MULTIDISCIPLINRY NATURE OF THE ENVIRONMENTAL STUDIES.pptx
Food
1. The Story of Environmental Health:
Food and Security
2. Objectives
By the end of this presentation, participants
should be able to…
• Explain the term “farm to fork”
• Describe two or more ways in which food
can be contaminated
• Discuss environmental health strategies for
prevention/risk reduction
3. Presentation Structure
• Background: Public Health and
Environmental Health
• Definitions and Importance
• The Food System
• Strategies to Protect the Food System
• Resources
5. Core Functions of Public Health
• Assessing the public’s health
• Promoting sound policies
• Assuring effectiveness
6. What is Environmental Health?
“Public health
programs designed to
protect the public
health from hazards
which exist or could
exist in the physical
environment.”
--Minnesota SCHSAC Environmental Health
Leadership Team, December, 2002, Diagram
courtesy of Australia’s EnHealth.
Diagram courtesy of Australia’s EnHealth.
7. Environmental Links to Health Concerns
• Drinking Water
• Food
• Land
• Built
Environment
• Indoor Air
• Emergencies
8. Foodborne Illness Definitions
• Outbreak the occurrence of two or more
cases of a similar illness resulting from
the ingestion of a common food. (CDC)
• Agro-terrorism: [Terrorism] directed
against agriculture, livestock, or other
food supplies with biological, chemical, or
[physical] radiological weapons. (FBI)
9. Importance of Preventing
Foodborne Diseases
• Many are ill or die
– 76 million US cases each year (estimated)
– Of these…,
• 325,000 hospitalized
• 5,000 died (CDC)
• Cost in 2000: $6.9 billion per year for 5
bacterial pathogens (USDA/ERS)
10. Potential Impacts
• Death and
illness
• Economic
consequences
• Panic/alarm
• Loss of
confidence, or
disruption, in
food supply
11. Complex System, Many Food Interests
Food can be
contaminated at
any point, from
farm inputs
to fork.
Farm
Transport
Mill / Slaughter /
Food Processor
Restaurant/Retail
Transport/Imports
Consumer
Photo: www.bcsalmon.ca/bcsmc/ffact2.htm
Inputs
13. Rajneeshee Religious Group
Most “successful” food terrorism yet . . .
751 reported cases of salmonella
poisoning linked to 10 Oregon
salad bars
1984 criminal investigation, but
intent actually revealed by ex-
follower in 1985
Why? Plan to make certain voters
sick, so chosen candidates would
win and support group in land
dispute
14.
15. Strategies: Community/Retail
Standards Protect Consumers
• Adherence to existing standards
1. Verification and Assurance
2. Common Sense Management Plans
3. Hazard Analysis Critical Control Points
4. Active Managerial Control of Risk Factors
…BUT…be aware… “Complete Safety”
cannot be assured!
16. 1. Verification and Assurance
• Inspections
• Investigations
• Industry education
17. - Do I know my process/product?
– Am I aware of what could cause a
problem?
– Do I understand how to control threats?
– Have my key employees been involved in
planning?
– Has effective training occurred?
2. Common Sense
Management Plans
18. 3. Hazard Analysis Critical
Control Points (HACCP)
• A system for ensuring safe food production
• May be used from “Farm to Fork”
The objective is to make the product safely
and to be able to prove it!-- Bill Schafer, U of M
19. HACCP Principles
1. Hazard Analysis
2. Critical Control Point
3. Criteria/Standards
4. Monitoring
5. Corrective Action
6. Record Keeping
7. Verification/Validation
20. 4. Active Managerial Control
(AMC) of Risk Factors
• System for controlling risk
• Places responsibility on establishment
• Manager certification
• On-going worker education
• Recognizing accomplishment of
safe food!
21. Strategies: Surveillance
(Finding Illness and
Confirming with Lab Testing)
• FoodElert
– 24/7 emergency contacts for the food industry
• Sharing of food testing results by
government labs (FoodNet, PulseNet)
• Poison Control Centers (FERN)
22. MN Public Phone number: 1- 877- FOOD ILL
(1- 877- 366-3455) to report foodborne illness
• Federal: Information Sharing and Assessment Centers
(PDD 63: www.fas.org/irp/offdocs/pdd/pdd-63.htm)
• Food Center is one of 8 ISACs
www.fmi.org/isac/
• Members can report national food threats
– fax web form to (202) 323-2079 or (202) 323-2082
Strategies: Public-Private
Collaboration
23. Strategies: Communication
The Health Alert Network
Links all local and state public health
agencies
Alerts public health contacts, health care
providers, emergency workers, etc.
26. Summary
• Private and public cooperation is required to
maintain and strengthen the food system.
• Following established guidelines will enhance
security, including watching for signs and
symptoms of:
chemical , biological, and physical contamination.
• Core public health measures help ensure safer
food, including:
assessing threats, developing common sense and
practical policies, communicating, and assuring food
safety standards are met.
27. Key Minnesota Emergency Contacts
• Your Local Health Department
• Minnesota Department of Health
– Acute Disease Investigation and Control:
Metro: 612- 676-5414 MN: 1-877-676-5414
– Environmental Health Services:
Metro: 612- 215-0871 MN: 1-877-631-8363
• Poison Control Center 1-800-222-1222
28. For more information, contact your
local health department or…
Minnesota Department of Health,
Environmental Health Division
Phone: 651-215-0700, TTD: 651-215-0707
http://www.health.state.mn.us/divs/eh
29. Sources
• CDC: www.cdc.gov
• FDA: www.cfsan.fda.gov
• www.foodsafety.gov (gateway site)
• USDA: www.fsis.usda.gov
• Minnesota Board of Animal Health:
http://www.bah.state.mn.us/diseases/
• University Of Minnesota Animal Health and Food
Safety http://www.cahfs.umn.edu
Editor's Notes
Having enough food to eat, ensuring that people were well-fed, used to be described by the term “Food Security.” Now we are concerned about the safety of eating food, opening of a new chapter in the EH story which we will call Food and Security.
By the end of this presentation, participants should be able to…
Explain the term “farm to fork”
Describe two or more ways in which food can be contaminated
Discuss environmental health strategies for prevention or reduction of risk from food.
(show if time permits)
(show if time permits) Continuing a quick review of public health, both the state and federal constitutions refer to government’s role in protecting the public’s health, and this is a duty that falls on government. Minnesota law authorizes a shared role with local government for public health, allowing many programs to be delegated to local public health agencies. Public health professionals approach their responsibilities in two ways:
Number one: Encouraging people to do things that benefit their health (like promoting safe indoor air, and educating restaurant managers that they must know how to make and serve safe food)
And number two: Requiring certain actions (like inspecting restaurants to be sure they make and serve safe food).
(show if time permits) First, let me try to establish a common understanding of Public Health, and Environmental Health. The National Institutes of Health identified three core functions of public health. You should see examples of these three functions as we move through today’s discussion.
Assessing—does not mean grading tests like in school, but it means understanding health trends and changes over time, and who's affected. For example: this includes watching reports of illness so that sound actions can be taken.
Promoting sound policies—means providing education or guidelines. For example: public health staff determine which children should be screened, and at what ages, for exposure to environmental lead
Assuring effectiveness—means that problems are being identified and that effective programs address the issue. For example: If drinking water is polluted, EH staff make sure that it becomes safe to drink again.
(If more information is desired, see the Core Essentials of Public Health presentations provided by the Office of Public Health Practice. Call Nicole Parsons at 651-296-9615 or your local or MDH district office public health nurse for more details on the next presentations.)
(show if time permits) Environmental Health (the pink area) is a part of public health (the yellow block) that protects people from their environments. EH often extends into other areas, like planning and zoning and public works. Environmental health professionals work closely with those who protect the environment (the blue block), like the Department of Natural Resources (DNR), the Minnesota Pollution Control Agency (MPCA), the Department of Agriculture, the Board of Soil and Water (say: “bowser”), and others.
(use if time permits) Drinking Water, Food, Land, the Built Environment, Indoor Air and Chemical and Radiological Emergencies can all cause potential environmental problems for people’s health. We call these problems “health effects.” Health Effects related to food contamination can include … acute gastrointestinal disease, or more difficult problems that sometimes lead to death, like bloody diarrhea and HUS. (say the letters)
(Hemolytic uremic syndrome (HUS) is a life-threatening complication of infection with Shiga toxin-producing E. coli, including E. coli O 157. HUS is characterized by the acute onset of microangiopathic hemolytic anemia, renal injury, and low platelet count. Thrombotic thrombocytopenic purpura (TTP) is also characterized by these features but also can include central nervous system involvement and fever, and may have a more gradual onset. Most cases of HUS (but few cases of TTP) occur after an acute gastrointestinal illness (usually diarrheal). Source: http://www.cdc.gov/epo/dphsi/print/hemolytic1995.htm )
Foodborne illness, or “Food Poisoning,” is used to describe more than 200 illnesses that people may suffer if they eat food that are contaminated with pathogens, or toxic microorganisms. An outbreak may occur naturally. Agro-terrorism is intentionally hurting or frightening people by involving the food system. The difference is one of intent– whether someone intended to hurt others. Even one case of a rare disease can be of concern. http://www.cdc.gov/foodborneoutbreaks/us_outb/fbo2000/chemical00.htm
Foodborne diseases have hurt and killed an estimated 76 million cases of foodborne disease each year in the United States. The great majority of these cases are mild and cause symptoms for only a day or two. Some cases are more serious, with about 325,000 people hospitalized, and 5,000 deaths related to foodborne diseases each year. The most severe cases tend to occur in the very old, the very young, those who have an illness already that reduces their immune system function, and in healthy people exposed to a very high dose of an organism.
These diseases can be costly. In 2000, USDA’s Economic Research Service (ERS) estimated costs released in 2000 for medical costs, productivity losses, and costs of premature deaths for diseases caused by five foodborne pathogens total $6.9 billion per year in the US. The five bacterial pathogens included are: Campylobacter (all serotypes), Salmonella (nontyphoidal), E. coli O157, E. coli non-O157 STEC, and Listeria monocytogenes. The estimates for all five pathogens are based on estimates for cases, hospitalizations, and deaths attributable to these pathogens released by the Centers for Disease Control and Prevention (CDC) in 1999. Of course, there are many other pathogens that also cause disease, these are just the top five that have been identified.
(Sources: http://www.cdc.gov/ncidod/dbmd/diseaseinfo/foodborneinfections_g.htm#consumercando; http://www.ers.usda.gov/briefing/FoodborneDisease/features.htm, accessed July 3, 2003.)
As stated earlier, the potential impacts could be severe. Many of us watched in horror as the mad cow and later hoof and mouth epidemics swept across Europe virtually wiping out the livestock industry in some countries, and causing major disruption in the lives of people in the affected areas. (None of these events have been linked to terrorism.)
On an economic level, the United Kingdom (England) estimates they lost about 2 Billion (when translated into US dollars), when foot and mouth disease struck. ½ was lost in agriculture, and ½ was lost in tourism revenues (restaurants, travel restrictions).
In the US, southern California is now fighting a major bird epidemic, from “Exotic Newcastle Disease,” where thousands of chickens have had to be vaccinated or killed. If this epidemic is not controlled, the disease could spread and wipe out entire flocks of healthy chickens and even endangered and exotic birds. Obviously, this could create a lack of confidence in our food supply, too.
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This is a simplified picture of our food chain. All possible links in the food chain, from farm to fork, could be vulnerable. Our food supply is relatively unguarded, especially at the farm or producer level, so food can be contaminated at any point, including imports (although this is changing with greater attention to protecting borders and meeting manufacturing standards). (Farm inputs can be water, pesticides, fertilizers, animal feed, and so on.)
One problem remaining with protecting ourselves from agro-terrorism is the lack of publicly-known data about outbreaks. According to the Centers for Disease Control (CDC), only 32% of the reported outbreaks have a known cause. The actual number of outbreaks is believed to be much higher than reported. It is estimated that 1.4 million salmonella infections occur each year, but the CDC gets reports of only about 38,000 annually, so it would be difficult to know what is outside the normal range of disease, and would trigger alarms about food contamination.
(Fork image from www.bcsalmon.ca/bcsmc/ jpg/fork.jpg)
One of our presentation goals is to alert you of potential risks. A “contaminant” is: A substance that is either present in an environment where it does not belong or is present at levels that might cause harmful (adverse) health effects. Potential contaminants could be biological, chemical or physical.
Biologicals include microbes and microbial toxins. These include naturally occurring strains as well as engineered/weaponized strains. Biological Contamination occurs frequently in food, primarily due to cross-contamination between raw and cooked foods, improper holding at the correct time and temperature, and breakdowns in hand-washing. Salmonella: is found in many environmental sources, like water, food, and soil. Clostridium botulinum or C. Bot is a bacteria that is well known for producing one of the most potent toxins known to man. (Say: klo strid’ ee um, or see’ bot)
A chemical event could occur if someone were to store cleaners and pesticides near food, utensils or the food preparation areas. Chemicals include familiar substances like pesticides and cleaners to more exotic chemicals, such as ricin (say: “rye’ sin”) which is a potent agent that could harm the central nervous system.
Physical hazards are non-food items in the food, like broken glass or metal pieces. Radioactive contaminants would fall in this category.
Investigators from the health department, the sanitarians, may not be immediately able to determine why or how the item got into the food. If it looks like it may be intentional, they may call in law enforcement.
(Source for definition: http://www.atsdr.cdc.gov/glossary.html#G-A-, accessed September 29, 2003)
Occasionally, something really strange happens with food. This is one instance:
“…One known case of intentional contamination of food by a radical group, the Rajneeshees, in 1984 caused 751 cases of salmonella typhimurium in a small town in Oregon. In a trial run to see whether their idea worked, they contaminated several restaurant salad bars with salmonella they had isolated from standard hospital laboratory antibiotic sensitivity disks purchased from a Seattle medical supply company.[6] After this trial run, they were planning on using a much more dangerous salmonella that causes typhoid fever. The intentional nature of this outbreak wasn’t discovered until a year later when a cult member confessed the incident to the local police. This was after a complete CDC investigation that could not determine the cause. (The same strain of salmonella the Rajneeshees used caused an outbreak of 16,000 confirmed cases in the Midwest in 1985 when post-pasteurized milk became contaminated; an estimated 170,000 people were affected”)
“ Today, due to increased medical surveillance, as well as cooperation and coordination among public health entities and law enforcement, the same outbreak would be viewed as highly suspect, and would likely be approached differently.” Source: FBI: www.fbi.gov/publications/terror/terror99.pdf, accessed July 7, 2003)
Source: A large community outbreak of salmonellosis caused by intentional contamination of restaurant salad bars, JAMA 1997 Aug 6;278(5):389-95 (ABSTRACT) www.slu.edu/colleges/sph/csbei/bioterrorism/case_studies/large.htm
Photo of Baghwan Shree Rajneesh from www.cnn.com/HEALTH/9708/05/ nfm.food.bioterrorism/ (accessed July, 2, 2003)
In this next section I will talk about some existing or new measures that will reduce the likelihood of a terrorist attack and or mitigate the impact of an attack.
Environmental health professionals assure you of safe food through ongoing inspections, including looking for good practices, but may also involve corrective enforcement and on-the-spot training to ensure that standards are met and used.
Standards/guidelines are already in place that, if adhered to, would greatly enhance the safety of our food, making it very difficult for a major attack on the food system to be successful. Basic food safety requirements like obtaining raw materials from approved sources and limiting access to sensitive areas are some of the existing standards.
(Info from Sue Hibberd, MDH, 6/18/2003 and Paul Allwood, MDH, 9/3/2003)
Inspections are one of the more traditional food safety measures. This photograph shows an FDA inspector working at the winter Olympics. Inspections provide us an opportunity to regularly look in on what the food industry is doing and provides assurances for industry and the public. Through regular inspections we help food industry identify potential weaknesses and offer way to fix them.
Investigations may be initiated in response to Foodborne illness/complaints. Through systematic investigation of foodborne disease outbreaks we can identify the source of contaminants and the way in which contamination occurred. In the Oregon attack, deliberate contamination was suspected fairly early on because the investigation couldn’t find any other reasonable explanation for the illnesses….but back in the mid 80’s that was considered too unlikely so it was dismissed.
Food worker education is an important element in the food safety puzzle. Much of this education takes place on a one-on-one basis during inspections. In addition, most of the retail food establishments in Minnesota are required to have at least person who is certified by the state as having enough food safety knowledge to manage a food establishments.
If you plan for a crisis, it may never occur, but you will be better prepared to deal with and prevent potential crises. Here are some of the important elements.
Plan: who to contact, when, what is an emergency, food flow, number of employees, who is trained to do what jobs, develop checklists…
After you plan, ongoing training can help build capacity. Training can include: 1. How and why to maintain high levels of cleanliness and sanitation;
2. How and why to restrict access of non-essential personnel to kitchens and other food preparation areas;
3. Encouraging employees to monitor their work areas;
4. Encouraging customers to report suspicious behavior;
5. How and why to remove clutter and unwanted chemicals from the establishment;
6. How and why to ensure that salad bars are supervised; and
7. How and why to inspect orders of goods coming to the establishments, and maintain tracking systems of ingredients, storage, and outgoing food. (From: http://www.health.state.mn.us/divs/eh/emergency/food/index.htm)
Monitor: Deliveries and when put away,
Reporting: If a problem occurs, people will get sick and someone will call the foodborne illness hotline or the state epidemiologist 1-877-676-5414. (See sample epi questionnaire from http://www.health.state.mn.us/divs/dpc/ades/fvzd/questionnaire00.pdf) The restaurant could then be closed, or a recall issued.
Originally developed to minimize hazards for food used in the U.S. space program (NASA), HACCP (say: haz’ sip) is now required for agencies enforced by the FDA. Local food manufacturers embrace the principles, too. HACCP is common sense application of scientifically-proven principles.
(Distribute next slide with HACCP principles, if desired.)
(show if time permits) Say: haz’ sip –These are the principles of HACCP. If participants want to learn more, there are many good classes provided by experts.
Active Managerial Control, or AMC, includes all of these factors. The system may include training staff, overseeing all deliveries, designing the facility to include surveillance cameras and temperature controls. Positive reinforcement of good restaurants through meeting inspection requirements and noticing a good performance could possibly be quite marketable for the restaurant, too.
Using the correct strategies is important to do the job well. One tool used in public health is surveillance, that is, to look for unusual situations. Relationships between laboratories are being built to create effective networks, and industry is getting into the act.
1) The private Food Marketing Institute and the grocery manufacturers of America are using a Rapid Alert Database known as FoodElert. This database provides an up-to-date list of food safety and security contacts for the food industry on a 24/7 basis. The database will be used to share recall information, warnings about terrorist or criminal activities, and questions about suspicious terrorist or criminal activity that others may be experiencing.
2) Food NET from CDC lists monthly reports from state labs. The success showing that Campylobacter and Listeria are on the decline and Escherichia coli O157 and Salmonella are not declining, so that more work needs to be done to meet national health goals.
PulseNet is a special demonstration program in which the Minnesota Public Health Lab participates to identify the particular genetic strain of the disease, to allow scientists to link across the country, which served to identify a Mexican parsley as causing disease in many restaurants across the US.
3) Poison Control Centers regularly communicate with MDH Acute Disease epidemiologists and lab staff. One CDC/National Center for Environmental Health (NCEH) national project underway since April of 2003 has been to collect unusual signs and symptoms reported by all poison control centers to alert officials of possible terrorism activity. Food Emergency Response Network (FERN) a network of certified state and local labs committed to analyzing food samples if a terror event occurs includes 30 state/federal labs working on biologicals, 8 federal labs working on chemicals, and 18 fed/university labs working on radiological agents.
There are also many private labs across the country that are certified to test for many biological and chemical contaminants, and to be alert about what they cannot test for.
(Sources: FoodNet, PulseNet : http://www.cdc.gov/foodnet/default.htm; and http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5215a4.htm.
FERN: Contact Gary Dykstra (Gdykstra@ora.fda.gov) for more info or the regional FDA office.)
Minnesota has had food reporting collaborations for many years, and people can call “1- 877- 366-3455, or 1- 877- FOOD ILL” to report illnesses so that the food causing illness can be taken out of the food system.
Note: Medical professionals can call MDH (Acute Infectious Disease Epidemiology) to report illnesses at 1-877-676-5414 anytime.
This reporting function is now being coordinated nationally. In 1998, (before the 9/11/2001 attacks) President Bill Clinton established the 1998 Decision Directive 63 to recognize eight critical infrastructure sectors deemed essential to the nation's well-being. President George W. Bush signed the 2001 Executive Order 13231. Among the key objectives of these orders was the establishment of Information Sharing and Analysis Centers, or ISACs, to improve security by facilitating information sharing. These ISACs are all public/private collaborations. The Food Marketing Institute and the US Government collaborate in the Food Information Sharing and Assessment Center, available on the FMI website. Members, like restaurants, can report any food threats to ISAC. (You can download a form at : http://www.fmi.org/isac/sampleform.pdf) See http://www.nipc.gov/infosharing/infosharing6.htm
The PDD63 includes: (* = 8 original items)
*Food: http://www.fmi.org/isac/; *Water Supply: http://www.amwa.net/isac/
*Financial Services: http://www.fsisac.com/
* (now split into 2) Electric Power: http://www.nerc.com/%7Efilez/cipfiles.html and Oil & Gas: http://www.energyisac.com
* (now split into 3) Telecommunications: http://www.ncs.gov/ncc/main.html and Information Technology: https://www.it-isac.org/ and Interstate: http://www.nascio.org
*transportation/mass transit/Surface Transportation: http://www.surface_transportationisac.org/
*Emergency Fire Services: http://www.usfa.fema.gov/dhtml/fire-service/cipc.cfm
*Emergency Law Enforcement: http://www.nipc.gov/infosharing/infosharing5.htm
*Public Health (ISAC in development); and (New) Chemicals Industry: http://chemicalisac.chemtrec.com/
(share if time permits) For example--Reports on Threats to Supermarkets April 25, 2002 The general media has picked up what was intended to be information only for FBI field agents and some state and local police agencies but was not intended to be issued to the public or to specific industry groups. These reports say that al-Qaida terrorists might be planning attacks against supermarkets and/or shopping centers in America. This information came from interrogating the recently captured bin Laden aide Abu Zubaydah. This is not an official NIPC alert and the Food ISAC was not asked to put out an alert to our members. The information is uncorroborated …. http://www.fmi.org/isac/cssa.htm accessed July 2, 2003)
Another piece of reducing risk and reacting quickly to potential threats is quick communication.
The Health Alert Network or HAN (say: haan), provides active two-way communication to exchange information during a disease outbreak. The HAN Links 51 local public health agencies in all 87 Minnesota counties including the separate boards of health in Bloomington, Edina, Richfield, and Minneapolis. The information provided alerts to public health contacts, health care providers, and emergency workers in the local area.
The HAN has proven its national importance with telling health professionals and emergency responders of SARS, West Nile Virus, and other diseases that required a rapid response. It has not been used to warn of food outbreaks yet.
This has been known for a long time. The first sign is from the 1940’s, instructing people on what to do. However, some people do not wash their hands after using the toilet and before eating. They may need some encouragement to change a behavior. This Handwashing-on-a-Stick” fan, with a packet of soap, was distributed at the 2003 Minnesota State Fair. Initial results show that men were more likely to wash their hands during this campaign.
(Ask Colleen Paulus of the MDH Environmental Health Services Section for more research results associated with this social marketing effort.)
Here, the Safe or Sorry “cooks” are state and local public health staff working side by side. Many middle-school children, and adults, across Minnesota have learned how to prepare food safely, and not be sorry about food borne illness.
Participants learn to:
-Wash hands thoroughly with soap and water before and after handling food; -Wash raw vegetables and fruits with running water before eating;-Always clean surfaces like cutting boards that touch raw foods between each use; -Cook meat, poultry, and eggs thoroughly to an internal temperature of 160° F; -Refrigerate (40° F or below) or freeze (0° F or below) leftovers promptly; and
-Don't eat perishable foods (meat, poultry, fish, eggs, dairy foods) if they have been out of refrigeration for more than 2 hours.
Contact the MDH or your local public health staff for a presentation by the SOS cooks.
http://jama.ama-assn.org/cgi/content/full/290/10/1408 also has this information in English and Spanish
Some ideas participants should remember include the following:
First, industry and government cooperation is required to maintain and strengthen the food system.
Next, following established guidelines will enhance security, including watching for signs and symptoms of chemical, biological, and physical contamination.
Finally, core public health measures help ensure safer food, including assessing threats, developing common sense and practical policies, communicating with each other, and assuring food safety standards are met.
This is one resource for you.
(add your local health department here)
http://www.health.state.mn.us/strategies/ for more information on MDH-collected ideas about best practices in public health.
Here are other resources for you.
Thank you for your time.
Questions?
(Please make a note of all questions and send them to [email_address] or call Deb at the Minnesota Department of Health at ph: 651-215-1323. They can be used to pull together fact sheets or to revise this presentation. Thanks. )
(Please direct any comments (audiences presented to, good points, needed improvements, or other reactions) about this presentation to [email_address] or call Deb at the Minnesota Department of Health at ph: 651-215-1323.)
