82% reported using THC-containing products; 33% reported exclusive use of THC-containing products. Consider posting reminders or signage (poster for clinical settings available in. Healthcare providers should assure patients have social support and access to mental health and substance use disorder services. In published reports primarily including hospitalized patients, most patients with EVALI who received corticosteroids had rapid improvement; dosages have been previously described. This resource is intended for adults who educate or serve youth ages 11 – 18 (teachers, youth ministers, coaches, scout leaders, … Some patients who have not received corticosteroids have also had clinical improvement with cessation of e-cigarette, or vaping, product use, and comparative studies have not been conducted. Vitamin E acetate is strongly linked to the EVALI outbreak. CDC will continue to update guidance related to EVALI as appropriate. CDC, the U.S. Food and Drug Administration (FDA), state and local health departments, and other clinical and public health partners are investigating a national outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI). In August 2019, CDC started collecting data from states on EVALI cases using a standardized case report form. Influenza testing should be strongly considered, particularly during influenza season. You will be subject to the destination website's privacy policy when you follow the link. If you have questions about CDC’s investigation into the lung injuries associated with use of e-cigarette, or vaping, products, contact CDC-INFO or call 1-800-232-4636. 57% reported using nicotine-containing products; 14% reported exclusive use of nicotine-containing products. If product use is confirmed, the types of substances used (e.g., THC, nicotine) and where they were obtained should be ascertained. They are all evidence based and have been validated as effective tools. Interim guidance for healthcare providers for managing patients with suspected EVALI can be found here, and is summarized in a management algorithmpdf icon and discharge readiness checklistpdf icon. Medication reconciliation and patient counseling should be provided by the inpatient pharmacist to help ensure medication adherence. MYTH -Vaping is a healthy alternative to cigarettes.. Resuming use of e-cigarette, or vaping, products during recovery from EVALI has the potential to cause slowed recovery, recurrence of symptoms, or further lung injury. Healthcare providers should evaluate for causes of community-acquired pneumonia according to established guidelines as indicated by imaging findings. Centers for Disease Control and Prevention. To explain, the CDC vaping study assessed the air in a closed vape shop environment with normal habits of consistent usage throughout an eight-hour workday. For those who have experienced chain vaping, or repetitive usage in a short period of time, you may notice that there is an increase in heat when you do not allow your equipment to cool down. If EVALI is suspected, health care providers should ask about the use of e-cigarette, or vaping, products in a confidential and nonjudgmental manner. 6% reported acquiring products from both commercial and informal sources. Reasons for the decline are likely multifactorial and may be related to the following: Increased public awareness of the risk associated with THC-containing e-cigarette, or vaping, product use as a result of the rapid public health response. If you have questions about CDC’s investigation into the lung injuries associated with use of e-cigarette, or vaping, products, contact CDC-INFO or call 1-800-232-4636. Some patients with history of e-cigarette, or vaping, product use who are evaluated for respiratory, gastrointestinal, or constitutional symptoms might be candidates for outpatient management. Quitlines and Other Cessation Support Resources, About Electronic Cigarettes (E-Cigarettes), Quick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults, Outbreak of Lung Injury Associated with E-cigarette Use, or Vaping, Tobacco Ingredient and Nicotine Reporting, Government Departments, Agencies, and Resources, American Indians/Alaska Natives and Tobacco Use, Asian Americans, Native Hawaiians, or Pacific Islanders and Tobacco Use, Lesbian, Gay, Bisexual, and Transgender Persons and Tobacco Use, Cigarette Smoking and Tobacco Use Among People of Low Socioeconomic Status, Tobacco Use and Quitting Among Individuals With Behavioral Health Conditions, What We Know: Tobacco Use and Quitting Among Individuals With Behavioral Health Conditions, Promising Policies And Practices To Address Tobacco Use By Persons With Mental And Substance Use Disorders, New York Implements Tobacco-Free Campus Policies, Grant Funding in Oklahoma Changes Systems for Accessing and Addressing Tobacco Use, Provider Training Results in Hawaii Behavioral Health Facilities Providing Counseling to Help Clients Quit, Texas Provides NRT as Part of a Range of Tobacco Cessation Measures in Mental Health Treatment Settings, New York and Oklahoma Make it Easier for Persons with Behavior Health Conditions to Access Non-Nicotine Cessation Medications, Alaska Native Adult Tobacco Survey Guidance Manual, Morbidity and Mortality Weekly Reports (MMWR), Surgeon General's Reports on Smoking and Tobacco Use, 2016 SGR—E-Cigarette Use Among Youth and Young Adults, Best Practices for Comprehensive Tobacco Control Programs, U.S. Department of Health & Human Services. The follow-up evaluation should include: clinical assessment to confirm that the patient’s respiratory status is stable; ongoing education about EVALI; ensuring adherence with medication regimens such as tapering of corticosteroids (if prescribed at the time of hospital discharge); reinforcing the importance of abstinence from e-cigarette, or vaping, product use; facilitating connection to outpatient care by all providers or services indicated by patients’ medical history or conditions; connecting patients to needed social, mental health, and substance use disorder resources; and establishing connections to necessary services. Centers for Disease Control and Prevention’s Vaping Visual Dictionary. National ED data and active case reporting from state health departments around the country show a sharp rise in symptoms or cases of EVALI in August 2019, a peak in September 2019, and a gradual, but persistent decline since then. Longer-term pulmonary follow-up should generally occur within 2–4 weeks after discharge (often at completion of the corticosteroid taper) to assess pulmonary function and resolution of radiographic findings. CHRISTOPHER M. JONES PHARMD, DRPH, MPH INCIDENT MANAGER CDC 2019 LUNG INJURY RESPONSE. CDC encourages clinicians to continue to report possible cases of EVALI to their local or state health department for further investigation. CDC will continue to provide assistance to states, as needed, related to EVALI and will provide any updates at: CDC and FDA recommend that people not use THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online dealers. Who are the adults vaping? Quitlines and Other Cessation Support Resources, About Electronic Cigarettes (E-Cigarettes), Quick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults, Outbreak of Lung Injury Associated with E-cigarette Use, or Vaping, Tobacco Ingredient and Nicotine Reporting, Government Departments, Agencies, and Resources, American Indians/Alaska Natives and Tobacco Use, Asian Americans, Native Hawaiians, or Pacific Islanders and Tobacco Use, Lesbian, Gay, Bisexual, and Transgender Persons and Tobacco Use, Cigarette Smoking and Tobacco Use Among People of Low Socioeconomic Status, Tobacco Use and Quitting Among Individuals With Behavioral Health Conditions, What We Know: Tobacco Use and Quitting Among Individuals With Behavioral Health Conditions, Promising Policies And Practices To Address Tobacco Use By Persons With Mental And Substance Use Disorders, New York Implements Tobacco-Free Campus Policies, Grant Funding in Oklahoma Changes Systems for Accessing and Addressing Tobacco Use, Provider Training Results in Hawaii Behavioral Health Facilities Providing Counseling to Help Clients Quit, Texas Provides NRT as Part of a Range of Tobacco Cessation Measures in Mental Health Treatment Settings, New York and Oklahoma Make it Easier for Persons with Behavior Health Conditions to Access Non-Nicotine Cessation Medications, Alaska Native Adult Tobacco Survey Guidance Manual, Morbidity and Mortality Weekly Reports (MMWR), Surgeon General's Reports on Smoking and Tobacco Use, 2016 SGR—E-Cigarette Use Among Youth and Young Adults, Best Practices for Comprehensive Tobacco Control Programs, U.S. Department of Health & Human Services. CDC encourages clinicians to continue to report possible cases of e-cigarette, or vaping, product use-associated lung injury (EVALI) to their local or state health department for further investigation. Use of corticosteroids for the treatment of EVALI in the outpatient setting has not been well studied and should be considered with caution. The median age of patients was 24 years and ranged from 13–85 years. It might be difficult to differentiate EVALI, a diagnosis of exclusion, from influenza or community-acquired pneumonia on initial assessment, and EVALI might co-occur with respiratory infections. Saving Lives, Protecting People, If you have questions about CDC’s investigation into the lung injuries associated with use of e-cigarette, or vaping, products, contact, Key Facts about E-Cigarette Use, or Vaping, Epi Chart of Reported Hospital Admissions, Emergency department (ED) visits related to e-cigarette, or vaping, products, FDA-approved smoking cessation medications, National Center for Chronic Disease Prevention and Health Promotion, National Tobacco Control Programs in Action, Interagency Committee on Smoking and Health, Cessation Materials for State Tobacco Control Programs, Chronic Obstructive Pulmonary Disease (COPD). The US Centers for Disease Control and Prevention is now aware of 153 possible cases of severe lung disease in 16 states that could be caused by vaping… FACT - Vape e-juice may contain nicotine, chemicals that cause cancer, and can lead to health problems including wheezing, coughing, sinus infections, nosebleeds, shortness of breath and asthma.. Healthcare providers should also advise patients with a history of EVALI to return as soon as possible if they develop new or worsening respiratory symptoms, with or without fever, for early evaluation with influenza testing and early initiation of antiviral or antibiotic treatment, as indicated. (United States Surgeon General, 2019) The Centers for Disease Control and Prevention (CDC), the Office of the Surgeon General, and the National Institutes of Health (NIH) recognize this rapid increase in adolescents using nicotine via a vape device, and have independently concluded the use of these devices has reversed all or much of the progress that has previously been made to decrease the … Removal of vitamin E acetate from some products. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. National and state data from patient reports and product sample testing show tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online dealers, are linked to most EVALI cases and play a major role in the outbreak. Hospitalized patients should be documented as clinically stable for 24-48 hours prior to discharge and have close post-discharge follow-up (optimally within 48 hours of discharge) as outlined in this interim guidance. National Center for Chronic Disease Prevention and Health Promotion. E-CIGARETTES, OR VAPING, PRODUCT USE ASSOCIATED LUNG INJURY (EVALI): EPIDEMIOLOGY AND POLICY UPDATE Inside CDC's Vaping Investigation : Shots - Health News Given the scope and the mysterious nature of vaping-related illness, the Centers for Disease Control and Prevention set … Vaping’s popularity has grown exponentially since its introduction to the US market in 2003. Equality in Smoking & Disease: Nobody Wins! Alabama, California (4), Connecticut, Delaware, District of Columbia, Florida (2), Georgia (6), Illinois (5), Indiana (6), Kansas (2), Kentucky, Louisiana (2), Massachusetts (5), Michigan (3), Minnesota (3), Mississippi, Missouri (2), Montana, Nebraska, New Jersey, New York (4), Oregon (2), Pennsylvania, Rhode Island, South Carolina, Tennessee (2), Texas (4), Utah, Virginia and Washington (2). A chest radiograph (CXR) should be considered for patients with a history of e-cigarette, or vaping, product use, who have respiratory or gastrointestinal symptoms, particularly when chest pain, dyspnea, or decreased oxygen saturation (<95% while breathing room air) are present. 78% reported acquiring products only from informal sources (family/friends, dealers, online, or other sources). 50% of EVALI patients who reported using THC-containing products provided data on product source. MYTH - Vaping has nothing to do with smoking regular cigarettes.. CDC: “About Electronic Cigarettes (E-Cigarettes),” "Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping." Adults using nicotine-containing e-cigarette, or vaping, products as an alternative to cigarettes should not go back to smoking; they should weigh all available information and consider using. Vitamin E acetate was identified in bronchoalveolar lavage (BAL) fluid samples (fluid samples collected from the lungs) from 48 of the 51 EVALI patients, but not in the BAL fluid from the healthy comparison group. The median age of deceased patients was 49.5 years and ranged from 15-75 years, Among the 2,668 hospitalized EVALI cases or deaths reported to CDC (. Learn best practices for the patient interview with. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. Hospital admission should be strongly considered for patients with concurrent illness such as influenza and potential EVALI, especially if respiratory distress, comorbidities that compromise pulmonary reserve, or decreased oxygen saturation (<95% while breathing room air) are present. Candidates for outpatient management should have normal oxygen saturation (≥95% while breathing room air), no respiratory distress, no comorbidities that might compromise pulmonary reserve, reliable access to care, strong social support systems, and should be able to ensure follow up within 24–48 hours of initial evaluation and to seek medical care promptly if respiratory symptoms worsen; in some cases, patients who initially had mild symptoms experienced a rapid worsening of symptoms within 48 hours. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. However, CDC continues to monitor EVALI-related trends using emergency department data from the National Syndromic Surveillance Program’s BioSense/ESSENCE platform. The data were voluntarily collected and submitted by each state to CDC on a routine basis. Evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC or non-THC products, in some of the reported EVALI cases. Healthcare providers should confirm patients have a follow-up appointment with a primary care provider or pulmonology specialist, optimally within 48 hours of discharge. • E‐cigarettes are used primarily by •current smokers (63%) •former smokers (24%), most of whom had quit in the past 4 years • e‐cigarette users are more likely to be: •Younger •Better educated •Higher income •Both genders •Dual users They are all evidence based and have been validated as effective tools. The National Institute for Occupational Safety and Health (NIOSH) issued the report — titled “Evaluation of Chemical Exposures at a Vape Shop” — in July, but the testing took place in January of 2016. The best way to avoid potentially harmful effects is to not use THC-containing e-cigarette, or vaping, products. To receive email updates about Smoking & Tobacco Use, enter your email address: Discontinue E-cigarette, or Vaping, Product Use, Centers for Disease Control and Prevention. Treatment with empiric antimicrobials, including antivirals, should be considered in accordance with established guidelines and local microbiology and resistance patterns for community-acquired pneumonia. Its use has sky-rocketed since the unveiling of the vaping pods in 2017 which may account for the advent of the vaping related illnesses we are now seeing. You will be subject to the destination website's privacy policy when you follow the link. Vitamin E acetate is used as an additive, most notably in THC-containing e-cigarette, or vaping, products. As of February 18, 2020, a total of 2,807 hospitalized EVALI cases or deaths have been reported to CDC from all 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands). Emergency department (ED) visits related to e-cigarette, or vaping, products … Antiviral treatment also can be considered for any previously healthy, symptomatic outpatient not at high risk for influenza complications, who is diagnosed with confirmed or suspected influenza, on the basis of clinical judgment, if treatment can be initiated within 48 hours of illness onset. Managed and funded by the Centers for Disease Control (CDC) Established in 2001, under the Division of Population Health Mission: To solidify the scientific foundation for preventing excessive alcohol use. Evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC or non-THC products, in some of the reported EVALI cases. If EVALI is suspected, health care providers should ask about the use of e-cigarette, or vaping, products in a confidential and nonjudgmental manner. Vitamin E is a vitamin found in many foods, including vegetable oils, cereals, meat, fruits, and vegetables. Healthcare providers should emphasize the importance of, It is not known whether patients with EVALI are at higher risk for severe complications of influenza or other respiratory infections. To receive email updates about Smoking & Tobacco Use, enter your email address: Key Facts about Use of E-Cigarette, or Vaping, Products, Number of Hospitalized EVALI Cases or Deaths Reported to CDC as of February 18, 2020, Dates of symptom onset and hospital admission for patients with lung injury associated with e-cigarette use, or vaping — United States, March 31, 2019–February 15, 2020, Centers for Disease Control and Prevention. Persons engaging in ongoing cannabis use that leads to significant impairment or distress should seek evidence-based treatment by a healthcare professional. Prevalence of “ever Vape” is 25% for high school students - 30% of 12th graders reporting ever vaped from 2015 data. Ask about recent use of e-cigarette, or vaping, products in a confidential and nonjudgmental manner. CDC’s Office on Smoking and Health (OSH) developed this presentation to educate youth on e-cigarettes, including the health risks, the factors that lead to e-cigarette use, and what youth can do to avoid all tobacco products, including e-cigarettes. THC is the psychoactive mind-altering compound of marijuana that produces the “high.”. Some e-cigarette labels do not disclose that they contain nicotine, and some e-cigarettes marketed as containing 0% nicotine have been found to contain nicotine. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. If product use is confirmed, ask about the types of substances used (e.g., [tetrahydrocannabinol] THC and nicotine) and where they were obtained. E-cigarettes work by heating a liquid to produce an aerosol that users inhale into their lungs. Use of vaping (as with other substances) increases dramatically between grade 6 and higher grades suggesting key opportunity for intervention. Electronic cigarettes, eliquid brands and generally speaking, vaping, have set off a firestorm of controversy. Three criteria define EVALI: e-cigarette use or vaping within 90 days from symptom onset, abnormalities on chest imaging and the exclusion of other potential sources of injury like infection. E-cigarette, or vaping, products (nicotine- or THC-containing) should never be used by youths, young adults, or women who are pregnant. It is also available as a dietary supplement and in many cosmetic products, like skin creams. Vitamin E acetate is strongly linked to the EVALI outbreak. The most critical step in assessing EVALI is to ask patients about recent use of e-cigarette, or vaping, products. Vitamin E acetate has been found in product samples tested by FDA and state laboratories and in patient lung fluid samples tested by CDC from geographically diverse states. During 2019, the Centers for Disease Control and Prevention (CDC) worked with the Food and Drug Administration (FDA), state health departments, and public health and clinical partners to investigate the multistate outbreak of E-cigarette, or Vaping, product use Associated Lung Injury (EVALI). Saving Lives, Protecting People, If you have questions about CDC’s investigation into the lung injuries associated with use of e-cigarette, or vaping, products, contact, Emergency department (ED) visits related to e-cigarette, or vaping, products, FDA-approved smoking cessation medications, Additional Resources for Healthcare Providers, National Center for Chronic Disease Prevention and Health Promotion, National Tobacco Control Programs in Action, Interagency Committee on Smoking and Health, Cessation Materials for State Tobacco Control Programs, Chronic Obstructive Pulmonary Disease (COPD). National and state data from patient reports and product sample testing show tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online dealers, are linked to most EVALI cases and play a major role in the outbreak. For More Information Schools Against Vaping recommends free legal analysis by NAPOLILAW.COM The CDC & VapingJUUL Class Action LawsuitVape VerdictVaping Fact SheetNegative Impacts of VapingThe Vape Complaint – Los […] FACT - Young people who took up vaping were more than four times more likely … INTRODUCTION: Recently, the CDC has started to recognize the emerging problem of electronic vaping associated lung injury (EVALI) with the first case described in August 2019. For more information and resources for key stakeholders, visit For Healthcare Providers and For State and Local Health Departments. In addition, administration of pneumococcal vaccine should be considered for patients with a history of EVALI according to. However, previous research suggests that when vitamin E acetate is inhaled, it may interfere with normal lung functioning. A recent CDC study found that 99% of the e-cigarettes sold in assessed venues in the United States contained nicotine. EVALI remains a diagnosis of exclusion because, at present, no specific test or marker exists for its diagnosis, and evaluation should be guided by clinical judgment. Vitamin E acetate usually does not cause harm when ingested as a vitamin supplement or applied to the skin. The liquid can contain: nicotine, tetrahydrocannabinol (THC) and cannabinoid (CBD) oils, and other substances, flavorings, and additives. EVALI (e-cigarette, or vaping, product use associated lung injury) ● As of November 20, 2019, 2,290 cases of EVALI have been reported to CDC (Centers for Disease Control and Prevention) ● Forty-seven deaths have been confirmed ● Most patients have reported a history of using products containing THC, the psychoactive compound in cannabis. Patients who have experienced prolonged immobilization during hospitalization (particularly those with intensive care unit-related deconditioning and muscle atrophy) might benefit from physical therapy. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Ongoing engagement with addiction medicine and mental health services should be considered as indicated. Last year, the Centers for Disease Control and Prevention (CDC) received its first report on an illness known as electronic cigarette or vaping product use-associated lung injury (EVALI). How do I decide which curriculum will work best for my school?These are just of few of the many evidence-based vape prevention curricula available. may be abbreviated as e-cigs or vapes, and refer to any device similar to an e-cigarette. CDC encourages clinicians to continue to report possible cases of e-cigarette, or vaping, product use-associated lung injury (EVALI) to their local or state health department for further investigation. CDC will continue to update guidance related to EVALI as appropriate. CDC and FDA recommend that people not use THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, or family, or in-person or online dealers. General resources are also available. Equality in Smoking & Disease: Nobody Wins! Patients discharged from the hospital after inpatient treatment for EVALI should have a follow-up visit with a primary care provider or pulmonology specialist, optimally within 48 hours. Influenza cannot be distinguished from EVALI by signs, symptoms, clinical features at presentation (medical examination), or testing. Vitamin E acetate has not been found in the lung fluid of people that do not have EVALI. 69% reported acquiring products only from commercial sources. This module provides an understanding of the inner workings of e-cigarettes, the content of the aerosols they produce, and thirdhand smoke. On September 16, 2019, CDC activated the Emergency Operations Center. Vape Facts : CDC Data Exposes The Truth Vape facts are hard to come by in this day and age. CDC twenty four seven. Below you will find links to evidence based curriculum for your school. •E-cigarettes and vapes are the most common tobacco product used by teens • Often leads to use of other tobacco products, or even marijuana • According to the CDC, nearly 9 out of 10 adult smokers began smoking before the age of 18 • E-cigarettes and vapes are sold everywhere • Be aware, know what to look for, know the language, and educate others ICD-10-CM coding guidancepdf icon for healthcare encounters related to EVALI are also available. A new report by a U.S. government agency says that their tests showed that levels of “vaping-related chemicals” in the air of a vape shop were all below workplace safety limits.. Centers for Disease Control and Prevention 9 Updated Guidance for Health Care Providers Regarding the Management Approach of Patients with Suspected E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) Mary E. Evans, MD, MPH Timothy M. … These data do not suggest a resurgence of EVALI at this time. The CDC has recently released new studies on vaping, and the data proves to be rather positive. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. View curriculum CDC twenty four seven. ... PowerPoint Presentation Last modified by: Using an e-cigarette is commonly called vaping. More health and medical news on the Mayo Clinic News Network. Rapid recognition of EVALI patients by healthcare providers is critical to reduce severe outcomes. 16% reported acquiring products only from commercial sources (recreational and/or medical dispensaries, vape or smoke shops, stores, and pop-up shops). 15% reported acquiring products from both commercial and informal sources. Vitamin E acetate has not been found in the lung fluid of people that do not have EVALI. Persons engaging in ongoing cannabis use that leads to significant impairment or distress should seek evidence-based treatment from a healthcare professional. The real cause of lung illness has seemingly been … Adults using nicotine-containing e-cigarette, or vaping, products as an alternative to cigarettes should not go back to smoking; they should weigh all available information and consider using. Adults who do not currently use tobacco products should not start using e-cigarette, or vaping, products. Sixty-eight deaths have been confirmed in 29 states and the District of Columbia (as of February 18, 2020). PRESENTED ON: October 18-21, 2020. This 25-page CDC presentation identifies and defines various types of vape devices, pods, and e-liquid ingredients, and explains vaping terminology and much more. Were voluntarily collected and submitted by each state to CDC on a routine basis 2020! Policy when you follow the link, people should not be added any! Considered for patients with a primary care provider or pulmonology specialist, optimally within 48 of... Resources for key stakeholders, visit for healthcare encounters related to EVALI as appropriate however, continues! May interfere with normal lung functioning persons engaging in ongoing cannabis use that leads significant! A resurgence of EVALI in the outpatient setting has not been found in many cosmetic products, like skin.... ; 14 % reported acquiring products only from informal sources many foods, including products through... 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