Changes in food production
In developed countries such as Australia, there have been a number of structural changes in the food supply system.
These include intense farming practices, more extensive food distribution systems and the increasing move towards minimally processed food.

If potential hazards associated with these practices are not recognised and controlled, they can contribute to an increased risk of foodborne illness.

Extensive food distribution systems

There is a trend, both in Australia and internationally towards wider geographic distribution of food from large centralised processors.
This increases the potential for rapid, widespread distribution of contaminated product.

In 1985, 185,000 people in Chicago contracted salmonellosis from contaminated pasteurised milk distributed by one dairy plant.

In one outbreak in 1994, over 200,000 people across the United States contracted salmonellosis from contaminated icecream made in Minnesota and distributed nationally.

Industry consolidation and mass distribution of foods increase the risk that breakdowns in food safety will cause further widespread outbreaks of foodborne disease.

Outbreaks can be difficult to detect as the increase in cases may not be apparent against the background level of illness (Tauxe 1997). Often it is a fortuitous concentration of cases in one location or the identification of an unusual strain that leads to the identification of a widespread outbreak.

Our changing eating habits
Around sixty to eighty per cent of foodborne illness arises from the food service industry.
Fast food restaurants and salad bars, rare 50 years ago, are today a primary source of food consumption for many Australians.

It is estimated that the number of food service outlets in Australia, has grown 57 per cent with Australians spending 30 per cent of their food budget on take away food and dining out .
Food Standards Australia New Zealand Incidence of Food Borne Illness

In Australia, New Zealand, the United States and the United Kingdom, around 60 per cent to 80 per cent of foodborne illness arises from the food service sector (Crerar et al 1996; Auckland Healthcare 1998; Bryan 1980; Cowden at al 1995; Todd 1985).

New and emerging pathogens
Three of the four most significant foodborne pathogens,
Campylobacter, Listeria and enterohaemorrhagic E. coli (EHEC), were unrecognised as causes of foodborne illness 20 years ago (United States General Accounting Office 1996).

Campylobacter jejuni was first identified as a human pathogen in 1973 and is now the most commonly reported bacterial cause of foodborne illness in the United States .

Unlike other foodborne pathogens, C. jejuniis often associated with sporadic infections and can lead to long-term effects including reactive arthritis and Guillain-Barré syndrome.
Handling raw poultry and eating undercooked poultry have been identified as major risk factors for contracting campylobacteriosis.


Although there is an increasing incidence of foodborne illness, only a small proportion of food poisoning cases are formally reported (Hennessey et al 1996; Crerar et al 1996; Kaferstein 1997; United States General Accounting Office 1996).

The Foodborne Diseases Active Surveillance Network (FoodNet) was established in the United States in 1995 to provide better data on the incidence of foodborne illness (United States Department of Health and Human Services 1998).

FoodNet undertakes active surveillance for foodborne diseases and related epidemiological studies and currently covers 6 per cent of the United States population. Reference: Food Standards Australia New Zealand Incidence of Food Borne Illness  2007

The U.S. Centers for Disease Control report on foodborne illness rates for seven pathogens in 2007 looks depressingly like the reports for the last six years.

Food contaminated with disease-causing bacteria are still causing 76 million cases of food poisoming in the U.S. each year, sending 325,000 Americans to the hospital and killing 5,000, mostly young children, the elderly and those with chronic illnesses.

Last year the CDC acknowledged that there has been virtually no change in the rate of Campylobacter since 2001.
Source: Consumer Federation of America  April 11, 2008
CDC, Preliminary FoodNet Data on the Incidence of Infection with Pathogens Transmitted Commonly Through Foods—10 States, 2007, Mortality and Morbidity Weekly Report, April 11, 2008.

Fried rice and Bacillus cereus.
Incidences of rice-associated food poisoning have been linked to the practice of preparing bulk rice in advance, in anticipation of subsequent need.

Fried rice is a leading cause of Bacillus cereus emetic-type food poisoning in Australia. B. cereus is frequently present in uncooked rice, and heat-resistant spores may survive cooking.

If cooked rice is subsequently held at room temperature, surviving spores will germinate into vegetative forms.
The vegetative forms will multiply, these forms may then produce a heat-stable toxin and this low molecular weight toxin can survive brief heating, such as stir frying.

There are two illness associated with B. cereus, emetic and diarrhoeal illness.
The emetic illness is caused by the ingestion of a heat-stable toxin produced by the microorganisms in the food.

The diarrhoeal illness is caused by the ingestion of moderate to high number of B. cereus and their subsequent production of toxin in the stomach.

Symptoms:
The emetic type of food poisoning, with symptoms similar to that caused by Staphylococcus aureus, is characterised by nausea and vomiting.

The symptoms of B. cereus diarrhoeal illness, similar to Clostridium perfringens food poisoning, include watery diarrhoea, abdominal cramps, and pain.
Nausea may sometimes occur, and vomiting rarely occurs.

Onset times for the emetic illness is usually ½ to 6 hours after consumption of contaminated foods.
For the diarrhoeal illness onset times are usually 6 to 15 hours.
The emetic illness usually lasts less than 24 hours, while the diarrhoeal illness usually persist for 24 hours in most instances.
Source A.C.T Health   2006  www.health.act.gov.au   Reference.  http://www.safefood.net.au/

Bacillus cereus
B. cereus food poisoning is the general description, although two recognized types of illness are caused by two distinct metabolites.
The diarrheal type of illness is caused by a large molecular weight protein, while the vomiting (emetic) type of illness is believed to be caused by a low molecular weight, heat-stable peptide

Associated Foods:
A wide variety of foods including meats, milk, vegetables, and fish have been associated with the diarrheal type food poisoning.

The vomiting-type outbreaks have generally been associated with rice products; however, other starchy foods such as potato, pasta and cheese products have also been implicated.
Food mixtures such as sauces, puddings, soups, casseroles, pastries, and salads have frequently been incriminated in food poisoning outbreaks.

Melbourne, Vic: Food poisoning outbreak   27/03/2002
Contaminated rice is believed to be the cause of severe food poisoning that hit more than 250 people celebrating the Islamic New Year in Melbourne's northern suburbs.
Health authorities tested samples of the suspect rice and other food served at the festival after 10 hospitals and medical centres were flooded with violently ill people.
Initial tests on rice dishes indicated the likely bacterial germ was bacillus cereus
The outbreak was the worst mass food poisoning in Victoria since 1997 when more than 550 people fell ill after eating pork rolls infected with salmonella.
Source:  EMERGENCY MANAGEMENT AUSTRALIA,

Lectin In Undercooked Red Beans And Rice Causes Food Poisoning
Lectins, a family of proteins believed to be a natural insecticide that is abundant in undercooked legumes and grains, can cause food poisoning.

Red Kidney Bean Poisoning
Is caused by a toxic agent, Phytohaemagglutnin (Kidney Bean Lectin).
This toxic agent is found in many species of beans, but it is in highest concentration in red kidney beans (Phaseolus vulgaris).

The unit of toxin measure is the hemagglutinating unit (hau).
Raw kidney beans contain from 20,000 to 70,000 hau, while fully cooked beans contain from 200 to 400 hau.
White kidney beans, another variety of Phaseolus vulgaris, contain about one-third the amount of toxin as the red variety; broad beans (Vicia faba) contain 5 to 10% the amount that red kidney beans contain.

Symptoms
As few as 4 or 5 beans can bring on symptoms.
Onset of symptoms varies from between 1 to 3 hours and is usually marked by extreme nausea, followed by vomiting, which may be very severe.
Diarrhea develops somewhat later (from one to a few hours), and some persons report abdominal pain and have been hospitalized, but recovery is usually rapid (3 - 4 hours after onset of symptoms) and spontaneous.

" .. ingestion of lectin has also been linked to colorectal cancer and celiac disease, a common problem in which individuals are sensitive to gluten, a mixture of proteins derived from wheat flour that includes lectins.
The small intestine of the celiac sufferer is unable to properly absorb nutrients after gluten ingestion.  "
Source:  Dr. Paul L. McNeil, Medical College of Georgia, U.S. 4-Aug-07 http://www.accessibility.com.au/news/
The syndrome
is usually caused by the ingestion of raw, soaked kidney beans, either alone or in salads or casseroles.
Several outbreaks have been associated with "slow cookers" or crock pots, or in casseroles which had not reached a high enough internal temperature to destroy the glycoprotein lectin.
It has been shown that heating to 80 degrees C. may potentiate the toxicity five-fold, so that these beans are more toxic than if eaten raw.
In studies of casseroles cooked in slow cookers, internal temperatures often did not exceed 75 degrees Celsius.
Source   FDA (U.S. Food and Drug Administration) Center for Food Safety & Applied Nutrition   Reference.  Bad Bug Book (Foodborne Pathogenic Microorganisms and Natural Toxins Handbook).

NOTE: To render kidney, and other, beans safe for consumption:
* Soak in water for at least 5 hours.
* Pour away the water.
* Boil briskly in fresh water for at least 10 minutes.
* Undercooked beans may be more toxic than raw beans.
This procedure has been recommended by the PHLS (Public Health Laboratory Services, Colindale, U.K.)

Tutu toxin in honey.
Tutin, a picrotoxin, is a naturally occurring toxin found in honey.
The toxin is produced as a result of bees gathering honeydew secreted by bugs feeding on sap of the poisonous ‘tutu’ plant (Coriaria arborea).

The toxin has no effect on bees and honeydew honey is chemically very similar to floral honey and cannot be distinguished by taste, sight or smell from other non-toxic honeys.
It cannot be degraded by any heating or processing of honey. The toxins are believed to be very stable, and poisoning cases have resulted from people eating honey that was several years old.

Comb honey poses a greater risk because it is eaten directly off the comb, increasing the chance of consuming honey with a high concentration of tutin.

Tutu is widely distributed throughout New Zealand, particularly along stream banks and in regenerating native scrub.
It historically occurs primarily in the Coromandel Peninsula, Eastern Bay of Plenty (EBOP) and the Marlborough Sounds, although it is possible it could occur elsewhere. Test results from the honey incident in March 2008 confirmed that the suspected tutu toxins and its derivative hyenanchin, were present in comb honey from the Coromandel Peninsula.

March 2008. New Zealand
22 People were poisoned after eating comb honey contaminated with tutin and its derivative hyenanchin.

Exposure to honey containing this naturally occurring toxin can produce symptoms such as vomiting, delirium, giddiness, increased excitability, or in more severe cases stupor, coma and violent convulsions.
It is generally accepted that as little as one teaspoon (approximately 10 ml) of unblended honey can have a severe effect on the human nervous system.

Prior to the March 2008 incident, the last recorded case from commercial honey was in 1974 involving 13 patients. There have been nine cases since 1974 with the last known poisoning occurring in 1991 in the EBOP area. Two poisonings have been caused by comb honey produced by hobby beekeepers in the Marlborough Sounds in 1982 and 1983 and the highest levels of tutin ever measured in honey were produced in this area.
Source:  http://www.foodstandards.gov.au/newsroom/foodsurveillancenewsletter/winter2008.cfm

Honey Intoxication.
Honey intoxication is caused by the consumption of honey produced from the nectar of rhododendrons. The grayanotoxins cause the intoxication.
The specific grayanotoxins vary with the plant species.
These compounds are diterpenes, polyhydroxylated cyclic hydrocarbons that do not contain nitrogen.
Other names associated with the disease is rhododendron poisoning, mad honey intoxication or grayanotoxin poisoning.

Symptoms.
The intoxication is rarely fatal and generally lasts for no more than 24 hours.
Generally the disease induces dizziness, weakness, excessive perspiration, nausea, and vomiting shortly after the toxic honey is ingested.

Other symptoms that can occur are low blood pressure or shock, bradyarrhythima (slowness of the heart beat associated with an irregularity in the heart rhythm), sinus bradycardia (a slow sinus rhythm, with a heart rate less than 60), nodal rhythm (pertaining to a node, particularly the atrioventricular node), Wolff-Parkinson-White syndrome (anomalous atrioventricular excitation) and complete atrioventricular block.
In severe intoxication, loss of coordination and progressive muscular weakness result.

Several cases of grayanotoxin poisonings in humans have been documented in the 1980s. These reports come from Turkey and Austria.
The Austrian case resulted from the consumption of honey that was brought back from a visit to Turkey.
From 1984 to 1986, 16 patients were treated for honey intoxication in Turkey. The symptoms started approximately 1 h after 50 g of honey was consumed. In an average of 24 h, all of the patients recovered..

The Austrian case shows that with increased travel throughout the world, the risk of grayanotoxin poisoning is possible outside the areas of Ericaceae-dominated vegetation, namely, Turkey, Japan, Brazil, United States, Nepal, and British Columbia.
Source:   Bad Bug Book (Foodborne Pathogenic Microorganisms and Natural Toxins Handbook).

Fungus in our Food.  ( Mycotoxins  )

Mycotoxins are toxic chemical products formed by mould species including Penicillium, Aspergillus and Fusarium.
These moulds can readily colonise food crops such as cereal grains, nuts and fruits, either in the field or post harvest.

Consumption of foods produced from these commodities poses a potential risk to human health because the toxins are resistant to various food processes, including heat treatment.
Mycotoxins rarely cause acute illness in developed countries, but long term consumption of low levels has been linked to disease.
The mycotoxins of concern to the international food industry are:

As harvest conditions in Australia are predominantly warm and dry, the threat of mycotoxin production in cereals is much lower here than in most other regions.

Contamination of Australian peanut crops by aflatoxins is an ongoing issue however, particularly when plants become drought stressed in seasons when there is low rainfall preceding harvest.
Source:  Food Safety and Hygiene, November 2006  http://www.foodscience.com.au/fshbull/fshbull43a.htm

Ochratoxin.
Ochratoxin is present in a large variety of foods because it is produced by several fungal strains of the Penicillium and Aspergillus species that have varied physiologies and ecologies.

Ochratoxin is considered to be nephrotoxic, teratogenic, and immunotoxic, and has been classified by the IARC as a Class 2B carcinogen, probable human carcinogen.

Ochratoxin A, themaintoxin in this group, is found in wheat, corn, and oats having fungal infection and in cheese and meat products of animals consuming ochratoxin-contaminated grains (Aish and others 2004).

A. ochraceus is found on dry foods such as dried and smoked fish, soybeans, garbanzo beans, nuts, and dried fruit.

A. carbonarius is the major pathogen in grapes and grape product including raisins, wines, and wine vinegars.
Although reported to occur in foods around the world, the main regions of concern are Europe and, for some foods, Africa.

The Joint Expert Committee on Food Additives of the Food and Agriculture Organization of the United Nations and theWorld Health Organization (JECFA 2001) presented data indicating that cereals, wine, grape juice, coffee, and pork are the major sources of human ochratoxin exposure, at levels of 58%, 21%, 7%, 5%, and 3% of total ochratoxin intake, respectively.

Levels reported range from 100 to 700 ng/kg in cereals, 30 to 9000 ng/L in European wines, 170 to 1300 ng/kg in coffee, and 150 to 2900 ng/kg in pork (Sage and others 2004).
Ochratoxin presence in European wines is a relatively recent concern, with red wines typically containing higher ochratoxin levels than rose or white wines. Because of the large variety of food matrices in which ochratoxin has been found, there is no universally suitable method of analysis.

Carcinogenic Toxins.
" The greatest human health concern related to mycotoxins is the cancer risk based on long-term, low-level exposure to carcinogenic toxins such as the aflatoxins, ochratoxin A, fumonisins, and zearalenone. "

" In some regions of Africa (Transkei), Asia (China), and Europe (Italy) the exposure to fumonisins from maize is connected with higher incidence of oesophageal cancer. "
Source:  Peraica M, Domijan A-M. MYCOTOXINS IN FOOD AND HUMAN HEALTH
  Arh Hig Rada Toksikol 2001;52:pp. 23–35

Deoxynivalenol contamination.

Another mycotoxin of contemporary relevance is Deoxynivalenol produced in wheat, maize, and barley.
It is found frequently in US, Canadian, European and Chinese wheat mostly associated with cool, wet growing and harvest seasons that favour the formation of scabs caused by Fusarium graminearum.

Outbreaks had been reported from India, China and the USA. While the outbreaks in India and China occurred among the general population the outbreak in the USA had occurred in children in 17 schools in seven states who had consumed burritos as part of the school lunch programme.

During that period, heavy contamination of deoxynivalenol was reported in wheat in several states in the USA. Deoxynivalenol toxicosis symptoms include nausea, vomiting and pain in the abdomen. No mortalities were reported.
Source:  Source:  Asia Pac J Clin Nutr 2008;17(S1):91-94
  Human health problems associated with current agricultural food production
Secretary General, Federation of Asian Nutrition Societies, Centre for Science, Society and Culture M 11, Kakateeyanagar, Habshiguda, Hyderabad, India.

Recombinant DNA technology and genetically modified foods.

" Risk to human health from Genetically Modified (GM) foods is mainly related to toxicity, allergenicity and antibiotic resistance.

The risk of toxicity may be directly related to the nature of the product whose synthesis is controlled by the transgene or the changes in metabolism and composition that result from the gene transfer.

Most of the toxicity risks can be assessed using scientific methods.
The introduction of newer proteins in transgenic crops from organisms, which have not been consumed in foods before, have the potential to become allergens.

Health risk assessment of genetically modified organisms (GMOs) cultivated for food or feed is widely debated throughout the world, and very little data have been published on mid- or long-term toxicological studies with mammals.

StarLink maize was genetically engineered by Aventis Crop Science to express an insecticidal Bt derived protein Cry9C.
The US Environmental Protection Agency (EPA) had approved the registration of StarLink maize for restricted use as animal feed and not for human consumption, due to the presence of certain allergenic properties.

The Centre for Disease Control in the USA found that 28 persons had experienced allergic reactions after the ingestion of taco shells made by Kraft foods that were found to have traces of Starlink maize.

This resulted in a huge recall of the product from the market by the US Food and Drug Administration (FDA).

This example clearly indicate the possibility of health concerns arising from certain GM food events which were hastily approved "

Source:  Asia Pac J Clin Nutr 2008;17(S1):91-94
  Human health problems associated with current agricultural food production
Secretary General, Federation of Asian Nutrition Societies, Centre for Science, Society and Culture M 11, Kakateeyanagar, Habshiguda, Hyderabad, India.
NEW FOOD SCANDAL ROCKS THE USA SAFEWAY BRAND CONTAINS ILLEGAL GM MAIZE http://www.gene.ch/genet/2000/Oct/msg00016.html

Histamine Fish Poisoning  (HFP)
Eating fish with high levels of histamine can result in histamine fish poisoning (HFP).
HFP was previously also called Scombroid Fish Poisoning.

Histamines in fish can cause allergic reactions in people ranging from mild skin discomfort to nausea, vomiting and diarrhoea. The level of histamine in fish, canned, frozen or fresh is affected by the presence of certain proteins which are converted to allergenic products by bacteria present. Correct temperature control can limit the production of histamines.

Fish are a particular concern when it comes to maintaining temperatures of less than 5ºC.
This is because if the fish contain an amino acid called Histidine, the bacteria can turn this into Histamine which is a physiological amine responsible for many allergic reactions.

Once histamine is formed it is not destroyed by freezing, cooking, smoking, curing or canning
This is the same histamine that causes problems for some people when high levels are produced in cheese and red wine.
Histamine eaten in spoiled fish appears to be more toxic than an equal amount of histamine taken orally in a solution. It is thought that the other biogenic amines (Putrescine, Cadaverine ) produced in fish may potentiate the histamine action.

The symptoms of Fish Poisoning ( HFP ) can be very similar to a severe allergic reaction, and can happen within minutes to hours after ingestion of the toxic fish and may include:
· A burning/tingling sensation in/around the mouth.
· Rash and/or swelling over the chest and /or neck.
· Lowering of blood pressure.
· Headache.
· Itchy skin.
· Nausea.
· Vomiting.
· Diarrhoea.
Most of these symptoms will stop after a few hours.

Tuna and mackerel, members of the family Scombroidae tend to have high levels of histidine and are therefore more likely to be implicated in allergic reactions.
However, many non-scombroid species, for example sardines, blue fish, mahi mahi have caused HFP, so the term Scombroid Fish Poisoning is a misnomer.

The key to controlling histamine production is rapid cooling of the fish once caught and maintaining a temperature of less than 5ºC until it is cooked.
Best practice is to prevent amine production in the first place.
Source A.C.T Health   2006  www.health.act.gov.au

Ciguatera fish poisoning.
Ciguatera fish poisoning is caused by the consumption of fish contaminated by naturally occurring toxins produced by the algal dinoflagellate Gambierdiscus toxicus associated with coral reefs.

Ciguatoxin, which accumulates through the food chain, is thermostable and is not destroyed by cooking, freezing or other fish-processing methods. It does not affect the taste or texture of the fish. In humans, ciguatoxin produces gastrointestinal and characteristic neurological symptoms, consisting mainly of sensory disturbances

Ciguatera fish poisoning is widespread, affecting mainly tropical and sub-tropical areas of the world.
Most reported outbreaks in Australia have involved Spanish mackerel, but numerous other species of fish, including red bass, the chinaman and coral trout, have been implicated

An outbreak of 30 cases of ciguatera fish poisoning in outer Melbourne in September 1997 was traced to a 16.2 kg Maori Wrasse fish imported into Victoria from Trunk Reef in Queensland.

The incubation period ranged from 2 to 27 hours (median 8 hours). Symptoms varied in severity
Source:  Communicable Diseases Intelligence Volume 24, No 11, November 2000.  http://www.health.gov.au/

Nematode  Anisakis: which infects marine animals.
Common in a broad range of fish in Northern and Southern Southern hemispheres.
Humans become incidental hosts by consuming raw or undercooked seafood.
Allergic reactions occur in patients sensitised to allergens in Anisakis these include anaphylaxis or acute urticaria, when infected fish is eaten.
Recently described as a cause of anaphylaxis and other acute allergic reactions after eating fish,in regular fish eaters.
Most reports are from Spain and Japan.

Viruses
Hepatitis A, rotavirus, Norwalk virus group. (noroviruses)

Bottled Mineral Water
Bottled water could account for 12 per cent of infections by the bacterium campylobacter jejuni, the biggest cause of food-borne infection in the western world, say scientists.

As many as 6,000 of the 50,000 cases reported in England and Wales each year may be due to the bacterium, which causes stomach pains and diarrhoea, but in rare cases can prove fatal.

Contaminated water supplies, milk and poultry are recognised risk factors for campylobacter jejuni.

New research shows that bottled mineral water and non-lettuce salad vegetables such as tomato and cucumber are also potential hazards.
Bottled water was found to account for 12 per cent of the cases studied, salad 21 per cent and chicken 31 per cent.

Reference:  Article Published in the American journal Emerging Infectious Diseases by    Dr Meirion Evans, University of Wales in Cardiff. 2003
The Independent, (London), Oct 3, 2003 by John von Radowitz

Cases of the top two food poisoning germs (salmonella and campylobacter) are set to soar to more than 120,000 in just three months this summer according to the Food Standards Agency (FSA) U.K.
9 June 2008  http://www.food.gov.uk/news/pressreleases/2008/jun/germwatch

Our Drinking Water
Protozoan parasites such as Cryptosporidia and Giardia lamblia, and viruses like hepatitis A and E, rotavirus, Norovirus, poliovirus and echovirus can be present in drinking water even when the water is chlorinated.
People can become extremely sick by swallowing a few protozoa since they rapidly reproduce once inside a host organism.
Cryptosporidium caused a cryptosporidiosis outbreak in Milwaukee in 1993 that resulted in over 400,000 cases of serious illness and 100 deaths.
Emerging Issues in Water and Infectious Disease, World Health Organization, 2003

Britain orders Tests for drugs in drinking water supply.   29 September 2008

" Drinking water supplies are to be tested for the presence of prescription drugs amid fears that rivers are being contaminated by the growing quantity of pharmaceuticals flushed unwittingly down the drain.

Powerful anti-cancer drugs are of particular concern as they can be excreted unaltered from the body into the sewerage system.
They are thought to be potentially dangerous because they are highly toxic to dividing cells, are easily dissolved in water and are difficult to destroy by conventional water-treatment techniques.

Scientists are also worried that even if cytotoxic drugs are getting into the water supply at doses too low to affect adults, they may still pose a significant risk to babies in the womb because they would be potentially susceptible to the effects of anti-cancer substances aimed at preventing cell division. "

Britons consume 2,700kg of 5-fluorouracil – just one of 50 cytotoxic drugs. By comparison, they consume about 45kg of the active ingredient of the contraceptive pill, which is believed to be responsible for freshwater fish changing sex.
Scientists in Germany have found pharmaceutical drugs in Berlin's water supply and have called for further research into what could be a Europe-wide problem.
Source:  http://www.independent.co.uk/news/science/tests-for-drugs-in-tap-water-945268.html

Recycled Water.

" ...increased recycling of water in Australia could lead to concerns over the environmental impact of low concentrations of endocrine disruptors, pharmaceutical drugs and their metabolites, cosmetic materials, and natural hormones, all have which have been detected in fresh water in Europe and North America. "