which helps reduce overhead, although for some clients they keep a few storage trailers. while the company is operating only as b b business, it sees great opportunities in the b c space and is interested in working with apartment complexes. joro: educating consumers to reduce their carbon footprint joro was launched in by sanchali pal and cressica brazier who sought to apply massachusetts institute of technology (mit) research to help address the complex problem of climate change. the company's main business model leverages an app which helps people measure and reduce their carbon footprint. on its website and app joro states: " if everyone improved their footprint by . % each year for the next years, we'd achieve the global paris climate targets to keep average temperature rise below . c. together, we can cut our emissions in half by " (joro, ). joro provides simple suggestions on how to achieve such reduction, from walking and biking less than miles, to taking public transit for distances less than miles, to limiting meat to one meal per day, or turning the thermostat down by ℉. in addition, consumers can buy carbon offsets. in joro conducted a beta pilot with , app users and reported that participants reduced their carbon footprint by % on average ( % of this reduction was result of behavior change and % a result of carbon offset). the top five behavior changes reported by joro active users included reducing meat consumption, cold water washing, walking and biking more, unplugging devices when not in use, and avoiding red meat (joro, ). preserve: upcycling plastics and offering plantbased products preserve is a privately-held company which is also certified as b-corp (benefit corporation), focusing not just on profits but also on delivering value for all stakeholders. it was founded in by entrepreneur eric hudson, who in the early s saw the waste problem and tried to solve it by focusing on recycling (preserve, ). in preserve had employees and some sales representatives. its core business involves taking post-consumer/post-industrial polypropylene (# ) plastic and upcycling it in a variety of reusable products -toothbrushes, cutlery, and containers. in it launched the preserve ocean plastic initiative (popi) with the goal to utilize high-density polyethylene (hdpe) plastic that was "headed for the ocean." recently it also began offering compostable single use cutlery in response to growing demand. its partnerships with retailers, companies, and materials suppliers ensure low cost, continuous supply of post-consumer/postindustrial polypropylene. preserve uses digital marketing to reach customers. while the company offers competitive pricing, mr. hudson shares "we don't offer premium price, but our price is higher. we seek to be parity priced with everything we do. our reusable plates are a little higher price than something that you'd find from china, and certainly more expensive than the disposable alternatives." preserve's business has grown over the years driven by increasing awareness of environmental problems and demand for reusable and compostable products. as of january , preserve's products sold in countries (an increase from just two years earlier). project repat: upcycling old t-shirts into blankets nathan rothstein and ross lohr started the company in with the goal to solve the problem of excess clothing via upcycling. "people do not realize that majority of donated cloths do not get reused or recycled", explained erin kizer, project repat chief operating officer. customers send their old t-shirts and project repat makes blankets from them and sends them back. the company has robust system for tracking orders and three local partners to make the blankets -precision sportswear in fall river, massachusetts, opportunity threads in north carolina, and open arms studio in texas (project repat, ). to reduce costs, they only sell online and use various social media platforms. a few years ago, they opened a store in newton, massachusetts, but found that e-commerce was a more effective platform for their type of business. as of project repat had four employees and operations in massachusetts, north carolina, and texas. to reduce the environmental impacts of shipping they use low carbon footprint bags to send the blankets and recycle all cardboard boxes from customers. they are committed to be zero waste company and send all their waste for recycling, which presently is costly and one of their big challenges. finding supply chain partners in the u.s. is another challenge as most of this work has been outsourced to asia. while the company's products provide social and environmental benefits (jobs, local manufacturing and waste prevention), in their messaging they do not focus on these but instead on the intrinsic value of the products. "we pitch it as a way to preserve value as people have emotional connection to old t-shirts. promoting environmental friendly choices doesn't translate to sales," explained kizer. semi-new computers: extending computers' useful lives via charlie thompson and marlene archer spent many years working in the computer industry before starting semi-new computers. in the s ms. archer was at boston computer society where members would match donations to non-profit organizations. often such donations included refurbished computers. when she began working at harvard university ten years later, she met the university sustainability director which led to the discussion about surplus computers. she found repair & refurbishing that harvard business school, for example, replaces all its computers every three years even though % of them are in excellent condition. the conversation led to launching a program to repair and donate surplus computers, which became known as semi-new computers (semi-new computers, ). over the years the two co-founders launched some innovative initiatives and partnerships. for instance, they developed a partnership with autistic students in lexington, massachusetts (part of a job readiness training), where the students helped clean and prepare the computers. funding for the training was provided by the native towns of the students ( towns participated) and harvard university provided the old computers. another innovative initiative was the bridge program, where semi-new computers trained harvard university employees who may not speak english well (e.g., janitors). the goal of the program was to teach such people basic computer skills and provide them with refurbished computers for use at home. according to mr. thompson, "this was very labor-intensive process; people didn't have internet access at home, they didn't know how to set up a computer. we had to send someone to help them." over the years the business has faced numerous challenges. initially they used to sell new and used computers (which they received from other large organizations in the boston area), but there was no significant difference in price and functionality (e.g., if -years old computer costs $ and a -years old is $ , people would just buy the new one). as a result, semi-new computers began sending refurbished computers to nigeria, ghana and sierra leone. software presents another major challenge with computer refurbishing, due to the constant upgrades and the cost of new software. as mr. thompson summed it up, "we had a vision to make boston a refurbished hub. right now it doesn't make sense to scale up as the economics doesn't work." as of the two co-founders were considered consultants to harvard university and their company was based at the harvard recycling center, although they continued to work with other universities and major corporations (semi-new computers, ). they were also actively volunteering at the cambridge fixit clinic to help people repair 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entrepreneur-environment nexus: uncertainty, innovation and allocation highlights • entrepreneurs as civic and political actors who help create momentum for political changes • their value proposition based on time & cost savings, social & env. impact, and quality service • it, sustainability networks, and social media -key to developing viable business models • key challenges: costly sustainable actions, impact measurement, resources, brand awareness • shifting to sls requires stakeholder collaborations and bold policy action the role of entrepreneurs in advancing sustainable lifestyles: challenges, impacts, and future opportunities vesela veleva: conceptualization, methodology, data collection and analysis, writing-original draft preparation the authors would like to thank all participating companies and the university of massachusetts boston for funding this research through the umass boston public service grant, project: p . higher cost of product compared to imports from china; lack of interest from consumers; lack of resources (funding and time) to do good measurement (e.g., policies to tax raw materials (so recycled materials will be price competitive); investment in better recycling technology j o u r n a l p r e -p r o o f ☒ the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐the authors declare the following financial interests/personal relationships which may be considered as potential competing interests: vesela veleva sept. , j o u r n a l p r e -p r o o f key: cord- -ud az s authors: sahoo, banshidhar; poria, swarup title: disease control in a food chain model supplying alternative food date: - - journal: appl math model doi: . /j.apm. . . sha: doc_id: cord_uid: ud az s necessity to find a non-chemical method of disease control is being increasingly felt due to its eco-friendly nature. in this paper the role of alternative food as a disease controller in a disease induced predator–prey system is studied. stability criteria and the persistence conditions for the system are derived. bifurcation analysis is done with respect to rate of infection. the main goal of this study is to show the non-trivial consequences of providing alternative food in a disease induced predator–prey system. numerical simulation results illustrate that there exists a critical infection rate above which disease free system cannot be reached in absence of alternative food whereas supply of suitable alternative food makes the system disease free up to certain infection level. we have computed the disease free regions in various parametric planes. this study is aimed to introduce a new non-chemical method for controlling disease in a predator–prey system. mathematical models are increasingly used to guide public health policy decisions and for controlling infectious disease. epidemic dynamics is an important method of studying the spread of infectious disease qualitatively and quantitatively. it is based on the specific property of population growth, the spread rules of infectious diseases, and the related social factors to construct mathematical models reflecting the dynamic properties of infectious diseases, to analyse the dynamical behaviour and to do some simulations. the research results are helpful to predict the developing tendency of the infectious disease, to determine the key factors of the spread of infectious disease and to seek the optimum strategies for preventing and controlling the spread of infectious diseases. mathematical models have a long history in infectious disease ecology starting with bernoulli's [ ] modelling of smallpox and including ross's [ ] analysis of malaria. the earliest attempt to provide a quantitative understanding of the dynamics of malaria transmission was that of ross ( ) . ross models consisted of a few differential equations to describe changes in densities of susceptible and infected people, and susceptible and infected mosquitoes. based on his modelling, ross introduced the concept of a threshold density and concluded that 'in order to counteract malaria anywhere we need not banish anopheles there entirely we need only to reduce their numbers below a certain figure [ ] . classical papers of mathematical modelling of infectious disease was by kermack and mckendrick ( [ ] , [ ] , and [ ] ). these papers had a major influence on the development of mathematical models for disease spread and are still relevant in many epidemic situations. aim of ecological modelling is to understand the prevalence and distribution of a species, together with the factors that determine incidence, spread, and persistence (anderson and may [ ] ; may and anderson [ ] ; bascompte and rodriguez-trelles [ ] ). we now have models for many of the most important human emerging infectious diseases e.g., hiv (may and anderson [ ] ), malaria (aron and may [ ] ; macdonald [ ] ), sars-coronavirus (anderson et al. [ ] ), rabies (murray and seward [ ] ), and influenza (ferguson and anderson [ ] ). mathematical models are also being used to explore wildlife disease dynamics (grenfell and dobson [ ] ; hudson et al. [ ] ) and possible routes of zoonotic disease emergence. understanding disease dynamics across hosts is an essential first step in understanding and articulating those conditions under which new diseases can emerge from wildlife reservoirs [ ] . a predator-prey system with infected prey in polluted environment is proposed by sinha et al. [ ] . anderson and may [ ] were probably the first who considered the disease factor in a predator-prey dynamics and found that the pathogen tends to destabilize the predator-prey interaction. in rosenzweig predator-prey model, hadeler and freedman [ ] determined a threshold above which an infected equilibrium or an infected periodic solution appear. chattopadhyay and arino [ ] considered a three species ecoepidemiological model and studied local stability of equilibrium points, extinction criteria of species and found condition for hopf-bifurcation in an equivalent two-dimensional model. haque and chattopadhyay [ ] studied the role of transmissible diseases in a prey dependent predator-prey system with prey infection. bhattacharyya et al. [ ] proposed a epidemiological model with nonlinear infection incidence. in , scientists [ , ] investigated infectious disease model and suggested disease control strategies. over the last years, disease control has relied heavily on the use of chemical fungicides, bacteriocides and soil fumigants. however, there are now many problems associated with their continued deployment including increasing pressure to reduce chemical use in the environment in general, development of pesticide resistance in many pathogens, and decreasing availability of active ingredients through stricter registration and difficulty in finding novel active compounds. consequently, the search for alternative non-chemical methods of disease control continues to gain significance. some investigations [ ] [ ] [ ] were done for population control in a predator-prey model providing alternative food to predator. disease controlling aspects of predator-prey model providing alternative food to predator is unexplored. in this paper we formulate a diseased predator-prey model in presence of alternative food for predator. this is a totally new research area which has applications in many important practical fields. this paper aims to analyse the role of alternative food for controlling disease in the system. to model the disease induced predator-prey system with alternative food to predator we do the following assumptions: (a) in the presence of disease, the prey population consists of two sub classes, namely, the susceptible prey sðtÞ and infected prey iðtÞ and the density of the predator is denoted by pðtÞ at time t. (b) in presence of disease, the susceptible prey population grows logistically with intrinsic growth rate r and environmental carrying capacity k . (c) the susceptible prey population become infected at a rate of w, following the law of mass action. (d) infected prey population is not in a state of reproduction and does not compete for the resource. (e) the interaction between predator and susceptible prey is of holling type-ii and that between predator and infected prey is of holling type-i (mass action law) in presence of alternative food. this combination of functional forms are taken because the capturing of infected prey is easier than the susceptible prey. (f) predators are provided with alternative food of constant biomass a which is distributed uniformly in the habitat. the constant biomass assumption is valid for many arthropod predators because they can feed on plant-provided alternative food sources such as pollen or nectar which approximately remains constant. (g) the number of encounters per predator with the alternative food is proportional to the density of the alternative food. (h) the proportionality constant characterizes the ability of the predator to identify the alternative food. with the above assumptions, we formulate the following model: the constants a ; a are maximal predation rate of predator for susceptible prey and infected prey, respectively. the terms c ; c are conversion rates of susceptible prey and infected prey to predator, respectively; b is the half saturation constant for predator; d and d are constant death rates for i and p, respectively. if h represents the handling time of the predator per prey and h represents the handling time of the predator per unit quantity of alternative food, then a ¼ h =h . if the constant e ; e represent ability of the predator to detect the prey item and to detect alternative food, respectively, then l ¼ e =e . the term la represents effectual alternative food for the predator. we nondimensionalize the system ( ) using s ¼ s k ; i ¼ i k ; p ¼ p k and t ¼ r t and obtain the following system ds dt we analyse the system dynamics assuming sðtÞ p ; iðtÞ p and pðtÞ p . the constant c represents the infection rate of the prey. the terms a and n are the parameters which characterize the alternative food. from the relation a ¼ h =h , it can be inferred that a is directly proportional to the handling time h of the alternative food. hence the parameter a is proportionally related to the ''quality'' of the alternative food. if the relation h < h holds, then the predator can easily capture alternative food than prey species which implies that the alternative food is of high quality. therefore for high quality of alternative food a is less than . again, from the relation n ¼ la b , it can be inferred that n is directly proportional to the biomass of the alternative food ðaÞ and thus n is a representative of the ''quantity'' of the alternative food that is supplied to predator [ ] . this paper is organized as follows: in section , the existence condition for equilibrium points of the system are derived. the stability analysis of equilibrium points are done in section . persistence conditions of the system are derived in section . we have analysed the dynamics of this model through bifurcation analysis with respect to the rate of infection and quantity of alternative food in section . finally, we draw conclusions in section . in this section, positivity and boundedness for the system ( ) are established. since the state variables s; i and p represent population size, positivity implies that they never become negative. the boundedness may be interpreted as a natural restriction to growth as a consequence of limited resources. the system ( ) can be written as _ þ and fðxÞ is given by it can be shown that whenever xð Þ r þ such that x i ¼ then f i ðxÞj x i ¼ p (for i = , , ). now any solution of _ x ¼ fðxÞ with x r þ , say xðtÞ ¼ xðt; x Þ, is such that xðtÞ r þ for all t > (nagumo [ ] ). theorem . all solutions of the system ( ) which initiated in r þ are uniformly bounded. proof. let ðsðtÞ; iðtÞ; pðtÞÞ be any solution of the system ( ) with positive initial condition. let us consider that, therefore, dw dt Àhðs þ i þ pÞ À ð À sÞ þ , where h = min f ; d; e À cng. thus, dw dt þ hw À ð À sÞ . that is, dw dt þ hw , since ð À sÞ p . applying the theory of differential inequality we obtain < w < À e Àht h þ wðsð Þ; ið Þ; pð ÞÞe Àht : for t ! , we have < w < h . hence all the solutions of ( ) that initiate in r þ are confined in the region. h þ s, for any s > g. this proves the theorem. lemma . if ciðtÞ, then lim t! sðtÞ ¼ . if csðtÞ bpðtÞ þan , then lim t! iðtÞ ¼ . proof. ds dt ¼ sð À sÞ À cis À asp þanþbs sð À ciÞ. therefore, sðtÞ sðt Þexpð r t t ð À ciðtÞÞdrÞ. hence lim t! sðtÞ ¼ , provided ciðtÞ. hence lim t! iðtÞ ¼ , provided csðtÞ bpðtÞ þan , i.e., c bpðtÞ sðtÞð þanÞ . the system ( ) possesses the following equilibrium points. exists if e þ nðea À cÞ > and À e À be > nðc þ eaÞ. therefore, the existence criteria of disease free boundary equilibrium point is e cÀea < n < ÀeÀbe cþea . (iv) the predator free boundary equilibrium point , if infection rate is greater than the death rate of infected prey. þanþbs and s à is the positive root of the equation the sufficient conditions of the existence of e à in the interior of the first octant are easily obtained as follows: t À t t p ; d > cs and e > ðsþcnÞ þanþbs . therefore, the values of e d ; e p and e à depend on the quality (a) and quantity (n) of alternative food. the existence conditions of e d ; e p and e à are also depend on a and n. proof. the jacobian matrix jðe t Þ at e t is given by we observe that jðe t Þ has one positive eigenvalue , therefore e t is always unstable. the jacobian matrix jðe a Þ at e a is given by where, a ¼ À s À a pð þanÞ ð þanþb sÞ ; a ¼ Àc s; a ¼ Àa s the characteristic equation of the jacobian matrix jðe d Þ is given by þan < e and ðc À Þŝ < cî þ d À . proof. the jacobian matrix jðe p Þ at e p ðŝ;î; Þ is given by the characteristic roots of the jacobian matrix jðe p Þ are ðŝþcnÞ þanþbŝ þ gî þan À e and the roots of the equation k À ½ðc À Þŝ À cî À d þ k þ c ŝî þ ðcŝ À dÞð À ŝ À cîÞ ¼ . hence e p is locally stable if the conditions given in the theorem are satisfied. theorem . the interior equilibrium point e à for the system ( ) is locally stable if the conditions x > ; x > and x x À x > hold, where x's are given in the proof of the theorem. proof. the jacobian matrix jðe Ã Þ at the interior point e à ðs à ; i à ; p Ã Þ is where, a ¼ À s à À ci à À ap à ð þanÞ þan À e. the characteristic equation of the jacobian matrix jðe Ã Þ is given by using the routh-hurwitz criteria [ ] we observe that the system ( ) is locally stable at the equilibrium point e à if the conditions x > ; x > and x x À x > hold. therefore, we observe that the stability conditions for all the equilibrium points depend on the parameters n and a. butler et al. [ ] , freedman and waltman [ , ] developed the following definition of persistence: if a population nðtÞ is such that nðtÞ > , then. proof. let x ¼ ðs; i; pÞ be a point in the positive quadrant and oðxÞ be orbit through x and x be the omega limit set of the orbit through x. note that xðxÞ is bounded. we claim that e t r xðxÞ. if e t xðxÞ then by the butler-mcgehee lemma [ ] there exist a point p in xðxÞ where w s ðe t Þ denotes the stable manifold of e t . since oðpÞ lies in xðxÞ and w s ðe t Þ is the i À p plane, we conclude that oðpÞ is unbounded, which is contrary to the boundedness of the system. the condition ðŝþcnÞ þanþbŝ þ gî þan > e implies that e p is unstable and therefore e p r xðxÞ. lastly, we show that no periodic orbits in the s À p plane or e d xðxÞ. let r i ; i ¼ ; ; . . . ; n denote the closed orbit of the periodic solution ð/ r ðtÞ; w r ðtÞÞ in s À p plane such that r i lies inside r iÀ . let the jacobian matrix j r ð/ r ðtÞ; ; w r ðtÞÞ corresponding to r i is given by here f i ¼ Àd þ c/ r ðtÞ À bw r ðtÞ þan . computing the fundamental matrix of the linear periodic system we find that its floquet multiplier in the i-direction is e f r ðtÞ . then proceeding in an analogous manner like kumar and freedman [ ] , we conclude that no r i lies on xðxÞ . thus, xðxÞ lies in the positive quadrant and system ( ) is persistent. finally, since only the closed orbits and the equilibria from the omega limit set of the solutions on boundary of r þ and the system ( ) is dissipative. now using a theorem of butler et al. [ ] , we conclude that system ( ) is uniformly persistent. note that the persistence condition of the system depends on infection rate, death rate of infected prey, death rate of predator, capturing rate of predator on infected prey and quality and quantity of alternative food. in this section, we perform numerical simulations with the help of parameter values taken from data of field works and experimental data (see, table ) which remains fixed for all numerical simulations. in our numerical simulations we have varied the infection rate c, quality of alternative food a and quantity of alternative food n. the bifurcation diagram of the system ( ) with respect to infection rate of prey in the range c : in absence of alternative food (i.e., a ¼ ; n ¼ ) to predator is presented in fig. . fig. shows that within c : , there is no infected prey species in the system and the susceptible prey and predator species have periodic behaviour. but, for : < c : , the susceptible prey, infected prey and predator species have limit cycle oscillations. all prey and predator species settle down to their respective steady states after c > : . notice that the average density of the infected prey species becomes higher than the average density of susceptible prey for c > : . with the increase of infection rate susceptible prey becomes infected at higher rate and as a result the density of susceptible prey population decreases and the density of infected prey population increases. the bifurcation diagram of the system ( ) with respect to infection rate c in the range c : in presence of alternative food (a ¼ : ; n ¼ : ) to predator is plotted in the fig. . it is evident from fig. that the system becomes disease free within c : in presence of alternative food. therefore, supply of alternative food to predator makes the system disease free in : c : which is impossible in absence of alternative food. the infected prey population oscillates within : < c < : and it reaches steady state after c > : . the susceptible prey and predator species have periodic behaviour for c : and finally they settle down to their respective steady state after c > : . we plot dynamical behaviours of the infected prey population in absence of alternative food as well as in presence of alternative food in fig. . time evolution of infected prey is plotted in fig. (a) in absence of alternative food taking c ¼ : , on the other hand fig. (b) represents time evolution of the infected prey species for same infection rate in presence of alternative food (a ¼ : ; n ¼ : ). fig. (c) depicts the time evolution of infected prey without alternative food with infection rate c ¼ whereas fig. (d) represents the disease free dynamics for ða ¼ : ; n ¼ : Þ with same infection rate. fig. . bifurcation diagram of the system ( ) with respect to infection rate of the prey in absence alternative food i.e., for a ¼ and n ¼ . [ , ] . e predator mortality rate . - . [ , ] . from the fig. , it is clear that the system becomes disease free under suitable supply of alternative food even if the infection rate is high which is impossible in absence of alternative food. in fig. , the an plane is divided into infected and uninfected regions for fixed infection rate c. we have determined the regions for c ¼ : ( fig. (a) ) and for c ¼ (fig. (b) ) considering other parameters values are as in table . fig. (a) is plotted in the an parametric plane for a : and n : with constant infection rate c ¼ : , whereas fig. (b) divides the an plane into infected and uninfected regions for a : and n : with constant infection rate c ¼ . we observe from fig. that it is impossible to make the system disease free in absence of alternative food for higher infection rate c (> : ) but disease free system can be achieved by suitable supply of alternative food. it is obvious that disease free solution exists for high quality of alternative food even if it is supplied in small quantity. on the other hand if alternative food is of low quality then high quantity of alternative food may not efficient to make the system disease free. therefore high quality of alternative food supply is very efficient for disease control. the cn and ca-planes are divided into infected and uninfected regions which are presented in fig. (a) for a ¼ : and in fig. (b) for n ¼ : , respectively. fig. (a) is the parametric plane cn for c : and n fixing a ¼ : . the fig. (a) shows that the system becomes disease free for small quantity of alternative food for lower infection rate c(< : ). but for higher infection rate, the supply level n increases depending on the increase of infection rate. there exists a critical infection rate above which alternative food may not be useful to make the system disease free. it is clear from fig. (b) that disease free state can be reached for higher infection rate (c > : ) supplying high quality of alternative food. it is evident from fig. (b) that for lower infection rate quality of alternative is not so important for obtaining disease free system. we examine some nontrivial consequences of alternative food to predator in a infected predator-prey model. we have studied stability and persistence criterion of the system in presence of alternative food. one parameter bifurcation analysis is done with respect to infection rate using experimental and field data. numerical simulation results predict that the system becomes disease free for lower infection rate ( c : ) in absence of alternative food (fig. ) . this is happening because infected prey is weaker than susceptible prey and is easily captured by predator. this will reduce the number of infected prey and ultimately the system may becomes disease free without alternative food at certain stage for lower infection rate. however, for higher infection rate (c > : ), disease free system cannot be obtained without alternative food table . the an-plane is divided into infected and uninfected regions. this figure indicates that for high quality of alternative food, small quantity of it is sufficient to make the system disease free. (fig. ) . whereas for higher infection rate disease free state may be reached by supplying suitable alternative food (figs. and ). it is evident from our study that high quality of alternative food (a < ) has the capability of making the system disease free for higher infection rate. quantity of alternative food supply increases with the increase of infection rate for fixed quality to obtain a disease free system. possible reason behind it is that with the supply of high quality or high quantity of alternative food, the predator catches the alternative food as well as infected prey at higher rate compare to susceptible prey. as a result, the growth rate of predator species will increase with the supply of high quality or high quantity of alternative food and it captures the infected prey population at faster rate than susceptible prey. due to this, infected prey population become very very small at certain stage and consequently infection cannot spread at that stage and the system becomes disease free. notice that there is a critical infection rate above which the alternative food may not be useful to make the system disease free. results presented in the present paper provided a useful platform to understand the role of alternative food as disease controller in a diseased food chain model. a possible interesting aspects for future developments are to study the role of alternative food as a disease controller in different types of disease induced food chain models and also the study the effects of supplying alternative food to a network of infected food chain models. this new non-chemical method of disease control will be very useful for biological conservation of prey species in real world biological systems. essai dune nouvelle analyse de la mortalite causee par la petite verole the prevention of malaria on the delayed ross-macdonald model for malaria transmission contributions to the mathematical theory of epidemics, part i contributions to the mathematical 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three competitive populations a mathematical model of facultative mutualism with populations interacting in a food chain estimation of bioenergetics parameters for a stunted northern pikeminnow population of south central british columbia the role of predation in plankton models chaos in a three-species food chain the relationship of the nutritive state of the prey organism paramecium aurelia to the growth and encystment of didinium nasutum factors affecting reproduction and mortality among baboons in the okavango delta survival of adult female elk in yellowstone following wolf restoration we are grateful to editors and the anonymous referee for their critical comments and suggestions which have immensely improved the content and presentation of the paper. the research work of s. poria is supported by the university grants commission (ugc), india (f. no. - / (ns/pe), dated th december, ). key: cord- -gj adoq authors: oh, ga-eun (grace) title: when dessert comes close: the effects of anticipating indulgent consumption and dietary restraint on healthy food preference at restaurants date: - - journal: int j hosp manag doi: . /j.ijhm. . sha: doc_id: cord_uid: gj adoq when dining in restaurants, diners often anticipate indulgent consumption, such as enjoying a dessert. this study examined the effects of anticipating such indulgence on preferences for healthy food among restrained and unrestrained eaters. two experiments revealed that anticipating indulgent consumption reduced restrained eaters’ preference for the immediate consumption of healthy food. conversely, unrestrained eaters’ expectation of indulgent consumption increased or did not change their preference for a healthy option. the interactive effect of indulgence anticipation and dietary restraint on healthy food preference held regardless of availability of nutrition information. the findings suggest that, despite increasing concern for healthy eating, restrained consumers ironically show a preference for unhealthy food options when anticipating a dessert consumption opportunity. the present study provides theoretical implications for consumption anticipation, sequential consumption, and dietary restraint, and practical implications for restaurateurs as well as for consumers, health professionals, and policymakers regarding healthy eating. eating at restaurants continues to be increasingly popular in the us. indeed, estimated annual sales in the restaurant industry reached $ billion in (national restaurant association, ). however, frequently eating outside of the home is related to an augmented risk of becoming overweight and even obese, which is a dire public health issue (nago et al., ; bhutani et al., ) . in recent years, responding to the need for healthy eating promulgated by policymakers and consumers, restaurants increasingly offer more healthy food options (national restaurant association, ) and introduce healthier alternatives to conventionally indulgent food (i.e., relatively unhealthy but tasty food) (wilcox et al., ) . despite such restaurant initiatives, consumers do not always prioritize consuming healthful food alternatives (international food information council, ) . in fact, consumers' preferences for healthy food can be changed by how they perceive their consumption occasion. when the consumption occasion is perceived as extraordinary (e.g., "once-in-a-lifetime experience"), consumers augment their indulgent food intake (minton and liu, ) . when they have a justifiable reason for indulgence, they prefer indulgent food (e.g., chocolate cake) to non-indulgent food (mukhopadhyay and johar, ) and consume a higher number of calories of the given food (prinsen et al., ) . prior research has noted the importance of examining under which conditions consumers opt for healthy versus indulgent food options at restaurants. following this charge, the current study introduces anticipation of future indulgence as a novel situational factor that may influence healthy food preference at restaurants. when dining in restaurants, diners often expect to engage in indulgent consumption. for example, when choosing an entrée, diners may expect dessert options to follow. in fact, waiting to engage in indulgent consumption of a dessert, for example, at a restaurant is prevalent (e.g., a free piece of cake on birthdays and anniversaries; bai et al., ; "cheesecake day on july th in the us, " schaltegger, ) . although particularly palatable, such offerings are perceived to be unhealthy (her and seo, ) and, indeed, contain a high number of calories (bleich et al., ) , which is conducive to excessive energy intake. although anticipation of indulgent food consumption is prevalent, prior research has primarily explored the effect of consumption anticipation on the emotional and hedonic experiences related to anticipated consumption (frederick et al., ; hur and jang, ; kumar et al., ; mandel and nowlis, ) . for example, scholars have found that anticipating experiential consumption is more pleasurable than anticipating material consumption (kumar et al., ) . notwithstanding extant work, little is known about whether a situation affording indulgence anticipation affects diners' healthy food preferences in the context of sequential decision making. prior literature on sequential consumption decisions provides two opposite predictions (dhar and simonson, ) : as a function of indulgence anticipation, people may prefer either healthy food (i.e., to balance out future indulgence, which is inconsistent with future indulgence) or unhealthy food for the immediate consumption (i.e., to highlight a hedonic goal, which is consistent with future indulgence). although previous empiricism in sequential decision making generally predicts a balancing pattern (i.e., preferring healthy food for immediate consumption when anticipating future indulgence) (dhar and simonson, ; kivetz and zheng, ; khan and dhar, ; sim and cheon, ) , what determines the patterns of sequential decisions is largely unknown. thus, we investigate how anticipating indulgent food consumption (i.e., a dessert) impacts consumers' healthy food preferences prior to indulgent consumption (i.e., selection of the entrée) in the sequential consumption context at restaurants. building on extant literature on dietary restraint, we examine the foregoing issue by considering whether the effect of anticipation varies depending on a particular consumer segment at restaurants: restrained versus unrestrained eaters. restrained eaters are motivated to control their weight through eating regulation; unrestrained eaters, in contrast, are not motivated to do so (polivy and herman, ) . thus, restrained and unrestrained eaters tend to respond differently to situational factors regarding dietary regulation (bublitz et al., ) . because restrained eaters have strong motivational conflict between a goal of dietary regulation and one of eating enjoyment, they are prone to eating more indulgent food when tempted by indulgent food cues . adding to prior findings concerning restrained eaters' ironic vulnerability to such enticing situations (heatherton et al., ; polivy and herman, ; stroebe et al., ) , we propose that the effect of anticipating future indulgence varies across consumer segments based on one's degree of dietary restraint. in addition, many countries have introduced menu labeling to inform consumers and promote healthy eating (european food information council, ) , thus inducing restaurateurs to employ such labeling. at a restaurant offering both relatively healthy and unhealthy choices, providing nutrition information might help consumers readily discern the healthiness of different items by highlighting the positive (negative) aspects of healthy (unhealthy) food choices (trudel and murray, ) . thus, we explore whether providing nutrition information is a necessary contextual condition for the effect of anticipating indulgence and dietary restraint on preference for healthy food in a restaurant. the present research provides important implications for restaurateurs by suggesting that promotion or recommendations of food items can be targeted differently to different consumer segments (i.e., restrained versus unrestrained eaters here), depending on whether indulgent food consumption is anticipated. our findings also offer suggestions for consumers, nutrition and health experts, and policymakers by showing how healthy food preference can be affected by anticipation of indulgent food consumption. in the present study, to test our predictions for the interactive effect of indulgence anticipation and dietary restraint on healthy food preference, we focus on behavioral response measured by preference for or choice of healthy food for immediate consumption in restaurant settings. we also test whether providing nutrition information should precede the interactive effect of anticipation and dietary restraint on preference for healthy food. our hypotheses are tested in two studies adopting a scenario-based experiment. the theoretical underpinnings of the research objectives and our predictions, as well as the implications of the present study, are elucidated below. dietary restraint refers to individual differences in behavior and motivation to manage weight through dietary regulation (bublitz et al., ) . it is an important antecedent of eating decisions (rideout et al., ; polivy and herman, ) . individuals high in dietary restraint-restrained eaters-tend to restrict food intake by setting rules (e.g., forbidding consumption of indulgent food items, such as milkshakes or cake), rather than follow their internal energy needs (knight and boland, ) . ironically, unlike health-conscious consumers who maintain persistent preferences for healthy food items (her and seo, ) , restrained eaters do not always avoid eating unhealthy foods. indeed, they sometimes increase their intake of "forbidden" foods, dampening their regulatory interests. such instances arise when they lack sufficient cognitive resources to follow the rules (ward and mann, ) or have already violated their restraint goals (polivy and herman, ; polivy et al., ) . also, restrained eaters give in to temptation when indulgent food is presented in small sizes and packages (scott et al., ) . as such, their preference for healthy food weakens in the presence of tempting food cues (van koningsbruggen et al., ) . according to stroebe et al.'s ( ) goal conflict model of eating, restrained eaters' vulnerability to temptation is attributed to conflict between their goal of a strong desire to enjoy indulgent food and a dietary regulation goal for weight control. once accessibility of the goal of consumption enjoyment is heightened by situational cues, the goal of eating regulation, which is incompatible with the goal of consumption enjoyment, is inhibited. the consequence is that restrained eaters seek more indulgent food . conversely, unrestrained eaters have no strong interest in regulating their food intake (polivy and herman, ) . as such, they do not have motivational conflict regarding consuming indulgent foods and are not susceptible to indulgent food cues . rather, unrestrained eaters have a tendency to balance their consumption across consumption episodes, as they follow their natural internal cues (e.g., satiation, hunger). for example, one study found that, after unrestrained eaters drank a chocolate milkshake, they ate less ice cream (polivy et al., ) . the foregoing findings suggest that restrained eaters respond to opportunities to eat indulgent food differently from unrestrained eaters owing to differences in their respective interests to regulate food intake and resultant goal conflict between eating enjoyment and weight control. consumers often decide what to eat in the context of anticipated indulgence (zemack-rugar and corus, ) . for example, at a restaurant offering a three-course dinner, consumers know they will receive dessert after finishing the entrée. when consumers anticipate pleasurable experiences, the anticipation generates positive reactions associated with the prospective consumption (frederick et al., ; nowlis et al., ; ryan et al., ) . similarly, when diners anticipate a dessert, they conceivably would have positive reactions to the upcoming opportunity to indulge. however, depending on individuals' dietary restraint, the expected pleasure from anticipating indulgence might differ. when restrained eaters think of indulgent foods, they experience more hedonic thoughts than unrestrained eaters (papies et al., ) . such increased hedonic thoughts would induce a desire for indulgence. for example, exposure to indulgent food cues (e.g., pizza) increases one's desire and craving for the cued food, as well as its actual intake, only for restrained eaters, but not for unrestrained eaters (fedoroff et al., ) . similarly, when indulgent consumption is anticipated, restrained eaters might focus more on the hedonically pleasurable aspects of indulgent food, further impelling their desire for eating indulgent food. the heightened desire would be translated into increased preference for indulgent food, as once the desire arises, tempering it becomes difficult (hofmann et al., ) . consequently, anticipation of indulgent food may make restrained eaters prefer relatively unhealthy food for immediate consumption. after all, such consumption may well slake their hedonic craving for indulgent food. in the context of sequential consumption decisions (e.g., ordering a dessert after an entrée has been served and consumed in a restaurant) (her and seo, ) , prior research has shown that, despite restrained eaters' concerns for weight control, when encountering challenges to dietary goals, they tend to forgo restraint goals and willingly consume indulgent food. this prior consumption of indulgent food tends to have deleterious effects on their persistent goal pursuit (heatherton et al., ; polivy et al., ; polivy and herman, ) . for example, knight and boland ( ) found that, after restrained eaters had consumed a milkshake, they ate more ice cream than when they had not consumed a milkshake earlier. this ironic outcome, termed the "whatthe-hell" effect (cochran and tesser, ) , stems from violating one's goal of restricting food intake. because prior indulgent food consumption triggers perceptions of a goal violation among restrained eaters, anticipating indulgent food consumption might also create a sense of prospective goal violation, due to restrained eaters' sensitivity to dietary goal challenges. as a result, not only realized but also anticipated goal failures (e.g., eating dessert in the future) might negatively impact their adherence to a goal of dietary restraint. for example, those who are highly sensitive to their goal failure have difficulty in remaining true to the goal when they expect to violate their goal in the future (zemack-rugar and corus, ) . similarly, dieters regard indulgent food items as "tempting sins" (effron et al., ) and restrained eaters see them as "forbidden food" (lemmens et al., ) . therefore, anticipating indulgent food can signal a future goal violation to restrained eaters, which may demotivate them from pursuing their dietary goals (e.g., "what the hell-my diet will be ruined anyway."). thus, restrained eaters might be more willing to select indulgent food alternatives instead of healthy ones for immediate consumption. furthermore, anticipating future indulgent consumption might lead restrained eaters to justify indulgent food consumption in the present. although indulgent consumption produces guilt (giner-sorolla, ) , justifications can reduce guilt associated with indulgence (khan and dhar, ) , thus contributing to augmented indulgent consumption. moreover, as temptations increase, so do justifications (van de ven et al., ) . likewise, when anticipating eating indulgent food, which is an obvious temptation to restrained eaters (fujita et al., ) , restrained eaters might become motivated to reason that deviating from their restraint goal temporarily (e.g., "it's a cheating day") is permissible. such reasoning is conducive to subsequent regulatory failure among those with low resilience for returning to their goal pursuit (zemack-rugar et al., ) . indeed, restrained eaters are known for their reluctance to return to their regulatory goal after realizing a previous goal failure: they tend to believe that maintaining their dietary goal is unnecessary if it has already been violated (polivy and herman, ) . as a result of the justifications for future indulgence, restrained eaters may willfully abandon healthy alternatives and choose indulgent alternatives while experiencing reduced guilt. in contrast, unrestrained eaters have relatively weak interest in controlling food intake, owing to a low concern with restricting what they eat; as such, they do not experience conflict between indulgence and self-control in food consumption . thus, unrestrained eaters tend to be less tempted by palatable food cues than are restrained eaters (papies et al., ; fedoroff et al., ) . merely thinking about indulgent food in a social context activates hedonic thoughts in restrained eaters but does not activate them in unrestrained eaters (papies et al., ) . this finding suggests that anticipating eating indulgent food might not strongly lead to unrestrained eaters' prolonged desire to consume indulgent food. in fact, indulgent food cues do not increase unrestrained eaters' desire for the indulgent food or actual indulgent food intake (fedoroff et al., ) . moreover, due to the absence of dietary restraining goals of unrestrained eaters (bublitz et al., ; polivy and herman, ) , such individuals are unlikely to experience a sense of goal failure as there is no restrictive dietary goal to violate from the beginning. thus, they are not likely to be as responsive to the anticipation as are restrained eaters. for the same reason, unrestrained eaters seemingly have no need to justify their upcoming indulgent consumption; thus, anticipating indulgent food might not especially encourage them to justify continued indulgence. given the foregoing, we propose that, when unrestrained eaters anticipate future indulgent consumption, they will increase healthy food preference for immediate consumption. though unrestrained eaters are not dedicated to restrictive diet rules as are restrained eaters, extant literature suggests that unrestrained eaters naturally seek a balance regarding what they consume across consumption episodes. for example, after drinking a milkshake, unrestrained eaters reduced their intake of another indulgent food in the subsequent consumption episode (polivy et al., ) , which suggests that they apparently have a compensatory eating tendency. unlike restrained eaters who rely on external cues (e.g., the presence of attractive foods) (scott et al., ) , unrestrained eaters attend to internal cues for their organic intake regulation (e.g., their own hunger, how filling they perceive foods to be) (polivy and herman, ) . in other words, unrestrained eaters' inclination to rely on internal cues would contribute to their tendency to balance caloric intake across consumption decisions. when unrestrained eaters anticipate indulgent food consumption, they may expect a sense of fullness from eating indulgent food later and, as a result, try to balance their food choices in advance. choosing healthy food items that are often lighter than unhealthy items can be a prospective way to buffer the upcoming expected feeling of satiation from anticipated indulgence. thus, given relatively healthy and unhealthy food choices, unrestrained eaters will prefer healthy food for immediate consumption more when they know indulgent consumption will follow. in summary, we propose that the effect of anticipating indulgent food on preference for healthy food will depend on dietary restraint. formally, our hypotheses are as follows: h (a). when anticipating indulgent food consumption, restrained eaters will be less likely to prefer healthy food. h (b). when anticipating indulgent food consumption, unrestrained eaters will be more likely to prefer healthy food. we further investigate the role of nutrition information in the interactive effect of anticipation and dietary restraint on healthy food preference. over the last decade, provision of nutrition information for food items has become prevalent; menu labeling has been mandated for foods at restaurants and food retailers with or more locations in the us since (food and drug administration, ). despite expectations that menu labeling would enhance healthy eating, a metaanalysis revealed only a negligible effect on choices of lower-calorie options (zlatevska et al., ) . nonetheless, disclosure of calorie information influences food choices depending on contextual factors, such as perceived healthiness of retailers (wei and miao, ) and other items on the menu (yoon and george, ) . thus, we do not expect providing nutrition information to have a main effect on the preference for healthy food. however, disclosure of nutrition information, such as menu labeling, can help consumers readily detect the difference between relatively healthy and unhealthy foods. first, disclosing nutrition information increases the salience of the information (goswami and urminsky, ; trudel and murray, ), which can highlight the relative healthiness of choices. second, providing nutrition information about food items influences individuals' attitudes towards them (kozup et al., ) , since the link between information suggestive of food healthiness and attitude is mediated by perceptions of healthiness (shin and mattila, ) . this suggests that providing nutrition information would influence the perceived healthiness of food items and facilitate identification of relatively healthy and unhealthy foods from the menu. moreover, providing nutrition information can influence perceptions of another critical attribute: tastiness. consumers tend to perceive unhealthy options as tastier than healthy options (raghunathan et al., ) . if anticipating indulgence increases restrained eaters' preference for indulgent food, provision of nutrition information might help them find and choose unhealthy foods that can meet their desire for indulgent food. conversely, if unrestrained eaters seek options to balance their expected future indulgence, they might readily find seemingly healthy foods by using nutrition information. however, when nutrition information is unavailable, people might not easily detect the differences between food items in terms of healthiness and tastiness. put simply, the absence of nutrition information might deter both restrained and unrestrained eaters from identifying healthy or unhealthy food. as a result, when anticipating future indulgence, in the lack of nutrition information provided for food options, restrained eaters might not reduce their preference for healthy food for immediate consumption; unrestrained eaters, though, might not increase their healthy food preference. in short, we predict that provision of nutrition information will be necessary for the interactive effect of anticipation and dietary restraint on preference for healthy food. h . the interactive effect of anticipation and dietary restraint on healthy food preference will be pronounced only when nutrition information is provided for healthy and unhealthy foods. in the absence of nutrition information, this interactive effect will not be observed. the conceptual framework of this study is shown in fig. . h a and h b are tested in both studies and ; h , in study . study aims to test the different effects of anticipating future indulgence on the preference for healthy and unhealthy options among restrained versus unrestrained eaters (h a; h b). this study employed a (anticipation of future indulgence: no vs. yes) x measured dietary restraint design with the first factor manipulated as between-subjects. at a university in a large asian city, four hundred twenty-six undergraduate students ( female; male, m age = . ) participated in exchange for partial course credit in . students unwilling to participate were offered the alternative of working on another assignment to achieve the same course credit; thus, participation was voluntary. we received written informed consent before the study. students were allowed to terminate participation in the middle of the experiment if they wished. participants were between and years old, with . % under years old. the study was introduced as a restaurant study. the survey was programmed on a qualtrics survey webpage. participants worked on a pc in a separate cubicle in a lab. at the beginning of the experiment, participants were instructed to imagine that they were about to choose an entrée option. they were then randomly assigned to either the anticipation or the no-anticipation condition. in the anticipation condition, participants learned that they might eat a dessert after the entrée; in the no-anticipation condition, participants were not informed of this. in both conditions, participants received the same entrée menu listing two options with accompanying nutrition information: rib eye steak and strawberry avocado salad (see supplementary material a). nutrition information was provided to enable participants to distinguish the healthiness of the items. participants subsequently chose an entrée and then rated how healthy each entrée option was. before asking demographic questions at the end of the experiment, we measured participants' dietary restraint. we included two attention check questions in the middle of the survey to ensure that participants paid attention to the instructions. these questions had five options, but the instructions clearly mentioned that participants should not choose any of them ("this question is meant to check if you are really paying attention to our questions. please don't click any answer, and instead go directly to the next page."). participants who chose any item in either attention check question were regarded as having failed the attention check. this kind of attention check has been used to discard unqualified data (oppenheimer et al., ) . we planned to exclude participants who failed these two attention checks. preference for healthy versus unhealthy food was measured with a binary choice measure ( = choice of an unhealthy option; = choice of a healthy option). we measured the perceived healthiness of the two food options with a one-item scale for each option ("how healthy do you think each option is?"; = very unhealthy, = very healthy) to confirm that the participants perceived the two items as healthy and unhealthy as intended. we also assessed the number of calories participants recalled each item had. to measure participants' dietary restraint, we used herman and polivy's ( ) -item dietary restraint scale (α = . , m = . , sd = . ). to ensure participants' anticipating dessert differed between the two experimental conditions as intended, we asked if they expected to have dessert after their entrée choice (yes vs. no) as a manipulation check. additionally, before asking them demographic questions, we also inquired about the number of hours that had elapsed since they had eaten their most recent meal; this was done to estimate their hunger level during the study to control for it. before analyzing the data, we excluded eleven participants because they failed to pass the attention check. we then analyzed the remaining participants (n = ; female; male, m age = . ; n = in the no-anticipation condition; n = in the anticipation condition). we compared the perceived healthiness of the two choices. participants perceived the salad (m = . ) as healthier than the steak (m = . ; f( , ) = . , p < . ), thus suggesting the highcalorie option was perceived as less healthy than the low-calorie option. for the manipulation check, we asked if participants expected to eat dessert when making an entrée choice. as intended, . % of the participants in the anticipation condition indicated they expected to have dessert after the entrée. in contrast, in the no-anticipation condition, only . % of participants anticipated eating dessert (pearson's χ ( ) = . , p < . ). this indicates that our manipulation of anticipation was successful. additionally, though all participants received identical nutrition information regarding menu items, we tested whether anticipating future indulgence might unexpectedly influence recalled calories. manipulation of anticipation did not affect the recalled calorie counts of healthy (m no_anticipation = . calories; m anticipation = . calories; f( , ) = . , p = . ; analysis conducted with three missing values) or unhealthy (m no_anticipation = . calories; m anticipation = . calories; f( , ) = . , p = . ; analysis conducted with three missing values) options. we used a binary logistic regression with anticipation as the independent variable and dietary restraint as a moderator by adopting the hayes' ( ) process model with iterations of bootstrapping. the dependent variable was choice of a low-calorie option ( = choice of a high-calorie option; = choice of a low-calorie option). anticipation was a binary variable ( = no anticipation; = anticipation), and the dietary restraint scale was treated as continuous after standardization, rather than dividing the data into two groups. recent research has recommended using continuous variables and avoiding simply dichotomizing data, as dichotomization (i.e., splitting the data based on the median) loses information from the available data and imposes the risk of spurious results (fitzsimons, ; hou et al., ; spiller et al., ) . as predicted, the binary logistic regression revealed that, although the main effects of dietary restraint (z = . , p = . ) and anticipation were not significant (z = −. , p = . ), the two-way interaction was significant (z = − . , p = . ; see table ). to test the simple effects of anticipation, using process model , we conducted a johnson-neyman analysis (johnson and fay, ) using a non-standardized value of the dietary restraint scale to find the regions of values of dietary restraint ( - in the present data) in which the simple effect of anticipation becomes significant (mohr et al., ) . johnson-neyman analysis revealed that more restrained eaters ( . sd above the mean of the scale or restraint score > . ) significantly reduced their preference for a low-calorie option when expecting future dessert consumption than when not expecting it (b = −. , z = − . , p = . ; at dietary restraint = . ; see fig. ). this supports the prediction that anticipating future dessert consumption reduces preference for healthy food among restrained eaters (h a). in contrast, below this johnson-neyman point (dietary restraint = . ), the simple effect of anticipation was not significant at any point of dietary restraint. still, the effect of anticipation was only marginally significant (b = . , z = . , p = . ) at the lowest point of the scale ( . sd below the mean or restraint score of ), which corresponds to the most unrestrained individuals. thus, the results do not support h b. however, consistent with the prediction, the direction of the effect suggests that unrestrained eaters tend to show higher preference for relatively healthy food when anticipating dessert. to supplement the johnson-neyman technique, spotlight analyses (spiller et al., ) were also conducted at various spotlighted values of dietary restraint (table ) to test whether the simple effects of the independent variable (manipulated anticipation) were significant at seven spotlighted values of the continuous variable (measured dietary restraint), in addition to the johnson-nayman point. we adopted several values, with the value of as a reference value in the middle ( , , , , , , ) , as the restraint value of has been used to classify restrained eaters and unrestrained eaters in previous research (herman and polivy, ; polivy et al., ) . this approach is compatible with recent recommendations regarding statistical analyses (spiller et al., ; krishna, ) and previous research adopting a similar model (sharifi, ) . as reflected in table , due to anticipation, those having high dietary restraint scores (e.g., dietary restraint = . , , ) were significantly less likely to choose a healthy entrée; those with low dietary restraint scores (e.g., dietary restraint = , , ), however, were not more likely to choose a healthy entrée. we conducted the similar regression analysis to the main analysis, after adding a control variable that might influence a preference between relatively healthy and unhealthy food items. we measured the number of hours since participants had consumed their last meal (m = . ; sd = . , after excluding one unrealistic response) as a proxy for hunger. the hours since the last meal might be related to higher preferences for an unhealthy option, since high-calorie foods can better satisfy hunger. even when controlling for hours since the last meal (b = −. , z = − . , p = . ), the results remained similar to those without a control in terms of the pattern and significance of the effects found in hypotheses testing (see tables b. and b. for the analysis results controlling for hours since the last meal in supplementary material b). in study , expecting future dessert consumption reduced restrained eaters' preference for relatively healthy food for immediate consumption (the entrée), consistent with h a. merely expecting dessert consumption decreased restrained eaters' pursuit of dietary regulation even though they had not consumed dessert and, thus, had not yet failed to keep their restraint. although restrained eaters could have proactively compensated for their future dessert consumption by choosing a healthy option for immediate consumption, they preferred unhealthy food more in the present. on the contrary, among unrestrained eaters, the effect of anticipation was not significant even at the lowest point of the dietary restraint, not supporting h b. however, the directionality of the results suggests that unrestrained eaters became more likely to make a relatively healthy choice in response to the anticipation. while study provides initial evidence of the interactive effect of anticipated indulgence and dietary restraint on current preference for healthy food, it has several limitations. we recruited only undergraduate students from an asian city, most ( . %) who were less than years old. as younger adults tend to place lower importance than older adults on attributes related to nutrition and weight control in making dietary choices, such as consuming fewer fruits and vegetables (glanz et al., ) , the overall choice probability of a healthy option was quite low. additionally, evidence for h b was weak, as only a marginally significant effect was found at the lowest end of the scale. therefore, in study , to expand the generalizability of our findings, we aimed to test these hypotheses (h a; h b) on american consumers having a broader age range. additionally, in study , we did not consider participants' dietary restrictions, such as being vegetarian, and provided only non-vegetarian options. despite the low prevalence of vegetarian diets in the city ( . % in ; lee, ) , the responses of vegetarian participants might have affected the results. to address this concern, in study , we recruited only non-vegetarian participants by introducing a screening question prior to the study. finally, in study , all participants received nutrition information regarding options. these nutrition data might have contributed to the effect of expecting future indulgence because of their salience (goswami and urminsky, ; trudel and murray, ) , potentially helping consumers distinguish the relative healthiness of different items. in the absence of nutrition information, consumers might not be able to find an item that matches their preference for healthy food consumption (h ). thus, in the next study, we aimed to replicate the findings of study with a different sample and to test whether the interactive effect of anticipation and dietary restraint on healthy food preference holds only in the presence of nutrition information (h ). as noted above, study examined whether the availability of nutrition information could moderate the effect of anticipating future consumption. we added the nutrition information availability factor to the design from study and tested whether the interactive effect of anticipation and dietary restraint on healthy food preference is observed only when nutrition information is presented (h ). furthermore, although study used an asian sample, in study , we attempted to replicate the findings utilizing american participants. the present study used a (anticipating future indulgence: no vs. yes) x measured dietary restraint x (nutrition information: available vs. unavailable) design with the first and last factors as between-subjects. in study , we recruited participants living in the us for an online experiment in exchange for $ . compensation on amazon mechanical turk (mturk) in . mturk was employed to reach participants of diverse ages in the us beyond undergraduate students, as mturk has a demographically diverse sample pool (buhrmester et al., ) . the results of experiments relying on data obtained through mturk have been shown to be reliable and compatible with data obtained through student samples or community samples (critcher and lee, ; goodman et al., ; kees et al., ) . moreover, mturk was used in recent studies of consumer behavior in restaurants and hospitality service encounters (ahn and seo, ; fan et al., ; im and qu, ; line et al., ; , thus showing the reliability of the data obtained. we predetermined to recruit only non-vegetarian participants to eliminate noise, as we offered solely non-vegetarian choices. on the first page of the survey, we asked participants several questions to filter out vegetarians. as advised by zhou and fishbach ( ) , to use an mturk sample cautiously, we report the attrition of participants below. initially, participants started the survey, but participants ( . %) did not answer any questions before being assigned to an experimental condition. additionally, prior to the condition assignment, participants who indicated that they were vegetarian were not allowed to participate. after being assigned an experimental condition, only six participants quit in the middle of the survey (two in the nutrition information and anticipation condition, three in the nutrition information and no-anticipation condition, and one in the no-nutrition information and anticipation condition). this study revealed a relatively low dropout rate ( . %); dropout rates of mturk studies are often higher than % (zhou and fishbach, ) . more importantly, the dropout rates of participants did not depend on the experimental condition (pearson χ ( ) = . , p = . ), thus suggesting that attrition is not likely to have reduced the validity of the conclusions of the present research (zhou and fishbach, ) . finally, we received completed responses from the remaining participants ( female; male; m age = . ), aged - years old. a qualtrics survey was programmed for an online experiment. at the beginning, participants received a menu of two sandwich options for lunch: black angus steak and turkey lite (see supplementary material a). we manipulated anticipating future indulgence in the same way as in study . we also manipulated nutrition information availability by showing the nutrition information panel only in the nutrition information condition, not in the no-nutrition information condition. all participants indicated their preference between the two options. they also rated the perceived healthiness of each option and recalled or estimated the calories in the two options. we measured participants' dietary restraint using the same scale as in study . although recent investigations suggest that the attention levels of mturk participants are no lower than those of student or alternative internet samples (thomas and clifford, ) , to ensure the quality of attention as with the student sample in study , two attention check questions were asked in the middle of the survey. to test whether the scenarios led to the intended anticipation manipulation, we pretested the anticipation manipulation method by separately recruiting american participants (n = ; female; m age = . , with one missing response) from mturk. as in study , we asked whether participants knew that they might have dessert after the entrée (yes vs. no). as expected, in the anticipation condition (n = ), . % of participants indicated they expected that they might have dessert after the entrée; in the no-anticipation condition (n = ), only . % indicated so (pearson χ ( ) = . , p < . ). this suggests that the method successfully produced the intended manipulation of anticipation. the relative preference for the two food options was measured on a five-point scale ( = "strongly prefer black angus steak"; = "strongly prefer turkey lite"). the healthiness of each option was measured with the same question as in study . additionally, we assessed participants' recalled calorie counts for the two options in the nutrition information condition, while we measured participants' estimated calorie counts for the two options in the no-nutrition information condition to ensure that the information we provided was not surprisingly different from what people could guess without being informed. we measured participants' dietary restraint using the same -item restraint scale as in study (α = . , m = . , sd = . ). before analysis, six participants were excluded for failing to clear the attention check questions ( % exclusion rate). thus, we tested our hypothesis using the remaining sample (n = ; female; males; m age = . ; n no_nutrition_information/no_anticipation = ; n no_nutrition_information/anticipation_of_dessert = ; n nutrition_information/no_anticipation = ; n nutrition_information/anticipation_of_dessert = ). as intended, the turkey sandwich (m = . ) was perceived as healthier than the steak sandwich (m = . ; f( , ) = . , p < . ). additionally, we compared the recalled and estimated calories of the two options in the nutrition information condition versus the no-nutrition information condition. the calorie estimates of the two options in the no-nutrition information condition (m steak = . calories; m turkey = . calories) were not significantly different from the recalled values in the nutrition information condition (m steak = . calories; f( , ) = . ; p = . ; m turkey = . calories; f( , ) = . , p = . ). this thus suggests that the calorie information did not provide additional information to participants in the nutrition information condition but simply increased the salience of the information. we conducted a regression analysis to test the three-way interaction, (anticipating dessert consumption: no vs. yes) x measured dietary restraint x (nutrition information availability: no vs. yes) by using hayes' ( ) process model with iterations of bootstrapping. anticipation was treated as the main independent variable ( = no anticipation; = anticipation), dietary restraint as a first moderator, and nutrition availability as a second moderator ( = no nutrition information; = nutrition information). the dietary restraint scale was standardized before analysis. the three-way interaction was not significant (b = . , t( ) = . , p = . ). this shows that nutrition information availability did not moderate the interactive effect of anticipation and dietary restraint on healthy food preference, thus failing to support h . however, the two-way interaction of anticipation and restraint was significant (b = −. , t( ) = − . , p = . ), consistent with study . due to the insignificant moderation by nutrition information availability, we collapsed the nutrition information conditions and tested the interactive effect of anticipation and dietary restraint on healthy food preference in a separate regression (see table ) by using process model (hayes, ) with iterations, consistent with study . as predicted, the regression revealed a significant interaction of anticipation and dietary restraint (b = −. , t ( ) = − . , p = . ; see fig. ) with an insignificant main effect of anticipation (b = . , t( ) = . , p = . ) and a significant effect of dietary restraint (b = . , t( ) = . , p = . ). to probe the significant interaction, we again adopted the johnson-neyman technique (johnson and fay, ) and applied a non-standardized scale of dietary restraint measurement. among restrained eaters ( . sd above the mean of the scale or restraint score > . ), expecting to eat indulgent food in the near future reduced their healthy food preference for immediate consumption (b = −. , t( ) = . , p = . ; at restraint score = . ; see fig. ), consistent with the findings of study and supporting h a. on the contrary, among unrestrained eaters ( . sd below the mean of the scale or restraint score < . ), anticipating food consumption increased their preference for a healthy option for immediate consumption (b = . , t ( ) = . , p = . ; at restraint score = . ). this was consistent with the hypothesis regarding the positive effect of anticipation on healthy food preference among unrestrained eaters (h b). in other words, the results showed that expecting to eat indulgent food reduced restrained eaters' healthy food preference, whereas it increased healthy food preference among unrestrained eaters. consistent with study , we conducted spotlight analyses (spiller et al., ) at varying spotlighted values of dietary restraint ( , , , , , , ) in addition to the johnson-neyman points to test simple effects of anticipation in the full range of the dietary restraint score (table ). the analyses revealed that, as a function of anticipation, those having high dietary restraint scores (e.g., dietary restraint = . , , ) preferred a healthy entrée significantly less, whereas those having low dietary restraint scores (e.g., dietary restraint = . , , ) preferred a healthy entrée significantly more. also, we analyzed the data after adding hours since the last meal (m = . ; sd = . , after excluding one unrealistic response) as a control variable to the regression conducted to test the two-way interaction of anticipation and dietary restraint on healthy food preference. note. anticipation: condition ( = no anticipation; = anticipation); dietary restraint (standardized). * represents % significance level. ** represents . % significance level. in study , inconsistent with our prediction (h ), the interaction of anticipation and dietary restraint on healthy food preference was not dependent on the availability of nutrition information. because the names of the food items in the study unequivocally suggested food healthiness even before adding the nutrition information, the provision of nutrition information did not increase the salience of the information from the menu. nonetheless, anticipating having dessert in the near future reduced restrained eaters' preference for healthy food, replicating the findings of study and supporting h a. in contrast, unrestrained eaters exhibited the opposite response to anticipating indulgent food consumption, thus supporting h b. the insignificant effect of the anticipation in increasing healthy food preference among unrestrained eaters (h b) in study might be partly due to the relatively small calorie difference between the two entrées ( calories). in the case of a large gap between the calorie counts of unhealthy and healthy entrées ( calories) in study , anticipating eating dessert increased the preference for a relatively healthy option among highly unrestrained eaters, consistent with our hypothesis (h b). presumably, when the calorie gap is large, unrestrained eaters might perceive an unhealthy alternative to be too filling and decide on a lighter option. this research demonstrated that the effect of anticipating future indulgence on healthy food preference was moderated by individuals' dietary restraint. when expecting to consume indulgent food later, restrained eaters were less likely to choose healthy food for immediate consumption (h a), the result consistently found in both studies. in contrast, the opposite effect of anticipation among unrestrained eaters (h b) was only shown in study . unlike our prediction (h ), the interactive effect of dietary restraint and anticipating future dessert consumption on healthy food preference was not moderated by the availability of nutrition information but, in fact, persisted regardless. in short, anticipating future indulgence reduced restrained eaters' preference for healthy food and tended to increase unrestrained eaters' preference for healthy food. the present study contributes to knowledge about consumption anticipation, sequential consumption decision making, and dietary restraint. first, the findings extend extant work on consumption anticipation by introducing consumers' healthy food choice and preferences in restaurant contexts beyond simply measuring general intention to indulge (zemack-rugar and corus, ) . although previous research has examined the effect of anticipating healthy food consumption (hur and jang, ; sim and cheon, ) , the impact of anticipating indulgent food consumption has received minimal attention (see zemack-rugar and corus, for an exception). our results show that anticipating indulgent food, such as dessert, can change healthy food preferences for immediate consumption (an entrée here) in a restaurant setting. specifically, we showed the moderating role of dietary restraint in the effect of consumption anticipation. when anticipating indulgent consumption, restrained eaters preferred healthy food less, whereas unrestrained eaters preferred healthy food more in a restaurant setting. second, previous research on sequential decision making regarding food items has predominantly shown a balancing strategy such that, once consumers choose a healthy food, they subsequently select an unhealthy food and vice versa (dhar and simonson, ; fishbach and dhar, ; khan and dhar, ; kivetz and zheng, ; mukhopadhyay and johar, ; sim and cheon, ) . this study reveals the condition under which consumers choose a balancing strategy or opt to indulge now and later, advancing knowledge on sequential consumption decisions. when indulgent food consumption was impending, unrestrained eaters tended to exhibit a balancing strategy by increasing their preference for a healthy food option, which is consistent with prior research (khan and dhar, ; sim and cheon, ) . however, restrained eaters sought indulgent consumption immediately and later, forgoing the balancing strategy. as such, restrained eaters pursued an eating enjoyment goal in both present and future consumption occasions, showing that they used a "highlighting" strategy (dhar and simonson, ) . this strategy refers to the tendency to highlight one consumption goal (e.g., enjoyment) while sacrificing a competing goal (e.g., health) across consecutive consumption decisions (dhar and simonson, ) . our investigation suggests that consumers do not always adopt a balancing strategy as a response to anticipation of indulgent consumption. rather, the interplay of dietary restraint and anticipating future indulgence shapes whether consumers choose a balancing or highlighting strategy vis-a-vis healthy and unhealthy food choices. lastly, this research contributes to knowledge about dietary restraint by showing the divergent responses of restrained versus unrestrained eaters to anticipating indulgent food consumption on healthy food preferences. the results are consistent with the implications of extant literature, which demonstrates that in stressful and goal-violating situations restrained eaters give in to tempting foods and fail to retain their dietary restraint (heatherton et al., ; herman and polivy, ; lowe and kral, ; polivy et al., ) . our findings suggest that, in addition to the realized goal violation by previously consuming indulgent food (polivy et al., ; knight and boland, ) , the mere anticipation of future indulgent consumption can thwart restrained eaters' restraint goals, which is a prospective version of the "what-the-hell effect" (cochran and tesser, ) . this is another novel situation under which restrained eaters' weaknesses manifest in a dietary goal violation. by contrast, unrestrained eaters' healthy food preference tended to increase when anticipating future indulgence although unrestrained eaters' anticipation effect was significant solely in study , which only weakly supports our hypothesis (h b). this result might be partly due to the prospective nature of anticipating future consumption, unlike the effects found in prior research based on actual past food consumption (polivy et al., ) . because satiation and hunger can be psychologically influenced by imagining consumption (morewedge et al., ) , when unrestrained eaters merely anticipate future dessert consumption, their satiation might be similarly influenced. however, the biological effects of actually eating food on satiation or hunger are not likely to occur owing to the anticipation. thus, in the absence of such internal biological cues that suggest the need for compensation, unrestrained eaters may have a weaker drive to prefer healthy food immediately. thus, the balancing tendency between unrestrained eaters' consecutive consumption decisions might be weaker when indulgent consumption is only anticipated. in sum, the present findings provide stronger evidence for restrained eaters' continuing indulgence than for unrestrained eaters' compensation when they expect indulgent consumption to follow. the current findings also provide practical implications relevant to the restaurant industry. first, despite increasing attention to healthy eating from consumers and business (jeong and jang, ; shin and mattila, ) , our empiricism reveals that even restrained eaters, who otherwise may prefer healthy food items, showed an increased preference for unhealthy food when anticipating indulgent food; unrestrained eaters, though, responded in an opposite way to the anticipation. this knowledge can be utilized by restaurateurs in designing effective targeting and promotion strategies by varying food items in terms of healthiness. for example, restaurants that provide indulgent items that can induce anticipation (e.g., dessert) can target consumers differently depending on their dietary restraint: a set of relatively indulgent entrées would better be recommended to restrained consumers, but an array of relatively healthy entrées would be especially valuable for promotion to unrestrained consumers. similarly, a promotional offer consisting of an unhealthy entrée and indulgent dessert together might be better directed at restrained eaters, whereas a promotional offer of a relatively healthy entrée and indulgent dessert together might be more appealing to unrestrained eaters. for restaurants that chiefly provide healthy alternatives that are not likely to induce an anticipation effect, they could seek to attract those who prefer healthy choices, such as restrained eaters (polivy and herman, ) and health-conscious consumers (her and seo, ; shin and matilla, ) . matching recommendations and promotions to healthy preferences of diners with varying degrees of dietary restraint may further contribute to their satisfaction with the dining experience. our findings provide implications for consumers, nutrition and health experts, and policymakers vis-a-vis consumer health. although dessert-related promotions (e.g., a free giveaway on a birthday or an anniversary) are often used to incentivize restaurant visits (lee et al., ) and to build consumer loyalty (lee et al., ; bai et al., ) , they can unexpectedly lead restrained eaters to like indulgent food more and become vulnerable to continued unhealthy food consumption and excessive energy intake. because people's self-regulatory failure is positively related to their body mass index (papies et al., ) , if indulgent consumption becomes too frequent, it would pose potential harm to consumers' weight management and health (her and seo, ) . accordingly, consumers, nutrition and health experts, and policymakers should be aware of this unintended effect of indulgence anticipation. to achieve a more balanced diet for consumers, health professionals and policymakers could use educational communications that emphasize the importance of consumers' being circumspect when they are likely to anticipate future indulgence. for example, the messages could depict situations in which indulgent items are likely to be available and suggest the benefits of individuals' focusing on the tastiness and hedonically pleasurable aspects of relatively healthy food items for the immediate consumption. in fact, this approach would be worth applying to the current context of anticipation, owing to extant research which has shown that focusing on positive tasting experiences of eating healthy food items can increase selection of healthy food choices (petit et al., ) . despite the aforementioned contributions, our study has limitations. first, in both studies, we measured a hypothetical choice or preference that should be tested in more realistic consumption settings. second, because we did not measure which specific kinds of dessert they imagined, we cannot rule out the possibility that the manipulation of future indulgence could activate representations of qualitatively different kinds of foods across participants. third, though the possibility of future indulgence did not assume any responsibility of participants regarding a decision to indulge, perceived lack of responsibility might have contributed to the current findings. because low responsibility regarding decisions about indulgent consumption liberates people from regulating their consumption (hagen et al., ) , consumers might behave differently depending on how responsible they feel for their future indulgence (e.g., being offered a free dessert vs. choosing to order a dessert). future research could examine whether perceived responsibility for future indulgence can moderate the interplay between anticipating indulgence and dietary restraint. fourth, whereas various mechanisms to predict the interactive effect of anticipation and dietary restraint on healthy food preference were discussed, the present investigation did not demonstrate specific mechanisms. future work on the underlying mechanism would advance our knowledge of the underlying process of how anticipating indulgent food consumption influences restrained (versus unrestrained) eaters' preference for healthy food. lastly, when expecting to eat dessert in the near future, restrained eaters show a dysfunctional response contrary to their concern for dietary restraint. to minimize setbacks from future lapses among restrained eaters, researchers might develop a strategy to help them retain their restraint. framing current healthy food consumption as an opportunity to gain license might help restrained eaters achieve a balance preemptively before having an indulgent dessert (khan and dhar, ; mukhopadhyay and johar, ). none. consumer responses to interactive restaurant self-service technology (irsst): the role of gadget-loving propensity restaurant customer loyalty: a qualitative assessment of niche brands frequency of eating out at both fast-food and sit-down restaurants was associated with high body mass index 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research conclusions mandatory calorie disclosure: a comprehensive analysis of its effect on consumers and retailers the work described in this paper was supported by the institute of international business and governance, which had been established and supported by a grant from the research grants of the hong kong special administrative region, china (ugc/ids/ / ). supplementary material related to this article can be found, in the online version, at https://doi.org/ . /j.ijhm. . . key: cord- -lepsuyns authors: braimoh, ademola title: building resilient food systems in africa date: - - journal: nan doi: . /j.oneear. . . sha: doc_id: cord_uid: lepsuyns climate change constitutes a significant threat to food security and poverty reduction in africa, and the food system is severely off target in meeting development goals. policy response should focus on investing in agricultural public goods, scaling up digital solutions, and developing innovative finance mechanisms to enhance resilience. food security is a major development challenge in africa. demand for food has been growing rapidly and will continue to do so in the conceivable future, exceeding % per year through . population growth at the rate of about % per year, per capita income growth and urbanization, and changing consumer preference toward processed foods and more nutritious and higher calorie foods are the major drivers of demand. today, africa is a net food importer, at an annual cost of $ billion. and as climate change progresses, food security concerns only grow. adapting africa's food system to climate change will be crucial if it is to achieve food security and lift people out of poverty. about million of africa's population ( %) are undernourished, and the number could increase to million by if appropriate adaptation measures are not taken. crop productivity declines by % for every degree of warming above historical levels. from devastating droughts in southern africa and west africa to cyclones and intense flooding in east africa, extreme weather is putting millions of africans at risk of food insecurity. at the same time, climate change is predicted to reduce the income of people in the bottom % by more than % by , further constraining their ability to respond to climate shocks and adapt to climate change. this only grows more worrying in light of the coronavirus pandemic that is highly disrupting the food market and exacerbating food price inflation. climate impacts will continue to deepen existing vulnerabilities and low capacities, leading to poverty, fragility, conflict, and violence. for africa to be prepared for this troubling and uncertain future, it is vital that resilience is built into its food systems. in response to the climate and food security challenges, members of the african union met at malabo in june . the resulting ''malabo declaration'' provides the direction for africa's agriculture transformation for the period - , within the framework of the comprehensive africa agriculture development programme (caadp). among its goals were pledges to enhance investment finance in agriculture, boost intra-african trade in agricultural commodities and services, end hunger, and halve poverty. it also explicitly aims to enhance the resilience of livelihoods and production systems to climate variability. however, the biennial review of progress indicated that africa's food system is severely off track. while out of reporting african union member states improved their overall agricultural transformation scores compared to , only four countries surpassed the benchmark. similar trends are seen throughout the report, with few countries on track to meet specific targets. however, there are exceptions. boosting intra-african trade in agricultural commodities and services is on track in countries. regional trade helps to maintain farm gate prices and safeguard farmers' incomes while serving as an important buffer to offset production shortfalls in a country and helping to stabilize food prices for consumers. in addition, countries are on track for increasing the total area of land under irrigation. however, this is only million hectares, less than % of africa's poten-tially irrigable lands. only countries are on track in implementing policies to enhance resilience to climate variability, indicating more needs to be done in meeting this goal. creating momentum for resilience current progress toward achieving the malabo declaration's targets reveals the pressing need to accelerate progress toward food systems' resilience in africa. but it also reminds us that africa has vast agricultural potential. throughout africa, there exists over million hectares of uncultivated land that can be brought to productive use in climate-smart ways. the expansion of irrigation can help intensify the use of farm labor by facilitating year-round cultivation, improving crop response to fertilizers and improved seeds, and promoting the adoption of higher-value crops such as fruits and vegetables. developing the agricultural sector is also a pathway toward reducing poverty. on average, growth in agriculture is two to three times more effective in reducing poverty than the same amount of gdp growth elsewhere in the economy. africa's food and beverage markets are expected to top $ trillion in value by compared to usa's $ billion in . african agriculture is also energized by entrepreneurial youth and an engaged private sector that is taking note of its potential. young africans are making agriculture a viable business, creating opportunities for farmers as well as themselves. if africa is to build a resilient food system and lift agricultural workers out of poverty, it is essential that this potential is unlocked. for agriculture in africa to not only persist but to flourish in an uncertain future, improved policy responses are crucial. african governments need to strengthen enabling environment through improved policies and investments in agricultural public goods, scale up digital solutions for agriculture, and develop innovative financing schemes through public-private partnerships. foster policies for enabling climate action the starting point for a more enduring agricultural transformation in africa is to implement policies that enable effective climate action. such policies are needed across a wide variety of domains, including agricultural research and extension, market information systems, and development and maintenance of rural roads. policies must also eliminate agricultural, trade, and macroeconomic regulations that reduce farmers' incomes, which could increase agricultural output by . %. investments in international and agricultural research can result in the development of varieties that are tolerant to harsh conditions. publicly financed agricultural research should focus on emerging problems faced by farmers, designing inclusive knowledge management systems to strengthen farmers' knowledge of climate-smart agricultural practices, facilitate sharing of improved techniques, and support the integration of indigenous knowledge systems with modern science. doubling agricultural research spending could increase agricultural output by . %- . %. doubling irrigated land area can increase agricultural output by . %, while public spending to increase average schooling level of agricultural labor force to years will increase output by . %. better policies are also needed to improve land governance to ensure equitable access to land. small and commercial farmers must also have access to input and credit and product markets, and receive similar prices for their products, and policies should create the opportunities for rural labor force to migrate to access rural employment. technologies for collecting, storing, analyzing, and sharing information digitally, including mobile phones and the internet, have great potential to improve efficiency, equity, and environmental sustainability of the food system. from videobased agricultural advice to the internet of things-enabled climate-smart irrigation tools to agroweather advisories that provide personally relevant information on weather and impending disasters and help farmers capitalize on changing conditions, digital solutions could be a game-changer in boosting agricultural productivity and resilience in a sustainable way in africa. the technologies enable actors within the food system to make informed decisions, improve productivity and incomes, and achieve better nutrition, health, and resilience outcomes. furthermore, digital technologies can be applied for agriculture e-commerce, thereby helping to match buyers with sellers, shorten agricultural value chains, provide access to new markets, reduce transaction costs, and create new business opportunities for actors within the food system. in addition, digital agriculture can successfully leverage africa's youth bulge. about to million youth enter the workforce each year, but only . million jobs are created, leaving several million youths unemployed. rural youth are well-placed to benefit from jobs created by digital agricultural innovation since they are more likely to own mobile phones. however, increasing the adoption of digital technologies in the food system will require expanding mobile internet coverage, currently at % of the population, and promoting the availability of relevant digital applications tailored to different actors within the food system. as network coverage increases, so do potential users of digital solutions, which increases the incentives for digital solution providers to develop relevant applications. additionally, farmers and aggregators require the knowledge and skills to use digital technologies. for example, farmers must know that a certain technology exists, believe it will solve a problem, and then learn how to apply the technology. to encourage adoption more broadly, digital technologies should be user friendly and require low-level skills and literacy for its use, for example, with interactive voice response functionality. for current and new generations to make use of digital technology and engage profitably in agriculture, they need entrepreneurial programs that provide a package of services to overcome the multiple constraints they face. these services include trainings, access to land, inputs, finance and markets, and mentoring. producer organizations, nongovernmental organizations, and social enterprises can be instrumental in designing and delivering effective entrepreneurship programs. another strategic approach is to upgrade skills in agriculture universities and training institutes by revamping training curriculum to include the application of information and communications technology (ict) tools, as well as improved techniques of food storage and processing, and the application of renewable energy in agricultural value chains. develop innovative financing instruments the agricultural financing gap in many african countries surpasses government budgets and available donor funding. to maximize finance, it is important to leverage private sector resources and minimize the burden of public debt. innovative financing leverages all sources of financing to support agricultural growth and resilience, crowding in private investment to optimize the use of scarce public resources. sources of private finance for the food system are growing and includes farmers' own-savings, local and international banks, microfinance institutions, value chains actors, impact investors, development finance institutions, private sector foundations, and agricultural investment funds. because the agricultural sector is prone to considerable production, market, and enabling environment risks, blended finance can be used to support high-impact projects where perceived risk is higher than actual risk. this is especially true for new projects with which investors are unfamiliar. high levels of direct public participation in markets leave little space for private sector activities in the agricultural sector in many african countries. public sector dominance needs to be reduced, and public sources instead need to be used to increase the flows of capital to enhance resilience in africa. this should focus on enhancing farmers' access to tailored and demand-driven financial services, building the capacity of financial institutions to manage exposure to specific agricultural risks, and supporting financial institutions in reducing transaction costs. it should be noted, however, that reduced public sector dominance is not a sufficient condition to increase productivity and commentary resilience; there is still a crucial need for public resources to finance essential agricultural public goods and services as discussed above. food system resilience is an unfinished agenda in africa, compounded by the coronavirus pandemic. several countries are lagging in terms of efforts to meet food security, poverty reduction, and climate change goals. african governments need to improve the enabling environment for the food system to thrive by increasing investments in agricultural public goods, supporting smallholders to benefit from digital revolution, and developing innovative financing instruments through public-private partnerships. these measures could do much to transform african agriculture, increase food security, reduce extreme poverty, and boost shared prosperity in the region. a meta-analysis of crop yield under climate change and adaptation unbreakable: building the resilience of the poor in the face of natural disasters second biennial review report of the african union commission on the implementation of the malabo declaration on accelerated agricultural growth and transformation for shared prosperity and improved livelihoods (african union the (evolving) role of agriculture in poverty reduction: an empirical perspective growing africa: unlocking the potential of agribusiness resources, policies, and agricultural productivity in sub-saharan africa future of food: harnessing digital technologies to improve food system outcomes jobs for youth in africa: catalyzing youth opportunity across africa mobile industry impact report: sustainable development goals (gsma) future of food: shaping the food system to deliver jobs future of food: maximizing finance for development in agricultural value chains making climate finance work in agriculture key: cord- -phsr jp authors: nan title: abstracts tps date: - - journal: allergy doi: . /all. sha: doc_id: cord_uid: phsr jp nan (either in men or women) between metabolic syndrome and incident asthma. conclusion: this study confirmed the significance of obesity as a risk factor for incident asthma. moreover, obesity appeared to be a stronger risk factor than metabolic syndrome. | relationship between helminth infection, blood eosinophils and asthma symptoms in a rural community from the tropics peñaranda d; alvarez l; sierra n; lopez j; zakzuk j; caraballo l institute for immunological research. university of cartagena, cartagena, colombia background: immune response to helminths shares many features with the allergic response. in tropical regions where helminths are highly prevalent, asthma is still a major public health burden. large clinical cohorts suggest that high blood eosinophils (hbe=> cells/ mm ) are associated with asthma exacerbations. however, the association between hbe and asthma severity in rural communities with prevalent helminthic infections is unclear. method: patients with wheezing symptoms in the last year living in a rural tropical community (santa catalina, colombia) where helminths are highly prevalent, were recruited for this study. blood eosinophils were assessed by complete blood count. parasitic infection was evaluated with two serial coprological exams (kato-katz method) and skin prick tests were conducted to determine reactivity to ascaris. results: seventy-three patients (mean age: ; range: - years old) were recruited in this study. a. lumbricoides and t. trichuria active infection ( . % and . %, respectively) were not related to age or gender. a positive spt to ascaris extract, aba- and d. pteronyssinus was observed in %, . % and . %, respectively. mean eosinophil count was cells/mm ; . % had hbe. rate of patients with at least one emergency department visit was . % and hospitalization, . %. blood eosinophil counts (as a continuous variable) were inversely associated with age (p = . ) and higher in helminth infection (p = . ). in crude univariate analysis, exacerbations (er and/or hospitalization) were associated with age (or: . ; % ci: . - . , p < . ) and hbe (or: . ; %ci: . - . , p = . ), but not with helminth infection. for a better definition of asthma, multivariate analysis done in those > years old indicated that hbe, helminth infection and positive ascaris spt were not associated with asthma exacerbations. conclusion: uncontrolled asthma is common in rural places of the tropics. since helminth infection influences eosinophilia, the clinical value of hbe to predict exacerbations is limited in helminth-endemic populations. castro mc ; ferreira j ; sarmento d ; carvalho c ; matos a ; bicho m chln-immunoallergy; lisbon medical school-genetic department, lisboa, portugal; lisbon medical school-genetic department, lisboa, portugal background: the bioavailability of no and endothelial homeostasis depends on the functional polymorphism of -bp del/ins within intron- of dhfr (dihydrofolate reductase enzyme) (rs ) that could interfere in the regeneration of bh (tetrahydrobiopterin) from bh ( , -dihydrobiopterin) and contributes to endothelial dysfunction in asthma. method: asthmatics (n = ) compared with control group (n = ).the polymorphism was analyzed by pcr. control of asthma assessed by (acq and paqlq). statistical analysis with spss . establishing a significance level of p < . . results: there are women and males in asthmatics and women and males in controls (p = . ). in asthmatics: age ( x ± sd): . ± . ; and in control group: age ( x ± sd): . ± . . the genotype frequencies in asthmatics are: dd ( . %); id ( . %); ii ( . %); in control group: dd ( . %); id ( . %); ii ( . %); there is no statistical difference between groups (p = . ). the allelic frequencies in asthmatics are: allele d ( . %); allele i ( . %); in control group: allele d ( %); allele i ( %); there is no statistical difference between groups (p = . ). the genotype frequencies in the uncontrolled asthmatics are: dd ( . %); id ( . %); ii ( . %) ; in the controlled asthmatics are: dd ( . %); id ( . %); ii ( . %); there is statistical difference between groups (p = . ). genotypes id and ii are more frequent in the uncontrolled asthmatics. the allelic frequencies in the uncontrolled asthmatics are: allele d ( . %); allele i ( . %); in the controlled asthmatics are: allele d ( . %); allele i ( . %); there is a trend to have differences between groups (p = . ). allele i is more frequent among uncontrolled asthmatics. the uncontrolled asthmatics are older than the controlled asthmatics (p < . ). there is no differences in gender distribution (p = . ). the genotype ii confers a risk of being uncontrolled asthmatic of . times when compared with controlled asthmatics and adjusted for age: or b : . [ . - . ]; p = . . physiopathology and the emergence of evidence-based clinical guidelines. however, variation still exists among some diagnostic aspects of asthma in real life. it is unknown to what degree diagnosis is affected by the treating physician's medical specialty. results: a total of gps, pediatricians, allergists, pulmonologists and otolaryngologists (orls) replied. although for general application of diagnostic clinical criteria all physicians rated similarly, in general accordance with the mag suggestions, a third of non-pulmonologist practitioners don't recognize chest discomfort as one of the clue symptoms of asthma, but they erroneously believe crackles are (p = . ). we found agreement in almost half of all physicians to erroneously believe that viral illness' induced wheezing in non atopic children predisposes asthma. conversely, - % are aware that allergic sensitization predisposes to asthma. most specialists -except pulmonologists (p = . )-incorrectly listed fev as the best parameter to identify airflow obstruction (ao) and fev /fvc to assess ao severity. % of gps do not know peak expiratory flow (pef) measurements could be valuable, and % of all specialists are not aware that changes in pef can also be used to confirm ao reversibility. to classify asthma, only pulmonologists adequately considered the level of control in similar proportion than severity ( % and %, respectively), which is uniformly the preferred method by most other specialists. conclusion: although in general many clinical aspects of asthma diagnosis seem to be accurately assessed, there is a wide specialityspecific variation regarding some aspects of phenotyping and classification, diverging from mag's recommendations. as such, our results can help to detect knowledge-gaps and to guide the development of more focused specialty-specific learning tools to improve clinical impressions, process medical evidence, and apply it to patient care. | issues, continuous medical education on treatment of acute asthma, exercise induced asthma and asthma in pregnancy should include, per medical specialty background: to unify and improve the management of asthma, including asthma exacerbations, the mexican guideline on asthma ( . %) of employees who stated increased symptoms with flour exposure. among all workers ( . %) employees were diagnosed as asthma and ( . %) workers were diagnosed as ba. conclusion: wheat flour sensitivity is high among workers who are exposed to wheat flour, however the prevalence of ba is similar to the previous data in the literature. johnsen cr ; callesen kt ; jensen bm ; poulsen lk clinic of allergy, dept. of dermato-allergology, gentofte hospital, copenhagen, denmark; laboratory of allergy, gentofte hospital, copenhagen, denmark background: enzymes are well known as sensitizers and causes of occupational allergy primarily in the industries producing and using the products. we present a case of occupational contact urticaria, rhino-conjunctivitis and asthma in a year male chef who was using a transglutaminase enzyme powder obtained from fermentation of streptomyces mobaraense as meat glue in processing of fine culinary dishes. this transglutaminase has been used for protein food preparation in industrial settings since to improve the texture of protein rich foods such as surimi or ham. in this case it was used in small scale in a gastronomy restaurant kitchen spraying enzyme powder with a sieve over raw meat without any protective equipment in contrast to the producer's recommendation. the chef was also found allergic to dried, edible mushrooms also forming part of the meat dish prepared with the transglutaminase enzyme powder. in one occasion he experienced an oral reaction with itching and swelling of the mucosa in the mouth, stridor, angioedema of the face, and urticaria after ingestion of beef meat treated with transglutaminase and rolled in horn of plenty dried mushroom powder. no other symptoms of food allergy were reported but a known cat allergy was. background: formaldehyde and xylene are occupational skin and respiratory irritant and/or sensitizer, exposure to those may be associated with dermatitis, rhinitis and asthma. health care workers, as nurses, laboratory technicians, doctors could be exposed in different tasks in operating rooms, endoscopy and in pathology laboratory. we describe three cases of work-related rhinitis in technicians employed in the same unit of hospital pathology . first case: a woman of years old underwent medical examination in our occupational allergy unit because allergy respiratory symptoms. she has been working for years in pathology laboratory and was exposed to xylene and formaldehyde. she developed rhinitis, rhinosinusitis, hyposmia and cough with sputum after years started work. she had negative skin prick test for common aeroallergens. lung function was normal with a fev /fvc ratio of % of predict. blood cells count reveled % of eosinophils ( /mmc) with total leucocytes. second case: a woman of years old was affected by moderate persistent allergic rhinitis with positive skin prick tests to house dust mite, dog and cat. in the last year rhinitis symptoms worsened in relation to work and improved during vacation. when she was exposed mostly to formaldehyde during shift at the end of it she usually experienced face skin and conjunctival erythema. she developed work-related symptoms after years of exposure in the pathology unit. third case: a woman of years old, who has been working for years in the pathology unit and was exposed to formaldehyde and xylene, in the last year developed moderate-severe persistent rhinitis with hyposmia and chronic cough. she referred to otorhinolaryngologist and an irritant induced rhinitis was diagnosed. she had negative skin prick test for common allergens and normal lung function. results and conclusion: the workers experienced respiratory symptoms in relation to work exposure to formaldehyde and xylene. the suspected causal agents were monitored in the work environment and an exceeding of the recommended limit values was found. preventive measure were adopted with a reduction of exposure and symptoms improve only in the second and third case. challenge test with mannitol is considered to be more specific than test with methacholine. also, duration of procedure is shorter and safer. therefore the study aim was to compare the usefulness of these two tests in monitoring of sict. method: four bakery workers with suspicion of oa underwent single-blind, placebo-controlled sict with workplace allergens accompanied by evaluation of nsbhr with mannitol and methacholine before and after sict. clinical examination, spirometry, skin prick tests (spts) to common aeroallergens and occupational allergens, serum specific ige antibodies to occupational aeroallergens were also performed. results: positive spts results to occupational aeroallergens were found in all bakery workers, specific ige to flours were detected only in two subjects. three out of the four patients displayed positive sict reaction (in two cases early spirometric response). in all of these patients, airway response to methacholine increased significantly. in the first two patients also airway reaction to mannitol was significant, whereas in one subject with early reaction there was no increase in nsbr after mannitol inhalation. the patient with negative sict results did not reveal any changes in nsbr before and after the test, neither to methacholine nor mannitol. | rice-induced occupational anaphylaxis and socio-economic impact-case report method: in this prospective study, a total of students completed a self-administrated questionnaire that comprised different questions and gave information about the participants and their glove use, working habits, signs and symptoms related to these gloves, precautions taken to minimize it, etc. skin prick test is performed through commercial extract latex gloves (stallergenes), while patch test is prepared through latex gloves and adhesives. two types of gloves are used: gloves that contain latex and gloves without latex (vinyl gloves), which are used also as e negative control. results: questionnaire items and diagnostic tests revealed that one-fourth of subjects were suspicious for latex gloves hypersensitivity. their mean value for skin reactions like irritant or allergic dermatitis or contact urticaria was between % and %, while for other symptoms the mean value was under %. logistic regression analysis revealed an association between different questionnaire items and positive allergy tests among suspected cases and diagnosed cases of latex allergy. approximately % of people who work with laboratory animals experience some allergic symptoms and about % of animal technicians go on to develop serious symptoms of asthma. uk government guidelines state that employers must prevent or adequately control exposure of employees to animal allergens and should undertake monitoring to ensure that suitable controls remain effective. the most widely used monitoring method is personal iom filters. however, these need to be attached to a pump and carried by the technician which can be cumbersome and awkward. previous data has demonstrated that allergens from dust mite, cat, dog and pollen could be captured and quantified by a novel type of nasal filter. in this current study, we sought to assess the feasibility of using the nasal filters for the assessment of exposure to mouse allergen in a laboratory facility. method: technicians working in a laboratory animal facility were asked to wear the filters during normal routine work. for comparison, they were also asked to wear an iom filter for the same duration. allergen was extracted from nasal and iom filters by gentle rocking in pbs-tween for two hours. levels of the major mouse urinary protein (mus m ) were quantified using our multiplex array technology, which is highly sensitive and allows for quantification of mus m down to . ng/ml. results: significant levels of mus m were detected in the nasal filter extracts and these levels correlated with the type of activity that was being performed by the technician, as well as the housing environment of the mice. levels were compared to the suggested 'safe' limit of allergen exposure of ng/m . we also found that the technicians grew accustomed to the nasal filters quickly and found them far more practical for every day monitoring that wearing the iom filter and pump. conclusion: these data indicate that nasal filters may be considered a simple and easily wearable method for monitoring laboratory animal allergen exposure. future studies are planned to assess the feasibility of wearing the filters for analysing exposure to other laboratory animal allergens from rat and guinea pig. havana university lower co emission, water and feed consumption and limited waste production. insects are currently allowed both for human and animal feeding in some eu countries, including italy and the risk profile related to production and consumption of insects as food and feed, including risk of allergenicity, is currently under evaluation by efsa. both food and feed products derived from insects require multiple manipulations by the breeder and/or by the workers who transform the insect into the commercial products, thus the occupational exposure have to be considered too. the aim of this work is to evaluate the allergenicity of tenebrio molitor, one most used species for animal feeding. method: t. molitor proteins were extracted from intact dried larvae and from flour of dried larvae. the protein extracts were separated in one-dimensional electrophoresis conclusion: according to these results, the larva flour seems to be less immunoreactive than the intact counterpart, probably due to the processing that causes the degradation of protein bands over kda. working in gastronomy is associated with exposure to many factors with an irritating and allergic potential influencing respiratory system. food products and organic dust are the source of inhaled allergens which may cause sensitization during apprenticeship. the study aim is a prospective observation of incidence of sensitization to selected environmental and occupational allergens among culinary school apprentices and identification of work-related allergic diseases in this group. method: the cohort comprised apprentices. they were examined in the first and the second year of education. questionnaire and allergological tests [(skin prick test) spt to common and occupational allergens, ige level evaluation (total and specific for occupational allergens) and pulmonary tests] were performed]. results: the most frequent symptoms reported by examined apprentices were rhinitis ( . %), conjunctivitis ( %), skin symptoms ( . %), dyspnea ( . %) and cough ( . %). subjects developed nasal symptoms during the second year of education, while in cases the skin symptoms and in subjects conjunctivitis appeared. in cases the work-related symptoms were reported. the most frequent positive results of spts were obtained with dermatophagoides pteronyssinus . %, dermatophagoides farinae . %, grass pollens . %. positive spt to rye and barley flour were found in respectively . % and . % apprentices. . % of apprentices had specific ige to flours. the preliminary results indicate that work-related allergy symptoms and hypersensitivity to occupational allergens are rarely found among culinary school apprentices in the first years of education. the further observation will allow to evaluate the trends in incidence of allergy to occupational allergens, as well as the clinical presentation of allergy in that group. | how multifaceted the clinical presentation and etiology of allergic diseases could be? method: the study was done in children from west georgia randomly and on based of questionnaire of representative cohort. ( ) ( ) ( ) . the cohort was children, - years old, risk factors were studied by way of interviewing, clinical-laboratory dates. for assessing the risk factors, was used 'case control' method. the statistical processing of material was done with computer program sps/sv . inclusion criteria for enrolment were: collectors of dust, gender, existence of moisture and mold consuming of tabasco, atopic dermatitis and seasonality. results: the groups, which we have studied, prevalence of acute respiratory viral infection was %, bronchitis − . %, allergic rhinitis . %, atopic dermatitis . %, food allergy . %. the reliability was high (p < . ) in families with bronchial asthma compared with healthy population. bronchial asthma was detected in . % of population. the hereditary load of allergic diseases in patients with bronchial asthma was . % and in healthy cohort it was . % (p < . ). conclusion: based on the results, we can conclude that, ecological factors and genetic predisposition significantly influences on prevalence of sensibilisation of house dust mite, molds and formation of bronchial asthma. as the genetic and environmental factors that act on an immune system are better elucidated and their roles established, the implementation of more enduring preventive efforts will be developed. however, at present, the best approach to the child at high risk for the development of allergies is to institute dietary and environmental control measures early to decrease sensitization, and to recognize and appropriately treat the evolving signs and symptoms of allergic disease. background: plantation of road-side avenue trees has become a major part of the urbanization programme in kolkata metropolis of india for megacity beautification and environmental management. due to evergreen habits, gulmohor (delonix regia) and chhatim (alstonia scholaris) are frequently selected for plantation programme to generate green belts. however, an increasing incidence of seasonal pollinosis was observed among the inhabitants living in close vicinity to these trees suggesting a possible link between the airborne pollen load and the concomitant respiratory hazards. this prompted us to investigate the allergens in the pollen of these two dominant avenue trees. method: aerobiological surveys were conducted at multiple sites of kolkata for a period of two years using seven-day volumetric burkard sampler to record the pollen concentration in the outdoor ambient air. clinical data and residual blood of pollinosis patients were collected from a public hospital. allergens were detected in the pollen proteome fractionated in d gel by ige-serology. the major igereactive proteins were partially purified by ammonium sulphate fractionation followed by ion-exchange chromatography. the allergenic activity of the fractions was tested by histamine release assay. results: a clear correlation was observed between the pollinosis related morbidity and the aeropollen load especially during the peak flowering period of these two trees. about % and % of the patients displayed positive spt response and ige-reactivity using pollen extracts of gulmohor and chhatim respectively. immunoproteomic analyses revealed the presence of - ige-reactive components in the d pollen proteome of these species. hierarchical cluster analysis with patient immunoblot data identified a kda and a kda protein as major allergens of gulmohor and chhatim respectively. the purified fractions containing each of these two major allergens induced histamine release from granulocytes within a range between and %. method: immortalized human keratinocyte cell line (hacat) and primary normal human epidermal keratinocytes (nheks) were differentiated with calcium chloride for and days, respectively. following the differentiation, the cells were treated with il- ( ng/ml), il- ( ng/ml), and/or hcho ( × ^- %) for hours. the mrna expression of flg, ivl, lor, dsg , dsg , dsc , dsc , as well as tslp was analyzed using quantitative real-time pcr. results: hcho exposure decreased the mrna expressions of structural components (flg, ivl, and lor) and cell adhesion molecules (dsg , dsg , dsc , and dsc ) in a short-period time of exposure ( hours). we also found that hcho exposure significantly enhanced il- -and/or il- -induced tslp production in nheks as well as hacat. interestingly, exposure to hcho alone is enough to increase the tslp mrna expression in both cells. conclusion: our results suggest that hcho exposure might synergistically damage the skin barrier function with il- and il- by increasing tslp expression and decreasing structural components as well as cell adhesion molecules. | skin prick test reactivity to aeroallergens in adult allergy clinic in a tertiary hospital: a -year retrospective study results: five different human sera were screened for specific ige level against different allergen sources using test methods of three different suppliers. the sensitivity of the three different methods can be arranged in the ascending order manufacturer a < manufacturer c < manufacturer b. with the test of manufacturer a, % of the measurements were below the detection limit ( . ku/l), with the test of manufacturer c, % of the measurements were below the detection limit, whereas the test of manufacturer b leads to values below the detection limit in % of the cases. in terms of variation coefficient, the test system of manufacturer c had the best performance. test systems of manufacturers a and b exhibited comparable variation coefficients, which were considerably higher than that of manufacturer c. conclusion: based on these test results, only the test of supplier c is recommendable for determination of levels of specific ige for diagnostics of allergic patients. with the test of manufacturer a, elevated levels of specific ige antibodies for many allergens cannot be detected due to the poor sensitivity of the test system. the test system of supplier b exhibits a good sensitivity but the coefficient of variation is rather high for a diagnostic test. this drawback could be circumvented by multiple determination of one test parameter. although this is an advisable strategy in general, the routine in diagnostic laboratories is incompatible with this approach, since throughput would decrease while costs would increase. this study is another good example for the need of the implementation of a characterized standard material with known values of sige, as demanded by wojtalewicz et al. method: cd c and cd expression on basophils were monitored upon exposure of whole blood samples (< hours) to anti-ige and/or allergenic extracts. staining was conducted on exposed samples using dry room temperature stable antibody panels (dura innovations format) coated in well plates, eliminating all antibody pipetting steps from the workflow. red blood cells were lysed and data was acquired (without further wash steps) on a cytoflex flow cytometer (beckman coulter). staining and lysing were automated using a biomek (beckman coulter). results: the described no-wash preparation protocol, already established for manual preparation mode in tubes, could be trans- conclusion: the hr-test was significantly less likely to be positive, if a patient suffered from monosymptomatic ae than in ae patients with concomitant urticaria. this could signify a higher likelihood of treatment response to antihistamine and other anti-allergic medication in the latter group. background: pathogenetic mechanisms of allergy are polymorphic. they include ige-dependent and ige-independent, allergen-specific granulocyte-mediated and lymphocytic reactions, as well as nonspecific hypersensitivity, which are realized through a variety of mediators: histamine, tryptase, etc. allergen bucal challenge mimics the natural situation and is useful for understanding the mechanisms of allergic airway inflammation and airway hyperresponsiveness (ahr).saliva used as a non-invasive readily available bio-sample for diagnosis instead of blood. biomarkers in saliva are associated with the pathogenesis and clinical outcome of allergic diseases method: aim: to examine mediators for ahr with buccal(mucosal) challenge tests. we examined patients with allergic asthma(the history, positive skin prick test, serum specific ige) and healthy volunteers. saliva were collected. then, both groups were subjected to buccal(mucosal) allergen challenge by a water-salt solution of the mite allergen dermatophagoides pteronyssinus. saliva was recollected in minutes and hours after the provocation. the level of myeloperoxidase, elastase, tryptase in saliva were determined by the elisa. that provocative test did not cause clinical symptoms development or reduction in nasal bronchial patency in any patient. results: in patients with allergopathology, an initially increased level of myeloperoxidase and tryptase in minutes after the provocation, elastase increased in hours (table ) . tryptase in saliva after minutes increased till . ( . ; . ) (me, pg/ml (lq;uq)), p = . . increased tryptase is presence of increased cellular inflammation, e.g. mast cells. its ige-dependent hypersensitivity, because there was the correlation between the elevated level of tryptase and positive prick tests. elevated levels of myeloperoxidase and elastase in saliva may be the criteria for the neutrophil hypersensitivity and ige-independent reactions. in healthy volunteers this increase was not observed. the identification of tryptase, myeloperoxidase, elastase can be used for diagnosis of types of ahr. tryptase is a mediator of early (immediate) response to allergen. increased myeloperoxidase and elastase indicates the involvement of the eosinophils and neutrophils in the oral mucous membrane in the allergic process. these mediators have additional roles in the late phase response. elevated levels of myeloperoxidase and elastase in saliva may be the criteria for the neutrophil hypersensitivity. conclusion: safe and acute in vitro methods allow to conduct early etiological diagnosis of allergy, which contributes to the effectiveness of therapy; the detection of polyvalent sensitization dictates the need for molecular diagnostics to single allergens, which has a higher prognostic level and the clinical significance of predicting the appropriateness and effectiveness of allergen-specific therapy; laboratory diagnostics of the allergy allows to reveal sensitization at the ( , ) ( , ) ( , . ) *p = . ; **p = . ; ***p = . . subclinical level, which increases early diagnosis and identify persons with a predisposition to allergy; the establishment of causal aller- background: antibacterial chemicals like parabens and triclosan have been associated with allergic disease in children. parabens are also suspected to affect metabolic functions, possibly due to their weak endocrine disrupting properties. furthermore, a possible link has been suggested for eczema and adiposity, and thus, how body burden of chemical exposures affect both of these outcomes are of interest. we aimed to describe the association between exposure to parabens and eczema and body mass index (bmi) in an adult population in norway. method: urine biomarkers of butyl-, ethyl-, methyl-and propylparabens were quantified by mass-spectrometry in adult participants (median age= years) from the rhinessa study in bergen, norway. linear regression models adjusted for gender, age and bmi (for eczema outcomes) and with clustering for siblings, were applied to model possible association between specific gravity standardized urine biomarker concentrations of parabens with bmi and eczema. results: propyl-(ppb) and methyl-parabens (mpb) were detected in % of the urine samples; ethyl (epb) in % and butyl (bpb) in % of the samples. in women, epb and bpb were detectable in % and %, respectively. participants with current eczema ( %) had lower level of several parabens compared to those without eczema (bpb for both genders; epb in women only and sum of all parabens in men only). body burden of epb (geometric mean (gm)) was . μg/l in women with current eczema compared to . μg/l in women without eczema (p = . ). body burden of parabens (mpb and epb) were inversely associated with obesity (bmi> , ( . %) ), as compared to normal range bmi (bmi= . - ( . %)) in both men and women. the concentration of mpb for obese women was gm= μg/l compared to μg/l in women with normal range bmi. for men, the gm for mpb was . μg/l in obese compared to . μg/l in normal weight men (p = . ). conclusion: person with eczema or obesity had lower paraben levels in urine. we speculate that these chemicals might be stored in adipose tissue, and therefore excreted in urine in lower levels among the obese. eczema and obesity was not strongly associated in the current study. method: we retrospectively analysed medical records of patients who were patch-tested with our dental screening series of substances. adverse reactions to dental materials were suspected based on subjective complaints in the oral cavity and/or objective conditions of the oral mucosa. square plastic chambers on hypoallergenic tape were used. patch tests were applied to the upper back and removed by the patient after hours. readings were performed and days after application (d and d ). results were evaluated according to the international contact dermatitis research group guidelines. positive patch test reactions fulfilled the criteria of at least a one plus (+) reaction on d and/or d . the term »contact allergy« is usually used for such reactions. we prefer the term »contact sensitization«. clinical relevance of positive reactions to dental materials was not systematically assessed in this analysis. conclusion: we report a high frequency of positive reactions on d that were not seen on d . this finding demonstrates the importance of an additional late patch test reading in patients with suspected contact allergy to dental materials. background: psoriasis is a chronic inflammatory skin disease. its etiopathogenesis is not exactly known. it is believed that the disease occurs in people with genetic tendency with the effect of a triggering factor. in some studies it is observed that contact dermatitis in psoriasis is increased with respect to normal population. for this reason it is proposed that allergen materials could trigger psoriasis. in this study it is aimed to determine contact allergy frequency in psoriasis cases using patch test. results: of the cases were plaque, of them were guttate, of them were palmoplantar and of them were inverse type. more positivity rate is observed in psoriasis cases ( . %) than control ( %). the positively responsed materials with respect to decreasing number of patients are found as follows: nickel sulphate ( . %), thimerosal ( . %), peru balsam( %), p-phenylenediamine( . %), colophony( . %), n-isopropyl-n-fenil- -fenilendiamin( . %), mercaptobenzothiazole( . %), benzocaine( . %), most frequently plaque type and following guttate type positive responses are observed in evaluations with respect to clinical types. no statistical significance is found between patch test results and pasi values in psoriasis cases. conclusion: patients with psoriasis should be carefully evaluated. sometimes some materials may trigger psoriasis. the composition of the pigments that professional tattooists use are varied inorganic salts of metals or organic vegetable pigments. red tattoos, especially those that contain mercury, are the most common cause of late reactions. method: year-old male patient with no previous allergy history known, who gets a tattoo on his right leg and develops within months, cutaneous erythema and pruritus on the same location as the tattoo. true test ® for skin allergy patch epicutaneous testing is performed. results: and hours reading: showed positiveness for mercury ++, with no late positive reactions after that. conclusion: as allergists we should be familiar with the different types of tattoos available, and know the possible cutaneous complications that each of these decorative techniques can present. it is our responsibility to be able to diagnose any complications at an early stage, establish the most appropriate treatment and, if possible, prevent them by informing the possible users. background: within otorhinolaryngological pathology chronic eczematous otitis externa is one of the most common, usually treated with topical medication successfully; however, there are cases in which the poor response to treatment, or the recurrence thereof, may be due to causes secondary to the medication itself, as observed in cases of allergic contact dermatitis caused by these drugs. case report: we present a -year-old male patient without relevant pathological antecedents or known allergies, who consulted the otorhinolaryngology service of our center for otorrhea of days of evolution, bilateral external otitis is diagnosed and a topical otological combination is recommended (beclomethasone dipropionate . % and clioquinol %, excipient: macrogol) with improvement. however, during the following years the patient presents exacerbations and remissions of the condition, with negative or inconclusive microbiological studies. during all that time he was using the prior topical treatment and other combination treatments of topical antibiotics, corticosteroids and local antiseptics. more aggressive causes of external otitis such as malignant external otitis were ruled out. during the third year of follow-up, a clear relationship of exacerbations was observed with the use of the first combination of topical drugs, so it was decided to investigate allergic sensitization. material and methods: we perform patch tests using true test ® , standard spanish series (geidac -spanish group for investigation of contact allergy dermatitis), topical corticosteroid battery, antiseptic, as well as topical medications used by the patient. results: from the first reading on day two, positivity was observed for: mixture of quinolines ++ patient's otological combination ++ and chlorquinaldol ++; being confirmed in the reading at day four. eczematous external chronic otitis is diagnosed with allergic sensitization to quinolines (clioquinol, chlorquinaldol). we conclude that in the case of chronic external otitis, allergic contact dermatitis should also be investigated as a possible cause, and it is important to perform epicutaneous tests with the patient's own products to evaluate non-common or hidden allergens that may be relevant to their current pathology. most common causes of acd. it is important to distinguish local findings of infection from acd caused by topical antibiotic treatments. here we present a patient with acd with topical use of bacitracin and neomycin combination therapy due to recurrent blepharitis. an -year-old male patient presented with the complaints of itching, redness, swelling of the eyelids and facial edema. he had used various topical ophthalmic antibiotherapy and eye shampoo for years due to recurrent blepharitis. five days ago, due to the redness of the eyelids, burning sensation in the eye, itching of the eyes; he was examined by an ophthalmologist. the eyelids and eyelashes were scaly and dry. the patient was treated with warm water soaked cloth dressing, mechanical eyelash cleaning and topical antibiotherapy (neomycin-simple combination therapy). after the second day of treatment, the patient's topical ophthalmic antibiotherapy was discontinued due to an augmentation of the redness in the eye- | contact allergy after exposure to ivy (hedera helix l) potent steroid treatment associated with systemic antihistamines, but with no improvement. on dermatological examination a small, well delineated, eczema-like plaque was noticed on a digital finger, as a new finding striking with her old burn scars. she denied any symptoms and was in good health condition. a mm punch biopsy was performed and histological report established the diagnosis of squamous cell carcinoma. the patient was transferred to oncology department for further investigation and treatment. conclusion: early diagnosis and prompt surgical therapy are recommended to all patients with chronic wounds and scars who develop malignant transformation. *written informed consent for the publication of potentially identifiable personal details of patient (gender, age, illness, location) was obtained. **in relation to this presentation, i declare that there are no conflicts of interest. ertugrul a; hizli demirkale z; bostanci i dr sami ulus maternity and children training and research hospital, ankara, turkey introduction: the incidence of contact sensitization among adolescent has been increasing. nickel is one of the important causes of allergic contact dermatitis (acd) in this age group. increased exposure to nickel and deterioration of the skin barrier are among the important risk factors in children. the gold standard for diagnosis is skin patch test. we report here an adolescent patient who has allergic sensitization to nickel and cobalt. case: a -year-old female patient admitted in our clinic with a complaint of edema on her face. the patient had applied chickpea water to her face at least once a day for one week because of her acnes. her medical history revealed that she had experienced similar edema on her face after applications of clay mask one year ago. she was diagnosed with cellulitis and she had been treated with antibiotics for five days. on her physical examination, angioedema was observed on her face, especially on the glabellar region. eosinophilia was not found on her laboratory data. c-reactive protein (crp), c and c esterase inhibitor protein levels were also normal. the skin prick test was performed with aeroallergens, chickpea, lentil, bean and nuts, and no reaction had been observed. the patch test was performed with 'thin-layer-rapid-use-epicutaneous' (t.r.u.e) test and chickpea. the patient had positive reactions to nickel and cobalt. detailed questioning disclosed that the patient was preparing the chickpea water in a metal pot. result: chickpea water and clay mask contain varying amounts of nickel. it was thought that the edema of the patient is due to nickel allergic contact sensitization. an increased exposure to nickel and cobalt raises the frequency of sensitization. nickel allergy can cause different clinics ranging from localized lesions to systemic reactions. we want to emphasize that a detailed medical history and the patch test would enable clinicians to demonstrate hidden allergens and then make a correct diagnosis. case report: autoimmune progesterone dermatitis is a condition of hypersensitivity to progestogens. it is not an easy diagnosis given the variety of clinical presentations it may have, ranging from eczema, urticaria, erythema multiforme, folliculitis, to angioedema or even anaphylaxis. manifestations are cyclical, occurring when the levels of progesterone are higher, this is, at the luteal phase of the menstrual cycle, and disappear during menses, with the physiological decrease of the hormone. it can also be triggered by exposure to exogenous progestins. we report the case of a -year-old woman with a cyclical erythematous and violaceous rash related to the menstrual period. the symptoms typically began - days before the onset of menses and ended - days before. the diagnosis was based in the clinical history and intradermal skin tests: skin prick testing with levonorgestrel and medroxyprogesterone were negative, but the intradermal skin test with medroxyprogesterone was positive at a concentration of mg/ml. we performed intradermal testing with the same concentration in three other women with no symptoms to exclude an irritative reaction, which were negative. autoimmune progesterone dermatitis is, perhaps, not so rare, but rather poorly recognized and reported, and thus, underdiagnosed. clinicians should be aware and include always this condition in the differential diagnosis, especially in cases of atypical or intractable skin eruptions. case report: a year old male was referred to a community allergy clinic for assessment of chronic urticaria (cu). allergy assessments for foods, inhalant and inducible physical triggers revealed no association. an autoimmune workup followed, with treatment consisting of standard dose antihistamines (h and h ). blood work revealed a persistently low hemoglobin with low-normal ferritin. hematology consulted and followed attempted iron replacement to no avail. skin biopsy revealed neutrophilic rich urticaria with the presence of eosinophils. serum protein electrophoresis (spep) revealed a monoclonal gammopathy with elevated igm, felt to be of undetermined significance (mgus). c-reactive protein (crp) was consistently elevated ( , ) in conjunction with anemia. rheumatology consulted and cleared of any evidence of vasculitis. hematology considered the anemia to be of chronic disease linked to cu. the cu was resistant to treatment including high dose antihistami- background: isolated head and neck angioedema (ae) can be mediated by bradykinin (bk) or histamin (hi) . the objective of our study was to determine which etiology was most frequent in cases of death by asphyxiating ae in france. we sought all cases of death by isolated asphyxiating ae reported in france between and via death certificates and/or the national pharmacovigilance database. results: the overall mortality by asphyxiating ae for all causes was . / million inhabitants. the death rate of bkae per million inhabitants was . and lethality of . per thousand patients per year. the death rate of hiae per million inhabitants was . and lethality of . per thousand patients per year. we found a times higher risk of death in case of bkae than hiae. conclusion: consequently, particularly severe episodes must be initially considered as bradykinin mediated and quickly reassess any first-line treatment that is inappropriate. case report: we present the case of a -year-old man who suffered recurrent abdominal pain since age of eight, leading to unnecessary emergency surgical interventions and endoscopies before hereditary angioedema due to c inhibitor deficiency (c -inh-hae) was diagnosed at the age of . rare subcutaneous swellings were considered allergic reactions preventing proper diagnosis. family history, positive for recurrent abdominal pain and swellings was totally neglected until diagnosis of c -inh-hae type i was established through appearance of severe oro-facial symptoms in the propositus' grandson. the diagnosis was suggested by the boy's mother, directed by educational materials available in the international hae patients' association website (www.haei.org). this report highlights and emphasizes the importance of accurately evaluated personal and family history to suspect condition that are scarcely known to the majority of physicians. highlights: diagnostic delay in hae and iatrogenic procedures are an underestimated problem, hiding undefined consequences, possibly destructing an entire lifetime. correct, publically available information provided by patients' associations raise awareness about the disease and could put the milestone of establishing correct diagnosis. de luque v ; lara p ; guardia p ; jimenez ar virgen macarena hospital, seville, spain; hospital virgen macarena sevilla, seville, spain background: in the protocol for the study of patients who consult for recurrent acute angioedema with facial involvement, the contactant battery is included (epicutaneous test). we review the results in our patients with facial angioedema to evaluate the contactants to which these patients present sensitization, some of them coexisting with contact dermatitis clinic. we reviewed the patients referred to the clinic for recurrent acute angioedema with facial involvement and to whom a standard battery epicutaneous test was requested. in all these patients, other habitual triggers included in the diagnostic protocol (food, medications, autoimmune diseases, bradyinergic aea/complement deficit …) were ruled out. conclusion: it seems to be profitable to continue including in the diagnostic battery of patients who consult for aea with facial affectation, study of epicutaneous with standard battery. it is a small sample, but the data correlate with what has been published, being more frequent the sensitization to contactants in women and the contactant more frequently involved nickel sulphate. | ace inhibitor-related angioedema-the value of history taking background: angioedema is a well-recognized side effect of angiotensin-converting enzyme (ace) inhibitor therapy. although it occurs in < % of the patients who take these drugs, it seems to be responsible for % of the episodes of angioedema. this entity is underdiagnosed and failure to recognize it leads to recurrence of episodes, with an impact on morbidity and increased risk of serious reactions. our objective is to analyze the clinical, therapeutic and orientation approach of patients diagnosed with ace inhibitor-related angioedema, evaluated at the outpatient consultation (oa) of immunoallergology (ia). a -year retrospective study was performed by analyzing the clinical files of all patients diagnosed with angioedema observed in oa of ia. the following variables were analyzed: gender; age; clinical data; evaluation in emergency department (ed); therapy in the episode; evolution and orientation. the chi-square test was used to study the association between categorical variables: "established therapy"/"disease evolution" and "place of reference"/"withdrawal of ace inhibitor". results: review of cases of patients referred for angioedema. only in % the final diagnosis was "ace inhibitor-related angioedema". the mean age of the patients was . years and % were male. the location of angioedema occurred in the tongue in % and in the remaining sites (lip, hemiface, tongue and hemiface, tongue and lip) appeared in the same frequency, %. none of the patients had airway obstruction. during the episode of angioedema, % of patients were not referred to ed and the therapeutic approach was done with antihistamines in %. in patients who were referred to ed ( %), antihistamines and corticosteroids medications were administered in %. regarding the evolution, it was verified that the duration of the episode was independent of the established therapy (p > . ). regarding the place of reference, % of the patients were referred form hospital (ec or ed) and, in these, the ace inhibitor was suspended in %. in patients referred from general practitioners ( %), in none of them the ace inhibitor had been withdrawal. a causal association between the use of ace inhibitors and the episode of angioedema becomes crucial, since drug withdrawal is indicated. a reference for ai oa should be weighed. therapy with antihistamines and corticosteroids has no proven efficacy. hereditary angioedema (hae) seen by physicians belonging to the hae scientific committee of the aaaeic background: patients with c -inh-hae frequently suffer from anxiety and stress. the impact of prophylactic treatment on anxiety and stress in c -inh-hae patients is largely unknown. here, we analyzed data from the apex- study, a phase ii study that investigated the effects of the oral kallikrein inhibitor bcx . method: c -inh-hae patients with a history of at least hae attacks per month were randomized to receive four different doses ( , , , . mg) of bcx or placebo for days. the depression anxiety stress scale (dass) was administered at baseline and at day . the dass consists of three self-reported scales designed to measure the negative emotional states of anxiety and stress. subjects used a -point severity/frequency scale to rate the extent to which they have experienced each state. results: baseline dass total scores as well as anxiety and stress domain mean (sd) scores for the mg treatment arm (n = ) were . ( . ), . ( . ), and . ( . ) points respectively. placebo scores were generally similar or slightly lower at baseline than for the mg treatment arm. the dass questionnaire data showed statistically significant improvements in total score vs. placebo at day (− . method: a two-phase mixed methods approach was used to develop the hae-rt tool including: phase : delphi study [hae specialists (n = ) and national patient advocacy group members (n = )] was conducted to reach consensus ( % agreement) on predictor variables to include in the tool. phase : retrospective chart review was conducted to assess the predictive findings of the decided variables. a convenient patient sample presenting with angioedema (with and without hae) between january -january were included in the study. results: nine of invited experts ( %) participated in the delphi study. of hae-specific predictive variables, reached consensuses including: (i) recurrent angioedema; (ii) absence of urticaria; (iii) recurrent abdominal pain/swelling; (iv) lack of response to allergic therapy. the retrospective study included patients (n = with hae; n = non-hae; overall % female). hae patients were significantly more likely to have a family history of hae ( % vs %; p < . ); previous recurrent angioedema ( %; p < . ); present with no hives ( %; p < . ); previous recurrent abdominal pain ( %; p < . ); and % responded to allergy treatments (p < . ). a regression analysis categorized observed frequencies (actual patient outcomes from chart review) versus predicted (by model); plotted on a by table and calculated the sensitivity and specificity of the hae-rt which resulted in one hundred percent for both. conclusion: our study demonstrated that expert involvement led to the identification and prioritization of variables that when included an hae-rt tool, were associated with a high level of sensitivity and specificity when applied to known patients. the next step is to observe the effect of the hae-rt tool on patient care in the ed. method: evaluation of cardiovascular manifestation included morphology, serum level of troponin t, electrocardiography (ecg) and echocardiography. evaluation of pulmonary manifestation included spirometry, diffusing capacity of the lung for carbon monoxide (dlco) and evaluation for mastocytosis included bone marrow biopsy and serum total tryptase measurements. results: in the study there were patients - women and men between and years old (the average age was ). there were ( . %) patients with mpcm, ( . %) with bmm, ( . %) with ism and ( . %) with ssm. the average level of serum tryptase was . μg/l ( . - ) . troponin levels was within the normal range in all patients. one patient had lowered the ejection fraction (eflv= %). no one patient had restriction. the average value of a forced lung capacity was . l ( %) and a total here, we describe a case series of twelve mis patients seen at our department over a -year period and report how many of these patients have sm. common phenotypical manifestations of acute hae episodes in this region, to review therapeutic challenges in a rural setting in comparison with world standards, and lastly to evaluate the socio-economic burden inflicted by the disease. method: a sample of individuals from a total of . the exclusion criteria was the inability to attend booked appointments more than times in year ( ). the following methods were used: an interview to formulate a family tree identifying affected individuals in contiguous generations, and review of the acute presentations in the past year ( ) . a questionnaire to obtain the relevant hae associated socio-economic burdens. a chart review to identify the therapeutic strategies in this region. c inh levels, and complement c to confirm the diagnosis. results: polygamy as a local culture was found to be an important factor that perpetuated the genetic burden of the disease. c inh and c levels confirmed hae in all participants individually. clinical features during acute attacks included swelling of extremities ( %), facial swelling ( %), neck swelling ( %), and laryngeal swelling ( %). therapeutic strategies for acute attacks included fresh frozen plasma or fresh dried plasma. danazol was used for prophylaxis. hae has had a significant negative impact upon the socioeconomic status of the affected individuals. conclusion: hae is a newly identified disorder in the broad spectrum of allergy medicine in kwazulu-natal. the diagnosis is simple to confirm but requires an initial high index of suspicion, and therapeutic management still poses a challenge in this region due to lack of resources. genetic counselling is of paramount importance during intervention since polygamy forms part of most cultures in this region. a support strategy is highly recommended in order to help alleviate the socio-economic burden posed by the disease in this region. the socio-economic burden secondary to hae ( participants/ identical questions each) question ( - points) question ( - points) question ( - points) question ( - points) question ( - point) method: a total of medical faculty senior year students were included to study on a voluntary basis. students are divided into two groups. one group was given visual user guide that has not been modified, and a visual user guide on which we have modified to the other group ( figure ). then they were asked to show how to use the inhaler spacer. results: the mean age of the volunteers was . ± years and ( . %) were male. there were students in the group without modification of the visual user guide and students in the other group with modified the visual user guide. sixty-four per cent of the modified user guide group showed correct use of the inhaler spacer, while % of the unmodified group showed correct use (p = . ). the group that given modified visual user guide was more successful in all of the display steps of the inhaler spacer. conclusion: modification of the currently available visual user guide of inhaler spacer in our country will increase the correct usage rate. results: mean fev , fvc, fev /fvc z-score were . ( . - . ), . ( . - . ), . ( . - . ), respectively. restriction had ( . %) and obturation ( . %) patients. fev (p < . , r = . ) and fvc (p = . , r = . ) decreased with age (%pv and z-score). background: children who were treated for leukemia are known to have developed long term impairment of lung function. the reasons that complication are only partially known. the aim of this study was to asses pulmonary function in children treated the lower dlco is the most frequent abnormality in childhood leukemic survivors. hsct and pulmonary infection (in particular cmv pneumonia) is a strong risk factor for impairment of dlco in children. clinical manifestation of dlco impairment is poor exercise tolerance. a screening for respiratory abnormalities in survivors following treatment for childhood haematologic malignancies, seems to be of significant importance. | phenotyping allergic respiratory diseases: an unsupervised classification using latent class analysis allergen groups was significantly associated to uawi (aor[ % ci]: . [ . - . ] ), compared to uasi. results: . % of br and % of py were women, median age was years, % br and % py reported having more than four years of training. although they recognized the main symptoms of ar, % br and % py never asked whether the patient had a medical diagnosis of ar; . % br and . % py did not ask whether the symptoms occurred when close to animals or allergens; % br and % of py did not ask if the patient had a medical diagnosis of asthma; % br and % py did not ask if rhinitis worsens asthma symptoms and . % br and . % py did not ask whether symptoms of rhinitis interfere with their daily activities. results: there was a predominance of female (br: %, py . %, uy: %) median age years old, / worked in the community and / in the emergency departments, % of the br had more than years of education, % from py had between and years, and % from uy had been graduated for less than year. br/uy recognize the main symptoms of ar, however % of those from uy do not ask: if the patient has physician diagnosis of ar, % present shortness of breath, and % a medical diagnosis of asthma, % if rhinitis worsens asthma symptoms and % if symptoms of rhinitis interfere with the patient's daily activities. the prescribed treatment varied a lot, the intranasal corticosteroid use rate was: bd: %, pd: % and ud: %. % of doctors in py, . % in br and % of uy never refer the patient to the specialist. . % of pcd of br, % of py and . % of uy are aware of aria guideline. conclusion: although ar is largely attended by pcp, recognition of symptoms and their impact on asthma, as well as the knowledge about aria guide is low and treatment is not always prescribed according to best practice. allergy education programs, with an emphasis on ar and aria guide, need to be directed to pcp in la for the better assistance of ar patients. | assessing knowledge of allergic rhinitis among final year medical and pharmacy students in croatia-curriculum change necessity? the two factor structured questionnaire was formed by the authors regarding the topics mentioned. t-test was used for statistical analysis. the global results were formed as composites of ( ) ar general characteristics, ( ) ar treatment approach, and ( ) the participants' overall knowledge. of the respondents, ( . %) were female and ( . %) were male (p < . ). medical students had a median score of of correct answers on ( ), of on ( ), and of on ( ), whereas pharmacy students had median score of of correct answers on ( ), of on ( ), and of on ( ). there were no significant differences in knowledge between two student groups. the results indicate an inadequate level of knowledge of ar in both groups, especially regarding the therapy approach. since general practitioners and community pharmacists have a major role in providing treatment to patients suffering from ar, it is important to develop advanced knowledge on this topic during medical and pharmacy degree courses. despite a relatively small study population, it would be advisable to introduce change by improving the core curriculum regarding ar with more emphasis on treatment, but additional research on this topic is necessary. tan r ; cvetkovski b ; kritikos v ; price d ; yan k ; smith p ; bosnic-anticevich s woolcock institute of medical research; university of sydney, sydney, australia; observational pragmatic research institute pte ltd, singapore, singapore; royal prince alfred hospital, sydney, australia; clinical medicine, southport, australia; griffith university, sydney, australia background: people with allergic rhinitis symptoms frequently selfselect over-the-counter medications from community pharmacies without seeking advice from a health care professional. this increases the incidence of complications due to delayed diagnosis and suboptimal treatment. this study aims to (i) compare the demographics, clinical characteristics and medication selected, between pharmacy customers who choose to self-select and those who interacted with a pharmacist when purchasing medication for allergic rhinitis symptoms, and (ii) identify the key factors associated with allergic rhinitis patients' medication self-selection behaviour. a cross-sectional observational study was conducted in a convenience sample of community pharmacies from the sydney metropolitan area. data were collected using a researcher administered questionnaire that included: demographics, pattern of allergic rhinitis symptoms, their impact on quality of life, factors triggering allergic rhinitis symptoms and medication(s) selected. logistic regression was used to identify key factors associated with participants' medication self-selection behaviour. results: of the recruited participants, were identified with allergic rhinitis, of which . % were female, . % were aged more than years old, . % had a diagnosis of allergic rhinitis, and . % self-selected medication(s). significant differences were noted in allergic rhinitis symptoms, impact of allergic rhinitis on quality of life and medication(s) selected between participants who chose to self-select and those who interacted with a pharmacist. participants who experienced moderate-severe wheeze were times more likely to self-select allergic rhinitis medication(s), and those who had allergic rhinitis symptoms impacting on their quality of life were . times less likely to self-select allergic rhinitis medication(s). conclusion: there is a high incidence of self-selection of over-thecounter treatments for allergic rhinitis symptoms in community pharmacy, with the majority of allergic rhinitis sufferers failing to seek pharmacist advice. this research identified predictors of medication self-selection behaviour in community pharmacy among people with allergic rhinitis, which can inform the design of tools/strategies and targeted interventions, aimed at improving pharmacist engagement and future practice in optimising allergic rhinitis management. the weir family health clinic, cork, ireland; university college, cork, ireland background: allergic rhinitis is a common condition that is predominantly managed in primary care. the incidence of allergic rhinitis is increasing. it is frequently under diagnosed, misdiagnosed and mistreated. it has a significant impact on patients' health related quality of life and represents a huge cost both to healthcare systems and society. the aim of this study was to implement appropriate guidelines regarding the management of allergic rhinitis in primary care and evaluate the effect on patients' health related quality of life. method: patients with a history of allergic rhinitis were selected from three general practice bases in west cork, ireland and quality of life of patients was assessed initially in year one and followed up one year later in a general practice setting using the standardised rhinoconjunctivitis quality of life questionnaire (rqlq). allergic rhinitis and its impact on asthma (aria) guidelines and appropriate prescribing were implemented during this year and patient education and structured follow up was arranged in the intervention group. this was compared with the control group who received usual care. results: valid responses were received, from the control group and from the intervention group. the study demonstrated a statistically significant difference in quality of life in the intervention group. in the adult intervention group the quality of life score decreased between and representing an improvement in their quality of life, (t = . ; df= ; p < . ). the difference in the score between the control and intervention groups in was also statistically significant.(t = . ; df= ; p < . ). the numbers in the adolescent groups and paediatric group also demonstrated an improvement in quality of life but the sample size was too small to demonstrate a statistically significant difference. conclusion: as the majority of patients rely on their general practitioners for treatment and diagnosis of allergic rhinitis, primary care represents an important area to target in the management of allergic rhinitis to improve patients' quality of life. the implementation of guidelines has been shown to improve patients' quality of life. this study demonstrates this care can be delivered in a primary care setting with an improvement in patients quality of life but substantial investment in education and resources available to primary care physicians is needed. | the predictive value of allergy tests in the diagnosis of peanut allergy in adults rey-garcia h; gunawardana n; wheeler k; scadding g; durham s; skypala i royal brompton hospital, london, united kingdom background: adults presenting with either new-onset symptoms attributed to peanuts or with early-onset peanut allergy, often wish to know whether they should continue to avoid peanuts. clinical history and standard tests may be sufficient to provide an answer, but for many the tests are inconclusive and an oral food challenge is required. this review was undertaken to determine the most accurate tests. conclusion: these data suggests that peanut spt and ara h provide the most accurate prediction of the outcome of oral food challenge in adults. should components not be available, then spt would be the test of choice being more accurate in all aspects than sige. combining spt and sige improves the sensitivity and negative predictive value of spt alone. however, the best combination is spt and ara h , which increases the overall accuracy to %. further studies are needed before it can be determined whether peanut diagnostic tests can replace the oral food challenge in adult patients. method: retrospective chart review was carried out in a community allergy clinic. patients with rap, bloating and altered stools who underwent bt were characterized by age, gender and atopic status. a separate study to assess patients' outcome post-dietary counselling was carried out to determine impact on symptom management. results: thirty-four patients were assessed for fi from january to december . female gender predominated ( / , %) with an average age of years at presentation. results of fi were positive in / ( %), borderline in / ( %) and negative in / ( %). the average age of patients with a positive, borderline and negative tests were , and , respectively. of the patients who tested positive for fi, ( . %) had comorbid inhalant allergies alone, ( . %) had comorbid (unrelated) food allergies alone, ( . %) had inhalant and food (unrelated) allergies, and ( . %) were non-atopic. of the patients who tested negative for fi, ( . %) had comorbid inhalant allergies alone, ( %) had comorbid (unrelated) food allergies alone, ( . %) had inhalant and food (unrelated) allergies, and ( . %) were non-atopic. conclusion: patients investigated for carbohydrate intolerance with rap, bloating and altered stools were predominantly female ( %). fi was confirmed in half. atopic status did not help differentiate between the fi positive or negative groups. results of a fod-map elimination diet are separately reported. conclusion: post-bt, % of patients reported symptom improvement. patients who implemented fructose or fodmap avoidance reported symptom improvement. one patient who tested negative for fi reported symptom improvement with a low fodmap diet. patients suspected as being fructose intolerant may benefit from a fructose restriction or fodmap diet, while awaiting bt confirmation. this form of dietary intervention may assist and shorten the natural history of non-specific chronic gi symptoms. inappropriate referrals to a uk paediatric tertiary allergy clinic demonstrate lack of allergy education and knowledge in primary care marriage de bristol royal hospital for children, bristol, united kingdom background: up to % of children have a food allergy. allergy has become an explanation for all manner of nebulous symptoms and self-diagnosis is common. sham allergy tests are easily available giving incorrect results and resulting in unnecessary, potentially harmful abstracts | parentally-imposed dietary exclusions. there are million allergyrelated google searches per year. the rising prevalence of perceived allergic disease has led to an increase in health service utilisation, including increased referrals to secondary care. clinic waiting lists are long and children with severe food allergies have to wait longer than necessary to be seen method: uk paediatric tertiary allergy clinic referrals were prospectively reviewed over three months. five inappropriate referrals deemed most reflective of poor knowledge in primary care were selected as case summaries to highlight this gap in knowledge. results: : schoolchild referred for investigation of allergic cause for a red, watery eye after splashing juice in her eye whilst cutting a kiwi, despite having a co-existent dendritic ulcer. : schoolchild referred for peanut allergy testing after inhaling a peanut and developing wheeze, with all respiratory symptoms resolving following peanut removal. : young child referred for peanut allergy testing after developing a rash on leg following skin contact with faeces hours after ingestion of peanut butter. : teenage boy referred for investigation of likely peanut allergy despite eating peanut butter and tree nuts almost every day. the family were concerned he was allergic to peanut butter. : toddler referred for milk allergy investigation after developing urticaria lasting hours minutes after drinking a bottle of milk. the child had consumed cow's milk formula since birth, and continued to consume milk daily for a further five months following the episode of urticaria. conclusion: provision of allergy services in the uk is poor and lack of investment in allergy services has led to suboptimal recognition and management of food allergy in primary care. allergy education provision for primary care practitioners is inadequate and fails to empower healthcare professionals to discern between allergy requiring full investigation and management, parentally-diagnosed allergy or symptoms which clearly have no association with allergy. progress to improve primary care training for allergy needs to be optimised to prevent further unnecessary referrals and lengthening clinic waiting lists. background: in case of allergic reactions to food or insect venom, quick and adequate treatment, based on clear instruction for use of emergency medication and calling for help, is necessary. however, daily practice shows that patients do not use the prescribed emergency medication because they are afraid to use the epinephrine auto-injector or they do not know how to use it. information and instruction offered by a reliable app could be a useful aid. we aim to develop an app for adult patients and children older than years with allergy to food or insect venom, which offers a step-wise approach to support patients, their relatives or acquaintances in case of an allergic reaction. method: first, the content of the app, including a step-wise approach to treat the allergic reaction has been determined, based on literature, a survey about needs of patients and on consultations of healthcare professionals. subsequently, a web-based prototype has been developed with an adult profile and children profile. the content and flow of this prototype was tested by the project group, as well as by selected healthcare professionals and patients and improved according to the test results. next, the revised prototype was submitted to representatives of patient and professional organizations for final approval. currently the procedure for ce approval is ongoing. finally, the app will be built and offered to the market for ios and android. results: a web-based prototype of the allergy app is available with two profiles: adult and older children. the app is useful for patients with a doctor's diagnosed allergy to food or insect venom, who received emergency medication and instructions to use prescribed medication in case of an allergic reaction. based on severity of complaints, the user is informed about the steps to treat the allergic reaction. in case of a moderate to severe reaction, the patient is advised to use an epinephrine auto-injector, to call the emergency number and, if prescribed, to use medication such as antihistamines, prednisone or inhaler. besides that, the app provides links to websites of expertise centres and patient organisations and includes instructions how to use the epinephrine auto-injector. conclusion: the allergy app will help patients, their relatives or acquaintances to adequately treat an allergic reaction to food or insect venom. involving patients and professionals in the development of the app will contribute to its acceptability and usability. | electronic documentation of drug allergies in a tertiary hospital in singapore: are we relying too much on it? choo kjl; garuna murthee k; naing cs singapore general hospital, singapore, singapore background: singapore has hospitals shared between public and private healthcare system. its healthcare system, ranked # in the world by who in serves a multi-racial population of . million of which % are above years old. drug allergy alert cards (medik awas) were started in s by singapore medical association to improve patient safety. work on computerisation of drug allergy and medical alerts started in the s, a precursor to today's critical medical information system (cmis). cmis serves as a platform across all public hospitals in singapore. it promotes uniform reporting of drug allergy and notification of adverse drug events to the health science authority. yet, we found that there is a lack of awareness of one's own drug allergies. method: all patients admitted to ward (general medicine ward) at singapore general hospital from july to oct were screen for any previously documented drug allergies. consenting patients who had previously documented drug allergies on cmis were interviewed to document their demographics, education level, current medications, knowledge of their own drug allergies and possession of a drug medication alert card. the answers were then compared with their electronic documentation of drug allergies for accuracy. we interviewed patients aged - with documented drug allergies during the recruitment period. % had secondary school education or higher. the majority ( %) spoke english and ( . %) mandarin. almost half had medical problems and are on long term medications (mean . medications); hypertension and diabetes being the top two common diseases. % of the patients could accurately relay their drug allergies; antibiotics and analgesia being the most labelled. only % had a drug allergy alert card while the rest both rely on the hospital's electronic documentation and/or their caregivers to record and relay their allergies to future prescribers. about % received prescription from multiple healthcare sites in both the public and private healthcare system. we found patients' knowledge of their own drug allergies dismal. the cmis electronic documentation provided a false sense of security. unfortunately, the cmis platform is not available to all private hospitals, increasing the risk of mis-prescription due to the lack of information. unless this is made available nationally, patients with drug allergies should be given some written documentation, either a letter or medik awas. how frequent are they and how are they treated? method: for this cross-sectional study, participants were recruited in the waiting rooms of local doctors in the rural bavarian forest region of southern germany (q / ). a paper questionnaire was handed out to the participants, asking for allergies (pollen, animal hair, bee and wasp venom, drugs, food, house dust mites, contact allergies and other allergies) and how or rather by whom (e.g. general practitioner, specialist, self-treatment) these allergies are treated. results: participants with a mean age of . years (sd= . ) and % women were included in this study. . % indicated to have at least one allergy, including pollen allergy most frequently ( . %). women had significantly more often at least one allergy than men (rr= . ; ci [ . ; . ] ) and for almost all examined allergies a significant higher risk of disease. younger age groups indicated more often to have at least one allergy ( - [. ; . ]) seemed to be affected less. participants indicated most frequently that their allergy was treated by a general practitioner ( . %), except of the - -yearold young adults who indicated "no treatment" most frequently ( . %). conclusion: there is a high self-reported prevalence of allergies in the examined rural bavarian region, that increases with decreasing age and is significantly higher among women. moreover, the data on the absence of an appropriated treatment for allergies is alarming. therefore, medical care needs to be improved in rural regions to lower the burden of allergies. | the prevalence of the burnout syndrome among medical professionals involved in allergology education programmes astafieva n ; kobzev d ; gamova i ; perfilova i ; udovichenko e ; skuchaeva l ; michailova i ≥ ) and rpa (low ≥ - , subscales were calculated and analyzed. results: on average students demonstrated: moderate/high ee scores ( - ); moderate/high dp scores ( - ) and moderate rpa scores ( ); higher rpa scores were common ( . %) among junior students, which is also linked with their levels of engagement, and lower ( %) among senior students. junior specialist (starting specialization) had very low scores in all subscales and expressed a very high motivation in their course and new profession. clinical allergologists with significant experience demonstrated moderate / high ee scores ( - ); low dp ( ) ( ) ( ) ( ) ( ) and rpa (below ) scores. high ee scores associated with pressures of service were compensated by a substantial loyalty to their profession and positive assessment of the outcomes of their work. clinical academics demonstrated the highest level of ee scores ( + among + % of the group) with low to moderate dp and rpa scores, the latter being associated with a loyalty to their profession. it was also possible to identify a correlation between engagement in research activities and lower rpa scores. conclusion: burnout is a complex and multifaceted phenomena, which requires further investigation. however, this research identified that students and junior specialists involved in allergology and clinical immunology programmes with higher levels of engagement and motivation to acquire new specialist knowledge had lower levels of ee, while loyalty to the profession and positive assessment of the outcomes of clinical and research work allows to compensate high levels of ee among experienced practitioners and clinical academics and to reduce burnout effects overall. | appeal (allergy to peanuts impacting emotions and life): the first pan-european study to evaluate the psychosocial burden of living with peanut allergy deutscher allergie-und asthmabund (daab)/german allergy and asthma association, mönchengladbach, germany; food allergy italia, padua, italy; aepnaa asociación española de personas con alergia a alimentos y látex, madrid, spain; afpral association pour la prevention des allergies, paris, france; asthma-allergy denmark, roskilde, denmark; anaphylaxis campaign ireland, cork, ireland; brainsell ltd, london, united kingdom; aimmune therapeutics, london, united kingdom background: peanut allergy, one of the most common and rapidly growing food allergies, is most frequently a lifelong condition. current management is limited to avoidance and symptomatic treatment of allergic reactions when accidental exposures occur. peanut allergy can affect the quality of life (qol) of individuals and also that of parents/caregivers and family members. appeal was designed to assess the impact of peanut allergy on qol in peanut-allergic individuals and their parents/caregivers and families. method: the first, quantitative part of appeal is described here and consisted of a pan-european, cross-sectional online survey of approximately minutes in length. the study was conducted in the uk, republic of ireland, france, spain, germany, italy, the netherlands and denmark. over participants were recruited via patient advocacy groups or directly through a specialist survey recruitment panel. ethics committee approval was obtained and all participants provided their informed consent. eligible participants were: ( ) parents or caregivers of a child/adult with peanut allergy; ( ) parents or caregivers responding as a proxy for a child aged under ; ( ) adults. all allergic subjects had self-reported diagnosed peanut allergy. after several screening questions, eligible participants answered a set of clinical questions about their (or their child's) allergies and other conditions, details on the peanut allergy diagnosis, contact with healthcare professionals, worst allergic reaction to date and use of emergency medicine. depending on whether they were an allergic adult, a parent responding on behalf of the child, or a parent/caregiver recounting their own experience, they then answered specific questions on restrictions on life choices, coping strategies and the impact of peanut allergy on feelings and emotions of families, friends and other people. sociodemographic questions completed the questionnaire. the results of the survey are being summarized using descriptive statistics and the data are being analysed on a pan-european level, by country, and according to the participant's perspective (parent, caregiver or individual). conclusion: this comprehensive, pan-european online survey has been specifically designed to uncover the psychosocial burden and effect on qol of peanut allergy in terms of individuals' lives and those of their families. results: pediatric patients were included in the study. . % (n = ) were male. the median age of onset of symptoms (interquartile range) was months ( - ).the median age (interquartile range) of diagnosis was months ( - ). initial reactions associated with cmpa were observed in . % of patients before months old. patients' diagnoses were atopic dermatitis ( %), urticariaangioedema ( %), anaphylaxis ( . %), proctocolitis ( . %), atopic dermatitis and urticaria ( . %), food protein induced enterocolitis ( . %) and eosinophilic esophagitis ( . % method: the study involved patients, who are two years old (and above), diagnosed with cow milk allergy and are observed for at least six months in our hospital. socio-demographic features of the patients, their symptoms, symptom-start ages, age of diagnosis, clinical findings at diagnosis and during observation were recorded in data collection questionnaires. results: the samples were ( . %) boys. the average symptomstart age was observed to be months , average diagnosis age months ( - ) and average age of final check months . when symptoms at entry were observed, . % of the patients had dermal system, . % gastrointestinal system, respiratory system disorders, and % were detected to have developed anaphylaxis. among the patients diagnosed with cow milk allergy, . % showed food reaction to nutrients with lge agents, . % to mixed types, and % to nutrients with non-lge agents. it was also observed that, in the end of . ± . -month observations, sensitivity to cow milk was observed to continue in ( . %) of our patients. when tolerance improvement rates among the patients were compared, anaphylaxis (p < . ) during entry were observed to be influential in continued allergic state. ( . %) patients were able to consume yoghurt, ( . %) patients could consume dairy products and ( . %) patients could not consume dairy products. conclusion: in the end of our investigation, it was observed that ( . %) of the patients developed cow milk tolerance before the age of . when the factors enabling the continuation of sensitivity in cow milk allergy were investigated, anaphylaxis during entry, entry specific lge and pasteurized milk antigen as well as high skinprick test results were detected to be significant. | initial lower threshold was a risk factor of severe adverse reaction during oral immunotherapy for cow's milk anaphylaxis results: before oit, median age was . years old, median threshold to induce initial reaction was . ml, to induce anaphylaxis was . ml of cm and median milk specific ige was . ku/l. twentyseven subjects ( %) dropped out from the protocol, subjects | investigation of heat and matrix effect on milk proteins' allergenicity and the development of hypoallergenic food products reduce some milk proteins' allergenicity (ß-lactoglobulin) . in this project we aimed to investigate the effect of heat and matrix on different milk protein fractions through maillard reaction and eventually develop hypoallergenic food products that have milk protein with low reaction risk. method: milk cake matrix is prepared in different flour/sugar (f/s) ratio ( f/ s, f/ s, . f/ s) and baked minutes at °c. proteins that cake contains are separated using sds page and stained with coomassie blue to check total protein. in parallel specific proteins are detected by western blotting using pooled sera from patients with milk specific ige> ku/l for incubation results: in normal milk cake recipe ( f/ s) ß-lactoglobulin bands are disappeared but casein bands did not differ in size. in order to investigate the matrix effect f/s ratio is changed and it is found that when this ratio decreases, with the affect of heat and maillard reaction, milk casein bands' intensities also decrease in sds gel coomassie staining. in western blot experiments it is also shown that milk specific ige bound weakly to casein bands in low f/s ratio cake ( . f/ s) whereas in cakes that have high f/s ( f/ s) ratio it bound significantly higher. and ß-lactoglobulin proteins' structure and lower the milk specific ige bindings to milk proteins in low f/s ratio cake through maillard reaction. | extensively hydrolyzed formulas for the management of cow's milk protein allergy in infants: is extensive hydrolysis sufficient to guarantee success? method: to better understand the range of ehfs, we aimed to analyse samples of commercially available ehfs from countries and various manufacturers, with a focus on suitability for cmpa management. samples were de-identified and coded for the analyses. molecular weight (mw) distribution of hydrolysates and residual proteins and peptide profiling were assessed with sds-page gel and size exclusion-high-performance liquid chromatography (se-hplc), as they reflect both the design of the formula and the quality management applied during production. osmolarity, nitrogen fractions, lactose content, total and free amino acids, β-lactoglobulin, and casein content were quantified and β-lactoglobulin residual allergenicity was assessed. results: peptide mw distribution displayed significant variation, with the percentage of peptides with mw > . kda varying from % to %. mw distribution was shown to be positively correlated with β-lactoglobulin specific in vitro degranulation. twenty % of samples had non-measurable β-lactoglobulin content (smaller than or at the limit of quantification (loq): . mg/kg); however, % of samples had β-lactoglobulin content greater than the loq, with high variability from . to mg/kg. surprisingly, even in samples featuring a high degree of hydrolysis, significant levels of residual β-lactoglobulin were quantified. conclusion: lack of consensus over the definition of 'extensively hydrolysed' is reflected in the wide range of degree of hydrolysis in commercially available ehfs, and can result in products that are mislabelled as 'extensively hydrolysed' and may be high-risk or even unsuitable for the management of cmpa. results of these analyses also highlight that degree of hydrolysis alone is not sensitive enough to characterise ehfs, and that whilst a high degree of hydrolysis is desirable, further quality control measures are essential to ensure clinically safe and suitable products. actionable guidelines to better define hypoallergenic formulas based on extensively hydrolysed milk proteins are warranted. background: assessing the effect of baked milk products on accelerating unheated milk tolerance in patients with cow's milk allergy. method: a randomized clinical trial was done on patients ( months- years old) divided randomly to case and control groups matched for age and sex. baked milk in form of muffin for months followed by baked cheese in form of pizza for next months was given to the patients in case group. skin prick test and serum ige (sige) levels (immunocap) of milk, casein and betalactoglobulin were measured before and after the study. the ones having milk sige less than ku/l and being asymptomatic during the study underwent oral food challenge test for evaluating unheated milk tolerance. chualalongkorn university, bangkok, thailand; kk women's and children's hospital, singapore, singapore; university of the philippines, philippine general hospital, manila, philippines background: problems in recognising cow's milk allergy (cma) and lactose intolerance (li) in infancy may lead to a delayed or incorrect diagnosis, as well as inappropriate dietary interventions. method: between january and november , a survey was conducted online in china, india, singapore, thailand, mexico, kuwait, united kingdom, australia, and paper-based in the philippines. the survey consisted of multiple-choice questions on cma and li in infants aged under months, two case scenarios (non-ige cma and anaphylaxis) and questions on educational needs (likert scale [ ] [ ] [ ] [ ] [ ] . data on the type of medical practitioner and clinical setting were collected. responses were summarised as percentages and categorised by country. results: responses were received from general practitioners ( . %), paediatricians ( . %), paediatric allergists ( . %), paediatric gastroenterologists ( . %) and other specialities ( . %). there were significant misconceptions about the clinical importance of primary li in infancy. while primary li rarely manifests before years of age, . % of participants felt it was a significant clinical problem in the first year of life. regarding secondary li, % of respondents recommended lactose restriction for viral gastroenteritis, and % for cow's milk protein-induced enteropathy. while the management of ige cma was relatively well understood, there were greater knowledge gaps for non-ige cma. % of practitioners appropriately identified extensively hydrolysed formula (ehf) as first-line treatment of cma in formula-fed infants. however, the distinction between lactose-free and lactose-containing ehf appeared to be an area of uncertainty. in india, . % used soy-based formulas as first- results: patch tests were positive in ( . %) and negative in others. positivity to milk was seen in patients ( . %), to soy in ( . %), to egg white in / ( . %), to wheat in / ( %), to potatoes / ( . %), to corn (maize) in / ( . %), to rice in / , and to peanut in / ( . %). patients were requested to withdraw the suspected food(s) from their diets during a months period. preliminary follow-up data show the improvement of one or more symptom in / patients (gastroesophageal reflux in , appetite in , stool consistency in , respiratory symptoms in , pain in , eczema in ). conclusion: patch tests are informative, easy to use tools in order to identify potential causes of common lasting symptoms in children with negative or weak rast results and introduce beneficial changes in the daily diet. longer follow-up is necessary in order to refine and assess the benefit of such strategy. background: currently in the us, in children suffer from food allergies. at present, there is no cure and strict avoidance of the relevant foods is the only way to prevent allergic reactions. elimination diets put infants and children at risk for nutritional deficiencies and impaired growth. we examined the role of the registered dietitian (rd) in advising patients and families of food allergic children. method: a retrospective review of clinical notes was performed for the first consecutive children who required a dietetic consultation in a dedicated food allergy clinic. we examined common questions from parents that were addressed by the dietician during the consultation. results: patients were aged months - years (median: months) and were diagnosed with the following food allergies: cow's milk: . %, egg: %, tree nut: %, peanut: %, wheat: %, soy: %, fruit/vegetable: %, legume: %, fish: %, sesame: %. the most common questions for the dietitian included: ways to meet nutritional needs following a prescribed allergen-restricted diet ( %), meeting vitamin d and calcium requirements on a milk protein-free diet ( %), suitable oral supplements and recommended serving sizes ( %), appropriate order of solid foods introduction in food protein-induced enterocolitis syndrome (fpies) ( %), cautionary food ingredient statements ( %), baked milk protein introduction ( %), cross-reactivity risk of milk protein with soy ( %) and crossreactivity of nuts in retail bakeries ( %). conclusion: parents of children with food allergies have multiple questions with regards to nutrition. dietetic input in the food allergy clinic addresses important issues for children and families including successful avoidance of allergen-containing foods while ensuring optimal nutrition, decreased exposure to high-risk situations and avoidance of allergen cross-contamination. | multicenter prospective study of a stepwise single dose oral food challenge of egg background: oral food challenges (ofcs) are necessary for allergy management. we previously reported that a low-dose ofc can avoid complete elimination, even if patients react to higher doses of causative foods. nevertheless, this approach has only been validated in a retrospective single-center trial. we have previously reported that the median time for initial symptom onset is minutes for egg ofc using a single exposure. therefore, this study aimed to confirm the safety and effectiveness of a stepwise single-dose ofc in a multicenter, prospective study. who showed a positive reaction to low-dose ofc, only patient ( %) showed a severe reaction: barking cough immediately improved with adrenaline inhalation. among patients with a positive reaction to medium-dose ofc, none had a severe reaction. the median times to symptom onset were and minutes following low-dose and medium-dose ofc, respectively. patients in the three groups, divided according to threshold doses, differed significantly in sige levels against egg white and ovomucoid. conclusion: this multicenter prospective study confirmed that stepwise single-dose ofc to egg will help to clarify the severity of egg allergy, and will contribute to improved food allergy manage- method: the study design was a retrospective cohort study extracting data from the electronic chart of children older than years who visited our out-patient clinic for egg or milk allergy and who underwent an oral food challenge test (ofc) twice within months between november and december . the patients were divided into five groups according to their treatment schedule, which consisted of those who: a) started from / of the first ofc reaction threshold and maintained / till the end of oit; b) started from / of the threshold and maintained / ; c) started from / of the threshold and maintained / , d); conventional slow oit (started from just below the first ofc reaction and increased . - . times every few weeks); or e) continued elimination. we determined the presence or absence of an increase in threshold reacted to the allergen, any adverse events during oit, and food-specific ige reduction. results: the number of participants was and their median age was years. the number of patients in groups a, b, c, d, and e was , , , , and , respectively. the percentage of patients in groups a, b and c showing an increase in reaction threshold to the allergen was higher than that in group e (p < . ), and that in group b was higher than that in group d (p < . ). the number (percentage) for group a, b, c, d, and e was ( . %), ( . %), ( . %), ( . %), and ( . %), respectively. there was a significant difference in the frequency of adverse events during oit between group a-c and d, which was as follows: ( . %), ( . %), ( . %), and ( . %), for the respective groups (p < . ). there was no significant difference in the percentage of patients showing a decrease in food-specific ige in each group. conclusion: the regimen starting from / of the ofc reaction threshold and maintaining the dose at / was safer and more effective for increasing the threshold reacted to the allergen than the 'conventional slow oit' regimen. elimination continuation was not effective for increasing the threshold reacted to the allergen. legumes allergy was presented in different clinical features; urticaria and angioedema in ( %) patients, anaphylaxis in ( . %) patients, atopic dermatitis in ( . %) patients, eosinophilic esophagitis in ( . %) patients and as food-related enterocolitis in ( . %) patient. thirteen ( . %) of the patients had asthma, ( . %) had allergic rhinitis. fourteen ( . %) of the patients with single legume allergy showed improvement. the patients who developed tolerance, of these ( . %) had peanut allergy, ( . %) had lentil allergy and ( . %) had chickpea allergy. two of patients with multiple legumes allergies, it developed tolerance to all the legumes they are allergic. conclusion: peanut and lentils were the most frequent legumes that displayed allergic reactions in our study. in these patients the rate of allergy to non-legumes food is high. in patients who were allergic to single legumes, the symptoms were ameliorated in . %. conclusion: cashew nut is a potent allergen and can cause quite severe reactions. avoidance of pistachio nut and other related allergens should be advised to patients after allergologic investigation. in the majority of the patients, presence of atopic dermatitis with food allergy is noteworthy. therefore, it would be useful to investigate these patients for cashew and other tree nut allergy before they present with a serious clinical reaction. and jellyfish sting. serum allergen-specific ige test was negative; skin prick test was positive for natto and pork. we performed an oral food challenge with natto, pork, crustaceans, and wheat, and she developed a general itchy rash after hours of eating natto. h blocker was administered and she recovered soon. however, the general itchy rash relapsed after hours. hence, we intramuscularly injected epinephrine, h -blocker, and steroids; then, her symptoms did not relapse. based on these findings, we inferred that anaphylaxis caused by natto could be associated with a jellyfish sting. discussion: although association between japanese fermented soybeans (natto) allergy and jellyfish sting has been previously reported, its anaphylaxis is a rare event. in this case, we suggest that anaphylaxis was caused by natto allergy, which was perhaps related to jellyfish sting. hence, further investigation is essential to elucidate the association between fermented soybeans allergy and jellyfish sting. introduction: non-celiac gluten sensitivity (ncgs) is a syndrome characterized by intestinal and extra intestinal symptoms related to the ingestion of gluten-containing food, in subjects that are not affected by either celiac disease (cd) or wheat allergy (wa).once the gluten-containing foodstuff is removed from the diet, the patients will have relief of their symptoms. case: a -year-old girl was referred by his general practitioner with history of occasional constipation and abdominal pain (especially after main meals and defecation), short stature and low weight. the growth indices were proper for her age till she was . then after there was a stunting. she had short stature and low weight. despite different types of supplementation, there was no improvement in growth indices, so she was referred to a pediatric endocrinologist for gh therapy. primary investigations and anti-ttg, iga, anti-ema all were normal. after a consultation with a pediatric gastroenterologist, a genetic study of hladq and were done because of the highly suspicion of celiac disease. the results were also negative. at last she was referred to immunology-allergy clinic for evaluation of probable food allergy. ige level was checked and a prick test was performed which they were not indicative of any suggestive food allergy. because of the history of the abdominal pain and constipation which was more prominent after meals, negative results of genetic study, spt to wheat, and serologic markers, a gluten free diet was suggested for her with the suspicious of non celiac gluten sensitivity. a significant improvement in her symptoms was noticed within weeks of starting gluten free diet. she has kg of weight gain and height improved from cm to cm in months. she continued to improve on a gfd and when seen in the follow-up clinic months later reported complete resolution of symptoms and another cm and kg gain in her height and weight. conclusion: non-celiac gluten sensitivity syndrome is a diagnosis made by excluding celiac disease and wheat allergy. it should be taken into consideration especially in patients who have the suspicious symptoms of celiac without supporting lab data, and also negative spt to wheat. the young man in question along with his parents were keen to proceed, so with some hesitation we proceeded to a hazelnut oral provocation challenge, having very carefully explained the risks of undertaking such a challenge. he successfully completed the challenge and experienced no allergic symptoms and is now able to have hazelnuts in his everyday diet. discussion: this young man wanted to confirm if indeed he was allergic to hazelnuts. not being hazelnut allergic would mean that he would be no longer allergic to any nut and would not have to take precautions prior eating products. positive results to both cor a and cor a , hazelnut storage proteins are associated with the patient possibly experiencing systemic reactions, at a higher risk of experiencing anaphylaxis it they were to ingest hazelnut. these facts in conjunction with his specific ige to hazelnut would have prevented us from proceeding to challenge was it not for this young man's persistence that he wanted to proceed to challenge despite the risks. conclusion: appearances are deceptive, as this case demonstrates; allergen-specific ige and component testing can only predict the probability of an allergic reaction, the final test in the diagnostic process is the oral provocation challenge. the patient and his family were happy for me to share the above with other health care professionals. method: we present the case of a female of years old diagnosed of acu with poor control of the symptoms at maximum doses of antihistamines. we decided to associate omalizumab treatment. the patient had a good control of the symptoms with omalizumab at dose of mg/ weeks, but in the th month she presented an erythematous, raised and pruritic lesion in the area of injection together with localized abdominal edema at hours of the administration, with two weeks of evolution without symptomatic treatment. we decided to discontinue omalizumab alter a second episode with half doses. results: we performed a skin biopsy of the lesion and epicutaneous tests with the drug. immediate hypersensitivity tests were not taking due to the impossibility of stopping antihistamines. skin biopsy showed a perivascular lymphocytic inflammation of the superficial and deep dermis with frequent presence of perivascular and interstitial eosinophils, suggestive of a hypersensitivity reaction. results: nine months before presentation at our clinic, the patient had been hospitalized and treated with imipenem and tmp/smx for pulmonary nocardiosis. once discharged, she had been prescribed oral tmp/smx alone, according to antimicrobial susceptibility. at our first evaluation, the patient presented with fever, macular erythematous non-pruritic (vasculitic-like) skin lesions on the upper limbs, polyarthralgia and bilateral ankle arthritis. tmp/smx was transiently stopped. after four days, there was a dramatic improvement, with resolution of all signs and symptoms. she was tentatively diagnosed with a viral infection and thus tmp/smx was started again. however, after three days, the symptoms (fever, arthritis and skin lesions) recurred. laboratory investigations showed increased levels of inflammatory markers. complete blood count with differential, serum creatinine, urinary sediment, liver enzymes, rheumatoid factor, antinuclear antibody, c , c , immune complexes, serology for rickettsia, borrelia and coxiella were all negative. hence, tmp/smx was stopped again and cutaneous lesions, fever and arthritis resolved spontaneously in five days. conclusion: given the clinical course and the resolution after the withdrawal of tmp/smx, we diagnosed a sslr due to sulfonamides. to the best of our knowledge, this is the first case of sslr occurring after a nine-month therapy with tmp/smx and allergists/immunologists should be aware of the possibility of such a reaction even after months. case report: * we received written informed consent for publication of these clinical details and/or clinical images included in my abstract was obtained from the patient. drug rash with eosinophilia and systemic symptoms (dress) syndrome is a severe adverse cutaneous reaction that usually appears - weeks after treatment with the causative drug. this syndrome is characterized by severe dermal rash, fever, eosinophilia, and internal organ involvement, and clinically, diffuse maculopapular eruption, exfoliative dermatitis, and facial edema are often observed. we performed blood tests and laryngeal fiberscopy for the diagnosis of the patient. intradermal test with delayed reading and patch test were performed months after the end of treatment. a -year-old man had begun treatment with carbamazepine for epilepsy. after weeks of treatment, he observed skin rash with pruritus on both lower extremities, and after weeks, his skin lesions had begun to spread over his whole body, and he complained of several new symptoms, including hoarseness, dyspnea at rest, and dysphagia. an examination revealed maculopapular rash, facial edema, and bilateral cervical lymphadenopathy. laryngeal fiberscopy revealed both arytenoid and epiglottic swelling. laboratory studies revealed eosinophil counts of /μl and increase in alanine aminotransferase level to u/l. a diagnosis of dress syndrome was definite according to the regiscar group criteria. carbamazepine, the suspected culprit drug, was withdrawn, and systemic corticosteroid was initiated. the patient experienced rapid improvements in hoarseness, dyspnea, and dysphagia. after days of treatment, laryngeal fiberscopy revealed complete resolution of both arytenoid and epiglottic swelling. to the best of our knowledge, our case is the first reported case of dress syndrome to manifest with laryngeal edema. case report: bortezomib (velcade Ⓡ ), a targeted therapy works by blocking the action of proteasomes in side cells, is commonly used to treat newly diagnosed as well as relapsed/refractory myeloma. bortezomib has been reported to have gastrointestinal symptoms, peripheral neuropathy, neuropathic pain and thrombocytopenia as its most common side-effects. although several cases of skin lesion caused by bortezomib have been reported, severe cutaneous adverse reaction (scar) such as stevens-johnson syndrome (sjs) is very rare. we here report a case of bortezomib induced sjs. a -year-old female patient, who was diagnosed with multiple myeloma, received bortezomib and melphalan /dexamethasone therapy. after the th dose of bortezomib, she presented with fever and maculopapular skin rashes spreading from face to the trunk. erosive lesions in the oral mucosa and corneal ulceration with conjuntival injection were observed. she was diagnosed as sjs. the symptoms of sjs improved after bortezomib was discontinued and systemic steroids and intravenous immunoglobulin were administered. drug patch test was performed, the result was positive in bortezomib. this is the first case report of bortezomib induced sjs in this country, which was diagnosed by a patch test. although the scar by bortezomib is generally considered very rare, we suggest that clinicians be aware of potential adverse reactions, including sjs. case report: we report the case of a healthy -year-old woman with history of red erythematous macules in both hands, one hour after taking a fluconazole ( mg) tab for a vaginal candidiasis. it faded spontaneously. she didn't recall if she had ever taken that medicine, but denied known drug allergies. although fde is primarily a clinical diagnosis, we conducted an oral challenge test with fluconazole ( mg). two hours after intake of the drug the patient started complaints of pain and erythema in both hands and the challenge was stopped. two days after the challenge, she developed red painful erythematous macules on the same sites of the first episode. due to the specificity of the challenge, local patch testing was not performed. introduction: the classic form of a fixed drug eruption is one or more anular or oval erythematous patches as a result of systemic exposure to a drug. these skin lesions normally resolve with hyperpigmentation and may recur in the same location with re-exposure to the drug. other types of fixed drug eruptions have been described, being fixed drug urticaria a rare form of presentation. ( , ) case report: in the last years, a year old woman has developed more than episodes of a wheal in the right supraciliary region minutes after taking mg of oral ibuprofen. the symptoms resolved in less than hours without treatment and without leaving residual lesion. after the last episode, she refers good tolerance to g of oral paracetamol. she denies local traumas. she also refers mild spring rhinoconjunctivitis well controlled with antihistamine, and sneezing with house dust. a -year-old-m patient had psoriasis vulgaris for years, and had been using methotrexate at intervals of years. despite the addition of phototherapy, he underwent a new treatment with biological agent (antitumor-necrosis-factor; anti-tnf), since the disease control was insufficient. before anti-tnf, preventive treatment against latent tuberculosis (tb) activation was indicated with positivity in tuberculin skin test ( mm). he was given inh mg/day, and at the th day of treatment, desquamation, erythema, and subsequent exfoliation developed in his hands and foots dorsum. inh was withdrawn. in order to distinguish the lesions from psoriasis attack, skin biopsy was performed and reported as erythema multiforme-like dermatitis with no relation to psoriasis. the lesions were completely improved at weeks of topical steroids, and inh was re-initiated at the same dose. a week after the initiation of the drug, skin lesions similar to previous reoccurred with more severity and progression from distal to proximal extremities. cell counts, renal and hepatic function tests, and hepatitis markers in blood were in normal limits. skin lesions were retracted after weeks of topical steroids, and withdrawal of inh. there was positivity in skin patch test with inh at hours. finally, for tb prevention an alternative drug rifampicin ( mg/kg/day) was given, and the patient successfully completed with no adverse event. his psoriasis lesions were improved with anti-tnf which was started after month of tb prevention with rifampicin. in these days which the use of biologic agents is increasingly widespread, inh use will be more prevalent than the past. even tough, it is effective and safe in most of the patients, its adverse event dermatitis may be a reason to withdraw in patients with dermatological diseases. in this case, diagnostic drug allergy evaluation should be performed to optimize the second-line treatment of tb infection, in addition to early withdrawal of the culprit drugs. background: around % of cancer patients will receive radiotherapy (ionizing radiations) as a treatment, either as a single therapy or as an adjuvant to chemotherapy and surgery. several side effects have been described due to radiotherapy, of which we can mention erythema multiforme and stevens johnson syndrome, but in lower prevalence. erythema multiforme can be described as an acute skin condition and may be present within a wide spectrum of severity. erythema multiforme minor represents a localized eruption of the skin with minimal or no mucosal involvement. the papules evolve into pathognomonic target or iris lesions that appear within a -hour period and begin on the extremities (see the following image). lesions remain in a fixed location for at least days and then begin to heal. it is considered to be a type iv hypersensitivity reaction associated with certain infections, medications, and other various triggers precipitating factors and complex interactions may trigger the appearance of signs and symptoms. these include especially recurrent herpes simplex virus (hsv), epstein-barr virus (ebv), histoplasmosis, alcohol, systemic diseases and immunological factors. method: -year-old male diagnosed with prostate adenocarcinoma who underwent transurethral resection and was taking trinomia (ramipril, atorvastatin, acetyl-salicylic acid) after his th rte external radiotherapy session, he presented erythematous maculo-papular lesions in the suprapubic area with some vesicles. therefore, withdrawal of treatment was decided and the performance of a skin biopsy. days later, regarding the improvement of the lesions, rte was continued, presenting incipient exacerbations of the lesions but it allowed us to end the cycle of treatment. results: skin biopsy results (anatomical pathology): basal keratinocytes, which blur the dermoepidermal interface, with lymphocyte exocytosis at this level, associated with isolated images of spongiosis. the dermis shows a superficial perivascular lymphocytic inflammatory infiltrate of moderate intensity. compatible with erythema multiforme. conclusion: radiotherapy is a technique of increasing use, so it is important to recognize the associated cutaneous lesions that appear less frequently and are sometimes underdiagnosed. diagnosis is both clinic and pathological and is usually late in most cases so it is vital to take into account this skin disease complication in order to be properly managed. including chinese herbal medicine is usually considered to be without any allergic and adverse reaction. method: visits were made to pharmacies in hong kong and luoyang, china and a martial art monastery/temple in dengfeng, china. some cam were found to have ingredients with potential allergic and adverse reaction. results: three cam, one from hong kong ( ), one from shaolin martial art monastery/temple in dengfeng ( ) and one from luoyang ( ), china were found to contain chinese herbal medicine with potential allergic and adverse reaction. ( ) cordyceps ling-zhi complex ingredients: cordyceps sinensis "caterpillar fungus", tremella fuciformis "snow fungus", ganoderma lucidum (ling-zhi) "reishi mushroom" and others years old female patient who has ulcers in oral mucosa and purple, itchy lesions on her right hand palmar area, little finger, index finger, on her left hand palmar area, pollex finger. in her history, she has relapsing vaginal yeast and she hasn't any hypersensitivity reaction with fluconazole before month ago she started to take fluconazole because of vaginal candidiasis. after using fluconazole she started to itch from described areas and dark redpurple eruptions appeared. she was prescribed oral methylprednisolone and topical pomade which included corticosteroid for four days but she didn't aware of fluconazole related drug reaction. lastly four days ago she took fluconazole and metronidazole for severe vaginal yeast. hours later pruritus, same eruption appear on the same area, lip and tongue angioedema than she had dyspnea, dizziness, hypotension, arrhythmia and consciousness. she had admitted to the emergency department and performed adrenalin. after a day bullae and ulcers came into existence in her oral mucosa. in her blood analysis there was mild increase in white blood cell count ( . /mm ), eosinophil count was normal ( /mm ), biochemistry parameters were in normal limits, crp and sedimentation rate were in normal limits, total ige was iu/l. introduction: tuberculosis is a disease that most commonly affects the lungs, which is transmitted by the respiratory tract and drugs are the most important factor in the treatment. non-resistant tuberculosis infection is usually treated with hrze. in rare cases, a hypersensitivity reaction may develop against one or more of the drugs during treatment. case: a -year-old female patient was diagnosed with culturepositive pulmonary tuberculosis and hrez treatment was started by the related department. seven days later she referred to the policlinic with edema and itchy erythematous lesions which are common in her extremities, which developed after hours of taking her medication. liver and kidney function tests and eosinophil count were normal. drug eruption was considered with current physical examination findings. the treatment was interrupted, short time systemic corticosteroids and antihistamine treatment started. desensitization planned. there was no feature in the prick and patch tests with drugs. desensitization was performed with isoniazid, no reaction was observed during the procedure. six hours after the procedure, the patient applied to the emergency department with painful edema and pruritic erythematous lesions in the extremities. desensitization procedures with rifampicin, ethambutol, pyrazinamide were performed without any problems after the lesions were regressed. isoniazid was withdrawn from the treatment protocol. outcome: we would like to present on this case that drug eruption may develop in the form of maculopapular rash after desensitization. this study aims to compare ethmoid mucosa and nasal polyp regarding density of tissue eosinophil and its sensitivity, specificity, and correlation with clinical characteristics for diagnosing ecrs. method: patients with crs with polyps scheduled for endoscopic sinus surgery were enrolled. specimens were collected from polyp apex, polyp pedicle and ethmoid mucosa. tissue eosinophil from these three sites in the same patient were compared. using eosinophilic mucin as a reference, sensitivity, and specificity of each site for diagnosing ecrs was assessed. correlations between tissue eosinophilia (defined as greater than / hpf) and clinical characteristics of ecrs including asthma, serum eosinophilia, and eosinophilic mucin were analyzed using each site of specimens. results: thirty patients with crs with polyps were enrolled. polyp apex, polyp pedicle and ethmoid mucosa gave similar results regarding tissue eosinophilia in patients ( . %). eleven ( . %) patients were ecrs (having tissue eosinophilia at all sites) and five ( . %) were non ecrs (no tissue eosinophilia at any sites). median tissue eosinophil was significantly greater in polyp apex ( , and polyp pedicle ( , iqr: - ) than ethmoid mucosa ( , iqr: - ), p = . . sensitivity of polyp apex, polyp pedicle and ethmoid mucosa for diagnosing ecrs were %, % and % respectively. specificity were %, % and % respectively. correlations between tissue eosinophilia and asthma were significant when assessing ethmoid mucosa (p = . ), and polyp pedicle (p = . ) but not polyp apex (p = . ). correlations with serum eosinophilia, and eosinophilic mucin were not significant (p > . ) when assessing any specimens. gov/pubmed/) was performed using the following key words: "obstructive sleep apnea syndrome"; "allergy rhinitis"; "hypoxia"; "intermittent hypoxia"; "fluctuating hypoxia"; "cyclic hypoxia"; and "hif- α" results: osas may affect the prognosis of ar patients based on the following evidence: ) ar is thought to be a cause of osas. ) exposure to hypoxia could mediate immune activation in ar and affect the response to treatment. ) hif- α expression may be a risk factor for ar. ) intermittent hypoxia can induce robust expression of hif- α. conclusion: first, improvement of ventilation during sleep represents an efficient strategy for treating ar. therefore, continuous positive airway pressure or nasal surgery to resolve a nasal obstruction could be added to ar treatment. finally, medications that target hif- α, such as digoxin, can be tested as adjuvant therapy. method: forty patients diagnosed with allergic rhinitis and olfactory dysfunction were recruited in current study in the group and . patients of group were administered with no treatment and patients administered with the traditional chinese acupuncture therapy were incorporated into the group . before the treatment, all of them underwent t&t olfactory testing, nasal sinus computer tomography scanning and visual analog scale (vas; - ), and repeated the assessment after four-week treatment. results: improved total t&t olfactory testing scoring averages and vas scoring averages was observed in eleven patients treated with traditional chinese acupuncture compared with four patients in the observation group. no side effect was found. no significant differences in olfaction recovery were found according to age, gender, or duration of disease between the two groups. the observation group underwent nasal endoscopic sinus surgery and the control group underwent external approach surgery, and the therapeutic effect of the two groups were investigated. results: the total effective rate was % in observation group and % in control group, the total effective rate of observation group is significantly higher than control group (p < . ). the recurrence rate was % in observation group and % in control group, the recurrence rate of observation group is significantly lower than control group (p < . ). complication occurrence rate of observation group was % which is significantly lower than control group % (p < . ). the therapeutic effects of endoscopic sinus surgery on chronic sinusitis in geriatric patients are better than conventional external approach surgery which is worth clinical application. results: (descriptive). the equick app is user-friendly even for vkc patients with sub-optimal reading ability. home use between clinic appointments allows responsive temporal data gathering of qol, symptoms, medication scores and impact of medical interventions. equick may be used in future as a research tool in gathering outcome data following interventions for vkc. ectoine, a substance deriving from halophilic micro-organisms, is a strong water structure forming solute exerting cell protective antiinflammatory and antiallergic properties. method: purpose of our study was to assess the efficacy of the preventive administration of % ectoine eye-drops ( times a day for months) to shorten the duration of vkc relapses (which begin, in our country, very early in spring and usually end in october), or to mitigate the attacks, which are only controlled by topical corticosteroids or cyclosporine resulting in an important burden of side-effects. in this retrospective study, we included children of both sexes ( males and females), under the age of years (mean age . years), affected by vkc from more than years/seasons and treated for more than months during a year, with cyclosporine eye-drops. these patients underwent, from february to september , the additional-to-the-usual protocol treatment with % ectoine eyedrops. results: % of the included subjects astonishingly had no relapse of vkc, % needed topical cs or cyc treatment but it was started months later compared to previous years, % needed the topical drugs months later and % had a similar to previous years course (no ectoine efficacy). the treatment was well tolerated and only child had to stop it because of local allergy to the eye-drops. the preventive administration of % ectoine eyedrops was able to stabilize and to delay vkc attacks in more than % of the selected patients showing the importance of anti-inflammatory and anti-allergic properties of this product. following international criteria we considered normal levels of vitamin d the levels between nmol/l ( ng/ml) and nmol/l ( ng/ml), a potential deficiency between nmol/l and nmol/l and a severe deficiency less than nmol/l. results: . % ( children) of akc group patients presented vitamin d low levels, among them children showed a potential deficiency and a severe deficiency. . % ( subjects) of vkc patients suffered a deficiency in vitamin d which was mild in and severe in patients. . % ( children) of sac group showed a deficiency in vitamin d which was potential in and severe in subjects. conclusion: our study shows that in different forms of allergic conjunctivitis many children are suffering a vit. d deficiency and it can be supposed that a correlation between the severity of the allergic form and the level of vit. d deficiency exists. we recommend allergists and ophthalmologists to check vit. d levels in children suffering from allergic conjunctivitis because its deficiency is very common and many are unaware of it; in case of a vit. d insufficiency it is fundamental to give a vit. d suitable-to-the-case supplementation. method: children ( males and females, mean age . ± months) affected by vkc and allergic rhinitis from more than years were treated with mometasone furoate nasal spray spray bid × weeks in a month, for consecutive months as a co-seasonal treatment at the beginning of eye allergic symptoms. other systemic or topical treatments did not vary compared to the previous years. results: a quick questionnaire administered to children and their care-givers showed that nasal symptoms regressed after a mean period of . days from their beginning but, impressively, in more than % of them, these patients did not show a vkc typical relapse along the months of mometasone treatment, moreover the following summer period was milder in subjective ocular symptoms in more than % of the patients. our experience pointed out that incs adjunctive treatment was positively associated with a regression of eye and nose symptoms in children suffering from vkc, confirming previous literature data which concern milder forms (seasonal allergic conjunctivitis or allergic rhino-conjunctivitis) compared to the severe forms (like vkc) we analyzed in our work. one of the involved mechanisms of action can be the alleged effect on the reduction of substance p in tears; it is supposed to reflect the neuropeptides levels in ocular tissues. | patient response to mp-azeflu in an allergen exposure chamber onset of action (ooa) timing may impact treatment adherence. mp-azeflu, intranasal azelastine hydrochloride (aze) and fluticasone propionate (fp) in a single device, has proven to have greater efficacy and faster ooa than a combination of oral loratadine and intranasal fp (lora/infp), but the clinical relevance for patients is unclear. this single-center (ontario, canada), randomized, double-blind, double-dummy, three-period crossover trial examined by which extent mp-azeflu provides clinically relevant symptom improvements according to different efficacy parameters. method: ar symptoms were induced in asymptomatic, ragweedsensitive patients via ragweed pollen challenge in an environmental exposure chamber. patients received a single dose of mp-azeflu, lora/infp, or placebo and were monitored for hours. symptoms were assessed using total nasal symptom score (tnss) and total ocular symptom score. responder analyses included the number of patients to achieve relevant response (rr) to therapy ( % or % reduction in tnss), time to rr (ie, first time point at which rr was reached), and minimal clinically important difference (mcid) in ooa. background: nasal allergen provocation test (napt) is a standardized diagnostic tool indicated in the diagnosis of allergic rhinitis, to design and monitoring allergen immunotherapy, and to study the pathophysiology of airway allergy. unfortunately, until now very few studies have evaluated its reproducibility and safety. in this study we wanted to analyse the safety and reproducibility of napt in a large group of rhinitis patients and healthy controls. unit until december . a bilateral saline challenge followed by a bilateral napt were performed in symptoms-free individuals. the response was assessed by nasal-ocular symptoms and acoustic rhinometry. all subjects signed a written informed consent. the safety of napt was checked by the occurrence of extra-nasal/ ocular reactions (enor), severe adverse events (sae), and use of rescue medication (rm). enor was assessed by clinical symptoms, physical examination, cardiopulmonary auscultation, spirometry, and oxygen saturation. the reproducibility of napt was tested by comparison of the results in or more sessions with≥ -month interval. background: nasal hyperreactivity (nhr) is self-reported by a majority of patients with allergic rhinitis (ar) and is likely mediated by neural-immune interactions. the combination of fluticasone propionate (fp) and azelastine (aze) hydrochloride administered in a single spray (mp-azeflu) has been shown to be superior to fp or aze alone in patients with seasonal ar (sar). we hypothesize mp-aze-flu may reduce neuro-immune mediators in ar with nhr. in a post hoc analysis of three pivotal studies of mp-azeflu, we analyzed the efficacy of mp-azeflu, fp, and aze in patients with ar with and without nonallergic triggers. method: in three randomized, double-blind, controlled trials, patients with sar were randomized : : : to mp-azeflu, fp, aze, or placebo (pbo). patients self-reported sensitivity to nonallergic triggers. change from baseline in total nasal symptom score (tnss) and treatment differences between active agents and pbo were calculated. results: across patients in three studies, mean age was . years and mean age at ar symptom onset was . years. overall, % reported ≥ nonallergic trigger, which included sudden temperature/humidity change ( %), tobacco smoke ( %), perfumes/fragrances ( %), incense/candles ( %), and cleaning products ( %). change from baseline in tnss for patients with ar and nonallergic triggers was greater with mp-azeflu than with fp or aze (table) , and patients with nonallergic triggers improved slightly less than patients without nonallergic triggers in both the mp-azeflu and fp groups. background: in low-income countries (lics), assessment of phenotypes, prevalence and risk factors for allergy-related diseases (ards) using allergen-specific ige may be complicated by environmental exposures such as helminths. these exposures may also induce cross-reactive carbohydrate-specific ige profiles that could inhibit allergic effector responses. we sought to elucidate the molecular basis of ige sensitisation among individuals in uganda, using a component-resolved approach to ige measurement. we employed the isac ® allergen microarray to assess plasma ige reactivity to purified natural and recombinant allergen components in participants of three studies: a trial of intensive versus standard anthelminthic treatment in the rural helminth-endemic lake victoria islands (n = ), a parallel urban survey of allergy outcomes in a lower helminth exposure community (n = ) and a study on asthma risk factors in children from the urban setting and from nearby rural schools (n = ). data on sensitisation to crude allergen extracts were obtained by skin prick testing (spt) with cockroach and house dust mites (hdm), and by immunocap ige testing (cockroach, hdm, and peanut). results: the rural setting was characterised by high prevalence (≥ %) of sensitisation to crude extracts (immunocap ige> . ku/ l) but low sensitisation to the major, established, allergenic components on the microarray (≤ %, ige> . isu). however, sensitisation to cross-reactive carbohydrate determinant (ccd)-bearing components and venoms was more common in rural (up to %) versus urban (up to %) individuals, and was associated with helminth infection. urban individuals mounted higher responses to allergenic components of dust mites but responses to other components were similar between the two settings. sensitisation to allergenic components was higher among asthmatics and spt+ children but ccd sensitisation profiles were similar between asthmatics and nonasthmatics, and between spt+ and spt-school children. conclusion: we show that, in lics, ige to crude allergen extracts (detected in standard immunocap assays) reflects sensitisation to a myriad of environmental exposures (absent in more developed countries), such as ccds expressed by helminths, and may not accurately define ard phenotypes in this setting. however, our data does not seem to indicate that ccd-specific ige detected by isac ® microarray protects against ards. considered minor allergens. due to their sequence homology and conserved structure, they show a high cross-reactivity. the objectives were to study the ige/igg binding properties of polcalcin in relation to the calcium ions, and the ige cross-reactivity between purified polcalcin from olea europea (ole e ) and two recombinant polcalcins (rphl p and rbet v ). method: ole e was purified by immune-affinity chromatography using polyclonal antibodies anti-rche a . serum samples were obtained from patients allergic to grasses recruited at hospital de guadalajara (spain), all of them positive to phl p with sige values ranging from . to . ku/l. equal volumes of all sera were used to prepare a pool. calcium binding assay was performed either by addition or not, or depletion of ca + . ole e was incubated with . mm cacl or with mm egta ph . (ca + chelator agent) at the same time as the antibody in immunoblot or elisa assays with the pool of sera or with anti-che a polyclonal antibody. crossreactivity assay was performed by immunocap inhibition. aliquots of the pool of sera were previously incubated with amounts of ole e ranging from . to . ng. the same dilution of the pool of sera without ole e was used as a control. after hours of incubation, sige (ku/l) binding to rbet v or rphl p was determined. results: a kda protein was purified from the o. europea extract and identified by lc/ms-ms as ole e . in the calcium binding assay there were no differences between the samples with or without ca + . however, the addition of egta to the reaction completely inhibited the binding of the polyclonal antibody by immunoblot and also produced a . % reduction of ige binding by elisa. in the cross-reactivity assay, a % inhibition of ige binding was obtained with . ng of ole e for rbet v and . ng for rphl p . the maximum rate of achieved inhibition was . % for rbet v and . % for rphl p . conclusion: native purified ole e contains the ca + necessary to bind to the specific antibodies and the depletion of ca + inhibited this binding. high cross-reactivity of ole e with rphl p and rbet v was demonstrated. | effect of glutathione-s-transferase pi on the cysteine protease activity of the house dust mite allergen der p background: environmental proteases have been proposed to be involved in the pathogenesis of allergic disorders via different mechanisms, such as the disruption of epithelial tight junctions, the cleavage of surface proteins, the activation of damage and pathogen-associated molecular patterns receptors, and the alteration of redox status. der p from house dust mite is one of the most clinically relevant indoor allergens worldwide, which exhibits cysteine protease activity and has been linked to allergenic rhinitis and asthma. however, it is unknown whether the host microenvironment could regulate der p activity once it reaches the mucosal surface. glutathione-s-transferase pi (gstpi) is an anti-oxidant and detoxification enzyme. gstpi is the predominant gst in human lung epithelial cells, where it is expressed in high levels. polymorphic variants of gstpi have been associated to various inflammatory lung disorders such as allergic asthma. more recently, gstpi has been identified as a redox regulator through protein s-glutathionylation, a post-translational modification where glutathione (gsh) is conjugated to cysteine residues. method: this work aimed at determining if gstpi affects the cysteine-protease activity of der p , compared to gstmu -a different gst isoform-by using different in vitro approaches. results: we found that gstpi increased der p -activity, but not gstmu. our results suggested a potential role of gstpi in upregulating the protease activity of der p allergen. however, the clinical implications of these findings in allergic airway diseases needs for further investigations. | cari p , a novel polygalacturonase allergen from papaya acting as respiratory and food sensitizer biswas sarkar m; sircar g; ghosh n; das ak; jana k; dasgupta a; gupta bhattacharya s bose institute, kolkata, india background: papaya was globally reported to elicit ige-mediated hypersensitivity. certain papaya sensitive patients with food allergic symptoms were found to experience recurrent respiratory distresses at peak flowering period of papaya even after quitting the consumption of papaya fruits. the immunoreactive protein present both in pollen and fruit proteome was detected by ige-serology and identified by mass spectrometry. one such allergen, designated as cari p was cloned, and purified as recombinant protein. the ige-reactivity of rcari p was examined by immunoblot using patient sera. the allergenic activity of rcari p was evaluated by histamine release assay from ige-sensitized granulocytes. the aggregation and folding pattern of rcari p was assessed by size exclusion chromatography and circular dichroism spectroscopy respectively. the presence of cari p in papaya fruit was searched by igg-immunoblot using allergen-specific rabbit antisera. a mouse model of papaya allergy was established to study the role of rcari p in eliciting respiratory and food hypersensitivity. results: a kda ige reactive protein commonly present in pollen and fruit proteome of papaya was identified as endopolygalacturonase. recombinant cari p remained monomer and the cd-spectra revealed predominantly β-sheet characters. the melting curve of the allergen showed partial refolding from a fully denatured state indicating the possible presence of conformational ige-epitopes in addition to the linear ige-epitopes of food allergens. out of papaya allergic patients displayed ige reactivity to rcari p . rcari p at μg/ml, induced histamine release from challenged granulocytes within a range of % to % (i.e. ± . %; n = patients). expression of cari p was detected in the peel and pulp tissues of papaya fruits at two edible stages of fruit maturation. in mouse model, rcari p exhibited a comparable level of eosinophil infiltration and goblet cell hyperplasia in lung and duodenum histology. conclusion: cari p the first major allergen reported from papaya with a dual role in respiratory sensitization via pollen inhalation and sensitization of gut mucosa via fruit consumption. the recombinant allergen can be used as marker allergen for molecular diagnosis and immunotherapeutic management of papaya allergy. background: lipids can be potent stimulators of the immune system, and their role in allergy is highly investigated and debated. since many allergens bind lipids, one question that arises is the relative importance of the lipids versus the lipid-allergen complex in eliciting the immune response. also of interest is an evaluation of the importance of the allergen-lipid complex. in our characterization of the structure of the cockroach allergen bla g , we discovered that it could promiscuously bind a variety of lipids in a large central cavity. this suggested that bla g could be used as a prototypical allergen and lipid delivery vehicle to test in various models of sensitization. method: cd spectroscopy. nmr spectroscopy. molecular modeling. we have developed an hplc procedure to strip the phospholipids derived from the e. coli-based expression system, and reconstitute the allergen with a variety of lipids. using cd spectroscopy and nmr, we have verified that the protein conformation is highly similar in the presence and absence of lipids. temperature dependent cd spectroscopy revealed that unloaded bla g is the least stable, and the melting temperature increased with increasing fatty acid chain length up to c . similar cd melting experiments revealed that bla g could bind lipoteichoic acid (lta) from gram positive bacteria, but did not interact with lipopolysaccharide (lps) from gram negative bacteria. molecular modeling studies have suggested that the stoichiometry of phospholipid binding is likely phospholipids per bla g and give insight as to the different binding characteristics that would allow bla g to bind lta but exclude conclusion: these biophysical studies will allow the design of bla g -lipid systems to test a variety of sensitization models. | sal k , a new allergen from salsola kali sola jp; pedreño y; fernández j; cerezo a; peñalver m probelte pharma, murcia, spain background: the polcalcin from salsola kali was identified and sequenced (genbank kt ) and the recombinant protein was characterized as a minor allergen with a prevalence of % of patients with a spt positive to s. kali. the objective of this study was to purify the polcalcin from s. kali pollen and to include the allergen in the website for the systematic allergen nomenclature (www.allergen.org). method: the native polcalcin from s. kali (npsk) has been purified from pollen after a first step of protein extraction and then diverse chromatographic steps: a size exclusion chromatography to remove particles minor than kda, an ionic exchange chromatography, a hydrophobic interaction chromatography and a final step of size exclusion chromatography to obtain the purified sample of polcalcin. the purity of the npsk has been determined by sds-page and the binding capacity to a specific polcalcin antibody from rabbit serum was tested by immunoblot. the specific antibody had previously been obtained by immunization with the recombinant polcalcin from s. kali. the allergenicity of the npsk has been assayed by immunoblot with a pool of sera of patients sensitized to s. kali. the identity of the purified npsk has been analyzed by peptide footprint in hplc-ms/ms after digestion with trypsin. all the information about the polcalcin from s. kali was sent to who/iuis allergen nomenclature sub-committee. the npsk showed a high purity in sds-page with a molecular weight of approximately kda and this purified protein reacted with the specific polcalcin antibody from rabbit serum. the ige binding capacity of the npsk was confirmed by immunoblot using a pool of sera from patients sensitized to s. kali. the analysis of peptide footprint confirmed that the purified protein is a polcalcin. the who/iuis allergen nomenclature sub-committee included the polcalcin from s. kali in the website for the systematic allergen nomenclature as a new minor allergen named sal k . conclusion: the polcalcin from s. kali has been purified from pollen and tested for its ige binding. it is included in the website for the systematic allergen nomenclature as the new allergen sal k . background: alt a protein is the major allergen from the fungus alternaria alternata and responsible for chronic asthma, yet little is known about its physiological role and immunological activity. our main purpose was to investigate the mechanism through which alt a induces an allergic response in bronchial epithelium. method: although alt a has a unique topology, we studied the structural relationship by in silico procedures consisting of three distinct structural alignment methods in order to understand its nature. the immunological properties of the allergen were investigated by using monocyte cell line thp and human peripheral blood mononuclear cells. results: its crystal structure has been recently reported and claimed to be exclusively in fungi without equivalent in the protein data bank. data obtained in silico show that this allergen shows some structural relationships with a number of other β-barrel proteins such as human lipocalin (lcn ). besides, our experimental data demonstrate that alt a is also able to interact with lcn , human lipocalin. in this way, the results obtained from several immunological assays showed that alt a is able to produce a response of the immune system through different immune innate receptor pathway inducing the th cytokines. background: increasing evidence of cross reactivity syndromes between pollen grains and fruits, with immediate or delayed reactions, has been reported. while some syndromes such as the birch pollen/apple syndrome are well documented, some other such as the cypress pollen/peach syndrome remain to be understood. for the latter, significant progress has recently been made with the discovery of a new allergen family, the gibberellin regulated proteins (grps), which has been shown to be responsible for the observed cross reactivity i.e. pru p and bp ( , ) for the peach and the cypress pollen respectively. grps are small cationic proteins with anti-microbial properties and have been shown to be over produced in response to a stress. herein, the case of a patient, born and raised in the south of france but currently living in paris, has been studied. this patient has been suffering since childhood from allergic rhinoconjunctivitis to cypress pollen and from some oral symptoms to peach and other fruits (including pomegranate). method: in addition to the clinical exploration and cutaneous tests, a very thorough biological characterization of the patient samples has been performed through various specific ige quantitation techniques, western blotting after one and two-dimensional gel electrophoresis and flow cytometry based basophil activation testing (bat). results: specific iges to cypress pollen, birch pollen, peach, orange and apple have been found. pr allergenic proteins are recognized by iges but no ltps. the presence of specific iges to cypress pollen bp , peach peamaclein (pru p ) and a cationic kda protein from pomegranate has been shown through western blotting after gel electrophoresis separation of the protein extracts. the use of bat finally enabled to demonstrate that the basophils of this patient were, ex vivo, strongly activated with protein extracted from orange and cypress pollen and also with purified proteins such as bp and pru p . conclusion: these results unambiguously show that the cypress pollen grp, bp , is clinically relevant, similarly to its homologous protein in peach, pru p . it can be proposed that these two allergens are at the basis of the observed cross-reactivity syndrome. the search for new cross-reactive allergenic grps in pollen, fruits or vegetables may enable to better understand other pollen/food associated syndromes that still remain unexplained. background: nine allergens of phleum pratense have been described until now (iuis database) and classified into groups based on their function and cross-reactivity. group and allergens are considered the most immunodominant, due both to their greater ige-binding capacity and the number of patients ige-reactive to them. previously published studies have estimated that group is recognized by almost % of grass pollen-allergic patients, and group by %. however, until now a comparative of the ability of these allergens to provoke an immune response has not been performed. the objective was to study the immunogenicity of the major allergens phl p and phl p , by analyzing the ability of the recombinant forms (rphl p and rphl p a) to induce a humoral immune response. method: five mice were immunized with the same amount of each recombinant protein: rphl p and rphl p a (indoor biotechnologies) ( μg plus two boosters of μg). the specific igg antibodies produced by each mouse were tested against the recombinant proteins by direct elisa and the title of each of them was determined by optical density (o.d.). additionally, the recognition of both allergens in native and depigmented-polymerized (dpg-pol) extracts of p. pratense was studied by direct elisa using these generated antibodies. results: preimmune sera were negative. all mice produced antibodies against the corresponding recombinant protein. the immune response (sigg) was statistically significant higher in mice immunized with rphl p than in those immunized with rphl p ; it was needed times more rphl p serum than rphl p a serum to obtain the same o.d. values. the difference in responses was higher in the group of mice immunized with rphl p than with rphl p a. differences in the recognition of phl p and phl p in native and depigmented-polymerized extracts of phleum pratense was also observed. it was necessary times more rphl p serum to produce the same signal than rphl p a serum in native extract and it was necessary times more rphl p serum to produce the same signal than rphl p a serum in dpg-pol extract. conclusion: rphl p a is more immunogenic than rphl p , which was also probed with native and dpg-pol extracts. background: glioblastoma (gbm) is an incurable primary malignant brain tumour with a median life span of less than months despite multimodal treatments. therefore, there is a serious need for the development of innovative medications. several epidemiological studies underlined an inverse correlation between pre-existing igemediated allergy and gbm risk, where having such an allergy decreased the odds of developing gbm by to %. we aim to delineate the intrinsic immuno-biological and molecular mechanisms that can be responsible for these correlations, based on the hypothesis that allergies may promote a state of increased immuno-surveillance in the brain through the presence of immunological factors such as immunoglobulins, cytokines and cells involved in th -driven allergic reactions. we consider that as the major immune cell type of the brain, microglia should be implicated in this beneficial association and may favour the elimination of the nascent tumour in brain parenchyma in an allergic context. we implemented a long term allergic airway inflammation by repeated nasal instillation of house dust mite (hdm) extract in a syngeneic orthotropic mouse model of gbm. we followed animal survival and the tumour growth by mri. in addition, we purified microglia from allergic vs non-allergic mice in order to assess their cytotoxic function against the gbm cell line ex vivo and their secretory capacities. finally, we investigated immunoglobulin reactivity against gbm antigens in the context of allergic reactions by reverse phase protein array (rppa). we demonstrated an increase of the animal survival that was correlated with a delayed tumour engraftment and a reduced tumour growth. these phenotypes were associated with functional modification of microglia from sensitized mice. indeed, these microglia showed a rise in the production of il- and tnf-a as well as an increase in cytotoxic functions against a gbm cell line ex vivo. in parallel, we observed an increase in serum igg reactivity against gbm antigens in mice sensitized with hdm compared to control mice. results: in patients ( %) with cvid we recorded at least one temporary platelet count decrease below × /l compared to only patient ( %) with xla (p = . ). more importantly in patients ( %) with cvid this decrease was observed in a period longer than months compared to patient ( %) with xla (p = . ). in patients ( %) with cvid we recorded at least one temporary platelet count decrease below × /l and only in patients ( . %) with cvid this decrease was observed in a period longer than months. we did not record any platelet count decrease bellow × /l in patients with xla however the difference with cvid did not reach statistical significance. no thrombocyte count decrease bellow × /l was observed in either group. none of patients required immunosuppressive treatment for immune thrombocytopenia (itp). conclusion: although the statistical significance was documented only in temporary platelet count decrease below × /l it is obvious that numbers of thrombocytes commonly fluctuate in some patients with cvid. the mechanism leading to these temporary decreases is unclear. monitoring of complete blood count is a basic follow-up investigation in patients with cvid. introduction: wegener's granulomatosis (wg) is a systemic disease that may affect all organs, most frequently the ears, noses, throats, sinuses, lungs and kidneys. it is a rare autoimmune disease, also called granulomatosis with polyangiitis, and characterized by necrotizing granulomatous inflammation in small and medium sized blood vessels. anti-neutrophil cytoplasmic antibody against to proteinase (c-anca) is thought to be responsible for autoimmune inflammation. the coexistence of wg and common variable immunodeficiency (cvid) is extremely rare. in this report, we describe a patient with wg and cvid who was treated with immunosuppressive drugs and intravenous immunoglobin concomitantly. case report: a twenty-four-year-old male patient was referred to our clinic for immunological evaluation due to recurrent infections, fever of unknown origin and neutropenia. the patient had been diagnosed with wg and taking immunosuppressive therapy for three years. he had chronic renal failure due to wg and had also been on peritoneal dialysis for three years. serum igg, iga levels, peripheral blood cd + b cell percentage and absolute count of the patients were found to be low according to reference limits. he was diagnosed with cvid after excluding secondary reasons for hypogammaglobulinemia and he started to receive mg/kg intravenous immunoglobulin (ivig) therapy once in a month. also, the treatment that consists of mycophenolate mofetil (mmf) and glucocorticoids was continued to decrease c-anca levels in serum. he has been accepted as a candidate for kidney transplantation, and prepare for this purpose. discussion: the management of the patient with cvid and wg may be complicated. it is considerably difficult and needs competency and courage. moreover, the cases similar to ours, are extremely rare. therefore, the authors should share their own experiences on cvid and discuss them by comparing the data obtained from other cases. background: leukocyte adhesion deficiencies (lads) are a group of three genetic disorders leading to defective leukocyte adhesion to the endothelium and as a consequence decreased leukocyte recruitment and immune defense. lad-i is caused by mutations in the gene encoding the ß -integrin cd on chromosome .lad-iii is a rare primary immunodeficiency syndrome, characterized by homozygous mutations in the kindlin- gene (official symbol fermt ). we have aimed to evaluate our patients who were followed up with lad for the last years, retrospectively. method: all data of the cases were obtained from the file records of age at diagnosis. results: seven patients from separate families were included in the study. four patients were lad-iii and patients were lad-i. the female to male rate was / . the age of diagnosis is ranged from days to years. the median umbilical cord detachment was days ( - days groups: up to times ( people) and from to times ( people). healthy donors were examined as a control. flow cytofluorometry method was used to study peripheral blood and assess the parameters of innate and adaptive immunity results: it was found that at a frequency of edema up to times a year there are changes in the t-system of adaptive immunity, which are shown by a decrease in the expression of late activation markers (cd + hladr+ . ± . %, in control . ± . %), an increase in the number of cd + cd + cytotoxic lymphocytes ( . ± . x /l, in control . ± . x /l) and as an increase in their functional activity (cd + gr+ . ± . x /l, in control . ± . x /l). the nature of disorders of cellular factors of the innate immunity is manifested by decrease in the adaptive resources of neutrophils (kstnbt . ± . u.e., in control . ± . u.e.). patients with hae with a frequency of edema up to times a year, we observed the disorders of the humoral link of adaptive immunity, which consist in an increase in the number of circulating b lymphocytes ( . ± . x /l, in control . ± . x /l). in addition, with the strengthening of the hae clinic, changes in the system of innate immunity progressed very fast and consisted in increasing the amount (cd + . ± . x /l, in control . ± . x /l), and functional activity (cd + gr+ . ± . x /l, in control . ± . /l) of natural killer cells results: we included children, mostly males ( %), aged between month and years. . % of patients (n = / ) showed abnormal absolute results of lymphocyte count for age. we found more patients evaluated in the age group of to years ( . %), followed by - years ( . %), lymphopenia was found in . % of patients. b lymphocyte deficiency was the most common pattern ( %) followed, in decreasing order, by low cd , t cd , tcd and nk. many patients have more than one affected population ( . %) . some patients were affected in all three series ( . %). the cd / cd ratio decreased in . % of the patients. the majority of the children were males between the ages of month and years. . % of patients showed abnormal absolute lymphocyte count for age. b-cell deficiency was the most common pattern followed, in decreasing order, by low cd , t cd , tcd and nk. many patients have more than one affected population. | indicators of the humoral immunity in the mechanical jaundice of benign genesis the aim of the investigation was to study the indices of humoral immunity in patients with benign mj, depending on the level of bilirubin. method: patients with mj and practically healthy volunteers were examined. patients with a level of bilirubin less than μmol / l - , with a bilirubin level of - μmol / l - and with a bilirubin level of more than μmol / l - patients. the concentration of immunoglobulin classes a, m, e and g in serum was determined by enzyme immunoassay. the statistical significance of the differences was determined using the ranked mann-whitney test. the critical level of significance in checking statistical hypotheses was assumed to be p < . . results: of the contacted dermatologists, participated ( women, men; mean age . ± . ) which results in a response rate of . %. the guideline compliant prescription rate of biologicals in patients with csu was . %. the most prevalent barriers in the prescription were the high cost of the treatment ( . %), low reimbursement for doctors ( . %) and the fear of a recourse claim ( . %). however, a lack of evidence or an insufficient efficiency were not con- case report: eosinophil associated gastrointestinal disorders (egids) including eosinophilic colitis are commonly associated with atopy. aeroallergen sensitization may accompany food allergy in these patients. a case with eosinophilic colitis responsive to anti-ige monoclonal antibody (omalizumab) treatment is presented. an eleven-year-old boy had bloody diarrhea lasting nearly one month in autumn for last years. this year diarrhea lasted more than months. colonoscopic biopsy revealed lymphoplasmacytic inflammatory cells including eosinophils leading to a diagnosis of ulcerative colitis. corticosteroid and mesalazine treatment was started with a good clinical response. recurrence of diarrhea during corticosteroid dose reduction suggested corticosteroid dependent ulcerative colitis. eosinophilic/allergic colitis was an alternative diagnosis when seasonal recurrence, lack of weight loss, eosinophils in biopsy and high serum ige level were considered. colonoscopy done after cessation of therapy for one month, revealed exudative ulcerous lesions, lacerations, loss of haustration compatible with colitis (inflammatory/allergic?). presence of significant mucosa associated lymphoid tissue in biopsy supported any inflammatory, reactive process. he had recurrent bronchiolitis until age six and allergic rhinitis in spring for three years. total ige and mix aeroallergen specific ige were high ( iu/ml, . kua/l), absolute eosinophil count was normal ( /mm ). food skin prick and patch tests were negative. he had positive skin reactions with dermatophagoides, grass and olea pollens (induration diameter: , , mm, respectively). pulmonary function test was normal. he was considered as eosinophilic/allergic colitis and omalizumab was started according to manufacturer's dosing table ( mg/ weeks). rectal bleeding decreased after first dose and ceased after the second dose. early colonoscopy examination after rd month of therapy showed that exudations disappeared and haustrations became evident. microscopy revealed mild nonspecific colitis. few patients with eosinophilic colitis improved with omalizumab were reported before. ige-mediated processes are responsible from eosinophilic inflammation in egids, making anti-ige therapy as a promising treatment option. | design of liposomal carriers modified by glycoconjugates for liver cell delivery of nucleic acids used. the surface of liposomal nanoparticles can be modified to increase the selectivity of intracellular delivery. it is well known that asialoglycoprotein receptors of hepatocytes have a strong affinity to galactose carbohydrate. therefore, the aim of this study was to assess the effect of the modification of the liposome surface by glycoconjugates on the selectivity of intracellular transport of nucleic acids into the liver cells. method: liposomes based on ornornglu(c ) were chosen previously as the effective nucleic acid delivery system. we modified liposomes with novel lactose-based derivatives. every of four glycoconjugates was added to ornornglu(c ) in an amount of , and %. as a result, variants of modified liposomes were obtained. to determine the cytotoxicity, an mtt test was used. using luciferase test, the selectivity of penetration was evaluated on nonspecific t (human embryonic kidney) and specific hepg (human liver cells) cell lines. results: modified liposomal compositions ornornglu(c ) - + lacc ( %) and ornornglu(c ) - + lacggg ( %) had the lowest cytotoxicity similar to that for unmodified ornornglu(c ) . the ic , calculated based on the data of mtt test, was . and . , vs. . mg/ml, respectively. ornornglu(c ) - + lacggg ( %) showed a . -fold increase in transfection activity on the nonspecific t cells, compared to unmodified ornornglu(c ) , whereas the modification of ornornglu(c ) - + lacc ( %) resulted in a -fold decrease in transfection activity. however, the ability of these variants to penetrate the specific liver hepg cell was significantly higher by and times, respectively, than for unmodified ornornglu(c ) . results: the greatest inhibitory effect of sbfhd was observed in mdm infected with hiv- bal: % and % suppression of hiv replication was achieved at concentrations of . μg/ml and . μg/ ml, respectively. the activity in pbmc and dc was less pronounced (the respective ic values were . μg/ml and . μg/ml). studies in endometrial hec- a cells demonstrated that sbfhd suppressed cd -independent entry of hiv- ( tcid /ml) by %, %, and %, respectively, at , , and μg/ml. the effect was also observed after increasing the dose of the virus. at tcid /ml, sbfhd suppressed hiv infection by % ( μg/ml) and % ( μg/ml). the cytotoxicity of sbfhd in this system was low. similar results were obtained with colorectal caco- cells. sbfhd exhibited no spermicidal activity at concentrations of up to mg/ml. combining within a single microbicide two agents that target distinct steps of hiv life cycle will maximize its efficacy (via synergistic effects and/or interference with multiple stages of the transmission). we therefore explored the synergistic potential of combinations of sbfhd and azt, the classical nucleoside rt inhibitor. in these experiments, % suppression of hiv infection was reached at concentrations of sbfhd and azt, which were significantly lower than the respective ic values of each component (determined in parallel experiments). the synergistic effect was most pronounced for the combination of . μg/ml sbfhd (which is times less than the ic ) and . nm azt (which is times less than its ic ). cd expression was increased after the co-culture with reishi, shiitake and boletus mushrooms (c - . ( . - . )%; pma - . ( . - . )%; )%; shiitake - . ( . - . )%; boletus - . ( . - . )%). method: the study included men (mean age ± . years) before and immediately after staying in countries with a hot climate. results: the development of lymphopenia observed in the first week of observation. this was accompanied by a decrease in the number cd + lymphocytes expressing the markers of late activation (cd + hladr+ . ± . x /л и . ± . x /л). revealed significant decrease of cd + cd + foxp + regulatory cells in the first week after returning from the area of adverse climatic conditions, as well as a significant sustained decrease in the number cd + cd + hladr+(p < . ). change of the effector link of innate immunity was determined in significant reliable decrease in relative (cd + . ± % and . ± . %, respectively, p < . ) and absolute (cd + . ± . x /l and . ± . %, respectively, p < . ) in the number of a population of natural killer cells in the first week of observation. in the context of acute stress marked a significant increase in relative and absolute numbers of b lymphocytes ( ± . % ( . ± . × /l) before a trip to countries with a hot climate and ± . % ( . ± . × /l) in the first week after returning, p < . ). the activity is the production of antibodies was not changed. (ast) which is the intramuscular injection of patients own serum, is a promising therapy with a substantial efficiency on ciu patients. in this study we aim to assess the efficacy of ast on chronic urticaria patients by dlqi questionnaire. method: this was a single-blind randomized clinical trial which evaluated the efficacy of autologous serum therapy compared to oral antihistamines in patients with ciu. ciu patients received the ast. every session cc of each patient's blood was centrifuged at the speed of rpm for minutes and . cc of the serum was injected intramuscular into the patient's deltoid muscle weekly for weeks. the control group consisted of ciu patients took mg of cetirizine daily for weeks. patients answered the dlqi questionnaire at the first session of treatment as baseline and weeks after the last session(week ) as response to treatment. the mean baseline score of dlqi for ast group was conclusion: pharmacotherapeutic and inpatient costs for patients with prevalent ar and asthma were lower in those prescribed ait than in those not prescribed ait in all years, both with and without including the cost of ait itself. this indicates that treatment with ait is associated with lower cost burden for health services. background: immunotherapy with peptides rather than conventional whole allergens is being developed to improve the benefit/risk balance of subcutaneous immunotherapy (scit). lolium perenne peptides (lpp) demonstrated reduced allergenicity following ex-vivo analyses, allowing higher doses to be given over a shorter period to improve treatment adherence and compliance. such treatment resulted in significant reduction in symptoms and rescue medication intake during the grass pollen season. here we report the safety of lpp immunotherapy in adults. background: a new allergoid from alternaria alternata was characterized to determine its reduced allergenicity in vitro. the objective of this study was to determine the skin response to the allergoid and to evaluate the clinical tolerance of the immunotherapy with the allergoid product using a rush schedule. method: to assess the skin response (sr) two groups of patients were included: group with patients sensitized to a. alternata and with respiratory disease caused by this mold; group (control) with patients sensitized to others allergens and non-atopic patients. the sr was determined by spt using three concentrations of the allergoid: p (lowest concentration), p (four times higher than p ) and p (estimated to obtain a wheal area similar to histamine mg/ml). in spt was also used a native extract of a. alternata (n) and histamine mg/ml (h). all products were tested in duplicate in all patients and the sr was evaluated by comparing the median of the wheal area produced by different products. to evaluate the clinical tolerance to immunotherapy the patients of group were treated with the allergoid product using a rush schedule consisting in a dose of . + . ml the first day and . ml after one month (maintenance dose). the clinical tolerance was determined as the percentage of adverse reactions (ar) to the treatment and the classification of ar was established according to eaaci. the number of patients included to evaluate the sr was (group : ; group : , atopic and non-atopic) with an average age of . (range . the spt data from group were expressed as median and interquartile range of wheal area (mm ): h: . ( . - . ); n: . ( . - . ); p : . ( - . ); p : . ( - . ); p : . ( . - . ). it was determined that sr of allergoid was reduced in % respect to the native. the products n, p , p and p did not produce any response in patients of group . to evaluate clinical tolerance, patients of group were treated with the allergoid product with a rush schedule and only two ar were registered ( . % of doses). these were retarded local reactions with a wheal diameter higher than cm. no systemic reactions were registered and all patients continued the treatment. the allergoid from a. alternata produces a significant reduced response to spt due to its reduced allergenicity. the treatment with an allergoid product in a rush schedule is safety and clinically well tolerated. background: in our study we aim to determine the more effective, the total cost of years of patients using scit was tl per person whereas the total cost of years of patients using slit was tl per person. when we compare the total cost data of both groups, we found that they are close to each other. while the greatest portion of the cost data of patients with scit treatment was direct costs associated with the treatment itself ( %); the remaining part of the total cost was indirect ( %) with non-medical expenses such as transportation ( %). in the slit group, direct costs including drug expenditures have a larger percentage ( %) and it was significantly more costly compared to the direct costs of the scit group ( %). transportation costs were found to be more costly in the scit group ( %) when compared to the slit group ( %). similarly loss of parent work days in the scit group(% ) was found to be significantly more expensive compared with slit group ( %). our study results show that slit is a similar treatment for clinically and laboratorially and has a similar efficacy to scit to reduce the patients' complaints and to the need for medication. for cost-effectiveness however medicines for treatment of scit are less costly; when long term total treatment costs are calculated slit and scit treatment are economically close treatments. the protein content of the new acd was . μg/mg and the protein profile in sds-page and sec-hplc confirmed the presence of proteins with high molecular weight and the absence of smaller proteins. the content of free lysine in acd, involved in glutaraldehyde modification, was reduced in . % respect to ncd and it can be considered as the polymerization degree. regarding to the allergenic profile, through elisa inhibition was determined a reduction of times in the capacity to bind ige of the proteins in acd respect to ncd, whilst the igg binding capacity was maintained. in immunoblot there was no reaction of acd proteins to specific ige from sera. the analysis by peptide footprint determined the presence of fel d and others allergens in acd. the content of major allergen fel d in acd was determined as . μg/mg. the new developed and characterized allergoid from cat dander has an excellent safety profile and will allow a safer immunotherapy to treat the allergy to felis domesticus. results: the protein content of the new aaa was . μg/mg and the protein profile in sds-page and sec-hplc confirmed the presence of proteins with high molecular weight and the absence of smaller proteins. the content of free lysine in aaa, involved in glutaraldehyde modification, was reduced more than % respect to naa and it can be considered as the polymerization degree. regarding to the allergenic profile, in immunoblot there was no reaction of aaa proteins to specific ige from sera and by elisa inhibition was determined a reduction of % in the capacity to bind ige of the proteins in aaa respect to naa. the igg binding capacity in aaa was maintained. the analysis by peptide footprint determined the presence of alt a and others allergens in aaa. the content of major allergen alt a in aaa was determined as . μg/mg. a. alternata shows an excellent safety profile and allows a safer immunotherapy to treat the allergy to this mold. she was an otherwise healthy woman: she took no drugs and she did not have any remarkable concomitant diseases. the distribution and appearance of the remaining body hair was normal and the hormonal level profiles (lh, fsh, estrogens, progesterone and testosterone) did not show any significant alteration according to her age. a year old woman with allergic rhinitis underwent sq glutaraldehyde-modified ait to house dust mites (d pteronyssinus and g domesticus) without any incidences and complete tolerance to maintenance dose without local reactions during a year period. two years after ait discontinuation, patient first experienced a local urticarial reaction with multiple hives at previous sq ait injection sites minutes after mg of ibuprofen intake. these symptoms recurred at least in seven occasions when patient was exposed to ibuprofen (in five) and metamizol (in two). results: case : dermatologist diagnoses localized hypertrichosis. case : a single blind, placebo controlled oral challenge (sbpcoc) with ibuprofen mg was performed and elicited multiples hives in the circumscribed area in the arm where ait was conducted. subsequently, sbpcoc with aspirin was carried out showing the same reaction although a controlled challenge with celecoxib was negative. conclusion: local hypertrichosis is a very rare injection-disease associated with injected allergen vaccine treatment. we also firstly described a recall urticaria phenomenon after allergen immunotherapy which has been only elicited after different nsaids intake. results: there were included patients, in five spanish hospitals. following aria guidelines, . % of patients were diagnosed of persistent moderate/severe rhinitis. the mean age was . ± . years, being . % female. moreover, . % of the patients had concomitant mild/moderated asthma. the period between the diagnosis of rhino-conjunctivitis and the informed consent signing was . ± . years. according to international guidelines, eight systemic reactions were registered, representing . % of the administered doses: five reactions grade , (described as nonspecific ocular pruritus, nasal herpes, general discomfort, localized non-specific pruritus plus nausea and non-specific pruritus in throat), a grade i reaction described as rhinoconjunctivitis and two reactions grade ii, registered as generalized urticaria and asthma. all reactions were classified of mild or moderate intensity and only two required symptomatic treatment. there were five clinically significant delayed local reactions, which were higher than cm or involved modifications in next dose. regarding efficacy parameters, immunoglobulin titers between baseline and final visit according to specific igg and igg significantly increased. cutaneous reactivity also decreased significantly in the dose response skin prick test. results: patients were included, to accelerated and to polymerized cluster group schedules. according to aria criteria, . % of patients presented persistent moderate/severe rhinitis. the mean age was . ± . years, being . % male. moreover, . % had concomitant mild/moderated asthma. immunoglobulin titers method: the quantification of total proteins in the products was carried out by means of a colorimetric technique using the bradford reagent (sigma-aldrich™, us) in accordance with the manufacturer's instructions. the absorbances of each standard and samples were obtained in a scinco™ s- spectrophotometer (seoul, korea) at nm. all samples were analyzed in duplicate. the electrophoretic profile of the proteins in the tested allergens was obtained according to the procedure described by laemmli, under denaturing conditions in a polyacrylamide gel at . % concentration and stained in silver. in each lane approximately μg of total proteins were applied. commercial extracts of the main allergens marketed in mexico were obtained, rossel ® , alk ® , alerquin ® , alergomex ® , allerstan ® , ipi asac ® ; and they were assigned randomly with the numbers , , , , and . results: the following protein concentrations were found in the various extracts analyzed: see table conclusion: differences were found in the protein profiles ana- background: a new allergoid from cat dander was developed and characterized to determine its reduced allergenicity in a % and the maintenance of igg binding capacity. the objective of this study was to develop an immunogenicity assay in mice with the new allergoid and a native extract from cat dander. the study included female balb/c mice separated in three groups of mice each: group , immunized with a mold allergen extract (control); group , immunized with a native extract from cat dander with a fel d content of . μg per dose; group , immunized with the new allergoid from cat dander with a fel d content of . μg per dose. all mice were immunized four times by subcutaneous injections with a volume corresponding to / of the recommended human maintenance dose with an interval between injections of weeks. one week after the last injection the mice were sacrificed and the serum was obtained. to determine the specific antibody title indirect elisa were performed using a cat dander extract as antigen, sera from mice as primary antibody and antimouse igg or igg as secondary antibody. elisa assays were performed using serial dilutions of sera or a simple dilution by duplicate to determine the specific antibody title as arbitrary units/ml (au/ml). the data were analyzed by one-way anova and tukey hsd test to compare the averages of specific antibodies in each group. results: the immunization with both the native extract and the allergoid from cat dander produces specific igg and igg . regarding to igg, a higher title was observed in group respect to group in a curve obtained after elisa with serial dilutions of sera. the specific igg title obtained in terms of au/ml was . ± . in group , . ± . in group and . ± . in group . concerning to igg the au/ml obtained was . ± . in group , . ± . in group and . ± . in group . the increase of specific igg or igg in mice from group respect to mice from group and control group was statistically significant (p ˂ . ). the safety profile of the allergoid from cat dander allows a treatment with higher dose of allergens to produce a greater response to immunotherapy to induce formation of specific this was an open, multicenter clinical trial, in patients aged between to years with rhinoconjunctivitis with or without concomitant mild asthma sensitized to house dust mites (hdm). the aim was to evaluate the safety and tolerability of the vaccine. secondary endpoints included were: changes in immunoglobulin levels (specific ige, igg and igg ) versus d. pteronyssinus and d. farinae and changes in cutaneous reactivity. patients were under study treatment for weeks: five for the induction phase (weekly injections) and for the maintenance phase (monthly injections). results: patients were included. there were withdrawals from the trial; no one was related to treatment. the patients mean age was . years, being % female. . % were diagnosed of persistent moderate/severe rhinitis according to aria guidelines and . % presented concomitant mild asthma. regarding to safety results, systemic adverse reactions were registered which corresponded to . % from a total of administered doses. the most of systemic reactions were grade i, ( . %) described as rhinitis or urticaria, grade or nonspecific ( . %) and reaction ( . %), was grade ii. all of them were mild or moderate and only needed treatment. among local reactions, ( . %) were clinically relevant late local reactions, meaning a wheal at injection site > cm and /or requiring a dose readjustment in the next administration; ( . %) were clinically relevant immediate local reactions meaning a wheal > cm. concerning the efficacy parameters, cutaneous reactivity at the final visit versus baseline was, in average, significantly decreased, and specific titers of igg and igg against tested hdm increased significantly at final visit. patients completed the study. mean values in rqlq questionnaire (total score) decreased from . to . points ( . % score reduction) in final visit, reflecting a statistically significant improvement (p < . ). annual episodes of rhinoconjunctivitis decreased from . to . (p < . ). . % of patients improved from persistent to intermittent rhinoconjunctivitis (p < . ) and . % from moderate/severe to mild intensity (aria) (p < . ). moreover, . % of asthmatic patients at baseline, did not have any bronchial symptoms after -year treatment (p < . ). mean value of treatment satisfaction was . (sd= . ) and . (sd= . ) for patients and physicians respectively. | evaluation of safety and tolerability of "allergovac poliplus" in polysensitized patients with allergic rhinitis-rhinoconjunctivitis with or without asthma: an observational prospective study (apolo) background: the objetive of this study was the safety and tolerance assessment of "allergovac poliplus" scit treatment, with allergen combination-mixtures in polysensitized patients, as well as the evaluation of the clinical improvement and patients' satisfaction after treatment. method: this is a prospective observational clinical study. allergovac poliplus treatment is being administered in a " -day" or in an abbreviated schedule. polysensitized patients (to pollens or mites), with rhinitis or rhinoconjunctivitis, with or without asthma, and between - years have been included. all adverse events are being recorded. visual analog scales (vass) are being used to evaluate clinical improvement, tolerance and satisfaction after treatment ( months). results: a total of patients have been included, with an aver- results: in all groups prevailed severe forms of the disease and the phenotype of frequent exacerbations. groups were comparable in age composition and structure of severity. observations in the group of vaccinated pcv continue the dynamics of decreased dyspnea up to . ( . ; . ) results: of a total of pts under scait, were excluded due to data unavailability, and included (♀ ( %), mean age ± years (minutes: max md ), age range [ - ] being most prevalent ( %). the most frequent diagnosis was rhinitis/rhinosinusitis ( %), followed by asthma ( %), diagnosis coexisting in abstracts | pts ( %). other diagnosis such as conjunctivitis ( %), atopic eczema ( %) and food allergy ( %) were also found. mite sensitization occurred in patients ( %) of which ( %) were monosensitized. the pollen sensitization was verified in ( %) with monosensitized pts ( %). the double sensitization mitespollens was displayed in ( %). sensitization to epithelia and fungi occurred respectively in ( %) and pts ( %). it was found that pts ( %) presented sensitization to the groups of allergens (mites, pollens, fungi, dander). an average of ± pts started this treatment per year. prescription included laboratories with the following %: a- . ; b- . ; c- . ; d- . ; e- . ; f- . ; g- . ; h- . ; i- . ; j- . . option for extract of physical modification ( %), physical-chemical ( %) and chemical ( %). table shows the frequency of distribution of scait composition. conclusion: in this population sensitization to mites was predominant being the most prescribed scait followed thru sensitization to grasses with the respective scait. the majority of the population was polysensitized. however, in composition preference the choice of group of allergens prevailed and only % had more than one sort of pollen and % pollen+mites. polysensitization is a reality, nonetheless the choice of ait composition should be guided thru scientific criteria and not through the availability of mixtures encouraged by laboratories. background: allergen immunotherapy (ait) has been proven to be an effective treatment of allergic diseases in numerous studies. however, its use in seniors remains limited and questionable, due to common comorbidities and limited evidence of efficacy and safety of ait in aging population. the aim of presented study was to assess the safety of ait in patients over years of age undergoing subcutaneous immunotherapy (scit) and analyze the potential risk factors of adverse reactions in this population, compared to younger adults. we followed subcutaneous immunotherapy in a group of patients treated in the outpatient clinic of medical university of lodz, of whom were aged and older ( between the age of - , aged - and patients above the age of ). we recorded detailed information of each administration and corresponding adverse reactions over the period of years. we compiled results of our observations with patients' medical records to compile a database, which we then analyzed using statistical software. method: a total of cases with seasonal allergic rhinitis undergoing pre-seasonal immunotherapy and cases followed with conventional drug treatment were included in the study. immunotherapy and control groups were divided into monosensitized (only pollen) and polysensitized (at least additional allergen except pollens) patient groups according to skin prick test reactivity. all patients were followed between march-september with symptom and medication scores, and visual analogue scale (vas). the quality of life was assessed using the mini-rqlq questionnaire. phleum pratense (phl p) specific ige and specific igg (uni-cap , phadia) measurements were performed before and after weeks of immunotherapy in all patients. gramineae pollens were counted during the grass pollen seasons. results: mean age was . ± . and . ± years, female/ male ratio was / and / , the number of monosensitized/polysensitized patients were / and / in immunotherapy and control groups, respectively. in the immunotherapy group, june-july symptom scores, may-june-july-august vas scores and june combined symptom-medication scores were lower than the control group (p = . ). furthermore, improvements in activities-practical problems and other quality of life scores were significantly different between two groups (p < . ). in immunotherapy group, phl p specific ige and phl p specific igg levels measured after immunotherapy were significantly higher compared to those before immunotherapy (p < . , p < . , respectively). phl p specific igg levels measured after immunotherapy were also significantly higher in the immunotherapy group than in the control group (p < . ). there was no difference in terms of clinical and immunologic parameters in monosensitized and polysensitized patients (p > . ). conclusion: clinical improvement with pre-seasonal allergoid immunotherapy is accompanied by an important increase in specific igg blocking antibodies despite short-term injections. our findings show that pre-seasonal allergoid immunotherapy has similar clinical efficacy and b cell response in polysensitized subjects compared to monosensitized patients. | the safety trial of sequential sublingual immunotherapy with japanese cedar droplet and house dust mite tablet matsuoka t ; kuroda y ; igarashi s ; fukano c ; natsui k ; ohashi-doi k ; masuyama k university of yamanashi, yamanashi, yamanashi, japan; torii pharmaceutical co. ltd., tokyo, japan background: sublingual immunotherapy (slit) is recognized as the only treatment option with the potential to provide long-term posttreatment benefits. in japan, the prevalence of japanese cedar (jc) pollinosis is very high, about % of the population, of which the majority are co-sensitized to hdm. slit is now well established, safe and convenient treatment form for allergic disease, and recently, jc slit-droplet and hdm slit-tablet products were approved in japan for treatment of jc and hdm induced allergic rhinitis, respectively. however, the safety of sequential jc slit-droplet and hdm slittablet has not yet been investigated. therefore, we investigated the safety trial on slit combined with jc droplet and hdm tablet in allergic patients. method: eleven subjects with jc pollinosis and hdm rhinitis were enrolled. patients were treated once-daily with jc slit-drops for weeks, followed by weeks of sequential slit treatment where the jc slit-drops and the hdm slit-tablets were administered daily with a minute interval ( st: jc-slit drops, nd: hdm slit-tablet). the primary endpoint was the frequency and severity of adverse events (aes) during sequential slit by common terminology criteria for adverse events (ctcae) v . and slit grading system. serum antibodies were measured as the secondary endpoint. results: eleven patients were recruited. aes after jc slit-drops administration were found in patients out of cases ( %). aes after sequential slit were found in patients out of cases ( %). all aes were graded or . no severe aes were observed during the study period. the levels of jc-and hdm-specific ige and igg in serum were increased during treatment. conclusion: sequential-administration of jc slit-drops and hdm slit-tablets was well tolerated by patients suffering from both jc pollinosis and hdm rhinitis. background: according to the ema guideline on the clinical development of products for specific immunotherapy products should be tested in phase ii at different doses in several study-arms to establish a dose-response relationship for clinical efficacy before confirmatory trials can be initiated. allergen exposure in an aec may be used as primary endpoint. the study was a single-center, randomized, double blind, placebo-controlled, phase ii trial, treatment duration months. grass pollen allergic patients ( - years of age) with seasonal rhinitis/rhinoconjunctivitis (arc) with (mild, gina i) or without concomitant asthma were randomized to three different dosages of a liquid phase iii study is in preparation. as part of an effort to prepare the analysis plan using the csms as primary endpoint, the grass pollen data of the european aeroallergen network (ean) was used to identify the window within the grass pollen season (gps) with optimal correlation between the grass pollen counts and the csms. method: ean currently includes information from more than active and historical pollen-monitoring stations in europe including countries. the ean database used for analysis included grass pollen data collected during - . the daily allergy symptoms and medication were recorded spontaneously using an app questionnaire on the subject's smart phone. the csms was re-calculated using the ean database, using the recorded symptom scores with estimation of the medication score using similar methods as recently published. the correlation between the daily grass pollen count and the daily csms was analyzed with a mixed effects model accounting for patient-specific correlations and symptom levels. conclusion: these results confirm a statistically significant correlation between grass pollen counts and the csms. importantly, these findings suggest that the optimal window to observe treatment effects after immunotherapy may be a short interval after start of the gps and during the peak gps, due to generally higher csms values. this provides sufficient basis to consider additional sensitivity analyses to evaluate the treatment effect of grass mata mpl scit on the primary csms endpoint during a shortened window after the start of the gps and to consider excluding the overlapping period between the bps and gps from the primary analysis. | combo-vas as a tool to assess efficacy of allergen immunotherapy ciprandi g ; silvestri m ; olcese r ; tosca ma ospedale policlinico san martino, genoa, italy; istituto g. gaslini, genoa, italy background: allergen immunotherapy (ait) is at present the unique cure for respiratory and venom allergy. usually, ait lasts for some years, but its efficacy is longstanding. criteria for assessing ait efficacy are mainly based on symptom severity improvement and saving of symptomatic medications. in this regard, there are different score grading for both measuring symptom severity and drug use. visual analogue scale (vas) is a well-defined and validated method widely used in many diseases, including allergic disorders. vas is a psychometric tool measuring the patient's perception of symptoms, emotions, pain, drug use, etc. recently, it has been published an eaaci position paper concerning the recommendations for the standardization of clinical outcomes used in ait trials for allergic rhinoconjunctivitis, but it is complex. so we would propose a simpler way to measure ait efficacy by vas, in particular a combo-vas based on one vas for symptom and one for medications. results: globally patients were retrospectively evaluated. all of them were treated with a -year ait course: were defined as responders and as non-responders. in responders group the combo-vas mean value was (iqr - ) at baseline and (iqr - ) after ait treatment. in non-responders group combo-vas mean value was at baseline and (iqr - . ) at the end of ait. the difference was significant (p = . ). the d combo-vas was − . % in responder group and − % in non-responders group (p < . ). conclusion: combo-vas, i.e. the sum of vas for symptoms and medications, could be an easy and quick tool for assessing ait efficacy and reflects the patient's perception. therefore, it could be very fruitful in clinical practice. | rapid up-dosing in sublingual specific immunotherapy is safe, well-tolerated and effective in patients suffering from tree pollen allergic rhinitis background: an optimised up-dosing period of specific immunotherapy (sit) is desirable for better patient compliance because a long or complicated up-dosing scheme is sensitive to disruption. the aim of this study was to compare the safety, tolerability and effectiveness of an optimised up-dosing scheme with two preexisting schemes of sublingual sit (slit) in patients under standard medical care. method: this was a prospective, open, active controlled, multi-center non-interventional study in germany and austria to document the treatment of children and adults with allergic rhinoconjunctivitis and/or allergic asthma treated with a slit containing purified, aqueous extracts of birch, alder and hazel pollen. the investigators were free to select an up-dosing scheme for included patients: scheme a consisted of an up-dosing period of up to days at the patient's home using three different solution strengths to reach the maximum dose; ultra-rush scheme b performed only with the highest solution strength at the physician's office within hours, and the optimised scheme c which was initiated at the physician′s office and continued at home using exclusively the highest solution strength within (long-term) or (pre-seasonal) days. data on up-dosing and maintenance treatments were documented by physicians during patient visits and by patient diaries. the study was approved by ethic committees, and all patients or parents gave their informed consent. results: in total, patients aged - years were included into this study. scheme a was applied by patients, patients decided on regimen b, and patients on the optimised scheme c. conclusion: one-day ur-scit conducted in an outpatient clinic was safe and well-tolerated in patients with ad sensitized to hdm. ur-scit can be a safe and useful option to start a subcutaneous allergen immunotherapy for ad. | factors affecting on adherence to allergen specific immunotherapy results: among enrolled patients, ( . %) patients failed to complete at least years of ait, which were regarded to be nonadherent in this study. univariate analysis revealed that male, younger age group less than years, cluster and ultra-rush schedules, atopic dermatitis, the absence of associated diseases, and follow up of other department were found to be associated with nonadherence to ait. in multivariate analysis, younger age group less than years (or . , % ci . - . ), cluster ( . , . - . ) and ultra-rush schedules ( . , . - . ) , and absence of follow up of other department ( . , . - . ) were independently associated with non-adherence to ait. no association was found in gender, diagnosis of allergic diseases, kind of allergen extracts, and patients' distance from hospital. conclusion: various factors are related with ait non-adherence to interfere the effectiveness of immunotherapy. clinicians need to be aware of the factors associated with non-adherence to ait and consider them when choose to maximize ait adherence. | cost-effectiveness of allergen immunotherapy to grass in patients with allergic rhino-conjunctivitis and asthma background: allergen immunotherapy (ait) has been shown to reduce symptoms and medication use in subjects with rhino-conjunctivitis and asthma. however, long-term cost effectiveness of this therapy needs to be evaluated. our aim was to assess cost effective of ait, both subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit), vs. pharmacotherapy alone in subjects with rhino-conjunctivitis, with or without allergic asthma, to grass pollens. method: a markov cohort state-transition model with a time horizon of years was used to assess the costs and effects of -year ait in adults. relative efficacy of the treatments expressed as standardized mean difference was estimated using an indirect comparison on symptom and medication score extracted from available meta-analyses. the rhinitis symptom utility index was used as a proxy to estimate utility values for symptom score. the societal perspective, through the human capital technique, was used to estimate indirect costs, to represent the scenario of a country with nationalized medicine. data on drug and other medical costs were derived from published sources as well as ait duration and asthma occurrence. additional sensitivity analyses were performed to test the robustness of our results. results: in the base case analysis, using italy clinical practice patients with moderate-to severe allergic rhino-conjunctivitis (ss ranging from to points) and a mean age at entry of years, both scit and slit were associated with increased cost but superior efficacy compared to pharmacotherapy alone. the results were most sensitive to variation in efficacy estimates and ait persistence rates. conclusion: this analysis suggests that ait is cost effective relative to pharmacotherapy alone. scit, despite significantly higher indirect cost burden, seems to be the most cost effective option. the results should be interpreted in the context of the data input and modelling assumption used. | ielisa as a tool to measure ige binding towards single modified peanut allergens background: immunotherapy has shown to be a potential treatment for food allergies but needs further research to improve safety. modification of peanut allergens to reduce their allergenicity is a promising approach to develop a safe and effective immunotherapy as shown by the successful completion of a first-in-human safety and tolerability study using hal-mpe in adult patients with peanut allergy (eudract - - ) . in order to assess the impact of modification on individual peanut allergens and to assess its impact on ige binding by individual patient sera, we have developed peanut allergen-specific inhibition elisas. with this methodology we are able to identify patients with residual ige binding to modified peanut allergens. method: ige inhibition elisas (ielisas) were developed and performed to test ige binding towards purified ara h and ara h and their reduced and alkylated (modified) versions, using the individual responses of single patient sera. results: ara h -specific ielisas showed that modification of ara h results in > % reduction in ige-binding for all individual sera tested. ara h -specific ielisas showed that modification of ara h also results in > % reduced ige-binding for most of the sera, but some sera were identified which showed residual, %- % ige binding to mara h . in some of the latter sera, the presence of ige binding to a linear hydroxyproline-containing peptide could be confirmed as a possible source for the residual ige binding to mara h . we have developed a methodology to assess residual ige binding to modified peanut allergens. the sensitivity of the allergen-specific ielisas allowed us to discriminate between patient sera in which ige binding to mara h and to mara h was virtually completely absent and sera in which - % residual ige binding to ara h was observed. the clinical importance of these observations is yet unknown. future clinical studies will need to reveal whether the patient-specific ige binding profiles to individual modified peanut allergens do correlate with the adverse events profile of immunotherapy with modified peanut extract. | design of a phase ii allergen immunotherapy study to determine the optimally effective and safe dose of subcutaneously administered tyrosine adsorbed modified grass allergen+mpl (mpl) adjuvants for the treatment of allergic rhinoconjunctivitis (arc) due to grass pollen. there is increasing evidence that the effectiveness of allergy immunotherapy to control arc symptoms is related to the cumulative allergen (or allergoid) dose administered. previously, two clinical studies have been conducted using a conjunctival provocation test (cpt) as primary efficacy measure for a similar scit mata mpl product for birch allergy [eudract - - and - - ] . these studies showed a . fold increase in cumulative dose to achieve~ % increase in efficacy, with a relative reduction in total symptom score (tss) of . % compared to placebo and no safety signals of concern. the shape of the dose response curve was curvilinear, where this high dose almost reached plateau. method: this is a multi-center (~ clinical study centers across europe), randomized, double-blind, placebo-controlled, parallel-group study in~ adult patients with moderate to severe seasonal arc with or without mild asthma. a positive cpt is to be achieved at screening and verified prior to randomization. the primary outcome is the post-treatment tss following cpt. a wide range of cumulative dose regimens is used ( , , and su) applied over weekly injections to establish the shape of the dose response to support dose selection for phase iii. the design of the current phase ii grass allergoid scit study will be discussed, including the rational of using cumulative dose regimens and placebo and the pre-selected shapes of the dose response curves. in addition, the number of patients screened and randomized will be presented by country, gender and/or age category and screen failures will be categorized. conclusion: this phase ii study was initiated to establish the dose response of a grass mata mpl scit product, using cpt to measure the effect of a wide range of cumulative dose regimens. the achievement of its aim will be an important milestone in the development of an efficacious and safe state-of-the-art grass scit. conclusion: we observed that the specific nasal challenge with house dust mite generates an inflammatory response within the first hours, but we did not demonstrate any correlation with the response to immunotherapy after six months. | tolerability of a two week rush updosing with modified allergens in pollen allergic subjects in the day-to-day practice background: in two phase iv studies the tolerability of a subcutaneous rush up-dosing, using three injections in two weeks, has been tested and proven to be save in adults. in the course of a non-interventional study (nis) now the tolerability of this treatment scheme was tested in the day-to-day practice. conclusion: over % of the patients could reach the highest dose of . ml. the overall tolerability is very good. the data from daily practice confirm the data that were previously obtained in two phase iv studies. siges from patients, evaluated during the st semester of at an outpatient clinic. all patients presented persistent moderatesevere allergic rhinitis, in pollen season and had not been submitted to it. all patients had positive spt for grasses (grass) and olive (olea). sige-tot for phleum pratense and olea europaea and some sige-crd (rphl p , rphl p , rphl p , rphl p , role and nole ) were determined. physicians were divided into groups (group if < years of practice and group if≥ years of practice) and were asked to choose which it to prescribe for each patient (none, only grass, only olive or both grass and olive), according to spt and sige results. results: fifteen physicians ( % with ≥ years of practice) participated in the survey. considering only the sige-tot results, the it choice (group / ) was: no vaccine in %/ %; grass vaccine %/ %; olive vaccine %/ % and both grass and olive vaccines in %/ % of the patients (p = . ), the intergroup agreement was % (kappa . ). according to the sige-crd results the physicians chose (group / ): no vaccine at %/ %; grass vaccine in %/ %; olive vaccine in %/ % and both vaccines in %/ % of patients however, data on control of allergic rhinitis (ar) after discontinuation of therapy are insufficient. the aim of our study was to assess sustained control of ar in three consecutive years after grass-pollen slit discontinuation. method: a total number of patients [ ( . %) males; mean age years, age range - ] well-controlled after a three-year course of slit with grass pollen extract were prospectively evaluated in three consecutive years after discontinuation of therapy. conclusion: a three-year course of grass-pollen slit seemed to have a long-term effect on control of symptoms in patients with ar. the authors declare no conflict of interest. results: all patients showed a positive sensitization profile by skin prick test to either betula and/or alnus. in % of patients this profile was furtherly confirmed with serum specific ige levels to betv , (mean . ku/l). allergic symptoms in patients with birch/alnus pollen allergy after ingestion of certain food can result from crossreactivity of bet-v -specific ige to homologous pathogenesis-related proteins, particularly the pr- protein. conclusion: within the allergy history we emphasize on focusing on sao symptoms as many patients under-recognize them. among the sensitization profile of these patients it is quite important to highlight cross reactivity between bet v and alnus. the other patient suffered from anaphylaxis(grade ii) induced by minimum amount of lettuce consumption without co-factors. both patients suffered from oral allergy syndrome to peach and allergic rhinitis. spts to foods and pollens were performed with commercial extracts, prick-through-prick with fresh plant foods, while specific ige was determined accordingly. ltp syndrome was defined as a sensitization to pru p and symptoms elicited by at least unrelated plant foods. co-factors were also investigated. results: the first patient was sensitized to lettuce, peanut, hazelnut, sunflower's seed, peach and banana, and plane tree, olive tree, grasses, parietaria and mugwort. sige to lettuce was . kua/l, to pru p was . kua/l and total ige was . u/ml. co-factors, such as exercise, were involved. the second patient was sensitized to peanut, walnut, hazelnut, almond, sunflower's seed, cashew, lettuce and peach, and, plane tree, olive tree, grasses, parietaria, mugwort and willow. sige to lettuce was . kua/l, to pru p was and total ige was . ku/l. no co-factors were identified. background: garlic (allium sativum) is a vegetable that belongs to amaryllidaceae's family. hypersensitivity to garlic is not very common. it has been mainly reported in occupational allergy but it also may cause contact dermatitis, rhinoconjunctivitis, asthma, urticaria, gastrointestinal symptoms and anaphylaxis after its ingestion. some studies have identified alliin lyase, a kda protein, as a major garlic allergen and it seems to be a heat-sensitive allergen. we report on a -month-old infant who presented, minutes after an accidental ingestion of garlic sauce, generalized erythema and cough. she was still breastfeeding and she had never abstracts | eaten garlic before (although the mother usually consumed garlic). the patient had never tasted other vegetables belonging to amarylidaceae's family either but zucchini, with good tolerance. we performed skin tests and specific ige (sige) to different vegetables. a raw garlic extract was also carried out and analysed in the patient by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). results: prick by prick with garlic was positive ( mm) and negative to onion, leek, asparagus, zucchini and saffron. skin prick tests to commercial extracts of mugwort, grass pollen, peach ltp and profilin were negative as well. specific ige to garlic was . ku/l (out from a total ige ku/l) and ku/l to onion and asparagus. sds-page immunoblotting assay with patient′s serum revealed ige reactivity with proteins of kda and kda. conclusion: we report a garlic ige-mediated anaphylaxis case in an infant with proteins of and kda as the relevant allergens. the mechanism of sensitization in the present case remains unclear. the authors hypothesized that breastfeeding, cutaneous contact or inhalation might be possible mechanisms involved. chong kw ; saffari se ; chan n ; seah r ; tan ch ; goh sh ; goh a ; loh w allergy service, department of paediatric medicine, kk women's and children's hospital, singapore, singapore; centre for quantitative medicine, office of clinical sciences, duke-nus medical school, singapore, singapore; yong loo lin school of medicine, national university of singapore, singapore, singapore background: the predictive decision points for both peanut skin prick test (spt) wheal size and serum ige concentrations, in peanutsensitized children, have not been evaluated in singapore. we aim to assess these for purposes of risk stratification and prediction of oral food challenge (ofc)s' outcomes by means of a retrospective chart review. results: the number of patients evaluated was , of which had clinical diagnosis of peanut allergy based on recent immediate reaction to peanut (pa group) and were tolerating peanuts regularly (pt group). the mean age of both groups were similar, . ± . and . ± . years in pa and pt groups respectively. there was a high prevalence of atopic diseases in both groups, with atopic dermatitis ( . % in pa, . % in pt), and other food allergies ( . % in pa, . % in pt). presence of rhinitis was statistically higher in the pa group compared to the pt group, with odds ratio of . ( % ci: . - . ) . a wheal size of ≥ mm and a peanutspecific ige of ≥ ku/l provided for a % positive predictive value. the larger the wheal size on spt, the higher the probability of a clinical reaction to peanuts. the results will help us in deriving preliminary cut-off values when conducting future prospective studies with ofcs in our peanut-sensitized cohort (whom had no prior peanut exposure), and to eventually reduce the need for expensive and potentially risky food challenges. | ginger: flavory, spicy …allergenic? a report of four patients with allergy to ginger background: ginger (zingiber officinale) belongs to the family zingiberoidae, along with cardamom and turmeric. the edible portion is the horizontal rhizome, and it is very appreciated for its aroma and spicy flavor. it also presents great interest for its therapeutic and culinary use. hypersensitivity to ginger is rare and has been scarcely reported. we report cases (p , p , p , p ) of adverse reactions to ginger after its ingestion and with good tolerance to cardamom and turmeric. method: skin prick tests (spt) to environmental allergens and prick-by-prick with ginger were carried out. total ige, and specific ige to ginger were also determined. a raw ginger extract was prepared. this extract was analyzed in all the patients by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). background: food allergy is divided into groups according to pathophysiology: ige-mediated, ige-and non-ige (mixed type), and non-ige (cellular type). however, in clinical practice, patients who fall under more than one group may be observed. method: patients who were diagnosed with food allergy at our clinic from january to december were included in the study. the medical files of patients were retrospectively evaluated, their symptoms and findings after consumption of foods were recorded, and they were categorized into groups (ige-mediated type, non-ige type, and mixed type) according to their symptoms and findings. results: a total of patients ( . % male) with food allergies were included in the study. according to categorization via symptoms and findings, the distribution of patients was as follows: ( . %) ige-mediated type, ( . %) non-ige type, ( . %) mixed type. the remaining ( %) patients were found to show various combinations of symptoms and findings that fit more than one group. in this study, we observed that food allergy symptoms and findings were distributed in a broad range which caused difficulties in the categorization of more than one-third of our patients. background: fish allergic patients suffer a lifetime of strict dietary restrictions. crocodile meat is a nutritious alternative choice in many countries around the world; however, it has recently been reported to also trigger severe allergic reactions. in these two case reports from pediatric patients were sensitised to the major fish allergen parvalbumin (pv), a potential cross-allergen. bony fish contain predominantly pvs of the β-lineage, which are the most common trigger of allergic reactions in fish allergic patients. in most other vertebrates, pvs of the α-lineage are most abundant, which have been reported as a causal allergen in frog, cartilaginous fish, and chicken allergies. we aimed to evaluate the allergenicity of crocodile meat in fish allergic children, with focus on pv. method: over children with clinical history of ige-mediated fish allergy were identified, skin tested to commonly consumed fish species using commercial and in-house preparations, and serum samples were collected. a sub-cohort was skin tested to crocodile using heat-treated tail muscle tissue from saltwater crocodile (crocodylus porosus). extracted proteins and purified pvs were analysed by sds-page, immunoblotting, and mass spectrometry. serum from all fish allergic children was analysed for ige reactivity to the crocodile pv. this reactivity was compared to those of raw and heated crocodile protein extracts as well as protein extracts and purified pvs from frequently consumed fish species. results: more than fish allergic children were positive on skin testing to crocodile (wheal size> mm), demonstrating its clinical reactivity. in vitro analyses revealed ige reactivity to crocodile pv in serum from more than half of all patients. two βand one α-crocodile-pv isoforms were identified. pvs constituted approximately % of total proteins in heated crocodile extracts, with β-pv ( kda) being times less abundant, but up to times more ige-reactive than α-pv ( kda). αand β-pvs from crocodilians, including alligators and crocodiles, share more than % and % of their amino acid sequence, respectively. conclusion: crocodile pv is a new allergen as per the iuis guidelines. fish allergic patients may be at risk of severe allergic reactions upon ingestion of crocodile meat due to strong ige cross-reactivity of β-pvs. this study suggests that fish allergic individuals and health professionals need to be aware of potential allergic reactions to meat from crocodilians, termed 'fish-crocodile syndrome'. background: we present a -year-old nonatopic woman that in december after eating a seafood paella with green pepper presented asthenia, nasal obstruction, incoercible vomiting and diarrhea. later she ate a grilled loin sandwich in a bar and she had the same symptoms (she asked the waiter at the bar and the chef had cooked her sandwich in the same pan where he had cooked green pepper just before). after that, she suffered from abdominal pain, nausea, abdominal distension without diarrhea two hours after she ate an omelet sandwich with certain flavor of green pepper. at present even the casual smell of pepper causes her nausea. the woman eats everything including spices and just avoids pepper. method: skin prick tests were performed using extracts from food (nuts, fish, mollusk, fruits, vegetables, legumes), aeroallergens (mites, abstracts | pollens and epithelia) and purified proteins (pru p , profilin, polcalcin, alfalactoalbumin, betalactoglobuline, casein). we also performed prick by prick to raw and cooked green pepper. sds-page immunoblotting according to laemli under reducing conditions (with -mercaptoethanol) was performed to study the molecular mass of the ige-reactive proteins. extracts from green pepper and green pepper seed were used. the prick tests were all negative and the prick by prick test to raw and cooked green pepper was positive in both cases. blond was taken from all patients to specify the levels of allergenspecific ige against allergen components of immunocap isac test, the result≥ . isu-e was assumed as positive. results: in the study group, in patients ( %) specific antibodies against ltp were detected, the isu-e level range . - average . isu-e on average, in patients with detected ltp ige was detected for . components belonging to the ltp, however the highest number % patients were detected ige only for ltp. in subjects ( % of respondents with detected ltp), ige was detected against art v and this is the only ltp component whose occurrence was statistically significant (p = . ). in patients ige was detected against pru p , jug r , pla a ,; patients ige to ara h ; patients cor a ; patients ole e , patients tri a , and in person para j . background: the birch pollen-associated oral allergy syndrome (oas), an ige-mediated local allergic reaction, is the most common manifestation of pollen-associated food allergies. its origin is explained by cross-reactions between birch pollen-and food-allergens belonging to the pathogenesis-related protein subfamily (pr- ). [ ] so far, there is no marker available for its detection and no standardized test established to evaluate objectively the subjective feelings experienced by oas. the diagnosis is based on a characteristic history and on detecting the sensitization to triggering allergens in skin prick test (spt) and laboratory examination. method: the aim of this study was to evaluate whether the food skin prick test could be a helpful marker in the diagnosis of a birch pollen-associated oas. for this exploratory study, data from - was collected retrospectively at the dermatological outpatient department of the ordensklinikum linz elisabethinen. patients with positive spt results for birch pollen were included. the variables age, gender, tree pollen-(birch, alder, hazel) and food-spt, laboratory tests (ige, bet v , bet v , gly m ) and symptoms (oas, rhinoconjunctivitis allergica, atopic dermatitis, anaphylaxis) for statistical analysis. results: there was an association between food-spt and oas but also between the negative oas patients and food-spt (p = . - . ). all of the bet v sensitized patients with positive gly m results had also a positive food-spt result. conclusion: there was no evidence for a possible role of food-spt as helpful markers in the diagnosis of birch pollen associated oas. maybe gly m could be a helpful marker, but more data are needed. bet v seems to be the cause of birch-pollen associated oas, due to the dominant sensitization pattern to major allergens in austria. background: eggs are among the foods most frequently causing allergy. the most common one is hen egg, although we may consume other bird's eggs such as duck's, those of goose, quails and seagulls. clinical and serological crossreactivity between hen egg proteins and those of other birds eggs have been described. allergy to other species eggs are less frequent and are usually described in patients allergic to hen eggs. we report a case of food allergy after ingestion of duck egg in an adult patient without hen egg allergy. the patient was a year-old man who had symptoms of generalized itching, swelling uvula, erythema neck and deglutition difficulty immediately after he ate eggs from duck and hen. he claimed to have eaten hen eggs almost daily without clinical symptoms and he had not previously ingested duck egg. he denied allergic reactions to any other food but did complain of seasonal allergic rhinoconjunctivitis in the spring. we performed skin prick test with extracts of egg and feathers, prick by prick test with cooked and fresh yolk and white from duck and hen egg and oral challenge with hen eggs. specific serum ige was measured to hen proteins and we carried out a western blot with the proteins of allergenic extracts from different eggs (white and yolk of quail, chicken, goose and duck) and an inhibition of western blot with ovalbumin as inhibitor allergen. results: skin test with extracts of eggs and feathers, cooked and fresh hen and duck eggs were positive. total serum ige was . ku/l. specific ige to hen's egg was class two for hen egg white, ovoalbumin and class one for yolk and ovomucoid. oral challenge with heated egg yolk negative and with egg white was positive. the patient's serum recognized mainly and intensely several proteins of white and egg yolk of quail and duck with a molecular mass around to kda respectively. on the other hand a protein around and - kda was unique recognized in white eggs of hen and goose. the western blot inhibition revealed ovalbumin inhibited the protein recognized in the egg white but not egg yolk involved in. background: management of tree nut allergy is usually based on the avoidance of the suspected tree nut (tn), as well as peanuts and seeds, either because of the risk of cross-reactivity and/or contamination, or due to the clinical severity. objective: to assess the sensitization pattern and clinical reactivity patterns to different tn, peanut and sesame seeds (ss) in patients with a history of reaction to at least one of these foods. results: a total of patients with confirmed nut allergy were included; % female, median age [interquartile range] of years; % were atopic. the most frequently involved foods were walnuts ( %), hazelnuts ( %), almonds ( %) and peanuts ( %). anaphylaxis was the clinical presentation in % of the patients. in those with a history of reaction to only one nut ( ), the most prevalent was peanut ( %). in the patients that reacted to more than one nut, the most frequent combinations were walnut/hazelnut ( ), walnut/almond ( ) and almond/ hazelnut ( ). of these patients, tolerated other nuts. two had sesame seed allergy, one reacted only to ss. nine patients ( %) were sensitized to foods that they tolerated. fourteen ( %) patients were sensitized to ltp and of them reacted to more than one nut. conclusion: these data concur with the existence of different sensitization profiles (primary, concomitant or cross-reactive), which may predict different clinical reactivity patterns and therefore, influence dietary recommendations. background: buckwheat (fagopyrum esculentum) is a polygonaceae weed, not a cereal, which is increasingly been consumed and used as an alternative food in the diet of celiac patients. despite its wide use, allergy to buckwheat has unfrequently been reported in our setting. method: two female patients, aged and , suffered an immediate severe allergic reaction after eating a bread and a pancake containing buckwheat among its ingredients. the first patient presented generalized urticaria, palpebral angioedema and pharyngeal occupation. the second one showed those same symptoms, as well as abdominal pain, nausea, dyspnea, dizziness, hypotension and loss of consciousness. skin tests and specific ige determination to aeroallergens and food allergens were carried out, including prick-prick test with buckwheat and all other components contained in the food involved. buckwheat allergens were studied by sds-page and ige-immunoblotting of one of the patients. results: prick-prick tests yielded strongly positive results to the food itself and buckwheat, and negative to the remaining food components in both cases. cap was positive to buckwheat ( . ku/l and > ku/l, respectively). basal serum tryptase levels were normal. both patients were not sensitized to cereals, ltps, profilins or pr- proteins. for the first patient, the skin tests were negative for other foods, seeds and nuts. the cap was negative for ltps, profilins and storage proteins of peanut and other nuts. the second patient who had the most severe reaction, was also sensitized to hazelnut(cap . ku/l), pistachio ( . ku/l), almond( . ku/l), walnut( . ku/l) and sesame( . ku/l), which were not included in the pancake. the buckwheat immunoblot of the first case, under non-denaturing conditions, revealed a ige-binding protein of -kda. ige-immunoblotting under reducing condition showed protein bands of , , and kda in the buckwheat extract. conclusion: two cases of anaphylaxis by buckwheat flour contained in two frequently consumed foods are presented. the absence of sensitization to ltps, together with the pattern of specific ige binding in the immunoblot in one of the cases suggests that the responsible allergen could correspond to a storage protein of buckwheat, without cross-reactivity with other seed and nut allergens. buckwheat must be taken into account as an unsuspected food allergen capable of causing severe allergic reactions. background: allergy to linseed (linum usitatissimum) has infrequently been reported despite of its wide use in bread and in a range of "health food" products. linseed contains potent allergens which have not yet been characterized. we studied three patients who presented allergic reaction after eating different foods which contain linseed. two of them (patient p and patient p ) had anaphylaxis and the third one (patient p ) had oral syndrome, abdominal pain and diarrhoea. p was also allergic to mustard and p to sesame seed. all of them tolerated the remaining seeds, nuts and food. baseline tryptase levels were in normal range in all patients. skin tests and specific ige determination to inhalants and food allergens were carried out. linseed allergens were studied by sds-page and ige-immunoblotting. skin tests: patient : prick tests were positive to pollens and linseed, and negative to ltp, profilin, nuts, seed and the remaining food; patient : prick tests were positive to linseed and mustard and negative to other food and inhalants; patient : prick tests were positive to linseed, pollens, sesame and nuts (peanut, hazelnut, almond, pistachio). we present three cases of severe allergic reactions to linseed. the pattern of specific ige binding in the immunoblot seems to lead to storage proteins as the responsible allergens. | pr- sensitization-looking it up in food allergy background: pr- protein group sensitization is found in patients with respiratory allergy, mainly in areas inhabited by trees of the betulacea or fagacea families. its role in food allergy is, however, more frequently described in the context of cross reactivity. our aim was to characterize the pattern of molecular sensitization of food allergic patients sensitized to pr- protein group with immu-nocap isac ® (isac). the remaining patients, with more severe reactions, were all co-sensitized to either ltp and/or storage proteins (sp). only of the patients without pfa were co-sensitized to ltp or sp versus of with pfa (p < . ). conclusion: pr- sensitization is rare in our population. approximately half of the patients had allergy to plant foods, but the majority were co-sensitized to ltp and/or sp. the few patients only sensitized to pr- had minor reactions. among the patients without plant food allergy, co-sensitization to ltp and sp was significantly less common. according to these results, in our population, pr- seems to be less relevant to food allergy, when compared to reported results from other european countries. gür Çetinkaya p; uysal soyer Ö; esenboga s; sahiner Üm; sekerel be hacettepe medical school, ankara, turkey background: pistachio is a tree nut belonging to "anacardiacea" family, and constitutes % of tree nut allergies. this nut most often abstracts | cross-reacts up to % with cashew which is located in the same family. pistachio allergy is mostly seen in iran, turkey, the united states, and china where this tree nut is frequently consumed. in this study, we analyzed age and cut-off values for development of tolerance to pistachio. method: children who had reported allergic reactions with pistachio, and who have not consumed pistachio, but had positive spt and/or specific ige levels were enrolled into the study. spt and specific ige levels were measured in all patients. oral provocation(op) tests with pistachio were performed by patients, and of them had positive test result. the median age of tolerance development was months (iqr: . - . months). the most commonly involved systems during op tests were skin ( %, n = ), gastrointestinal system ( %, n = ), and lower respiratory tract ( %, n = ). concomitant allergic diseases were atopic dermatitis ( %), asthma ( %) and allergic rhinitis ( %). there was a positive correlation between skin prick test diameter (spt) and specific ige levels (spige) (r = . , p = . ). spt of≥ . mm to pistachio nut was found as highly predictive of clinical allergy (auc: . , %ci: . - . , p < . ). any relation was not determined between eosinophil, basophil counts, triptase levels, and op test positivity. conclusion: pistachio allergy is one of the frequently seen nut allergies in turkey which may cause serious allergic reactions including anaphylaxis. op test showed that tolerance was achieved by the median age of months, and a cut-off level of . mm was best predictor for positive reaction. in an oral challenge test, the patient responded with generalized urticaria, swelling of the lips and difficulty breathing at a cumulative dose of . g peanut protein, however, without blood pressure drop. (grade , moderate symptoms). the patient was treated with anti-ige for months (with mg every weeks sc). oral desensitization began with ingestion of μg peanut, escalating to mg, on the first day and escalating weekly doses of peanut from mg to mg ( peanuts). then anti-ige was discontinued while the patient ingested peanuts every day. we have followed the patient's sensitivity to peanuts from before anti-ige treatment to after anti-ige washout with basophil testing. results: the patient completed desensitization without side effects, and continues to ingest peanuts a day. basophil sensitivity was reduced -fold by anti-ige treatment, but returned to baseline levels after anti-ige washout. conclusion: anti-ige allows rapid desensitisation of peanut allergic subjects with peanut oral immunotherapy. in the majority of subjects, this desensitization is sustained after anti-ige is discontinued. additional studies will help clarify which patients would benefit most from this approach. the return of basophil response to pre-treatment levels suggests that the patient is desensitised, and depends on the daily ingestion of allergen. what do we (not) know? background: the use of biologic prosthesis is a well-established surgical procedure. acute and delayed complications may occur, but accurate epidemiologic data about allergic reaction to graft tissue is lacking. methods: a years old boy referred to our unit for urticaria and gastrointestinal symptoms which developed a few years before. he received a biologic porcine vascular duct during a cardiovascular surgery at days of life. at the age of urticarial episodes occurred, and a diagnosis of beef allergy was made. after the exclusion of beef meat from the diet, most symptoms resolved, but the child began to complain about occasional episodes of vomit and diarrhoea. results: skin prick tests confirmed the beef meat sensitization and prick-prick test resulted positive against raw pork meat but not against cooked pork meat. in vitro tests demonstrated the presence of pork meat specific iges ( . kua/l). component-resolved diagnostic tests revealed allergy sensitization toward bos d (bovine serum albumin, bsa; porcine serum albumin was not tested due to lack of a specific test). after accurate exclusion of pork meat from diet, a complete remission was achieved, and the diagnosis of pork meat allergy was confirmed. conclusion: bsa is a major beef allergen, responsible for the raw beef-cow milk cross-reactivity but with a scarce importance in milk allergy. it is highly homologous with human serum albumin and other mammalian serum albumins, including porcine albumin. porcine albumin is also highly homologous with cat serum albumin and therefore responsible for cross-reactivity in patients affected by cat-pork syndrome. we hypothesize that the implanted porcine tissue was the trigger for pork meat allergy in our patient, as this condition is exceptional in childhood and that our patient never owned a cat. few cases of pork allergy due to porcine tissue implantation have been reported so far. of interest, pig sensitization was recognized as a rare but possible cause of blood-culture negative endocarditis in patients with porcine bioprosthesis according with anamnesis, increased ige level against pork, tissue eosinophilia during autopsy. background: desensitization to foods is assuming a new paradigm in food allergy. this technique is becoming widespread especially for patients with egg and milk allergy, but the effect of desensitization on the consumption of similar but not identical foods is still uncertain. material and methods: we describe the case of a -year-old patient, with a history of chicken egg allergy, who had been successfully desensitized tolerating cooked and raw chicken eggs for a year. the patient came to the office after presenting an episode of anaphylaxis immediately after eating fried quail eggs. an immunological study was carried out. we performed skin prick test with chicken egg′s proteins (white, yolk, ovoalbumin and ovomucoid). an immunoblotting to detect specific ige to egg proteins was also performed. for this purpose, the following extracts were used: chicken egg white and yolk (commercial extract form alk) and quail egg white and yolk prepared following a similar procedure (extracted in % phosphate buffer (w/v)). conclusion: we present the case of a patient with specific allergy to quail egg white and yolk, probably through ovotransferin, but not to chicken egg. the desensitization against chicken eggs does not allow the consumption of eggs of other species of birds, such as quail eggs, and this indication must be made specifically to patients after a protocol of desensitization against chicken′s eggs. case report: seven years ago we presented the case of a year-old male, who suffered two acute episodes of oral pruritus, lip angioedema, epigastric pain, generalized urticaria and dizziness after ingesting lettuce. he previously tolerated salads (including lettuce). he was later diagnosed with non-ltp-dependent lettuce anaphylaxis and an aspartyl protease was identified as a new lettuce allergen with cross-reactivity with other members of the compositae family. since the diagnosis he has avoided lettuce and all the other compositae. we present the patient's curious outcome after years of follow up. methods: total ige, basal tryptase, specific ige to lettuce by immu-nocap, prick-prick and oral challenge tests with lettuce and other compositae. sds-page, immunoblotting and molecular characterization of ige binding bands by mass spectrometry. skin prick tests and specific ige to lettuce were repeated on several occasions in the following years. after years an oral challenge test with lettuce was carried out. results: prick-prick test was positive to fresh lettuce ( × mm) and to other compositae (raw endive, chicory, thistle, artichoke and chamomile). prick-prick test was negative with these boiled compositae. basal tryptase was . μg/l. total ige in serum was ul/ml. specific ige by immunocap was positive to lettuce ( . ku/l) and negative to profilin, ltps and thaumatin. oral challenge test with endive was positive and negative with cooked compositae (artichokes and thistle). sds-page and immunoblotting detected an intensely binding ige band about kda, common for endive and chicory, which was identified by mass spectrometry as an aspartyl protease. no bands were detected at ltp ( kda) and profilin ( kda) . in the first two years after the diagnosis, prick-prick test and specific ige to lettuce remained positive (cap . ku/l and . ku/l, respectively). after years, prick-prick test and specific ige to lettuce became negative (cap . ku/l). with this findings a new oral challenge test with lettuce was carried out which result turned out negative. we report the first case of spontaneous tolerance to lettuce in a patient who previously presented lettuce anaphylaxis and identify an aspartyl protease as the causative allergen. introduction: eosinophilic esophagitis (eoe) is an emergent allergic inflammatory disease that is triggered by food allergens and characterized by progressive esophageal dysfunction. recently, it has been seen that eoe develops in up to . % of patients with ige-mediated food allergy undergoing oral immunotherapy (oit). ingestion of baked milk and egg was associated with increased development of tolerance to regular milk and immunologic changes have been reported in subjects ingesting baked milk and egg, similar to those seen in food oral immunotherapy studies. case description: we present the case of a -year-old girl, with history of ige mediated cow′s milk allergy and rhino conjunctival and bronchial asthma symptoms. prick test against milk proteins showed: milk mm, alpha-lactalbumin mm, casein mm and to beta-lactoglobulin: negative. total ige: ku/l. specific ige to milk: , alpha-lactalbumin: , ku/l; casein: ku/l and beta-lactoglobulin: . ku/l. we performed an oral food challenge with baked milk which was well tolerated. then, we performed an oral food challenge with fresh milk and she presented facial urticaria and pharyngeal pruritus. after months eating baked milk every day, she had symptoms of dysphagia and esophageal food impaction. for this reason, we performed an esophagogastroduodenoscopy (egd) and biopsies which showed white exudates and vertical furrows. the histological study showed eosinophil count> per high-power field. eosinophilic esophagitis was diagnosed and she started treatment with esomeprazole mg. the egd was repeated weeks later with similar results in the biopsy. she was treated with a comprehensive diet free of cow′s milk proteins. after weeks she was asymptomatic and endoscopy and biopsy findings were normal. we report the case of a cow′s milk allergic patient who developed eoe after introduction baked cow′s milk which apparently was tolerated in her diet. the avoidance proved efficacy in inducing the remission of eoe. method: we examined bottle-feeding infants with food allergy aged from to months. serum vitamin levels were measured by immunoassay methods (retinol binding protein (rbp), vitamin b , hydroxy vitamin d), biochemistry methods (vitamin c, vitamin e) and microbiology methods (vitamin b , vitamin b ). as criteria for complete sufficiency standards adopted in the russian federation were used (the lower limit of normal levels: rbp - . μmol/l; b - ng/ml; -hydroxy vitamin d- ng/ml; vitamin c - . mg/dl, vitamin e - . mg/dl; vitamin b - μg/ml; vitamin b - ng/ ml). results: complete sufficiency were observed in infants ( . % cases), one vitamin deficiency in infants ( . %), two vitamins deficiency in infants ( . %), three and more vitamins deficiency in infants ( . %). should be used after vitamin status asses, mainly using monovitamin medication. results: patients were followed with the diagnoses of cma and asthma. age at the beginning of symptoms and start of oit were in the range of - months and - years, respectively. they had high total ige ( - iu/ml), milk spige ( . - kua/l), casein spige background: food allergies may affect up to % of school-aged children. it has been shown that approximately % of all anaphylactic reactions caused by food allergy are firstly presented at (pre) school. therefore, it is of high importance that (pre)schools have a policy on food allergy management and the use of an epinephrine auto-injector (eai). to our knowledge, limited is known on the policies of food allergy management at (pre)schools. the aim of this study was to investigate the policy on food allergy management in preschools and primary schools in the northern part of the netherlands. results: we included preschools and primary schools in this study. we showed that . % of the preschools and . % of the primary schools had a child(ren) with food allergy. only . % of the participating preschools and . % of the primary schools had a policy on allergen avoidance and only . % of the preschools and . % of the primary schools had a policy for the use of an eai. the majority of the pre-and primary schools in the northern part of the netherlands have children with food allergy. however, only a limited number of (pre)schools do have written guidelines for food allergy management in (pre)schools. additionally, there is limited experience how to use an eai at (pre)schools. therefore, an evidence-based policy on food allergy management in (pre) schools is needed. background: food allergies are the most common cause of anaphylaxis in childhood. here we present cases had anaphylaxis due to cow 's milk allergy, and treated with specific oral tolerance induction (sotİ) to cow' s milk. method: soti protocol was administered according to previously published by longo et al. skin prick test were performed according to standard methods with allergens. cow's milk specific ige was investigated with immunocap system. in all cases, the wheal size of the cow's milk in skin prick tests or the specific ige levels was higher than level of positive predictive value of %. results: case : a years old male patient who had anaphylaxis after milk consumption. soti treatment was started one year ago. there was no complications during the dose increasing phase. however, he had two episodes of anaphylaxis during the maintenance phase. in the final visit, we observed that he could drink ml milk and could consume dairy products. case : eight-year-old male patient has an intensive care-of-hospitalization story due to anaphylaxis three times after milk consumption. his accordance to strict diet was bad, and had frequent asthma attack. anaphylaxis developed times during the dose increasing phase in soti protocol. after soti treatment, he could consume ml cow's milk and dairy products without problems. case : a -year-old male patient followed-up for asthma and cow's milk allergy. it was learned that anaphylaxis developed times after milk consumption. he was fed in accordance with the milk-free diet. he has used fluticasone nebules, montelukast, mometasone nasal spray, and cetirizine. anaphylaxis developed times during the dose increase phase of soti administration. there were many mild to moderate anaphylactic episodes during the maintaining phase. after the soti treatment, he could consume ml milk and dairy products. background: cow's milk protein allergy (cmpa) is one of the most common food allergies in early childhood. small dietetic group sessions for parents of infant with non-ige mediated cmpa were held to meet increasing demands and reduce waiting times. parents were given information on cmpa, advice on weaning and milk reintroduction using a locally designed milk ladder. parents were also advised to contact the dietitians via telephone if they had further questions. we aim to evaluate the sustained effectiveness and patient satisfaction of the group sessions. method: parents and carers who attended the group dietetic sessions held between november and july were included in the survey. feedback were obtained via a self-designed questionnaire using a likert-type scale, rating several questions from (least satisfied) to (most satisfied). initial feedback was obtained directly after the session. we followed these patients up a year after the initial session via telephone and postal questionnaire. results: overall attendance rate of the group sessions held was % (n = ). during the initial survey, participants found the group session useful (mean score . out of ) and felt more confident in managing cmpa (mean score . ). we successfully obtained follow up feedback from participants. majority agreed that the group sessions have been informative (mean score . ). they also said they felt confident weaning their child on milk-free diet (mean score . ), and in reintroduction of cow's milk in diet (mean score . ). % (n = ) said that they would have preferred an individual session. % (n = ) have contacted the dieticians via telephone after the initial session, and % (n = ) had requested individual consultations. % (n = ) have attempted reintroduction of cow's milk in their child's diet using our local milk reintroduction guide. the mean age at first challenge was months (age range to months), with average of two attempts. % (n = ) have been successfully challenged and are managing well on a normal diet. we recognised the limitation in obtaining feedback via telephone and postal questionnaire, which resulted in the poor follow-up response rate. overall, parents felt more confident in managing cmpa and the positive responses were sustained a year on, highlighting the success of these group sessions. follow up opt-in sessions could be offered to provide additional support and allay parental anxiety in challenging their child with cow's milk at an appropriate age. results: goats and rabbits were immunized with specific allergoids, the allergoid-specific igg titer determined and sera pools produced. the allergoid reference material was comprehensively characterized. while ige reactivity of the allergoids was not detectable anymore, igg reactivity was maintained. allergoid-specific assay parameters as serum dilution, reference dilution and sample dilution factor to obtain at least six data points within the pseudo-linear range of the inhibition curve were determined. with these set parameters the evaluation of the analytical method was performed. the assay showed very good results in terms of linearity, accuracy, precision, reproducibility and robustness for all investigated allergoids as well as aluminum-adsorbed allergoid-preparations. conclusion: with the developed immunological inhibition assay, it is possible to determine the specific igg reactivity of allergoids in different preparations. the performance of the analytical method met all pre-defined acceptance criteria, which will be confirmed in the next step by a validation procedure according to ich-guidelines. case report: we present the case of a -year-old patient, diagnosed with rhinitis and asthma due to sensitization to pollens, as well as dyshidrosis and allergic contact dermatitis to cobalt. the patient presented a cutaneous pattern consisting of erythematous papules, some scaly, very pruritic, of initial appearance in the upper limbs - days after initiation of administration of specific immunotherapy extract (depigoid forte grasses, leti ® ). subsequently generalize lower limbs and neck. she presented them repeatedly and late after - days of the first doses administered. she referred partial control of pruritus with oral antihistamines, without total resolution of lesions for weeks. immunotherapy was suspended persisting the skin lesions for more weeks. according to the personal history of sensitization to metals, and the clinic presented in a temporal relationship with the use of an extract of immunotherapy with aluminum hydroxide, a study was requested with epicutaneous tests with aluminum hydroxide as well as with epicutaneous tests with immunotherapy extract. aluminium hydroxide and depìgoid forte grasses extract epicutaneous test were negative. in subsequent visits the patient reported that coinciding with the start of immunotherapy, presented at home and mainly in her bedroom a plague of cimex lectularius, popularly known as bedbugs, proving that they had been the cause of bites on their skin, and later skin reaction. patient reported that with the elimination of said pest the skin lesions disappeared. the administration of its immunotherapy extract was tolerated. cimex lectularius, commonly known as bed bugs, is a hemiptera insect of the family cimicidae. the clinical picture usually corresponds to multiple pruriginous lesions from the prurigo type, to multiple erythematous plaques, some infiltrated and others with a urticarial appearance, or even bullous. the lesions last for to weeks without treatment, and while the older ones heal, new ones may appear. in our patient it was not considered as an initial diagnosis, having considered immunotherapy as an etiological factor, but we must not forget that although in our country it is not a reason for frequent consultation, either due to underdiagnosis, because of the transitory nature of the pathology or because of scarce number of causative agents, it is important to consider insect bites in the differential diagnosis of dermatosis. di cara g; salvatori c; testa i; pacitto a; bizzarri i; isidori c; tarsia m; esposito s università degli studi di perugia-dipartimento di scienze chirurgiche e biomediche, perugia, italy background: house dust mites (hdm) are one of the most important allergens involved in childhood respiratory diseases, and the most frequently prescribed extract for sublingual immunotherapy in children (slit). despite the improvement of standardization methods for the production of slit, the differences in cultivation and purification processes used to produce raw materials for specific immunotherapy extracts may still impact on the final composition of mite allergen extracts. our study investigated the total protein and main allergen content of five commercial hdm sublingual immunotherapy extracts using sds-page and immunoblotting. recombinant allergens of group and group major allergens were used to test the immunogenicity of such extracts. method: hdm slit extracts were purchased from five italian suppliers (alk-abellò, allergy therapeutics, anallergo, lofarma, stallergenes). the protein composition of extracts was evaluated analysing equal volumes ( ml/lane) by sds-page ( % separating gel) and subsequent immunoblotting. for identification of allergens in the extracts, western blot analyses were performed with rabbit monoclonal antibodies (raybiotech) against der p and der p . the total protein content in the five tested commercial extracts showed a relevant variability. the protein contents ranged from . to . μg/mg for what concerns der p , while der p showed a greater variability, ranging from . to . μg/mg. sds-page showed a similar pattern of distribution in of the tested extracts, which showed protein bands of comparable intensity, while extracts showed a lower total protein count. extract showed a higher intensity band corresponding to the molecular weight of tropomyosin. western-blotting showed a similar concentration of der p in most extracts, while der p was more variable. conclusion: our analysis of five commercial extracts commonly used for sublingual specific immunotherapy against hdm showed important variations in term of total protein content. a less evident but still relevant difference was also evidenced when testing the major allergen content, with up to % variation in der p and up to a -fold variation in der p concentration. this differences, likely related to the different production and extraction methods, could still be responsible of a different immunological response in children who underwent slit. method: we evaluated children who had completed their immunotherapy treatment. along with demographic data we were able to record skin prick test (spt) results and mrqlq at start and end of treatment. we only included patients who had completed pre and post treatment questionnaires in the study to allow a comparison. the scores were evaluated using a student t test. results: patients' starting age ranged from to years (mean years). of the children had completed pre and post treatment questionnaires. all had grass pollen allergy confirmed on spt at the start of treatment. patients ( %) had isolated grass pollen allergy on spt and ( %) had multiple allergies. mean start treatment score for all patients was on mrqlq. mean score at end of treatment was , indicating a % reduction in total mrqlq score (p value < . ). for those with multiple allergies the mean total mrqlq scores were at start of treatment and at end of treatment, indicating a % reduction (p value . ). for those with isolated grass pollen allergy scores were at start of treatment and at end of treatment indicating a % reduction (p value < . ). conclusion: for children with uncontrolled symptoms of allergic rhinoconjunctivitis, grass pollen immunotherapy is associated with statistically significant improvement in quality of life. this improvement is most beneficial for patients with isolated grass-pollen sensitivity on spt. those with multiple aeroallergen sensitivities on spt did show an improvement (not statistically significant) post-treatment. grass-pollen immunotherapy is an effective treatment for rhinoconjunctivitis to offer patients in a rural dgh setting. background: allergic asthma is a common clinical refractory disease, most patients with asthma are accompanied by varying degrees of allergy. in clinical practice, treatment of this disease using specific immunotherapy has proven effective. in the current study, we examined the effectiveness of specific immunotherapy in a total of patients admitted to our hospital from to . method: to investigate the clinical efficacy of allergic asthma-specific immunotherapy. patients were selected, of which were males, aged to years, females, aged between to years old, all patients were clinically diagnosed only as allergic asthma. the patients were randomly divided into two groups, including the observation group containing cases, the control group of cases. all patients were first treated with conventional basic treatment. the observation group was subsequently treated with specific immunotherapy. both groups were followed-up and the treatment efficiency were analyzed. results: after treatment, both two groups of patients showed improvement, in the observation group, the effective rate was %, while for the control group, the effective rate was %. observation group showed significantly better outcomes than the control group. conclusion: in allergic asthma treatment, adding specific immunotherapy on the basis of routine treatment is beneficial and could be widely used in clinic. case report: atopic dermatitis(ad)is the most common itchy dermatosis that affects millions of children and adults. during recent years, diagnosis and treatment based on component resolved diagnostics (crd)is recommended. we report a -year-old boy with severe atopic dermatitis. he had positive family history of atopy. the atopic dermatitis was developed since infancy. he was referred to our clinic when he was years old. he had generalized xerosis with ulcerative eczematous lesions on his neck, popliteal and antecubital areas. he had mild eosinophilia and his serum total ige level was iu/ml. daily bleach bath, moisturizing agents, topical steroids and systemic antibiotics in addition to antihistamine were prescribed. he had multiple food and aeroallergen sensitization in skin prick test (spt). he started to eliminate some foods according to the spt results. he was suffering from recurrent relapse even after strict food avoidance; so treatment with cyclosporine was initiated for him, with partial response. crd showed sensitization to alternaria alternata (alt a specific ige: . ku/l). allergen immunotherapy by alternaria alternata was started. after accomplishment of buildup phase, he had significant improvement and we were successful to taper and finally discontinue cyclosporine. now he is on maintenance phase of immunotherapy, his skin is in optimal condition only by hydration and moisturization. result: a -year-old thai girl is a known case of severe asthma since one year old. her asthma was uncontrolled asthma even treatment with high dose combination of inhaled corticosteroid and long acting beta agonist (ics/laba), montelukast and omalizumab. spirometry revealed the force expiratory volume in one second (fev ): % predicted, fev /forced vital capacity (fvc): % predicted and % improvement of fev after salbutamol ug inhalation. allergic sensitization showed specific ige to cat: . kua/l. slit with cat allergen started at the dose of au per month and increased to au per month (scit dose is au per month) for three-year-and-six-month course. after slit, her asthma symptom improved significantly. she can exercise without exacerbation and plays sport at school. her last episode of asthma exacerbation was . year ago. her fev (% predicted) was improved from % predicted to % and the fev bronchodilator response decreased from % to %. conclusion: an improvement of pulmonary function and asthmatic symptoms of the presenting case would support the efficacy of slit of cat allergen in a patient with severe asthma. ra developed during pollen scit in this case might be related with immunomodulation effect of immunotherapy. background: we report a case of -year-old woman with allergic rhinoconjunctivitis and mild persistent asthma due to sensitisation to seasonal pollens and molds with bad clinical evolution and not response to conventional drug therapy. we decided to start subcutaneous allergen specific immunotherapy with alternaria extract in our immunotherapy unit in accordance with the guidelines of the european academy of allergology and clinical immunology (eaaci) and we used a cluster regimen. the immunotherapy was not well tolerated: the patient had two grade systemic reactions with the first dose in two attempts. method: sensitisation was diagnosed through skin prick test with aeroallergens standard panel and serum specific ige by elisa. due to the bad tolerance to immunotherapy, molds molecular diagnosis by immunocap, study of the molecular weight to specific ige binding proteins by sds-page ige immunoblotting, and cross-reactivity study by means of immunoblotting-inhibition assay were performed. a. fumigatus extract was able to produce a total ige binding inhibition on the kda band of a. alternata extract when ige immunoblotting assay was performed. conclusion: respiratory allergic disease due to alternaria is difficult to control, the use of subcutaneous specific immunotherapy could be of significant benefit. most of the allergic patients to a. alternata are sensitized to alt a , major allergen from a. alternata. however, our patient is sensitized to a kda alternaria protein due to cross-reactivity with a. fumigatus allergens, this sensitization could explain the bad tolerance to the alternaria immunotherapy. background: the association between natural pollen exposure, clinical symptoms as well as allergen-specific immune responses has not been investigated at a molecular level. our aim was to monitor the effect of seasonal birch and grass pollen exposure on clinical symptoms as well as specific b cell and t cell responses to defined allergen molecules in sensitized subjects during two consecutive years. method: grass pollen sensitized (n = ) and birch pollen sensitized (n = ) subjects were included in this study and were followed for two consecutive years ( ) ( ) . subjects were taking part in a clinical trial for the recombinant grass pollen vaccine (bm ) but did not receive immunotherapy for the allergen they were sensitized to. before, during and after the respective seasons ige and igg levels as well as t cell responses to the major birch pollen allergen bet v and the major grass pollen allergens phl p , , and were measured. pollen counts were recorded throughout the year and patients kept a daily diary including symptom medication score (sms) and visual analogue scale (vas). results: we noted that ige levels specific for bet v and the grass pollen allergens increased most in the seasons in which patients experienced the highest peak symptoms according to vas and sms but not depending on cumulative pollen counts. increases in allergen-specific t cell responses were observed in the pollen seasons as compared to shortly before the pollen seasons in the grass pollenallergic patients also in association with vas and sms but not in the birch pollen allergic subjects. no relevant changes of allergen-specific igg levels were observed during the two years observation in grass and birch pollen allergic patients. we found an association of increases of allergen-specific ige increases shortly after the pollen season with clinical symptoms in the pollen season as reflected by vas and sms which was not necessarily reflected by cumulative pollen counts in the season. these results may be important for the analysis of allergen-specific immunotherapy trials. background: the morbidity and mortality of severe asthma is much higher than that of mild to moderate asthma. this study was performed to understand the clinical characteristics of severe asthma in korea. results: data from the questionnaire showed that bronchial asthma was diagnosed before pregnancy only in women ( . %). patients ( . %) were diagnosed with chronic bronchitis at the pregestation stage. asthma attacks were experienced repeatedly during a lifetime in . % of patients, . % of patients noted long periods of dry cough at night, among them . % had wheezing. the cold did not precede the wheezing breathing in . % of patients. difficulty in breathing on waking was noted in . % of patients, at night- . %. after examination, the diagnosis of asthma was confirmed in . % of the respondents ( people). symptoms of rhinitis are noted in % of women surveyed, % of rhinitis was allergic. before examination, the diagnosis of ar was only in . % of patients. the incidence of symptoms of asthma and ar in pregnant women is significantly higher than the reported cases of these diseases, which leads to untimely initiation of treatment. method: a total of nonsmoker asthmatic patients without concomitant pulmonary pathology are recruited to our study. all patients underwent spirometry tests, measurement of fraction of exhaled nitric oxide and sputum induction to asses sputum cell counts, demographic features and current medications were recorded. using the variables of age at onset, bmi, allergy status, fev %, fev /fvc, asthma severity and induced sputum cytology cluster analysis is performed. results: clusters are identified. cluster : (n = ) early onset atopic asthma, consists of mild asthmatics with a good asthma control and lower bmi. cluster : (n = ) severe atopic asthma, consists of lowest spirometry measurements with a least act scores. induced sputum cytology shows a neutrophilic character, while having also the highest percentage of eosinophils. cluster (n = ) late onset obese asthma, nonatopic asthmatics having high spirometry measurements, with a lower act scores. cluster (n = ) nonatopic mild asthma, consists of patients with the best respiratory functions and least inflammation in means of lowest total ige, feno, sputum cell counts. conclusion: identification of asthma phenotypes in different countries will improve our understanding on the heterogeneity of the disease among the different geographies. results: results and discussion. in the course of analysis, obesity was more common in children with bronchial asthma − % than in the comparison group-in . %. obesity of the st degree was diagnosed in patients of the main group, ii degree-in , and iii degree- and iv degree-in patients e diagnosis of obesity, the sds indices of body mass index (bmi) were determined. obesitymore than + . (i degree: sds bmi . - . , ii degree: sds bmi . - . , iii degree: sds bmi . - . , iv degree: sds bmi ≥ . ). conclusion: thus, the results obtained indicate a high prevalence of constitutional-exogenous obesity in children with bronchial asthma and precedes the formation of the underlying disease e diagnosis of obesity, the sds indices of body mass index (bmi) were determined. obesity-more than + . (i degree: sds bmi . - . , ii degree: sds bmi . - . , iii degree: sds bmi . - . , iv degree: method: postal questionnaires were distributed to an unselected group of asthma patients (n = ). healthy non-asthmatic volunteers were recruited amongst university and hospital co-workers (n = ). the presence of self-reported nhr, the type of triggers evoking nasal symptoms, asthma phenotype, medication use and environmental factors were evaluated. results: patients and controls completed the questionnaire (responder rate of % and % respectively). nhr was reported in % of asthma patients and % in non-asthmatic controls (p < . ), with changes in temperature being the most important inducer of nasal symptoms ( % of asthmatics), followed by strong odours ( %) and cigarette smoke ( %). interestingly, nhr was more prevalent in patients with severe ( %) compared to mild ( %) asthma symptoms (p = . ), and more prevalent in atopic ( %) compared to non-atopic ( %) asthmatics (p = . ). most asthma patients reported more than one trigger evoking nasal symptoms, with % of patients reporting or more triggers evoking nasal symptoms. results: the mean score of cbcl questionnaire in case group with . ± . was significantly higher than in comparison with a control group with . ± . (p = . ). the mean scores of the subscales of social isolation (the case group: . vs control: . , p = . ), anxiety-depression ( . vs , p = . ), intellectual problems ( . vs . , p = . ), and aggressive behaviors ( . vs . , p = . ) were significantly higher in children with asthma than in healthy children. the study showed a significant correlation between the mean duration of asthma and a general score of cbcl (p = . , cc= . ). moreover, there was also a significant correlation between asthma severity and cbcl scoring (p = / , cc= . ). conclusion: behavioral disorders in children with asthma are significantly more than healthy children. the duration of asthma and the severity of asthma, are related to and can predict behavioral disorders in children with asthma. background: assessment of asthma control is an integral part of the management of asthma. whilst asthma control test (act) is a commonly used questionnaire to assess symptom control, its utility in predicting long term risk of exacerbation has not been well studied. aim: to analyze the factors associated with uncontrolled asthma symptoms using act and its impact on predicting future exacerbation. method: severe asthma patients on at least step background: most of the asthma-scoring tools detect the asthma severity from patients' symptoms but there is no scoring tool using parameters to define risk of asthma exacerbation. thus, this study use factor analysis to evaluate the relationship of parameters in childhood asthma. method: the descriptive study using factor analysis in asthmatic children aged less than years old, who attended thammasat university, the center of excellence for allergy, asthma and pulmonary diseases, thailand. the participants or caregivers were inter- the factors which have the major impact on asthma control are changing bed sheets less than once per month and using dust mite-proof bed sheets. this study is supporting non-pharmacological strategies but further studies are needed to create a more efficient asthmatic symptom checker. were not different between the controlled and uncontrolled group. the act score in the controlled group was significantly higher than the uncontrolled group (p < . ). the study showed that cigarette smoke is one of the significant factors that can trigger asthma exacerbation (p < . ) and mosquito repellent coil smoke is also significantly associated with asthma exacerbation (p < . background: experimental studies have demonstrated that tumor necrosis factor family member (tnfsf /light) plays an important role in airway remodeling. there is little data available concerning in vivo regulation of tnfsf /light expression in humans. the aim of this study was to evaluate serum concentration of tnfsf / light in different subsets of asthmatic patients. the study was performed on nonsmoking asthmatic patients (a), including mild-moderate-severe asthmatics controlled on inhaled corticosteroids (aics) and asthmatics evaluated twice during asthma exacerbation (aex) and during subsequent remission (arem). in addition age and sex matched nonsmoking healthy controls were included (hc). serum tnfsf /light concentration was evaluated using elisa method. in asthmatic patients lung function tests, exhaled nitric oxide concentration (feno), serum total ige concentration (t-ige), allergen-specific ige concentration (s-ige) and peripheral blood eosinophilia were evaluated. ( + /- pg/ml) was significantly greater than that in hc ( + / - pg/ml; p < . ). among all asthmatic patients studied the greatest tnfsf /light serum concentration was demonstrated in aex ( + /- pg/ml), which was significantly greater than that in aics ( + /- pg/ml p < . ). during resolution of asthma exacerbation a significant decrease in serum tnfsf /light concentration ( + /- pg/ml; p < . ) was demonstrated. in arem the mean serum tnfsf /light concentration was comparable to that seen in aics (p = . ) but was still significantly greater than in hc (p < . ). no significant correlation could be demonstrated between serum tnfsf /light concentration and baseline lung function parameters, exhaled nitric oxide concentration, serum t-ige or s-ige concentration or peripheral blood eosinophilia. conclusion: enhanced production of tnfsf /light seen in asthmatic patients, which is further upregulated during asthma exacerbations may play an important role in asthma pathogenesis. method: two models of aspergillus fumigatus-induced allergic airway inflammation were used in the study: long terms ( weeks) and short terms ( weeks background: chalcone is identified as an inhibitor of the interaction between cxcr or cxcr and their ligand cxcl . therefore it is called a neutraligand. the chemokine cxcl , interacting with the cxc-receptor (cxcr ) can play a role in the progression and development of bronchial asthma. asthma is defined as a chronic disease characterized by episodes of obstructive events which affects about million people over the world. the aim of this study is to approach the mechanism of the anti-inflammatory effect of the cxcl neutraligand chalcone and also to assess its impact on the migration of dendritic cells in a murine model of allergic airway inflammation. method: chalcone is administered intranasally to balb/c ovalbumin (ova) asthma mice and control groups as well. our results indicate that the cxcl neutraligand chalcone can modify the inflammatory reaction in an airway allergic hypereosinophilia model. furthermore, found out that cxcl neutraligand chalcone prevents dc migration to the airways and airway jnc ganglia during allergic airway inflammation. the detection of the cxcr -cxcl pathway and its role in the pathophysiological actions of asthma offers a promising target for allergic diseases treatments. method: four groups of balb/c mice were defined: control and asthmatic, with and without treatment. asthmatic groups were sensi- overexpression of ptgdr in pulmonary cells associated to a generalized increase of cytokine expression. conclusion: in a mouse model we confirmed the involvement of ptgdr in allergic asthma by the increase of its expression levels after ovalbumin sensitization. we also identified a reduction of ptgdr levels in response to dexamethasone treatment. the in vitro model suggests that ptgdr induces an inflammatory response, increasing the cytokines levels. | immune imbalance between transcription factor t-bet/gata and allergic asthma results: t-bet mrna expression of peripheral blood lymphocytes in patients with allergic asthma was lower than that of the normal control group, and the expression level of gata- mrna was higher than that of the normal control group (p < . ). the th percentage of peripheral blood lymphocyte subsets was lower than that of the normal control group (p < . ), the percentage of th cells was significantly higher than that of the normal control group (p < . ), and the changes in t-bet/gata expression and th /th ratio was highly correlated. our objectives were to assess the changes of bmp and bmp serum levels in the response to allergen and methacholine challenge tests and the correlation between bmp and bmp serum levels and fev before and after allergen and methacholine challenge tests. method: study group consisted of patients with asthma and healthy volunteers. spirometry, skin prick tests, allergen and methacholine challenge tests were performed in compliance with eaaci, ers and ats guidelines. personalized clinic surveys including act ™ were performed. venous blood was collected before and after hour, and hours afterwards the provocation to edta-ke-filled test tubes. evaluation of bmp and bmp serum protein levels was performed using specific elisa immunoassay kits according to the manufacturer's protocol. results: the increase in bmp and bmp serum level hours after provocation test correlates significantly with the concentration methacholine during provocation time (p < . ). bmp serum level before the provocation, hour and hours after provocation, correlates negatively with fev change (p < . ). the median bmp level hours after provocation was significantly lower in patients with negative methacholine challenge test compared to the control group (p = . ). the median bmp level hours after provocation was higher in patients with positive allergen provocation test than in patients with negative test results (p = . ). the bmp serum level hours after positive methacholine test is lower and correlates inversely with fev change in every time point, which could indicate that serum level of bmp is a predictive factor of fev change. the higher bmp serum level, the lower fev change was observed. this could suggest the protective influence of bmp in patients with obstructive pulmonary disease, i.e. asthma. the higher bmp serum level hours after positive allergen provocation test result shows that the bmp could be an indicator of the response to a specific trigger. background: inflammation and coagulation are closely linked events. thrombin is the key enzyme in coagulation system. besides its well-known functions in hemostasis, thrombin plays a role in inflammation. the aim of our study was to evaluate thrombin generation in children with mild asthma and demonstrate associations between thrombin levels and control of asthma. method: forty-two children with mild asthma and forty-nine healthy children included in the study. asthmatic children had no asthma exacerbation during the last months. patients (n = ) who had mild persistent asthma, were using either inhaled steroid or montelukast. all patients performed spirometry. thrombin levels were measured by thrombin generation test. thrombin peak levels, endogenous thrombin potential, thrombin lag time, time to thrombin peak and thrombin tail time were recorded. results: thrombin lag time was significantly longer in children with asthma ( . ± . ) compared to those in control group ( . ± . ) (p < . ). children with asthma also had longer thrombin tail time compared to control group ( . ± . vs . ± . , p = . ). thrombin peak was inversely correlated with fef - (- . , p < . ). thrombin lag time was inversely correlated with fef - (- . , p < . ). thrombin generation parameters did not show difference according to asthma control treatment, asthma control scores and having atopy. conclusion: coagulation/anticoagulation balance is disturbed in mild asthma but this disturbance may not be as strong as to increase thrombin levels. factors increasing inflammation may cause an increase in lag time, and increase in inflammation and excessive fibrin deposition may contribute to airway narrowing. background: cytokines represent key mediators in the onset and persistence of inflammatory process, in both asthma and copd. il- , which belongs to il- family, it might act in a similar way with il- at the beginning of the inflammatory process. its role in atopic skin diseases has already been demonstrated, but there are conflicting results related to its role in respiratory allergic diseases. the aim of the study was the evaluation of il- plasmatic level in patients with asthma and copd and the its correlation with clinical and lung function parameters. method: fifty consecutive patients with bronchoobstructive diseases were included in the study. thirty-two patients presented asthma and patients had copd. the evaluation included: number of exacerbation in the last year, disease's severity, spirometry. plasmatic levels of il- and il- were determined in all patients. results: the mean age was higher in patients with copd dermatophagoides pteronyssinus [house duste mite (hdm), ug/ mouse] were administered oro-tracheally on days , , , , , , and . at was performed in a treadmill during weeks in moderate intensity, from day until day . results: at inhibited hdm-induced total cells (p < . ), eosinophils (p < . ), neutrophils (p < . ) and lymphocytes (p < . ) in bronchoalveolar lavage (bal), and eosinophils (p < . ), neutrophils (p < . ) and lymphocytes (p < . ) in peribronchial space. at also reduced bal levels of il- (p < . ), il- (p < . ), il- (p < . ), cxcl (p < . ), il- (p < . ), il- (p < . ), il- (p < . ), while increased il- (p < . ). airway collagen fibers (p < . ), elastic fibers p < . ) and mucin (p < . ) were also reduced by at. at also inhibited hdm-induced airway hyperresponsiveness (ahr) to methacholine . mg/ml (p < . ), . mg/ml (p < . ), mg/ml (p < . ) and mg/ml (p < . ). mechanistically, at reduced the expression of stat (p < . ), stat (p < . ), stat (p < . ) and jak (p < . ), similarly by peribronchial leukocytes and by airway epithelial cells. socs expression (p < . ) was upregulated in leukocytes and in airway epithelial cells, socs (p < . ) was upregulated in leukocytes and socs down-regulated in leukocytes (p < . ) and in airway epithelial cells (p < . ). conclusion: at reduces asthma phenotype which is followed by positive modulation of socs-jak-stat signaling in peribronchial leukocytes and in airway epithelial cells. rodolfo a ; paciência i ; rama t ; leão l ; silva d ; rufo j ; mendes f ; padrão p ; oliveira fernandes e ; moreira p ; delgado l ; moreira a porto, portugal; potentially irritating chemicals that may have a cutaneous drying side effect. this study aimed to evaluate if skin barrier function, as measured by transepidermal water loss (tewl), is affected by a training session in swimmers compared with football players. environment impact on the human respiratory health (clinicaltrials.gov identifier: nct ) and football players were invited to participate. due to the lack of prior information no sample size calculation was possible and all athletes that provided informed consent were included in the analysis (n = , females, aged to years). tewl was measured using the tewameter ® tm before, immediately after, and minutes after a hours training session. the probe was held on the dorsum of hand, the volar forearm and the antecubital flexure for s. the average of two consecutive measurements was recorded. non-parametric statistic was used were appropriate. ethical approval was obtained from the university clinical research ethics committee and informed consent provided. results: mann-whitney u test showed significantly higher baseline median tewl level on football players hand's dorsum compared with swimmers, median (p -p ) respectively . ( . to . ) and . ( . to . ); p = . . friedman test revealed a significant effect of swimming on tewl on the hand's dorsum, volar forearm and antecubital flexure (p < . ) while football training affected only the hand's dorsum (p = . ). differences in changes after swimming and football training were significant only for tewl in volar forearm (p = . ). in conclusion, our exploratory findings do not provide support for a specific deleterious effect of swimming, compared with football training, on the training induced changes in tewl. background: exercise-induced bronchoconstriction (eib) is defined as transient, reversible airway narrowing occurring during or after exercise, is common among elite athletes and associated with epithelial damage. however, little is known about the existence of eib in young athletes. the goal of this study is to investigate the presence and to evaluate potential (bio)markers of eib in young high-school elite athletes in different sport disciplines versus age-matched control subjects. method: high-school selected elite athletes ( - years) from different sport disciplines: basketball (n = ), football (n = ) and swimming (n = ) performing at least hours of sport per week (median= h) and control subjects (performing less than hours of sport per week) were recruited. the eucapnic voluntary hyperventilation (evh) test was performed according to ats guidelines and adapted for this age group. lung function was measured before, immediately after and , , minutes after the evh test. the test was considered positive if a maximal fall in fev of % was measured on at least one time point and exhaustion was excluded. a blood sample was obtained at baseline. sputum induction and skin prick test for the most common allergens were performed after the evh test. results: fifteen swimmers had a positive evh test ( . %), which is higher than in basketball players ( . %), football players ( . %) and controls ( . %). . % of the swimmers were atopic which is also higher than in basketball players ( . %), football players ( . %) and controls ( . %). serum clara cell secretory protein (cc ) levels are significantly higher in swimmers ( . ± . ng/ml) compared to indoor athletes ( . ± . ng/ml) and controls ( . ± . ng/ml). a significant positive correlation was found between the magnitude of maximal fall in conclusion: young elite swimmers have a higher prevalence of eib compared to basketball and football players. atopy and/or chlorine is a risk factor for the development of eib in young elite athletes. cc levels and sputum uric acid levels are increased in athletes compared to control subjects suggesting the presence of epithelial damage already at young age. this is especially observed in young elite swimmers, pointing to a probable role of exposure to chlorineby-products in combination with intensive exercise. results: data from subjects ( females, . %) were analyzed. frast was positive in ( . %) patients ( females, median age of years (iqr - )). in this group, ( . %) had a previous diagnosis of asthma, ( . %) practiced federated sports, ( . %) had smoke cigarette exposition and ( . %) had a bmi > kg/m . . % of patients showed a Δfev % > % in the first minutes after finishing the challenge. median fev reduction was . % ) and ml . frast was more frequently positive in patients with previous diagnosis of asthma (p < . ). there were no differences related to conclusion: frast is an important tool to diagnose exerciseinduced bronchospasm without asthma (eib wa ), as well as to diagnose asthma. in our study, frast was fundamental to access eib wa in % of patients with rsee, and confirmed asthma diagnosis in % of cases with previous asthma diagnosis and negative sbt. there was no difference in the prevalence of atopy between patients with positive and negative frast. patients older than years-old presented higher Δfev % compared to younger patients (p = . ). higher levels of feno were observed in patients with positive frast (p = . , p = . ), both in patients with and without previous diagnosis of asthma. a positive correlation was observed between feno levels and Δfev % in the whole sample (r = , p = . ); when these data were analyzed considering a previous diagnosis of asthma, only patients with this condition showed a positive correlation of feno and Δfev % (r = . , p = . ). conclusion: our results evidenced that higher feno was associated with atopy and a positive frast, both in patients with and without previous diagnosis of asthma. higher feno seems to correlate with Δfev % in patients with previous diagnosis of asthma. background: specific immunotherapy is the casual treatment for allergic rhinitis. a year old professional footballer suffer from severe allergic rhinitis since two years. during may, june and july his level of playing, concentration and durability decreased about %. patient was complaining of runny nose, nasal blockage, each eyes, sneezing, tearing. method: we did skin prick tests -which showed greatest allergy to grass pollen. we confirmed the allergy by specific ige and nasal provocation tests. spirometry was done-fev %. the patient was qualified to undergo specific immunotherapy. however, because of his profession, it was hard to find a day without trainings to get the vaccine. after long discussion, patient decided to start specific immunotherapy-scit. results: the patient start the immunotherapy. he was attuning very irregularly, because of matches, injuries, trips, trainings, and lack of time. several times we had to call the patient to remind him about the immunotherapy. after one year of scit the patient felt big improvement. during grass pollen season he suffered from mild allergic symptoms, and just for few days. after next year of immunotherapy, the patient had no symptoms of allergic rhinitis during the grass pollen season. however, it was the reason for him, to stop sit, before rd year of immunotherapy. conclusion: such a treatment-specific immunotherapy-is a burdensome method for both, for professional athletes and doctors. such a patients need to be on special observation, and cooperation with trainers must be obtained, if we want to see results. to improve compliance we have to keep in touch with patients, to remind them about next visit. gherasim a ; choual i ; radu c ; khayath n ; beck n ; jacob a ; schoettel f ; domis n ; de blay f alyatec, strasbourg, france; hôpitaux universitaires de strasbourg, strasbourg, france background: late allergic response (lar) is a good asthma model. it has been shown, in individual challenge tests that mite allergen induces more frequently late allergic responses (lar) than cat allergen. the aim of this study is to compare the frequency of lar in asthmatic subjects allergic to mite with asthmatic subjects allergic to cat. method: asthmatic subjects allergic to mite were compared to subjects allergic to cat (gina or ). the subjects had prick tests≥ mm compared to the negative controls and specific ige ≥ . ku/l. the dose selected for the mite and cat allergen was the airborne allergen concentration inducing the most frequently early asthmatic response (ear) (a % drop in fev ) and lar (a % drop in fev ). results: the frequency of lar with mite allergens was . % and % with cat allergens (p = . ). the frequency of ear for mites was . %; of . % for ear or lar, and % for ear and lar. in contrast, with cat allergens, % of patients had an ear, % had ear or lar and % had an ear and lar. no significant differences was observed between cat and mite allergen regarding the severity and the time necessary to obtain an ear and lar. no significant differences was observed between cat and mite allergen regarding the severity and the time necessary to obtain an ear and lar. the frequency of lar in asthmatic subjects allergic to dust mite exposed in alyatec ® eec was higher than in asthmatics sensitized to cats. our results confirmed previous results with individual bronchial challenge. therefore, it appears that the mite model is more interesting in the study of asthma. exposure chamber in strasbourg (alyatec ® ) in asthmatic patients allergic to cat allergens gherasim a ; choual i ; radu c ; khayath n ; beck n ; jacob a ; schoettel f ; domis n ; de blay f alyatec, strasbourg, france; hôpitaux universitaires de strasbourg, strasbourg, france background: as recommended by the task force on environmental exposure chamber (eec), allergenic and non-allergenic exposure must be better controlled in eec. it is the aim of alyatec's eec. the aim of the study is to validate alyatec's eec by determining the concentration of fel d inducing % of early asthmatic response (ear) and/or late phase asthmatic response (lar) in subjects sensitized to cat. method: it was a randomized, double blind, cross-over study including group a: asthmatic subjects allergic to cat and group b: asthmatic subjects allergic to another allergen. all subjects were first exposed to placebo. group a was exposed to fel d concentrations. the number and size of particles were recorded online during the exposure. group b was exposed to the concentration of fel d which fulfills the objective of the study. the mean age of subjects was years (± ). for the concentrations of fel d , we obtained more than % ear and/or lar. the mean time necessary to obtain an ear was: . ± minutes and . ± minutes for the lar. the mean fall in fev during ear and lar was − . % and − . % respectively. we didn't observe any severe reaction. no subjects in group b experienced any symptoms during exposure. we have validated alyatec's eec in asthmatic subjects allergic to cat allergens. we also demonstrated its specificity. background: the best test and strategy for diagnosing asthma especially in those patients with negative bronchodilator reversibility tests still remains unclear. in this study we aimed to investigate the diagnostic yield of peak expiratory flow (pef) variability for the patients with symptoms suggesting asthma but negative bronchodilator reversibility tests. method: subjects referred to our outpatient clinic with suspicion of asthma were enrolled in this study. demographics and referral symptoms were recorded, asthma control test (act) scores and health related quality-of-life scores (aqlq, sf ) were calculated. monitoring of pef variability during -weeks and bronchial challenge test with methacholine (bpt) were analyzed. asthma was diagnosed by having pef variability ≥ % and/or positive bpt. results: thirty out of enrolled patients were diagnosed as having asthma. when we compare asthmatic patients with nonspecific respiratory symptomatic subjects there were statistically-significant differences regarding to wheezing (p = . ), activity limitation (p = . ), total symptom score (p = . ) and basal fef (p = . ) in the favor of asthma cases. multiple logistic regression analysis revealed that lower basal fef - was an independent predictive factor of asthma diagnosis (p = . ). when the bpt positivity was assessed as gold standard for the diagnosis of asthma, the sensitivity and specificity of pef variability for different cut-offvalues (≥ %, > % and >% ) were . - . %, . - . % ve - . %, respectively. conclusion: fef - is an important diagnostic parameter for asthma. although current guidelines recommend pef variability of % for the diagnosis of asthma in general, this cut off level may not be appropriate for this defined group of subjects. our results suggest to use a cutoff level of > % while excluding asthma and ≥ % while confirming the diagnosis of asthma for patients with asthma suspicion but without shown reversibility. de barayazarra s background: in recent years obesity has been considered as a factor that contributes to the development of asthma, increases exacerbations and leads to poor control of it due to resistance to drugs to control this pathology. it is known that obesity produces chronic systemic inflammation; one of the markers that are affected is the levels of c-reactive protein (crp), which are increased. objective: evaluate, lung function, the use of medications to control asthma and systemic inflammation, after bariatric surgery. results: obese asthmatic patients with surgery, non-asthmatic obese patients with surgery, obese asthmatic patients without surgery. a significant difference was found between the severity of obesity and forced expiratory volume in patients with asthma and without asthma of second (fev ) before surgery with an average of . % at the beginning of the study and . % at months (p: . ). in the non-operated group, fev at the beginning was % and . % at months (p: . ). the crp, before surgery in all operated patients had crp: , at months after surgery they became negative, crp: (p: . ). in obese asthmatics with surgery at the beginning, % used medication, and at months only % in obese asthmatic patients without surgery, . % used the medication at the beginning, at months . % (p: . ). method: patients with asthma aged to and a predetermined positive methacholine pc were recruited and underwent a single challenge to cause bronchoconstriction of~ % comparing the outcome of the device with spirometry. the subjects were monitored at baseline, after a~ % fall in fev and after bronchodilation back to baseline. the study protocol allowed for an interim analysis of the initial subjects at which point the sensor was calibrated to optimise sensitivity. a further subjects were studied using the optimised sensor. results: all subjects successfully completed the study. the device was found to be straightforward to use by both operator and subject with no concerns regarding safety. the initial sensitivity of the device was found to be suboptimal in the first eight patients to reliably detect changes in lung function. after adjustment to the device the tests results of the remaining subjects were analysed. . % of subjects were female. the mean age of all subjects was . years. an average baseline fev value of . (s.d. . ) was observed. changes in lung function were detected in % of subjects. a baseline value, drop in lung function and reversal were measured in % of subjects. the mean percentage drop observed in % of subjects using the investigational device was . %. the mean percentage increase observed using the investigational from drop to reversal was . %. the device (using ebc ) was able to detect changes in lung function tracked using fev . this provided proof of concept that the device could potentially be used to monitor lung function more effectively in the home than peak flow and supports further development to optimise the device and demonstrate functionality in clinical asthma. method: ninety four patients under years of age seen in the allergy department due to common asthma symptoms (wheezing, dyspnea, cough, chest tightness) with normal spirometry and negative bronchodilator response, underwent mct during and . the variables studied were: sex, age, body mass index (bmi), asthma symptoms, exercise symptoms, rhinoconjunctivitis, family history of atopy, sensitization to respiratory allergens, spirometric data and fractional exhaled nitric oxide (feno). results: of the total sample, half were women ( . %) and the other half were males ( . %). mean age was . years. bmi was normal in most of them (with an average of . kg/m ). the most common symptom among the patients with positive mct was cough ( . %), followed by dyspnea ( . %), wheezing ( %) and chest tightness ( . %). . % had symptoms of asthma with exercise and . % had rhinoconjunctivitis. . % had a family history of atopy. . % were sensitized to aeroallergens, mainly to pollens (grass and olive tree). . % of the mct′s were positives, with a mean pc of . mg/ml. . % had a moderate-severe result (pc ≤ mg/ml), . % mild (pc - mg/ml) and . % bordering (pc - mg/ml). the mean feno was . ppb. conclusion: in our series, the completion of a test of hrb was decisive to confirm the diagnosis of asthma in most patients of a pediatric population with symptoms of suspicion (cough, mainly), normal spirometry and negative bronchodilator response (with normal feno in most of them). therefore, we consider it important to include in the routine clinical practice hrb tests in the pediatric population with suggestive symptoms of asthma, despite normal functional and/or inflammation tests. | cut-points of the ′control of allergic rhinitis and asthma test′ (carat) asthma subscale based on an international survey patients with asthma) in kashan, iran. the data collection tool was a questionnaire with questions, designed to gather information on demographic asthma patients, the current use of mobile functionalities, and the willingness to use these functionalities to receive selfmanagement services, which was distributed among patients with informed consent. the collected data were analyzed by descriptive statistics method using spss software. results: the most use of patients from mobile phone functionalities was to receive information about asthma symptoms and allergens and irritants via mobile internet ( . %). patients were most likely to use social networking ( . %) in comparison with other mobile phone functionalities, to receive reminders about appointments and medication. the respondents were most likely to use social networks through mobile phone functionalities, to receive asthma self-management information ( . %), to communicate with other patients ( . %), to receive reminders about medication use, and to perform a peak flow meter test ( . %) and to get an alert when the asthma is not controlled ( . %). the findings show that asthma patients are currently using the internet search for educational information and they have a tendency to use social networks to receive asthma-related services. patients believe that mobile health is an appropriate intervention for providing educational information, reminders, and alerts and communication with other patients. | concordance between the determination of asthma control through the gina guidelines and the act questionnaire-results of the efimera study background: the exacerbation of asthma, progressive worsening of acute episodes, is one of the most frequent attending reasons at hospital emergency unit . several factors causing poor control of asthma, such as inadequate therapy, have been described. in the present study, estimations of asthma severity by researchers were assessed by comparing the concordance between the assessment of asthma control through the gina guidelines and the act questionnaire method: cross-sectional observational study on the evaluation of factors related to treatment that influence the poor control of asthma was assessed through the gina guidelines and the act questionnaire. patients referred to a pneumologist or allergist by a primary care for the first time were evaluated. two variables were collected for the assessment of asthma control: one derived from the gina guidelines and another derived from the act questionnaire. regarding the gina assessment, researchers' evaluations guidelines were compared with the scoring calculated from the variables registered in the crd. both measures were compared in terms of sensitivity-specificity to determine their ability to classify patients. the patients included in this study (n = ) had a mean age of ± years, with a % of women and an average disease evolution of . ± . . the control of asthma according to "gina results: pts were reasonably representative of those in sls asthma (at sls baseline: . % male; mean age . yrs; mean asthma control test [act] score . ) . the most frequently reported symptoms during sls asthma for these pts were cough/ breathlessness, followed by wheeze, phlegm and chest tightness; breathlessness and wheeze were perceived as the biggest impactors on pts' lives. the aspects of daily life most impacted by asthma were reported as walking at a hurried pace, strenuous physical activity, and asthma-related frustration. since sls began, % of pts in this subset reported improvements in overall asthma ( % no change; % worsening). perceived changes in symptoms are shown (table) . most pts ( . %) reported avoiding places with dust, smoke or fumes. most pts ( . %) perceived no change in overall qol; . % reported improvement. being an act responder during sls (total act score ≥ or ≥ change at end of sls) was associated with reported improvements in overall asthma symptoms, lower impact of asthma on qol, and higher perceived confidence/control in managing asthma. more pts ( . %) in the ff/vi arm reported an overall improvement in asthma vs uc ( . %); the most evident differences between treatment groups were for breathlessness, wheezing and chest tightness. improvements in confidence/control in managing asthma were reported by . %/ . % of pts (ff/vi) vs . %/ . % (uc). conclusion: breathlessness and wheezing were key symptoms in sls asthma and had the biggest impact on pts' daily lives. this patient-centred study enriches the findings of sls asthma. funding: gsk (study ) | asthma and copd treatment adherence and breach using tai questionnaire suarez-vergara m; fuentes-soltero f; garcia-nunez i; ignacio-garcia j background: adherence is defined as medication (inhalator) intake following the dosage and schedule prescribed. adherence mistakes are a public healthy problem according to the big morbi-mortality presented in patients with an incorrect intake. our aim is to evaluate the adherence level and fulfillment in patients with asthma or copd using tai (inhalators adherence test) questionnaire. method: patients with a diagnosis of persistent asthma or copd were selected. we used to size adherence and breach type the tai questionnaire. adherence is defined as good when patient′s test reaches points, medium ( - points) and bad (less than points). breach type is defined as erratic when points between questions to are less than , deliberate when questions to are less than , and unconscious when questions and are less than points. a correct fulfillment is defined when questionnaire reaches points plus points of conscious fulfillment. results: fifty-five patients more than years old (mean age . years and . % males) were selected. a . % of them were asthmatics, . % copd and . % a mix phenotype. a . % presented a correct fulfillment with conscious fulfillment, and the other . % presented good, medium or bad adherence with a breach type. according to adherence level, a medium adherence was defined in patients ( . %), with an erratic mistake in patients ( %). bad adherence was seen in patients ( . %) , with the three breach types in patients ( %). good adherence with unconscious breach type was defined in patients ( . %). conclusion: tai questionnaire confirms a good adherence and fulfillment in less than % patients. an erratic mistake is the most frequent breach type defined in our patients. educational protocols should be applied to improve adherence and fulfillment. | what is adhesion to treatment of asthmatic patients like in argentina according to the tai questionnaire? background: asthma is a chronic inflammatory disease of the airways, which requires an adequate treatment and control. the adhesion of a patient to an asthma treatment is a critical factor in order to achieve and maintain control. this adherence arises from a consensual agreement of the doctor-patient relationship; it is a complex multifactorial variable in which the variability in human behaviour in relation to its environment influences. background: the association between ambient pollen and asthma has been studied intensively with inconsistent results, attributed to differences in study population, geographic factors (geoclimatic features), data sources, measurement of pollen (different types of traps), and different outcome occurrence (hospitalizations or emergency department visits). we investigated the associations between daily sales of short-acting β -agonists (saba) and outdoor pollen concentrations in the central france area. the relationship between daily changes in pollen concentrations and daily saba sales obtained from the social security database was analysed with generalized additive models, taking into account confounding factors such as air pollution, weather conditions, and day of the week. results: the daily saba sales (mean, sd) rose from . ( . ) conclusion: this study indicates that outdoor pollens contribute to asthma morbidity in the general population. it confirms the highly allergenic role of fraxinus, betula and quercus pollens, but also shows a relatively unknown association between treated asthma and carpinus and platanus pollens, despite their counts being less than % of overall pollen concentration. results: of asthma patients (mean age . years, female . %), regular ocs use was identified for patients ( . %), periodic ocs use for patients ( . %), and no ocs use for patients ( . %) -year post-index. regular ocs users had a greater mean age, were more often male, and had greater eosinophil counts, lower lung function, and greater prevalence of comorbidities than did the periodic and no ocs users (p < . ). total yearly cost was greatest for the regular ocs users (€ ), followed by periodic ocs users (€ ) and no ocs users (€ ) (p < . ). among regular ocs users, hospital admissions were the main cost driver ( . % of total cost), while gp consultations were driving the total cost in periodic and no ocs users ( . % and . % of total cost, respectively). conclusion: in this sample of patients with asthma in sweden, the total yearly cost of health care resource utilization for a regular ocs user is twice as high as for a patient with no ocs use, demonstrating substantial economic and clinical burden in asthma patients on regular oral steroid treatment. method: children with physician-diagnosed asthma who attended to an outpatient pediatric allergy and asthma center were enrolled in the study along with control subjects. asthma severity and control status of the patients were evaluated according to recent gina guidelines. laboratory investigations including skin prick tests, complete blood counts with differential, total ige levels, serum periostin levels and pulmonary function tests were performed. results: a total of children ( with asthma and age and sex-matched control subjects) with a median age of . years (range . - . ) were enrolled. asthma severity was mild in ( . %), moderate in ( . %) and severe in ( . %) children. children with asthma had significantly higher periostin levels than controls ( . ± . vs . ± . ng/ml; p < . ). the mean serum periostin levels of children with severe asthma ( . ± . ) were significantly higher than in children with moderate asthma ( . ± . ) and mild asthma ( . ± . ) (p < . ). serum periostin levels were found to be significantly correlated with asthma severity (spearman's rho [r]=. , p < . ). analysis using roc curves identified the role of periostin levels in determining children with severe asthma (auc: . , % ci: . - . , p < . ]. conclusion: serum levels of periostin, a novel asthma biomarker, were higher in asthmatic children, and were associated with asthma severity. adam i ; selevestru r ; rogut v ; sciuca s background: nowadays, data from several epidemiological studies confirm the important role of fungi in respiratory disease in the indoor as well as in the outdoor environment. in general, exposure to fungi occurs via inhalation, skin contact, or ingestion. alternaria alternata is one of the most common fungi associated with presence asthma and persistence and severity of asthma. although exposure to a. alternata is also may represent a risk factor for development of asthma. in ukraine has been an increase in the number of the mold sensitized children for the last few years. at the same time we can see increasing frequency ba at the children of pre-school age. method: thirty five children aged - years with allergic rhinitis and high level of asthma predictive index (api) sensitized to a. alternata were included in a -year cohort study of the efficacy and safety of slit (diater laboratories, spain) using standardized sublingual extracts containing molds (alternaria alternata). treatment efficacy was analyzed using the score of symptoms such as difficulty in nasal breathing, rhinorrhea, sneezing, itching of the nasal mucosa (upper palate) and discharge from the nose and recurring wheezing. we also have analyzed the level api during the period investigation. symptoms were measured before starting treatment, and at , and months after starting immunotherapy. results: slit significantly reduced both symptoms and medication score: nasal symptoms ( % vs. control group) and the use of rescue medications ( % vs. control group), and improved fev (in children aged≥ years). in the slit group, api decreased by % for the first year, by % for the second year. no patient had a systemic reaction during therapy. our results have shown that slit is an effective treatment in pediatric patients suffering from allergic rhinitis and high api with significantly improved clinical outcomes (less symptoms and less medication intake) in comparison with children treated with symptomatic drugs only. in this study, large and statistically significant differences in symptom and medication scores were demonstrated in patients receiving slit compared to control group. sublingual immunotherapy is effective for allergic rhinitis in children especially early age and is generally advantageous because of the convenient administration and safety profile and ensure prevention of developed ba. bednarek a background: the classification of asthma based on the severity of its clinical course has been recommended by gina since . this division is useful for the patient's initial assessment when asthma is being diagnosed and essential decisions concerning an appropriate therapy are made. the objective of the work is to evaluate the influence of a clinical form of asthma on vaccine immunity in preschoolers following three years after the programme of mandatory vaccination has been realised. the study encompassed preschool children (mean age of . ± . years old) with asthma being newly diagnosed, including patients with mild asthma and ones with moderate asthma, whose vaccine immunity (igg specific antibody titer) was assessed after the mandatory early childhood vaccines had been administered. monovalent vaccines (hbv+ipv+hib) along with a three-component combined vaccine (dtwp) were given to children while a six-component vaccine (dtap+ipv+hib+hbv) was given to the remaining children. the vaccine doses were consistent with the polish immunisation programme and manufacturers' recommendations. the elisa immunoenzymatic method was applied to assess titer of specific antibodies to diphtheria, tetanus, pertussis, poliomyelitis and h. influenza type b. the level of hbv antibodies was measured chemiluminescently. the immunity class for particular vaccinations was assessed according to the test manufacturers' instructions. results: children suffering from mild asthma had considerably more frequently vaccinations on time (p < . ) and the type of vaccines (monovalent, highly-combined) administered to them did not have a significant influence on a clinical form of asthma in the children examined (p > . ). apart from the vaccines against hepatitis b and rubella where considerably more frequently a high antibody titer occurred in children with mild asthma, the titers of antibodies to other vaccines, namely diphtheria, tetanus, pertussis, hib and mumps, were not associated with a clinical form of asthma. the protective antibody titers in the children with asthma were found in % after vaccinating them against poliomyelitis (≥ u/ ml) and measles (≥ ml u/ml). significantly higher current weight was solely found in the children with mild asthma (m = . , sd= . ; p < . ). conclusion: there are some clinical and cultural differences among the four southern chinese cities within the canton province. this study identifies potentially modifiable environmental and treatment factors associated with poor asthma control and qol for healthcare interventions. having a smoker in the family is independently associated with poor asthma control and qol. were classified into two groups (levocetirizine group (l) and montelukast group (m)) and we treated each group for another week. to evaluate the therapeutic effectiveness, we used symptom score (ss) and ebc leukotriene e (lte ). ebc samples were collected with rtube. each parameter was checked at , , week therapeutic period. results: most ar patient showed clinically improvement with and week fluticasone therapy ( wk ss= . , wk ss= . , wk ss= . p < . in l group; wk ss= . , wk ss= . , wk ss= . p < . in m group). lte levels of ar were higher than control ( wk vs. pg/ml), and were reduced after week fluti- mic were: md allergic rhinitis, wheezing apart from colds, eosinophilia ≥ %. outcome was defined as md asthma and at least episode of asthma during the previous year or more than episodes of wheezing during the months regardless of asthma diagnosis. results: from a total of of parents approached, ( %) agreed to participate in a phone interview. ( %) children were diagnosed with asthma. the age at the time of admission (mean, abstracts | (sd)) was . ( . ), at the time of phone survey . ( . ) months, respectively. positive loose api at - years of age had sensitivity of . %, specificity %, positive predictive value (ppv) . %, negative predictive value (npv) . %. positive stringent api at - years of age had sensitivity of %, specificity %, ppv . %, npv %. background: asthma is the most common chronic airway disease in childhood, with a high unmet need for new treatments due to insufficient symptom control in a relevant percentage of patients. ethics and resource factors limit the feasibility of large, long pediatric trials required to assess outcomes such as exacerbations and symptoms. for diseases like asthma, where the disease process is largely similar in children and adults, with the same expected therapy outcome, the international council for harmonisation advise extrapolating adult data to those of a younger age, reducing unnecessary pediatric trials. here we assess the partial extrapolation used in the clinical development of tiotropium. phase trials in adults (aged - ), adolescents (aged - ) and children (aged - ) with symptomatic severe (primotina-/pensie-tina-/vivatina-asthma) or moderate asthma (mezzotina-/rubatina-/ canotina-asthma), respectively. trials lasted - weeks, all with tiotropium respimat μg add-on vs placebo as two puffs once daily. results: in adult trials, lung function, symptoms and exacerbation endpoints were evaluated in a confirmatory manner: tiotropium significantly improves lung function and asthma control, and reduces risk of exacerbation, vs placebo ( conclusion: based on similarities in disease profile and magnitude of treatment responses between age groups, it is reasonable to expect tiotropium add-on to produce clinically meaningful improvements in exacerbation and symptom endpoints in children and adolescents, as in adults. the robust tiotropium clinical program supports using a partial extrapolation to avoid overly long and large trials in pediatrics. | clinical state of treatment and examination during last years before remission about asthmatic children in long-term remission cases method: remission cases (no symptom and no therapy) for years of asthmatic children were studied. clinical background and treatment (drugs) was studied during last years before remission annually. acetylcholine inhalation test by standard method was performed, and respiratory threshold of acetylcholine (rt-ach) was obtained. fev %, and serum ige also examined. these data were compared before remission with years after remission. results: mean age of cases at year before remission was . years old. male to female ratio was . . severity of asthma was all mild type, and number of attack was to times in a year. there was no admitted case during this study. the long-term therapeutic drugs were leukotriene receptor antagonist (anti lt) in cases, and/or inhaled corticosteroids (ics) in cases, but cases had no treatment for the control. geometric mean of rt-ach (after then: years before and after remission) was μg/ml and μg/ml. the mean fev % was % and %. geometric mean of serum ige level was iu/l and iu/l. complicated cases of atopic dermatitis decreased after remission, but the incidence of allergic rhinitis increased slightly. conclusion: characteristics of asthmatic children during last years before remission were mild type, had several times of attack in a year, and the treatment was mainly anti lt and/or ics. fev % was within normal range, and serum ige level was not changed after remission. rt-ach had the tendency to improve during years before and after remission. these data is supposed that airway hyperresponsiveness is one of the indicators for quitting treatment. | clinical aspects of polyvalent mechanic bacterial lysate (pmbl) treatment in children with uncontrolled asthma our results indicate that long-term treatment with omalizumab in children can help to achieve better asthma control and reduce the amount doses of basic therapy. method: allergic rhinitis (ar) and allergic rhinoconjunctivitis (arc) diagnosed-patients' demographic information, accompanying-asthma, the allergic history of the family, the onset of symptoms, types of aeroallergens sensitivity were noted from patients' files in our hospital's pediatric allergy clinic. results: in this study, patients were evaluated. the mean age of the patients were . ± . years and % (n = ) were male. ( %) patients had ar and ( %) patients had arc. background: allergic rhinitis (ar) is a disease characterized by symptoms of nasal discharge/congestion, sneezing, and pruritus, and is caused by an ige-mediated immunological response to inhaled allergens. we aimed to evaluate pollen season and out of pollen season pulmonary function tests (sft) of patients with ar in our study. method: in our study, the demographic characteristics and aeroallergens were recorded from patients' files with ar diagnosed. in addition, pollen season and out of pollen season sfts were evaluated and compared. conclusion: in patients with ar, fev and fvc values are seen to be lower during the season even though there is no lower respiratory symptom. therefore, sfts of patients with ar should be evaluated during pollen season. results: among the clinical manifestations, the most common combination of allergic rhinitis (ar) and conjunctivitis (ac) is noted in . % of adults and . % of children, but in children aged - , the combination of ar and ac is observed only in . %, among - years old- . %, while in the remaining age groups it is encountered in more than %. higher percentage of isolated ar is also observed among young children- . %, and those of the results: allergic rhinitis was a main symptom in . % of children with pollen-food sensitization. in all of them concomitant allergic disorders were noticed: bronchial asthma ( . %), atopic dermatitis ( . %). only in . % temporal association between ingestion of pollen-related foods and nasal symptoms was observed (mainly apple and peanuts); occurring also outside the pollen period. the simultaneously sensitization to animal origin food allergens was stated in . % of children with sar, but only in two of them milk and white egg proteins were an additional exacerbation factor of nasal symptoms. in . % anaphylactic reactions to food allergens were registered. . % of children were asymptomatic despite pollen-food sensitization. the statistically significant differences were noticed in comparison to the control group. conclusion: . allergic rhinitis in children, similar to adults, is a common manifestation of pollen-food syndrome and this type of sensitization should be taken into account regardless to age. . children with pollen-related food allergy have the predisposition to multiorgan clinical manifestation. . the lack of association of symptoms with plant-origin foods in the majority of cases and the asymptomatic course of food sensitization in more than one third of patients indicate the need for follow-up. | clinical benefit of the screening of suspected food allergen using multiple allergen simultaneous test in the patient with pollen-food allergy syndrome (pfas) background: the quantitative fluoresce enzyme immunoassay immunocap (ic) system has been widely used for detection of allergen-specific ige for the diagnosis of allergy. however, the system can only detect ige against a single allergen, the multiple antigen simultaneous tests has been developed such as the fluorescence enzyme immunoassay view allergy (va) or chemiluminescent enzyme assay mast iv (ma) and both assay detect more than allergen-specific ige. in this study we examined the diagnostic capability of these two systems for screening test in the patient with pfas. method: total number of participants are (male/female: / ), aged . ± . (range ~ ) years old. all the patients showed oral allergy syndrome (oas) to rosaceae family plants (apple, peach) and/ or kiwi and/or banana, also showed tree pollen allergy. specific ige assay were performed using ic, ma or va. results of greater than class were to be regarded as positive, and the concordance rates between the assays were assessed. results: the correlation of sensitivity between pr- (rbet v , rmal d , rpru p , measured by ic) and specific ige to apple (measured by va), specific ige to peach (measured by ma) in oas patients to rosaceae family plants were assessed. rbet v , rmal d , rpru p were found to be . %, . %, . % positive measured by ic while the specific ige to apple (supposed to be including pr- ) were found to be % positive measured by va. on the other hand, the specific ige to peach (supposed to be including pr- ) were found to be only . % positive measured by ma, this detection rate was lower than that of va (p < . ). also, the correlation of sensitivity between pr- (ract d , measured by ic) and specific ige to kiwi in patients with oas to kiwi were assessed. ract d were found to be . % positive measured by ic while the specific ige to kiwi (supposed to be including pr- ) were found to be . % and . % measured by va and ma, respectively (p < . ). additionally, all the oas patients to banana found to be positive for the specific ige to banana measured by va, but only patient was detected as positive measured by ma. conclusion: in this study, we found that va showed better agreement of sensitivity and specificity with ic compared to ma in the oas patients to rosaceae family plants, kiwi, or banana. therefore, it may be clinically useful for screening of allergen specific background: the hygiene hypothesis for autoimmune and allergic diseases, which exists nowadays, shows that human immune system is dependent on various environment factors. we consider the effects of humic substances (hs) to be important in understanding the hygiene hypothesis. due to urbanization, the amount of human interaction with hs found in soil has significantly dropped. the goal of our work was to study allergenic potential and antimicrobial activ- conclusion: hs appear to be exogenous immunocorrectors, and also to have an ability of suppressing propagation of allergic reactions and sensibilization, which leads to conclusion that they seem to play a major role in hygiene hypothesis. moreover, hs selectively interact with bacterial cell wall, and this effect could be used in order to create antimicrobial drugs based on hs. background: peach tree pollen has been identified as having relevant allergens (the third most prevalent after olive tree and grass pollen) in areas of high cultivars (murcia, east-spain). when analyzing molecular components in sensitized patients, along with pru p , we have identified other relevant inhalant allergens one of which was named pru p x. because pollen of different species share allergens and with plantderived food, we have also studied peach tree pollen sensitization in a non-exposed population (madrid, central-spain). the aim was to study the association between peach tree pollen and several panallergens, as well as the relevance of pru p x in our area (madrid). method: a total of patients who came to our allergy unit in those patients with positive spt to at least one pollen we also performed peach tree pollen spt. if positive, we tested pru p , pho d , pho d and pru p x. to study the clinical relevance of these findings, we also performed nasal provocation test (npt) with peach tree pollen and pru p x. results: a total of patients were sensitized to peach tree pollen. from these, % had also positive spt to pru p and none of them to pru p x. positive spt to polcalcin were found in the % of the cases and to profilin in the %. in patients sensitized to peach tree pollen npt was performed being cases positive to peach tree pollen and none to pru p x. conclusion: peach tree pollen sensitization in non-exposed patients with allergy to other pollens is high although primary sensitization is unlikely. these patients present clinical response when exposed to that pollen that needs further evaluation. in our study, one third of the patients were also sensitized to polcalcin and pru p and none to pru p x. we have not found clinical response to this new inhalant allergen identified in highly exposed peach tree pollen population. results: the bet v elisa . -ep complete kit format (including pre-coated plates and all buffers and reagents) allowed for the consistent measurement of bet v in birch pollen extracts within the same lab (intralab cv= . %) and between different labs (interlab cv= . %). the average recovery from matrix spiked samples (crs in birch pollen extracts) ranged from - %, with an average recovery of % (n = ). assay time was reduced from several days to two hours compared to the original method. the performance of the bet v elisa . -ep kit was comparable to that of the stallergenes greer candidate standard method and has been successfully cross-validated. this will enable allergen manufacturers and regulatory authorities to adopt a standard method for bet v determination, which, ultimately, may be included in the european pharmacopoeia. the development of a certified elisa represents a major step forward in the standardization and quality control of allergen products. | an isoform of the ole e allergen assembled by proteomics could explain the cross-reactivity with pollen and food nsltps results: a total of peptides were obtained by de novo sequencing. ten of them allowed the completion of the full-length amino acid sequence of the allergen. after purification, role e was obtained with a yield of . mg/l of cell culture. immunological assays confirmed that the recombinant isoform of ole e shared most of the allergenic and antigenic properties of the natural allergen. moreover, we observed its implication in cross-reactivity with pollen extracts, and plant-derived food extracts. conclusion: these results suggest that the presence of this isoform in the olive pollen could explain the co-sensitization observed in some allergic patients between ole e and nsltps from foodderived extracts and might be used for a more effective clinical diagnosis of olive pollen sensitized patients. background: penicillium oxalicum, one of the prevalent airborne fungi in india, was selected to detect its spores as potential source of allergens and also to identify and characterise its major ige-reactive component. the airborne spores of penicillium oxalicum was detected by andersen -stage air sampler at different parts of west bengal. the allergenic potency of p.oxalicum was tested by spt, elisa and immunoblotting. total protein was resolved in -d and -d gel electrophoresis and allergens were identified by -d and -d immunoblots. identification of major ige-reactive protein spots was made by mass spectrometry based maldi-tof-tof. major allergen was partially purified by ion exchange chromatography. results: aerobiological investigation clearly indicated the predominance of p. oxalicum spores ( cfu m − ) in the air of west bengal, india. sensitivity of patients to spore antigens was highly correlated with rhinitis. in sds-page, bands were detected with molecular weight range of - kda. the allergenic potency of spores was confirmed by skin-prick test, elisa and dot-blotting. eleven ige-reactive proteins were detected as allergens by -d and -d immunoblots, of which % patients were sensitized to kda allergen. this kda protein was found to be the major allergen which was further characterized by mass spectrometry based maldi-tof-tof. this major allergen (pi . ) was partially purified by ion exchange chromatography. the eleven allergens were identified from spore of penicillium oxalicum fungi for the first time from india. immuno-proteomic identification of major ige-reactive protein ( kda background: airway epithelium (ae) is one of the largest cellular surfaces exposed to the environment. ae constitutes a physical barrier due to the presence of intercellular apical junctional complexes between neighboring cells. in the past years evidence indicates an association between epithelial airway dysfunctionality and allergic asthma. it is still unclear if an impaired epithelial barrier could be the cause of allergy development as opposed to the consequence. one of the most common comorbidities of asthma is house dust mite (hdm) allergy. it has been shown that hdm allergen der p can disrupt the epithelial airway due to its protease action against cellular apical junction complexes damaging the epithelial monolayer. in the last decade, metabolomics has been successfully employed as a new approach to describe metabolic changes in biological systems. metabolomics focuses on describing and identifying small molecules to explain complex biological processes. we theorized that metabolomics could be used as a new tool to detect damage of epithelial barrier in vitro after der p exposure. method: human cell line calu- cultured at air-liquid interphase (ali) was used as an in vitro model of bronchial epithelium. ali culture system allows establishing different compartments, mimicking the conditions found in the human airways: a basolateral compartment in which basolateral surface of the cells is in contact with the culture medium, and an apical compartment where the apical cellsurface is exposed to air. after days in ali, the cells were exposed to either der p or pbs as a control in the apical side for hours. then, apical and basolateral media were collected and processed for metabolomics analyses. results: metabolic profiles from samples were obtained, these were composed by and features for apical and basolateral media, respectively. of these, using mann-whitney unpaired test as statistical analysis, and features were found changed within the apical and basolateral compartments, respectively. specifically, in the apical compartment there were signals significantly increased and decreased after der p exposure; whereas for the basolateral compartment, signals were found to be significantly decreased and increased after exposure. background: mites are one of the major causes of allergies. it is known that allergen concentration varies depending on the species of mites and the degree of allergy induction is different, but the difference in microbiota according to mite species is not known. in addition to allergen, endotoxin or bacterial dna, adjuvants of allergen derived from the microbiota in the mites, are also present in the feces. bacterial endotoxin is found in gram-negative bacteria, acting on tlr and acting as an adjuvant to allergies. method: three species of mites (d. farinae, d. pteronyssinus, and t. putrescentiae), known to cause allergies, are cultured in same condition(autoclaved media, %rh, °c)and analyzed for microbiota of each species. using the next generation sequencing that complements the existing sanger sequencing, we analyze the difference of microbiome according to the dust mite species and measure the level of endotoxin. method: six hundred and thirty five patients ( . % males and . % females, mean age . years old, range to years old) were included. all of them referred respiratory symptoms (rhinitis, conjunctivitis or bronchial asthma) and had skin prick tests positive with any pollen. patients were skin prick tested with a battery of common pollens in our area, including three species of chenopodiaceae: chenopodium album, salsola kali and salsola oppositifolia. results: three hundred and forty tree ( %) patients were sensitised to pollen of any chenopidaceae species: ( . %) to chenopodium album, ( . %) to salsola kali and ( . %) to salsola oppositifolia. the prevalence of skin sensitisation to pollen of salsola oppositifolia was . % in the population studied and . % in patients sensi- results: in patients aged - years of age in . % of the cases ige reactivity was at least to one allergen tested. the majority of patients (more than / ) had a complex sensitization profile and reacted on average to more than allergens. the highest frequency of sensitization in ukraine among patients who turned to the clinic among adults was found phl p ( . %), amb a ( . %), fel d ( . %), bet v ( . %) and children ( . %, . %, . %, . %), respectively. when analyzing the results of tests for the source of the allergen, most often among house dust mites (hdm) allergens in adults and children is sensitization to fel d ( . %), as well as to hdm: in adults (der f - . % der p − . %, der f - . %, der p - . %) and in children ( . %, . %, . %, . %), respectively. among fungal allergens the most common is sensitization to alt a and varies from . % in adults to . % in children. among pollen allergens in adults is sensitization to phl p ( . %), amb a ( . %), bet v ( . %), cynd ( . %), art v ( . %), bet v ( . %) and in children ( . %, . %, . %, . %, . %, . %), respectively. tests for food allergens in adults and children are more common on pr- proteins. in children, sensitization to milk and egg proteins is more common than in adults. conclusion: most patients who came to the clinic have a complex ige reactivity profile in which pollen sensitization predominates. among hdm allergens, more than / of the examined have sensitization to the cat's proteins. sensitization to mold alternaria alternata in children occurs times more often than in adults. results: total children were examined, aged - years (median years). % children were sensible to two and more components . %to and more components. the frequency of sensitization to inhalation components was . %, to food abstracts | components- . %. among the most frequent inhalation components were feld - %, betv - %, amba - %, phlp - %, alta - %, the sensitization to house dust mites (hdm) was most often observed to der p - %. however, the analysis of these protein by the level of isu showed that the highest levels were for der f median (iqr . - . ), whereas for fel d - . (iqr . - . ). among food allergens, sensitization was most commonly observed to pr- proteins - %. children sensitized to pr- proteins were in most cases sensitized to -mal d ( %), cor a . ( %), pru p ( %).this co-sensitization was accompanied by a high correlation of isu levels among these components. sensitization to celery and kiwi was less common, the level of these proteins was also low. the frequency of sensitization to storage proteins was %, among which the highest level of isu was in ara h median . sensitization to ltp proteins was detected in % of children, among which the most commonly detected pru p protein was . %. the sensitization to profilins, which was evaluated at the level of bet v , was found in % of children, but the levels of these proteins were not high. among the food products of animal origin, the most frequent was sensitization to egg component gal d − . %, however, isu levels were the highest to milk component bos d − . (iqr . - . ). the most frequent causative inhalation allergens were epidermal allergens and weed pollen, however, the highest level of isu was to hdm and mould. among food allergens, the most commonly observed sensitization was to pr- proteins. hypereosinophilia of peripheral blood was observed in children under study, which was % ( . %). as a result of testing patients with a wide panel of allergens, % of the patients had diagnostic levels of antibodies to allergens siged , . %to allergens siged . in % of cases, a significant level of antibodies to plantain allergens sige w was detected, . % to dandelion allergens sige w , . % to evergreen trees sige t , to maple sige t to . %, to allergens of olive tree sige t - %, to the banana allergens sige f - . %, to the egg protein sige f in . %, in % to the milk allergens sige f , to the food mixture sige f x - . %, to allergens of mold fungi mx − . %. among the leading household allergens were registered in the st group and in the nd group of the investigated children -d pteronyssinus ( . %, . %), and d. farinae results: the prevalence results are expressed in the table . we have not observed any significant association in allergic rhinitis patients group with any ltp or pr- molecules. for atopic dermatitis only rara h (or with % ci - . ( . - . ) and njug r (or with % ci - . ( . - . )) were associated significantly. for asthma, the most important molecules were rbet v , raln g , rcor a . , rcor a . , rmal d , rpru p and rapi g (p-values for or less than . ). conclusion: future studies focusing on the evaluation the association of cross-reactive molecules with allergy phenotype should be done. background: the fuzzy/green kiwifruit (actinidia deliciosa), widely grown commercially, contains various pulp allergenic molecules, including the major allergen cysteine protease actinidin. methods. this case report is about a -year-old male patient with house dust mite allergic persistent rhinitis and intermittent asthma, presenting a convincing history of anaphylaxis immediately after eating a kiwifruit on empty stomach, followed, a few months later, by a severe oral allergy syndrome after licking a slice of raw kiwi. previously, the patient ate kiwi without any problems and had no manifestations of pollen or latex allergy. skin prick testing was done with commercial allergen extracts, while prick-prick testing was performed with raw kiwifruit, avocado and banana. molecular approach consisted in assessment of serum specific ige to native extracts and molecular allergen components using patient-friendly allergen nanobead array multiplex test and singleplex capsule-enclosed activated cellulose solid phase fluorescence enzyme immunoassay. results. regarding kiwifruit allergy, the patient presented positive prick-prick tests with raw edible kiwifruit components: outer pericarp and inner pericarp (each mm wheal) and columella/core ( mm wheal) and negative with kiwifruit whole seeds, avocado and banana, and pollen extracts. serum specific ige to kiwifruit were detected ( . ku/l), but specific ige values were negative (≤ . fiu/ml) for actinidin act d , thaumatin act d , kiwellin act d , nsltp type act d , bet v -like major latex/ripening-related protein act c , act c chitinase_iv, act d cross-reactive profilins bet v (birch pollen profilin) and hev b (latex profilin), and also negative (< . ku/ l) for pr- ract d . moreover, specific ige to avocado were nor found (≤ , fiu/ml). although ige against seed proteins cupin/ s globulin act d and s albumin act d were not determined, this was not considered of great importance since allergic symptoms were also induced by licking kiwi pulp, in which abundantly expressed actinidin enzymatically degrades seed storage proteins, and prick-prick test was negative to kiwifruit seeds. conclusion: in a patient with anaphylaxis to kiwifruit, positive skin tests to its pulp and detectable serum specific ige to actinidia deliciosa, a detailed molecular allergy diagnosis is necessary, including assessment for act d glycoallergen or other molecules, not performed in this patient. | is pr- sensitization a portuguese phenomenon as well? background: bet v , a major allergen found in birch pollen, belongs to the pr- protein group. in our practice, some bet v sensitized patients have been identified, residing in areas without this tree genus in its flora. our aim was to characterize a portuguese patient population with pr sensitization. method: a group of patients in whom immunocap isac ® (isac) study was performed, between january and june , were analyzed. all subjects with one or more pr- sensitizations were selected, and their clinical records reviewed. a sequential sample of the last subjects (n = ) who underwent isac study, was then used for comparison. results: out of isac studies performed, only were positive for pr- protein group. median age was . years, % (n = ) were male. pr- sensitized individuals were more likely to live in portalegre district compared to the control group ( / vs / ; p < . ). patients were positive for pr- family pollens ( . %), frequently bet v (n = ), followed by aln g (n = ) and cor a (n = ). out of the patients were sensitized to pr- foods, mostly cor a . (n = ) and mal d (n = ). skin prick tests revealed birch as the main sensitizing pollen as well ( / ). moreover, only four patients were skin prick tested for fagaceae trees which were positive for oak ( ), chestnut tree ( ) and cork tree ( ) . all patients were co-sensitized to other pollens, namely grass and all had respiratory allergy. nine patients were food allergic, although seven of them were co-sensitized to other cross reactive (ltp/profilin) or species specific proteins. conclusion: although pr- sensitization is known to be rare in our population, mostly alto alentejo inhabitants showed sensitization to this protein family in our sample, either by in vitro and/or in vivo methods. this phenomenon is consistent with the native plant species of this region, which should be taken into account when studying the allergic profile of these patients. in our sample, all pr- sensitized patients had respiratory allergy while this protein didn't seem to be relevant when it comes to food allergy. further studies are needed to characterize which plant species belonging to this protein family are more significant for our country's aerobiology context and to determine its clinical relevance. included. allergic asthma, rhinitis, conjunctivitis and eczema allergic symptoms were diagnosed. all patients were tested by immunocap with mugwort pollen extract and the natural components nart v , nart ar , nart v , and nart an . results: the positive frequency and sige levels of the four components in the artemisia allergic patients from southwestern china were significantly lower than that from the north. art v and art an were the highest recognized allergens, followed by art v and art ar . patients from northern china were more likely to have abstracts | asthma ( %) than patients from southwestern china ( %), and being sensitized to more than two allergens increased the risk of asthma. sensitization to art v , art v and art an played a significant role in the development of asthma. artemisia pollen allergic patients is helpful to assess the potential risk of asthma. conclusion: a small but significant part of the population react to ragweed pollen extract and are not identified as disease-positive by standard sige tests. there is a need for targeted tests towards a larger spectrum of allergen molecules. in ragweed allergic individuals, this allergy can be the main cause of overall sige levels and also of in vivo reactions (tested by spt). | molecular profile of pollen sensitization of tashkent residents with respiratory allergy background: in paediatric cohorts, a correlation between specific ige (sige) levels to house dust mite extract or allergen components and the occurrence of asthma has been shown. higher levels of sige to mite extract were associated with a higher risk of wheezing. moreover, asthmatic children recognized more allergens and had higher sige levels to nder p as well as rder p , and . we sought to investigate potential differences in sige levels or sensitization patterns between asthmatic and non-asthmatic patients in a mixed paediatric and adult house dust mite allergic cohort. method: total ige and specific ige against house dust mite extracts (dermatophagoides pteronyssinus and farinae) and allergen components (rder p , , , and ) were determined in house dust mite allergic patients. patients had diagnosed asthma ("asthmatic", % females, mean age ± years, % younger than years), whereas had rhinitis (and conjunctivitis) without respiratory symptoms ("non-asthmatic", % females, mean age ± years, % younger than years). results: total ige levels were markedly higher in asthmatic compared to non-asthmatic patients ( vs. ku/l, p = . ). positivity to rder p ( vs. %, p = . ) as well as rder p ( vs. %, p = . ) differed between both groups. specific ige levels to house dust mite extracts and allergen components (rder p , , , and ) and positivity to rder p and did not differ between both groups. conclusion: in contrast to previously published data, sige levels to house dust mite extracts or allergen components were not statistically different between asthmatic and non-asthmatic patients in our mixed paediatric and adult house dust mite allergic cohort. only higher total ige levels and a higher reactivity to rder p and were found in asthmatic patients. however, larger studies are needed to confirm clinical relevance of these findings. results: prior treatments reported at baseline (bsl) included: . % of pts were receiving or more second-generation h -ah at approved dose (recommended first-line), . % were receiving them at increased dose (second-line); . % were receiving omalizumab (third-line); . % had no treatment. the majority of pts ( . %) had uncontrolled csu (uct< ) at bsl (table) . treatment changes were most evident at the bsl visit, with an increase in pts receiving omalizumab ( . %) and a decrease in those receiving no treatment ( . %) vs. prior therapy. these changes were associated with improvements in rates of hives and/or angioedema, uct and qol scores at month , but only modest improvements thereafter (table) . a sub-analysis of pts with uct< and who were receiving the approved ( . %) or increased dose h -ah ( . %), revealed that few pts had recommended escalation from the approved to increased dose h -ah ( . - . %) or from increased dose h -ah to omalizumab ( . - . %) (table) . conclusion: poor physician adherence to guidelines was evident throughout aware. initial improvements in disease activity and qol plateaued after month , possibly owing to fewer changes to recommended therapies. greater physician adherence to guidelines is needed for better symptom control in pts with uncontrolled csu. results: we revealed that in russians urticaria is associated with rs *arg/gln genotype of the il gene (p = . ) and rs *cc genotype of tlr (p = . ) gene polymorphism. in tatars the association with disease development was shown for rs *tt genotype of tlr gene snp (p = . ). the rs *c allele of tlr gene polymorphism is associated with acute and chronic forms of urticaria (p = . and p = . , respectively) and rs *c allele of il gene polymorphismwith acute urticaria (p = . ). method: csu patients from the urtica cohort (clinicalttrials.gov number: nct ) participated in the study. a questionnaire was carried out evaluating the triggers identified by the patients, the comorbidities and the treatments received. patients with a self-report of skin exacerbation by foods, nonsteroidal antiinflammatory drug (nsaid) or physical triggers were subjected to a controlled provocation test with the suspect food, medication or physical stimuli report by the patient. the levels of anti-tpo ige were measured during a period of clinical control and during two exacerbations in all patients. results: % of the patients had at less one inducible urticaria demonstrated by provocation tests ( % dermographism, % cold, % pressure). self-reported exacerbation for a food ( %) or medication ( %) were high, but positive provocation tests were low ( % and % respectively). patients had (+) anti-tpo ige during the baseline period. among them, % presented a significant elevation of anti-tpo ige during at less one of the two exacerbations. . % of patients (n = ) with (−) anti-tpo ige, presented elevation of anti-tpo ige one of the two exacerbations. conclusion: foods, drugs and physical triggers must be verified by challenge tests to avoid unnecessary lifestyle restrictions in patients with csu, nevertheless self-report is usually greater than positive provocation tests. increase concentrations of anti-tpo ige seems to be implicated in urticaria exacerbations in some patients with csu. brzoza z ; adamczyk k ; wcislo-dziadecka d ; zbiciak-nylec m ; brzezinska-wcislo l adipokines. the aim of the study was to evaluate the possible contribution of leptin to chronic spontaneous urticaria pathophysiology. the study included chronic spontaneous urticaria patients and healthy subjects. the leptin level in both examined groups was measured. results: no statistically significant difference in leptin level was determined between the studied subgroups. we are among the first to present the effects of exploration aimed at assessment of the possible role of adipokines in chronic spontaneous urticaria pathogenesis. in this study we did not prove any difference in leptin level. in our opinion it is valuable to perform further studies in this area. the microorganisms were inactivated with phenol, and the concentration was adjusted to microbial cells/ml (labeled as a / ). dilutions / and / were made from the product labeled / . the dot blot technique was used to detect the presence of specific ige to the different microbial antigens and controls (anti ige / and fold dilution ½ and ¼). the dot blot images were processed with a documentation system (gel doc ez, bio-rad), and the different microbial antigens in different dilutions were compared with the positive anti-ige controls. results: all patients have specific anti ige to microbial antigens (see table below). the presence of microorganism-specific ige could explain, the relationship between the infections and / or microorganisms in ciu, as well, the urticaria control by omalizumab, even when it has not been detected ige sensitizations to common allergens. finally, these findings, showed that the bacterial allergy could be one line of research to understand the unresolved etiology of urticaria. background: dermographism is the most common form of inducible urticaria. it shows itself as hives made by scratching or rubbing on the surface where it has been produced and with the same morphology. the pathogenesis has not been clarified nor has it been associated until now with the sensitization to allergens. we have studied the relationship between the presence of dermographism and domestic mites sensitization. we have selected patients older than years old. all of them had symptoms compatible with dermographism at the moment of medical evaluation. at least one third of patients additionally showed rhinitis and/or asthma symptoms. we performed:: -skin prick tests with our basic neumoalergens (mites d. pteronyssinus y lepidoglyphus destructor, pollen, molds, dog, cat and horse dander, latex and anisakis simplex). -determination of specific ige levels for dermatophagoides pteronyssinus, lepidoglyphus destructor, and anisakis were measured in serum by using the immunocap (thermo fisher scientific). -blood count, serum immunoglobulins, antithyroid antibodies, serine tryptase and proteinogram. results: blood count, serum immunoglobulins, antithyroid antibodies, serine tryptase and proteinogram were normal. we divided patient in different groups. background: urticaria results from the appearance of pruritic papules and/or erythematous plaques caused by substances from mastocytes present in the skin, notably histamine. chronic urticaria is defined as flare-ups that occur at least two or three days per week over a six-week period. in addition, affected subjects are often prone to an atopic or auto-immune profile that promotes urticaria [ ] . the association of polyphenols (ambora, green tea) and the soothing active ingredients slow down the itching biological process from the outset by reducing the release of pruritic mediators (e.g. histamine, cytokines, etc.) of immune cells such as mastocytes and lymphocytes, involved in urticaria. in this context, the purpose of the study was to evaluate the efficacy and the tolerance of an anti-pruritic spray containing the polyphenols and the soothing ingredient. the tested product aims to quickly calm the itching in subjects with chronic urticaria. results: on average, the product was applied . times per day with a significant decrease of d-pruritus scale (- %) and sensations of itching (- %) between d and d . in terms of quality of life, a significant decrease of the skindex score was observed (- %). the product soothed the pruritus within seconds for all subjects and the anti-pruritic effect lasts at least hours for % of subjects. the product also showed very good cosmetic properties and was well tolerated; no intolerance case was reported. showed near complete remission. in the week before omalizumab and for a few days after, her urticaria flared but on of weeks she was largely asymptomatic (uas - ). after years of successful treatment she reported an increase in csu activity. no trigger factors could be identified. add-on treatment with cyclosporine was refused, montelukast showed no, and prednisolone only transient benefit. over a period of months wheals occurred almost daily and a maximal score of was achieved on uas . we replaced omalizumab with cyclosporine but this was subsequently discontinued due to side effects. months later the patients' csu remained poorly controlled with up to wheals occurring almost daily despite rupatadine mg/d. due to the good initial response to omalizumab and lack of good treatment alternatives, a trial of re-treatment was considered. results: within week of re-commencing omalizumab she once again achieved near complete remission of csu with uas ≤ on of weeks. the mechanism of action of omalizumab and the development of resistance to it in csu, are incompletely understood. our case shows that some csu patients developing resistance to omalizumab may benefit from a subsequent trial of re-treatment, particularly if treatment alternatives are poorly tolerated. manipulate and store data by electronic means. this includes e-mail, sms text messaging, video chat and online social media as well as all the different computing devices that perform a wide range of communication and information functions. a rapid increase in the use icts in recent decades is an enormous contributing factor in the development of a number of novel clinical and public health intervention strategies. the aim of the present study is to assess the level of ict use and to examine patterns of preferences among patients with chronic urticaria (cu). method: we will conduct an anonymous multicentre cross-sectional study, starting from january , to investigate the use of icts in patients with cu, using a questionnaire as a survey method. this questionnaire will assess the frequency of use of social media and icts in patients, and their preferences for receiving and asking disease-related information. the survey will consist of items, evaluating demographical information, time with disease, medication currently used, and additional aspects of social network use. results: we will use a chi-squared test to assess the association between internet access or owning a cell or smartphone, and age, gender, type of urticaria, educational level and number of years since diagnosis. we will employ the same test to assess the association between the independent variables previously introduced and the frequency of use of each ict type (short messaging service [sms], facebook, twitter, youtube, email, internet, linkedin and skype) as well as agreement in receiving and seeking information (i.e. asking questions to the practitioner) through such icts. we will perform adjusted regression analyses between categories of age, gender, educational level, type of urticaria, years since diagnosis and the use and level of interest shown in communicating through icts. our aim is to report on remarkable findings from a registry of a large sample of patients, potentially providing clues for its approach and results: patients with a median length of months suffering from urticaria were registered, being % women; mean age . years. in % of patients no causal agent was identified. parasites were found in . % and thyroid peroxidase antibodies in . %, while autologous serum skin test was positive in % and igg to mycoplasma in % of evaluations. two thirds of patients reported wheals on uas , with just / having concomitant angioedema. almost / reported significant affection on quality of life because of itch by cu-q ol. just % of patients achieved total control on first anti-histamines provided, and less than half had good control of urticaria. cetirizine was the first choice in %, followed by fexofenadine ( %) and first generation anti-histamines ( %). method: cases at - years of age which were being followedup in our clinic with diagnosis of chronic urticaria and were not receiving any antihistaminic medication for last one month were included in the study. cu-q ol, uas- , psqi and psg results of the patients were evaluated. correlation of data with each other in regard to sleep disturbances was evaluated. results: patients were included in the study. patients' mean total score in cu-q ol was . ± . . patients' mean uas- value was . ± . . mean total psqi was . ± . , the ratio of total scores ≥ and those with poor quality of sleep was . %. mean epworth sleepiness scale (ess) score was . ± . , with total score ≥ in . %. in psg, mean apnea-hypopnea index (ahi) was . ± . , with . % of the patients having ahi ≥ . when patients having ahi< were compared with patients having ahi ≥ , no significant difference was determined in regard to total cu-q ol score, mean score for questions concerning status of sleep, uas- and psqi. when correlation analysis was performed between cu-q ol and total score for questions concerning status of sleep, a positive correlation was determined with psqi (p = . ). conclusion: it was demonstrated in our study that patients with chronic urticaria had poor quality of sleep and this disturbance was independent from ahi. omalizumab was discontinued due to absence of improvement in csu symptoms after three consecutive doses. the plasmapheresis without intravenous immunoglobulin replacement was initiated. results: the symptoms were relieved during the first procedure and the disease improved shortly thereafter. the following weeks the symptoms still occurred but with lower intensity and severity. (angioedema was gone). the second attempt with omalizumab was successful after this course ( procedures of plasmapheresis). case report: rosacea is a chronic skin disorder associated with flushing, erythema, dryness, burning and stinging, and inflammatory papules and pustules. new treatments available or in development target the inflammatory and erythematous components of the disease. these agents include the selective alpha- receptor agonist brimonidine. allergic contact dermatitis to brimonidine is an unusual condition. in addition to this, urticarias due to brimonidine are rarely reported. we report on a -year-old woman who, immediately after apply a thin layer of brimonidine gel as preparation for a rosacea treatment on her face developed facial urticaria, which reverted in approximately four hours with systemic steroids. she had previously tolerated this product without any problems, but has not use it again ever since. skin prick-tests with brimonidine ( . mg/ml) and latex were realized in the patient. skin prick-tests with brimonidine were realized in eleven healthy control subjects. results: skin prick-tests with latex was negative in the patient. skin prick-tests with brimonidine were positive in the patient ( x mm). the prick-test with brimonidine was negative in teen healthy control subjects. we report on a case of immediate urticaria due to brimonidine and triggered by an immediate, probably ige-mediated, hypersensitivity mechanism. we highlight this case because it is the only case described in the literature with a positive prick-test. method: the study was in accordance with the helsinki declaration and was previously approved by the national comity of ethics. this was a one dose study conducted on fasting young healthy volunteers, of which were females and five males. the mean age was ± years old and the body weight . + . background: cetirizine is a potent h -receptor antagonist indicated in the treatment of allergic rhinitis and urticaria. cetirizine is widely used due to its potent antihistaminic effects in yielding strong and fast relief of itchy sensation, sneezy and rhinorrhea and its unlikely probability to manifest anticholinergic side effects in therapeutic doses. histamine flare and wheal inhibition by anti-h are widely used as a standard to test and compare the effect intensity and duration. our study aimed to test these effects of cetirizine in young healthy adults. method: this was a double-blind, single dose study in healthy young adults, previously approved by the national comity of ethics. eleven females and five males with a mean age ± years participated in this study. histamine skin pricks were tested before and after they received a tablet of mg cetirizine as previously scheduled. twenty minutes after each test flare and wheal were drawn in a transparent paper which was then scanned and measured with a software. wilcoxon signed ranks test two-sided with significance at % level was used to analyze the differences. claims that the preparation relieves itch within seconds of its application. we performed a simple study to verify this claim. we used irp in consecutive subjects, males, median age , range - years, whose workup implied ast. their preliminary diagnoses were "asthma" ( subjects), "allergic rhinitis" ( subjects), "atopic dermatitis" ( subjects) and "food allergy" ( subjects). all of them had refrained from systemic antihistamines for at least one week. standard skin prick tests (spt) were applied as appropriate, including histamine controls to assess the level of their skin sensitivity. subjects were asked to mark their sense of itch in the area of the skin to be tested on mm visual-analogue scales (vas) starting from " "-"no itch" to " "-"unbearable itch". vas assessments were repeated minutes after ast was done; then irp was applied according to the manufacturer's instructions, and the vas assessments were repeated after seconds and minutes. results: there vas assessments are shown in table format: table irp did not affect the wheal and flare of the histamine control, nor did it abolish positive spt. no differences were outlined between subjects with different diagnoses. the commercially available itch relieving preparation not containing defined pharmacological antihistamine is effecting in relieving itch associated with allergen skin testing. before ast ( ) . ± . vs ( ) p < . represent the first-line treatment for osteoporosis-related mastocytosis. we report a case of sm with bone pain and with an area of osteolysis in the femur as first sign and symptom. we had to consider the risk of adverse reaction when we decided to treat the patient with bp, but the patient was under antihistaminic treatment and also we made a premedication to reduce the risk. the pk/pd model available was informed by data from clinical trials. the pd endpoint data was available from two studies and used to characterize the effect of bilastine on wheal and flare. moreover, food effect had been characterized in pk studies and the data was used to model the effect of food in the pk of bilastine. the pk parameters relative to the fed state were then used to simulate the temporal evolution of the wheal effect using the pk/ pd model. all analyses were conducted by nonlinear mixed effect modeling (nonmem v . ). using the pk model developed (food effect model) and the pk/pd model already available, monte-carlo simulations for plasma concentrations and pd over time were performed for both the fed and the fasting states. results: . a reduced bioavailability (f) and a slow absorption constant characterized the pk of bilastine when administered concomitantly with food (f = % relative to the fasting state and ka = . hour − , a -fold reduction compared to fasting conditions). the rest of the pk parameters remained unchanged. onset of action was hour for bilastine both in fed and fasted conditions. maximum wheal inhibition occurred at . hours (fasted % and fed %). from to hours, the percentage reduction with bilastine for both fasted and fed was between % and % after the third day of treatment. a % inhibition in wheal effect was maintained during hours for both conditions after the third day. the results of the simulations show that even if the pk is altered with food, the pd is maintained unchanged. conclusion: even if a significant food effect was described for bilastine at a pk level, the difference is not translated directly into the pd. therefore, the antihistaminic effect of bilastine remains unaffected by the concomitant administration with food. the results of these simulations will be further confirmed in a dedicated clinical trial. results: we also found no correlation between the different tgt parameters and other clinical and analytical parameters associated with uc (table ) results: both cetirizine products have no differences in respect to the pharmacodynamic and pharmacokinetic parameters analyzed. the % confidence interval of the mean ratios of the auc - , auc -inf , cmax, auce - , and e max , between the test and the reference, were within the bioequivalence ranges ( %- %) in both cases. no statistical difference was revealed when comparing the respective t max and te max too. the two cetirizine products tested were bioequivalent. the bioequivalence was evident even when tested with the pharmacodynamic parameters. there is strong evidence that supports the use of histamine skin prick test for the bioequivalence evaluation of different cetirizine products. | bradykinin-mediated angioedema associated with combination of angiotensinconverting enzyme and dipeptidyl peptidase iv inhibitors: a disproportionality analysis from the who database method: we performed a disproportionality analysis using data from the who pharmacovigilance database by a case-noncase study, until the / / . we extracted all individual cases safety reports (icsrs) included in the high level term "angioedemas", according to the medical dictionary for regulatory activities classification. given the absence of term "bma", we selected only the icsrs of angioedema without associated symptoms evoking another underlying mechanism, such as histamine angioedema (e.g. pruritus, urticaria, rash, etc.). drug class exposure was "acei" and "dpp i", considered suspect or concomitant, using the atc classification. we results: there was no correlation between mother's disorders such as periodontitis, rhinitis, diabetes etc. and the onset of ar (p > . ). a multivariate analysis showed, neonatal jaundice (p < . ), respiratory system infection (p < . ), diarrhea (p < . ), eczema (p < . ) in the first months of life and home environmental factors (house decoration (p < . ), mold environment (p < . ), keeping flowers (p < . ), passive smoking (p < . )) increased the risk of ar. besides, there was no significant difference in current height and birth weight of the participants between ar and control group. however, ar group had significantly lower current weight (p = . ) and age (p < . ) compared with the control group. paternal age and maternal age in the ar group were significantly higher than the control group (p < . ). conclusion: diseases in the first months of life and home environmental factors increased the risk of sequential ar. the older parents increased the possibility of ar in the offspring. the data of general characteristics of participants were statistic analysis by z text analysis. *significance at p < . . results: anosmia was more frequent in crs than in rhinitis ( . % vs . %, p < . ) and in crswnp than in crssnp ( . % vs . %, p < . ). lms was higher in crs than in rhinitis ( [ - ] vs [ - ], p < . ) and in crswnp than in crssnp ( [ - ] vs [ ] [ ] [ ] [ ] [ ] [ ] [ ] , p < . ). in addition, lms was associated with loss of smell in patients with hyposmia (or = . [ . , . clinics. patients were submitted to confirmatory exams including oral provocation test with aspirin. nasal polyps were removed by functional endoscopic sinus surgery and eosinophils in this tissue were quantitated. eosinophil counts in peripheral blood was obtained. serum periostin was measured by elisa and total ige was determined using immunocap. as control groups, ( f/ m) patients with par and healthy subjects ( f/ m) were selected. samples of nasal tissue and blood were collected from these subjects during elective surgery for correction of anatomical variations, and compared with the patients with aerd. results: ar symptoms were significantly improved in the treatment group compared with the control group ( . % ( / ) vs . % ( / ); p < . ). furthermore, the mean total vas score for patients in the treatment group was reduced from . ± . before treatment to . ± . after treatment (p < . ). moreover, the reduction in free ige levels was greater in the treatment group than in the control group. the results of this study suggest that the chinese herbal medicine ber may be effective for improving the symptoms of ar. a multicenter clinical trial is needed to confirm this finding. results: in patients with "eosinophilic" polypoid rhinosinusitis, mucociliary transport was . ± . minutes, ph . ± . , suction- . ± . minutes, excretory- . ± . mlg and in patients with "neutrophilic" polypous rhinosinusitis, mucociliary transport was . ± . minutes, ph . ± . , suction- . ± . minutes, excretory- . ± . ml. the study showed that disruption of the transport function, changing the concentration of hydrogen ions method: this prospective controlled study was carried out on crs patients underwent ess. patients participating in the study were divided into two groups-group : partial middle turbinectomy (n = ) and group : partial middle turbinectomy and middle turbinate fenestration (n = ). objective assessment of olfactory function using the university of pennsylvania smell identification test (upsit) and subjective assessment of symptom using visual analogue score (vas) were performed before and months after surgery. results: there were significant improvement comparing postoperative and preoperative upsit in both group ( . ± . vs . ± . , p = . ) and group ( . ± . vs . ± . , p = . ). the vas were also significantly improved postoperatively compared to preoperatively in both group ( . ± . vs . ± . , p = . ) and group ( . ± . vs . ± . , p = . ). patients undergoing partial middle turbinectomy and middle turbinate fenestration were more likely to show improvements in upsit ( . ± . vs . ± . , p = . ) and vas ( . ± . vs . ± . , p = . ) compared to those with only partial middle turbinectomy. conclusion: partial middle turbinectomy and middle turbinate fenestration during ess is an effective method for improving postoperative olfactory function. | nasal irrigation for the alleviation of nasal symptoms in pregnant women with allergic rhinitis we sought to determine specific ige responses to bacterial pathogens in sera from cystic fibrosis patients and analyze their kinetic during disease course. genes, respectively. in contrast, most of healthy donors had normal homozygous genotype with tt- . ± . %(n = ) and cc- . ± . %(n = ) with low frequency of mutations; gg- . ± . %(n = ) and tt- . ± . %(n = ) and heterozygous genotype tg- . ± . %(n = ) and ct- . ± . %(n = ) for il- and il- genes, respectively. following a month treatment, there was a significant reduction of cytokine levels in the il - . ± . and increased in the il - . ± . , when compared to the beginning of therapy and after months (p < . ) results: at baseline the st group had serum levels of il- ( . ± . ) pg/l; il- ( . ± . ) pg/l and ifn-γ ( . ± . ) pg/ l; nd group had il- ( . ± . ) pg/l; il- ( . ± . ) pg/l and ifn-γ ( . ± . ) pg/l vs il- ( . ± . ) pg/l; il- ( . ± . ) pg/l; ifn-γ ( . ± . ) pg/l in the control group. after months, there was a significant decrease in pro-inflammatory cytokine levels in the st (il- : ± . ; ifn-γ: . ± . ) pg/l and nd group (il- : . ± . ; ifn-γ: . ± ) pg/l, respectively. conversely, il- increased in st and nd groups to . ± . pg/l and . ± . pg/l (p < . ). conclusion: prior to the study initiation patients with tuberculosis had higher il- , ifn-γ and lower il- content than healthy controls. two-month chemotherapy produced significant reduction in proinflammatory cytokines and increase in anti-inflammatory il- , with levels approaching those of healthy controls. thus, tuberculosis drugs appear to have the anti-inflammatory effect in tuberculosis patients, which was predictive of positive clinical outcome. | antibiotic resistance: ligands of innate immunity take the challenge in this work, we aimed to perform an ex vivo hrsv infection in precision-cut lung slices (pcls) from human, rhesus, and cynomolgus macaques, comparing whenever possible the response with the viral surrogate poly i:c. method: pcls containing airways were prepared from lung sections of human, rhesus, and cynomolgus macaques. the slices were inoculated with hrsv-a iu/ml, uv-inactivated hrsv, or vehicle control for hours. macaque slices were also incubated with poly i:c μg/ml with and without the immunosuppressive dexamethasone μg/ml. viral replication, tissue viability, and immune response assays were assessed in supernatants, lysates, or slices. the inoculum infectivity of iu/ml as well the uv-inactivation were confirmed by plaque-assay on hep- cells. immunofluorescence staining using a fitc-labeled anti-rsv showed the presence of infected macrophages in pcls, but not in mock infected samples. hrsv stimulation slightly decreased tissue viability, as seen by live/dead staining and ldh assay. the viral infection increased ip- production in pcls of human, rhesus, and cynomolgus macaques, reaching respectively . , . , and . fold-increase in comparison to the vehicle controls. poly i:c stimulation caused ip- response comparable to hrsv in rhesus and cynomolgus pcls. the ip- production ratio comparing hrsv/poly i:c was . in rhesus and . in cynomolgus pcls. conclusion: hrsv infects ex vivo pcls of human and non-human primates, inducing the release of the pro-inflammatory chemokine ip- . this response is comparable to the viral surrogate poly i:c. in the future, these systems can be used to further investigate host response to hrsv, especially in the context of asthma development. however, a relatively small number of reports are related to the association of ebv with allergic diseases, in particular atopic ones. we found that among patients with activated ebv infection, polysensitization was found to be . times more frequent, chest syndrome was . times more common and hyper-ige syndrome occurred . times more frequently. in most of these patients, atopy was not detected in medical history. method: we evaluated the laboratory test results of five boys ( . %) and six girls ( . %), children ( with hbov and with cov). their average age at the study time was . ± months. nasal swab specimens were taken from these patients who admitted to our hospital with respiratory symptoms between - . patients are recalled after an average of ± . months. isaac questionnaire and skin prick test to common inhalated allergens were performed. results: only one patient had family history of atopy. forty percent of the patients with cov and % of the patients with hbov developed rhinitis. one patient with cov and one patient with hbov developed recurrent wheezing. one patient with cov developed atopic dermatitis. all skin prick tests were negative. it was noteworthy that . % of the patients were passive smokers. conclusion: hbov and cov may be associated with rhinitis but there is a need for more patient groups for a clear result. rna_lig (ccg-agg-aug-cga-ggc-uug-uu) . to study chemotaxis in vitro, a boyden chamber was used -wellfiltrationplatemultiscreentm -mic with a pore size of μm (millipore, usa). chemotaxis was studied in dynamics after , minutes and a day using the above ligands. as control, rpmi- medium without glutamine was used (paneco, russia). the statistical analysis was carried out using the computer statistical program biostat conclusion: with all the data provided, a drug induced hypersensitivity was diagnosed. we present a case of immediate allergic reaction with eosinophilia due to carbapenems, with tolerance to other beta-lactams antibiotics. written informed consent of patient has been obtained in the two cases. discussion: the first case shows cutaneous immediate hypersensitivity response to infbeta a. literature reports a few cases of urticaria and anaphylaxis but this is the first for the pegylated formulation. polyethylene glycol (peg) confers to a drug modified pharmacokinetics, solubility and immunogenicity. immediate reaction to peg (macrogol) have been described when combinated in vaccines or drug pils. dmf is a known cause of contact dermatitis related to footwear, wallets and furniture. flushig is a reported side effect of dms in ms managed with dose reduction. this case shows the possibility to immediate sensitization to dmf. as the armamentarium to treat ms now combines immunomodulatory and biologic drugs, the avaliability of diagnostic and desensitization protocols for hypersensitivity reactions must be keeped in mind. case report: drug rash with eosinophilia and systemic symptoms (dress) syndrome is an uncommon but serious hypersensitivity drug reaction, manifested with rash, fever, lymphadenopathy and visceral organ involvement. table) . drug withdrawal and prednisolone treatment leaded to attenuating of mentioned skin symptoms within days, associated by occurrence of a exfoliative dermatitis. one week after admission, the patient developed fever that lasted for days with enlarged lymph nodes on submandibular, paracervical, axillar and inguinal regions. a preventive antibiotic therapy is started and weeks later, the lymph nodes were not palpable and the skin got the normal appearance. corticoid therapy is reduced gradually according to symptoms resolvement. case : a -year old woman presented to our department with a -day history of pruritic, macular rash, periorbital swelling, cheilitis and fever. she had started some weeks ago the allopurinol for asymptomatic hyperuricemia, had longer history for treatment of arterial hypertension and type- diabetes mellitus (olmersartan, nitrendipine, methyldopa, furosemide, regular and glargine insulin), and experienced nephrectomy and cholecystectomy. the patient was febrile, while blood tests revealed eosinophilia, increased seric creatinine/urea levels (due to nefrectomy), and severely-altered liver parameters (see table) . the allopurinol withdrawal, topical and systemic corticoid therapy, and the liver protectors attenuated serologic transaminases levels and patient's skin lesions within few days, followed by substantial improvement of laboratory findings one week after therapy start. the treatment dosage was gradually tapered and finally stopped within a period of months in accordance with attenuating and complete resolvement of the clinical and laboratory abnormalities. our case demonstrated that dress syndrome is a severe drug reaction, but the immediate introduction of treatment and supportive measures can improve disease's outcome even after a temporary exacerbation or severe affection of internal organs. case report: a -years-old woman, diagnosed of ischemic cardiopathy, developed an anaphylactic shock minutes after the administration of ml sulphur hexafluoride intravenous during an echocardiogram. she was treated in emergency room with a total recovery. months earlier, she had developed an extensive erythematous-maculopapular rash converging in plaques in relation with adhesive dressings which had been placed during a hospitalization due to thoracic pain. an allergic contact dermatitis was suspected and recommendations thereon were given. interestingly, an arteriogram with iodixanol (icm) was carried out one week before skin reaction with good immediate tolerance. methods: blood test: blood count and serum chemistry were done during both reactions to contrast media. serum tryptase level was not measured during the anaphylaxis, but its baseline level was quantified later. conclusions: we present a patient with a double sensitization to parenteral contrast media: an anaphylactic shock due to sulphur hexafluoride and an atypical delayed exanthema related to iodixanol, and diagnose was obtained with st in both cases. this is the first documented case with a positive immediate st to sulphur hexafluoride. with the culprit drugs mixed with % and % petrolatum resulted negative. patient was suspected to have behcet's disease, and consulted to rheumatology department. oral colchicum dispert twice a day was prescribed. afterwards, patient achieved to take oral amoxicillin-clavulanate for a week without any hypersensitivity; and has been following by oral colchicum dispert maintenance therapy since then. the reported patient had one anaphylactic perioperative reaction to morphine and another anaphylactic reaction to tramadol during her diagnostic investigation. remain the question if this patient had two allergic anaphylactic reactions with cross-reaction between morphine and tramadol, or two non-allergic anaphylaxis due to "hypersensitive" mast cells. case presentation: a -year-old female was diagnosed with rectal adenocarcinoma. one year after radical surgery, progression with pulmonary metastasis was shown. in first line of systemic therapy she received premedication with pantoprazole, metoclopramide, clemastine and dexamethasone, followed by cetuximab infusion. during first minutes of infusion, grade anaphylactic reaction occurred. a reaction started with generalized pruritus, urticaria, rhinitis, followed by hypotension, bradycardia and loss of consciousness. she was treated with fluids, clemastine and methylprednisolone. next day she received same premedication followed by panitumumab. during first minutes she had grade reaction with generalized urticaria. the third day she had generalized urticaria minutes after metoclopramide application. skin prick tests with cetuximab ( mg/ml) were negative, but intradermal test were posi- bat response was highly positive for both cetuximab and alpha-gal, with comparable values and dose response curves. thus, we showed %, %, %, % and % of cd positive basophils for stimulation with cetuximab ( - . μg/ml), and %, %, %, and % for stimulation with alpha-gal ( . - . ng/ml). bat response to panitumumab was negative (< %; - . μg/ml). drug provocation with panitumumab was negative and patient received treatment with panitumumab. in the operating theatre, the skin is disinfected using povidoneiodine and pupil dilation is carried out with tropicamide (showing no immediate reaction in the surgery). method: as we are dealing with a late cutaneous reaction, the study of the medicine involved is carried out by means of epicutaneous medicine testing. in order to do the study of aflibercept, we wore gowns, two sets of gloves, a mask, eye protection and in a containment hood in the outpatients hospital. the patient diagnosed himself with dermatitis when in contact with povidone-iodine and despite the fact that the cutaneous provocation was negative, it is known that when there is surgery involved, there needs to be moistness and occlusion for it to show up clinically. the application of this antiseptic seems to lose its irritation and allergic properties when it dries on the skin and therefore tends to give a negative result in these patients, but this does not mean that they are not allergic to this antiseptic. we report the case of a year old man who experienced erythema and pruritus immediately after an intravenous injection of ranitidine and hyoscine butylbromide given for gastric pain treatment. results: spt and idt were performed for ranitidine ( mg/ml and . mg/ml respectively) and hyoscine butylbromide ( . mg/ml and . mg/ml respectively) being exclusively positive for ranitidine at idt dose with a × mm papule (histamine control × mm). oral provocation test for hyoscine butylbromide was negative. bat for ranitidine and famotidine were carried out, being negative for both drugs. conclusion: skin tests for h ra are the best option when studying a suspected reaction to h ra and are also useful for assessing cross-reactivity between other h ra. the sensitivity for bat in diagnosis of drug allergy is about %, and the specificity up to %, although these percentages make reference to the common drugs studied (beta-lactams, quinolones, pyrazolones, etc). specific studies for h ra are still to be done. in our case we had a negative result for the bat test, although we proved ranitidine was responsible for the reaction. conclusion: gentamicin is an aminoglycoside antibiotic used systemically for septicemia and as prophylaxis during surgery. immediate type allergy (type i) to gentamicin is rarely reported. since , approximately only five cases have been reported in literature. in our case, initial theories were pointed towards cefazolin as beta-lactams report a higher rate of allergic reactions. after an exhaustive allergological study, results disproved our initial theory indicating gentamicin as the responsible drug. giangrande n ; bobadilla-gonzález p ; garcía-menaya jm ; cámara-hijón c allergy department, infanta cristina university hospital, badajoz, spain; clinical immunology department, san pedro de alcántara hospital, cáceres, spain background: polyethylene glycol (otherwise known as macrogol or peg) is a polymer with a wide application as an excipient, solvent and dispersing agent in food, cosmetic and pharmaceutical industry. it presents distinct length polymer chains with a molecular weight from to g/mol conferring them specific properties. macroglol with a molecular mass between and g/mol is commonly used as osmotic laxative previously to colon endoscopy and radiologic examinations. after the introduction, anaphylactic reactions to macroglol are rarely reported, considering it safe and well tolerated. we report on a -year-old man who, immediately after of the topical application of benzindamine in left inferior limb developed acute urticaria in this limb, which reverted in approximately hours with systemic steroids. she had previously tolerated this product without any problems. skin prick-tests with benzindamine ( . mg/ml) and latex were realized in the patient. skin prick-tests with benzindamine were realized in eleven healthy control subjects. results: skin prick-test with latex was negative in the patient. skin prick-test with benzindamine was positive in the patient ( × mm). the prick-tests with benzindamine were negative in eleven healthy control subjects. we report on a case of contact urticaria due to benzindamine and triggered by an immediate, probably ige-mediated, hypersensitivity mechanism. some of the drug used in daily clinical practice can cause allergic contact urticaria and should therefore be borne in mind. background: the use of new oral anticoagulants which act as direct inhibitors of activated factor x is constantly increasing, due to lower rates of serious and fatal bleeding events than warfarin/acenocoumarol. rivaroxaban, the first commercialized drug in this group, is the most used for prevention of thromboembolic events. however, < cases of hypersensitivity reactions have been described so far, most of them delayed and severe. to present a case of delayed hypersensitivity to rivaroxaban, diagnosed by a positive ltt (lymphoblastic transformation test). a year old woman with hypertension and chronic atrial fibrillation (af) was referred to our clinic for suspected drug allergy. she reported that months before, for af she was started on oral amiodarone and rivaroxaban, presenting on the seventh day with both of them generalized erythema, pruritus, micropapular rash and facial angioedema. no oral or other mucosal were observed, neither pustules, vesicles or blisters. blood eosinophilia, enlarged lymph nodes, renal and hepatic injury were discarded in emergency, where the new drugs were discontinued and replaced by acenocoumarol. the rash subsided one week later, with oral antihistamines. before and after the episode the patient also has been taking losartan and hydrosalurethyl, with good tolerance. she denied other adverse reactions. in allergy department we performed skin prick tests and intradermal tests with amiodarone ( . mg/ml and . mg/ml) and rivaroxaban ( . mg/ml and mg/ml), and a ltt with both drugs, months after the reaction. background: patients with history of beta lactam allergy, often self-reported, are commonly encountered in the hospital setting. this frequently leads to increase use of broad spectrum and more expensive antibiotics that may be unnecessary or even less efficacious at times due to fear and concerns about potential disastrous outcomes. nonetheless, with increasing awareness, many patients are now being referred to allergy service for formal evaluation. we aim to look at patients who underwent evaluation for beta-lactam hypersensitivity and determine the number of patients that were successfully de-labelled. method: a retrospective analysis was conducted with patients referred for evaluation of questionable beta-lactam allergy to the allergy service in our institution from the years - . initial evaluation process included a thorough history to determine the type of hypersensitivity reaction and suitability for further testing. patients underwent skin prick test (spt) and intradermal (idt) with either (a) both major and minor determinants of penicillin, benzyl penicillin, amoxicillin and ampicillin, and/or (b) the culprit drug itself. if skin testing was negative, oral or intravenous (iv) drug challenge was then performed after informed consent. clinical details and reactions were documented. patients were also contacted post challenge to ensure no delayed reaction had occurred. results: a total of patients were evaluated for beta-lactam allergy in the year period, of these were females and were males. of the referred patients had presumed penicillin group allergy and had cephalosporin group allergy ( patients had both penicillin group+cephalosporin allergy). cases ( %) were successfully de-labelled. beta-lactam allergy was confirmed in patients ( %); identified by positive spt in two patients, positive idt in six patients and positive drug challenge in patients ( patients developed rash/urticaria, had respiratory symptom and patients developed anaphylaxis). patients were referred before any drug allergy labelling was done, out of which were confirmed not to have beta-lactam allergy. conclusion: in our study, % of patients were confirmed not to have true beta-lactam allergy. we were able to successfully remove beta-lactam allergy label from the electronic record for % of the patients. results: a total of % referred amoxicillin-clavulanic acid (ax-clv) as trigger for the hypersensitivity reactions (hrs), followed by ax ( %), penicillin ( %) and cephalosporins ( %). almost % of hrs were immediate (< minutes). positivity of skin tests was observed in % subjects, of bat in % and of rast in %. in conclusion: the label of penicillin allergy is quite often erroneous. this involves using of more expensive and less effective therapeutic alternatives, which also facilitate the emergence of multi-resistant micro-organisms. hence the importance of confirming the diagnosis of allergy. finally, we did not find differences in the study of penicillin allergy in patients older than years compared with the general population. background: severe cutaneous delayed drug reactions (toxic epidermal necrolysis -ten-, stevens-johnson syndrome -sjs-, acute generalized exanthematous pustulosis -agepand drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome -dress/dihs-) among others, are a rare but potentially fatal complications of drug treatment. although its epidemiology has been described in different latitudes, it is unknown in latin america. our aim was to describe the epidemiological characteristics of severe cutaneous reactions to drugs in countries of latin america. method: an online questionnaire was designed to report new and old cases (since ). it was a modified and adapted version of enda questionnaire for drug allergy interesting group. sociodemographic data, type of reaction (ten, sjs, dress-dihs, agep), culprit drug (s), treatment, complications, mortality and sequelae, were described. three centers from colombia, one from argentina, one from brazil and one from paraguay were included. an excel database was created, in which cases were recorded and analyzed. results: thirty seven cases were reported. ( %) were women. the median age was years. ( %) had dress/dihs, ( %) ten, ( %) sjs, ( %) agep, ( %) other not classified scars, and ( . %) overlapping ten/sjs. the main culprit drugs were aromatic anticonvulsants in cases ( %), beta lactam antibiotics in ( %), non-beta lactam antibiotics in ( %) and allopurinol in ( . %). in % of the patients the suspect drug was withdrawn. thirty one patients ( . %) received systemic corticosteroids. complications occurred in cases ( %) and death in one patient ( . %). seven patients ( %) had some type of sequelae. countries, dress/dihs was the most frequently reported clinical entity, and the anticonvulsants were the main triggers. complications were frequent, but mortality was low. | drug-induced cough: analysis of nationwide spontaneous reports in korea over ten years using who-adverse reaction terminology (who-art) indicative of cough. results: from cases of spontaneously reported adverse drug event cases, a total of cases ( . %) were identified as drug-induced cough. most cases occurred in adults ( . % of the subjects) and females were more common than males ( . % vs . %). regarding severity, only cases ( . %) were classified as serious based on who criteria. the most common causative drug category was antineoplastic and immunomodulating agents ( . %), followed by cardiovascular drugs ( . %). the most common causative drugs were ace inhibitors including perindopril and ramipril. conclusion: in the nationwide spontaneous reports of adverse drug events, many cases of drug-induced cough have been reported so far. much attention is needed to find new causative drugs of cough in the future. background: allergological assessment to determine the mechanism of the perioperative reaction and to identify the agent responsible and recommendation of a range of drugs or agents likely for future surgery is essential, but it often poses a significant challenge. in this study, we analyze our experience in the investigation of adverse reactions during anesthesia in the last years. method: a total of patients who attended our allergy unit with suspected perioperative reactions between january and december were reviewed retrospectively. the severity of the perioperative allergic reactions was graded according to ring and messmer system. results: grade iii, ii and i reactions were observed in , and patients, respectively. in patient we didn't know the reaction suffered. tryptase measurements were available for patients. of those, and patients had elevated and normal levels respectively and suffered grade reaction. ige mediated reactions was diagnosed in patients ( %): for ßlactam antibiotics ( . %), for patent blue ( . %), for neuromuscular blocking agents-nmbas ( . %), for latex ( . %), for colloids ( . %) and for ranitidine ( . %) . cefazolin was the ß-lactam antibiotics causing the largest number of reactions. non-ige-mediated reactions was diagnosed in patients ( %). the allergy tests were negative and tryptase levels were normal. conclusion: in our series, among the patients who suffered allergy reactions during anaesthesia and the cause was subsequently identified, ß-lactam antibiotics were the most common causative agent ( . %), followed by patent blue ( . %), nmbas, latex, colloids and ranitidine ( . % each agent). in contrast, data from other authors indicated that nmbas were the most common cause of anaphylaxis, followed by latex, hypnotics, antibiotics, plasma substitutes and opioids. these differences might be due to the small size of our study, which was limited to our centre over the last years and thus may not be representative. diagnostic evaluation. all patients signed an informed consent. we made a retrospective analysis of their clinical records and excluded patients whose records were missing or incomplete. it was analyzed each patient's medical history (focusing allergic disease) and clinical reaction to the suspect drugs. signals/symptoms at pcc were characterized. we also studied the variation of the dpt's results when it was performed after a pcc. aim: to define and quantify the ongoing pharmacy needs in sustaining a large drug allergy assessment program. method: a retrospective review of pharmacy files was used to identify and quantify the drugs and dosages most frequently used and to determine prescription trends within the allergy testing program over the last years. results: initially, this reaction was thought to be a result of a drug allergy, but upon further review and the onset of fever, we determined that it met the diagnostic criteria of jhr. his twin brother was diagnosed with penicillin and betalactamic allergy. neutrophilia % was to be underlined in the blood test. after this, drug oral challenge with penicillin was performed, ruling out penicillin allergy. conclusion: it is not uncommon to confuse drug allergy with jhr. jhr should be an anticipated reaction to early doses of antibiotic treatment for treponemal diseases, such as syphilis. antibiotic treatment should be continued; it is not a warrant to stop treatment. clinicians should be aware and anticipate jhr as a potential complication to early doses of antibiotic for spirochetal diseases such as syphilis or lyme, leptospirosis. the patient was unresponsive in oral drug provocation tests with amoxicillin-clavulanic acid, clarithromycin and trimethoprim sulfamethoxazole for months. the patient could use these drugs. results: chronic abacterial inflammation of the prostate gland was accompanied by a significant increase in concentration of slpi, il- , tnf-α, il- in the seminal plasma and serum concentration, and a decrease in the concentration of il- and tgf-β compared to healthy men (p < . ). there was no statistically significant difference between slpi, il- , tnf-α, il- , il- , and tgf-β in the ejaculate of patients with inflammatory and non-inflammatory forms of cap (p < . ). the concentration of il- in ejaculate of patients with inflammatory forms of cap was significantly greater than in patients with non-inflammatory form of cap (p = . ). the inflammatory and non-inflammatory forms of cap are pathologically similar with changes in the concentration of the studied cytokines except for il- in both forms with signs of inflammation. the terms "leukocytic" vs "non-leukocytic" chronic abacterial prostatitis are more correct than "inflammatory" and "non-inflammatory" when describing chronic abacterial prostatitis. results: the status of all patients after dc immunotherapy was evaluated as satisfactory. heart rate, blood pressure in patients remained within the age norm. skin had normal color without rash or peripheral edema. there were no local or systemic allergic reactions. the body temperature after the injection did not exceed °c. conclusion: these results show, for the first time, that among mastocytosis patients, besides the already known periodontal disease risk factors that include diabetes, age, osteoporosis and alcohol consumption, the bone marrow mast cell burden is also associated with increased periodontal disease severity. results: metformin at relatively low doses ( - μm) was shown to mildly suppress ige-mediated responses, including degranulation ( % reduction, p = . ), tnf-α ( % reduction, p = . ) and il- ( % reduction, p = . ) secretions in bmmcs. importantly, metformin at the same doses potently inhibited mast cell responses in all parameters ( % reduction, p < . for degranulation; % reduction, p < . for tnf-α; % reduction, p < . for il- ) in mast cells treated with an ahr ligand, , -dihydroindolo[ , -b]carbazole- -carbaldehyde (ficz). mechanistically, its inhibitory effect was mediated through the suppression of ficz-induced mapk activation, intracellular calcium release and ros generation. metformin also blocked ahr-mediated pca in vivo ( % reduction, p < . ). conclusion: metformin, a common anti-diabetic agent, was shown to exert inhibitory effect on ahr-mediated mast cell activation in vitro and in vivo, suggesting its potential utility as a newer form of therapy for asthma and allergic diseases; this is particularly relevant when considering the adverse effect of the exposure to environmental polycyclic aromatic hydrocarbons. gasser p ; brigger d ; zbären n ; jardetzky t ; pennington l ; eggel a results: in one of affected family members, we were able to identify the c. a>g mutation in the plasminogen (plg) gene that was recently described to be associated with hereditary angioedema. this mutation leads to a missense mutation with an amino acid exchange p.lys glu in the rd kringle domain of plasminogen. there is no direct relationship between the earlier described cases with this mutation and the family we report here. in all affected members of the family, the symptoms manifested in early adulthood, with swelling of the face, the tongue and the larynx. the frequency of attacks was variable, between once in a year to once in a month. in one of the three family members, we found a slightly decreased level of coagulation factor xii and of plasminogen. icatibant proved to be very effective for the treatment of acute attacks in the affected family. the occurrence of the same c. a>g (p.lys glu) mutation in the plg gene in many families with no or only unknown distant relationship suggests that the disease might have been inherited through the generations without being purged from the population. the mutated amino acid exchange appears to be significant for the function of plasmin or plasminogen. we found a decrease in plasma levels of coagulation factor xii and plasminogen, which may be beneficial markers for diagnosis and monitoring of this disease. several biomarkers are useful in the diagnosis (fibrin degradation products (fdps), d dimer (dd), and fragments of prothrombin + ). also, a correlation between the levels of biomarkers and activity phases of the disease has been detected. alterations in coagulation parameters have an etiopathogenic role in the ae attack, but have not been considered as biomarkers of activity phases. tgt is a global coagulation test which quantifies in vitro the ability of plasma to generate thrombin and estimates alterations in coagulation parameters. the objective is to assess the usefulness of the thrombin generation test (tgt) to characterize patients with hereditary angioedema (hae). method: seventeen hae patients from hospital la fe were recruited to obtain blood samples in remission and during ae attacks. none of them experienced thromboembolic events. plasma was collected in citrate tubes to obtain platelet rich plasma. hemostatic parameters were analyzed:. tgt was conducted using a calibrated automated thrombogram (cat) method and a fluoroskan ascent as a reader. results were analyzed via thrombinoscope v . citrated plasma was incubated with calcium, tissue factor, phospholipids and a fluorogenic substrate. a thrombin generation curve is generated, obtaining parameters: latency time (lagtime), thrombin generation maximum speed (vo), maximum peak of thrombin generated (peak), time to generate the maximum peak of thrombin (ttpeak), total quantity of generated thrombin (etp), and the end time of thrombin generation (starttail). tgt parameters from healthy donors were used as controls. results: thirty-eight samples were collected from seventeen hae patients ( . % female). fifteen ( . %) samples were collected during ae attacks. tgt parameters and fdps were significantly higher in hae patients compared with controls (p < . ), although no significant differences were found in tgt between acute attacks and remission. a decrease trend in tgt is observed in ae attacks. fdps were increased during ae attacks, but normalized at remission periods. these results support the involvement of coagulation in the pathophysiology of hae, although no increase in prevalence of thrombosis is observed during acute attacks. method: the repeated measures design study included patients in two groups: the slit group, patients- follow-ups per allergen (p), and the vit group, patients- p. the slit group had patients treated for hdm ( p), and patients on pre-coseasonal pollen ait (grass p, ragweed p, birch p). the vit group had patients on rush protocol ( for bee and for wasp) and patients on conventional protocol ( bee, wasp, and for both). the ige and igg levels were measured by the immunocap method. the friedman test was used to compare data. results: when compared to placebo group, slit+vitamin d group therapy was more effective in the reduction of nasal symptoms (p = . ), asthma symptoms (p = . ) and combined symptommedication score (p = . ); there was no significant difference between groups in medication and ocular scores. we observed a significant improvement of fev (vitamin d group p = . , placebo group p = . ) and fev %vc levels (vitamin d group p = . , placebo group p < . ), within both groups, between visits. feno results did not differentiate statistically significantly the study participants in terms of receiving slit along with vitamin d or placebo. significant increase in the percentage of cd + cd + foxp + and in tlr positive cells in children receiving slit+ vitamin d was observed compared to placebo group. increase in cd + cd + fox-p + induction, and in tlr positive cells recruitment were independently associated with better clinical effect of slit in children. conclusion: overall, ait with a high-polymerized ash pollen extract was well tolerated. as ash pollen are supposed to be an important allergen during spring time, it is recommended to include spt and npt with ash pollen in the test panel for allergological diagnostic. additionally, determination of ash pollen specific ige could be applied. furthermore, appropriate ait should be considered for ash pollen allergic patients. a | impact of sublingual immunotherapy with a five-grass pollen tablet on grass pollen allergic rhinitis and asthma: a real-life, long-term analysis in france background: data on the fulfilment of prescriptions of symptomatic medications in patients with grass pollen allergy were analysed to evaluate the long-term effectiveness of sublingual immunotherapy (slit) on allergic rhinitis (ar) and asthma. method: by using data in the lifelink ™ treatment dynamics database (iqvia, paris, france), we compared two cohorts of patients with ar: a group treated with oralair® (stallergenes greer, antony, france) slit tablets (n = ), and a matched control group having received symptomatic medications only (n = ). oralair®'s effectiveness was assessed as the change in symptomatic medication fulfilments between the pre-index period (before the initiation of slit) and the follow-up period (after slit), and as the onset of asthma or the progression of pre-existing asthma (based on fulfilments of prescriptions for asthma medication). the number of fulfilments per year was calculated for each patient and each period. results: in line with prescribing guidelines, the mean duration of treatment with oralair® was . months per season for either seasons or seasons. the mean number of symptomatic medications for ar fulfilled per patient and per year in the pre-index period was . ± . in the slit tablet group and . ± . in the control group. in the follow-up period, this value fell for the slit tablet group (to . ± . ) but did not change significantly in the control group ( . ± . ). when considering individuals not taking any asthma medications in the pre-index period, asthma onset during the treatment period was observed in . % of those in the slit tablet group and in . % of those in the control group. the corresponding values for the follow-up period were . % in the slit tablet group and . % in the control group. when considering individuals already taking asthma medications in the pre-index period, the mean ± sd number of asthma medication fulfilments in the pre-index period was lower in the slit tablet group ( . ± . ) than in the control group ( . ± . ). the corresponding values for the treatment period were . ± . and . ± . , respectively. in the follow-up period, the number of asthma medication fulfilments fell more in the slit tablet group (to . ± . ) than in the control group ( . ± . ). oralair® tablets have long-term effectiveness by relieving allergic rhinitis and slowing a progression to asthma. b | a real-life, retrospective analysis evidencing slower long-term progression of asthma in grass pollen allergy patients treated with sublingual immunotherapy tablets | an examination of the reasons for treatment discontinuation and non-compliance to allergen immunotherapy background: allergic rhinitis (ar) patients treated with subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit) may be non-compliant or discontinue treatment too early, which can negatively impact efficacy. therefore, understanding the reasons for non-compliance and treatment discontinuation is vital to help improve compliance, persistence and thus outcomes. this study reported reasons for treatment discontinuation to scit and slit and non-compliance to slit in patients with ar in published real-world studies. method: a literature review was conducted in embase, medline, ebm reviews, psycinfo and econlit ( - ) using key search terms for allergic rhinitis, scit, slit, non-compliance and non-persistence. across all studies,~ % of patients were non-compliant, and -year drop-out rates ranged from % to %. reasons for noncompliance and treatment discontinuation in this subset of patients were stratified according to the who dimensions for adherence (patient-related, treatment-related, or socio-economic). results: from the publications identified, six studies reported reasons for non-compliance to slit (n = ) or treatment discontinuation (n = ) to scit or slit, and the results were grouped for analysis. the majority of patients cited treatment-related factors as the primary reason for discontinuation ( % for slit, % for scit). common reasons were a length of treatment for slit and frequency of injections for scit. % of patients discontinued scit due to patient-related factors such as travel to doctors and waiting time for administration. only % of slit patients discontinued due to patient-related factors. socio-economic reasons for discontinuation were low for both therapies ( % slit and % scit). conversely, for non-compliance to slit, socio-economic factors were the most frequently cited reasons ( %), and included taking time off work and financial concerns. conclusion: of patients who discontinued therapy, treatmentrelated factors were the most cited reasons for scit and slit, reflecting concerns with administration and treatment length. noncompliant slit patients cited socio-economic factors as common reasons for non-compliance, suggesting financial concerns over a long treatment course. differences in reasons for non-compliance and treatment discontinuation may be due to patients assigning differing importance for compliance (a day-to-day decision) compared to the long-term decision to discontinue treatment. results: % of patients had monosensitization to rbet v component. the rest % had combinations ige to rbet v and ige to one, two or even three minor allergens ( %, %, % accordingly). after courses of slit by standardized pollen extracts symptoms of arc and pfas decreased in % and % patients accordingly. in group patients with monosensitization to rbet v : patients had a reduction of arc ( % had - degree by ado); patients had reduction of pfas. patients hadn't finished treatment due to allergic reactions. among patients with sensitization to rbet v /v : patients had a reduction of arc ( % - to degree by ado); had reduction of pfas. patient hadn't finished treatment due to allergic reactions. in patients with sensitization to rbet v /v : patients had a reduction of arc ( % - to degree by ado); had reduction of pfas. patients with sensitization to rbet v /v /v showed the similar results: patients had a reduction of arc ( % - to degree by ado); had reduction of pfas. patients had sensitization to all cra, and only patient who also received slit with grass allergens had reduction of arc only ( degree by ado). as the result of the study it was identified that beneficial effect of slit is highest in patients with monosensitization to rbet v . the increase of sige sensitization profiles to minor birch allergens caused less efficacy of slit treatment. dermatophagoides pteronyssinus immunotherapy is independent of sensitization to blomia tropicalis among children with allergic rhinitis and asthma method: children ( - years old) with allergic rhinitis and asthma sensitised to both dp and bt received years dp-scit. clinical symptom and medication scores, serum specific ige and specific igg were evaluated during dp-scit. in order to investigate whether the treatment outcome was dependent on the sensitisation pattern between dp and bt, patients were further grouped into dp and bt co-sensitisation and cross-reaction, according to positive or negative ige against bt major allergen (btma) blo t and blo t . btma+ group, with specific ige to either blo t or blo t , was defined as the co-sensitized group; btma-group, with no detectable ige to both blo t and blo t , was defined as the cross-reactive group in this study. results: all the recruited patients completed year of dp-scit, ( %) patients completed years of treatment. after years of dp-scit, compared to baseline, all patients had significant reduction in symptom and medication scores. lung function (fev ) was significantly improved as well. % of the patients were free of medication use and asthma symptoms, % of them were free of rhinitis symptom, and the fev % in all patients were higher than % of predicted. dp-scit induced significant increases in dp and bt specific igg . in % of patients, dp specific igg increased more than fold and bt specific igg increased more than . fold. further investigation in btma groups showed moderate correlation (spearman r = . , p = . ) between specific ige against dp and bt in the btma-group (n = ), indicating specific ige cross-reactivity. no specific ige correlation (spearman r = . , p = . ) was found in the btma+ group (n = ) indicating co-sensitisation to both dp and bt. the two groups showed almost identical change in clinical responses. dp and bt specific igg significantly increased during dp-scit, no difference was found between the two btma groups. conclusion: dp-scit can induce specific igg cross-reacting with bt allergens. patients with specific ige sensitisations to both dp and bt may have clinical benefit from dp-scit treatment. moreover, the clinical benefit of scit was independent of ige cross-reactivity or co-sensitisation to dp and bt. method: we investigated allergic rhinitis children who were basically sensitized to house dust mite and received house dust mite slit for year and months. among patients, patients were mono-sensitized to house dust mite (group ) and patients were poly-sensitized aside from house dust mite (group ). we also assigned another allergic rhinitis children who were only treated by medication as control group. nasal symptoms (rhinorrhea, sneezing, nasal obstruction, nasal itching, sleep disturbance) and anti-allergic medications use were assessed at every -month visit. results: the symptoms of allergic rhinitis started to improve after months of slit and significantly improved after a year and a half in group and group compared with control group. there was no significant difference between group and group . anti-allergic medication use in group and group significantly decreased after a year and a half compared with control group and there was no significant difference between group and group . conclusion: house dust mite slit was more effective than treatment only by medication. the effect of house dust mite slit was similar between mono-sensitized and poly-sensitized allergic rhinitis children. house dust mite slit could also be recommended to polysensitized allergic rhinitis children. method: a prospective, randomized, double-blind, controlled, multicenter phase ii study was conducted with four different concentrations of cluster allergoid clustoid wiesenlieschgras (group : tu/ml; group : tu/ml; group : tu/ml; group : tu/ml). out of patients screened, grass pollen allergic patients ( - years) were randomized. the cluster build-up phase was followed by four monthly maintenance injections of . ml. the efficacy was evaluated by the change of the threshold concentration step needed to induce a positive reaction in a titrated nasal provocation test (tnpt) before start and after end of the study (pre-post analysis). the safety profile was assessed for each treatment group by analyzing treatment-related adverse events. background: allergen immunotherapy relies on the consistent administration of allergen extract, therefore compliance to these treatments (subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit) tablets and drops) is vital for efficacy. as scit is administered as an injection by a healthcare professional, and slit is self-administered, compliance to scit may be perceived as superior. therefore, a review of real-world studies investigating compliance to scit, slit-tablets or slit-drops was conducted. real-world studies, instead of clinical trials, were included in this review as they are more likely to reflect actual clinical practice and patient compliance. method: a literature review was conducted in embase, medline, ebm reviews, psycinfo and econlit ( - ) using key search terms for ar, scit, slit-tablets and slit-drops, and real-world compliance. compliance was reported according to ispor medication compliance and persistence work group definitions. results: from the publications identified, eight studies (seven slit [one slit-tablets, two slit-drops, four unspecified], one both scit+slit-tablets) reported compliance rates and were included in the analysis. real-world compliance rates ranged from % to % for slit administration and % for scit administration. only one study compared compliance of slit to scit, with similar rates reported over three years ( % and % respectively). three studies reported "good" compliance (physician-reported or patients consuming > % of allergen extract) to slit-drops or slit-tablets. the good compliance rates were higher for slit-drops ( %- %) compared to slit-tablets ( %- %). observed compliance to slit-drops or slittablets did not vary by country or geographical region. the percentage of patients defined as having "good" compliance to slit-tablets or slit-drops did not vary by study length or patient population. conclusion: whilst compliance to scit may be perceived as superior to slit-tablets and slit-drops, comparable compliance rates between scit, slit-tables and slit-drops were identified across real-world studies. differences between perception and real-world results may be explained by a lack of direct comparisons between scit and slit administration. limitations included discrepancies in definitions of compliance, as well as methodology between studies. however, these are common to reviews analysing compliance, regardless of therapy area. conclusion: in the allergic rhinitis patients, successful compliance for -year slit compared with control was approximately %. method: igg inhibition elisa: rabbit igg antibodies specific for grass allergen allergoids are pre-incubated with different concentrations of alum-adsorbed grass pollen allergoid. the mix is added to an allergoid coated microtiter plate. unbound igg will bind to the allergoid coat and is subsequently incubated with anti-igg hrp labeled conjugate and stained with tmb. results are expressed as percentage inhibition relative to the uninhibited value. the concentration of alum-adsorbed allergoid that is required to inhibit % igg is used as read-out. circular dichroism: far-uv cd spectra ( - nm) were recorded on a j- spectropolarimeter. a cuvette with a stirring compartment was used to keep the suspension homogeneous during measurement. results: the igg inhibition elisa assay is specific for grass pollen allergoids (not for other allergen allergoids), has a good inter-and intra-assay precision and is robust for assay variation. thermally stressed alum-adsorbed grass pollen allergoids were used to show that the igg inhibition assay can be used as a stability indicating method. severe thermal stressing resulted in a higher % inhibition value, indicating a loss of igg epitopes. furthermore, far-uv cd analyses showed that there is a close relation between the decreasing igg binding capacity ( % inhibition values) and the loss secondary protein structures by unfolding (cd-ratio / nm values). the igg inhibition assay was demonstrated to be a valuable method to determine the stability of alum-adsorbed grass pollen allergoid preparations. in addition, a relation was shown between the igg binding capacity and the change in secondary protein structures. | design of a pivotal phase iii trial of allergen specific immunotherapy (ait) using a high-dose house dust mite (hdm) allergoid in patients with allergic bronchial asthma method: male and female outpatients (age - years) asthmatics allergic to hdm are enrolled. during the baseline phase, the patient's minimal dose of ics required to achieve asthma control will be assessed. after the baseline period, approx. patients will receive double-blind placebo-controlled treatment for approx. months, followed by a nd period of weeks to assess the minimal ics dose and further months of observation for the assessment of asthma exacerbation. based on the results of the dose finding study regarding the efficacy endpoints and the safety profile, the optimal allergoid dose is considered to be pnu. results: competent authorities and ethic committees in all participating eu countries, serbia, russia and ukraine approved the study design. the primary endpoint of the trial is the change in predefined dose steps of the minimal daily ics dose required to achieve asthma control after approximately months of subcutaneous ait. all efficacy data will be determined using daily questionnaires and the acq by e-diary for months from october to january. the aim of this clinical trial is to demonstrate efficacy and to evaluate safety of ait with an allergoid preparation of major allergens of dermatophagoides pteronyssinus in patients suffering from allergic bronchial asthma caused by house dust mites. asthma increases the burden of allergic disease and health care costs, especially when uncontrolled. with the development of a high-dose preparation we intend to treat asthmatic patients highly efficiently. romantowski j; jassem e; lata j; wasilewska e; chelminska m; specjalski k; niedoszytko m background: specific immunotherapy (sit) is the only causal treatment in patients allergic to airborne allergens. it has been proven to be widely effective in allergic populations, but individual patients vary in terms of response to the therapy. the aim of the study was to assess the factors that might affect the efficacy of sit. method: patients treated with sit for grass pollen or house dust mites were included. the efficacy of sit was assessed with the use of allergy control score (acs), performed before and at least after one year of sit. the following variables were assessed as potential risk factors for a poorer response to sit: age, gender, type of allergy, type of allergen, type of vaccine, type of sit and smoking history. background: specific immunotherapy (sit) is a suitable treatment option for asthma and allergic rhinitis (ar), but it is not commonly used in korea. in the achievement of the treatment, it is important that immunotherapy is applied with ideal dose and regular intervals and it is essential for the patient compliance. the aim of this study is to investigate evaluate compliance with immunotherapy protocols of patients who were treated with sit in clinic and their satisfaction of the treatment. we performed a multicenter, cross-sectional survey using a specially designed questionnaire that was given to allergy specialists and patient in korea. a member of the trained research group conducted face-to-face questionnaire interviews with each respondent. conclusion: this study shows that most patients are ar with asthma. in our study sit compliance and satisfy are found to be high in both groups. aim: to identify the frequency of regress claims in a dermatological setting and to assess its impact on general prescription behaviour and immunotherapy. method: all physicians of the psoriasis-praxisnetz süd-west e.v. (n = ) were invited to participate in a web based questionnaire study on the topics of dermatology and medical law. the survey was separated into two sub-polls which were carried out after a first poll deciding whether the topic of medical law is of any interest for the dermatological practice. the topic of interest was located in the second poll. results: overall, dermatologists participated in this study. most participants were form bavaria, baden-wuerttemberg or rhineland-palatinate and had more than years of experience as a dermatologist. out of the participating physicians . % (n = ) already experienced a previous regress claim. of these, . % (n = ) stated, that the experienced regress claim changed their prescription behaviour. half of these participants (n = ) further stated, that the fear of a possible recourse affects their prescription behaviour, whereas only out of the other participants declared a possible influence. missing values excluded, this leads to a substantial hesitation in physicians who experienced a prior recourse ( . % vs . %). nevertheless, this seems not to affect the usage of allergen immunotherapy, as all physicians who already experienced a regress claim, stated to use allergen immunotherapy. the fear of a possible regress can change physicians' prescription behaviour but does not seem to have an effect on the prescription of allergen immunotherapy. therefore, the topic should be addressed from another perspective such as providing trainings on relevant regulations for physicians who experienced a prior recourse claim. this approach could also improve patient centred care related to modern treatments. results: the sds were significantly reduced in patients subjected to slit (p < . ) year after the onset it. vas also was significantly reduced (p < . ) with satisfied control of sar and the same time with translation from moderate-severe to mild-moderate sar, after slit. nbh was also significantly reduced (p < . ) year after the onset slit. in patients receiving pht only, sds, vas and severity of sar did not change and significantly higher (p < . ) from the value obtained in the experimental group. nbh also remained unchanged and significantly higher (p < . ) then in experimental group. precoseasonal slit added to pht shows short-term beneficial clinical effects in polysensitized patients with sar and scuad phenotype. results: ten studies ( children, adults; median sample size, ) met the inclusion criteria. the risk of bias was moderate to high in all but one studies. low strength evidence supports the assumption that ait is effective in reducing symptoms and medication use, with only out of studies reporting higher benefit in the ait group vs comparator group. subgroup analyses of studies sharing similar characteristics did not explain inconsistency. safety does not appear was not major concern for alternaria ait. conclusion: this is not enough strength of evidence to suggest that mold ait is efficacious for the treatment of respiratory allergies. high-quality studies with an adequate sample size are needed. abstracts | | tolerability of a two week rush updosing with modified trees, modified grasses or modified grasses/trees mixture in pollen allergic subjects in the day-to-day practice table) severe systemic reactions (grade iii and iv) did not occur. conclusion: rush immunotherapy is an effective therapeutic method for patients with allergic rhinitis. it seems that in cases requiring faster response to treatment, this immunotherapy can be considered as a substitute for conventional immunotherapy. | design of a pivotal phase iii allergen immunotherapy study to assess the efficacy and safety of subcutaneously administered tyrosine adsorbed modified birch allergen+mpl results: the design of this study, including sample size and primary and secondary endpoints, will be discussed based on prior experience gained in two dose finding studies. in addition, the number of patients screened and randomized will be presented by country, gender and/or age and screen failures will be categorized. results: the primary analysis showed an absolute difference in tcs between placebo and du of . ( %, p < . ). the odds of experiencing a severe day during the bps were approximately doubled in the placebo group compared to the du group (or = . , p < . ) and the odds of experiencing a mild day were halved (or = . , p < . ). similar results were seen for the tree pollen season (tps), covering both alder, hazel and birch pollen seasons. the total rqlq score was improved for du compared to placebo during the bps and tps (p < . , except for the last week of the tps), with the most pronounced effects during week - of the bps (absolute difference: . - . , p < . ). treatment was well tolerated. the most frequent adverse reactions were mild or moderate local reactions related to the sublingual administration. no deaths were reported and no serious adverse events were assessed as related to the sq tree slit-tablet. conclusion: treatment with the sq tree slit-tablet improved arc symptoms and need for symptomatic treatment. the du group had less "severe days" and more "mild days" during the pollen seasons. the quality of life was similarly improved. these findings substantiate the clinical relevance of the sq tree slit-tablet for patients with arc induced by pollen from the birch homologous group. nagaraju k ; nagaraju k ; katare s ; kapatkar v ; shah a ; rathod r results: total n = subjects (mean age . ± . years, . % males) completed entire study. the mean incidence of artis reduced from . ± . episodes at baseline to . ± . (p < . ), with . % subjects not suffering from any episode. the mean duration of episodes reduced from . ± . to . ± . days (p < . ). % of episodes (vs % at baseline, p < . ) required antibiotics for mean duration of . ± . days (vs. . ± . days, p < . ). none of arti episodes in follow-up period required hospitalization as against . % episodes, (mean duration ± . days; p < . ) before pidotimod therapy. the number of school days lost & work days lost showed reduction of . ± . days(p < . ) & . ± . days(p = . ) respectively. the average expenses incurred in treatment of artis shows significant reduction of rs. ± (p < . ). adverse events were reported in ( %) subjects, which were mild in nature. a statistically significant increase in absolute counts of t-& nk cells was seen in explorative assessment of immune markers. the study shows pidotimod to be well-tolerated effective therapy in reducing the incidence and severity of recurrent artis, thereby providing additional benefit of reduction in discomfort & healthcare cost due to recurrent artis. thus, pidotimod can be considered as potential therapeutic option for treatment of recurrent artis in children. martignago i ; ridolo e ; incorvaia c department of medicine and surgery, university of parma, parma, italy; cardiac/pulmonary rehabilitation, asst pini/cto, milan, italy background: two registered sublingual immunotherapy (slit) products are available to treat grass-pollen induced rhinoconjunctivitis, consisting of the -grass (phleum pratense) and the -grass pollen tablets. no study of direct comparison of the efficacy of the two products was performed. we report the case of a patient who was treated in different years with the -grass or the -grass tablets with contrasting efficacy. the patient was a -year old woman suffering from years of grass pollen induced rhinoconjunctivitis. in slit was started with the -grass pollen tablets, but in , due to unavailability of the product, slit was performed by the -grass pollen tablets. in the third year of treatment slit with the -grass pollen tablets was resumed. for the -grass tablets slit was initiated before the pollen season and stopped after months of treatment, while for the -grass tablets the treated was prescribed to be continuous. the efficacy of slit was evaluated by symptom-medication scores as reported in diary cards by the patient during the month of may, when the grass pollen usually reach the higher concentration in the atmosphere in lombardy, where the patient lives. results: the mean symptom-medication score in the first year of treatment ( -grass tablets) was . , compared with a mean score of . in the second year ( -grass tablets). the patient was unsatisfied of the symptoms control and asked to resume for the last year of slit the -grass tablets. the mean symptom-medication score in such year was . . no clinically relevant adverse event was reported with any slit product. conclusion: based on the momentary unavailability of the -grass pollen tablet, it was possible to assess in a same patient the clinical outcome associated to either of the two registered slit products. a significantly different efficacy of slit with the -grass tablets compared with the -grass tablets was observed. | fusion proteins consisting of bet v and phl p form ige-reactive aggregates with reduced allergenic activity najafi n ; hofer g ; gattinger p ; smiljkovic d ; blatt k ; selb r ; stoecklinger a ; keller w ; valent p ; niederberger v ; thalhamer j ; valenta r ; flicker s background: bet v and phl p representing major allergens in birch and grass pollen, occur as monomeric proteins with high allergenic activity as assessed by clinical provocation testing in patients. she did not suffer more hymenoptera stings after the last reaction. one bee sting several years before bst resulted in no reaction. she has no symptoms with honey, vegetable or other food ingestion. methods: total ige and specific ige were determined using inmu-nocap system (thermofisher, scientific inc). apis, vespula and polistes (hørsholm, denmark) were also performed. prick tests showed negative results for all extracts tested. intradermal skin tests were positive for apis at μg/ml, but negative for vespula and polistes. our patient was diagnosed of anaphylaxis due to apis venom, thus bst was contraindicated and an epinephrine autoinjector was prescribed. she rejected hymenoptera venom immunotherapy. conclusion: to our knowledge, this is the first case of anaphylactic reaction after bee sting therapy. bee sting therapy should be considered a risk factor for anaphylaxis. patient reported good control of their disease, improved their quality of life, tolerating contact and exposure to numerous horses as well as contact with clothes of people who had been exposed. although ita is absolute contraindication on uncontrolled asthma with a degree of evidence ia, our case had only "transitory" con- and immunocap among wasp allergen components-i , i , i were %; . , %; . and %; . respectively and honey bee allergen components-i , i , i were %; . , %; . and %; . respectively. agreement between polycheck and immuno-cap i and i allergen components were %; . and %; . respectively. agreement between polycheck and euroline i and i allergen component were %; . and %; . respectively. based on wasp and bee components in all three systems, sensitization pattern was analyzed. similar test results were found between euroline and immunocap systems. the comparative studies carried out showed a markedly higher compliance of results with the euroline tests compared to polycheck with the immunocap system. percent agreement was extremely high and kappa value was substantial or almost perfect in the case of bee venom allergy between euroline results: a total of patients were included; ( %) males, with a mean age of (± ) years; ( %) beekeepers, ( %) were atopic, ( %) had asthma, ( %) rhinitis and ( %) cardiovascular disease, and of these patients were on ace/beta blockers. vit with honeybee was proposed in ( %), wasp ( %) and polistes ( %). the mean duration of vit was (± ) months. however, completed less than months. of the total, patients ( %) were not treated with vit. eighty-eight patients ( %) participated in the telephone interview: completed vit ( %), were still on vit ( %) and did not undergo vit ( %). of those who completed vit, ( %) were restung and went to the emergency department (er). twenty-four patients ( %) were stung while still on vit. of those never on vit, ( %) were re-stung and went to er. the severity of the reactions according to mueller of the patients who completed vit (mean follow-up time was months ( - months)) and were stung again was: local reaction in ( %), grade i in ( %); grade iii in ( %). one had a toxic reaction after multiple stings. in those who were stung during vit, ( %) had local reactions, ( %) grade i and ( %) grade iii. of those who were not treated and were re-stung: ( %) had grade i, ( %) grade iii and ( %) grade iv. in this series, the patients who did not undergo vit presented a greater number of systemic reactions when re-stung as well as more severe reactions (p < . ). conclusion: in this group with indication for vit, the reactions of the re-stings were less severe in the patients who had completed or who were on venom immunotherapy, as expected. three quarters of those who did not undergo treatment had severe anaphylactic reactions when they were stung again. this study reinforces the importance and the efficacy of immunotherapy in the treatment of hymenoptera venom allergy. method: this is a retrospective, descriptive study of cases diag- method: data were issued from the reference centre in mastocytosis of toulouse university hospital. ms diagnosis was determined using world health organization diagnostic criteria. hymenoptera venom immunotherapy was performed with an ultra-rush protocol (table) . results: seven patients were included ( women, men), median age years old. during the anaphylactic reaction, cutaneous signs missed in all cases. the reaction was most often severe: grade (n = ), grade (n = ), grade (n = ). three patients suffered from digestive symptoms and one from respiratory manifestations. basal tryptase in serum reached . - . μg/l. hymenoptera venom specific ige were low ( . - . kui/l) except for one patient ( . kui/l). ait was initiated with vespula venom in patients, polistis in patient, apis mellifera and vespula in patient, vespula and polistis in patients. no reaction was observed during ait. four restringing accidents led to increase the cumulative dose to μg and μg in patients. in these patients, the diagnosis of mastocytosis was made due to the resting. conclusion: hymenoptera venom ait using ultra-rush protocol seems well tolerated in patients with systemic mastocytosis. specific studies are necessary to determine the real tolerance profile of this protocol. collaboration with reference centres for mastocytosis should be considered for all patients with mastocytosis associated to hymenoptera venom allergy. dose (μg/ml) results: see table. conclusion: there is a shift or immunomodulation in terms of sige to vespids. even in patients double sensitised who were receiving venom of only one of the vespids. albanesi m background: slit has been suggested as an alternative route for allergen-specific immunotherapy. aim of this study was to investigate allergen-specific antibody responses in birch pollen allergic children who had received slit for two years using recombinant allergens. method: children (n = ; - y o) with respiratory symptoms of birch pollen and oral allergic syndromes (oas) were studied. ten children received slit with staloral, were treated by slit with microgen, and children received only symptomatic therapy (control group). sige and sigg levels to rbet v , rbet v , rbet v were measured twice (before therapy started and after two years) using quantitative immunocap and a panel of more than microarrayed allergens using immunocap isac technology. clinical efficacy of slit was evaluated by recording symptoms upon allergen contact and need of rescue medication. results: all children were sensitized to the major birch pollen allergen, bet v and one patient from each of the groups showed to bet v , no patient had sige to bet v . after two years of slit clinical improvement was observed in the slit patients. in the staloral group there were no respiratory symptoms in patients and a decrease of symptom severity in the other cases as well as a partial or complete tolerance to pr allergen-containing food in the patients. microgen treatment had no influence on oas symptoms but decreased of pollinosis severity in children. however, there were no statistically significant differences of bet v -specific levels measured before and after treatment in the slit and control groups (mann-whitney, p > . ). in this real-life study we found that birch allergic children who had been treated with slit showed a reduction of clinical symptoms but we did not find a significant induction of allergen-specific igg levels in the slit-treated group when compared with children who had only symptomatic treatment. conclusion: our study confirms the scarcity of food additives allergy. it also suggests that even when the diagnostic of allergy was excluded with a negative oral food challenge, families remain suspicious about industrials feeding products containing food additives. these results should reassure health professionals and parents who incriminate too frequently food dyes and conservators when a manifestation which mimics allergic reactions occurs. background: autumn/winter birth has been reported to be a risk factor of food allergy (fa) development. a putative mechanism is that dry/cold weather causes and exacerbates infant atopic dermatitis (ad), which is a major risk factor for food sensitization through inflamed/damaged skin. we investigated prevalence of fa among infants under well skin care in relation with seasons of birth (sob). we recruited full-term newborn infants without perinatal diseases at an obstetric/pediatric clinic. participants were followed up for skin status and food allergy symptoms until months of age. sob were defined as spring (march-may), summer (june-august), autumn (september-november) and winter (december-february). ad was diagnosed based on the united kingdom working party's criteria. use of moisturizer (mo) and topical corticosteroids (tcs) was recorded. primary outcome was fa based on apparent immediate allergic reaction after ingestion of causative food. we classified infants who avoided any food because of sensitization or mother's anxiety as suspected fa. results: six hundred and thirty-one infants were screened for month-period and infants were enrolled in this study. of them, infants were born in spring-summer (s-born) and infants were born in autumn-winter (w-born). fa developed in ( . %) infants and ( . %) infants had suspected fa. there was no difference (p = . ) in prevalence of fa and suspected fa between s-born and w-born. multivariate analysis revealed ad at and months of age was a significant risk factor for fa with or= . ( %: . - . ) and or= . ( % ci: . - . ), respectively. prevalence of ad at months of age was higher in w-born than s-born but prevalence promptly decreased thereafter and stayed low with early use of mo and tcs. prevalence of ad was rather higher at months in s-born than w-born. results: cases and controls were included. the median age was years, (q -q - ). men and women were almost equally represented ( . % males). alcohol consumption associated with the intake of mammalian meat or innards as the trigger factor. the overall prevalence of a positive result of sige to α-gal was abstracts | . % ic % ( . , . ); cases _ . % ic % ( . , . ) controls _ . % ic % ( . , . )_. among cases sige anti α-gal positivity rate ranged from . % (rural), to . % (half-urban) and . % (urban). the rates of positivity were . %, (northern) . % (center) and % (mediterranean). a positive result of sige to α-gal was more frequently observed among men ( . %) than women ( . %) and associated with history of tick bites, practice of outdoor activities, pet's ownership and the antecedent of having eaten mammalian meats or innards previously to the development of symptoms background: a special challenge in the st century for allergists is allergy to food, which is considered "the second wave" of epidemics of allergic diseases. panallergens occur in unrelated organisms and perform a similar function in them. in their structure, they have highly conserved amino acid sequence regions and a similar three-dimensional structure, and thus meet the requirements for cross-recognition by ige. results: in patients ( %) isac test has been shown to have specific ige for panallergen components. mostly, the presence of ige for pr- proteins has been shown in patients. in patients ige to ltp; patients ige to ccd; patients to profilin; patients to tropomyosin; patients to serum albumin, person to tlp. an important aspect is undoubtedly the occurrence of simultaneous sensitization to several panallergens. analysis of data from the study group showed that isolated sensitization to one panallergen concerned only pr proteins ( patients), tropomyosin ( patients) and profilin ( patient). in the remaining patients, the analysis of the isac test results showed that two or more panallergens were allergic. in the study group, asige for the component responsible for the occurrence of real food allergy was detected in ( %) patients. mostly, the presence of ige for jug r has been shown in patients. in the study group, panallergens were more likely to be responsible for food intolerance than specific food allergens. results: of children, children had peanut allergy only, children had tree nut allergy only, and children had both. the mean age was . ± . years in peanut allergy, . ± . years in tree nut allergy, and . ± . years in both. male to female ratio was significantly higher in tree nut allergy ( . %) than peanut allergy ( . %). among tree nut allergens identified, walnut ( . %) was most frequent, followed by almond ( . %), hazelnut ( . %), pine nut ( . %), chestnut ( . %), cashew ( . %), pistachio ( . %), and macadamia ( . %). mean serum total ige level was kua/l in tree nut allergy and kua/l in peanut allergy. mean serum specific ige level to peanut, walnut, almond, hazelnut, and pine nut was . , . , . , . , . , and . kua/l, respectively. children with peanut allergy had higher rate of co-sensitization with soybean and higher soybean-specific ige levels than children with tree nut allergy. however, there was no difference in co-sensitization rate with tree pollen between peanut and tree nut allergy. children with peanut allergy showed significantly increased co-sensitization rate with egg white and wheat compared to children with tree nut allergy. a . % of the children with peanut allergy and . % of tree nut allergy showed co-sensitization with aeroallergens. a total of % of the children with peanut allergy showed decreased specific ige levels within - years. conclusion: prevalence of peanut and tree nut allergy is similar. tree nut allergy develops later than peanut allergy and more common in male. children with peanut allergy showed higher co-sensitization rate with soybean, egg white and wheat compared to children with tree nut allergy. | natural history of egg allergy in a large cohort of infants with food allergy shows its high prevalence but also its transient nature in a months of follow-up background: the cohort of infants ( boys, girls, - months) with the food allergy has been followed for months. as more than % of infants manifested atopic dermatitis (ad), a condition closely linked to egg sensitisation, we focused our attention on egg allergy, following its natural history as well as a development of atopic march. method: the diagnosis of food allergy was based on a personal history, clinical examination, skin prick tests and/or atopy patch tests with native foods. laboratory tests were performed within year of age the latest. the specific ige levels against food allergens were measured using immunocap or immulite. patients with ad were scored according to scorad system. the oral food challenges (ofcs) with cooked/baked egg were done in children at the age of months except for children at risk of anaphylaxis. results: within the whole cohort the allergy to cow milk proteins was confirmed in pts ( . %), to egg in pts ( . %), to wheat in pts( %), to lentil in pts ( . %) to banana in pts ( . %), to soya in pts ( . %) and to potatoes in pt ( . %). in a cohort of egg allergy patients we found out that: % of pts presented the early onset of allergy-up to months of age, % of pts presented severe ad (scorad > ), % of pts showed cosensitisation to peanuts, % of pts had early sensitisation to inhaled allergens, and majority % of pts presented with early onset allergic rhinitis and/or asthma. we proved that egg allergy is closely linked with the early onset of allergy symptoms, with severe forms of ad, co-sensitization to peanuts, early sensitisation to inhaled allergens and an early onset of allergic rhinitis and/or asthma. we also proved that the egg allergy in infancy is transient. the tolerance to baked/cooked egg was achieved in about % of pts at the age of years, unlike previously published results claiming the reach of tolerance in % of pts at the age of years. in these patients we studied: sex, personal history, type of reaction they presented, time of onset of symptoms and food involved. results: out of a total of patients over years of age (from to years old) who have been attended the consultation for the first time during these period, patients ( . %) ask about possible allergic food allergies. of these patients who came for possible allergic pathology, patients ( %) presented positive results. these are the other item we have studied: . sex of patients: % of the patients are women. these patients because of that, it is important to remember that food allergy can also appear in old people. the food that is mainly involved in our population is fish and seafood. a much higher percentage than in other populations, probably due to the mediterranean diet of spain. the symptoms mainly involved are itching and skin lesion, which is the characteristic symptom of a mild allergic reaction. in our population, there was patients with a anaphylactic shock, a much higher percentage than in other studies. the experience with this group of patients is still limited. more studies are needed to know better this patient profile. background: cow's milk allergy (cma) is the first atopic disease in children. diagnosis suspicion in the emergency room (er) is increasingly frequent, however, further assessment by an allergist is often difficult to schedule. therefore, screening for cma through a blood test (specific ige) while the infant is still in the er has gained momentum in recent years. we set out to analyse (a) symptoms which had led the emergency physician to prescribe specific ige, (b) the prevalence of confirmed cma among infants screened in the er, and (c) the long-term outcome of the screened infants. method: a retrospective study of medical records and laboratory results was performed. patients were infants under months, without a previous diagnosis of cma, attending one of the two pediatric er of the university hospitals of marseille, france. allergy blood tests were specific ige to cow's milk extract (immuno-cap, thermofisher, sweden). in infants with specific ige to cow's milk extract of . kua/l or higher, ige directed to the main three individual proteins (casein, alpha lactalbumin et beta lactoglobulin) were also measured. results: infants were included from december to june . the sex ratio was . . % of infants were atopic et % were currently or had been breastfed. the most prevalent symptoms were vomiting and reflux. one third of infants were hospitalized after the er visit. following the er visit, % of infants attended a specialized consultation with an allergist. % of infants with a follow-up visit were diagnosed with an ige mediated cma. infants with cma developed further food allergies (egg, nuts, cashew…). it is difficult to diagnose it. the emergency pediatrician are increasingly confronted to infant with symptoms evoking cma. thus they prescribe sige and extensively hydrolysed proteins because they know that ige-positive infants can be ige-negative during the interval between the er visit and the follow-up one. after bad results interpretation of blood assay after er visit, cma was probably over diagnosed without prick test for ige positive allergy and no eviction/ reintroduction test for non ige. the lack of allergist is probably leading to over prescription of blood assay in er to diagnose cma and prolonged eviction of milk. results: a total of patients were included ( % female) aged from to yo with an average . ± years. % of patients had history of atopic disease: % rhinitis, % asthma, % prior food allergy, % eczema, % drug allergy, % eosinophilic esophagitis (ee) and % chronic urticaria. mean serum total ige was . ui/ml. sensitization to aeroallergens was present in % of patients, the most common were dust mites ( . %), pollen ( . %) or both ( %). in ( %) patients, first symptoms of fa appeared ≥ yo, with an average age of ± . yo. in this group, were diagnosed with ee, with eosinophilic colitis and with eosinophilic gastritis. from the remaining patients, had history of reaction with more than food group (fg). cutaneous reactions were referred in % of patients followed by anaphylaxis ( %) and gastrointestinal symptoms ( %). the fg most commonly implied were: fresh fruits (n = ), seafood (n = ) and tree nuts (n = ). fa diagnosis was confirmed in % of patients, the remaining had negative ofc. in ( %) patients, their symptoms started under yo, with an average age of . ± yo. from this group, ( %) were diagnosed ee. from the remaining patients, cutaneous complaints were the most frequent ( %) followed by gastrointestinal ( %) and respiratory symptoms ( %). the most common fg implied were: fresh fruits(n = ), seafood(n = ) and tree nuts(n = ). only one anaphylaxis was referred. fa was confirmed in %, the remaining had negative ofc. in patients with history of anaphylaxis of had positive st and/ or sige; one had negative sp and sige, with ofc positive. the blood donors were classified based on their clinical symptoms related to possible as contact via fish intake: allergic to as ( %), chronic urticaria ( . %), unspecific dyspepsia ( . %) and asymptomatic ( . %). the prevalence of sensitization (anti-as ige > . kua/l) were . % (ic: . - . %; mean . kua/l; median . kua/l) with a maximum value of . kua/l. raw fish consumption was the only variable associated with statistical significance (p < . ) to as sensitization ( . % vs . %, respectively). albacore and codfish were the most consumed species associated to seropositive results ( %), followed by hake ( %). coastal population ( . % vs . %), non-previously frozen fish consumption ( . % vs . %) and > times per week fish consumption ( . %) were other seropositive associated factors. background: oral allergy syndrome (oas) is an ige-mediated allergy caused by raw fruits and vegetables in patients with pollen allergy, which is known as the most common food allergy in adults. however, there has been no nation-wide study on oral allergy syndrome in korea. the aim of this study is to investigate the prevalence and clinical manifestations of oas in korea. method: twenty two investigators from hospitals and private clinics participated in this study. the patients with allergic rhinoconjunctivitis and/or bronchial asthma with pollen allergy were enrolled to the survey. the questionnaires include demographics, a list of fruits and vegetables, and clinical manifestations of food allergy. pollen allergies were diagnosed by positive results of one or more pollen allergens including birch, alder, hazel, beech, oak, willow, poplar, bermuda, meadow, orchard, rye, timothy, mugwort, ragweed, hop japanese on allergy skin prick tests (allergen/histamine ratio ≥ +) and/or serum specific ige levels using multiple allergen simultaneous tests (mast ≥ +) or immunocap (≥ . ku/l). conclusion: this is the first nation-wide study for oas in korea. the prevalence of oas in korea was . %, in which substantial proportion had anaphylaxis. these results will provide useful information for clinicians to apply in clinical practice. we conducted a self-administered, questionnaire-based survey in - during the -month checkup. children were considered to have food allergies if they were diagnosed by a physician or if they had been instructed to avoid a causative food after medical examination by interview. we divided the year into three periods. the months of march-june were considered spring, july-october as summer/fall, and november-february as winter. while the season of onset for the boys occurred in . %, . %, and . % in spring, summer/fall, and winter, respectively, it was . %, . %, and . %, respectively, for the girls. thus, the onset rate was the highest in winter for both genders. in boys whose mothers did not consume folic acid (fol − ), the food allergy onset rate was significantly higher for boys whose mothers ate no eggs and for boys whose mothers ate - eggs per week than for those whose mothers ate eggs daily according to the dunnet multiple comparison test. however, no relationship was observed with egg intake if the mother had consumed folic acid (fol + ). on the basis of seasons, fol − and egg intake by mothers affected only children born in winter, with a significant difference in the dunnet multiple comparison. among mothers who did not eat eggs, fol + was . % and fol − was . %; for mothers who ate - eggs per week, fol + was . % and fol − was . %; and for mothers who ate eggs every day, fol + was . % and folwas . %. thus, consumption of folic acid seemingly annulated the effects of eating eggs. however, for girls, neither folic acid nor eating eggs had any effect on the onset rate. conclusion: since this effect varied according to the birth season, consumption of folic acid, a methyl group donor, appeared to affect the allergy onset in children. results: skin prick test with commercial extracts of tuna ( mm), cod ( mm), rooster ( mm), hake ( mm), salmon ( mm), trout ( mm) and anisakis ( mm ige to shrimp, lobster, crab and mixed seafood were all undetectable. dermatophagoides pteronyssinus , to assess for tropomyosins was negative. outcome: the patient continues to react to both hdm and shrimp, despite undetectable ige levels to tropomyosin associated components. this is the only testing available in south africa currently and hence we are unable to look at other proteins. the relationship between tropomyosins in shellfish allergy and mite allergy has been well documented and investigated, but other allergens are now also being implicated in cross-reactions. we also established the level of ige specific to allergen components using the immunocap isac method. allergen-specific ige was not elevated to any shrimp allergens available in immunocap isac: n pen m (tropomyosin), n pen m (arginine kinase) and n pen m (calcium binding sarcoplasmic protein). the patient was diagnosed with a shrimp allergy. the molecular diagnostics used did not explain which allergen component is the patient allergic to. it is possible that the patient is allergic to hemocyanin, which can also cross-react with house dust mite allergens, but confirmation of this diagnosis requires further investi- results: the groups were identical in terms of the age and sex (table ) . ara h ige correlated (spearman test) with the cumulative protein dose (threshold dose) r = − . (p = . ) but not with reaction severity r = . (p = . ), or the use of adrenaline r = . (p = . ). patients with ara h ige < ku/l had higher threshold doses ( vs mg) than children whose ara h ige was ≥ ku/l (p = . ). there were no significant differences in severity of the reaction or in use of adrenaline (table ) . the level of ara h ige is relevant in predicting the threshold dose at peanut exposure. a low reaction threshold dose increases the risk of reaction at an accidental exposure leading potentially to a severe reaction. flaxseed allergy is uncommon and most of the cases reported involved anaphylaxis. cross reactivity has been described with other seeds. case report: a -year-old atopic girl diagnosed with egg allergy and rhinoconjunctivitis and asthma due to pollens. when she was eight, she presented two reactions consisting of conjunctival, periorbicular, malar erythema and abdominal pain after eating egg free french toasts cooked with flaxseed. she was treated with oral antihistamines. the allergic workup included prick-by-prick test with flaxseed which was positive and skin prick tests with mites, molds, cockroach, cat, dog, profilin, ltp and pollens with positive results for olive and grass pollens. the serum total immunoglobulin (ig) e was u/l, and specific ige to flaxseed was . kua/l. the flaxseed extract was resolved with sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page) and an ige immunoblotting was performed under nonreducing conditions. the patient's serum showed specific recognition of a -kda band in the immunoblot. proteins were identified using mass spectrometry (maldi-tof) that showed results highly consistent with conlinin, a s storage protein of flaxseed. we described for the first time a patient with allergy to flaxseed due to conlinin, a s storage protein of flaxseed. background: cyperus esculentus is an herbaceous plant that has edible tubers called tiger nuts. in spain, they are used mainly in the elaboration of the well-known "horchata" or tiger nut milk, which is obtained by macerating tiger nuts with water and sugar. tiger nut allergy has rarely been reported, despite of its widespread consumption. case report: we present the case of a -year-old male with a history of oral syndrome allergy with several fruits (peach, melon, banana, kiwi, apple, pear and plum) and seasonal allergic rhinoconjunctivitis due to grass pollen. he reported oral pruritus, vomiting and cutaneous itching in both arms and hands immediately after drinking tiger nut milk. he became asymptomatic without treatment after - hours. the allergic workup included skin prick tests with profilin, ltp, latex and fruits that were positive to melon and watermelon and negative to profilin, ltp, latex and the rest of the fruits. prick-by-prick tests with melon, banana, kiwi, apple, pear, tiger nut and tiger nut milk were positive. the serum total immunoglobulin (ig) e was . μg/l, and specific ige was negative to profilin, ltp, bet v and all the tested fruits. background: specific blood ige tests for food allergens are mainly used to confirm a suspect food allergy than to diagnose such an allergy. this is due to the low positive predictive value and the high negative predictive value they have. nevertheless, they are very helpful when they are interpreted in the context of medical history by an experienced allergist. we analyzed the prevalence of sige in children with suspected food allergies. we retrospectively analyzed the all the consecutive laboratory tests of sige for food allergens during the two-year period ( ) ( ) ( ) . tests were of children diagnosed or suspected to have food allergies. a quantitative immunoblot assay was used to measure the circulated different sige. t-test, wilcoxon signed rank test, and chi-square were used to make comparisons. results: fifty-six ( . %) men and ( . %) females, . + . years old with a maximum of years and a minimum of months old were part of children whose tests were analyzed. one-third of the tests ( . %) reveals more than one sige present and . % of the tests resulted negative for the sige for the allergens tested (table) . only ( . %) children have very high concentrations (> iu/ml) of egg whites sige, and ( . %) have egg yolk sige. concentrations of . % of sige positive cases were . - . iu/ml. in our study more than half of the children suspected of food allergies resulted negative for sige for most common food allergens. seventy-nine percent of the positive cases had relatively low sige. only a few positive cases have higher sige than iu/ml. our data support the recommendation that sige couldn't be decisive in food allergic diagnosis, but they may help if they are interpreted cautiously. method: seven patients with a mean age of . years and female to male ratio of: : , with a background history of hypertension treated with an acei presented with oro-pharyngeal irritation (itch, tingling), face and tongue angioedema and laryngeal constriction, on ingesting fresh fruits (cherries, apples, plums, peaches, apricots, strawberries, grapes), vegetables (parsnips) and/or nuts (peanuts, hazelnuts). two patients required admission to emergency department and three received adrenaline auto-injector. six out of seven patients underwent skin prick testing to common aeroallergens and the index foods. in five cases, immunocap/isac testing was undertaken. in one case the diagnosis was based on the history and in one other case it was based on history and skin prick tests. results: a diagnosis of pfas was confirmed in all patients through the clinical history, spt and/or specific ige serology to the offending food confirming predominant sensitisation pr- allergens. primary food allergy and spontaneous angioedema was excluded in all patients. in the cohort studied, the pfas symptoms were unusually severe. we therefore postulate that this was secondary to concurrent use of acei. the management of these patients to sensitization to a β-casein with high homology between only the first milks. more precisely, the allergen candidate could be γcasein, which is derived from β-casein by proteolysis, whose abundance increases during cheese production from fresh milk, and which is absent in cow's milk. a lactoglobulin specific to buffalo's milk may also be responsible. in case of ewe's and goat's milk allergy without cow's milk allergy, sensitization to buffalo's milk should systemically be seeked out. we recommend inclusion of all mammalian milks in the list of the mandatory allergens for declaration on food products. method: prick tests with fruit battery, ltp and profilin was made. analytical with blood count, immunoglobulins, triptasa, total ige and specific ige to banana, apple and orange. finally, open oral provocation with fruits was performed. the diagnostic key was given by the mother of the patient who attended consultations because the infant had erythema in the temporary zone after drinking sea water on the beach. associated with salivation, the patient presented erythema in the malar area lasting a few seconds many times. the prick tests with fruits, ltp and profilin were negative. hemogram: eosinophils/μl, total ig e: . iu/ml, specific ige to fruits were negative. triptase: . μg/l. method: here we describe a variety of cases of nsltp allergy presenting to a tertiary allergy centre in the north west of england. results: nsltps have been found to be major allergens in various foods and they are likely to produce severe and systemic allergic reactions. this is reflected in the cases we present here. these proteins are highly cross-reactive due to extensive sequence homology and are panallergens. nsltps are remarkably heat stable and retains its allergenicity in processed foods. it is assumed that nsltps may sensitise both by inhalation and ingestion. an intriguing aspect in nsltp hypersensitivity is the extreme variability of its clinical expression. co-factors are often needed for the clinical expression of nsltp hypersensitivity. conclusion: patients regardless of where they are from, presenting with multiple severe/systemic food allergies need to be investigated for nsltp allergy. these patients require specific dietary advice on foods to avoid and a tailored management plan on how to deal with their allergic reactions. cow's milk as well as cow's milk products are tolerated. material and methods: skin prick tests with different sorts of milk, cheese and milk proteins were performed, specific ige antibodies were measured, a basophil activation test with cow's and goat's milk was performed and an oral provocation test (opt) with cow's milk, cow's milk cheese, raw milk and raw milk cheese was conducted. results: skin prick tests were positive for sheep's milk, goat's milk, goat's milk casein, feta, pecorino and parmesan cheese. elevated specific ige against goat's milk ( . ku/l) and sheep's milk ( . ku/ l) were detected. activation of basophil granulocytes after incubation of the patient's blood with cow's milk and goat's milk was measurable but also in the non-incubated control blood. all cow's milk products were tolerated in the opt. conclusion: despite consistent homologies between whey and casein proteins of mammals and high cross-reactivity between cow's, goat's and sheep's milk an isolated goat's and sheep's milk allergy with tolerance of cow's milk is possible. skin testing and specific ige help to distinguish from allergy against cow's milk proteins. diet counseling is possible after opt. introduction: salmon roe's allergy, without concomitant fish allergy, is rarely described in western countries. there are few studies on its allergenicity. objective: to report of a case of salmon roe allergy without concomitant fish allergy in a western country. case report: a -year-old male with house dust mite allergic rhinitis and asthma, describes for the st time, in , an acute episode of dyspnoea, rhinorrhoea, ocular pruritus, epigastric pain and nausea, a few minutes after the ingestion of a sushi meal with rice, salmon, salmon roe, wasabi, soy and ginger. these complaints motivated observation in the emergency room, where it was still documented uvular oedema. he was prescribed intramuscular adrenaline, intravenous steroids and anti-histamines with complete symptoms resolution. the patient declares not had eaten other foods, taken any drugs including nsaid, been infected or practised exercise. skin prick tests with food extracts (salmon and other fish, shellfish, soy, rice, egg total, egg white, egg yolk, ovalbumin and ovomucoid) were negative. skin prick-prick tests were positive for salmon roe ( × mm) and negative for egg (white and yolk), ginger, salmon, flying fish roe (tobiko), sturgeon roe (caviar) and black scabbard fish roe. specific-ige (sige) to salmon roe extract was . kua/l (immu-nocap-phadia) and negative against extracts from salmon fish and other fish (< . kua/l). sds-page immunoblotting with salmon roes extract showed a kda-ige binding band, that may correspond to a lipovitelin. after the allergic reaction the patient have tolerated abstracts | salmon fish and other fish roes (tobiko, caviar and black scabbard fish). no oral provocation test with salmon roes was performed given the severity of the reaction. conclusion: this report is an example of a severe allergic reaction to salmon roe without concomitant fish allergy, where the clinical history and the in vivo and in vitro tests were important to an accurate diagnosis. the authors believe this is the first report of a salmon roe anaphylaxis in our country and highlight the importance of this allergen in the western countries, given the increase of sushi consumption in these countries. case report: the prevalence of food allergy is increasing worldwide and consumer habits are changing. pomegranate (punica granatum) was commonly consumed in the mediterranean area but in the last few years became also popular in the different parts of europe. a -year-old boy was admitted to our emergency department suffering from allergic reaction within minutes after consumption of pomegranate. he presented with skin pruritus, generalized urticaria and eyelid edema. symptoms resolved within an hour after oral intake of cetirizine. prick-to-prick test with pomegranate was positive (wheal diameter × mm). he had a history of anaphylaxis with egg (urticaria and wheezing) at the age of month, meanwhile consumption of egg is well tolerated. an episode of anaphylaxis with unknown origin appeared at the age of years (urticaria, wheezing and abdominal pain). skin prick tests with aeroallergens revealed birch pollen allergy and he was diagnosed with allergic rhinoconjunctivitis. dietary elimination of pomegranate was suggested and adrenaline auto-injector was provided. we have analyzed omalizumab effectiveness and safety in patients with csu from our database. clinical response was categorized as: no response, partial or complete response by using the urticaria activity score (uas ). furthermore, the dosage, administration frequency and any side effects were recorded. results: effectiveness: out of patients ( %) achieved complete response. ( . %) after a single dose of mg ( patients) or mg ( ); patients ( . %) after two doses of mg ( patients) or mg ( ) results: multi-ethnic adolescents accounted for approximately . % of the total sample of adolescents. prevalence of asthma was significantly higher in multi-ethnic group than non multi-ethnic group. we examined if maternal or paternal foreign born status had a differential effect: in multi-ethnic family with foreign-born father, prevalence of asthma was significantly higher. parental region of country at birth had a significant influence on the prevalence of asthma. adjusted logistic regression analysis was used to determine risk factors for occurrence of allergic disease. residential area, perceived household economic status, parental region of country at birth, and body mass index (bmi) had a significant effect on prevalence of asthma. conclusion: population admixing appears to have significant effect on the prevalence of asthma. further study will be needed to clarify the effect of population admixing on prevalence of allergic disease. several studies have aimed to explore the possibility of mirs as biomarkers for various diseases. in our study we examined six different mirs, previously shown to be involved in eosinophil development and other immune responses, in serum from non-allergic and allergic asthmatics and healthy control subjects in order to determine their potential ability to be used as biomarkers for varying forms of asthma. method: serum from healthy individuals as well as age matched non-allergic asthmatics (naa) and allergic asthmatics (aa) were utilized. additionally, the naas and aas subjects had high eosinophila (≥ . × cells/l) compared to healthy controls (≤ . × cells/l) and eosinophil cationic protein (ecp) in serum was measured. asthmatic subjects were included irrespective of inhaled corticosteroid usage. rna was extracted from serum, reverse transcribed and subjected to qpcr analysis. expression changes in six candidate mirs, mir- , - , - a, - , - , and - , were investigated. results: two mirnas, mir- and mir- a, were significantly upregulated in aas as compared to naa or healthy subjects. additionally, mir- was upregulated in naa, but not aa or healthy subjects. furthermore, the expression change observed in the aa mirs appeared to correlate with the use of inhaled corticosteroids, but not in the naa mirs. finally, mir- and mir- expression levels were altered based on the number of eosinophils, which correlated to ecp levels, in naa subjects. conclusion: using six mirs found in the literature to be involved in eosinophila or immune responses, we were able to detect expression changes in the serum of healthy and asthmatic individuals. moreover, were able to distinguish between healthy individuals, aas, and naas on inhaled corticosteroids or with differing eosinophil levels, leading to the possibility that these mirs may be valuable future biomarkers for asthma. background: some studies report that certain sensitization profiles may increase the risk of a more serious allergic respiratory disease. the aim of this study was to describe the sensitization patterns to major allergens of dust mites in our area and investigate the association of these patterns with a specific clinical picture. method: multicenter study performed in hospitals for months. we recruited patients older than years with rhinitis and/or bronchial asthma, with a history of allergy to dust mites and both skin test and specific ige to d. pteronyssinus, d. farinae or l. destructor positive. der p and der p were determined to all of them. we analyzed patients with an average age of . years, . % women, . % smokers, . % rhinitis and asthma, . % only rhinitis and . % only asthma. % of patients presented sensitization to d. pteronyssinus, . % to d. farinae and . % to l. destructor. the detected sensitization patterns were: both der p /der p positive . %; der p positive . %, der p positive . % and both der p /der p negative . %. it was observed that patients with higher specific ige levels had more severe forms of respiratory disease, with isolated asthma or associated with rhinitis. for d. pteronyssinus, d. farinae, der p and der p > ku/l there is a greater number of cases of asthma associated with rhinitis, while for l. destructor > . ku/l greater number of cases of asthma. no relationship was observed between a specific sensitization pattern and an increased risk of asthma. conclusion: . specific ige values greater than ku/l for d. pteronyssinus, d. farinae, der p and der p , were significantly associated with a higher probability of asthma and this association was significant for l. destructor> . ku/l (class ). . there are four well-defined sensitization patterns in our population that are influenced by geographic location, being the double sensitization to der p and der p the most prevalent and allowing the correct characterization of % of the cases. none of them increased the risk of asthma. kobori t ; nagao m ; ekenkrantz t ; borres m ; sjölander a ; fujisawa t national mie hospital, tsu-city, japan; thermo fisher scientific, uppsala, sweden background: reliable biomarkers for diagnosis and management of asthma in young children are needed since pulmonary function test and exhaled no measurement, good biomarkers for asthma in older children and adults, are difficult to perform in young age. we have developed a sensitive and stable assay system to measure eosinophil-derived neurotoxin (edn), an eosinophil granule protein, that is released upon activation, and that may serve as a marker for eosinophilic inflammation also in young children. method: volunteer children from - years old were recruited and an isaac-based questionnaire was filled out by their caregivers. venous blood was obtained to measure serum and plasma edn and eosinophil count. edn was measured with a research assay developed on the immunocap ® platform. conclusion: blood edn may be a reliable biomarker for diagnosis of asthma in preschool children. conclusion: feno measurement as an add-on option in asthma management to identify asthma patients with th driven airway inflammation is less costly than the use of standard diagnostic methods. new biologics may have an additional impact on overall asthma treatment costs. our model demonstrates that incorporating feno measurement may help to optimize asthma medication and reduction in physician visits as well hospitalizations due to severe exacerbations. | peripheral airway inflammation assessed by fractional measurement of the exhaled breath temperature is a leading feature of asthma background: airway inflammation is considered to be a hallmark of asthma. the potential clinical benefits of assessing it non-invasively has led us to develop a method and device for measuring the temperature of the exhaled breath (ebt=exhaled breath temperature) reflecting the thermal state of the airway mucosa. studies have demonstrated that ebt is increased in asthma, proportionately to the level of control of the disease. in an attempt to further increase the usefulness of this approach, we have further developed a device to allow the assessment of the relative contribution of the central and peripheral airways (caw and paw). now we present the frebt data gathered from patients with suboptimal control of their asthma and from healthy subjects. method: in this cross-sectional study we included volunteers: patients with suboptimally controlled asthma of mild to moderate severity (median age , range - years, men) and nonsmoking subjects without respiratory disease (median age , range - years, men). we measured the fractions corresponding to caw and paw sampled with a fast reacting inflatable balloon valve system operated by a computer during a single breathing cycle. it allows steering of the expired airflow through channels with sensitive temperature sensors. during an initial deep inhalation, the inspired volume is measured and the sequence of valve openings is adjusted so as to yield volumes of air characteristic of caw or paw during expiration. the ratios between [pawebt-cawebt] over the total ebt [%] measured during the same manoeuvre (fractional ebt, frebt) were calculated and compared between asthmatics and controls. results: there was high statistically significant difference between the frebt ratios of asthmatics and controls: . ± . (mean ± sem) vs . ± . , p < . . as the magnitude of the ratio depends on the difference between pawebt and cawebt, higher values of the frebt ratio point to bigger contribution of the peripheral lung tissues, presumably indicative of peripheral inflammation. multiple regression analysis with frebt ratio as dependent variable identified only asthma diagnosis as significant predictor (p < . ) and excluded all other anthropometric indices. conclusion: peripheral airway inflammation assessed by frebt measurement appears to be a leading characteristic in asthmatics compared to healthy subjects. method: we examined outpatients ( % male, aged - year, mean age . years) with severe asthma according to ers/ ats ( ) definition treated with high dose of ics/laba± tiotropium, antileukotrienes and omalizumab. some patients (n = ) had orally steroid-dependent asthma. they referred to our secondary care center by gps. pulmonary function tests were measured by dry spirometer ( , vitalograph ltd., uk). skin prick tests or serum specific ige to common inhalant allergens (house dust mite, animal dander, pollen) were used to assess atopic status. results: seventy five percent (n = ) of patients with severe asthma had fao in % of those was diagnosed concomitant copd. duration of asthma was . years in patient with reversible airway obstruction (rao) and . years in those with iao (p > . ). early (before age years) onset of asthma was established in % of patients with rao and in % of patients with fao (p > . ). prevalence of atopy did not differ between both groups ( % vs %, p > . ) but total ige level in serum was higher in severe asthmatics with rao than fao ( me/ml vs me/ml respectively, p < . ). most of atopic patients with severe asthma both with fao ( %) and roa ( %, p > . ) were sensitized to house dust mites (d. pteronyssinus and d. farinae). hypersensitivity to pollen was diagnosed in % patients with foa and in % with rao (p > . ), to cat and dog dander in % and % respectively (p < . ). the majority ( %) of patients with severe asthma had fao. hypersensitivity to house dust mites was most common in severe atopic asthmatics with foa and roa where as sensitization to animal danger was associated with presence of foa. | loss of smell as a clinical marker of severe asthma and its association with upper airway inflammatory diseases background: asthma is frequently associated with rhinitis and chronic rhinosinusitis (crs) while severe asthma is more associated with crs with (crswnp) than without (crssnp) nasal polyps. loss of smell (los) is associated with crs, mainly with crswnp. we aimed to assess loss of smell as a clinical marker to discriminate crs from rhinitis and severe from non-severe asthma. method: in a cross-sectional multicentric study, asthmatic patients (n = ) were evaluated by pulmonologists and ent specialists using gina, aria, and epos definitions. los was evaluated by severity [vas scale, - mm, median (iqr,inter-quartil range)] and by prevalence of anosmia (hyposmia vas > - mm, anosmia vas> mm). results: los was present in . % of asthmatics (hyposmia . %, anosmia . %). los was more severe [ mm ( - ), p < . ] and anosmia more frequent ( . %, p < . ) in severe persistent asthma than in moderate [ mm ( - ); . %] mild [ mm ( - ); . %], or intermittent [ mm ( - ); . %] asthma. in addition, los was more severe [ mm ( - ) vs mm ( - ), p < . ] and anosmia more frequent [ . % vs . %, p < . ] in crs than in rhinitis patients. in those asthmatic patients with crs, los was even more severe [ mm vs mm ( - ) p < . ] and anosmia more frequent ( . % vs . %, p < . ) in crswnp than in crssnp. conclusion: loss of smell and specially anosmia may clearly discriminate severe from non-severe asthma and crs (specially with np) from rhinitis alone in asthma patients. thus, los may be considered a significant clinical marker of severe asthma and its association with upper airway inflammatory diseases. | last station in the eosinophilic asthma with chronic rhinosinusitis and/or nasal polyposis march: eosinophilic asthma with radiological findings associated with blood eosinophilia yilmaz i ; nazik bahçecioglu s ; türk m ; tutar n ; oymak fs ; gülmez i erciyes university school of medicine, kayseri, turkey; department of chest diseases, kayseri, turkey; division of immunology and allergy, kayseri, turkey background: eosinophilic asthma with chronic rhinosinusitis and/or nasal polyposis (eacrs/np) is a subphenotype of adult-onset eosinophilic asthma. blood eosinophil levels are shown to be highly elevated in patients with ea-crs/np and have potential for tissue infiltration. we aimed to demonstrate the clinical features of the patients who have a blood eosinophil level above % and have thorax computed tomography findings due to blood eosinophilia. results: we identified patients who met the above criteria. we defined this group as "eosinophilic asthma with chronic rhinosinusitis and/or nasal polyposis with radiological findings related to blood eosinophilia" (earr). the mean age was . ± years and % was female. nasal polyps, aspirin exacerbated respiratory disease and atopy was present in %, % and % of the patients, abstracts | respectively. the mean blood eosinophil count was . cells/mm ( %). the majority of earr patients had upper lobe dominant ground-glass opacities. the mean follow-up period was . ± . years. earr patients did not evolve into eosinophilic granulomatous polyangiitis in the follow-up. method: we aimed to identify features more probably associated with asthma in a unselected group of patients with diagnostic criteria for aco. we consecutively selected the first consecutive patients with diagnostic criteria for aco. all patients were evaluated by accurate clinical history interview, assessment of asthma control test (act) and copd activity test (cat), lung function and exhaled nitric oxide (fe no ) measurements, sputum cytology, blood eosinophil count, serum total ige and periostin levels, methacholine and adenosine-mono-phosphate (amp) bronchial challenges. all these measures were repeated after an oral corticosteroid (ocs) trial of methylprednisolone mg/day for days. we defined parameters that we expected improved after the ocs trial, and therefore considerable as markers of asthma: fev , fef - , fev /fvc, fe no , act, sputum and blood eosinophilia, methacholine and amp challenges. patients with improvement of at least of these parameters after ocs trials were defined as "responders" to the treatment, and therefore more likely to be asthmatic than copd or aco. results: five ( %) patients were classified as responders and they were characterized by having basal higher fe no values ( . ± . vs . ± . ppb, p = . ), greater bronchial reversibility basal values of serum periostin and total ige, and blood eosinophils were higher in responders but without reaching the statistical significance. conclusion: fe no and the degree of bronchial reversibility (and possibly also the degree of response to an amp challenge) are reliable biomarkers to distinguish asthmatics among those with suspect aco. method: the preliminary case-control study included obese persons with asthma who were matched for age and sex and nonobese asthma subjects. non fasting serum levels of adiponectin, and leptin were measured by commercially available immune assay kits, and routine biochemical parameters were analyzed in both the study groups. the results show statistically significant lower levels of serum adiponectin and higher serum leptin levels in obese asthma subjects with respect to non-obese asthma patients (p < . ). moreover, an inverse correlation was also observed between serum adiponectin and serum leptin in obese asthma subjects (p < . ). our results indicate the association of these hormones might act as a significant predictor in the progression of asthma. moreover, the role of serum adipokines is promising and might potentially act as a meaningful drug target in the pathogenesis of asthma. background: overweight/obesity is known to be a possible factor for poor asthma control. the aim of the study is to determine the serum concentrations of leptin in atopic asthmatic patients and its relationship with body mass index (bmi), asthma severity defined by medical treatment and asthma control defined by the asthma control test (act). method: we randomly selected adult patients previously diagnosed with allergic asthma based on gina (global initiative for asthma) guidelines, returning for follow-up to an outpatient allergy/ immunology clinic during november . following an informed consent, the patients were asked to fill act, their bmi was recorded, and elisa blood assays for leptin were drawn. exploratory data analysis, spearman's correlation ( % ci by bootstrapping), and partial correlations were performed. results: female/male ratio was / , mean bmi was . ± . conclusion: leptin was significantly associated with overweight/ obesity in asthmatic subjects, and showed higher values for women. leptin inverse correlation with act did not reach statistical significance, likely owing to underpowered estimates, in a small sample characterized by an elevated mean bmi and severe allergic asthma. background: immunoglobulin lowering may be associated with recurrent wheezing symptoms and clinic by increasing the tendency to viral respiratory tract infections. in this study, it was aimed to investigate the frequency of immunoglobulinemia in preschoolers with wheezing. the study was conducted between . . and . . between. university of health sciences, ankara child hospital, the children allergy and immunology clinic included patients who had been followed up and treated for at least one year with recurrent wheezing attacks within younger than months. the immunoglobulin (g, a, m) values of the patients were retrospectively analyzed. immunoglobulin levels were determined to be normal and low according to age limits. the study included patients ( . % male, . % female) under the age of years with a mean age of . months. the mean follow-up period of the patients is . years. in . % of these patients, at least one immunoglobulin was found to be low. none of these patients had any signs or symptoms of immunodeficiency. immunoglobulin a was low in % of the patients, immunoglobulin g in %, and immunoglobulin m in . % of all patients. conclusion: immunoglobulin was found to be low in these patients when there was no immunodeficiency and preschool wheeze was diagnosed. this should be etiologically investigated as to whether if this is a special group in preschoolers with recurrent wheezing and hypogammaglobulinemia combination. method: asthma severe unit is formed by allergists, pneumologists, pediatricians and otorhinolaryngologists. hematologists and immunologists make specific collaborations. we present the partial results of our data collection, which include patients with severe asthma according to ers/ats task force, selected by peripheral eosinophils > according to wagener et al. we followed them up to assess control for year. we obtained cellularity in sputum using induced sputum technique. values of il of th , th , th pathway, periostin and ilc were not yet available. results: median age was ± , feno ± , exacerbations previous year . ± . , act . ± , fev % ± and dose of inhaled corticoids (budesonide equivalent) ug ± . most of the patients were sensitized ( %) and . % were polysensitized. the most frequent sensitization was dust mites ( %). % had received immunotherapy of whom . % with lack of response. not sensitized patients were older. sputum cell analysis of patients was performed, % had sputum eosinophils> %, mean sputum eosinophil value was . ± . and peripherally ± . correlation among sputum and peripheral eosinophilia was . (p = . ). the peripherally eosinophil value > had a sensitivity of % and a specificity of % for the detection of sputum eosinophils > %. no differences were observed in sputum cell count depending on allergic sensitization. % had an uncontrolled asthma. presence of polysensitization, rhinitis or polyposis were not statistically related with the control. different patterns were observed in function of cause of poor control: patients with obstructive pattern (fev < %) were older and received more inhaled treatment. patients with high rate of exacerbations had more sputum eosinophilia and neutrophilia. both groups had worse act and received more oral steroids. patients who received oral steroids were more often sensitized to fungi in some follow-up visits. not significant differences were observed in control according to the act. asthma had more sputum neutrophilia, were older, received higher inhaled steroids dose and had adult onset asthma. the only control variable related with sputum eosinophilia was exacerbation. fungi sensitization was more frequent among patients with oral steroids. method: a randomized, double blind, placebo controlled study with patients from the de la salle university medical center with a mean age of with partly or uncontrolled asthma. they were assigned to either cm glucan or placebo group for two months. act score and %fev postbronchodilator were assessed at the st visit, th week follow up, and th week follow up visits. an independent and paired t-test were used to determine mean changes in act scores and %fev between the groups. results: in the two treatment groups, those in the cm glucan group had a greater % fev mean change of − . compared to placebo which had only − . , a mean difference of − . , and a trend toward significance with a t-test p value of . . in terms of changes in act score, those in the cm glucan group had a mean change of . and . for placebo, a mean difference of . and was not significant at t test p value of . . the result of the emanuel trial showed a trend of improvement among patients on both groups in terms of act score and %fev postbronchodilator. however, it was not statistically significant. | lung function improvements with tiotropium in patients across all ages: impact of episodes of asthma worsening during phase trials vogelberg c ; casale tb ; bleecker er ; goldstein s ; szefler s ; engel m ; el azzi g ; dewberry h ; hamelmann e method: post hoc analyses involved phase iii, randomized, double-blind, placebo-controlled trials: in patients aged - years (rubatina-/canotina-/vivatina-/pensietina-asthma) who received tiotropium ( or . μg) or placebo, as two puffs once-daily via the respimat, as add-on to ics ± other controllers; and in adults (pri-motina-asthma replicate trials) who received once-daily tiotropium μg or placebo, as add-on to ics/laba ± other controllers. we analyzed change from baseline for peak fev ( - h) and trough fev at week in vivatina-and pensietina-asthma, and week in pri-motina-/rubatina-/canotina-asthma, comparing patients with and without episodes of asthma worsening during the trials. asthma worsening was defined as an episode of progressive increase in dayto-day asthma symptoms (recorded by patients and confirmed by the investigator) or a decrease of patient's best morning pef ≥ % from mean for ≥ consecutive days. as a post hoc analysis, p values are nominal. results: there were no differences in baseline disease characteristics between those who experienced episodes of asthma worsening and those who did not, within specified age and asthma severity groups. placebo-adjusted lung function improvements were observed with tiotropium μg in patients who experienced episodes of asthma worsening and those who did not during the trials (table ) . there was some variability in subgroups with low numbers of patients. conclusion: once-daily tiotropium add-on had a similar efficacy in adult and pediatric patients with symptomatic asthma, irrespective of whether they experienced episodes of asthma worsening or not during the trials. these data support the broad efficacy of tiotropium and show largely consistent improvements in lung function even in patients who experience episodes of disease worsening. | cochrane review of the use of antibiotics for acute exacerbations of asthma method: we searched the cochrane airways trials register, trial registries and reference lists of primary studies. we extracted outcome data and assessed risk of bias in duplicate and used current cochrane methodology throughout. our primary outcomes were intensive care unit (itu) admission, duration of symptoms/exacerbation and adverse events. we included six studies, including a total of adults and children. trials were of varied methodological quality and we were able to perform only limited meta-analysis. one study reported a single itu admission but no other studies reported admissions to itu. two studies investigating macrolides reported diary card symptom score and showed antibiotics improved symptoms (md − . , % ci − . to − . ). one study including participants reported more symptom-free days in the macrolide group than usual care. one study of a penicillin including participants reported asthma symptoms at hospital discharge; the between group difference was reported as non-significant. serious adverse events were rare; events were reported across the three trials (n = ). the pooled effect estimate for all adverse events from three studies was imprecise (or . , % ci . - . ). no deaths were reported. conclusion: our results confirmed that omalizumab significantly improves disease control and is a safe add-on therapy. also in appropriate patients with controlled disease over time, efforts to stepdown other asthma medications will be appropriate. ( ) aerd: aspirin exacerbated respiratory disease; sd: standard deviation. data are n (%), mean ± sd or n/n (%). c-act: asthma control test for children, fev : forced expiratory volume in one second; fev /fvc: the ratio of forced expiratory volume in one second to forced vital capacity, pef: peak expiratory flow; feno: fractional exhaled nitric oxide, vas: visual analogue scale *these included allergic rhinitis, asthma, eczema, atopic dermatitis, food allergy, etc. **there were , and missing data in treatment a, b, and c, respectively. this study examines the potential treatment effects of sq ® hdm slit-tablet on qol measured by sf- v in people with aa and ar. the analyses are based on data from the mt- trial (eudract no. - - ) and utilize data from the sq-hdm treatment group ( subjects) and the placebo group ( subjects). throughout the trial, qol was measured at each of visit - via sf- v . this yielded psychometrically-based physical and mental health summary measures, as well as a sf- v total score. according to trial design, the use of inhaled corticosteroid (ics) was reduced by % for a three months period (visit and ) and completely withdrawn for the last three months of the trial (visit and ). results: by estimating a simple regression on differences in sf- v total score from baseline measurements (visit ), a positive and statistically significant treatment effect on the overall qol of the sq-hdm treatment compared to the placebo group in visit and was found. further analyses show that the qol improvements are mainly driven by increases in the general mental health score, which are carried through to visit . in particular, the mental health and role emotional domains show statistically significant improvements. the results show that the sq ® hdm slit-tablet improves qol measured by sf- v in patients with hdm induced aa and that this effect is driven by improvements in the mental health domains. | impact of treatment prescription, adherence to treatment and use of inhalers in asthma control-results of the efimera study method: cross-sectional multicenter observational study conducted with patients who use any type of medication with inhaler devices. patients referred from primary care and seen by a pneumologist or allergist for the first time were evaluated. the following data was collected in a single visit: adequate prescription according to gina guidelines (gina); specific and general treatment adherence using morisky-green questionnaire (mg) and inhaler adherence test (tai); disease control with asthma control test (act) and assessment of inhaler use technique were measured with the extended tai. results: patients included in this study (n = ) had a mean age of ± years, an average disease evolution of . ± . years, % of which were women. according to gina recommendations, . % of patients have insufficient or inadequate prescription. when measured by the mg test the . % of patients showed bad adherence, meanwhile measured by the tai test adherence was . % measurements of inhaler use technique resulted in % of patients having one or more mistakes regardless of whether the device was a mdi or dpi. several factors showed to be related with bad asthma control: inadequate prescription (or: . [ . - . background: it is well known that the constant and prolonged tobacco smoking affects the natural history of asthma. vaping is the act of inhaling and exhaling the vapor produced by an electronic device called e-cigarette (e-cig), whose basic structure includes a power source and an atomizer. two types of vaping are the most popular ("mtl" and "cloud chasing"). we have created a web-survey with questions concerning epidemiological data, quality of life and symptoms worsening in asthmatic vapers. the survey has been advertised through various social networks and local press. people responded, including asthmatics ( %). the asthmatics were: males %, under %, - years %, - years %, - years % and over %. % used ecig-only, % smoked and vaped together, %. those who preferred mtl-type of vape were % and "cloud chasing" were %. results: to the question: "has vaping ever worsened asthma symptoms?" % answered no, % yes. to the question: "as asthmatic, would you suggest to an asthmatic smoker to start vaping instead of smoking?" . % answered no, . % yes. to the question: "how much nicotine do your vaping liquids have?" % answered mg/ml, % . mg/ml, % mg/ml, % mg/ ml, % mg/ml, % mg/ml and % mg/ml. to the question: "do you take medications for your asthma?" % declared to use a drug as needed, % used a single drug daily, % used more than one drug daily and % declared "i don't take any asthma medication". we related (χ test) the worsening of asthma symptoms with the nicotine content (p = . ), the type of vaping (p = . ), the current therapy (p = . ) and we did not find a statistically significant correlation. vaping has undoubtedly shown an advantage in terms of improvement of symptoms compared to cigarette smoking (p = . ), in particular . % subjects who smoke and vape did not have a worsening of symptoms, while . % of them had a worsening. the vaper-only users who never worsened were ( . %) and ( . %) had a worsening. conclusion: despite the limits related to the online survey as a data source, e-cigs seem to be a useful tool in the pathway to quit smoking. in fact, % of the asthmatics who smoked traditional cigarettes would recommend switching to e-cig and % did not worse their asthma symptoms. background: despite the success of pharmacotherapy, more than half of patients with persistent bronchial asthma (ba) do not achieve disease control. in recent years, the issue of approaches to treatment based on the identification of phenotypes of the disease has been increasingly discussed. this approach becomes the key to optimizing therapy for asthma, allowing the personification of treatment. anti-ige-therapy using omalizumab is one of the most researched variants of phenotype-specific treatment. method: aim of our study was to investigate of the causes of uncontrolled predominantly atopic asthma, the frequency and effectiveness of the personalized therapy in real clinical practice. patients with uncontrolled severe atopic asthma were examined in outpatient department of the city hospital during . all patients underwent physical examination, pulmonary function testing, and total serum ige evaluation. results: % of patients had uncontrolled asthma due to inadequate basic therapy of the disease. the change in therapy allowed them to achieve control of the disease. obstructive sleep apnea syndrome (osas) was revealed in . % of patients. these patients underwent cpap (continuous positive airway pressure) therapy. % of patients had gastroesophageal reflux disease (gerd). % of patients had an elevated level of serum ige level and needed anti-ige therapy. in . % of cases, the initial serum ige level was more than iu/ml which was a contraindication to therapy of omalizumab. patients received omalizumab therapy. this therapy led to relief of symptoms and decreased frequency of asthma exacerbations. results: it was found that the prevalence of obesity among the patients with asthma and being treated in inpatient conditions in - was . % of patients, which is comparable to the prevalence of obesity among the population in general. the data of the patients suffering from asthma and obesity treated both in inpatient and outpatient conditions, was analyzed and it is set that obesity does not affect the severity of the clinical course of asthma. it is shown that obesity does not affect the control of symptoms of asthma. thus, the control of asthma symptoms depends on timeliness of diagnosis, the adequacy and terms of appointment of basic asthma therapy, the presence, severity and adequate treatment of concomitant diseases, psychoemotional background of patients, their compliance and adherence to therapy. results: the causes of smoking in asthmatics were not significantly different from the control (p > . ). patients most often used smoking as "support for emotional stability". the motivation to smoking cessation was higher in the asthmatics group ( %) than in the control group. the main reason for smoking cessation was a deterioration in health - %. the majority of smokers - %, performed attempts for smoking cessation. low level of br was revealed in % asthmatics ( % non-smoking asthma patients and . % of cases in the control group, p < . ), cf had low values and was lower in asthmatics group in compare to the control group (p < . ). the pac values correlated with the level of br: a low level was determined in % in smoking asthmatics, in % in nonsmokers with asthma and . % in smokers of the control group obstructive sleep apnea (osa). all of the patients were on regular treatment with low dose inhaled corticosteroids for at months and start treatment with continuous positive airway pressure (cpap) .to assess quality of life, we used asthma symptom control tools (asthma control test) .patients performed daily peak flow meter and spirometry (once a week) during period of weeks after start using cpap. results: during the study, of the followed patients had no exacerbation of asthma. four of patients during this period had exacerbation, due to upper airway infection so they were excluded from study. results of following showed that there was improvement in quality of life in all patients included in study but there no statistically significant improvement in pulmonary function tests fpt. huang y ; yao t ; huang y ; chiu c ; tsai z ; kao p ; lu k ; fang h ; lin c ; gau c ; lee w ; tsai h results: the rate of preterm birth among the study subjects was . %. the prevalence of physician-diagnosed rhinitis was . %. there was no significant association between preterm birth and physician-diagnosed rhinitis (p = . ). when stratifying by atopy status, we found that preterm birth was associated with physiciandiagnosed rhinitis among children without atopy (adjusted or [aor] = . , % ci = . - . , p = . ), but not among children with atopy (p = . ). when further classifying by gender, greater protective effect of preterm birth on rhinitis was only found in boys without atopy (aor = . , % ci = . - . , p = . ). the results suggest that preterm birth may have a protective effect against the development of childhood rhinitis in our study population. the protective effect is only observed in boys without atopy. further investigations will be merited to confirm these findings and to investigate underlying mechanisms. background: folic acid supplementation (fas) during pregnancy has been suggested due to its protective effect against neural tube defects. at present the effect of fas during pregnancy on childhood rhinitis has remained unclear. we aimed to investigate the relationship between fas during pregnancy and childhood rhinitis. logistic regression analysis with covariate adjustment was performed. adjusted covariates included sex, age, number of older siblings, breast feeding duration, maternal smoking during pregnancy, maternal allergy, maternal education level, maternal age and socioeconomic status results: the prevalence of physician-diagnosed rhinitis was . %. there is a significant association between fas and physician-diagnosed rhinitis (adjusted odds ratio [aor] = . ; % confidence interval [ci] = . - . for fas ≥ months) compared to the group of never use. in the stratified analysis by atopy status, maternal fas during pregnancy was significantly associated with physician-diagnosed rhinitis in the atopic group (aor = . , % ci = . - . for fas < months; and aor = . , % ci = . - . for fas ≥ months), but not in the non-atopic group. when further stratified by gender, significant association between maternal fas during pregnancy and physician-diagnosed rhinitis was only found in boys with atopy (aor = . , % ci = . - . for fas < months; and aor = . , % ci = . - . for fas ≥ months). the results demonstrate that maternal folic acid supplementation during pregnancy might increase the risk of childhood rhinitis, especially among boys with atopy. further investigation will be needed to validate our findings and to understand potential underlying mechanisms. according to sequence data from detected adv (in all groups of patients) belongs to species f type and samples to species c type (rei group). bv type was identified in strongly positive (ct ≤ ) swab samples in ari group. conclusion: simultaneous testing of respiratory and stool samples together shown that at least . %/ . % of study subjects had dual/mixed infections, respectively, including %/ . % of respiratory disease patients, . %/ % of gastroenteritis patients and . %/ . % of patients with combined respiratory/enteric infections. we found no virus combination specific for different groups of patients. | neonatal respiratory supports and future asthma-like presentation in prematurity with bronchopulmonary dysplasia results: of all the tests analyzed . % were males and . % females with a mean age . ± . years old. half of the tests ( . %) reveals positive specific-ige to more than one allergen and . % ( ) have no serum specific-ige for the tested allergens (table ) . sixteen patients ( . %) have very high concentrations (> iu/ml) of derm. pteronyssinus specific ige, ( . %) of derm. farina, ( . %) of rey pollen and ( . %) of oak and timothy grass pollen. further studies are needed in order to elucidate the effect of these cytokines on allergy development and protection. shinohara m ; matsumoto k department of pediatrics, ehime university hospital, toon, japan; department of allergy and clinical immunology, national research institute for child health and development, tokyo, japan background: probiotics consumption during perinatal and postnatal periods reportedly reduces the risk of atopic dermatitis in the offspring, whereas such probiotics consumption did not affect ige levels or the risks of other allergic diseases; the precise mechanism how probiotics consumption reduces the risk of atopic dermatitis remains unknown. we hypothesized that probiotics consumption may reduce skin hypersensitivity to histamine. to test this hypothesis, we investigated whether perinatal/postnatal consumption of yogurt associates with skin hypersensitivity to histamine or not. method: this was a cross-sectional study enrolled motherinfant (≥ -months-old) pairs. physician-diagnosed allergic diseases and food consumption, such as milk, fermented drinks, and yogurt, by mothers during the third trimester of pregnancy and by infants during the first months of life were assessed using self-questionnaires. skin prick tests (spts) to saline and mg/ml histamine were performed using bifurcated needles, and wheal sizes were measured minutes after the puncture. the spt wheal sizes in infants with eczema/atopic dermatitis (n = ) were significantly larger than those in infants without eczema/atopic dermatitis (n = ; . ± . mm vs . ± . mm, respectively, p = . ), and thus these infants were excluded from the further analyses. the spt wheal sizes to histamine in infants with daily yogurt consumption during the first the aim of this study was to evaluate the prevalence and clinical relevance of sensitization to profilins in atopic patients with food allergy. the study was performed on a group of children age - years with sensitization to at least one plant-derived food allergen (ige > . ku/l). the included patients had never been treated with allergen immunotherapy before the study. the presence of ige to recombinant (r) rbet v , rart v and ramb a in serum was evaluated using elisa method as previously described (jbc ; : ) . in addition serum level of igg to rbet v , rart v and ramb a was also evaluated. results: sensitization to profilins was found in out of ( . %) patients (p+). sensitization to all studied profilins was demonstrated in each p+ patient. the remaining children, with pollenfood sensitization, were not sensitized to any of the studied profilins and they served as a comparator group (p−). analysis of the clinical status revealed that asymptomatic patients in regard to plant-derived food hypersensitivity were found more frequently among p+ ( %) than p− ( . ; p < . ) patients. sensitization to profilin was associated with positive ige to the same food allergens as in the control group. clinical manifestation of pollen-food sensitization expressed as allergic rhinitis, bronchial asthma and atopic dermatitis was comparable between groups, except of oral allergy syndrome, which was not seen among p+ children. similarly, history of anaphylaxis to plant-derived foods was registered only among p− ( . %) patients. interestingly, all patients with sensitization to profilins had also elevated level of serum igg against rbet v , rart v and ramb a . results: no significant difference of physician-diagnosed eczema (p = . ) or current eczema (p = . ) was observed between children born full-term and preterm. after stratifying by atopy status, we found that children born preterm had a more than three-fold higher risk of having physician-diagnosed eczema (adjusted or (aor) = . ; % ci = . - . ; p = . ) and current eczema (aor = . ; % ci = . - . , p = . ) than their counterpart in the non-atopic group. no statistical significance was observed for the association between preterm birth and eczema in the atopic group. no association between preterm birth and eczema was found when stratifying by gender. our results reveal that non-atopic children born preterm have a higher risk of developing eczema. the results suggest potential modifiable effect of atopy on the association between preterm birth and eczema. further studies with a larger sample size are needed to validate the findings in this study. background: there is a need for more knowledge about factors of importance for a successful transition from childhood to adulthood among adolescents with allergic disease and especially those with severe allergy. therefore the aim of this study was to describe experiences of living with severe allergy from the adolescents and their parent's perspective and thereby identify factors of importance for transition from pediatric to adult care. method: a qualitative study was performed based on six focus groups interviews, two with adolescents and four with their parents. in total adolescents (age - years old) and parents participated. the interview guide contained questions about experiences of living with severe allergy. the transcribed data was analysed using systematic text condensation. results: in total four themes were presented, two themes occurred in both the adolescent and the parent's focus groups, to be special and to be prepared. for two themes there was a difference between the adolescents and their parents. the theme, the importance of the parents, only occurred in data from the adolescents and the theme the meetings with health care only occurred in the parent's data. the adolescents felt that they had low priority in the class and several stated they were teased at school and their parents felt that focus on their child often was in a negative way. the adolescents described that they took responsibility for their diseases while their parents expressed a need to protect. the adolescents stated that one of the parents were always present or had been during the years, the reason being safety and security. only the parents mentioned experiences from healthcare. parents who described that they had continuity in healthcare meetings and where met by high competence and with a professional approach were more satisfied with the support from the health care. one factor that was felt to be important was whether the doctor involved the youth in the conversation or not. the teenagers in this study relied on their parents while also taking responsibility for their illness at the same time. parents, on the other hand, showed a tendency to overprotect their adolescents. for healthcare professionals it is important to involve the adolescents in the care to facilitate the transition. results: . % of the children used antibiotics currently and . % out of them used antibiotics ≥ times yearly. current wheeze (w) was established in . %, sleep-disturbing w in . %, exerciseinduced w in . %, dry night cough apart from a cold in . %, and asthma in . %. current antibiotics use ≥ times yearly was positively associated with current w (aor: . ; . - . ; p < . ), sleep-disturbing w (aor: . ; . - . ; p < . ), exercise-induced w (aor: . ; . - . ; p = . ), dry night cough (aor: . ; . - . ; p < . ), and diagnosed asthma (aor: . ; . - . ; p = . ) while antibiotics use < times yearly was positively associated only with current w (p = . ) and dry night cough (p = . ). the results suggest an aggravating role of antibiotics use on asthma in school age thus further supporting the recommended restriction of antibiotics exposure. results: after questioning . % % ci, . - . were suffering from respiratory diseases, having symptoms of chronic disease: cough- . %, wheezing- . %, tightness in the chest- . %. the risk factors (passive smoking, open fire house warming and no air conditioning) were commonly met in major cases at ill children rather than healthy ones ( . % % ci, . - . ). as a result of studies made of the equal to . ± . , comparative the end of lessons equal . ± . (p ≤ . ); air relative humidity varies during lessons equal with . ± . (norma toilet %- %); co concentration exceeds allowable limits − . ± . (mac − . %). conclusion: respiratory morbidity in high school examined has a tendency to increase. we noticed deviations from the hygienic norms: the indoor temperature and relative humidity was lower and the co level was twice higher than the normal one. the "asthma ever" outcome was reported in cohorts. cohorts defined this as parental reported asthma (with or without specifying that it was doctor-diagnosed), cohorts used gp records as the only source of diagnosis, and used parental report or gp records. the "current asthma" outcome was reported in cohorts. there was little consistency with how current asthma was defined or worded, with different definitions used. the most common definition of current asthma, reported times, was "asthma ever and either asthma symptoms in the last months or asthma medication in the last months". other criteria included in asthma definitions were bronchial hyper-responsiveness, reversible airway obstruction, positive exercise test, and asthma symptoms reported at a previous questionnaire. only one "current asthma" definition was based exclusively on prescription data: "dispensed two asthma medication during the past year". nine cohorts reported asthma outcomes without specifying how it was defined, and were categorized as "asthma unspecified". conclusion: "asthma ever" and "current asthma" are two main asthma outcomes used to define asthma in child cohort studies. definitions of asthma vary substantially across cohorts. case report: thereby we present two case reports of two children with impairment verbal communication as part of asd and allergic diseases. the first patient was a year old boy with sneezing, rhinorrhea night cough and eye redness. he had been suffering for almost years from the above mentioned symptoms. he had family history for atopic diseases and was for month breastfed. specific ige revealed sensitization to birch, alder, hazel, oak, mugwort pollen and dog epithelia and dermatophagoides farinae. specific ige resulted positive for nuts and rye flour. the second patient was almost year of age in the tame that he presented in our hospital. he cried and screamed all the time because of severe atopic dermatitis and typical symptoms such as itching all over the body and his impairment of verbal communication. specific sensitization showed sensibilization to egg white and egg yolk, to nuts, rye and wheat flour. the food specific ige leaded to positive results to alder, birch, hazel and oak pollen, but also to grasses, ragweed and mugwort. prick by prick test showed positivity to egg white and egg yolk. atopy patch test to pollens resulted negative. results: the first patient symptoms were well controlled after treatment with antileukotrienes. his verbal communication was also improved after a year or more. the second three year old patient after required a combination of specific treatment with antihistamines, corticosteroids, immunosuppressive drugs and diet recommendation. afterwards he had a reduced level of itching and anxiety but compared to other children he had a severe eczema. erythema multiforme (em) is an acute, immune-mediated, mucocutaneous condition that is most commonly caused by infection and drugs. it is characterized by targetoid lesions, sometimes accompanied by oral, genital or ocular mucosal erosions. there was no pediatric patient that had previously been reported in the literature with development of type reaction after omalizumab treatment. we presented a case who developed em to omalizumab therapy. an year-old female patient was admitted to pediatric allergy clinic with complaints of fever and rash. she had been diagnosed with chronic spontaneous urticaria (csu) years ago and she was planned to treat with omalizumab ( mg, subcutaneously every week) because of the inadequate response of antihistamines at a medical center. her complete blood counts, liver, renal, thyroid function tests and serum c ,c ,c esterase inhibitor protein levels introduction: celiac disease is an autoimmune disease triggered by exposure to gluten in genetically predisposed individuals and characterized by chronic inflammation of the small intestine. chronic urticaria is a skin disease, characterized by the appearance of pruritic wheals with or without angioedema, whose underlying mechanism cannot be identified. objective: to report a sporadic case of an -year-old boy with chronic urticaria associated with celiac disease. methods: an -year-old boy(weight kg, rd- th percentiles) was admitted to our clinic with a -year history of chronic urticaria. during the first three years, he was under antihistamine treatment(of incremental doses)and occasionally received preparations of cortisone according to the eaaci guidelines. he was asymptomatic for years until treatment was discontinued. eight months earlier, after a viral infection, a recurrence of urticaria, involving the trunk and extremities without angioedema was noted. subsequently, he was under antihistamine treatment with cetirizine but had an uas- score of . total laboratory investigations were performed. results: laboratory control was negative except for positive antibodies to celiac disease(anti-transglutaminase > u/ml, anti-endomysial, gliadin antibodies).further control with colonoscopy and biopsies (from duodenum and stomach) were obtained. the histopathological findings along with the clinical findings indicate celiac disease, type b marsch-oberhuber and grade b corazza-villanacci. in the past, similar cases have been reported. efforts have been made to associate chronic urticaria with celiac disease, although the mechanism remains unclarified. evidence suggests that the duration of gluten exposure, among otherwise asymptomatic patients with celiac disease, is related to the development of other autoimmune mechanisms. this can be explained by resolution of urticaria manifestations after the onset of gluten-free diet. in our case, three months after gluten-free diet, an improvement of urticaria with decreased uas- score of was observed. conclusion: he specific case of subclinical diagnosis of celiac disease in a child with chronic resistant urticaria further reinforces the suggestion that screening for celiac disease should be included in the diagnostic approach of chronic urticaria. | allergy to gingival balm in an infant with cow's milk protein allergy we report a case of an infant with a diagnosis of cmpa with an allergic reaction to a gingival balm caused by the presence of cmp in its constitution. furthermore, it is important to reinforce that milk proteins were labeled in an unusual form which might increase the risk of misunderstanding. these findings illustrate the difficulty in implementing total avoidance of common food allergens as well as the need to improve their labeling, particularly in non-food products. bakiri ah results: after specific treatment with corticosteroids, antihistamines, emollient creams, disinfectants and antileukotriens he was feeling better, he was smiling again and wished to have the chance to play with his classmates again. conclusion: this case report shows an association between level of stress and risk for atopic dermatitis. as previously showed children with low educational level parents and boys with higher stress have increased risk of having severe atopic dermatitis as compared to "no stress" boys. so early treatment and diagnoses are key important factors improving the children`s social life. results: the data cover immigrants (mean age . , range - ) and locals (mean age . , range - ). a slight difference in male prevalence ( . % vs %, p = . ), and pet possession ( . % vs . %, p = . ) were found between immigrants and locals, respectively. no differences were find in term of age and symptoms at presentation. the pattern of sensitization to the different allergens showed no statistically significant differences between migrants and controls. the rate of monosensitization resulted slightly higher in migrants ( . %) than controls ( . %). pollen-only sensitization was statistically higher among migrants than control ( . % vs . %, p < . ). monosensitization was more frequent among patients who have been living in italy for less than years ( . % vs %, p = . ). the opposite phenomena can be seen among polysensitized patients. conclusion: migrants are more frequently monosensitized than locals and tends to cluster towards either a pollen or dust mite sensitization. sensitization to house dust mite tends to appear early (< years of stay). pollen or mixed sensitization is more frequent the longer the residence time. | allergenonline.org: update of comprehensive allergen and celiac protein searchable databases for risk assessment of novel food proteins goodman re ; baumert jl ; taylor sl ; ebisawa m ; ferreira f ; bohle b ; van ree r ; kleine-tebbe j ; abdelmoteleb m ; koning f ; amnuaycheewa p conclusion: allergen and cd databases have been updated following a described review process. they can be used to identify proteins that might represent risks of food allergy or cd for affected consumers. han dh ; lee jw ; yim hj ; ko yk ; kim d ; rhee c seoul national university hospital, seoul, south korea; seoul national university bundang hospital, seoul, south korea background: stress can change the immune response and aggravate various allergic diseases. we already demonstrated in previous allergic rhinitis cohort (arco) kids study that stress might be a risk factor for pediatric allergic rhinitis (ar). the aim of this arco study is to investigate relationship between stress intensity, symptoms severity and quality of life as well as allergic markers in adult ar patients. results: as stress intensity increased, the proportion of moderatesevere ar patients was significantly increased. ar patients in high stress group was likely to belong to moderate-severe group (or, . ; % ci, . - . ). global vas of ar symptom was . ± . in high stress group and . ± . in low stress group, respectively. the each rqlq domain score was significantly higher in high stress group than in low stress group. total rqlq scores were . ± . in high stress group and . ± . in low stress group, respectively. however, as the level of stress increased, there were no significant changes in serum levels of allergic markers. our results suggest that stress may affect ar symptom severity and quality of life in ar patients. | skincare and synbiotics for the prevention of atopic dermatitis or food allergy in newborn infants: a × factorial randomized non-treatment controlled trial dissanayake e ; tani y ; sahara m ; mitsuishi c ; nagai k ; sato y ; suzuki y ; nakano t ; yamaide f ; shimojo n (n = ). the skin care group was advised to apply an emollient - times/day especially on cheeks and peri-oral area. the synbiotics group consumed a mixture of fos ( g) and bifidobacterium bifidu-mol ( × )/day. the last group received both. emollient application was not prohibited in the no-intervention group. interventions were carried out from birth to months of age. the development of ad was assessed at month, months and months by a pediatrician and at year by a questionnaire. ad was diagnosed using guidelines of the japanese society of dermatology. sensitization to food allergens was assessed by allergen-specific ige levels at months of age. results: skin care and synbiotics, alone or in combination, did not prevent the development of ad at year of age or the sensitization to food allergens at months of age. conclusion: our data suggest that skin barrier protection using emollients may be insufficient to prevent the development of ad as other factors affecting skin barrier integrity and trans-epidermal water loss such as the method of skin washing may have an additional effect. the probiotic bacterial species used may also affect the outcome as lactobacilli have been shown to be more beneficial. more studies are required to confirm the effects of skin care and synbiotics on ad. results: in the population number of girls exceeded the one of boys (p < . ), especially within the age group from to years. questioning, for months, symptoms of allergic rhinitis (rhinorrhea, sneezing, nose itch, nasal obstruction and eyes' itch) were identified in . (p < . ); symptoms of bronchial asthma (wheezing ( %), episodes of cough at night ( . %), intolerance to physical load ( . %), indoor and outdoor ( . %), coughing and rales in response to stimulus ( . %)) in . % of the population; atopic dermatitis (dermatitis, itch, revelation in early age, involvement of large areas in early age, damage of extremities bending and stretching surfaces in adults)- . % (p < . ); food allergy- . % (p < . ) etc. at the second stage of clinical studies, on the basis of prick-testing, average ige, in our case, was - times greater than normal level. results of study of allergens showed sensibilization to domestic dust (d.f. and d.p.) ( , %) (p < . ). in . % of cases there was stated sensibilization conditioned by cat and dog epidermal allergens results: among the women with available serum, . % were sensitized of whom . % were monosensitised, and . % polysensitised (to two or more allergens). sensitisation to inhalant allergens dominated ( . %), with grass being most common ( . %). only . % were sensitized to food allergens, most often to peanuts ( . %), while among the . % who reported ddfa, ige reactivity to foods were identified in . %. compared to women with no asthma, women with dda ( . %) were in a significantly higher background: regular exercise has been known as beneficial that it reduces the risk of chronic diseases including allergic diseases. however, little has known regarding the relationship between exercise and allergic diseases in korean adolescents. we analyzed the national data whether exercise is related to the prevalence of allergic diseases in the population of korean adolescents method: data from sixth korean national health and nutrition examination survey ( - ) that included adolescents from to years old was analyzed. we defined regular exercise according to physical activity guidelines for americans. multivariate regression analysis was performed to find whether lack of exercise could be a risk factor for allergic diseases. results: the prevalence of asthma, allergic rhinitis (ar) and atopic dermatitis (ad) were . %, . % and . % in korean adolescents, respectively. after adjusting for factors, lack of exercise was not associated with asthma and ar, but was significantly related to ad in korean adolescents (adjusted odd ratio . , . - . , results: it was found that over % of ch up to y.o. having the ad within allergic disease (ads). the most significant symptom was a long-lasting itchy rash lasting for month in . ± . % of g and . ± . % of g. the first morbidity of ad was noticed at the age of up to y.o. among . ± . %. at the age of ch - y.o. and older than y.o. the skin ads onset was noticed for . ± . % and . ± . % accordingly. the ad sl was determined as follows: %moderate (mo), %severity (s), % were ± kua/l, ± iu/l respectively. skin prick tests were positive in . % of the patients ( . % multiple allergens). grass pollens ( %) and dermatophagoides ( . %) were the most common allergens. average vitamin a and d levels were . ± μg/l ( - ), . ± . ( - ) respectively. thirty percent of the patients vitamin d levels were mildly low, . percent was low. in control group % was mildly low, vitamin a levels was low in . % of the patients. none of the children in control group had low vitamin a levels. we didn't find any statistical significant difference for both vitamin levels between patient and control groups. vitamin a deficiency was mostly found in asthma patients whereas vitamin d deficiency was mostly in allergic rhinitis and asthma groups. passive smoking and vitamin d deficiency was significantly related (p = . ). there wasn't any relation between asthma attacks and vitamin levels. conclusion: in conclusion vitamin a and d levels weren't found significantly related with allergic diseases but was found lower than control group. patients having chronic diseases are one of the population groups that are chronically exposed to drugs. this study aims at evaluate the impact of this factors in developing drug allergies in the medical staff. method: this was a cross-sectional study that included nurses from the uhc "mother theresa" of tirana. they were asked to fill up a questionnaire where questions about chronic diseases and drug allergies were included. . % were females and the mean age was . (+ . ) years old. relative risks with % ci were calculated for different groups. results: . % ( ) nurses reported to have at least a chronic disease. the most common non-atopic disease was hta followed by the groups of autoimmune and thyroid diseases. nurses who had one chronic disease have a rr of . ( % ci = . - . , p < . ) to develop a drug disease higher than those who didn't had any chronic disease, and those who have more than one chronic disease have a rr of , p < . ) to develop a drug disease. the presence of chronic diseases can be a risk factor to develop a drug allergy probably through the increased risk to drug exposure. these patients may be exposed to drugs not only through therapy but also through hospitalizations and other forms of health care. lapeere h ; oosterlinck p ; vermeir p ; vermeire i ; coppens m ; gevaert p ghent university hospital/ghent university, ghent, belgium; ghent university hospital, ghent, belgium; ghent university hospital/ghent university, ghent, belgium background: the key to managing latex allergies in healthcare professionals and patients lies in correct recognition and appropriate action. . million people are employed in the health care sector. while there are no overall statistics on the prevalence of latex allergy in that work force, studies do indicate that %- % of health care workers regularly exposed are sensitized, compared with %- % of the general population. latex allergy is defined as an immune mediated reaction to latex products (e.g. balloons, contact dermatitis for gloves, condoms, surgical catheters); these encompass immediate and delayed hypersensitivity reactions. method: based on the experience of the belgian dutch pathway network, a -phase method to develop, implement, evaluate and continuously follow up a care pathway for latex allergy was designed and implemented. the purpose of the study was to develop and implementation of latex allergy clinical care pathways to provide all staff at ghent university hospital with appropriate knowledge and skills to identify and manage patients who have a known latex allergy or those at risk of developing latex allergy. results: care pathways, also known as clinical pathways, are used all over the world to implement and monitor patient-centered care processes in a transparent way. care pathways are defined as a complex intervention. -phase method consists of: ) screening phase; ) project management phase; ) diagnostic-and objectification phase; ) development phase; ) implementation phase; ) evaluation phase and ) continuous follow-up phase. this phased approach is based on the deming cycle, better known as the "plando-study-act" (pdsa)-cycle. conclusion: this method can offer support to multidisciplinary teams (re)designing and implementing safe, efficient, effective, person-centered, timely, equitable, continuous and integrated care processes. however, the method is no guarantee to success. the key to success is the collaboration and critical attitude of the entire multidisciplinary team when implementing pathways. background: cord blood ige (cb-ige) were considered to be a useful predictive tool for allergic symptoms especially in early childhood. there is only sparse knowledge about their importance for health in later life. the aim of our work was to determine the importance of cb-ige for allergic symptoms in young adults. we also studied the possible modifying factors for cb-ige concentration. results: resutls shown as daily mean, pollen grains/m³: table . the daily means of pollen concentrations of cupressus arizonica, platanus acerifolia and plantago lanceolata in our area differs from other sites in madrid city. although cupressus arizonica and platanus acerifolia counting were lower, plantago lanceolata counts were higher, representing a relevant pollen in our area. the clinical relevance of these findings is under evaluation by our group. method: grass pollen counts were performed since - using a burkard days spore trap located in our allergy center in madrid. the beginning of the algid period of pollination was considered the first of three consecutive days with more than grains/m and the end, the last day of three consecutive days with more than grains/m . madrid, barajas meteorological station data, was used. skin prick tests (pt) to grass pollen was also studied in comparison conclusion: total grass pollen concentration did not suffer any increase or decrease in its counts despite the dramatic increase of the temperature. an advance at the beginning and the end of the season was seen. these changes significantly correlate with the temperature increase during may and july. discrete decrease in the sensitization prevalence. since several years, the reference method to monitor the biological particles concentrations has been the hirst method: a volumetric pollen trap, located on the roof of building for background measurements, sucks continuously l of air per minute, particles depositing by impaction on a coated tape. the tape is then analyzed by optical microscopy. the hirst method produces accurate but past data. nowadays, many researches are focused on the development on new devices to get real time information. method: rapid-e from plair sa is a device using red laser beam to determine the size and the shape of sucked particles and an ultraviolet ray to measure the fluorescence of these particles. the results: the correlation coefficients got between rapid-e and hirst trap are higher than % for most of calibrated pollens, this correlation reaching % for all pollen taxa: • plane % • pine % • birch % • oak % • plantain % • dactylus % • urticaceae % conclusion: new calibrations are planned for and a real time information will be set up. results: the quinquennial media concentrations since - were . ; . ; . ; . ; . ; . ; . and . grains/m . the quinquennial media temperatures were . ; . ; . ; . ; . ; . ; . and . °c. increase of . °c (r s = . p < . ). the beginning and the end of the actual season advanced days respectively in regard to the period from to . the annual prevalence of positive pt to platanus in was % an % in . the quinquennial media from to was , , and %. conclusion: platanus pollen counts had a dramatic increase that meaningfully correlates with the dramatic increase of the temperature. a discreet advance at the beginning and the end of the season was seen. these changes did not influence in a longer duration of the season. we observed a significant increase in platanus pollen sensitization prevalence whiting madrid pollinosis patients. results: the quinquennial media concentrations since - were , , , , , , and grains/m . the quinquennial media temperatures were . ; . ; . ; . ; . ; . ; . and . °c. increase of . °c (r s = . p < . ). the actual season beginning advanced in days and the end has results: over % of house dust samples collected between april and may from central european countries were found to contain bet v allergen at levels well above the limit of detection of . μg/g for elisa . ep kit and . μg/g on maria. samples were found to have much higher levels of bet v allergen from midto-late april, particularly those that were collected in germany, belgium and hungary. samples taken from outside of the pollination season were tested and found to be negative for bet v . in conclusion, we found that bet v allergen can be detected and quantified in house dust samples. these data suggest that household dust is a source of pollen allergen and could therefore be contributing to asthma and allergic rhinitis symptoms in individuals affected by pollen allergy. household dust may also be considered as a source of bet v allergen which could contribute to allergic sensitization. | cupressaceae pollen in the atmosphere of alentejo: disruption of pollen grain during air transport spring, depending on the temperature. despite being considered moderately allergenic, it might be responsible for winter allergic outbreaks. as ornamental trees, they are found scattered throughout the territory but are more abundant in pockets of wild forest, outside alentejo. despite being more common in mountain, this pollen type is captured in considerable amounts in alentejo, portugal, where its aerobiological features and allergenic impacts are poorly characterized. the aim of this work is to characterize the aerobiology of cupressaceae pollen, to evaluate the effect the meteorological conditions and the source of this allergenic pollen type in the atmosphere of evora, alentejo. method: pollen were collected using a hirst type -day pollen trap and pollen was identified following standard methodology. background: allergic rhinitis caused by pollen is one of the most common allergic diseases. the presence of pollen in the air is currently centrally monitored at roof top levels, and not in the direct living environment of sensitized subjects. in the current project we aimed to develop a handheld pollen sampler, called pollensniffer, that can collect pollen in the living environment of the allergic subjects. as a first step this device was validated against the standard burkard pollen sampler and used to monitor local pollen concentrations at street level in the city of leiden. method: rooftop level pollen were monitored routinely by a hirst type pollen sampler (burkard, uk). the pollensniffer ( | does the allergy risk due to pollen exposure information is useful for the allergy sufferers? sindt c; oliver g; thibaudon m background: in france the information for the allergy sufferers is not made with pollen counts, which have not a real signification, but with the allergy risk due to pollen exposure. method: since more than years, rnsa (réseau national de surveillance aérobiologique), the french aerobiology network, has measured the pollen exposure in the main cities of france, using background: the effect of environmental factors on allergic sensitizations is still unclear. rural areas vs cities have different exposure levels to pollutants and aeroallergens. these differences could give clues on the causes of higher allergic sensitization rates in children exposed to city air. method: two studies with children aged years old were initialized to analyse the airborne drives of allergic sensitization: seal (günzburg, children) and ae r kids (munich, children). capillary blood was collected and the parents filled in a questionary. sensitization rates were quantified using the immunocap ® isac sige array. pollen data were measured at both locations. results: in günzburg more children were sensitized to aeroallergens, however munich children showed significant higher sensitization to phl p (p < . ), despite the lower concentration of pollen. in günzburg % children had no sensitization at all compared to % in munich. % of the children in munich spend at least hour per day outside and % of the total have no animals at home. % felt symptoms of hay fever in the last months, the majority between march and june, which correlated with the pollen flight. results: the total rate of atopy in crd patients was . %, and asthma patients was the highest ( . %). the positive rate of phadiatop in urban asthma patients ( . %) was significantly higher than that in rural areas ( . %, p < . ) and the phadiatop positive rate of office staff ( . %) was significantly higher than that of outdoor workers ( . %, p < . ). the total rate of atopy in copd patients was . %, and in patients with acute exacerbation was . %. beside, atopy is a risk factor for dyspnea (or = . , p < . ), and the fvc levels in copd patients with atopy were significantly lower than those without ( . l vs . l, p < . ). optimal scaling analysis show that, there were a correlation between the tige and smoking coefficient (cronbach's alpha = . %). in addition, the correlation between the level of tige and phadiatop sige was so strong in the patients with mild to moderate asthma (r s = . , p < . ), but it was weak in severe asthma patients (r s = . , p < . ), and up to . % of the gold iii iv patients with low phadiatop level (≤ ku/l) had a high level of tige (≥ ku/l) compared gold i ii ( . %). conclusion: the rate of atopy in patients with crd is high, and atopy is an important factor affecting the process of crd. the patients with severe copd or asthma is likely to has high serum tige level but the level of common allergen sige is low, so the allergy screening strategy should be adjusted and we should pay attention to those patients, therefore, it is necessary to screen the sensitization situation of crd patients at first, and the results can guide the treatment, management and prevention of crd. background: due to a limited amount of epidemiological data [ ] it has been thought that many severe allergic asthmatics in germany remain unidentified and are therefore not adequately treated. a pilot project demonstrated that more than % of patients, having been mean total ige (sd) was . ( . ) ku/l. . % of the patients had no sensitization towards any of the specific iges tested, whereas % were positively tested on - allergens and further . % showed sensitizations towards > allergens. conclusion: approximately % of online recruited (severe) asthmatics had a total ige level of > ku/l and ≥ sensitization (allergen-specific ige) towards atopic allergens. this further supports the high prevalence of atopy in asthma. results: patients (mean age: ± . years, range - years, m/f ratio: . ) who suffered from allergic rhinitis or allergic rhinoconjunctivitis enrolled in this study. highest rate of skin sensitivity was for weeds/grasses pollen including salsola kali, amaranthus retroflexus, chenopodium album and compositae family ( . %, . %, . % and . % respectively). among tree's pollen; ash ( %), walnut ( . %) and mesquite ( . %) were the most common. less than % of patients showed skin reactivity to indoor allergens and storage mites, mix of cockroaches and house dust were the most common ( . %, . % and . % respectively). the results of current study confirmed the importance of weed/grass and trees pollen as the major source of allergic sensitization in our area. interestingly the rate of sensitization to indoor allergens was low which can be explained by geo-climatic situation. background: there are few studies of cutaneous sensitivity to gramineae in our region. mostly of them use allergens of foreign species. the study aims to estimate the prevalence of skin sensitivity to widespread grasses in our region. method: this is a retrospective observational study of patients with seasonal allergic rhinitis. patients were studied using skin tests with pollens extracts from pooideae, chloridoideae and panicoideae grass species. results: the prevalence of positive reaction to pollen from pooideae subfamily was . % (ic: . %- . %). in turn, prevalence of allergy to panicoideae subfamily pollens was . % (ic: . %- . %) and positive reaction to chloridoideae subfamily reach . % (ic: . %- . %). cochran test suggests that prevalence in those three groups is different (χ = . , p < . ). when comparing just the groups of allergens from pooideae and panicoideae differences are also significant (χ = . , p < . ). in particular, . % (ic: . %- . %) of patients were allergic to paspalum notatum. regarding cross-reactivity between subfamilies, we find a no crosscorrelation between pooideae and panicoideae (χ = . , p = . ). conclusion: in bahia blanca, patients with seasonal rhinitis are sensitive to pooideae, chloridoideae and panicoideae. paspalum notatum, belonging to panicoideae, has a significant prevalence, high reactivity and low cross-reactivity within the group of species studied. this last species is relevant because it is a native grass from the northwest region of our country, paraguay and the south of brazil. prevalence of grass positive skin tests in patients with seasonal rhinitis by species. allergen frequency percentage % ci results: correlation analyzes were performed between sige and spt and area results. the concentration with the highest correlation by diameter and area for blo t was μg/ml and for der f of μg/ml. in the case of der p the concentration with the highest correlation for the diameter was μg/ml and for the area of μg/ml. when evaluating the reproducibility of the results according to the area and the greater diameter of the spt, a strong agreement was observed for blo t in the concentrations of μg/ml and . μg/ml. results: among the patients, the majority of allergens-positive was t , accounting for . %, followed by f ( . %), f ( . %), ds ( . %) and ccd ( . %). the prevalence of plant-related allergens (t , w , f , f , w and u ) in ccd-positive patients were significantly higher than those in ccd-negative patients (all results: with our new point-of-care methods using a selected recombinant protein e other markers, we were able to detect the disease early as days post-infection and more than % of positive cases from chronic and low endemicity areas (which are characterized by hard to detect patients with extremely low parasite load, < eggs per gram of feces) were obtained. plus, chromatography poc-cca ® test was improved by our group with a urine concentration step that turned its sensibility from % to %. conclusion: monoclonal antibody and recombinant protein technologies allowed superior detection methods when comparing it to the conventional ones. in conclusion, data showed % of sensitivity of chronic patients and % of acute patients. marton c county hospital, oradea, romania background: allergic rhinitis is a disease that affects about a quarter of the population, a disease with an important negative impact on daily activities, both on learning and working ability, as well as spending leisure time or sleeping. in the western part of romania, the most popular and blamed allergen is ambrosia, in the late summer months. it is a plant of the compositae/asteraceae family, along with goldenrod, sunflower, dandelion, cocklebur, chamomile, wormwood, daisy, etc. allergen identification is important for applying prophylactic measures, but especially for determining the allergen to be desensitized. considering the possible cross-reactivity within the compositae plant family, as well as the possibility of co-sensitization, as well as the number of patients sensitized to these pollens, which is steadily increasing, i considered is necessary a broad screening for a more precise identification of the allergen and increase chances for a successful desensitization. method: the observational study includes patients who presented on october for testing with standardized allergen extracts, as recommended. criteria for inclusion: patients with specific symptoms of rhinoconjunctivitis in august and september, with or without asthma symptoms, who returned for allergic prick test after the end of treatment. criteria for exclusion: patients who disagreed with cutaneous testing, who did not discontinue antihistamine treatment or who had been treated for other diseases with drugs that influence skin testing. background: in recent years, cationic liposomes are thought to be the most effective and non-toxical nucleic acids`transport system, so most of gene therapy drugs are developed on their base. however, lipoplexes are quickly captured by reticuloendothelial system cells after the injection and taken out of a blood stream. there are many modification methods of liposomal surface for liposomes with prolonged pharmacokinetic properties production. addition of hydrophilic polymers (peg) is seemed to be the most promising approach, that is able not only to create steric barrier on the particle`s surface and prevent the interaction with blood plasma lipoproteins, but also inhibits the protein adsorption, opsonisation and subsequent degradation in human body. the aim of this study is the evaluation of liposomal surface modification by hydrophilic polymers influence on nucleic acids`lipoplexes conjugation and on their physico-chemical and biological properties. method: liposomes preparation (including peg-modified liposomes), size determination by photon-correlation spectroscopy, examination of transfection efficacy by luciferase assay. (c h ) ) were obtained. also the modified liposomes were produced by addition of % of peg (by mass) during thin lipid layer preparation step. the size distribution was analysed by photon-correlation spectroscopy. it was shown that peg addition does not increase the par- conclusion: it can be noted that addition of peg can change the lipoplex formation but the cationic liposomes still remain an effective rna delivery system. and peg modification will be able to impart prolonged properties for the vehicle in bloodstream. foundation (grant № - - ). ory c may cause a cross reaction with fel d (cat), can f (dog), equ c (horse), mus m (mouse) and rat n (rat). february eight patients that were treated at our institution were diagnosed with rabbit allergy. results: all eight patients with the diagnosis of rabbit allergy presented with signs of upper respiratory involvement. two patients had itching teary eyes, watery nasal discharge and sneezing while feeding farm rabbits. one of those also presented with dyspnea. four patients developed problems whenever in contact with domestic rabbits. one patient developed allergic rhinoconjunctivitis whenever she was home-her parents own a rabbit, but while away in her college room she had no problems. another patient had dyspnea whenever visiting his girlfriend's house. she owned a rabbit. two patients developed asthma-like symptoms, one also presented with angioedema. the other two had developed allergic rhinoconjunctivitis. two patients have problems in contact with cats, one of them also with cows, however skin prick tests were also positive to rabbit. three out of eight patients developed allergic asthma with a positive methacholine test. six patients had a positive house dust mite prick test. all patients were diagnosed with a positive prick tests to rabbit allergens. all were treated with a nasal steroid and antihistaminesic. they were also advised to avoid contact with the animal. conclusion: domestic rabbit-induced asthma and/or allergic rhinoconjunctivitis is possible, however it is still rare in our environment. it is very important to always ask the patient about their pets in general, not just focusing on cats or dogs. only with a thorough examination and history we can find the true cause of the patient's allergy where pets play an important role. korea. changes of protein and major allergen concentration were measured over one year by bradford assay, two-site elsia, and sds-page after reconstitution of the lyophilized allergen extracts in various buffer (normal saline, . % phenol saline, and or % glycerol with saline) and stored at room temperature (rt, ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) or refrigerated ( °c). results: more than % of the initial protein concentration in all four extracts examined was detected over one year when % glycerol was added and refrigerated, whereas . %- . % remained in the extracts at rt. the addition of % glycerol to the storage buffer was found to prevent protein degradation at rt. all four extracts were found to be stable when reconstituted in % glycerol. amb a , a major allergen of ragweed, was almost completely degraded in weeks at rt when reconstituted in a buffer without % glycerol. however, . %- . % of amb a content was detected after one year of incubation at °c in all buffer conditions except . % phenol. conclusion: addition of % glycerol as well as refrigeration was found to be the important to increase the shelf-life of allergen extracts from pollens of allergenic importance. results: this is the first genetic study of the bulgarian hae patients. genetic defects were identified in hae families are: nonsense, splice-site defects, frameshift mutations, indel non frameshift, missense, and large deletion of exon . novel mutations, not previously reported in human gene mutation databases were discovered, and were predicted to be deleterious due to the expected effect on dna transcript and protein. descriptive statistics were used to summarize the eq- d-y descriptive system responses and vas scores by treatment and visit. results: twelve patients with hae type i and a median (range) age of . ( ) ( ) ( ) ( ) ( ) years were enrolled, ( . %) of whom were female. during bop, treatment with u c inh, and u c -inh, ≤ . %, ≤ . %, and none of the patients, respectively, reported having problems with mobility, self-care, doing usual activities, pain or discomfort, and feeling worried, sad or unhappy. the mean [sd] eq- d vas scores increased from . ( . results: overall, the model-derived median exposure and peak concentration across all weight ranges in paediatric patients is predicted to be higher with wb vs weight-based dosing (table) . the effect was most pronounced in patients aged - years, where the wb dosing achieved approximately % higher values than weight-based dosing for median auc - ( ng hour/ml vs ng hour/ml, respectively) and c max values ( ng/ml vs ng/ml, respectively). the wb levels are closer to those in adults receiving mg icatibant (median auc - ng hour/ml; median c max ng/ ml) but never exceed them. results: samples from patients were analysed. lanadelumab concentrations in plasma increased with higher doses and dosing frequencies. steady state was reached around week (range week to week as evaluated by predose concentrations). at baseline, mean (sd) chmwk levels were . % ( . ), . % ( . ), . % ( . ) and . % ( . ) for patients in the placebo and lanadelumab mg q wks, mg q wks and mg q wks treatment arms, respectively. by week , mean (sd) chmwk levels decreased to . % ( . ), . % ( . ), and . % ( . ) following treatment with lanadelumab mg q wks, mg q wks, and mg q wks, respectively, and remained reduced throughout the treatment period. conversely, chmwk levels remained elevated at . % ( . ) at week in patients who received placebo. patients in the placebo group had the highest attack rates over the -week treatment period (mean . attacks/month), whereas the rates were markedly lower in patients treated with lanadelumab mg q wks ( . attacks/month), mg q wks ( . attacks/month) and mg q wks ( . attacks/month). dose-and frequency-dependent manner. exposure to lanadelumab was associated with decreased chmwk levels (indicating inhibition of plasma kallikrein activity) and lower hae attack rates, corroborating the efficacy findings and utility of chmwk as a bioactivity marker in the help study. with cyklokapron (tranexamic acid) since she was years old and took the medication very irregularly due to lack of efficacy. one year before presentation at our clinic, she married and moved to vienna. we started a treatment with the bradykinin- receptorantagonist icatibant sc at the beginning of the menses and if needed a second time at the time of ovulation. she responded well until she got pregnant. during pregnancy, she developed weekly attacks with increasing severity. therefore, a weekly treatment with humanplasma-derived, pasteurized, nanofiltered c -inhibitor (inh)-concentrate, units iv once a week was started and had to be increased to twice per week after one month of therapy due to increasing number and severity of attacks. results: with this treatment attack frequency and severity attenuated. in january she had a normal delivery at term and gave birth to an otherwise healthy son. treatment had to be continued during year of lactation period and also thereafter due to persistent attack severity. conclusion: there are only limited data for the use of humanplasma-derived, pasteurized, nanofiltered c -inh concentrate during pregnancy and lactation period. this case confirms the safety and efficacy of the named drug during these periods. wheals are yet classified. the best characterized stem from hereditary or acquired c inhibitor deficiency (c -inh-hae and c -inh-aae) . last year, the french angioedema network (creak) joined the registry of angioedema without wheals (cloud-r hae). here we present the contribution of the grenoble alpes university hospital (chuga) to this disease registry. the study population is composed of patients with a proved diagnosis of c -inh-hae/aae. the following items are collected: patients' personal-demographic data, clinical/laboratory/genetic characteristics, major comorbidities, treatments (prophylaxis/acute attacks). data from existing registries at chuga are merged into cloud-r hae and missing data obtained at follow-up visits. as from cloud-r hae structure, patients can directly provide information on angioedema attacks and their treatment through a dedicated electronic app, web connection or paper support, which is then transferred into the registry at chuga. method: in a retrospective study, we included a total number of patients, suffering from a chronic skin disease, whose lesions did not improve or even worsened under immunosuppressive treatment ( chronic ulcers/pyoderma gangrenosum, bullous autoimmune diseases, skin lymphomas). ffpe tissue was examined for the presence of cmv dna by pcr. next, within the framework of a small prospective study (n = ) we analyzed the seroprevalence of cmv as well as the presence of cmv dna in lesional skin in patients that had been diagnosed with a chronic skin disease and in whom longterm immunosuppressive therapy had been initiated. results: in the retrospective study cmv dna could only be detected in / chronic ulcers/pyoderma gangrenosum ( . %), but not in bullous autoimmune diseases and skin lymphomas. / patients ( . %) of the prospective study group were seropositive for anti-cmv-igg, as compared to / patients ( . %) in an ageand sex-matched control group. anti-cmv-igm could be detected in method: in this study, we aimed at testing the diagnostic potential of skin function measurements in ss. sixteen patients with conformed diagnosis ss were enrolled in the study. skin fibrosis was assessed by conventional rss and involvement of inner organs and serum inflammation parameters were determined. four objective criteria, namely transepidermal water loss (tewl), corneometry, ph and elasticity, were assessed at nine predefined sites of the body. results were compared to patients with atopic dermatitis (n = ) and acne vulgaris (n = ). method: a multicenter prospective observational study was conducted to investigate the clinical significance of serum scca in children as a biomarker for ad. patients with ad younger than years old and age-matched healthy children without any allergic disease were enrolled in this study. the severity of ad was evaluated using the objective scorad (o-scorad). the serum levels of scca , tarc and total ige were also measured. results: in total, patients with ad and non-allergic healthy children were recruited. the serum levels of scca had the strongest significant correlation with o-scorad, compared with tarc and ige (r = . , and . , respectively). after standard treatment with topical steroids and emollients resulting in an improvement of symptoms, the serum levels of scca and tarc decreased significantly. the area under the curve (auc) for the roc curve was higher for scca ( . ) than for tarc ( . ) or ige ( . ). the difference in aucs between a single cut-off value and age-dependent cut-off values was not significant for scca , compared with that for tarc ( . and . , respectively). conclusion: scca is a more reliable biomarker than tarc for the diagnosis of ad and for determining the clinical severity of ad in children. challenges in predicting severity of atopic eczema patients results: before modeling, we checked for significant differences between patients and controls. these were detected for the levels of ccl , ccl , cxcl , ige and ldh. next, we assessed whether single serum proteins already explain disease severity by calculating correlations. twelve of the proteins, namely gcsf, il- , il- , il- , ccl , il- ra, cxcl , ifng, ccl , il- ß, ccl , and il- , significantly correlate with severity (r range: . - . ). finally, we built a model for the severity of ae based on all measured serum proteins. ten of the proteins are included in the best-fit model (adjusted r = . ). the overall correlation between original and predicted severity scores is high (r = . ) nevertheless the cross validation prediction error is substantial with %. conclusion: applied in daily practice, a prediction error of % translates to a possible miscalculation of scorad points in both directions and therefore the model is of no practical use. aside from using model-based quality measures like cross validation prediction errors to infer the usefulness of predictive models, testing them in independent cohorts could validate these models. collaborations among scientists working on similar approaches would lead to an increase in statistical power and ideally to more robust models. only robust and validated models are going to have the chance to take the step forward from being a result of computational modeling to being applied in the clinical practice of assessing disease severity in patients. jargosch m ; lauffer f ; pätzold k ; krause l ; garzorz-stark n ; schmidt-weber c ; eyerich s ; eyerich k preclinical studies in cell cultures, mice, guinea pigs and rabbits, comprising sterility, cytotoxicity, systemic toxicity, skin irritation, delay contact sensitization and phototoxicity tests, demonstrated safety of this therapeutic agent. we next conducted a single-blinded, intra-individually controlled, phased clinical trial on patients with keloids. the aim was to determine the effects of -month therapy on keloid volume and symptoms of pain and itch. two similar keloids on each subject were selectedone was treated with once-daily, self-administered application of triamcinolone-loaded ( . mg/patch) microneedles for weeks, while the other served as control with no intervention. outcome measures were (a) keloid volume using a -dimensional high-resolution ( . mm) scanner and (b) pain and itch scores on - numerical rating scales. evaluations were performed at baseline, and weeks. in phase of the trial, the whole process was repeated using microneedles loaded with a higher dose of triamcinolone ( . mg/patch). case report: a -year-old girl was admitted to our department with a single round-shaped lesion in the popliteal fossa which spread to extremities, trunk and face and persisted for several weeks and then faded slowly to residual hyperpigmented patches. courses of antihistamines, antibiotics, cyclosporine a, fluconazole, hydroxychloroquine, prednisolone and topical steroids were ineffective. also patient has had history of itchy urticarial rash and angioedema since -year-old, suffered from the flares triggered by physical exertion, stress, cold air and water, spicy food, which resolved within - hours. the patient's father and -year-old brother also had chronic urticaria induced by the same stimuli. the physical examination revealed multiple pink-to-red non-scaly, non-pruritic papules coalescing into annular, arcuate, polycyclic plaques ( - cm) with central clearing, centrifugal spread, indu- | the role of humoral immunity in the pathogenesis of psoriasis results: we found significantly increased levels of iga in the serum of treatment-naïve psoriasis patients correlating with disease score. however, iga was only observed in dermal vessels of skin sections. we next performed in-depth analysis of peripheral b cell subsets using flow cytometry. among all investigated subsets, we only found a moderate positive correlation of cd + plasma cells with iga levels and disease score in untreated psoriasis patients. however, in the group of treated psoriasis patients, neither did iga levels drop nor did plasma cells correlate with iga levels and disease score, rather hinting at an epiphenomenal finding. confirming our hypothesis that psoriasis can develop in the absence of proper humoral immunity, we present a patient who suffered concomitantly from both psoriasis and a hereditary common variable immune defect (cvid). conclusion: here, we provide new insights in the immunology of psoriasis, demonstrating the clear dominance of t cells over shifts in b cell subsets. conclusion: allergic diseases show an increasing incidence in geriatric age. this is partly due to the growing emphasis on a more accurate and careful diagnosis of the aging population. we must also take into consideration the influence of other factors, besides comorbidities and therapeutic regimens in elderly that might affects the immune response, such as environmental pollution as well as food contamination and changing dietary habits of elderly such as easy access to exotic food. one of the challenges in the decades to come is recognizing and fulfilling the need for accurate and timely diagnostics of allergic manifestations in elderly patients, as important part of achieving the best possible quality of life for this growing age group. method: sixty-eight patients with various forms of psoriasis and healthy subjects (healthy control group) were assessed after informed consent was obtained. all subjects were asked to complete a questionnaire including age, gender, duration of psoriasis, concomitant diseases and medications. in the group of patients psoriasis was with only skin involvement with skin plus joints involvement ranging from moderate to severe. psoriaticplaques were evaluated by a specialized medical team using the psoriasis area and severity index (pasi). all patients were seen by a dermatologist and clinical immunologist, who collected data considering the demographic, health status and any other relevant details. blood samples included serum levels of -hydroxycholecalciferol and tnf-α using an elisa kit (germany). method: % ethanolic extract of sp (sp etoh ) and its five major chemical constituents are prepared. to elucidate whether human orai modulated by sp etoh and its chemical constituents, conventional whole-cell patch clamp performed in horai -overexpressing hek t cell. we also assessed whether sp etoh and its constituents could inhibit mast cell degranulation and t cell activation. results: in jurkat t lymphocytes, we found that mg/ml sp etoh inhibited orai current (i orai ) by . ± . %, while one of its constituents (compound v (com v ); μm) inhibited i oria by . ± . %. investigation of human primary t cell proliferation induced by co-stimulation with antibodies to cluster of differentiation and , and of rbl- h mast cell degranulation following ige-antigen complex stimulation, revealed that μm com v inhibited both t cell proliferation (by . ± . %) and mast cell degranulation (by . ± . %); these effects were concentrationdependent, and no cytotoxicity was observed. conclusion: considering that most regional plants have not been investigated chemically or pharmaceutically, they remain as untapped potential sources of topical agents for drugs and other application. our findings suggest that com v , which derived from sp etoh , represents a promising candidate compound for the development of therapeutic agents for the prevention and treatment of allergic diseases. results: the cohort consists of caucasian patients. eight of them ( %) are women. the mean age (and range) at the clinical presentation of disease was years ( - years). the mean age at diagnosis for men was years and years for women. all patients have a positive history of recurrent and/or persistent lip swelling, of them ( %) report oral ulceration, cases ( %) have history of previous or current facial palsy and patients ( %) present tongue fissuring. concurrent cd has been diagnosed in one patient. biopsy reports were available for patients ( %); in cases ( %) non-caseating granulomas were seen. various therapeutic approaches have been described: intralesional corticosteroids had a good response in patients, infliximab was partially effective in cases; oral corticosteroids and/or methotrexate seem to cause a partial symptoms improvement. conclusion: this is the first attempt, in our knowledge, to (a) centralize all data of patients with ofg in a national registry with the aim of carrying out epidemiological data and (b) develop italian guidelines including a diagnostic-therapeutic flow chart, shared by the participating centers. the registry will guide the clinicians in the identification and management of the ofg patients, reducing the diagnostic delay and hopefully improving quality of life. case report: a -year-old girl without personal history of atopy, got a temporary tattoo with henna. after three days, she developed a local exudative, erythematous eruption with painful blisters lesions that followed the contours of the tattoo. she had neither fever nor other lesions. she was treated with topic methylprednisolone-gentamicin showing an important improvement days after. as a liquenoid scar remained in tattoo area, trofolastin ® (centella asiatica, αtocopherol, hydrolysed collagen, elastin) patch was prescribed to be placed on the scar. forty-eight hours later, the patch was removed and was newly observed an exudative, erythematous and painful wound that required oral treatment with amoxicillin-clavulanic. after three days, the girl developed on a maculopapular, generalized and itching rash. she was treated with dexchlorpheniramine and methylprednisolone with a complete resolution in days and she was referred to our allergy unit to be studied because of a suspicion of drug allergy to amoxicillin-clavulanic acid. an allergy workup was performed after obtaining an informed consent. case report: it may be sometimes difficult to find the causing allergen in allergic contact dermatitis. face is a region on which various materials contact. in this manuscript a woman case is presented who shows patch test positivity to her husband's shaving product. a years old woman applied because of allergic contact dermatitis on her face. it is learnt that lesions have been continuing for a long time, occasionally getting well with corticosteroid creams; but continuing again. patch test was performed with european standard series and cosmetic products she was using. negative result was observed. following, patch test was performed for the products her husband was using. positive results were obtained for the shaving cream of her husband was using. in detailed anamnesis, it is learnt that the lesions developed approximately month after her husband started to use this cream. it is advised not to use this product to her husband. the disease did not repeat again. it should not be forgotten that cases with allergic contact dermatitis could get in touch with allergenic materials via individuals in close contact. gül Ü akdeniz university faculty of medicine, department of dermatology, antalya, turkey case report: tnf-alpha plays role in etiopathogenesis of allergic contact dermatitis (acd). in mice which lack tnf-alpha, the response of late type hypersensitivity is spoiled. in addition, tnfalpha blocker are also used in some cases with acd. in this poster the results of european standard patch test is given in which acd is observed and tnf-alpha blocker are used without dermatological indication. cases who use tnf-alpha blocker applied because of acd: there was lesion in one case on face, in other case on face and hand, and in the last case only on hand. european standard patch test was performed to patients who were continuing to use tnf-alpha blocker. in one case no positive response was observed, while in two cases positive response to more than one allergen were obtained. in conclusion, tnf-alpha blockages cannot suppress the response of delayed type hypersensitivity. | case of allergy to nickel on the background of its intake in food peredelskaya m case report: nickel is one of the most commonly used metals; it is used for the manufacture of jewelry, plates and dishes, and medical products. a patient n, years old, female, complains of pruritic rash on the body skin with the itch intensity up to - points and the number of lesions more than . allergic background: for quite some time now the patient noted occasional eruptions on her skin after a contact with jewelry made of non-precious metals. previously patch skin tests with nickel showed a positive reaction. the patient sought emergency medical care with complaints of a number of itchy lesions erupted on her whole body during the last hours. on admittance: state of moderate severity, the patient was emotionally labile, focused on her body sensations, tearful. on the skin of face, upper and lower extremities and torso a punctuate purpura with lesions up to . cm diameter, prone to confluent. a physical status was within normal limits. in order to control the itching, as well as to sedate the patient, antihistamines of the first generation were administrated parenterally; but the eruptions kept to progress and to intensify; lesions were spread throughout the whole body, merged in gigantic areas. system glucocorticosteroids therapy was administrated, with mg of prednisolone, but then new lesions kept appearing in a large number, including after-meal rash. water, tea, bakery products, thin yoghurts did not impact the skin condition, whereas the intake of pasta, cereals, and similar products provoked intensifying of eruptions. the patient observation revealed a sharp increase in the rash after such manipulations as intravenous injections or blood sampling from the vein, the process spreading from the injection site to the entire arm. a detailed anamnesis of the disease: on the eve of the start of hives, the patient purchased a coffee machine (with metal nickel-plated parts) and started to use it. diagnosis: a systemic contact dermatitis. an allergy to nickel. the injection treatment was discontinued and a therapy with per oral gcs and antihistamines of the second generation was administrated. a recommendation was given to cook and to eat food using ceramic or wooden utensils. three days later marked positive dynamics of the skin process has been noted. the episode of systemic contact dermatitis has developed due to exposure to nickel from ingestion in food, as well as during the parenteral treatment. background: anaphylaxis reactions during anesthesia can have a mortality of %- %. / of the anaphylaxis in the operating room are due to the use of neuromuscular blockers. rocuronium is frequently involved because is oftenly used. we present a case of a years old man with an anaphylaxis shock due to the administration of rocuronium. method: years old man with no personal history of interest that is going to undergo vertebral surgery. minutes after anesthetic induction with fentanyl, propofol and rocuronium he started with lowering of oxygen saturation. orotracheal intubation is performed and, with the suspicion of anaphylaxis shock, adrenaline, antihistamines and corticoids were administered. after minutes without improvement, mg of sugammadex was administered, given the possibility that the condition was secondary to the use of rocuronium. tryptasa level was . results: skin test to fentanyl, propofol, látex and rocuronium were done weeks after and only rocuronium test was positive. conclusion: in summary, the occurrence of anaphylactic shock after neuromuscular blockers is widely described in medical literature. there are conflicting data about the use of sugammadex as coadjutant treatment in case of anaphylaxis due to the use of rocuronium. we believe is a good option when conventional treatment is not useful. case report: a -year-old woman with past history of allergic rhinitis and hypertension was admitted to the obstetrics service in labor of first child in april . epidural anesthesia with ropivacain and sufentanil was administered. as there was no labor progression, eighteen hours later she was admitted to undergo cesarean section and epidural anesthesia was re-administered. metoclopramide, ampicilin and ranitidine were given intravenously. during ranitidine perfusion, the patient presented general cutaneous erythema and pruritus, tongue, lips and eyelids angioedema and dyspnea. perfusion was suspended and hydrocortisone and supplementary oxygen administered. she denied any type of previous adverse reaction to drugs and any symptoms with use of latex-containing material. allergic evaluation revealed negative latex skin prick test (spt) and negative penicillin, amoxicillin and ampicillin specific ige assay. skin prick and intradermal tests with sufentanil, ppl, mdm, amoxicillin and ampicilin were negative. oral amoxicilin and metoclopramide provocation challenge were negative. spt and subcutaneous provocation challenge with ropivacain were negative. spt with ranitidine was negative but skin intradermal test proved to be positive. the patient was taught to avoid histamine h receptor antagonists and use as a safe alternative proton pump inhibitors. conclusion: anaphylaxis during anesthesia is an unpredictable, severe, and rare reaction. the identification of responsible drugs is a complex task. we report a case in which a commonly used and generally safe drug caused a severe reaction, which demonstrated that even the least obvious culprit should not be disregarded. epidemiologic data suggest that the number of cases of chx allergy appears to be increasing. background: chlorhexidine is a synthetic chemical with excellent antiseptic and disinfectant quality frequently used in everyday products and medical devices. the prevalence of allergic reactions towards chlorhexidine is rare, though there is increasing evidence for its allergenic potential. in this case we report about a patient with serious perioperative anaphylaxis. next to multiple potential allergens that he was exposed to, a chlorhexidine containing lubrication gel has been used for urinary catheterisation. within minutes post-exposure, the patient developed generalized urticaria, bronchospasm, tachycardia and hypotension. material and methods: we performed skin prick tests and intradermal tests with all substances documented in the anaesthesia chart, further we analysed specific immunoglobulin e (sige) antibodies and performed oral provocation challenges for exclusion. results: in the skin tests all substances except for chlorhexidine (spt: mm wheal diameter/ mm erythema) were negative. a sensitization for chlorhexidine was further corroborated by chlorhexidine-specific ige antibody ( . ku/l) in the patient's serum. in addition, the challenges for the drugs without sensitization (cefuroxime, lidocaine) were tolerated. considering all potentially relevant allergens that the patient was exposed to and the proof of specific sensitization, we diagnosed an immediate-type allergy towards chlorhexidine. conclusion: with the ubiquitous use of chlorhexidine an increase in hypersensitivity reactions including immediate-type allergic reactions is observed. anaphylactic reactions are rare, but potentially life-threatening, the diagnosis is crucial. as a warning declaration in medical devices is missing, the diagnosis of chlorhexidine allergy might be easily under-recognized or misdiagnosed. unfortunately, until now validated provocation tests are not existent, but the evaluation of combined skin tests and sige is sensitive and specific. | an approach to incidence of death due to anaphylaxis in spain ( spain ( - background: reports about death due to anaphylaxis are still scarce because of its rarity and limited information to few countries. also, data source analysis is usually not included. we report incidence of death due to anaphylaxis in spain using two databases. method: we used a hospital series of anaphylaxis deaths from the spanish hospital system and a series from the national institute of toxicology and forensic sciences (intcf) predominantly formed by extra-hospital deaths. deaths from the spanish hospital system were extracted using codes from icd- -cm, related to anaphylaxis among all deaths occured in the - period. for extracting deaths due to anaphylaxis at the intcf in the same period, two allergist researchers identified these deaths among cases with suspicion of anaphylaxis cause. a regression logistic was run to discriminate the probability of anaphylaxis death belonging to each database. incidence rates were calculated for the different groups (age, sex) using the spanish population as the denominator. temporal trends were calculated from the hospital database using poisson regression models with the number of cases of anaphylaxis detected each year as the dependent variable, and age and sex as covariates. results: there were four positive predictors of fatal anaphylaxis after the logistic model (usual allergen, positive specific ige, suggestive symptoms and previous reaction to the same allergen case report: we were informed that a girl was admitted to the pediatric endocrinology department due to early breast development. she had been diagnosed as central precocious puberty (pp). later, triptorelin acetate (ta) therapy had been started monthly. within minutes after first sc injection of ta at home, she had developed shortness of breath, decreased air entry, and coughing for ten minutes and lastly she had developed vomiting for minutes. her symptoms were accompanied by a pruritic blanchable maculopapular rash on her ears, cheeks, lips, and eyelids approximately for two hours. although they had applied emergency department of the local hospital. based on the diagnosis of anaphylaxis she was immediately treated with adrenalin. she was subsequently hospitalized for possible recurrence and discharged next day without any further events. treatment with another preparation, leuprolide aseptate(la-lucrin), as an alternative treatment was started with premedication against anaphylaxis risk only at first time and the patient did not develop any reactions. the patient is still on this treatment with no complications. anaphylaxis is diagnosed in the presence of a detectable allergen accompanied by symptoms of two systems. our patient had symptoms of the three systems as described above, that is, dyspnea with coughing, hives, nausea, and vomiting. main treatment of anaphylaxis is the epinephrine use. early usage maximizes the likelihood of survival. diagnostic tests with culprit drug were not performed in our hospital if the patient had the anaphylactic drug reaction and grouped as "physician diagnosed anaphylaxis". there has been only one report regarding anaphylaxis to ta treatment in cpp in turkey. in the literature, anaphylactic reactions against ta have been reported only in few pediatric cases. gnrh analogues are important to ensure the physiological growth in precocious puberty. because anaphylaxis can be lethal, and gnrh analogues are similar structure; the present case suggests that one should bear in mind the possibility of anaphylaxis in all patients who receive gonadotropin-releasing hormone and anologs and monitor such patients carefully as needed. furthermore, we must provide sufficient information of adverse reactions, including anaphylaxis, to patients. hence, managements against anaphylactic shocks should be recognized and treatment should be given immediately. | an anaphylactic shock induced by the rocuronium anesthesia: a case report cabrera v; barrios j; callero a; gonzález ce; pérez e; martínez ja hospital universitario nuestra sra de la candelaria, santa cruz, spain background: the anesthetic act is a unique pharmacological situation, where the patient is exposed to a multitude of substances.among them, neuromuscular blocking agents are the leading cause of preanesthetic anaphylaxis, with a frequency of between %- %.followed by latex in second place and antibiotics in third place. among the neuromuscular relaxants, most reactions are due to suxamethonium or succinyl-choline in . %, followed by atracurium, rocuronium and verocuronium.the one that produces the least reactions is cisatracurium. method: a -year-old woman presented a type iii anaphylaxis of the brown classification during the anesthetic induction in a surgery scheduled for laparoscopic cholecystectomy. for which adrenaline, dexchlorpheniramine, hydrocortisone, ranitidine and sugammadex was administered and was transferred with orotracheal intubation to the anesthetic resuscitation room. due to good evolution of the patient, she was extubated within three hours. the drugs involved in the reaction were: rocuronium, amoxicillin-clavulanic, fentanyl, propofol, midazolam, lidocaine and atropine. there was a high suspicion by the anesthesiology and resuscitation service that the abstracts reaction could have been due to the neuromuscular relaxant used, in this case rocuronium, since the reaction was reversed with sugammadex. the patient had undergone surgeries under general anesthesia previously without incidents. a specific allergy study was performed with laboratory tests with tryptase, skin tests with drugs and basophil activation test for rocuronium, sugammadex-rocuronium mixture and cisatracurium. • serial measurement of serum tryptase: . u/l, . u/l y . u/l there is no activation of basophils for sugammadex-rocuronium mixture and cisatracurium. the patient is diagnosed with rocuronium allergy. sugammadex not only acts as an antidote to reverse the neuromuscular block against rocuronium, but also has antiallergic properties by inhibiting mast cells. as an alternative for future interventions, the patient can use cisatracurium, as the skin tests and the basophil activation test are negative. unal d yedikule chest disease, istanbul, turkey case report: tetracycline hydrochloride may rarely cause hypersensitivity reactions. (hrs). immediate type reactions are at the level of case presentations and anaphylaxis is reported. we report a patient with late onset anaphylaxis caused by tetracycline. a -year-old woman referred to our allergy outpatient clinic because of urticaria due to an antibiotic that she does not remember the name of. the patient reported that many years before she had presented urticaria on her arms and legs one hour after taking the drug. to confirm drug allergy invivo and invitro testing have to performed. for many drugs there was no validated skin test. for all that invitro tests are often less sensitive and more expensive. therefore single blind placebo controlled drug provocation tests (sbpcdpt) is the gold standard in the diagnosis of drug hypersensitivity reactions. we did not know which group of antibiotics were allergy to the patient. because the patient had history of asthma and atypical pneumonia we were performed the allergy tests with clarithromycin and she had tolerated. it was necessary to use tetracycline because of patient had vaginal infection. skin tests have not yet been validated for tetracyclines. for skin prick tests of tetracycline that is only available as tablet, not in a soluble form. therefore, the tablet was smashed and diluted with . % nacl. it was also tested. healthy controls to exclude irritation. because of skin prick tests with tetracycline negative. sbpcdpt was planned. sbpcdpt was performed by progressively increasing four divided doses at minute intervals. two hours after last dose the patient experienced dyspnea, palpitations, and hypotension. as the reaction was considered to be anaphylaxis, she was given . mg of intramuscular epinephrine, intravenous mg of pheniramine, and mg of methylprednisolone. the reaction resolved within hours. blood tryptase level was . ug/l taken at the nd hour of the reaction approximately months after the anaphylaxis, serum tryptase level was . ug/l the serum tryptase level and the patient's clinic confirmed anaphylaxis due to tetracycline. we had proved late onset anaphylaxis due to tetracycline with the patient's clinic and serum tryptase level. anaphylaxis due to tetracycline is limited to case reports and small series but to our knowledge, there is no previous report of late onset tetracycline anaphylaxis. | case series of ige mediated anaphylactic shock due to polysorbate case : an -year-old male patient with hypertension, hypothyroidism and episodes of sustained monomorphic ventricular tachycardia (smvt), developed an anaphylactic shock after the administration of injectable amiodarone due to smvt. serum tryptase levels reached . μg/l during the reaction (baseline . μg/ l). skin tests were positive to injectable amiodarone (prick mg/ ml, intradermal . mg/ml) and polysorbate and (prick-prick). skin prick-prick to amiodarone and dronedarone tablets were negative. the patient tolerated oral amiodarone. we report an anaphylactic reaction during the first intravenous administration of amiodarone in a female patient being treated for supraventricular tachycardia. bat was positive, suggesting a direct effect on basophil activation, as the patient was not previously exposed to the drug. | anaphylaxis during labor: don't forget to think of an amniotic fluid embolism case report: a -year old primigravida ( weeks of gestational age) was admitted with signs of pre-eclampsia and labor was induced. benzylpenicillin and ropivacaine (epidural anesthesia) was administered > hours before the event. eighteen minutes after starting an infusion with oxytocin ( ml/h) and a vaginal toucher, the patient developed a decreased level of consciousness, generalized edema/erythema and thoracic pain, followed within minutes by fetal bradycardia and maternal collapse. after resuscitation, an urgent sectio was performed, and a baby girl was born. patient was extubated the same day. serum tryptase, hours after the event, was . μg/l (basal tryptase level . μg/l). allergy workup demonstrated negative specific ige and skin tests for latex and chlorhexidine, negative skin and provocation testing for ropivacain. however, skin testing was hampered by dermographism: intradermal (idr) testing of benzylpenicillin ( iu/ml, / - / ) and oxytocin ( ie/ml, / - / ) showed extensive erythema. idr testing of oxytocin in healthy volunteers showed pallor around the injection site (n = ). intravenous provocation with benzylpenicillin was uneventful. a basophil activation test with oxytocin (patient and control) was negative. an additional bone marrow evaluation showed no evidence for mastocytosis. although clinical criteria for anaphylaxis were fulfilled, a diagnosis of an amniotic fluid embolism (afe) was concluded. no drugs were prohibited. patient gave consent for publication. conclusions: afe is one of the most devastating conditions in obstetrics, occurring typically during labor and delivery or immediately postpartum. the pathogenesis remains incompletely understood, however, it has been suggested that afe involves an anaphylactic reaction to fetal tissue exposure associated with breaches of the maternal-fetal physiological barrier, supported by transiently increased serum tryptase levels. the diagnosis is primarily clinical, and generally one of exclusion. no specific antemortem diagnostic tests are available to confirm afe. postmortem identification of fetal squames in the maternal pulmonary circulation gives final diagnosis. differential diagnosis includes drug-induced anaphylaxis or mastocytosis, which were ruled out in our case. method: the patient presented after hymenoptera stings dyspnoea, generalized erythema with pruritus, edema of the face that required emergency therapy in episodes. results: an angio-ct was performed at the inferior limbs with optiray and minutes after the end of the investigation, the patient presented an anaphylactic shock requiring admission to the icu for days. conclusion: the patient's progression was slowly favorable. results: thirty seven cases were reported. ( %) were women. the median age was years. ( %) had dress/dihs, ( %) ten, ( %) sjs, ( %) agep, ( %) other not classified scars, and ( . %) overlapping ten/sjs. in % of the patients the suspect drug was withdrawn. thirty one patients ( %) received systemic anti-inflammatory treatment. twenty six patients ( %) received intravenous (iv) corticosteroids alone, ( %) iv corticosteroids plus ivig, ( . %) iv corticosteroids plus ivig, infliximab and colchicine, and ( . %) iv corticosteroids plus infliximab and cyclosporin. there were complications in cases ( %), and death occurred in the patient with overlapping ten/sjs who had received corticosteroids plus immunoglobulin. in this study, our aim was to evaluate severe ihr to icm. method: we retrospectively analysed patient who consulted to our allergy unit between july and july reporting symptoms within hour after icm administration. from a total of patients, we selected eight that had suffered an anaphylactic reaction. a written informed consent had been obtained for diagnostic procedures. introduction: immediate type hypersensitivity reactions to pemetrexed have been reported as very rare case reports. as limited availability of alternative therapies in chemotherapeutic allergy, desensitization plays an important role in ensuring reuse of the culprit drug. we report a case of pemetrexed anaphylaxis and successful desensitization. case: years old female patient with lung adenocarcinoma had been treated with cisplatin-pemetrexed as second-line therapy. during the th cycle within minutes after the end of pemetrexed infusion she had chest pain, shortness of breath, cough, swallowing difficulty, erythema on face and body, nausea and vomiting. she was diagnosed as anaphylaxis and adrenaline was administered besides antihistamine and methylprednisolone. symptoms and findings of the patient were improved within minutes. oncologists decelerated no suitable alternative therapy for the patient. although skin tests (prick test with / concentration, intradermal test with / - / concentration) were negative with pemetrexed, taking into account the severity of the reaction, pemetrexed desensitization was applied with the consent of the patient. no reaction was observed during the procedure result: desensitization is a successful and safe method of reusing the culprit drug. successful desensitization of pemetrexed with immediate type hypersensitivity reaction is described. the years old man was admitted emergency department with fever, rash (maculo-papular) and pain in joints. it was the th day of taking of amoxicillin. the hematological abnormalities were revealed -eosinophilia, increased erythrocytes sedimentation rate. the level of serum ecp was μg/l. the liver functional tests were increased too. hepatomegaly and cervical lymphadenopathy were observed. the patient was treated as a dress syndrome (infusion therapy, systemic steroids) and discharged after weeks with improvement. all hematologic parameters were in normal limits. lymphadenopathies were resolved. the level of ecp was retaken - μg/l. patient was prescribed oral steroids till normalization of limits of ecp. it lasted weeks after discharging. the serum level of ecp can play key role in the management of dress syndrome and in the making of diagnostic processes. until now, allergic or anaphylactic reactions to peg have been rarely reported. although patient with hypersensitivity to peg should avoid peg-containing drugs or products, patient who needs colonoscopy has few alternative bowel cleansing methods. no successful desensitization to peg has been reported to date. we report a case of successful desensitization and subsequent safe colonoscopic examination in patient with allergic reaction to peg. method: a -year-old woman developed generalized urticaria, pruritus, throat swelling, and shortness of breath immediately after taking a bowel preparation solution for colonoscopy. she had the first symptoms years ago, and has had more experiences so far. the symptoms appeared within - minutes of taking cleansing solution, and the endoscopy was no longer possible. seven years ago, she underwent endoscopy with no specific symptom. when the last symptom occurred a year ago, she was treated at emergency room because of severe dyspnea and dizziness. the patient came to our clinic for the proper diagnosis of allergy reaction and possible colonoscopic evaluation. objectives: to describe a successful desensitization to vedolizumab in one patient diagnosed with ulcerative colitis, refractory to infliximab and intolerant to azathioprine and sulfasalazine. methods: our patient was a year old woman receiving treatment with intravenous vedolizumab ( mg/cycle). cycles and were well tolerated, but in cycles , and she experienced hypotension and dyspnea, in spite of premedication with oral dexamethasone and metoclopramide. during cycle , she also showed facial angioedema, systemic urticarial reaction and oropharyngeal pruritus treated with methylprednisolone and ebastine. the results of prick (vedolizumab concentration mg/ml) and intradermal skin tests ( : and : ) with vedolizumab were negative in our patient and in ten healthy controls. total ige level was . ui/ml and specific ige against dermatophagoides were positive, being negative for hamster epithelium and latex. since vedolizumab was the only therapeutic alternative, the patient was planned to undergo vedolizumab desensitization according to an -step protocol. patient informed consent was obtained previously. premedication consisting of ebastine, acetylsalicylic acid, montelukast and methylprednisolone one hour before desensitization was administered. desensitization protocol was performed with a total duration of hours and minutes and a total dose of mg. dose steps were . , . , . , . , . , , and . mg. conclusions: our -step protocol desensitization to vedolizumab resulted safe and effective in our patient and it has allowed the continuation of treatment with vedolizumab for her ulcerative colitis. montelukast, anti h and h blockers were used for the pretreatment of desensitization. all procedures (skin and blood tests, desensitization) were carried out with the informed consent of the patient. we present an exceptional, non-immediate case of fever after cisplatin and etoposide infusion with positive skin test. case report: a -year-old man, recently diagnostic of lung cancer stadium iv, in first line of treatment with cisplatin and etoposide, started hours after finishing the nd infusion: facial erythema that becomes generalized after - hours from infusion. twelve hours later, developed warmth sensation, shivering and fever ( °c) that persisted despite the use of several oral antipyretics treatment. infectious disease was discarded, so he was referred to our department in order to assess further administration of cisplatin and etoposide. methodology: skin testing was performed days after the last reaction to minimize false-negative results, as follows (a) cisplatin prick test ( mg/ml) and intradermal tests ( . mg/ml); (b) etoposide prick test ( mg/ml) and intradermal tests ( mg/ml); with histamine as the positive control and nacl-diluent as the negative control. the results of skin test were negative for immediate reading. but two hours later, intradermal test for cisplatin turned into red and itchy and hours later, still associated a wheal. the patient was classified as high-risk (lung diseases, forced expiratory volume in second < l) and underwent programmed inpatient desensitization according to the standardized birmingham women's hospital protocol. desensitization was performed in the medical intensive care unit. the patient received only standard oncology premedication. he tolerated the final dose of cisplatin with no breakthrough reactions followed by etoposide standard infusion. two additional desensitization procedures were performed, with no breakthrough reactions. therapy ended when the disease worsened. the importance of this case, lies in the fact that fever has not been described as a clinical hypersensitivity reaction for cisplatin but for oxaliplatin. although a non-immediate reaction at the nd infusion of cisplatin could scarcely suggest a hypersensitivity reaction, the positive skin test and successful desensitization with this drug, could suggest it. introduction: propylthiouracil is commonly used as the first treatment option in patients with hyperthyroidism. although it is generally a well-tolerated drug, it may lead to some side effects including liver damage, leucopenia and skin rash. among skin rash findings, urticaria is considerably common. nevertheless, in cases that developed urticaria, a rapid desensitization protocol specific to propylthiouracil has not been encountered. we represented a case in which we applied successful oral desensitization via a scheme in accordance with general desensitization principles in a case that developed propylthiouracil-induced urticaria. case report: propylthiouracil at a dose of mg/day was initiated for a year-old female patient with diagnosis of hyperthyroidism in internal diseases clinic. the patient developed widespread itching and swelling in the body - hours after she took the first dose of the drug. she had experienced a similar reaction with use of propylthiouracil in . the patient who was breastfeeding a baby and did not have any treatment option other than propylthiouracil was referred to us with pre-diagnosis of drug allergy. the patient was thought to have propylthiouracil-induced hypersensitivity reaction and desensitization was planned. we prepared a desensitization scheme in accordance with general desensitization principles (table ). in accordance with this prepared scheme, we successfully applied the desensitization protocol with propylthiouracil for the patient. the patient gave informed consent before testing and desensitization. results: spt was negative, but idt reaction was positive at : method: we present a desensitization protocol to intravenous etoposide used in a -year-old male for non-hodgkin's lymphoma who was referred to the department of allergy at sotiria general hospital of athens. within minutes after receiving the first dose of the drug, the patient complained for flushing, retrosternal pain, difficulty in breathing and weakness. the infusion was ceased immediately and the patient received proper treatment with gradual recovery of the symptoms. the next day, skin prick test (spt) and intradermal test (id) were performed with etoposide at dilution : ( mg/ml). both of the tests, spt and id, were negative. histamine and nacl . % were also used as positive and negative controls, respectively. a desensitization protocol of three-day cycle with intravenous etoposide was conducted. premedication for days was administered including methylprednisolone, cetirizine, ranitidine, paracetamol and montelukast. results: the desensitization protocol of the first day consisted of steps of rapid pulses administered at increasing infusion rates every minutes, and step of drip infusion at a final rate of ml/hour ( mg/ . ml) until completion of the infusion. the following days, the patient received a modified rapid protocol consisting of the administration of the calculated dose of mg in only one step of infusion rate of ml/hour completing in only hours and minutes. the same protocol was applied in another three-day cycle with no adverse reactions. conclusions: hsrs to etoposide are rarely described in the literature. we propose a three-day modified rapid desensitization protocol to intravenous etoposide that could be particularly useful compared to other time-consuming desensitization protocols. case report: imatinib, a tyrosine kinase inhibitor, sometimes causes cutaneous reactions that can be of various severity. we present a case of a patient who was started on imatinib mg daily and after months developed diffuse mildly pruritic rash with some desquamation of palms of the hands. the dose of imatinib was reduced to mg daily and therapy with prednisone mg was started. after resolution of rash, the dose of prednisone was tapered to mg daily, but the rash reappeared, although milder in intensity. the dose of prednisone was increased and levocetirizine added and rash resolved. prednisone was slowly discontinued and rash did not appear. in the case of reactions to imatinib the dose of drug can be reduced and short course of oral corticosteroid given. milder reactions can be treated with antihistamine or topical corticosteroid. therefore, when adverse skin reaction to imatinib occurs, induction of tolerance to this important drug should be attempted. method: the exosomes were collected from in vitro primary human sinonasal epithelia cell, which derived from three different groups (normal control, chronic rhinosinusitis and chronic rhinosinusitis with asthma). generation of exosomes in epithelia was confirmed by nanosight, tem and western blot. the proteins of exosomes were identified by proteomics analysis. the cellular proliferation and ciliogenesis were analyzed by cck and qpcr.the ciliary beat frequency was detected by sava system. we found that epithelial cellular exosomes from chronic rhinosinusitis and chronic rhinosinusitis with asthma could reduce the multiplication rate of normal epithelial cell at a certain concentration (≥ μg/ml).we found that exosomes from chronic rhinosinusitis with or without asthma could interrupt the cellular ciliogenesis and ciliary beat frequency. using mass spectrometric analysis we demonstrated that the epithelial exosomes contained different proteins in different disease states. conclusion: our findings first identified that exosomes could be secreted by nasal epithelial cells. we also demonstrated exosomes from chronic rhinosinusitis with or without asthma could be a pathogenic factor in the remodeling of sinonasal mucosa. it could be considered as a significant biomarker for detecting the progress of chronic rhinosinusitis and a alternative therapy target. background: mucociliary transport (mct) is a major respiratory tract host defense mechanism and chronic exposure to allergen can deteriorate the these defense mechanism. the aim of this study was to investigate the effects common allergen (dp/df) on human nasal mucociliary transport in allergic rhinitis patients, and to determine the pathophysiology of ciliary beat frequency (cbf) during allergeninduced change method: allergic nasal mucosa cells of allergic rhinitis patients were exposed to common allergen (dp/df), and cbf was analyzed using an optical flow technique with the peak detection method results: the allergen(dp/df) exposed group showed a decreased cbf when compared to the control group. in the cytotoxicity assay, difference in survival rates was not found between the two groups. in the allergen(df/df)-exposed group, protein kinase c (pkc) activity was increased during a pkc activity assay. the broad pkc inhibitor, calphostin c abolished the allergen(dp/df)-induced decrease of cbf. the allergen-induced decrease of cbf was abolished by gf x, a novel pkc (npkc) isoform inhibitor, whereas the decrease was not attenuated by g€o- , a specific inhibitor of conventional pkc (cpkc) isoform. conclusion: allergen may inhibit cbf via an npkc-dependent mechanism. therefore, we have confirmed that chronic exposure to allergen could decrease cbf by increasing pkc activity. method: ova-alum allergic rhinitis mouse model (ar model) and poly(i:c) induced il- dominant mouse model (neutrophil dominant model) were used. both mouse models were exposed to tio particles for hours twice daily for days, while the controls (n = ) were not. sirius red staining for eosinophil infiltration, immunohistochemistry for neutrophil and il- a, serum immunoglobulin (ig) g and e were assayed by using enzyme-linked immunosorbent assay. in addition, the expression of interleukin (il)- , il- , and interferon (ifn)-γ in the nasal mucosa and cervical lymph nodes was measured by immunohistochemistry, and real-time reverse transcription-polymerase chain reaction (rt-pcr), il- monoclonal antibody (secukinumab) was administered in vivo to evaluate il- a dependency. results: tio exposure did not influence eosinophil infiltration in both ar and neutrophil dominant model. however, tio exposure increased neutrophil infiltration in both models and neutrophil infiltration was correlated with il- expression in the nasal mucosa. serum igg and ige levels were changed significantly in the tio exposed group. th cytokines (il- , il- ) and th cytokine, ifn-γ were not changed significantly in both models after tio exposure, however, il- were increased in tio exposure group. and these increased type pathway and neutrophil infiltration were reversed after il- monoclonal antibody administration. conclusion: exposure to airborne tio induced neutrophil infiltration in the nasal mucosa. the type response seems to play a dominant role in the nasal immune response following airborne tio exposure. | toll-like receptor ligands increase type i interferon induced b-cell activating factor expression in chronic rhinosinusitis with nasal polyposis results: first: paf-r mrna expression was very low in fibroblasts from nm and np (data not shown). paf-r mrna expression was detected in whole sinonasal tissue, submerged and ali epithelial cell cultures from both controls nm and np. paf-r mrna was also detected in peripheral blood eosinophils. although no differences were found between nm and np tissues and cultures, paf-r mrna expression was significantly higher (p < . ) in eosinophils than in upper airway tissues and cells. second: protein paf-r was found expressed in whole tissue (predominantly in the epithelium and submucosal glands), submerged and ali epithelial cell cultures from both nm and np. peripheral blood eosinophils also showed paf-r protein expression. conclusion: both paf-r mrna and protein expression was found in sinonasal nm and np tissues (epithelium and submucosal glands) and in peripheral blood eosinophils. these findings suggest the paf/ paf-r system could play a pathophysiological role in crswnp through the modulation of structural and inflammatory cell functions. "this study was funded with a research grant from uriach group". background: allergic rhinitis (ar) is an increasingly more common nasal inflammatory disease in which an antigen such as pollen or dust mites triggers symptoms such as itching, sneezing, and rhinorrhea, which can lead to nasal obstruction. ar is mediated by thelper type cells together with mast cells, eosinophils, and several inflammatory cytokines and chemokines. for example, recent abstracts | research indicates that hypoxia-inducible factor α (hif- α) is involved in the mechanism of ar development. the anti-heart failure drug digoxin has a specific inhibitory effect on hif- α, and thus, the aim of the present research was to explore the anti-hypertensive effect and mechanism of digoxin in ar. method: an animal model of ovalbumin-induced ar was established in guinea pigs. the experimental group was treated with digoxin through the tail vein. for the comparison of symptoms between the experimental and control groups, the incidence of sneezing was recorded, and the eosinophilic interleukin il- and il- levels in nasal secretions were measured by enzyme-linked immunosorbent assays. western blotting and reverse transcription polymerase chain reaction analyses were conducted to evaluated hif- α expression in guinea pig nasal mucosa. results: the ar symptoms of guinea pigs in the experimental group were significantly improved after administration of digoxin. specifically, the experimental group exhibited a significantly lower numbers of sneezing times(average . ± . vs . ± . , p < . ) and lower il- and il- secretion levels (p < . ) compared with the control group. moreover, guinea pigs of the experimental group showed less severe nasal mucosa edema, lower hif- α production, and reduced eosinophil infiltration in nasal mucosa compared with the control group. conclusion: the anti-heart failure drug digoxin may ameliorate the symptoms of ar by inhibiting hif- α production. campo p ; eguiluz i ; bogas g ; gomez f ; ariza a ; espino t ; torres mj ; rondon c allergy unit-regional hospital of malaga-ibima, malaga, spain; allergy laboratory_regional hospital of malaga-ibima, malaga, spain background: similarly to what has been described in allergic rhinitis, there is an important association of local allergic rhinitis (lar) with lower airway symptoms suggestive of asthma, being selfreported in . % of lar patients after five years of follow-up, and increasing to . % after years. however, clinical suspicion alone it is not enough for asthma diagnosis and could overstate its real prevalence. the aim was to evaluate the real prevalence of asthma in lar patients based on validated objective methods. method: seventy-five patients ( with lar, with non-allergic rhinitis (nar), with allergic rhinitis (ar)), and healthy controls (hc) were included. all patients had perennial history of rhinitis and bronchial symptoms suggestive of mild-moderate asthma for at least two years. non-specific airways hyperresponsiveness (methacholine challenge test, using tidal breath method following ats guidelines) was performed in all subjects. results: subjects were mostly young females, non-smokers. median μg/day of inhaled corticosteroids (budesonide/equivalent dose) was similar in all groups. median fev % in ar group ( . %) was significantly lower compared to lar ( %, p = . ), nar ( %, p = . ) and hc ( %, p = . ). in the lar group, / ( . %) had a positive methacholine, / ( %) in the nar, / ( . %) in ar group and / ( %) in hc. patients with lar had a significant lower percentage of confirmed asthma than ar (p = . ) and similar to nar (p = . ). no differences were detected between ar vs nar (p = . ). conclusion: presence of objectively demonstrated asthma was lower in lar compared to ar, and with better lung function. conclusion: ambient air pollution influenced the hospital visit of patients with rhinitis, even, the level of pollutants, below the national standard. so , o , no , and pm could increase an incidence of rhinitis and/or induce an aggravation of rhinitis symptoms. health care provider might expect upraising patients with rhinitis in the clinic with increase of air pollutants, even under the standard levels. results: during relapse of erosive oral lichen planus mononuclear cells obtained from peripheral blood of patients showed increased number of nk-cells cd + cd + in acute ( . ± . %) and chronic ( . ± . %) disease periods, and cd + grb cells in acute ( . ± . %) and chronic ( . ± . %) disease periods, p < . . in patients with the non-erosive forms of olp there were cd + cd + and cd + grb cells in acute ( . ± . %) and ( . ± . %) and chronic disease ( . ± . %) and ( . ± . %), p < . . the number of cd + cd + and cd + grb cells in the controls were ( . ± . %) and ( . ± . %), p < . . conclusion: acute relapse of erosive oral lichen planus, unlike nonerosive forms, is characterized by increases in the number of cd + cd + and cd + grb cells. chronic disease in patients with erosive oral lichen planus showed a steady increase in the number of cd + cd + killer cells and cd grb lymphocytes. bite", were observed in patients ( %). typical hyper-and hypopigmentation were observed in six patients mainly on the fingers and the cheekbones. fibrosis of the skin of the fingers often leads to flexion contractions, which we observed in patients. we were watching two-sided swelling of the fingers, but it was very pronounced in patients ( %). % of our patients have impaired motility of the esophagus. accelerated esr and c-reactive protein were found in patients as follows- intensively accelerated and moderate. in our patients with positive ana, we observed patients -at low titer : at and titration : in patients. the spectrum of ana found by us in raynaud's syndrome patients is closer to scleroderma than to lupus. we underline the importance of ana ( %) and anti-cc antibodies ( %) for the early diagnosis of raynaud's syndrome and scleroderma, which is also seen in our patients. anti-scl- antibodies were observed in patients coinciding with other publications describing about % of the patients. low levels of complement were observed in patients. low hemoglobin levels were observed in patient, with no iron deficiency. conclusion: . we observed a typical fibrinoid necrosis and polymorphonuclear infiltration, and collagen accumulation in the walls of small and medium-sized blood vessels. results: statistically significant increase of il level ( . pg/ml [ . ; . ]; . pg/ml [ . ; . ] respectively) was determined in patients with uc both in acute stage and remission compared to controls ( . pg/ml [ . ; . ] , (p = . ; . respectively). statistically significant increase of il a level ( pg/ml [ . ; . ] ); . pg/ml [ . ; . ] respectively) was also observed in patients both in acute stage and remission compared to controls ( . pg/ml [ . ; . ], p = . , p = . respectively). besides statistically significant increase of ifnγ both in acute stage ( . pg/ml [ . ; . ] ) and remission ( . pg/ml [ . ; . ]) compared to controls ( . pg/ml [ . ; . ], p = . ; . respectively) was revealed. background: the presence of antinuclear antibodies (ana) is commonly associated with a broad spectrum of connective tissue diseases. low titres might be detected rarely also in healthy individuals, especially in higher age. an indirect immunofluorescence (iif) detection of ana antibodies on hep- cells is the most frequently used laboratory method in this respect. the method is quite reliable regarding sensitivity, however the specificity of this test is lower. we would appreciate a biomarker for clinical discrimination of ana- other autoantibodies were tested in relation to basic diagnosis. results: a cohort of patients was divided into groups according to main diagnosis: immunodeficiency, connective tissue diseases, bronchial asthma and allergic rhinitis, recurrent infectious diseases, gastrointestinal diseases, endocrinopathy and others and the last group was generated from healthy subjects. the presence of anti dfs antibodies was highest in the group of recurrent infections, mostly in females. in these subjects homogenous pattern of ana antibodies by iif was also detected quite often, probably induced by non-specific activation of immune system. on the other hand, in a group of connective tissue diseases, we have not found any anti dfs positive patient. the clinical impact of anti-dfs antibodies is not yet finally confirmed, but their low frequency in connective tissue diseases and presence in %- % of healthy subject suggests their potential role as a new biomarker to be used as a negative predictive factor in non aard. confirmation of presence or absence of anti-dfs antibodies seems to be helpful to exclude potential diagnostic errors in iif ana positive patients. background: multiple sclerosis is a debilitating autoimmune and degenerative condition of the central nervous system, that predominantly affects young adults. both genetic and environmental factors are associated with increased risk for this disease. we propose that the effect of environmental factors, particularly latitude of childhood, is mediated through epigenetic mechanisms. specifically, we propose that unfavourable gene methylation predisposes individuals to multiple sclerosis, that this is set in childhood and adolescence, and transmitted from haematopoietic stem cells to progeny. method: cd + , cd + and cd + cell subsets were isolated from peripheral blood of healthy controls. libraries enriched for cpg islands and promoter regions were generated using modified reduced representation bisulfite sequencing and subjected to next generation sequencing. site specific methylation profiling of genome wide cpg islands, including ms susceptibility genes was conducted using methpipe software. results: genomic coverage was consistent with other published methylomes using modified reduced representation bisulfite sequencing. the methylation signature of peripheral blood derived subsets showed greater differences in methylation compared to buccal cells than with each other. individuals displayed differences in cd + methylomes, and these were recapitulated in the progeny cd + and cd + cells for those individuals. methylation of specific genes regions (e.g. prf ), were consistent with the known biological function of these genes and their potential contribution to ms risk. the vast majority of cpg islands interrogated show recapitulation of their methylation signature from cd + to progeny. however, individual differences and cell subset differences identified, likely reflect the known biological function of these genes in progeny cells. our preliminary results are consistent with the hypothesis that the epigenetic signature (that predisposes to ms risk) is set in childhood and adolescence. the physiological basis underlying the setting of this epigenetic signature is still to be elucidated, but may involve uv light and/or vitamin d, and may provide novel therapeutic targets, especially at a personalised level, for treatment of ms. background: auto-inflammatory diseases are rare disorders characterized by recurrent episodes of fever/inflammation affecting serosal surfaces, joints, eyes and skin without autoantibody production or an underlying infection. innate immunity is implicated in their pathogenesis and the underlying genetic defect has been identified in a fraction of the syndromes. during last years, the increased knowledge about auto-inflammatory diseases and the difficulty in their characterization aroused great interest to better understand these pathologies. the acidic soluble fraction of salivary proteome of patients and controls (hc) were analyzed by rp-hplc-esi-ms. known salivary proteins (salivary acidic proline-rich phosphoproteins (aprps), histatins (hst), salivary cystatins s, sn and sa, statherin, p-b peptide, α-defensins - , cystatins b, c, thymosin β- , s a , s a , s a , and s a proteins) and several derivatives (acetylated, glutathionylated, phosphorylated, and oxidized forms) were searched in the chromatographic profiles by xic (extracted ion current) procedure. adult patients (mean age ± sd: . ± . ; f, m) were enrolled and compared with sex/age matched healthy controls (mean age ± sd: . ± . ; f, m). patients are classified on the base of clinical manifestations as follows: patients with fmf (mean age ± sd: ± . ; f, m), and with unclassified fever syndrome (uc) (mean age ± sd: . ± . ; f, m). results: fmf patients showed low levels of α-defensins , and , this last was absent, with respect hc, and high levels of the glutathionylated proteoforms of cystatin b, and s a , and of antileukoproteinase (slpi). similar results were obtained on saliva of unclassified patients, which showed also levels of cystatin c higher than controls. interestingly, proteins and peptides typically secreted by salivary glands (cystatin c, histatins, statherin, aprps) were found more abundant in uc patients than in controls, and in some cases also than fmf patients (see table) . an evaluation of relative abundance of phosphorylation of phosphorylated proteins/peptides highlighted a significant hypophosphorylation of hst- , prp- and prp- in uc patients with respect to controls, probably due to a less active fam c kinase responsible for their phosphorylation conclusion: we show by a top-down proteomics approach a wide salivary modification, highlighting dysregulation in neutrophil-derived proteins and significant differences between fmm and uc patients. the control group consisted of healthy donors aged - years. immunological methods of investigation included determination of membrane antigens b cells: cd − cd + cd + , cd + cd + cd + , cd + cd + cd , cd + cd + cd + , cd + cd + cd + , cd + cd + cd + , cd + cd + cd l + cd + , cd + cd ra + cd + cd + , by flow cytometry. results: in the study subpopulation composition of lymphocytes in seropositive variant form of ra visceral a statistically significant increase in relative amount as b -cells with immunophenotype cd + cd + cd + ( . ± . % . ± . %) and b lymphocytes with the phenotype cd + cd − cd − cd + ( . ± . % and . ± . %). in the analysis of the processes of maturation and differentiation of b cells detected statistically reliable increase of the relative number of mature cd + cd − cd + naïve b cells cd + cd ra + cd number of mature cd + cd − cd + naïve b cells cd + cd ra + cd − cd + ( . ± . % and . ± . %) compared to the control group. in the study of surface markers b lymphocytes revealed an increase of expression of costimulatory cd + cd + ( ± . % and . ± . %) molecules and increasing the relative amount of cd l . ± . % ( . ± . %) ligand on cd + cd + cd + subpopulation of t-lymphocytes. analysis of surface antigenic receptor b cells in the visceral form of ra showed an increased expression of early markers of cd + cd + cd + ( . ± . % and . ± . %), cd + cd + cd + ( . ± . % . ± . %) activation in comparison with the control group. case: a year-old male patient who works as a dental technician with a history of lung silicosis and recurrent sinusitis applied to an orthopedics clinic for left hip pain and difficulty in walking. he has a history of keeping a dog during childhood. hip mri revealed a × cm sized mass on left iliac wing extended to gluteus muscle and subcutaneous tissue. incisional biopsy was reported as chronic granulomatous osteomyelitis. the lesion was considered as tuberculous abscess. despite anti-tuberculous (fourdrug regimen) treatment for one year, the lesion showed no regression. excisional biopsy was carried out by the same orthopedics clinic. chronic inflammatory reaction and fibrosis was considered to be due to cyst hydatid in the detailed evaluation. antiechinococcus igg and igm was performed with elisa and found positive. no other lesion was detected in lungs and liver. albendazole mg twice a day was initiated and substantial regression observed after three months. atypical and sustained infections made us think of primary immunodeficiency disorders. immunoglobulin subgroups were as follows: iga: < mg/dl ( - case description: year-old male was firstly admitted to gastroenterologist due to intermittent diarrhea, abdominal pain and reactive lymphadenopathy. celiac disease was suspected as genetic test showed hla dq (hla-dqa * and hla-dqb * ), histological evaluation of duodenum biopsy provided picture of lymphoid hyperplasia and marsh iiia variant. however, laboratory testing for celiac disease showed very low amount of antibodies against transglutaminase. gluten free diet for almost one year was ineffective as patient had a continuous problem of gaining weight due to chronic diarrhea. additional questioning revealed recurrent respiratory tract infections with a need of antibiotics more than two times/year during last decade. lymphocyte phenotyping by flow cytometry showed that cd , cd , cd , cd are in normal ranges, but amounts of all immunoglobulins are low: igm < . g/l, igg . g/l and iga . g/l. based on clinical symptoms and immunological evaluation diagnosis of cvid was confirmed, and replacement therapy with subcutaneous immunoglobulin ( mg/kg/month) was initiated. after six months of treatment patient affirmed reduction of gastrointestinal symptoms; he gained kg of weight, has no more infections and stable sufficient level of igg ( . g/l). conclusions: this clinical case shows the importance of immune testing for primary immunodeficiency in all subjects (despite age) with unusual symptoms of autoimmune and/or infectious disorders. cvid may have manifestation of various symptoms, which can lead to misdiagnosis, as well as inadequate treatment. results: in our sample, all patients who progressed to hypogammaglobulinemia were receiving lymphomas. there is no immunoglobulin dosage record prior to treatment. of the cases, mean age was years ( men and women), lost follow-up, and of them also presented neutropenia. seventeen patients who continued in followup required ivig replacement, due to infectious exacerbations, mainly pneumonia and sinusitis. the mean serum igg dosage at the time of onset of ivig replacement was g/dl. the mean time between the first dose of rtm and the need for ivig replacement ranged from to years, with an average of years. the iga dosage was used as a parameter for the recovery of hypogammaglobulinemia, and it was observed that only of the patients presented recovery of the condition up to the moment. conclusion: given the data, we considered the immunoglobulin dosage to be important before initiating rtm treatment and periodically, in order to indicate the replacement of ivig or igsc in a timely manner avoiding complications such as potentially serious infections. background: steinert's disease, also known as type myotonic dystrophy (md ), is the most common dystrophy of the adult. it is inherited with an autosomal dominant mechanism. it causes myotonia, progressive muscles atrophy, muscular weakness, and problems at the heart's conduction tissue and at the respiratory muscles. in patients with myotonic dystrophy, hypogammaglobulinemia is frequently described. the associations and the pathogenesis between those affections are not totally clear, but it is recognized an increased catabolism of the immunoglobulin in these patients. in most of the cases, hypogammaglobulinemia affects only the igg class and does not become clinically manifest. however, replacement treatment is not always successful in these patients. we report the case of a patient with myotonic dystrophy and hypogammaglobulinemia. case report: a -years-old man with md came to our attention for a history of recurrent infections of the upper respiratory tract and persistent infection by helicobacter pylori. at the laboratory tests, we documented low serum igg levels ( mg/dl), normal igm and iga levels and protective antibodies against tetanus consisting with the diagnosis of hypogammaglobulinemia. due to the recurrent infections, he started replacement therapy with ivig ( . g/kg/ months), switched one year ago to facilitated subcutaneous ig (fscig) with achievement of protective serum igg levels (> mg/dl) and significantly reduction of infectious episodes. conclusion: hypogammaglobulinemia is frequently reported in patients with md . in literature most of the cases described does not become clinically manifest, but in our case, the patient was symptomatic with recurrent infections. the replacement therapy with fscig showed both clinical effectiveness and safety. | real-world experience of a novel, highly purified % liquid iv human immunoglobulin for the treatment of antibody deficiencies guidelines for immunoglobulin use (july ). a highly purified % liquid iv human immunoglobulin (ig), with low levels of iga, anti-a and anti-b haemagglutinins, factors xia, xiia, kallikrein and aggregates (i e) was recently approved for use in the uk. here i report our centre's experience in using this novel % i e in three patients with antibody deficiencies. case presentations: a patient who presented in clinic with a first diagnosis of pid, was initiated on % i e at g infused every four weeks. after starting i e, they experienced a decrease in the rate and frequency of infections, in line with expectations for igrt. a young patient on home therapy with a % subcutaneous ig for pid presented in clinic with low trough igg levels. non-compliance was identified as the cause of these low trough levels and therapy was switched to % i e at g infused every four weeks in a clinical setting. both the rate and severity of infections reduced and trough igg levels normalised. an older patient on igrt for sad was reviewed in clinic due to discontinuation of their current igrt product. they were switched to % i e at g infused every four weeks. the efficacy and tolerability of i e was comparable to their previous therapy. a detailed analysis of patient, clinical and safety parameters associated with the initiation of % i e will be presented, including infection rates, white cell counts, c-reactive protein levels, tolerability and infusion-related adverse events. conclusion: these cases highlight the real-world use of % i e in two patients with pid and one patient with sad. they show that i e was well-tolerated and efficacious in one treatment-naïve, and two previously-treated patients. method: prospective study of families with one or more members with c -inh-hae followed in hospitals in the northern area of spain. a cohort of patients from families with c -inh-hae was evaluated for familiar diagnosis of c -inh-hae one or several patients from the same family were chosen and were given a questionnaire to identify the total family members from the family branch affected by c -inh-hae that had been already studied (members with diagnosis of c -inh-hae and healthy members) and those that had not been previously studied. we also register the difficulties for obtaining these data. family members not previously studied and that consent to be contacted were asked for study of c -inh-hae. for c -inh-hae screening we use c blood levels results: we have studied families with c -inh-hae, ( %) type and ( %) type ii; families had all their known members already studied for c -inh-hae ( %): families have all their members studied ( . %), families have % or their known members studied ( . %) and families had less than % of their total known members studied. we have identified members from unrelated families that had not been previously studied for hae, healthy, had low c levels and had presented symptoms of hae; had not presented symptoms of angioedema, had normal c levels, and low antigenic and functional c -inh levels. difficulties for a complete family testing study have been: family dispersion, scarce or no family relationship, do not wish to know their possible pathology conclusion: it is crucial to insist on the study of the relatives of patients with hae. we propose to include a questionnaire to identify all patient's relatives at medical reviews of hae patients. case: a- year old boy was admitted to our clinic with the history of recurrent respiratory tract infections. his all immunoglobulins were low (igg < mg/dl, iga < . mg/dl, igm < . mg/dl) associated with the absence of b cells. his aunt cousin also had xlaa missense point mutation, c c>t in exon of the btk gene was identified in both affected cousins. the patient was commenced on regular ivig treatment every weeks. at the age of , he suffered from intermittent fever attacks, abdominal pain and weight loss. tests for giardia lamblia, clostridium difficile and cryptosporidium, noro virus or parasites were negative. mr-enterography revealed intra-abdominal fluid and thickened walls of his jejunum and cecum. histopathological examination of the biopsy material obtained from terminal ileum, colon and cecum showed crohn disease. initially, he was treated with prednisolone and infliximab. because of the lack of response, infliximab treatment was switched to adalimumab. terminal ileum was resected to relieve obstruction complication. although he had been treated with adalimumab for year, a significant improvement was not observed. vedolizumab (entyvio ™ ), is a humanized monoclonal antibody α β integrin-receptor antagonist, was commenced. induction dosing was mg infusions at , , and weeks followed by a maintenance phase at week intervals. at the month of the treatment, fever and abdominal pain attacks reduced, while his weight and oral intake increased. no side effects were observed. discussion: vedolizumab is effective for inducing and maintaining remission in adults with inflammatory bowel disease (ibd); however, there is limited pediatric data. this is the first immunocompromised child treated with vedolizumab. the symptoms of the patient receded and no side effect observed during months of the treatment. results: louis-bar syndrome is a multisystem progressive disease with polymorphic manifestations which varies by age. the locomotor disability of these children is determined by neurological disorders, the exitus being caused by respiratory infectious and malignancies. the children involved in the study, had frequent episodes of respiratory infectious (bronchitis, pneumonia, atelectasis, empyema, lung abscess), ent infections (otitis, mastoiditis, sinusitis), chronic pulmonary disease (pulmonary fibrosis, bronchiectasis). index of death in this group is high ( . %). in one of the boy, the pulmonary ct showed lymphadenopathy, later was confirmed non-hodgkin lymphoma, with subsequent death. another child died from pulmonary and systemic infectious complications. results: in this paper we present the clinical and morphological analysis of children with nezelof syndrome diagnosed post-mortem. clinically were predominantly the generalized intrauterine infections or their development in the postnatal period. at macroscopic examination all patients had thymic hypoplasia. later on the microscopic study of the thymus specimens determined dysplastic changes, defined by the presence of concentrically arranged epithelial cells. in all patients, was determined the total lack of hassall corpuscles and its predecessors. besides the above-mentioned modifications in all specimens, there was no cortico-medullary segregation. thymic parenchyma outside pseudorrhagia was made up of a reticular stroma with total lymphocyte depletion. conclusion: nezelof syndrome is a severe primary immunodeficiency associated with thymic dysplasia and alymphocytosis, which is manifested early with generalized infections and major risk of death in neonatal and infant. background: the study was aimed to evaluate the cytokine profile in nasal secretion and blood serum in patients with seasonal (sar) and perennial allergic rhinitis (par) with a potential for additional sensitization with microbial allergens. method: the inclusion criteria for ar were as follows: a diagnosis of ar for more than years, the absence of nonallergic disorders of the nasopharynx, age of patients from years to years.control group: healthy volunteers at the age of - years without any allergic disorders at examination.in order to evaluate the innate and adaptive immunity, the cytokine profile of blood serum (il- , il- , and tgf-β) and nasal secretion (tslp, il- β, tnf-α, and gm-csf) was determined. to determine tslp, tgf-β, il- , and gm-csf concentrations, enzyme-linked immunosorbent assay kits were used (ebioscience, bender medsystems, r&d systems, mn, usa). we have noticed a significant correlation (r = , p = ) between the tslp concentration in nasal secretion and as-ige level to staphilococcus aureus enterotoxin (allergen component m ) in patients with par. there was a significant correlation conclusion: staphylococcal superantigens might be one of the stimuli of local tslp hyperproduction by the epithelium. there was a significant correlation between gm-csf concentrations in nasal secretion and the intensity of sensitization to a staphylococcal enterotoxin (seb) in the patients with ar. seb is one of the polyclonal t cells activators, which may account for increased concentrations of cytokines such as gm-csf locally within the system of mucosal immunity. the patients with ar and additional high sensitization to ses demonstrated a higher tnf-α production profile due to macrophage and tcell activation by these toxins. | evaluation of circulating osteopontin level as potential biomarker of allergic asthma in patients with caucasian and south-east asian ethnicity background: osteopontin (opn) is a pleomorphic cytokine known to influence a wide range of immune cells; allergic asthma was previously associated with high circulating opn levels. in the present study, we aimed to verify if opn may qualify as biomarker of activated immune response in allergic patients belonging to two different ethnic groups: caucasians and south-east asians. method: serum opn levels were measured by elisa test (human osteopontin duoset, r&d systems) in a series of italian adult patients affected by extrinsic asthma, allergic rhinitis, hymenoptera venom allergy, food allergy, allergic contact dermatitis and ige mediated hypersensitivity to beta lactams. healthy subjects served as controls. ethnic chinese subjects were recruited at the national university of singapore (nus) as cross-sectional cohort of an ongoing epidemiological study on the national prevalence of allergic diseases, and opn levels were detected by luminex (milliplex map, merck) and elisa assays (r&d systems). results: in the italian cohort, opn levels were significantly higher in cases compared to controls (p = . by the mann-whitney test). statistically higher opn levels were found in asthma (p = . ) and food allergy (p = . ) groups in comparison to controls. no significant differences were found (p = . ) between singaporeans with lifetime asthma and healthy controls, only the highest opn levels were heterogeneously found to correlate with asthma. however, a strong gender effect was shown, in both cases (p < . ) and controls (p < . ), with males presenting higher opn levels in comparison to females. consequently, we checked the mrna expression levels of opn gene (spp ) with illumina chips in whole blood of males and females, and no difference was found (p < . ). several experiments with western blots and different gel types were performed to verify if possible post-transcriptional/posttranslational modifications of opn could explain these findings. conclusion: opn seems to be a promising biomarker for current, active allergic asthma in caucasians even though technical difficulties, due to opn intrinsically disordered structure, the complex enzymatic metabolism, and the low circulating levels, significantly affect the experiments. further studies are needed to confirm these data. | mortality, intubation, and healthcare cost in patients with allergic bronchopulmonary aspergillosis in a hospital setting: a nationwide study fan x; luo y; yue b background: abpa is a complex hypersensitivity reaction to aspergillus fumigatus that colonize in airways, it is almost exclusively seen in patients with asthma or cystic fibrosis(cf). this study is to estimate hospitalization outcomes and healthcare cost of hospitalized patients with abpa. method: we conducted the study using data from national inpatient sample(nis) from to . diagnosis were identified using icd- -cm codes. hospitalization with a primary diagnosis of abpa and hospitalization with a primary diagnosis of acute respiratory failure/acute and chronic respiratory failure/respiratory distress/ asthma/cf and a secondary diagnosis of abpa were included. the study population was divided into groups including abpa with asthma, and abpa with cf. mortality and intubation rate were the primary outcomes; length of stay and total hospitalization cost(adjusted to cost in based on medical care cpi) were secondary outcomes. student t-test and chi-square were used for univariable analysis, linear and logistic regression were used for multivariable analysis. results: a total of hospitalizations with abpa were included, with hospitalizations with abpa and asthma, and hospitalizations with abpa and cf. the overall mortality rate was . % ( % ci: . %- . %), the mortality for abpa with asthma was . % ( % ci: . %- . %) and for abpa with cf was . % ( % ci: . %- . %). the overall intubation rate was . % ( % ci: . %- . %); the intubation rate for abpa with asthma was . % ( % ci: . %- . %) and . % were early intubation (< days); the intubation rate for abpa with cf was . % ( % ci: . %- . %) and . % were early intubation. the overall mean length of stay(los) was . ( % ci: . - . ) days, while the los for abpa with asthma was . ( % ci: . - . ) days and the los for abpa with cf was . ( % ci: . - . ) days. the overall total cost was million usd, the total cost for abpa with asthma was . million usd with a mean of , while the total cost for abpa with cf was million usd with a mean of . conclusion: mortality among hospitalized patients with abpa is low< %. intubation rate is relatively low, intubation, especially early intubation (< days), is more common in patients with asthma. although abpa is not a common disease in inpatient population, it does have a high health care cost and despite lower intubation rate, patients with abpa and cf generally have a longer hospital stay with a higher hospitalization cost. | frequent exacerbations of bronchitis with wheezing in adults: is it possible to predict and prevent asthma? case report: frequent episodes of bronchitis, accompanied by wheezing and dry with a prolonged duration in adults, the clinical course may be similar to bronchial asthma. the aim is to assess the risk of asthma in adult patients with or more episodes of acute bronchitis per year, had a prolonged duration and accompanied by a dry wheezing. for years in two regional clinical pulmonology centers were observed in patients ( men and women) with average age ± . years. each had at least episodes of acute bronchitis per year, which was accompanied by prolonged cough and presence of wheezes. average number of acute episodes per year was . ± . . in the course of the observation the patients were divided into equal groups. the first group consisted of persons treated in acute episodes of the disease symptomatic therapy, including inhaled β -agonists short-acting short course. in the second group to the corresponding treatment added montelukast mg per day lasting for month. in all cases of exacerbation had a viral nature. held in the period of remission of allergic sensitization, the survey revealed. starting from the first year of follow-up all patients were vaccinated against influenza annually. by the end of the fifth year of observation in the first group in cases was diagnosed of bronchial asthma- cases easy persistent asthma and case moderate. the diagnosis was exhibited in accordance with the gina criteria. in the second group, the diagnosis of bronchial asthma were exposed to patient (hazard ratio of . ). prospective observation suggests that the use of anti-inflammatory potential antileukotriene medicines in complex therapy of recurrent acute episodes of bronchitis accompanied by a dry wheezing in adults may be a factor preventing the development of asthma. for more conclusive results require more extensive research. background: chemokine receptors play an important role in regulating the migration of t lymphocytes, monocytes and neutrophils from the peripheral blood into inflamed tissue, such as lung. however, little is known about their expression on natural killer (nk) and natural killer t (nkt) cells in patients with chronic obstructive pulmonary disease (copd). therefore the aim of the study was to determine the chemokine receptor profile of peripheral blood nk and nkt cells of copd patients. method: for analysis of lymphocytes subtypes the flow cytometry method was used. the study population consisted of smokers with copd, healthy smokers and healthy non-smokers. results: we observed an increase in blood nk cells expressing cxcr receptors in smokers with copd compared to healthy smokers (p = . ) and healthy non-smokers (p < . ). the percentage of nkt cells containing cxcr receptors was also significantly higher in blood of smokers with copd compared to healthy smokers (p = . ) and healthy non-smokers (p < . ). copd smokers had significantly higher proportion of ccr + nk cells than smokers without copd (p = . ) and healthy non-smokers (p < . ). increased proportion of blood nkt cells expressing ccr on their surface was observed in smoking copd patients compared to healthy smokers (p = . ) and healthy non-smokers (p < . ). there were no significant changes in the percentage of cxcr + and ccr + nk and nkt cells between healthy smokers and non-smokers. in addition, no differences were seen in the proportion of nk and nkt cells expressing cxcr , cxcr , ccr and ccr among all studied groups. method: patients with copd in stable condition (gold stage ) aged - years old, smoking history of ≥ pack-years, were studied. bmi of patients were divided into groups: obese (n = ) (bmi- . - . kg/m ) and non-obese (n = ) (bmi- . - . kg/ m ). ten subjects with normal lung function and bmi were the control group. the level of il- assessed in induced sputum (pg/ml) was measured using an elisa (raybiotech ® ). serum levels of crp were measured using the "vector-best" (russia federation). spirometry was performed according to american thoracic society and the european respiratory society (ats/ers) guidelines. results: obese copd patients had significantly increased concentrations of il- compared with healthy subjects and non-obese copd patients by . fold ( . ± . pg/ml vs . ± . pg/ ml) (p < . ) and . fold, ( . ± . pg/ml vs . ± . pg/ml)(p < . ), respectively. non-obese copd patients had higher levels of il- by . fold compared with healthy subjects ( . ± . pg/ml vs . ± . pg/ml) (p < . ). results: among these three groups, the level of cer in lung cancer patients ( . ± . g/l) was significantly higher than that in ild patients ( . ± . g/l) and healthy individuals ( . ± . g/l) (p < . ). meanwhile, the levels of c and c in healthy individuals, which are . ± . g/l and . ± . g/l respectively, were both significantly higher than that in lung cancer patients (c : . ± . g/l, c : . ± . g/l) and ild patients (c : . ± . g/l, c : . ± . g/l), (c : p < . , c : p < . ). results from optimal scaling demonstrated that lung cancer was closely associated with immune factors including crp, cer, c and c (cronbach's alpha = . %). conclusion: for ild patients, when the level of crp and cer is increased and the level of c and c is decreased simultaneously, the risk of the development of lung cancer should be considered for these patients. results: among pbmc subpopulations, endurance exercises impacted the number of nkt and activated t cells with nkt cell numbers greater in male bobsledders vs bullet shooting and biathlon ( . % and . %, respectively). the number of activated t cells (cd + ) was greater in bullet shooting and bobsleigh athletes vs the biathlon group ( . % and . %, respectively). in female athletes the number of cd + cells in the shooting and bobsled groups was greater by . % and . %, respectively vs the biathlon group (p < . ). increased il- occurred in bobsleds in comparison to bullet shooting and biathlon: % and % in male and . % and % in female, respectively (p < . ). the concentration of il- in male bobsledders and biathlon was % and % greater, respectively, compared with bullet shooting (p < . ). serum concentrations of ifnγ in male as well as female athletes showed an increase of . % and . %, respectively vs biathletes (p < . ). increased il- occurred in the male biathlon group by . % and %, respectively, vs the bullet shooting and bobsleigh athletes (p < . ). il- was increased in the male biathlon group, compared to bullet shooting and bobsledders by . % and . %, respectively (p < . ). conclusion: prolonged endurance exercises impacts secretion of pro-and anti-inflammatory cytokines in athletes of different sport specializations. concentrations of studied cytokines did not exceed reference values perhaps due to specialized sport nutrition, which may restore immune function during endurance exercises. background: oral immunotherapy (oit) is a promising therapeutic approach to treat food allergic patients. recently, we have shown that the use of a mixture of short-chain-and long-chain fructo-oligosaccharides (scfos/lcfos) improves the efficacy of oit in cow's milk and peanut allergic mice. however, concerns with regard to safety and long-term efficacy of oit remain and there is a need to identify novel biomarkers (panels) that predict, monitor and/or evaluate the effects of oit. here we present a method for the selection of candidate biomarkers by using the computational approaches bayesian networks (bn) and topological data analysis (tda). method: data were used from scfos/lcfos diet-supported oit studies performed in independent cow's milk allergy (cma) and independent peanut allergy (pna) experiments in mice. first, a subset of the data was used for learning the data structure and their interactions in terms of a bn. this bn was used to compare the key parameters in both experimental food allergy models. finally, the relations within the dataset in combination with the bn were explored to identify and rank candidate biomarkers for the effect of oit by applying tda. the bn was able to predict the efficacy of oit in the cma and in the pna model with % and % accuracy respectively, thereby identifying a set of parameters (allergen-specific ige and igg , body temperature, mmcp- , earswelling) being key in the mechanisms involved in both scfos/lcfos-aided oit food allergy models. the tda zoomed in on the full set of previously analyzed parameters and identified clusters of biomarkers closely linked to biologically relevant clinical symptoms but also unrelated and redundant parameters within the network. taken together, this enables the prioritization of candidate biomarkers. moreover, the tda indicated differences between pna and cma models in how the data are related to each other. here we provide promising bioinformatics methods to compare mechanistic features between two different food allergies and to determine the biological relevance of biomarker (panels) of oit for food allergy. we have shown that the key drivers that influence pna and cma are similar, but that these phenotypically similar diseases show mechanistic differences in their subnetworks. these new insights provide excellent starting points to generate new hypotheses to explain why cma has a different disease pattern than pna and to select biomarkers that are useful in future clinical studies. | functional and immunoreactive levels of igg correlate with clinical responses during the maintenance phase of house dust mite immunotherapy basophils were identified as ssc low cd high , and cd was used as an activation marker. reactivity was confirmed by anti-ige as a positive control. results: in patients, basophil reactivity and sensitivity was comparable for grass pollen extract and recombinant phl p , while phl p only caused a lower basophil activation. in one patient, recombinant phl p did not cause any basophil activation, while phl p elicited an even higher sensitivity and reactivity than grass pollen extract. conclusion: in patients, basophil reactivity was comparable for grass pollen extract and recombinant phl p , while phl p only caused a minor basophil activation. in one patient, recombinant phl p did not cause any basophil activation, while phl p elicited an even higher sensitivity and reactivity than grass pollen extract. reactivity of extract and the main sensitizing components correlated, while sensitivity did not. | in vitro assessment of hypersensitivity to allergen before and after allergen immunotherapy with whole blood basophil histamine release assay wbbhr assay in these patients was performed - days before and - days after ait. heparinized whole blood samples ( ml) of each patient after substitution of plasma with pipes buffer were incubated one hour at °c with different concentrations of birch pollen extract (t ) in u-shape -well micro-titer plates. after incubation plates were centrifuged and supernatants from each well of the plate were directly analyzed for histamine content by reversedphase high performance liquid chromatography with electro-spray ionization mass-spectrometry (rp-hplc-esi-ms). results were expressed as ng/ml released histamine. sensitivity (limit of quantification) was - ng/ml. to compare results of histamine release in patients before and after ait data were calculated as area under the curve (auc) values. results: in contrast to pre-immunotherapy activity of blood basophils there were significant decreases in hr induced by t extract after ait. according to auc values all patients demonstrated decrease in hr after ait in compare to hr before ait in a range of %- % demonstrating a decrease of hypersensitivity to birch allergens. analysis of basophil hr in patients received s.c. or s.l. the asthma and rhinoconjunctivitis symptom scores during and after pollination season decreased significantly and showed correlation with histamine release by t . | immunotherapy with the recombinant b cell epitope-based grass pollen allergy vaccine bm induces a biphasic allergen-specific igg and igg response background: immunotherapy with the recombinant b cell epitopebased grass pollen allergy vaccine has been shown to reduce symptoms of grass pollen allergy in a multicenter, double-blind, placebocontrolled study. aim of this study was to investigate the levels and kinetics allergen-specific igg responses in a double-blind, placebocontrolled phase iib combined field and exposure chamber trial studying the effects of three, four and five pre-seasonal injections of bm as compared to placebo. method: a quantitative elisa assay based on purified human monoclonal allergen-specific igg as well as igg antibodies as standards was developed to measure allergen-specific igg and igg concentrations induced by ait with bm . results: we found rises in levels of both tested allergen-specific igg subclasses in the actively but not placebo-treated patients. phl p -and phl p -specific igg levels up to μg/ml and μg/ml, respectively and phl p -and phl p -specific igg levels of up to μg/ml and μg/ml, respectively were measured in bm treated patients. five pre-seasonal injections induced the highest allergen-specific igg levels. interestingly, allergen-specific igg and igg antibodies showed a biphasic response with early rises of allergen-specific igg which declined quickly after the pollen season and a delayed but very sustained allergen-specific igg response. conclusion: treatment with bm induces a biphasic allergen-specific igg response consisting of an early igg and a sustained allergen-specific igg response which may be responsible for early and sustained protection against allergic symptoms. | t reg cd + cd high in peripheral blood in patient with grass pollen allergy during sublingual specific immunotherapy slit the aim of this study was to evaluate t reg cd + cd high in peripheral blood in patients with grass pollen allergy during sublingual immunotherapy slit. method: we examined adult patients, aged - , female and male. patients were qualified to slit after confirmation of allergy-by skin prick tests, specific ige and nasal provocation tests. we determined t reg cd + cd high from blood sampling of those patients (by flow cytometry method), before the slit, after reaching the maintenance dose, before the grass pollen season, during the grass pollen season, and after one year of slit. results: during slit the percentage of t reg cd + cd high increase after reaching the maintenance dose, then it decreased before and during the grass pollen season, and again increase after one year os slit. we observed, that in the group with significant improvement of symptoms, t regcd + cd high decreased during grass pollen season, comparing to group without clinical improvement. conclusion: slit as a method of immunotherapy influence on levels of t reg cd + cd high cells. the observed decreased levels of these cells during the grass pollen season might be consider as a prognosing marker of clinical improvement. | t reg cd + cd high from peripheral blood during subcutaneous specific immunotherapy (scit) for grass pollen hofman a; hofman j; hofman t centrum alergologii, poznan, poland background: specific immunotherapy is the only causal method for grass pollen allergic rhinitis. however, we don't observe in every patients satisfying clinical effects. because the treatment of allergic rhinitis takes - years, and is quite expensive, everyone is constantly looking for a perfect parameter, which may prognose the effectiveness of specific immunotherapy (sit). the aim of this study was to evaluate t reg cd + cd high lymphocytes from peripheral blood in patients during subcutaneous specific immunotherapy (scit) for grass pollen . method: we examined adult patients ( female, male), age - , who undergo scit for grass pollen allergy. we have done skin prick tests and specific ige in those patients. additionally, we confirmed the allergy by nasal provocation tests. we have determined lymphocytes t reg cd + cd high from blood sampling from those patients, with flow cytometry method: before immunotherapy, after reaching the maintenance dose of scit, before and during the grass pollen season, and after one year of scit. our control group was represented by adult healthy volunteers. after one year of scit we divided patients into two groups-with and without clinical improvement. results: in allergic patients we have observed decreased levels of t reg cd + cd high compared to control group before the start for scit. during immunotherapy, the percentage of t reg cd + cd high increased after reaching the maintenance dose, however it did not reached the level of healthy volunteers. again, levels of t reg cd + cd high decreased before and during the grass pollen season, and increased after one year of scit. we compared also patient with significant improvement of clinical symptoms, and without. and we observed that the level of t regs cd + cd high decreased during pollen season in improved group, and increased in the group without clinical improvement. conclusion: in patients with grass pollen allergy, during the grass pollen season, decrease of t reg cd + cd high cells might be con- results: in the group of patients treated with sit gene expression analysis revealed significant change in ifng expression (p = . ) (comparison between sample a and b). comparison between samples a and c showed significantly different expression in genes: afap l (p = . ), commd (p = . ), pik cd (p = . ), and twist (p = . ). duncan's multiple range test confirmed difference between sample a and c for commd (p = . ) and also revealed new significant difference in tbx in samples a and b (p = . ; in wilcoxon's test p = . ). k nearest neighbors algorithm was built based on ifng, pik cd, commd expression. the results of the study indicate, that there is a significant change in the expression of a few genes during the build-up phase of sit. it may be suspected, that this change contribute to the mechanisms involved in the building tolerance to allergen. k nearest neighbors algorithm may be useful for sit efficacy prediction. | regulation of cytokine thymic stromal lymphopoietin (tslp) in modulating tgf-ß induced interstitial inflammation and cellular fibrosis background: thymic stromal lymphopoietin (tslp) has previously been linked to allergic inflammatory diseases, tissue fibrosis and organ dysfunction. it remains unclear, however, whether tslp plays any role in the occurrence of renal fibrosis, so this study investigated that underlying mechanism. method: an in vitro fibrosis model was established by treating normal rat kidney fibroblast (nrk- f) cells with transforming growth factor-β (tgf-β ), after which the levels of various fibrogenic markers (e.g., fibronectin) and downstream fibrogenic signal proteins (e.g., smad ) were investigated. also, tslp shrna was used to silence the effects of tslp, while an elisa was conducted to evaluate the fibronectin secretions. results: the level of fibronectin in the nrk- f cells was doseand time-dependently increased by the administration of exogenous tslp (p < . ). tslp also significantly increased the level of fibrosis signaling, in addition to inducing a marked decrease in the down-regulation of smad . interestingly, the application of tslp shrna caused a dramatic reversal of the tgf-β -induced cellular fibrosis while simultaneously leading to the suppression of fibronectin and fibrogenic signal proteins. conclusion: taken together, these observations provide insights into how extracellular matrices develop and could lead to potential therapeutic interventions for the suppression of renal inflammation and fibrosis. abstracts | | effects of two years treatment with the recombinant b cell epitope-based grass pollen allergy vaccine bm on allergen-specific b and t cell responses background: bm contains recombinant fusion proteins of nonallergenic peptides from ige-binding sites of the four major timothy grass pollen allergens phl p , , and and pres protein from the hepatitis b virus as a carrier. in a multicentre, double-blind, placebocontrolled trial, grass pollen allergic subjects were treated for two years either with bm or placebo. here we investigated in detail the effect of immunization with bm on allergen-specific t and b cell responses. during the study from subjects treated in the vienna centre (bm : n = , placebo: n = ) were investigated regarding proliferation using h thymidine incorporation and cytokine production in response to various recombinant allergens at different time points. grass pollen allergen-specific ige, igg and igg levels were determined by immunocap and elisa. results: a significant increase of allergen-specific igg and igg levels was found in the bm -but not in the placebo group in both years (year > year ) after treatment. there was no difference regarding t cell proliferation in response to phl p and phl p after first grass pollen season between actively and placebo-treated patients whereas proliferation in particular of phl p -specific responses seemed to be blunted in the active group in the second year. no significant differences regarding allergen-specific th , th and tolerogenic (i.e., il- ) cytokines were observed between bm and placebo-treated patients. the findings indicate that the bm induces high levels of allergen-specific blocking antibodies which may reduce allergen-specific t cell proliferation but does not induce significant increases of regulatory cytokines in t cells. this study was supported by grants f , f and dk -b of the austrian science fund (fwf). hospital universitario ramón y cajal, madrid, spain; department of immunology iis-fundación jiménez díaz, uam, madrid, spain background: shiitake mushroom (sm) (lentula edodes) is an edible fungi native to east asia. it is traditionally cultivated and used in many asian countries and its consumption is increasing worldwide. direct skin exposure to sm can cause cutaneous reactions, including allergic contact dermatitis and urticaria, while its oral intake may prompt "shiitake flagellate dermatitis" (sfd), which is a distinctive itching linear erythematous eruption. sfd is usually considered a toxic reaction to lentinan, a thermolabile polysaccharide that increases interleukin- . we report cases (p , p , p ) of shiitake flagellate dermatitis studied in our centre. method: skin prick tests (spt) to environmental allergens-including moulds -, prick-by-prick and patch test with raw and cooked sm were carried out. total ige and specific ige to mushroom, white mushroom and environmental moulds were also determined. a raw and cooked shittake mushroom extracts were prepared. both extracts were analyzed in all the patients by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). results: skin prick tests, prick-by-prick, patch tests and specific ige were all negative except for p , who had positive prick-by-prick to raw shiitake mushroom. sds-page ige immunoblotting assays with the patient's sera revealed ige-reactivity with proteins ranging from kda to kda for p , p and p . we report cases of shiitake flagellate dermatitis with demonstrated ige-sensitization. physicians should take into account that some cutaneous reactions considered as toxic might be allergic reactions. vorozhko i ; sokolnikov a ; sentsova t ; donnikov a ; ilyenko l ; denisova s background: allergic diseases such as asthma, rhinitis and food allergy have increased in recent decades in tropical countries. the tropics has climatic, environmental and ecological peculiarities that allow us to emit several hypotheses that could explain this phenomenon. in one of them, it is postulated that the increase of the sensitization to food, is due to the presence of lower serum levels of vitamin d, product of the adoption of a western lifestyle, with lower sun exposure, which in its turn diminishes the immunomodulatory action of this vitamin at intestinal level, favoring the sensitization against food antigens. we evaluate differences between the titers of serum antibodies against food antigens between two populations with african ancestry but different environment (rural vs urban) and investigate the influence of vitamin d levels. method: an observational, cross-sectional and descriptive study was carried out on afro-descendant children living in san basilio de palenque (rural) or in the city of cartagena, bolivar (urban). the sensitization was determined by a positive skin prick test to allergen extracts, including foods, and, specific ige, iga and igg to egg, milk and peanut extract, as well vitamin d, were measured by elisa. antibody and vitamin d titers were correlated by spearman's test and comparisons between groups were done using the wilcoxon rank sum test. a p < . was considered significant. results: atopy was more prevalent in the urban population ( % vs %, p < . ). however, none participant tested was positive for food allergens. regarding vitamin d levels, these were found to be higher in the rural population compared to the urban group (p < . ). among the antibodies analyzed, only ige against peanut showed differences, which were higher in rural population (p < . ) as well as those of iga to peanut, which were higher in the urban population (p < . ). we observed only a significant correlation between peanut specific ige (rho . , p < . ) and iga (rho - . , p < . ) response and vitamin d. conclusion: in our study, we found differences between the peanut specific ige and iga response in urban and rural populations. the correlation between the levels of specific ige and iga to peanut and vitamin d, suggest that this vitamin may influence peanut sensitization in this population, besides other components like diet and genetic and environmental factors. | evaluation of inhaled allergen sensitivity in patients with food allergies younger than two years of age kulhas celik i ; aldemir es ; buyuktiryaki b ; ginis t ; toyran m ; dibek misirlioglu e ; kocabas cn ; civelek e carbohydrates and pyruvate was observed in the severe group compared to the rest of allergic groups. in addition, an increment in lactate was noticed. these metabolites were closely associated with the energy metabolism. other metabolic changes included increased levels of fatty acids such as myristate, palmitate and laureate. these fatty acids might be precursors of arachidonic acid, a key molecule in inflammation. finally, alterations in some amino acids and adenosine were found method: to evaluate these critical processes, five-week old germ-free c h/hen mice were split into two groups; were intraperitoneally sensitized to the peanut allergen ara h and remained ns. upon reaching weeks of age, mice were intragastrically challenged with purified ara h . mice were harvested in two groups: -minutes and -minutes post-gavage. upon harvest, the left lobe of the liver was collected and sera were removed. sera and livers were evaluated for drp-ara h using an in-house quantitative sandwich enzyme-linked immunosorbent assay (elisa). a sample of the proximal small intestine was monitored for drp-ara h using immunohistochemistry (ihc) and for mast cell degranulation using toluidine blue stain. results: sensitization does not have a large effect on the concentration of allergen present in the sera or liver. however, s mice allowed to digest ara h for -minutes were more likely to display tissues positive for detection of drp-ara h than ns mice at the same time point. conclusion: there is drastic biological variation among mice in their capacity to absorb and transport allergens. the elisa used in these analyses proved effective in the quantitative detection of drp-ara h in both liver and sera samples, while ihc provided inconsistent results for the detection of drp-ara h in tissues. however, in positive ihc samples, staining was indicative of paracellular transport across the epithelial barrier. | eczema induces a high ovalbuminspecific ige/igg ratio and affinity maturation during the lactation period irahara m; kido h; shinahara w inst. for enz. res., tokushima university, tokyo, japan background: recent articles have revealed that ingestion of foods induces oral tolerance and cutaneous sensitization induces food allergy. relationships with levels of immunoglobulin subclasses, affinity of allergen-specific ige, and development of food allergy have also been indicated. however, relationships with levels and affinity of specific immunoglobulins and eczema during early infancy remain poorly understood. therefore, the present study aimed to elucidate these relationships. method: this study enrolled women who visited naruto hospital (tokushima prefecture, japan) in late pregnancy and their children. blood samples and information on skin condition were taken every months from neonate to months old. egg white and milk allergen-specific immunoglobulin subclasses and affinity of ovalbumin (ova)-specific ige levels were measured using the densely carboxylated protein (dcp) microarray with μl of serum. results: this study included infants whose parents agreed to join this study. of these, infants ( %) were diagnosed with eczema by months old. egg white (ew) and milk-specific igg were detected in a few subjects at months old. however, these specific ige and igg were detected in some subjects at that time ew-and ova-specific ige levels and ige/igg ratios were significantly higher in participants with eczema than in those without eczema at months old. moreover, subjects with high ova-specific ige/igg ratios showed higher affinity ova-specific ige antibodies than subjects with low ova-specific ige/igg ratios. these results were not reflected in milk-specific ige levels. the milk-specific ige level differed between breast feeding and formula-fed infants, with no difference in the ige/igg ratio. conclusion: eczema contributed to high ew-and ova-specific ige levels and ige/igg ratios. high ova-specific ige/igg ratios involved high affinity ova-specific ige antibodies. however, the milk source during early infancy had no effect on the specific ige/igg ratio with eczema. these results suggest different sensitization routes provoke different results in levels and affinity of immunoglobulins. | purification and characterization of naturally occurring post-translationally cleaved ara h , an allergen that contributes substantially to the peanut allergome background: the s albumin ara h is one of the most important peanut allergens. a post-translationally cleaved ara h isoform has been described in the past but had not been characterized in detail, nor had its relevance for peanut allergy been investigated. method: post-translationally cleaved ara h (para h ) and intact ara h (intact ara h ) were purified from virginia type peanuts and the cleavage site was mapped using high-resolution mass spectrometry. biochemical characteristics were determined by sds-page, uv absorbance spectroscopy, far uv cd spectroscopy, and immunochemical reactivity of both forms of ara h was compared by igg immunoblotting and ige-elisa using sera from individuals sensitized to peanut. reversed-phase liquid chromatography was applied to study the occurrence and abundance of para h in various peanut types. results: compared to intact ara h , para h lacks a -amino acid stretch, resembling amino acids - (uniprot accession number q g ) in the non-structured loop. consequently, para h consists of chains; a n-terminal chain of approximately kda, and a c-terminal chain of approximately kda, held together by disulfide bonds. intermediate post-translationally cleaved products, in which this stretch is cleaved but not removed, are also present. the secondary structure and ige-binding of para h resembles that of intact ara h , indicating that the loss of the non-structured loop is not critical for maintaining conformational ige-epitopes. both forms of ara h were reactive with several commercially available igg antibodies. the peanut cultivars runner, virginia, valencia, and spanish contained para h at equivalent levels, suggesting para h is a consistent and important constituent of the peanut proteome. conclusion: a post-translationally cleaved form of ara h is abundant in the main peanut market types, and has ige-binding comparable to intact ara h . this should be taken into account when ara h is investigated in peanut-containing products. | release of major peanut allergens from their matrix at various ph and at saliva conditions; ara h and ara h are quickly bioaccessible background: the oral mucosa is the first immune organ that encounters allergens upon ingestion of food. peanut is often consumed in solid form, and it is not known if peanut allergens are released from the food already in the mouth. we set out to investigate the solubility of individual peanut allergens at conditions that mimic the first exposure site, i.e. the mouth. method: light roast peanut flour was suspended in buffers of various ph mimicking saliva. protein concentration was measured in supernatant, and release of major allergens ara h , ara h , ara h , and ara h was assessed by sds-page. also, the allergen profile of un-dissolved material was assessed. results: peanut protein solubility is poor in the ph range - , while at low ph ( . ) and at moderately high ph (> ), the solubility is higher. at all conditions tested, there was a substantial amount of un-dissolved protein. this indicates that the ph range of saliva, between . and . in healthy individuals, may be critical for the release of peanut protein from its matrix. in this ph range from . to . , ara h and ara h are readily released, while ara h and ara h are poorly released. increasing the ph from . to . slightly increased the release of ara h and ara h , but still the recovery was low (approximately % for both ara h and ara h ) compared to that of ara h and ara h (approximately % and %, respectively). this remarkable difference in extraction kinetics suggests that ara h and ara h are the first allergens an individual is exposed to upon ingestion of peanut-containing food. conclusion: based on our observations, we conclude that the peanut allergens ara h and ara h are quickly bio-accessible in the mouth upon ingestion of peanut. this new insight may contribute to the understanding of the extraordinary allergenicity of ara h and ara h compared to other peanut allergens. background: in proven cases of non-ige mediated cow's milk allergy clinical response can be partial even when treated with amino acid formulae e.g pain in infants. residual intestinal symptoms can be related to ongoing nerve hypersensitivity, changes in microbiome or motility disturbance. mast cells are thought to play crucial role in non-ige mediated food allergy. ketotifen is a first generation h antihistamine which has mast cell stabilising properties with pain blocking and anti tnf-a effect. hence ketotifen could have important role in symptom resolution where diet elimination has not been successful. we aim to find out effectiveness of ketotifen to unresponsive/partially responsive symptoms such as pain in non-ige mediated cow's milk allergy infants. method: children who presented to single specialist centre over years had their case notes reviewed retrospectively. inclusion criteria were those children with confirmed non-ige mediated cow's milk allergy by elimination of cow's milk with improvement of symptoms and worsening of symptoms on reintroduction of dairy. where symptoms partially responded e.g pain, ketotifen was used at . - mg once at night for weeks and symptoms were reassessed. statistical analysis was performed using r v . . with significance was set at p = . . results: patients were identified with patients excluded due to unconfirmed non-ige mediated allergy. of the case ( males, age - months), atopic co-morbidities were found in % children. common symptoms were abdominal pain ( %), vomiting ( %), back arching ( %), constipation ( %), bloating ( %), food aversion ( %) and diarrhoea ( %). we compared the children who had symptom improvement on ketotifen and cow's milk elimination against children who improved on cow's milk elimination alone. significant difference of symptom improvement was found with abdominal pain; % using ketotifen compared to % who did not use results: a total of analysis for ttgiga have been performed for a total of patients during the study period ( , , , ) . patients showed at least once a positive ttgiga. among these, had a negative result at first testing, and were positive at the second (n = ) or third testing (n = ). despite an increasing number of ttgiga requests, the number of positive results decreased. wige were rarely requested but were positive in about % of tested sera (table a and b). the amount of laboratory requests for ttgiga has increased, while those for wige remains stable and is rare. wheat allergy seems to be rarely investigated in our center and may deserve more attention. case report: eosinophil-associated gastrointestinal disorders (egids), including eosinophilic gastroenteritis (eog), are a inflammatory diseases, characterized by gastrointestinal symptoms and eosinophilic infiltration. patients with eoe have an increased incidence of allergy, with increased ige mediated food and inhalant sensitivities. use of either a targeted food allergen avoidance approach (based on allergy testing) or untargeted approach (based on food allergen avoidance) results in the resolution of eosinophilia in the gastrointestinal tract of %- % of adult. we describe a case of a -year-old patient diagnosed with eosinophilic enteritis, associated to protein-losing enteropathy. the patient experienced severe diarrhea, nausea, vomiting and weight loss, that caused a severe dysproteinaemia and electrolytes abnormalities. an upper and lower endoscopy was performed, showing an ulcerative ileitis. the histological pattern was characterized by eosinophilic infiltration of ileum and duodenum> hpf. she presented also high levels of total ige ( k/ui), high serum tryptase ( μg/l, n.v. ≤ . ) and sensitization to the lipid transfer protein (ltp) of peach. the patient was prescribed to a six-food elimination diet (sfed) and underwent high doses of oral and intravenously corticosteroids, but a satisfactory therapeutic response was not achieved. we hypothesized that ige has a role in the mechanism of aeg and that blocking ige would have improved disease symptoms and reduced allergic inflammation, as measured by a decrease in intestinal tissue eosinophilia. we started off-label administration of omalizumab mg/month subcutaneously, the same dosage schedule used in allergic asthma and, by other authors, in eosinophilic gastrointestinal disease after achieving informed consent by patient. except for an exacerbation of symptoms occurred months after starting the therapy, when a further endoscopy, showing a gastrointestinal eosinophilic infiltration> hpf, was performed, a significant improvement of both gastrointestinal and cutaneous symptoms was observed during therapy, together with a normalization of laboratory parameters. after months a clinical remission of disease was obtained and administration was stopped. although a histological remission during the first few months of treatment was not obtained, in a subset of aeg patients, ige plays a role in the pathophysiology of the disease and that anti-ige therapy with omalizumab may result in disease remission. | fullerene c reduces the allergic inflammation in food allergy mouse model background: a food allergy (fa) is an abnormal immune response to food. the signs and symptoms may range from mild to severe. they may include itchiness, swelling of the tongue, vomiting, diarrhea, hives, trouble breathing, or low blood pressure. food allergy is becoming increasingly common. fullerene c has the unique electronic properties making it an attractive candidate for allergic diseases therapy. the main purpose of our research was to assess therapeutic effect of fullerene c in a mouse model of fa. method: new efficient method for producing a water-soluble fullerene c has been developed. fa experimental model was induced in balb/c mice by the intragastrical (ig) ova administration after subcutaneous (sc) sensitization. fullerene c was administrated ig once a week, or twice a week, or daily. ova-specific antibodies were assessed by elisa. splenocytes cytokine production upon ova in vitro stimulation was detected by elisa. samples of jejunum of the small intestine were removed for histological examination immediately after the last ig allergen administration. results: it was shown that ova-specific ige and il- level were significant decreased in groups treated with water-soluble fullerene c . the greatest effect was observed in mice receiving fullerene c daily. the ifn-gamma level was significantly higher in ig c treated groups. the histologic analysis of jejunum of the small intestine samples showed that c -therapy improved the histologic picture. the greatest effect was observed in mice receiving fullerene c daily too. conclusion: taken together, these results demonstrate that the water-soluble fullerene c exhibits a significant anti-inflammatory effect in a mouse model of fa, and possesses a high therapeutic potential. background: a -year-old male reported eight episodes of anaphylaxis after exercise. all the ingested food eight hours before each episode was analyzed. before each episode, he had always eaten chicken or turkey meat, and he tolerated these foods without exercising. in one of the episodes the patient had taken a tablet of dexketoprofen a few hours before. since several years, he referred chest tightness after eating some fish (emperor, salmon and whiff), however he tolerated others. the patient denied having eaten fish before any of the episodes of anaphylaxis. method: commercial skin prick tests (spts) and prick by prick tests (pp) with all food ingested and fishes were performed. tryptase, total serum ige (ige) and specific ige (sige) (immunocap. thermo-fisher scientific, uppsala, sweden) to the foods involved were determined. a controlled oral provocation test (opt) with dexketoprofen was performed. results: spt was positive to tuna extract ( mm) and negative ( mm) for the rest of fish extracts. it was also negative for chicken meat extract and other foods tested. pps were positive for raw and cooked turkey meat ( mm), raw and cooked tuna ( and mm), raw emperor ( mm), raw and cooked whiff ( and mm) and raw hake ( mm). pps were negative to raw and cooked chicken meat. ige was ui/ml and tryptase . ng/l. sige was slightly positive to hake, cod and chicken meat. dexketoprofen opt was negative. at that moment, we recommended the patient to avoid chicken and turkey, as well as the fishes which he had symptoms with. since then, he has not suffered any new episode of anaphylaxis despite exercising daily. protein extracts from turkey meat, tuna, emperor, salmon, hake and whiff were prepared and analyzed by sds-page. conclusion: recently, triosephosphate-isomerase ( kda) has been identified as a new chicken meat allergen. this allergen could be responsible for the cross-reactivity between bird and fish meat and the episodes of anaphylaxis after exercise in our patient. the triosephosphate-isomerase has not been implicated previously as a cross-reactive allergen involved in the fish-chicken syndrome. results: twenty-three patients were included, % male, median age years (iqr . ), % atopic, % asthmatic. non-specific lipid transfer proteins (nsltp) were implicated in % (n = ) and ω- -gliadin in % (n = ). eighteen ( %) patients referred anaphylaxis in the reaction with co-factor, ( %) urticaria/angioedema, had both depending on the co-factor. all patients in which ω- -gliadin was the allergen involved had anaphylaxis in the presence of co-factor, with tolerance to wheat without it. in patients in which nsltp was the allergen involved, ( %) had anaphylaxis in the presence of co-factor. reaction with co-factor was more severe than without in ( %) patients; patients had no previous history of reaction and subsequently tolerated the culprit food. only patient had anaphylaxis in the absence of co-factor; the remaining presented oral allergy syndrome and/or urticaria. exercise was the main co-factor, present in patients. nonsteroidal anti-inflammatory drugs (nsaids) were the only co-factor in patients; all of them had anaphylaxis, with allergy to ω- -gliadin, to nsltps. all subsequently tolerated the nsaids involved. conclusion: nsltps and ω- -gliadin were the most frequently involved allergens in cefa, with exercise being the most frequent co-factor. nsaids were relevant co-factors, even when ω- -gliadin was the allergen involved. several patients subsequently tolerated culprit foods and nsaids, difficulting the diagnosis and further emphasizing the importance of a correct cofactor evaluation. molecular allergens had an important role in the diagnosis, avoiding unnecessary ofc. information about co-factors must be included in all patients with allergy to nsltps and ω- -gliadin. | allergy to wheat-dependent exerciseinduced anaphylaxis (wdeia) proteins, without? -gliadins as responsible ferreira a ; castillo m ; martins s ; pineda f unidade de imunoalergologia hospital das forças armadas., lisbon, portugal; departamento de aplicaciones. diater laboratorios, madrid, spain background: the second well-characterized form of allergy to wheat proteins is wheat-dependent exercise-induced anaphylaxis (wdeia), with the ω -gliadins (part of the gluten protein fraction) being the major group of proteins which are responsible, but other forms of food allergy have also been reported, with the proteins responsible including gluten proteins, cm proteins and non-specific lipid transfer proteins. the patient was a -year-old man who visited the hospital with acute urticaria just eat bread before run ( minutes). according the components of bread. it was formed by a mixture of wheat, rye and barley. with a history (for several years) of episodes of severe urticaria after intake a mixture of cereals and/or different kinds of beer. results: prick test and specific ige with wheat, rye and barley were negative and the proteins from allergenic extract from these cereals, and also the gliadins and glutenins fractions were transferred onto a pvdf membrane to carried out a western blot technique with the patient's serum. the patient's serum recognized several proteins from wheat and millet gliadins not compatible in molecular mass with a ω -gliadins. the association of w gliadin as responsible for the symptoms produced after the intake of products containing wheat and exercise is well referenced but in the case of this patient could have other proteins involved as triggers of their symptoms. suksawat y phramongkutklao hospital, bangkok, thailand background: food-dependent, exercise induced anaphylaxis (fdeia) is an anaphylactic condition that develops in patients who ingest specific food followed by exercise. a variety of foods have been described to be the cause including shellfish, wheat and vegetables. the mechanisms of fdeia is believed that exercise increases allergen absorption or decreases threshold of mast cell. the investigations such as skin prick test or specific ige for food are useful because food sensitization is demonstrated. however, a challenge test including ingestion of suspected food followed by exercise is the only method to diagnose this disease. we report a case of fdeia in a -year-old adolescent male. result: he presented with generalized urticaria and hypotension after eating a barbecue buffet which was one hour followed by playing taekwondo. after treatment with intramuscular adrenaline, antihistamine and systemic steroid, his condition was improved. the barbecue buffet consists of many kinds of food including shrimp, squid, salmon and pork meat which were previously tolerated. he had no past history of anaphylaxis or drug allergy. he was referred to our allergy unit for investigation. we performed skin prick test with food allergens and many kinds of fresh foods that he ate on that day and the result was positive to shrimp ( mm. in diameter). three-day challenge protocol was set up a month after recovery and we used aspirin as a cofactor. on the first day, open challenge for gram of shrimp was administered and the result was negative. on the second day, exercise challenge test based on the american thoracic society guideline was also negative. however, on the last day, he developed generalized urticaria five minutes after the same exercise challenge test which was hour preceded by aspirin intake and gram of shrimp ingestion. but his vital signs appeared to be stable. the patient was administered intramuscular adrenaline and antihistamine with full recovery. he was strongly advised to avoid shrimp for - hours before exercise and carry an adrenaline autoinjector. the-three day challenge protocol is a definite tool to confirm the diagnosis of fdeia. a correct diagnosis is important to avoid unnecessary restricted diet. | food dependent exercise induced anaphylaxis in peach allergic patient-case report consumption of different types of food (pancakes with cream cheese and fruit, peach, chinese dish, sandwiches-all eaten on other occasions without symptoms) and co-occurring physical exercise (dancing, shopping, walking). during diagnosis we performed spt with inhaled and food allergens (allergopharma), prick by prick tests with peach, banana, apple, pear and bread. we established the concentration of allergen specific ige (peach, wheat flour, peanuts, hazelnuts) and the level of ige specific to allergen components (immunocap isac). we performed exercise provocation test and open food challenge with peach. results: spt were negative with all tested food and inhaled allergens (inc.egg; milk; cocoa; tomato; carp; apple; banana; strawberry; rye flour; wheat flour; peanuts; hazelnut; citrus, d. farinae; d. pteronyssinus; grass; weeds; clad. herbarium; alt. tenuis; dog; cat; poplar; hazel; alder; birch; mugwort). prick by prick tests were positive with fresh peach. concentration of peach specific ige was . ku/l. in immunocap isac we found elevated levels of ige specific to ltps from different allergen sources (jug r - . ; pru p - . ; pla a - . ; tri a - . [isu-e]). open food challenge with a medium size peach was negative. exercise provocation test without allergen exposition was negative. exercise provocation test after eating a medium size peach concluded with severe lip and eyelids edema, followed by whizzing, dyspnea and urticarial. patient received adrenaline . mg im, steroids and antihistamines with good clinical effect. conclusion: patient was diagnosed with food dependent exercise induced anaphylaxis (fdeia) due to ltp allergy. she was advised to eat peeled fruit and vegetables, avoid cofactors of allergic diseases and carry rescue set (adrenaline, steroids and antihistamines). cases reports: we report case of fdeia and cases of wdeia. case : -year-old woman with intermittent severe allergic rhinitis and food allergies since childhood. in the last years she registered weekly episodes of fdeia (urticaria, angioedema, wheeze, drop of bp) especially when during effort and after alcohol intake. prick tests were positive for grass pollen, mugworth, ragweed, dust mites, celery, soy, sesame, pistachio, mango, honey and shellfish. she followed years of subcutaneous immunotherapy for grasses pollen. the fdeia episodes frequency and severity diminished during it. provocation test for celery and mango were positive, for alcohol, soy, sesame, pistachio, honey and shellfish were negative. case : -year old man with a -year history of acute gluten induced urticaria, recently developed episodes of wdeia (flushing, severe urticaria and angioedema, wheeze) when he went for gym. skin test was highly positive for wheat flour and dust mites, in vitro tests for omega gliadin and wheat-specific ige were positive. food challenge for wheat was positive. he followed oral immunotherapy for wheat. the wdeia episodes were rare and mild. case : -years old female with mild allergic rhinitis and controlled asthma, with wdeia (urticaria, angioedema, wheeze, drop of bp) in the last years. skin tests showed positive results for wheat flour, dust mites and dog hair. omega- gliadin and wheat specific ige were high, but the provocation test for wheat was negative meanwhile combined wheat and effort provocation test was positive. -year-old female athlete, otherwise healthy, experienced three episodes of fdeia following running sessions. two reactions were preceded by intake of salad containing lettuce, tomato and sunflower seeds and the third one occurred after eating celery salad. the patient denied occurrence of any symptoms with physical exertion or food ingestion alone. physical examination and blood testing did not reveal any abnormalities. the differential diagnosis was performed. in skin prick test and specific serum ige antibodies sensitization to house dust mite, grass and mugwort were found. the spt and specific ige assay to culprit and most common food allergens were negative. the molecular diagnostic has been applied (faber, caam, rome, italy). the test scored positive for art v, blo t, der f, der p, eur m, lol p, phl p. no positive results for available food molecules including celery, tomato, sunflower seeds and lettuce were found. the detection of culprit food in fdeia is of crucial meaning as the syndrome can be life-threatening. the molecular diagnostic has been applied already in diagnosis of wheat-dependent exercise-induced anaphylaxis (wdeia) proving ω- -gliadin sensitization in the majority of the cases. as the presented case did not reveal sensitization to culprit food in traditional allergy tests the molecular diagnostic was performed. this test did not show sensitization to culprit food either. however, not all of the molecules are available in molecular assays yet. cross-reactivity reaction to mugwort and grass has to be considered. the pathophysiological components of physical exertion has to be taken into consideration as well. this could contribute to the assessment of reasonability of molecular approach in diagnostic work-up for fdeia and to the establishment of standardized protocols for diagnosis and management of that syndrome. case report: food allergy to wheat is rare in adults, often reported in exercise-induced anaphylaxis. food-dependent exercise-induced anaphylaxis (fdeia) is a form of food allergy induced by exercise. fdeia symptoms can include urticaria/angioedema, respiratory and gastrointestinal manifestations and hypotension/shock. a -year-old male patient presented to the emergency department, was admitted after an episode of hives, hypotension and loss of consciousness. his consciousness was restored after treatment with epinephrine, glucocorticoids as well as fluids, and thereafter, the patient reported that the anaphylactic episode occurred when he started rapidly walking hour after eating a slice of pizza. he mentioned that the offended food was tolerated always when it was not followed by a physical exercise. review of his past medical history and family one were non-contributory with respect to this episode. the allergy skin prick testing for common foods revealed a positive response only to wheat, while and other laboratory test values were within normal ranges. the patient is discharged after instructions on the use of epinephrine auto-injector. he was also advised to avoid wheat containing products up to hours prior to physical exercise. our case demonstrated that fdeia can be characterized by the onset of anaphylaxis soon after physical exercise, when preceded by the ingestion of the responsible food. avoidance of the combination of the exposure to respective allergen and exercise is the most efficient precautive measure toward subsequent fdeia episodes. | residual exercise-induced allergic reactions after successful rush oral immunotherapies for milk and wheat method: we conducted roit for children (median . years old) with milk allergy and children (median . years old) with wheat allergy during - . after - days of the rush phase in the hospital and a slow-increasing phase at home, patients consumed the maintenance dose ( . g milk protein or g wheat protein). after at least three months of the maintenance phase without allergic symptoms, we conducted an exercise provocation test (ept) after eating the target food. if the ept was positive, we repeated it after a couple of years to check for remission. the presence or absence of eiars was based primarily on the results of epts but also on the clinical history in some cases. results: as of december , milk-and wheat-allergic patients were able to continue ingesting the maintenance dose (desensitization). in these patients, milk-and wheat-allergic patients underwent the first ept at a median of ( - ) days after roit, and the result was positive in ( . %) and ( . %) patients, respectively. among these ept-positive patients, milk-and wheat-allergic patients conducted a second ept at a median of ( - ) days after the first ept. the result of the second ept was positive in milk-and wheat-allergic patients. in addition, clinical histories of eiars were subsequently observed in milk-and wheat-allergic patients after negative results on an ept. altogether, ( . %) milk-and ( . %) wheat-allergic patients still had eiars even after getting desensitization as of december conclusion: patients with persistent milk and wheat allergy often have residual eairs even after three to five years of desensitization due to the administration of successful roit. abstracts | | anaphylaxis caused by omega- -gliadin initially diagnosed as idiopathic anaphylaxis: a case report tziotou m ; syrigos k ; syrigou e ; sinaniotis a department of allergy,, athens, greece; gpp,, athens, greece case report: we report the case of a -year-old man who experienced two episodes of wheat dependent exercise induced anaphylaxis, initially diagnosed as idiopathic anaphylaxis. first episode: the patient woke up in the morning and drove to his resort. while driving, he ate a piece of cheese and ham pie. when he arrived, he walked some meters to the garden and started feeling pruritus and dizziness. he lost consciousness and recovered by himself. he was carried to hospital where his vital signs were normal. the patient has a history of atrial fibrillation and has been on flecainide bid and aspirin at noon for the last four years. a month after the first episode he visited an allergist. skin prick tests to aeroallergens and prick to prick tests to the ingredients of the pie were negative. tryptase levels were within normal limits and skin biopsy was negative for mastocytosis. an endocrinology workup was also negative. the patient was prescribed an epinephrine autoinjector and was asymptomatic for eight months. second episode: that morning he had a cup of milk and two slices of toast for breakfast and started working in the garden. two hours later he experienced pruritus and urticaria and fell unconscious. his wife had to administer two epinephrine autoinjectors before he regained consciousness. after the second episode it was decided to start treatment with omalizumab. two months later he experienced an episode of urticaria while working in the garden. he could not recall what he had eaten before. based on history, we thought that a cofactor might contribute to the occurrence of anaphylaxis. we performed skin prick tests with peach (ltp) and gliadin, allergens associated with food dependent exercise induced anaphylaxis in our region. the test to gliadin was positive. specific ige in serum to omega- -gliadin was also positive, while specific iges to all ltps tested were negative. the patient was advised to avoid wheat and has been asymptomatic ever since. cases diagnosed with idiopathic anaphylaxis may actually be cases in which the culprit allergen has not been identified. detailed history and extensive workup may contribute to the successful management of these patients. written informed consent has been obtained from the patient. | wheat-dependent exercise-induced anaphylaxis (wdeia) and nsaids: clinical history is crucial conclusions :we present a case clinically compatible with wdeia with nsaids intake as augmenting factor. this case emphasizes that a carefully and thoroughly taken medical history is of crucial importance, otherwise wdeia can easily be unrecognized. as a result, non-allergic hyperreactivity to nsaids could be excluded and the diagnose of selective allergy to arylpropionic acids was made. exercise challenge test could not be performed in our case. case report: kounis syndrome (ks) has been defined as an acute coronary syndrome that manifests as unstable vasospastic or non-vasospastic angina, and even as acute myocardial infarction. it is triggered by the release of inflammatory mediators following an allergic insult. a -year-old woman with type ii diabetes and hypertension, and unstable angina pectoris as cardiovascular risk factors, has consumed chamomile tea. thirty minutes later, she developed generalized itching, skin rash, swelling of the face and the throat, chest tightness, dyspnea and syncope. the patient was transferred immediately to the emergency department, and sodium chloride, mg prednisolone, mg dexamethasone, mg methylprednisolone, ui heparin, mg voltaren were intravenously administered along the subsequent minutes under simultaneous treatment with oxygen therapy. an ekg examination is performed based on the patient disease's history, showing a . - mm st-depression on d -d leads, mm on v , and . mm on the v -v ones. in addition, . mm st-elevation on the avr and mm on the v derivation was observed, associated by a negative t-wave on the v , v , and avr leads. blood tests revealed a normal troponin i level (of . ng/ml). five hours later in the ekg was noticed: isolined st-segments, and negative t waves on the d , avr, and v leads. ultrasound examination revealed normal heart kinetics and function. following the heart changes, the patient was administered sol. heparin ui twice i.v., nebivolol mg, plavix mg, atorvastatin mg, abstracts | monocinque mg, ordinary insulin ui s.c., glargine insulin ui s.c., and sol. furosemide mg i.v. the patient progressed favorably, and four days after the anaphylactic episode the ekg revealed a . mm st-depression on leads v , and v , negative t-wave on avl lead, and normalized one on the v one. this case emphasizes the role of serious allergic reactions as cause of acute coronary syndrome in patients with altered coronary arteries and food intake as cause of kounis syndrome. | recall urticaria in two young patients with alpha-gal-syndrome after tick bites case report: patient a (m, age ) had suffered from - anaphylactic reactions (hives, nausea, dyspnea and dizziness) within the past months. all episodes occurred - hours after ingestion of red meat, once with alcohol as a co-factor. all episodes started with a wheal measuring about . cm in exact the same spot where he had been bitten by a tick one year before. specific ige to galactose-alpha- , -galactose (alpha-gal) was positive ( . ku/l). skin prick testing using raw pork kidney suspension and intradermal testing with gelafundin ® % diluted : also showed positive reactions. we performed an oral challenge with cooked pork kidney under careful monitoring being able to reproduce the recall urticaria as described above with a cumulative dose of g pork kidney. we stopped the challenge and treated the patient with antihistamines and corticosteroids. patient b (m, age ) reported on several anaphylactic reactions within the past years with symptoms including abdominal pain, diarrhea, as well as dyspnea and loss of consciousness in one of the episodes. all episodes occurred several hours after ingesting food. furthermore the patient remembered a tick bite about years before the first anaphylactic reaction, which repeatedly became inflamed and only healed completely over months. every episode started with pruritus and a wheal in the area of the former tick bite (in loco). specific ige to galactose-alpha- , -galactose was positive ( . ku/l) as well as the skin prick testing with cooked pork kidney and intradermal testing with gelafundin ® % diluted : . this patient refused performance of oral challenge tests. an elimination diet of red meat for months resulted in the absence of the symptoms as described. the diagnosis of alpha-gal-syndrome with recall urticaria in loco was made in both cases. this symptom may also be useful in evaluating results of oral challenge tests as well as an important clinical sign in medical history. pali-schöll i ; meinlschmidt p ; purschke b ; hofstetter g ; einhorn l ; mothes-luksch n ; jensen-jarolim e ; jäger h background: insects have gained interest as alternative nutrient source for humans and animals. however, being a "novel food" in the industrialized part of the world, several safety aspects, like allergenicity, need to be thoroughly addressed. in the present work we evaluated the cross-recognition of ige from patients allergic to crustaceans, house dust mite or stable flies, using house cricket acheta domesticus (ad), desert locust schistocerca gregaria (sg) and mealworm tenebrio molitor (tm). we further investigated changes of immune-recognition in terms of ige-binding in differently processed insect extracts. method: migratory locust locusta migratoria (lm) was subjected to different extraction methods, enzymatic hydrolysis or thermal processing, whereas tm larvae (tml) were evaluated after different centrifugation modes and ph levels. results: we revealed that ige from patients with crustacean allergy shows cross-recognition of acheta domesticus, schistocerca gregaria and stable flies. ige from house dust mite allergic individuals binds to acheta domesticus and schistocerca gregaria. importantly, the cross-reactivity to lm can be deleted by enzymatic hydrolysis with different enzymes or heat treatment (cooking, autoclaving), but not by different extraction methods. changes of ph and varying centrifugation steps are not sufficient to reduce ige-binding to tml. our results show that patients allergic to crustaceans, house dust mite or stable flies-allergic patients cross-recognize desert locust and house cricket proteins, and crustacean-allergic patients also flies proteins. furthermore, we confirm that the appropriate food processing method of insect proteins can reduce the risk of cross-reactivity for crustaceans-and house dust mite-allergic patients. the study was supported by the austrian science fund fwf (grant sfb f -b to ejj). results: the mean age at diagnosis was years in children and years in adults, more frequent in males ( : ). in the pediatric group, three had first-degree relatives with eoe and three had celiac disease. two children had performed milk oral immunotherapy and five adults aeroallergens subcutaneous immunotherapy. most of them were atopics with sensitization to aeroallergens ( . % of children and . % of adults) and food allergens ( % of children and . % of adults), without statistically significant differences. the most frequent foods were fruits and nuts in both groups. we found significant statistical differences in fruits ( % of children abstracts | and . % of adults; p = . ) and cereals sensitization ( % of children and . % of adults; p < . ). in the clinical presentation we observed significant statistical differences in impaction ( . % of children and . % of adults; p < . ), dysphagia ( . % of children and . % of adults; p < . ) and abdominal pain ( % of children and . % of adults; p = . ). in the endoscopic findings children had more frequently exudates ( . %; p < . ) and adults had esophageal trachealization ( %; p < . ). significant statistical differences were found in the treatment with topical corticosteroids ( % of children and . % of adults; p < . ) obtaining a variable positive response. . % of patients in both groups received food elimination diet, % with four or more foods. conclusion: eoe presents differences in the sensitization profile, clinical manifestations and endoscopic findings according to the age of presentation. the response to pharmacological treatment is variable and a high percentage of patients receive food elimination diets. it is a pathology difficult to control, therefore new non-invasive techniques would be useful in order to facilitate its management. | modulation of gut microbiota in patients with nickel allergy and ibs after diet and probiotics supplementation mb ; garcía-figueroa be department of allergy department of allergy fang l united states | bcx improves health-related quality of life in hereditary angioedema with c -inhibitor deficiency bygum a fang l former yugoslav republic of; division of clinical immunology huissoon a bygum a ; panovska vg united states callejas fdb alobid i ; muñoz-cano r izquierdo i icahn school of medicine at mount sinai method: the case report form was developed by experienced allergists, and the web-based registry was established in cooperation with a professional medical software team. twenty-two departments from hospitals took part during the first year %), whereas in adults, drugs ( . %) were more common than foods ( . %). the most common food triggers were eggs ( . %), milk ( . %), and walnut ( . %) in children, and shrimps ( . %), wheat ( . %), and crab ( . %) in adults. among drug triggers in adults, antibiotics ( . %) were the most common cause followed by nsaids ( . %), and h -blockers ( . %). the onset time was≤ minutes in . %. in children, home was the place of occurrence in more than half of the cases, whereas adults experienced anaphylaxis in out-of-home settings more often than children. cofactors were present in %. among the cases registered via the emergency department of participating hospitals, epinephrine was administered in . % ( . % in adults, . % in children) and the route of administration was im in . %, iv in . %, both im and iv in . %, and subcutaneous in . %. the number of epinephrine administration was single in % conclusion: this multicenter prospective registry would provide a better understanding of anaphylaxis, and provide visionary modalities to improve the management and prevention of anaphylaxis in future a case of kounis syndrome after chamomile tea consumption characterized by symptoms related to esophageal dysfunction and esophageal mucosal infiltration by eosinophils objective: characterize patients (pts) with eoe diagnosis and analyze the differences between pts with diagnosis at pediatric (ch, < years old) and adult age epicutaneous tests(epict)], serum total ige and eos, findings in upper digestive endoscopy (ude) and biopsies. the correlation between food sensitization, clinical severity (visits to er services or hospitalization due to complications of eoe, sclin) or severe histology results: pts ( % male, average age ± years) ad and , respectively. % ch and % ad were atopics. the most frequent symptoms of eoe were dysphagia ( %) and gastroesophageal reflux( %) in ch; impaction( %) and dysphagia( %) in ad. % ch and % ad had aeroallergens sensitization. % ch and % ad had food sensitization. the most frequent positive tests were for ch: spt to milk( %) and shellfish( %), epict to shellfish( %) and meat( %); for ad: spt to milk( %), fresh fruits and nuts both %), epict to shellfish( %) and meat( %). ude showed: % striation and white plaques in % ch shist ( %) was associated with sclin ( %), p = . in ch; but this was not observed in ad group there was no correlation between food sensitization and sclin or shist in both groups(p > . ). the average values of serum total ige (kua/l) were in ch and in ad; eos were and , respectively in ch and ad allergy unit-fondazione policlinico universitario a. gemelli, università cattolica del sacro cuore conclusion: ltp with a fixed dose ( iu in ml) of ready-touse shp led to fewer severe attacks, a higher proportion of attack-free patients, and a clinically meaningful and statistically significant reduction in cumulative attack severity and daily severity in hae patients relative to placebo. background: c -inh-hae is a rare, potentially life-threatening disease characterized by episodes of subcutaneous and/or submucosal swelling. apex- was a phase , double-blind, placebo-controlled study to evaluate the prevention of attacks with bcx , a once daily oral kallikrein inhibitor, in patients with c -inh-hae.method: patients with c -inh-hae with a history of at least hae attacks per month were randomized to receive four different doses of bcx ( mg, mg, mg, . mg) or placebo for days. blood samples for bcx concentrations and kallikrein inhibition were obtained from patients before dosing and for hours post-dose on day . pk analyses and pk-pd modeling were done in phoenix winnonlin v . and sas v . . the pk population included , , , and subjects in the mg, mg, mg, and . mg groups respectively.after daily dosing achieved steady state, c max was reached at a median of - hours after dosing. there was a greater than dose proportional increase in exposure (auc tau and c max ) over the . -mg to -mg dose range, with an approximate -fold increase in exposure with a . -fold increase in dose. at doses ≥ mg, which showed statistically significant and clinically meaningful reductions in hae attack rates, geometric mean plasma trough concentrations (c tau ) were maintained at or above the minimum target concentration ( -fold ec ) estimated to be required for adequate plasma kallikrein inhibition. percentages of study subjects at steady-state with bcx plasma concentrations> -fold ec were %, %, % and % in the . , , , and mg dose groups, respectively. a -mg dose provided a mean c tau of slightly above . fold ec , with a corresponding reduction in hae attack rate of % (p < . ) compared with placebo. consistent with the exposure data, a dose dependent inhibition of kallikrein was observed with bcx treatment over the dose range. the drug effect on kallikrein inhibition was highly correlated with exposure (r = . ). in patients with c -inh-hae, bcx treatment at doses ≥ mg resulted in clinically meaningful reductions in the mean weekly hae attack rate. concentrations of bcx at doses ≥ mg were maintained at or above a c tau of -fold the kallikrein inhibition ec in most patients, and kallikrein inhibition was highly correlated with bcx plasma concentrations.background: c -inh-hae is a rare, life-threatening disease characterized by recurrent episodes of subcutaneous and/or submucosal swelling that lead to considerable morbidity and a poor quality of life (qol). apex- was a phase , double-blind, placebo-controlled study to evaluate the prevention of attacks with bcx , a once daily oral kallikrein inhibitor, in patients with c -inh-hae.method: patients with c -inh-hae with at least hae attacks per month were randomized to four different bcx doses ( mg, mg, mg, . mg) or placebo. subject-reported qol assessments were conducted at the start and end of treatment using the disease specific angioedema quality of life (ae-qol) questionnaire that measures domains (function, fatigue, nutrition, fear/ shame) and has minimal clinically important difference (mcid) of points. the changes from baseline in total and domain scores was compared between the treatment and placebo groups. modified angioedema activity score (aas) values across domains (daily activities, appearance, physical discomfort, overall severity) were calculated for each attack and a total score was derived for each subject by summing scores from each attack. total scores were compared to placebo using an ancova model with adjustment for qualifying attack rate. reduction of attacks was statistically significant for all top doses and there was a dose related increase in adverse events.results: in the mg dose group, qol assessed by ae-qol was significantly improved after weeks of treatment compared to placebo for ae-qol total score (- . , p < . ) as well as across all domains (function: - . , p = . ; fatigue: - . , p = . ; fears/shame: - . , p < . ; nutrition: - . , p = . ). all other treatment groups showed a trend towards improvement. qol improved the most in the mg group, and % of subjects in the mg group showed ae-qol reduction of more than points. disease activity as assessed by the aas was significantly reduced in the mg, mg and mg dose groups as compared to placebo, whereas there was no significant reduction in the . mg dose group. results: there were no marked differences in the age, sex, total ige titer, comorbidity of bronchial asthma and atopic dermatitis or the starting dose of rush oit among the groups. all patients in the low-bmfi group achieved ≥ % of the target dose, whereas . % of the middle-bmfi group and % of the high-bmfi group failed to achieve the target dose (p < . ). results: a total of infants were diagnosed with food allergy (ige-mediated and mixed type) at our center during the study period, of these patients underwent prick test for inhalant sensitivity, and ( . % male) of these were younger than years of age. conclusion: sensitivity to inhaled allergen were found in of ( . %) patients with food allergy. therefore, we believe that inhalant sensitivity should be evaluated in these patients. there is also a requirement for further studies to identify the influence of inhaled antigens on the disease activity of patients with allergic conditions. method: in this study, we aimed to perform the metabolic profiling of severe profilin mediated food allergic patients looking for biomarkers that might both, predict the prognosis of the disease and understand the molecular mechanisms of inflammation underneath. other allergic patients (mild and moderate) and non-allergic were recruited in the study as comparative groups. the allergic patients class was predicted using a mathematical algorithm from non-allergic vs severe model results: plasma samples from non-allergic subjects, mild, moderate and severe allergic patients were measured using gas chromatography coupled to mass spectrometry (gc-ms). the samples were from different hospitals in spain covering the areas with the highest pollen exposure. the metabolic profile was composed of metabolites for each sample. results after the statistical analysis showed differences between the groups. firstly, a clear reduction of several abstracts conclusion: we found, as expected, a predominance of males with eoe diagnosis. ch were more frequently atopic and had aeroallergen and food sensitization. impaction and esophageal stenosis were more frequent in ad than ch. shist was associated with sclin only in ch. method: three children with ee, boys aged . - years, were assessed over months to years. results: cases developed in infancy. one had dyspepsia and low weight gain in infancy soon after feeding began. another had symptoms in infancy but not diagnosed until age with dysphagia and esophageal stricture.. the third case was diagnosed at years old after episodes of food impaction in the esophagus beginning at age . all cases had allergic comorbid diseases including atopic dermatitis in all and allergic rhinitis in . skin prick tests were positive to several food allergens (cow's milk, egg protein) in , to dust mite in and to pollens in . serum total ige levels ranged from to iu/ml. eosinophils in peripheral blood were elevated in all , reaching %- %. treatment included restricted diet and topical budesonide - mg daily depending with periodic endoscopic biopsy.in all cases clinical improvement occurred by one month of treatment, with endoscopic confirmation. morphological improvement fol- the study aimed to evaluate the effects of probiotic supplementation, in addition to diet, in ibs and snas patients, in terms of modulation of faecal microbiota population, reduction of gi and cutaneous symptoms, increase of patient's quality of life and modification of gut dysbiosis.method: forty patients aged between and years, affected by ibs, ni sensitization and ltp sensitization were enrolled to evaluate gut dysbiosis. dna extraction method (next generation sequencing) with commercial kit (microbiopassport ® ) was performed on stool samples. ibs patients were divided in two groups, according a gluten free diet prescription or a low fodmaps diet prescription for three months. similarly, (suspected) snas patients (confirmed by % ni sulfate in petrolatum patch test) were prescribed a low ni diet ( μg/kg nickel content during the first four weeks and then up to μg/kg up to three months). two ltp (lipid transfer protein) sensitized patients underwent a ltp free diet.gut dysbiosis was re-assessed after a fixed probiotic supplementation. a sex-age matched group of individuals without history of ibs, snas or any gastrointestinal disease was considered as control.gastrointestinal symptoms were evaluated using the visual analogue scale before and after treatment. conclusion: our preliminary findings suggest that probiotic implementation could be useful in patients with snas on a low-ni diet to increase population diversity, which could contribute to restore the intestinal homoeostatic conditions.