Coffee contains furan and its derivatives, but their health risks remain unclear. This study quantified the levels of six furanic compounds (furan, 2-methylfuran, 3-methylfuran, 2,5-dimethylfuran, 2-ethylfuran, and 2-pentylfuran) in 214 coffee products marketed in Beijing and evaluated the health risks to 2588 consumers based on population-specific consumption data. Furan (98%, nd–8120 μg/kg) and 2-methylfuran (98%, nd–23683 μg/kg) had the highest detection rates and concentrations. Coffee beans and powders exhibited the highest average furan concentrations at 4679 and 2993 μg/kg, respectively, followed by instant coffee and take-out coffee, which were 293 and 40 μg/kg, respectively. However, take-out coffee was the predominant product category consumed and therefore the main contributor to dietary exposure. The mean dietary exposures to furan and the sum of furan, 2-methylfuran, and 3-methylfuran derived from coffee products, after accounting for preparation-related furan losses, were 64.06 and 181.77 ng/kg bw/day, respectively, with corresponding 95th percentile exposures of 131.07 and 368.97 ng/kg bw/day. For non-neoplastic effects, the mean margins of exposure (MOE) for furan and the sum of the three compounds were 999 and 352, with 95th percentile MOEs of 488 and 173, respectively. For the neoplastic effects of furan, the mean and 95th percentile MOE were 14,556 and 9,995, respectively. The lowest MOE values were observed for consumers aged 18–44 years, particularly females, and for those aged 18 years or younger. Generally, high coffee consumers with MOEs below 10,000 have health concerns. This study provides robust scientific data for coffee safety management, with global implications for similar urban populations.

OBJECTIVES:Beijing, a large urban center with complex food supply chains, faces increasing challenges from foodborne Campylobacter infections. However, local data on antimicrobial resistance, source attribution, and pathogenic characteristics remain limited. This study aimed to clarify long-term trends, resistance patterns, and likely infection sources of Campylobacter in Beijing to inform prevention and treatment strategies. METHODS:From 2016 to 2023, 27,691 stool samples were collected from patients with foodborne diseases in 45 hospitals across Beijing. Campylobacter isolates were recovered and identified, followed by antimicrobial susceptibility testing, and whole-genome sequencing. A core-genome MLST-based extreme gradient boosting (XGBoost) model was applied for machine-learning source attribution. RESULTS:A total of 1204 Campylobacter isolates were identified, including 1005 C. jejuni, 198 C. coli and one C. fetus. The proportion of C. coli increased compared with the early surveillance years and reached its highest level in 2023. Both C. jejuni and C. coli showed >90% resistance to fluoroquinolones and tetracyclines, and C. coli has a much higher resistance rate to macrolide. Machine-learning analysis identified chicken as the major source for C. coli infections, accounting for 75.76% cases. CONCLUSIONS:This 8-year genomic surveillance highlights the sustained and increasing contribution of C. coli and extensive resistance in Beijing, supporting targeted control measures and antibiotic stewardship in foodborne disease management.

Poisonous mushroom poisoning is one of the important causes of foodborne disease outbreaks in China， serving as the leading cause of fatalities associated with foodborne diseases. In recent years， the incident ratio shows a rising tendency. Therefore， clarifying the epidemiological characteristics of poisonous mushroom poisoning is a necessary precondition for lowering the mortality ratio. This review retrieved and synthesized the research literature on mushroom poisoning epidemiology in China published over the past decade， with reported data as early as 2003. Comprehensive evidence were analyzed across four dimensions including temporal trends， geographic distribution， demographic patterns， and exposure settings. The limitations of existing research were also evaluated. Based on the findings， this review outlines prospects for future research and prevention strategies against poisonous mushroom poisoning.

ObjectiveTo comprehensively understand the evaluation， actual needs and suggestions of standard users on National Food Safety Standards training， and identify the shortcomings in the training process in a timely manner， and continuously improve training methods and contents to enhance training effectiveness.MethodsKirkpatrick’s training effectiveness evaluation model was used to evaluate the overall training effectiveness at the reaction， learning， behavior and results levels.ResultsAfter the training， participants’ mastery of knowledge covered in the training improved significantly （T=32.032， P0.05）， and the average test score before and after the training increased from 81.20 to 83.73. More than 95.00% of the trainees were satisfied with the training， but about 3.99% of the trainees thought that the training was not satisfactory. The proportion of participants from manufacturing enterprises who were very satisfied （83.57%） was much higher than that in other sectors. Satisfaction with the completeness of the training materials， the learning environment， and the overall competence of the instructors was the highest， all reaching 100%. The satisfaction rate of training applicability is as high as 96%. While 60.80% of the trainees reported knowledge acquisition， only 13.62% reported improved awareness. In telephone follow-up interviews， the satisfaction rate （“very satisfied” and “satisfied”） for the systematic organization of the course content exceeded 95.00%. However， satisfaction scores for the practicality and breadth of the course content were slightly lower， with satisfaction rates of 75.00% and 73.00%， respectively. Multivariable analysis showed that the training applicability and perceived training benefits were associated with satisfaction （P0.05）.ConclusionThe trainees were generally satisfied with the applicability and perceived benefits from the food safety standard training. They expected more similar training programs and suggested incorporating case studies and practice-oriented teaching to increase the diversify of the training methods in the future.

During the 2019 Chinese National Microbiological Food Safety Surveillance program, Listeria monocytogenes was detected in ice cream samples produced by Manufacturer A. By comparing the sequences of isolates derived from the ice cream with those of isolates derived from humans, we identified one human-derived isolate that was genetically indistinguishable from one ice cream-derived isolates. The patient was hospitalized with listeriosis in Beijing, China in March 2019. Food history obtained from the patient indicated that he had consumed ice cream produced by Manufacturer A during the 30-day period before the onset of illness. No cases of listeriosis were detected after the ice cream produced by Manufacturer A was removed from the shelves. Overall, this report presents the first case of L. monocytogenes infection associated with ice cream in China.

BACKGROUND:Food medicine homology originated in ancient China and has been officially named food-medicine dual-purpose substances (FMS). However, the relationship between residents' knowledge, attitudes, practices (KAP) and FMS among adults in China remains unclear. This study evaluated the current situation of FMS-related knowledge, awareness and actual consumption behaviors and practices of Chinese residents to provide a basis for both perfect related regulations and scientific advice on FMS consumption. METHODS:A cross-sectional online survey on FMS perception and consumption was conducted through a convenience sampling strategy from August to December 2020. A total of 2,815 residents (96.3% were aged between 18 and 50 years old, 47.8% were male and 52.2% were female) from 31 provinces were recruited for this study. Descriptive analysis and multivariate logistic regression analysis was performed in the statistical analysis. RESULTS:The results showed that residents' identification of FMS had an accurate response rate of 22.7% (640/2,815). Educational level was the factor associated with residents' knowledge of FMS. A total of 62.0% (1,744/2,815) of the residents would take the initiative to learn more about FMS. 93.8% (2,639/2,815) of them thought that manufacturers should make clear food labels when they add FMS. Almost half of the residents bought FMS products frequently (more than 12 times per year), and 96.1% (1,880/2,747) of the residents bought FMS mainly used for healthcare. Among the FMS they had ever consumed, the two most frequently consumed FMS by residents were yam (35.3%) and wolfberry (15.9%). 40.6%(1,143/2,815) of residents hoped that the government could increase publicity and conduct more popular science activities. CONCLUSION:The findings indicate that adult residents in China who have substantial knowledge of FMS are not optimistic; however, they express positive attitudes toward knowing and consuming FMS, and there is a high need for labeling and a high demand for consumption. It is imperative to enhance research and policy development regarding FMS, to actively promote FMS knowledge, and to guide residents towards a more scientific and rational consumption of FMS in the future.

Nontyphoidal Salmonella (NTS) is the most commonly reported foodborne gastrointestinal infection and ranks among the top three causes of foodborne bacterial outbreaks in China. This study analyzed NTS data from the Foodborne Disease Surveillance System in China from 2013 to 2022 to summarize epidemiological features and assess reporting rate changes. We employed joinpoint regression model to calculate the annual percentage change in NTS reporting rate, sex reporting rate, as well as rural-urban reporting rate. We applied the Pearson correlation coefficient to evaluate the correlation of NTS reporting rate and the national per capita consumption of major foods and cases of COVID-19. During this period, 55,266 NTS cases were reported, with reporting rates increasing significantly (AAPC [CRR] = 21.89

OBJECTIVE A quantitative microbiological risk assessment was conducted for non-typhoidal Salmonella(NTS)in raw chicken from retail stores to consumers in Beijing.METHODS The monitoring of microorganisms and pathogenic factors data was used to estimate the initial contamination level of NTS in the retail raw chicken.The growth model of NTS were referenced from the ComBase data base.Exposure assessment model was reference from scientific literature.Using the@Risk 7.5 software for simulation analysis,combined with the dose-response relationship,estimate the risk of residents developing NTS disease.RESULTS The risk of Salmonella infection per meal among Beijing residents due to consuming chicken and kitchen cross contamination was 6.21 cases per 100 000,with an average annual incidence of 51 955.42 cases.Sensitivity analysis shows that the initial contamination level of NTS in chicken purchased by residents,the average intake of ready to eat food per meal by residents,and refrigeration storage temperature are positively correlated,while they are negatively correlated with NTS exposure temperature and exposure time during cooking.CONCLUSION Measures such as reducing the initial concentration of NTS in chicken,setting a reasonable refrigerator temperature,and reduce the occurrence of kitchen cross contamination can effectively reduce the risk of NTS disease.

Listeriosis is a relatively rare but severe foodborne disease, which has significant public health concern of persons with underlying conditions and pregnant women. This study aimed to estimate the morbidity, mortality, and fatality rates of listeriosis over a 10-year period and clarify the epidemiological features of the pathogen in Beijing, China, based on voluntary reporting of sentinel surveillance. A total of 228 listeriosis cases were reported with annual morbidity rate of 1.054 per million inhabitants, including 113 maternal-neonatal cases with mean annual morbidity rate of 63.401 per million live births in Beijing from 2013 to 2022.The morbidity rate increased from 0.094 to 0.868 per million inhabitants from 2013 to 2019 (p for trend = 0.003). The overall and maternal-neonatal fatality rate were 31.82% and 42.86%, respectively. Four serogroups were identified in this study, and 1/2b predominated (89 strains). We observed the morbidity rate of listeriosis increased in Beijing over the past 10 years. Maternal-neonatal cases accounted for a higher proportion than that described in other countries, considering population base and fertility policy in China, official recommendations targeting pregnant women should be actively promoted.

Objective To provide a reference for the scientific prevention and control of foodborne diarrhea among the 6-17 year-old population by analyzing the surveillance data of foodborne diarrhea cases in this age group from sentinel hospitals in Beijing from 2013 to 2022.Methods The clinical information of foodborne diarrhea cases aged 6-17 years who visited 36 sentinel hospitals in Beijing from 2013 to 2022 was collected,and stool samples or anal swabs were collected for pathogen detection.The x2 test was used for rate comparisons,and multivariate logistic regression was applied to analyze the influencing factors of pathogen infection.Results From 2013 to 2022,a total of 2 128 foodborne diarrhea cases aged 6-17 years were reported by Beijing sentinel hospitals,with males outnumbering females(1.95∶1).The number of cases was highest in the outer suburbs,accounting for 36.75％(782/2 128).The peak period for pathogen detection was from July to September each year,while norovirus was mostly detected in winter and spring.Logistic regression results showed that compared with the 15-17 year-old group,the 12-14 year-old group(OR=0.512,95％CI:0.326-0.804)had a lower risk of pathogen infection.Compared with the outer suburbs,the risk of pathogen infection was higher in urban areas(OR=1.447,95％CI:1.029-2.034)and inner suburbs(OR=1.543,95％CI:1.119-2.129).Summer(OR=7.674,95％CI:3.688-15.968)was the season with the highest risk of pathogen infection,and the inner suburbs(OR=3.348,95％CI:1.690-6.634)had the highest risk of norovirus detection.Cases with fever(OR=1.806,95％CI:1.358-2.403)and diarrhea ≥10 times/24 h(OR=1.832,95％CI:1.300-2.581)had a higher risk of pathogen infection.Cases with abdominal pain(OR=2.109,95％CI:1.146-3.881)and dehydration(OR=2.327,95％CI:1.146-3.881)had a higher risk of norovirus detection.Conclusion From 2013 to 2022,foodborne diarrhea cases among the 6-17 year-old population in Beijing were predominantly male,with suburban areas being the key regions for prevention and control.The epidemiological and clinical characteristics of cases infected with different pathogens can be used to provide a basis for food safety and health education and clinical diagnosis.

Organophosphate esters (OPEs) and their metabolites (mOPEs) are emerging pollutants. In this study, 18 OPEs and 10 mOPEs were measured in the 6th and 7th Beijing total diet studies (TDSs), and the dietary intakes of these pollutants by Beijing adults were estimated to assess related health concerns. Most OPEs and mOPEs had high detecting frequencies in both TDSs, which indicated that various foods in Beijing have been universally contaminated with OPEs and mOPEs. Statistical analysis further confirmed that the levels of both ∑OPEs and ∑mOPEs in the 7th Beijing TDS were significantly higher than those in the 6th study, indicating heavier contamination of both OPEs and their metabolites with time. Along with increasing OPE/mOPE contamination level and food consumption values, significant increases of EDIs were observed during the two studies, with the average EDIs of ∑OPEs increasing from 5.07 to 24.1 ng/kg bw/day, and that of ∑mOPEs increasing from 2.07 to 7.23 ng/kg bw/day. Although a comparison between EDIs and reference of doses (RfDs) indicated that current intakes of OPEs could still not cause significant health risks, the sharply increasing contamination levels and EDIs suggested the necessity to continuously monitor these emerging food contaminants.

Objective To construct an evaluation index system for foodborne disease surveillance system in Beijing,and to provide reference foodborne disease system evaluation in Beijing.Methods Based on the actual situation of foodborne disease surveillance in Beijing,the evaluation index framework was established through literature search,and the Delphi method was applied to the index system for two rounds of expert consultation,and finally the three-level evaluation index system of foodborne disease surveillance system was established.Results The evaluation index system of foodborne disease surveillance system was divided into three levels,including 3 primary indexes,24 secondary indexes and 94 tertiary indexes.The indexes are sorted by weight,and the primary indexes are the monitoring system structure and function(0.402 3),the monitoring system operation guarantee(0.321 5),and the monitoring system performance(0.276 2).The top 3 secondary indexes were monitoring definition(0.065 0),monitoring purpose(0.063 1)and monitoring content(0.059 3).The top 3 third-level indexes were food-borne disease case definition(0.032 7),food-borne cluster case definition(0.032 3)and active surveillance case definition(0.031 0).The average score of importance of each index was 7.68(5.62-9.18),and the average coefficient of variation was 0.21(0.11-0.39).Conclusion The index system established in this study covers the structure and function of the surveillance system,monitoring performance and operation guarantee,etc.The research method is appropriate and the results are reliable,which has reference significance for the evaluation of foodborne disease surveillance system in other regions in the future.

What is already known on this topic?:Foodborne diseases present a substantial global health risk. Traditional diagnostic methods have constraints, but advancements in molecular techniques, like quantitative polymerase chain reaction (qPCR), provide a hopeful solution.What is added by this report?:We examined 1,011 stool samples from individuals suspected of foodborne illnesses. Our analysis indicated a significant presence of Clostridium perfringens, Salmonella enterica, enterotoxigenic Escherichia coli (ETEC), and adenovirus. Notably, co-infections were identified in 71.22% of the samples.What are the implications for public health practice?:The data emphasize a notable prevalence of co-infections, highlighting the complexity of foodborne illnesses. This study underscores the significance of utilizing contemporary diagnostic methods in densely populated urban areas such as Beijing Municipality.

Objectives: Using a sporadic case of listeriosis suspected to have been caused by consuming a pre-packaged cold-chain ready-to-eat (RTE) food in Beijing, China in 2021 as an exemplar, this study demonstrated the importance of thoroughly investigating the source of listeriosis up to the production point for mitigating infection risk during routine monitoring of Listeria in food facilities and national surveillance program using whole-genome sequencing (WGS). Methods: Epidemiological, laboratory, traceback, and plant investigations were used to identify the source of infection. Results: WGS showed the isolate from the patient was genetically indistinguishable from that of the implicated food. During a plant investigation, L. monocytogenes was detected in 26% (9/35) of the environmental samples and one of two raw material samples, confirming the source. Conclusion: To our knowledge, this is the first investigation in China linking a case of L. monocytogenes infection to a suspected food and its production environment. This report highlights the risk of L. monocytogenes contamination of RTE food and demonstrates the role of food safety risk monitoring in identifying potential sources of infection. Reinforcing control programs in RTE processing plants, intensified surveillance of microorganisms in food products and targeted health education is required to mitigate the infection risk. (c) 2024 The Author(s). Published by Elsevier Ltd on behalf of The British Infection Association. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

The prevalence of listeriosis in China has been increasing in recent years. Listeriosis primarily spreads through contaminated food. However, the resilient causative organism, Listeria monocytogenes, and its extended incubation period pose challenges in identifying risk factors associated with food consumption and food-handling habits. This study aimed to identify the risk factors associated with food consumption and food-handling habits for listeriosis in China. A matched case-control study (1:1 ratio) was conducted, which enrolled all eligible cases of listeriosis between 1 January 2013 and 31 December 2022 in China. Basic information and possible risk factors associated with food consumption and food-handling habits were collected. Overall, 359 patients were enrolled, including 208 perinatal and 151 non-perinatal cases. Univariate and multivariable logistic analyzes were performed for the perinatal group. For the perinatal and non-perinatal groups, ice cream and Chinese cold dishes were the high-risk foods for listeriosis (odds ratio (OR) 2.09 95% confidence interval (CI): 1.23-3.55; OR 3.17 95% CI: 1.29-7.81), respectively; consumption of leftovers and pet ownership were the high-risk food-handling habits (OR 1.92 95% CI: 1.03-3.59; OR 3.00 95% CI: 1.11-8.11), respectively. In both groups, separation of raw and cooked foods was a protective factor (OR 0.27 95% CI: 0.14-0.51; OR 0.35 95% CI: 0.14-0.89), while refrigerator cleaning reduced the infection risk by 64.94-70.41% only in the perinatal group. The identification of high-risk foods and food-handling habits for listeriosis is important for improving food safety guidelines for vulnerable populations.

Introduction:Vibrio parahaemolyticus (V. parahaemolyticus) is a common foodborne pathogen in coastal areas of China. Most epidemiological studies on V. parahaemolyticus have focused on foodborne disease outbreaks, with fewer studies based on long-term, continuous, and systematic sentinel surveillance. Methods:Data were collected from the national foodborne disease active surveillance program in 31 provincial-level administrative divisions (PLADs) in China from 2013 to 2022. V. parahaemolyticus-positive cases were collected for further analysis in this study. Results:From 2013 to 2022, the National Foodborne Disease Case Surveillance System identified 23,818 cases of V. parahaemolyticus foodborne infection in China. Patient ages ranged from 2 months to 100 years, with an average age of 38.41 years. These cases primarily occurred in coastal areas during summer. A new serotype, O10:K4, emerged in 2020 and has become the dominant serotype over O3:K6. Conclusions:V. parahaemolyticus infection is common in the eastern coastal areas of China and is strongly associated with aquatic food consumption. This study recommends that food regulatory authorities increase routine surveillance and inspection during high-risk periods and in high-risk areas. Authorities should also use social media platforms to conduct extensive public education campaigns on the prevention and control of V. parahaemolyticus-associated foodborne disease.

Objective To develop a theoretical grading method for foodborne disease risk assessment during major events in Beijing,using a major sports event as an example,and to provide references and experiences for foodborne disease risk assessment during other major events in China.Methods According to the World Health Organization's list of foodbome diseases,combined with the foodborne diseases monitored by the Beijing Foodborne Disease Surveillance System during the major sports event from 2016 to 2020(November to April of the following year)as risk factors,the risk levels of foodborne diseases in the key population and the general population of a major sports event in Beijing were evaluated using the risk matrix method and the Borda count method.Results A total of 25 foodborne disease risk factors were identified in 3 major categories and 7 subcategories.The risk levels of foodborne disease in both the key population and the general population were concentrated in the high risk(H),moderate risk(M),and low risk(L)levels.For the key population,there were 5 H-level risk factors(20％),11 M-level risk factors(44％),and 9 L-level risk factors(36％),of which rodenticides and tetrodotoxin poisoning were the most important risk factors.For the general population,there were 4 H-level risk factors(16％),6 M-level risk factors(24％),and 15 L-level risk factors(60％).Among them,norovirus and kidney bean poisoning were the most important risk factors.Conclusions Foodborne disease risk assessment for major events should be based on the characteristics of the event,previous experience with major events,and foodborne disease surveillance data from the same period.Prevention measures should focus on high and medium risk factors and those at the top of the Borda ordinal,and carry out monitoring and testing in the procurement,storage,processing and other links of raw materials,formulate recipes scientifically,do a good job in personnel health and training,and prevent cross-contamination.

Objective To provide scientific basis for the prevention and control of foodborne diseases among the geriatrics in China's Mainland,the epidemiological characteristics of foodborne diseases was understood.Methods Information on acute gastroenteritis cases aged ≥65 years in China's Foodborne Disease Case Surveillance System from 2018 to 2022 was collected and analyzed.Results The overall prevelance of foodborne disease monitoring pathogens among the geriatrics in China was 9.15％(7 218/78 904,95％CI:8.95％,9.35％,with Salmonella spp.being the highest(4.90％,3 860/78 699,95％CI:4.75％,5.06％),Norovirus(2.07％,1 517/73 173,95％CI:1.97％,2.18％),Diarrheogenic E.coli(1.39％,1 015/72 763,95％CI:1.31％,1.48％),Vibrio parahaemolyticus(1.00％,782/78386,95％CI:0.93％,1.07％)and Shigella spp.(0.19％,147/78 611,95％CI:0.16％,0.22％).The prevelance of Salmonella spp.in male elderly was higher than that in female,while the prevelance of Vibrio parahaemolyticus in female was higher than that in male.The higher the age,the lower the prevelance was.Geriatrics with foodborne diseases had obvious seasonality.The prevelances of Salmonella spp.,Shigella spp.,Vibrio parahaemolyticus and diarrheogenic E.coli reach their peak in July and August,while Norovirus reaches its peak in February and March.The overall prevelance varies across different regions of the country,and the differences are statistically significant(x2=546.85,P＜0.001).The categories of suspicious exposed foods mainly include meat and meat products,grains and its products,vegetables and its products,etc,with households being the main place of consumption.Conclusion Salmonella spp.has the highest prevelance in active surveillance of acute gastroenteritis among the geriatrics in China's Mainland.The epidemiological characteristics of surveilled pathogens vary in different gender,age and regions,taking targeted measures should be formulated based on the corresponding distribution of characteristics to prevent foodborne diseases in geriatrics.

The genus Arcobacter has been associated with illnesses in both animals and humans, where Arcobacter butzleri, Arcobacter cryaerophilus, and Arcobacter skirrowii have been linked to numerous cases of gastrointestinal diseases in humans. While isolated instances of Arcobacter infection have been reported in certain areas, comprehensive data reflecting the global impact of Arcobacter infection are lacking. This meta-analysis was conducted with the objective of assessing the aggregated prevalence of Arcobacter across diverse sources on a global scale. We conducted a thorough literature search of the Scopus, PubMed, and ScienceDirect databases to identify studies published from 1992 to 2022 on Arcobacter prevalence in humans and food-producing animals. We utilized multilevel random effects meta-analysis models to gauge the average occurrence of Arcobacter and to examine various factors that could influence incidence outcomes. Seventy-five articles were included in the meta-analysis. The pooled prevalence of Arcobacter spp. from different sources was 21.9

What is already known about this topic? Foodborne diseases, representing significant food safety and public health challenges globally, are not well- documented in terms of incidence, particularly for cases characterized by acute gastroenteritis (AGI) in China. What is added by this report? This study developed a pyramid model to estimate the incidence of five pathogens, stratified by gender and age. The estimated incidences per 100,000 people with 95% % uncertainty intervals (UI) UI ) are as follows: Norovirus, 3,188.28 (95% % UI : 2,518.03, 7,296.96); Salmonella spp., 1,295.59 (95% % UI : 1,002.62, 1,573.11); diarrheagenic E. coli (DEC), 782.62 (95% % UI : 651.19, 932.05); Vibrio parahaemolyticus , , 404.06 (95% % UI : 342.19, 468.93); and Shigella spp., 26.73 (95% % UI : 21.05, 33.46). What are the implications for public health practice? This study elucidates the incidence rates across various gender and age groups, thereby identifying priority populations for targeted preventive interventions aimed at reducing disease burden. These insights are crucial for the development of public health policies and management of food safety risks.