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1.
Int J Hyg Environ Health ; 251: 114183, 2023 Jun.
Article in English | MEDLINE | ID: mdl-37148759

ABSTRACT

The European Human Biomonitoring Initiative (HBM4EU) ran from 2017 to 2022 with the aim of advancing and harmonizing human biomonitoring in Europe. More than 40,000 analyses were performed on human samples in different human biomonitoring studies in HBM4EU, addressing the chemical exposure of the general population, temporal developments, occupational exposure and a public health intervention on mercury in populations with high fish consumption. The analyses covered 15 priority groups of organic chemicals and metals and were carried out by a network of laboratories meeting the requirements of a comprehensive quality assurance and control system. The coordination of the chemical analyses included establishing contacts between sample owners and qualified laboratories and monitoring the progress of the chemical analyses during the analytical phase, also addressing status and consequences of Covid-19 measures. Other challenges were related to the novelty and complexity of HBM4EU, including administrative and financial matters and implementation of standardized procedures. Many individual contacts were necessary in the initial phase of HBM4EU. However, there is a potential to develop more streamlined and standardized communication and coordination in the analytical phase of a consolidated European HBM programme.


Subject(s)
COVID-19 , Occupational Exposure , Humans , Biological Monitoring , Environmental Exposure/analysis , Environmental Monitoring/methods , Occupational Exposure/analysis , Europe
2.
Sci Total Environ ; 874: 162374, 2023 May 20.
Article in English | MEDLINE | ID: mdl-36828075

ABSTRACT

Several chemicals with widespread consumer uses have been identified as endocrine-disrupting chemicals (EDCs), with a potential risk to humans. The occurrence in indoor dust and resulting human exposure have been reviewed for six groups of known and suspected EDCs, including phthalates and non-phthalate plasticizers, flame retardants, bisphenols, per- and polyfluoroalkyl substances (PFAS), biocides and personal care product additives (PCPs). Some banned or restricted EDCs, such as polybrominated diphenyl ethers (PBDEs), di-(2-ethylhexyl) phthalate (DEHP), bisphenol A (BPA), perfluorooctanesulfonic acid (PFOS) and perfluorooctanoic acid (PFOA), are still widely detected in indoor dust in most countries, even as the predominating compounds of their group, but generally with decreasing trends. Meanwhile, alternatives that are also potential EDCs, such as bisphenol S (BPS), bisphenol F (BPF), decabromodiphenyl ethane (DBDPE) and organophosphate flame retardants (OPFRs), and PFAS precursors, such as fluorotelomer alcohols, have been detected in indoor dust with increasing frequencies and concentrations. Associations between some known and suspected EDCs, such as phthalate and non-phthalate plasticizers, FRs and BPs, in indoor dust and paired human samples indicate indoor dust as an important human exposure pathway. Although the estimated daily intake (EDI) of most of the investigated compounds was mostly below reference values, the co-exposure to a multitude of known or suspected EDCs requires a better understanding of mixture effects.


Subject(s)
Air Pollution, Indoor , Endocrine Disruptors , Flame Retardants , Humans , Environmental Exposure/analysis , Environmental Monitoring , Plasticizers , Dust/analysis , Flame Retardants/analysis , Air Pollution, Indoor/analysis , Halogenated Diphenyl Ethers/analysis
3.
Int J Hyg Environ Health ; 248: 114098, 2023 03.
Article in English | MEDLINE | ID: mdl-36565602

ABSTRACT

Human biomonitoring involves the use of human samples and data to investigate exposure to environmental chemicals and their impact on human health. HBM4EU developed a coordinated and harmonized approach involving 29 countries in Europe plus Israel. Addressing ethical issues has been an indispensable prerequisite, from the application phase, grant agreement, project performance to the closing of the project. HBM4EU has established a better understanding of the ethics in such projects and the need for a standardised way of reporting and handling of ethics and data exchange, securing compliance with ethics standards, transparency, transferability and sustainability. The main reflections were: KNOWLEDGE: Ethics awareness, norms and practices are dynamic and increased throughout the project, much learning and experience is achieved by practice and dialogue. ATTITUDE: Rules and standards were very diversely known and needed to adhere to local practices. ASSISTANCE: Good results achieved from webinars, training, help desk, and individual consultations. STANDARDISATION: Was achieved by templates and naming convention across documents. MANAGEMENT: The establishment of the SharePoint directory with uploading of all requested documents assisted collaboration and exchange. Also, a designated task for ethics within the management/coordination work package and the enthusiasm of the task leader were essential. COMPLIANCE: Some, but not all partners were very good at complying with deadlines and standards. TRANSFERABILITY AND SUSTAINABILITY: All documents are archived in the SharePoint directory while a system assuring updating is recommended. TRANSPARENCY: Assured by public access to annual ethics reports. The ethics reports bridged to the annual work plans (AWPs). EVALUATION: The Ethics Check by the Commission was successful.


Subject(s)
Biological Monitoring , Humans , Europe , Israel , Biological Monitoring/ethics , Biological Monitoring/methods
4.
Article in English | MEDLINE | ID: mdl-35055557

ABSTRACT

Exposure to polycyclic aromatic hydrocarbons (PAHs) through diet is gaining concern due to the risk it poses to human health. This study evaluated the bioaccessibility of PAHs contained in charcoal-grilled beef and chicken in different segments of the gastrointestinal tract (GIT) with regard to the degree of doneness and fat content of the meats. The levels of 15 PAHs in the grilled meat samples and bioaccessible fractions were determined using high-performance liquid chromatography (HPLC) equipped with PAH column, and UV and fluorescence detectors. Total PAHs were found in beef (30.73 ng/g) and chicken (70.93 ng/g) before its digestion, and different PAHs' bioaccessibility were observed in the different segments of GIT, with the highest in the stomach followed by the small intestine, despite the relatively higher bioaccessibility of individual PAHs in grilled beef as compared to those in grilled chicken. Additionally, the PAHs' bioaccessibility increased with the increase in the degree of doneness. Positive linear correlation was observed for the PAHs' bioaccessibility and the fat contents of grilled meat. Overall, this study highlights the influence of meat doneness (cooking time) and fat contents on the bioaccessibility and bioaccumulation of PAHs.


Subject(s)
Polycyclic Aromatic Hydrocarbons , Animals , Cattle , Charcoal/chemistry , Chickens , Cooking/methods , Humans , Meat/analysis , Polycyclic Aromatic Hydrocarbons/analysis
5.
Anal Chim Acta ; 1193: 338828, 2022 Feb 08.
Article in English | MEDLINE | ID: mdl-35058002

ABSTRACT

Human biomonitoring is a powerful approach in assessing exposure to environmental pollutants. Flame retardants (FRs) are of particular concern due to their wide distribution in the environment and adverse health effects. This article reviews studies published in 2009-2020 on the chemical analysis of FRs in a variety of human samples and discusses the characteristics of the analytical methods applied to different FR biomarkers of exposure, including polybrominated diphenyl ethers (PBDEs), hexabromocyclododecane (HBCD), novel halogenated flame retardants (NHFRs), bromophenols, incl. tetrabromobisphenol A (TBBPA), and organophosphorous flame retardants (PFRs). Among the extraction techniques, liquid-liquid extraction (LLE) and solid phase extraction (SPE) were used most frequently due to the good efficiencies in the isolation of the majority of the FR biomarkers, but with challenges for highly lipophilic FRs. Gas chromatography-mass spectrometry (GC-MS) is mainly applied in the instrumental analysis of PBDEs and most NHFRs, with recent inclusions of GC-MS/MS and high resolution MS techniques. Liquid chromatography-MS/MS is mainly applied to HBCD, bromophenols, incl. TBBPA, and PFRs (including metabolites), however, GC-based analysis following derivatization has also been used for phenolic compounds and PFR metabolites. Developments are noticed towards more universal analytical methods, which enable widening method scopes in the human biomonitoring of FRs. Challenges exist with regard to sensitivity required for the low concentrations of FRs in the general population and limited sample material for some human matrices. A strong focus on quality assurance/quality control (QA/QC) measures is required in the analysis of FR biomarkers in human samples, related to their variety of physical-chemical properties, low levels in most human samples and the risk of contamination.


Subject(s)
Flame Retardants , Flame Retardants/analysis , Gas Chromatography-Mass Spectrometry , Halogenated Diphenyl Ethers/analysis , Humans , Solid Phase Extraction , Tandem Mass Spectrometry
6.
Chemosphere ; 287(Pt 3): 132306, 2022 Jan.
Article in English | MEDLINE | ID: mdl-34826946

ABSTRACT

The progress in sensitivity and resolution in mass spectrometers in recent years provides the possibility to detect a broad range of organic compounds in a single procedure. For this reason, suspect and non-target screening techniques are gaining attention since they enable the detection of hundreds of known and unknown emerging contaminants in various matrices of environmental, food and human sources. Sample preparation is a critical step before analysis as it can significantly affect selectivity, sensitivity and reproducibility. The lack of generic sample preparation protocols is obvious in this fast-growing analytical field, and most studies use those of traditional targeted analysis methods. Among them, solvent extraction and solid phase extraction (SPE) are widely used to extract emerging contaminants from solid and liquid sample types, respectively. Sequential solvent extraction and a combination of different SPE sorbents can cover a broad range of chemicals in the samples. Gel permeation chromatography (GPC) and adsorption chromatography, including acidification, are typically used to remove matrix components such as lipids from complex matrices, but usually at the expense of compound losses. Ideally, the purification of samples intended for non-target analysis should be selective of matrix interferences. Recent studies have suggested quality assurance/quality control measures for suspect and non-target screening, based on expansion and extrapolation of target compound lists, but method validations remain challenging in the absence of analytical standards and harmonized sample preparation approaches.


Subject(s)
Solid Phase Extraction , Tandem Mass Spectrometry , Humans , Reproducibility of Results
7.
Compr Rev Food Sci Food Saf ; 19(4): 1777-1808, 2020 07.
Article in English | MEDLINE | ID: mdl-33337096

ABSTRACT

Mycotoxins such as aflatoxins (AFs), ochratoxin A (OTA) fumonisins (FMN), deoxynivalenol (DON), zearalenone (ZEN), and patulin are stable at regular food process practices. Ozone (O3 ) is a strong oxidizer and generally considered as a safe antimicrobial agent in food industries. Ozone disrupts fungal cells through oxidizing sulfhydryl and amino acid groups of enzymes or attacks the polyunsaturated fatty acids of the cell wall. Fusarium is the most sensitive mycotoxigenic fungi to ozonation followed by Aspergillus and Penicillium. Studies have shown complete inactivation of Fusarium and Aspergillus by O3 gas. Spore germination and toxin production have also been reduced after ozone fumigation. Both naturally and artificially, mycotoxin-contaminated samples have shown significant mycotoxin reduction after ozonation. Although the mechanism of detoxification is not very clear for some mycotoxins, it is believed that ozone reacts with the functional groups in the mycotoxin molecules, changes their molecular structures, and forms products with lower molecular weight, less double bonds, and less toxicity. Although some minor physicochemical changes were observed in some ozone-treated foods, these changes may or may not affect the use of the ozonated product depending on the further application of it. The effectiveness of the ozonation process depends on the exposure time, ozone concentration, temperature, moisture content of the product, and relative humidity. Due to its strong oxidizing property and corrosiveness, there are strict limits for O3 gas exposure. O3 gas has limited penetration and decomposes quickly. However, ozone treatment can be used as a safe and green technology for food preservation and control of contaminants.


Subject(s)
Fungi/drug effects , Mycotoxins/chemistry , Ozone/pharmacology , Anti-Infective Agents/pharmacology , Food Contamination/prevention & control , Food Microbiology , Fumigation/methods , Ozone/chemistry
8.
Compr Rev Food Sci Food Saf ; 18(5): 1563-1621, 2019 Sep.
Article in English | MEDLINE | ID: mdl-33336912

ABSTRACT

Food product safety is a public health concern. Most of the food safety analytical and detection methods are expensive, labor intensive, and time consuming. A safe, rapid, reliable, and nondestructive detection method is needed to assure consumers that food products are safe to consume. Terahertz (THz) radiation, which has properties of both microwave and infrared, can penetrate and interact with many commonly used materials. Owing to the technological developments in sources and detectors, THz spectroscopic imaging has transitioned from a laboratory-scale technique into a versatile imaging tool with many practical applications. In recent years, THz imaging has been shown to have great potential as an emerging nondestructive tool for food inspection. THz spectroscopy provides qualitative and quantitative information about food samples. The main applications of THz in food industries include detection of moisture, foreign bodies, inspection, and quality control. Other applications of THz technology in the food industry include detection of harmful compounds, antibiotics, and microorganisms. THz spectroscopy is a great tool for characterization of carbohydrates, amino acids, fatty acids, and vitamins. Despite its potential applications, THz technology has some limitations, such as limited penetration, scattering effect, limited sensitivity, and low limit of detection. THz technology is still expensive, and there is no available THz database library for food compounds. The scanning speed needs to be improved in the future generations of THz systems. Although many technological aspects need to be improved, THz technology has already been established in the food industry as a powerful tool with great detection and quantification ability. This paper reviews various applications of THz spectroscopy and imaging in the food industry.

9.
Article in English | MEDLINE | ID: mdl-29913103

ABSTRACT

Natural antioxidants in spices and herbs have attracted considerable attention as potential inhibitors against the formation of mutagenic heterocyclic amines (HCAs) in heat-processed meat. In this study, the inhibitory activity of four spices/herbs and their mixtures on HCAs formation in grilled beef were examined. A simplex centroid mixture design with four components comprising turmeric, curry leaf, torch ginger and lemon grass in 19 different proportions were applied on beef samples before grilling at 240 ºC for 10 min. The HCAs were extracted from the samples using solid phase extraction (SPE) method and analysed using Liquid chromatography mass spectrometry LC-MS/MS. All spices/herbs in single or mixture forms were found to reduce total HCA concentrations in marinated grilled beef ranging from 21.2% for beef marinated with curry leaf to 94.7% for the combination of turmeric and lemon grass (50:50 w/w). At the optimum marinade formula (turmeric: lemon grass 52.4%: 47.6%), concentration of 2-amino-3-methylimidazo[4,5-f]quinolone (IQ), 2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP), Harman, Norharman and AαC were 2.2, 1.4, 0.5, 2.8 and 1.2 ng/g, respectively. The results of the mutagenic activity demonstrated that this optimised marinade formula significantly (p < 0.05) diminished mutagenicity of marinated grilled beef in bacterial Ames test.


Subject(s)
Amines/antagonists & inhibitors , Antioxidants/pharmacology , Heterocyclic Compounds/antagonists & inhibitors , Plant Extracts/pharmacology , Red Meat/analysis , Spices/analysis , Animals , Antioxidants/analysis , Cattle , Chromatography, Liquid , Mass Spectrometry , Mutagens/analysis , Plant Extracts/analysis , Plants, Medicinal/chemistry , Solid Phase Extraction
10.
Article in English | MEDLINE | ID: mdl-28604234

ABSTRACT

This study investigated the effects of particle size and milling temperature on the extraction efficiencies of pesticide residues from cereal flour. Samples of cereal grains (barley, oat, rye and wheat) were milled using a centrifugal mill with four different sieves (0.2, 1.0, 3.0 and 5.0 mm) or a knife mill both at room temperature and after freezing of the grain at -80°C overnight. The incurred pesticides in the test materials were extracted by the QuEChERS method and analysed by LC-MS/MS and GC-MS/MS. The particle size distribution for the milled samples was determined using a vibratory sieve shaker. Based on the pesticide levels recovered from each of the different millings and the corresponding particle size distributions, it was confirmed that smaller average particle sizes increase the extraction efficiency up to 31%, with all other factors equal. The cereals milled at room temperature produced lower pesticide extraction efficiencies compared with cereals milled when still frozen, especially for heat-sensitive pesticides. Furthermore, milling frozen grains was easier and resulted in more homogeneous samples with smaller relative particle sizes.


Subject(s)
Edible Grain/chemistry , Flour/analysis , Food Contamination/analysis , Pesticide Residues/isolation & purification , Chromatography, Gas , Chromatography, Liquid , Particle Size , Pesticide Residues/chemistry , Tandem Mass Spectrometry , Temperature
11.
J Agric Food Chem ; 65(28): 5759-5767, 2017 Jul 19.
Article in English | MEDLINE | ID: mdl-28598613

ABSTRACT

The guidance document SANTE 11945/2015 recommends that cereal samples be milled to a particle size preferably smaller than 1.0 mm and that extensive heating of the samples should be avoided. The aim of the present study was therefore to investigate the differences in milling procedures, obtained particle size distributions, and the resulting pesticide residue recovery when cereal samples were milled at the European Union National Reference Laboratories (NRLs) with their routine milling procedures. A total of 23 NRLs participated in the study. The oat and rye samples milled by each NRL were sent to the European Union Reference Laboratory on Cereals and Feedingstuff (EURL) for the determination of the particle size distribution and pesticide residue recovery. The results showed that the NRLs used several different brands and types of mills. Large variations in the particle size distributions and pesticide extraction efficiencies were observed even between samples milled by the same type of mill.


Subject(s)
Avena/chemistry , Food Analysis/standards , Food Contamination/analysis , Pesticide Residues/analysis , Secale/chemistry , European Union , Food Handling , Laboratories/standards
12.
Food Nutr Res ; 60: 30463, 2016.
Article in English | MEDLINE | ID: mdl-27356909

ABSTRACT

BACKGROUND: Excessive dietary sodium intake causes several diseases, such as hypertension, cardiovascular and renal disease, etc. Hence, reducing sodium intake has been highly recommended. In this study the effect of monosodium glutamate (MSG), as an umami substance, on saltiness and sodium reduction was investigated. METHODS AND RESULTS: The trained panellists were presented with basic spicy soups (curry chicken and chili chicken) containing different amounts of sodium chloride (NaCl) (0-1.2%) and MSG (0-1.2%). They tasted the optimum concentrations of NaCl and MSG for the two spicy soups and the overall acceptability were 0.8% and 0.7%, respectively. There was no significant effect of spiciness level on the saltiness and umami taste of both soups. The optimum levels of combined NaCl and MSG for overall acceptance in the chili and curry soups were 0.3% and 0.7%, respectively. The results showed that with the addition of MSG, it is possible to reduce sodium intake without changing the overall acceptability of the spicy soup. A 32.5% reduction in sodium level is made feasible by adding 0.7% MSG to the spicy soups. CONCLUSIONS: This study suggests that low-sodium soups can be developed by the addition of appropriate amounts of MSG, while maintaining the acceptability of the spicy soups. It was also proven that it is feasible to reduce sodium intake by replacing NaCl with MSG.

13.
Asian Pac J Cancer Prev ; 17(1): 15-23, 2016.
Article in English | MEDLINE | ID: mdl-26838201

ABSTRACT

Polycyclic aromatic hydrocarbons (PAHs) are primarily formed as a result of thermal treatment of food, especially barbecuing or grilling. Contamination by PAHs is due to generation by direct pyrolysis of food nutrients and deposition from smoke produced through incomplete combustion of thermal agents. PAHs are ubiquitous compounds, well-known to be carcinogenic, which can reach the food in different ways. As an important human exposure pathway of contaminants, dietary intake of PAHs is of increasing concern for assessing cancer risk in the human body. In addition, the risks associated with consumption of barbecued meat may increase if consumers use cooking practices that enhance the concentrations of contaminants and their bioaccessibility. Since total PAHs always overestimate the actual amount that is available for absorption by the body, bioaccessibility of PAHs is to be preferred. Bioaccessibility of PAHs in food is the fraction of PAHs mobilized from food matrices during gastrointestinal digestion. An in vitro human digestion model was chosen for assessing the bioaccessibility of PAHs in food as it offers a simple, rapid, low cost alternative to human and animal studies; providing insights which may not be achievable in in vivo studies. Thus, this review aimed not only to provide an overview of general aspects of PAHs such as the formation, carcinogenicity, sources, occurrence, and factors affecting PAH concentrations, but also to enhance understanding of bioaccessibility assessment using an in vitro digestion model.


Subject(s)
Carcinogens/toxicity , Meat/adverse effects , Neoplasms/etiology , Polycyclic Aromatic Hydrocarbons/adverse effects , Animals , Biological Availability , Environmental Exposure/adverse effects , Humans , Risk Assessment
14.
J Food Prot ; 78(1): 172-9, 2015 Jan.
Article in English | MEDLINE | ID: mdl-25581193

ABSTRACT

High-quality fish oil for human consumption requires low levels of toxic elements. The aim of this study was to compare different oil extraction methods to identify the most efficient method for extracting fish oil of high quality with the least contamination. The methods used in this study were Soxhlet extraction, enzymatic extraction, wet reduction, and supercritical fluid extraction. The results showed that toxic elements in fish oil could be reduced using supercritical CO2 at a modest temperature (60°C) and pressure (35 MPa) with little reduction in the oil yield. There were significant reductions in mercury (85 to 100%), cadmium (97 to 100%), and lead (100%) content of the fish oil extracted using the supercritical fluid extraction method. The fish oil extracted using conventional methods contained toxic elements at levels much higher than the accepted limits of 0.1 µg/g.


Subject(s)
Arsenic/isolation & purification , Cadmium/isolation & purification , Chromatography, Supercritical Fluid/methods , Fish Oils/chemistry , Lead/isolation & purification , Mercury/isolation & purification , Animals , Carbon Dioxide , Chemical Fractionation/methods , Chromatography/methods , Fatty Acids/chemistry , Perciformes , Pressure , Solvents , Temperature
15.
Rev Environ Contam Toxicol ; 220: 45-66, 2012.
Article in English | MEDLINE | ID: mdl-22610296

ABSTRACT

Although several studies have been published on levels of mercury contamination of the environment, and of food and human tissues in Peninsular Malaysia, there is a serious dearth of research that has been performed in East Malaysia (Sabah and Sarawak). Industry is rapidly developing in East Malaysia, and, hence, there is a need for establishing baseline levels of mercury contamination in environmental media in that part of the country by performing monitoring studies. Residues of total mercury and inorganic in food samples have been determined in nearly all previous studies that have been conducted; however, few researchers have analyzed samples for the presence of methlymercury residues. Because methylmercury is the most toxic form of mercury, and because there is a growing public awareness of the risk posed by methylmercury exposure that is associated with fish and seafood consumption, further monitoring studies on methylmercury in food are also essential. From the results of previous studies, it is obvious that the economic development in Malaysia, in recent years, has affected the aquatic environment of the country. Primary areas of environmental concern are centered on the rivers of the west Peninsular Malaysian coast, and the coastal waters of the Straits of Malacca, wherein industrial activities are rapidly expanding. The sources of existing mercury input to both of these areas of Malaysia should be studied and identified. Considering the high levels of mercury that now exists in human tissues, efforts should be continued, and accelerated in the future, if possible, to monitor mercury contamination levels in the coastal states, and particularly along the west Peninsular Malaysian coast. Most studies that have been carried out on mercury residues in environmental samples are dated, having been conducted 20-30 years ago; therefore, the need to collect much more and more current data is urgent. Furthermore, establishing baseline levels of mercury exposure to humans in Malaysia will be useful in establishing the levels at which detrimental effects in both humans and marine life may occur, and therefore the levels at which warning should be raised or limits established. In particular, we believe that two or three monitoring centers should be established in Peninsular Malaysia, and one in East Malaysia for the specific purpose of monitoring for the presence of hazardous environmental chemicals, and particularly monitoring for heavy metals such as mercury that reach food that is subject to consistent human consumption.


Subject(s)
Drug Contamination , Food Contamination , Mercury/toxicity , Water Pollutants, Chemical/toxicity , Environmental Monitoring , Geologic Sediments/analysis , Humans , Malaysia
16.
Clin Rev Allergy Immunol ; 42(3): 365-85, 2012 Jun.
Article in English | MEDLINE | ID: mdl-22045217

ABSTRACT

Seafood is common item in the world diet; Asian countries have the highest rates of fish consumption in the world, which is higher than world average. Several studies have been conducted on the epidemiology and clinical characteristics of seafood allergy in different countries, and some of the fish and seafood allergens unique to those regions have been characterized. Review on published data showed that seafood allergy is very ubiquitous in some regions of the world. Fish and shellfish are the most common seafood that cause adverse allergic reactions among nations; the symptoms ranged from oral allergy syndromes to urticaria and anaphylaxis. The major identified allergens are parvalbumin in fish and tropomyosin in shellfish. Nevertheless, such studies are lacking from some regions with high fish and seafood consumption. Furthermore, the published data are mostly from small groups of populations, which large-scale epidemiological studies need to be performed.


Subject(s)
Food Hypersensitivity/epidemiology , Seafood/adverse effects , Africa/epidemiology , Allergens/immunology , Animals , Asia/epidemiology , Crustacea/immunology , Europe/epidemiology , Fishes/immunology , Food Hypersensitivity/diagnosis , Humans , Mollusca/immunology , Prevalence , United States/epidemiology
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