SARS-CoV-2 infection in meat and poultry workers after the “first wave” (Summer 2020): a cross-sectional study on knowledge, attitudes, practices (KAP) of Italian occupational physicians
SARS-CoV-2 infection in meat and poultry workers
Keywords:
SARS-CoV-2, COVID-19, Poultry, Meat-Packing, Health knowledge, Attitudes, PracticesAbstract
Background and aim: This cross-sectional study assessed knowledge, attitudes and practices (KAP) of Italian Occupational Physicians (OPs) on Coronavirus disease 2019 (COVID-19) among meat/poultry processing plant workers (MPWs) (Summer season 2020).
Methods: Data were collected through an online questionnaire including demographic characteristics, and items about COVID-19-related KAP in MPWs. A logistic regression was modelled in order to characterize explanatory variables of the outcome variable of having any professional experience as OP in meat/poultry processing industry.
Results: A total of 424 OPs (mean age 49.0 ± 9.1years; 49.5% males) participated into the survey. Despite a generally good level of knowledge on SARS-CoV-2 pandemic, OPs having professional experience with MPWs failed to recognize any increased risk for COVID-19 (Odds Ratio [OR] 0.162; 95% Confidence intervals [95%CI] 0.039-0.670), and were less likely to recommend periodical tests via nasal swabs (OR 0.168, 95%CI 0.047-0.605). On the contrary, they identified socioeconomic status of MPWs as a risk factor (OR 5.686, 95%CI 1.413-22.881), recommending cleaning interventions on changing rooms and canteens (OR 16.090, 95%CI 1.099-259.244).
Conclusions: In conclusion, we reported a diffuse underestimation of the risk for COVID-19, that was alarmingly higher among professionals who should be more familiar with the specific requirements of MPWs. Some significant knowledge gaps were also clearly identified, stressing the opportunity for tailored educative interventions (www.actabiomedica.it)
References
You Y, Leahy K, Resnick C, Howard T, Carroll KC, Silbergeld EK. Exposure to pathogens among workers in a poultry slaughter and processing plant. American Journal of Industrial Medicine. 2016;59(6): 453–464. https://doi.org/10.1002/ajim.22594.
Dreyfus A, Heuer C, Wilson P, Collins-Emerson J, Baker MG, Benschop J. Risk of infection and associated influenza-like disease among abattoir workers due to two Leptospira species. Epidemiology and Infection. 2015;143(10): 2095–2105. https://doi.org/10.1017/S0950268814002477.
Dreyfus A, Wilson P, Collins-Emerson J, Benschop J, Moore S, Heuer C. Risk factors for new infection with Leptospira in meat workers in New Zealand. Occupational and Environmental Medicine. 2015;72(3): 219–225. https://doi.org/10.1136/oemed-2014-102457.
Woldeyohannes SM, Gilks CF, Baker P, Perkins NR, Reid SA. Seroprevlance of Coxiella burnetii among abattoir and slaughterhouse workers: A meta-analysis. One Health. 2018;6(October): 23–28. https://doi.org/10.1016/j.onehlt.2018.09.002.
Donaghy M, Prempeh H, Macdonald N. Outbreak of Q fever in workers at a meat processing plant in Scotland, July 2006. Euro surveillance. 2006;11(8): 10–12. https://doi.org/10.2807/esw.11.34.03031-en.
Wallach JC, García JL, Cardinali PS, Seijo AP, Benchetrit AG, Echazarreta SE, et al. High Incidence of Respiratory Involvement in a Cluster of Brucella suis-Infected Workers from a Pork Processing Plant in Argentina. Zoonoses and Public Health. 2017;64(7): 550–553. https://doi.org/10.1111/zph.12339.
Abdissa R, Haile W, Fite AT, Beyi AF, Agga GE, Edao BM, et al. Prevalence of Escherichia coli O157: H7 in beef cattle at slaughter and beef carcasses at retail shops in Ethiopia. BMC Infectious Diseases. 2017;17(1): 1–6. https://doi.org/10.1186/s12879-017-2372-2.
Dahms C, Hubner NO, Kossow A, Mellmann A, Dittmann K, Kramer A. Occurrence of ESBL-producing Escherichia coli in livestock and farm workers in Mecklenburg-Western Pomerania, Germany. PLoS ONE. 2015;10(11): 1–13. https://doi.org/10.1371/journal.pone.0143326.
Tahir MF, Abbas MA, Ghafoor T, Dil S, Shahid MA, Bullo MMH, et al. Seroprevalence and risk factors of avian influenza H9 virus among poultry professionals in Rawalpindi, Pakistan. Journal of Infection and Public Health. 2019;12(4): 482–485. https://doi.org/10.1016/j.jiph.2018.11.009.
Heidari A, Mancin M, Nili H, Pourghanbari GH, Lankarani KB, Leardini S, et al. Serological evidence of H9N2 avian influenza virus exposure among poultry workers from Fars province of Iran. Virology Journal. 2016;13(1): 1–9. https://doi.org/10.1186/s12985-016-0472-z.
Ma MJ, Zhao T, Chen SH, Xia X, Yang XX, Wang GL, et al. Avian influenza a virus infection among workers at live poultry markets, china, 2013–2016. Emerging Infectious Diseases. 2018;24(7): 1246–1256. https://doi.org/10.3201/eid2407.172059.
Osoro EM, Lidechi S, Marwanga D, Nyaundi J, Mwatondo A, Muturi M, et al. Seroprevalence of influenza A virus in pigs and low risk of acute respiratory illness among pig workers in Kenya. Environmental Health and Preventive Medicine. 2019;24(1): 1–9. https://doi.org/10.1186/s12199-019-0808-6.
Puzelli S, Rizzo C, Fabiani C, Facchini M, Gaibani P, Landini MP, et al. Influenza a(H7N7) virus among poultry workers, Italy, 2013. Emerging Infectious Diseases. 2016;22(8): 1512–1513. https://doi.org/10.3201/eid2208.160246.
Petersen E, Koopmans M, Go U, Hamer DH, Petrosillo N, Castelli F, et al. Comparing SARS-CoV-2 with SARS-CoV and influenza pandemics. Lancet. 2020; S1473-3099(20)30484-9.
Hirotsu Y, Maejima M, Shibusawa M, Nagakubo Y, Hosaka K, Amemiya K, et al. Pooling RT-PCR test of SARS-CoV-2 for large cohort of ‘healthy’ and infection-suspected patients: A prospective and consecutive study on 1,000 individuals. medRxiv. 2020; 2020.05.04.20088146. https://doi.org/10.1101/2020.05.04.20088146.
Quan C, Wang Q, Zhang J, Zhao M, Dai Q, Huang T, et al. Avian influenza A viruses among occupationally exposed populations, China, 2014-2016. Emerging Infectious Diseases. 2019;25(12): 2215–2225. https://doi.org/10.3201/eid2512.190261.
Dyal JW, Grant MiP, Broadwater K, Bjork A, Waltenburg MA, Gibbins JD, et al. COVID-19 among workers in meat and poultry processing facilities, April 2020. MMWR: Morbidity & Mortality Weekly Report. 2020;69(18): e3. https://doi.org/10.15585/mmwr.mm6918e3.
Middleton J, Reintjes R, Lopes H. Meat plants — a new front line in the covid-19 pandemic. British Medical Journal. 2020;370: m2716. https://doi.org/10.1136/bmj.m2716.
Donahue M, Sreenivasan N, Stover D, Rajasingham A, Watson J, Bealle A, et al. Notes from the Field: Characteristics of Meat Processing Facility Workers with Confirmed SARS-CoV-2 Infection - Nebraska, April-May 2020. MMWR. Morbidity and mortality weekly report. 2020;69(31): 1020–1022. https://doi.org/10.15585/mmwr.mm6931a3.
Steinberg J, Kennedy ED, Basler C, Grant MP, Jacobs JR, Ortbahn D, et al. COVID-19 Outbreak Among Employees at a Meat Processing Facility - South Dakota, March-April 2020. MMWR. Morbidity and mortality weekly report. 2020;69(31): 1015–1019. https://doi.org/10.15585/mmwr.mm6931a2.
Odone A, Delmonte D, Scognamiglio T, Signorelli C. COVID-19 deaths in Lombardy, Italy: data in context. Lancet Public Health. 2020; S2468-2667(20)30099-2. https://doi.org/10.1016/ S2468-2667(20)30099-2.
Barcaccia G, D’Agostino V, Zotti A, Cozzi B. Impact of the SARS-CoV-2 on the Italian agri-food sector: An analysis of the quarter of pandemic lockdown and clues for a socio-economic and territorial restart. Sustainability (Switzerland). 2020;12(14). https://doi.org/10.3390/su12145651.
Distante C, Piscitelli P, Miani A. Covid-19 outbreak progression in italian regions: Approaching the peak by the end of march in northern Italy and first week of april in southern Italy. International Journal of Environmental Research and Public Health. 2020;17(9). https://doi.org/10.3390/ijerph17093025.
Romagnani P, Gnone G, Guzzi F, Negrini S, Guastalla A, Annunziato F, et al. The COVID-19 infection: lessons from the Italian experience. Journal of Public Health Policy. 2020;(0123456789). https://doi.org/10.1057/s41271-020-00229-y.
Garzillo EM, Monaco MGL, Spacone A, Inglese E, Lamberti M, Pompei D. SARS-CoV-2 emergency in the workplace: are companies ready to protect their workers? A cross-sectional survey. International journal of occupational safety and ergonomics : JOSE. 2020;0(0): 1–20. https://doi.org/10.1080/10803548.2020.1810457.
Parks CA, Nugent NB, Fleischhacker SE, Yaroch AL. Food System Workers are the Unexpected but Under Protected COVID Heroes. The Journal of nutrition. 2020;150(8): 2006–2008. https://doi.org/10.1093/jn/nxaa173.
Marinaccio A, Boccuni F, Rondinone BM, Brusco A, D’Amario S, Iavicoli S. Occupational factors in the COVID-19 pandemic in Italy: compensation claims applications support establishing an occupational surveillance system. Occupational and Environmental Medicine. 2020;77(12): 818–821. https://doi.org/10.1136/oemed-2020-106844.
de Natale G, de Natale L, Troise C, Marchitelli V, Coviello A, Holmberg KG, et al. The evolution of COVID-19 in Italy after the spring of 2020: An unpredicted summer respite followed by a second wave. medRxiv. 2020; https://doi.org/10.1101/2020.08.29.20184127.
de Nadai M, Roomp K, Lepri B, Oliver N. The impact of control and mitigation strategies during the second wave of coronavirus infections in Spain and Italy. Scientific Reports. 2022;12(1). https://doi.org/10.1038/s41598-022-05041-0.
Emilia Romagna Regional Government. REGIONE EMILIA-ROMAGNA No. 144 of July 13th, 2020. 2020.
Durando P, Dini G, Massa E, La Torre G. Tackling biological risk in the workplace: updates and prospects regarding vaccinations for subjects at risk of occupational exposure in Italy. Vaccines. 2019;7(4): 1–8. https://doi.org/10.3390/vaccines7040141.
Manzoli L, Sotgiu G, Magnavita N, Durando P, Barchitta M, Carducci A, et al. Evidence-based approach for continuous improvement of occupational health. Epidemiologia e Prevenzione. 2015;39(4S1): 81–85.
Riccò M, Cattani S, Casagranda F, Gualerzi G, Signorelli C. Knowledge, attitudes, beliefs and practices of occupational physicians towards vaccinations of health care workers: A cross sectional pilot study in North-Eastern Italy. International Journal of Occupational Medicine and Environmental Health. 2017;30(5): 775–790. https://doi.org/10.13075/ijomeh.1896.00895.
Betsch C, Wicker S. Personal attitudes and misconceptions, not official recommendations guide occupational physicians’ vaccination decisions. Vaccine. 2014;32(35): 4478–4484. https://doi.org/10.1016/j.vaccine.2014.06.046.
Riccò M, Ferraro P, Peruzzi S, Balzarini F, Ranzieri S. Mandate or Not Mandate: Knowledge, Attitudes, and Practices of Italian Occupational Physicians towards SARS-CoV-2 Immunization at the Beginning of Vaccination Campaign. Vaccines. 2021;9(8): 889. https://doi.org/10.3390/vaccines9080889.
Chirico F, Magnavita N. The Crucial Role of Occupational Health Surveillance for Health-care Workers During the COVID-19 Pandemic. Workplace Health and Safety. 2020;68(1): 5–6. https://doi.org/10.1177/2165079920950161.
Comar M, Brumat M, Concas MP, Argentini G, Bianco A, Bicego L, et al. COVID-19 experience: first Italian survey on healthcare staff members from a Mother-Child Research hospital using combined molecular and rapid immunoassays test. medRxiv. 2020; 2020.04.19.20071563. https://doi.org/10.1101/2020.04.19.20071563.
Riccò M, Ferraro P, Gualerzi G, Ranzieri S, Bragazzi NL, Balzarini F, et al. Point-of-Care diagnostic of SARS-CoV-2: knowledge, attitudes, and beliefs (KAP) of medical workforce in Italy. Acta Biomed. 2020;91(2): 0–000. https://doi.org/10.23750/abm.v91i2.9573.
Bragazzi NL, Riccò M, Pacifico A, Malagoli P, Khalaf Kridin |, Pigatto P, et al. COVID-19 knowledge prevents biologics discontinuation: Data from an Italian multicenter survey during RED-ZONE declaration. 2020; https://doi.org/10.1111/dth.13508.
Moro M, Vigezzi G Pietro, Capraro M, Biancardi A, Nizzero P, Signorelli C, et al. 2019-novel coronavirus survey: knowledge and attitudes of hospital staff of a large Italian teaching hospital. Acta bio-medica : Atenei Parmensis. 2020;91(3-S): 29–34. https://doi.org/10.23750/abm.v91i3-S.9419.
Porru S, Carta A, Monaco MGL, Verlato G, Battaggia A, Parpaiola M, et al. Health surveillance and response to sars-cov-2 mass testing in health workers of a large italian hospital in verona, veneto. International Journal of Environmental Research and Public Health. 2020;17(14): 1–11. https://doi.org/10.3390/ijerph17145104.
Motta Zanin G, Gentile E, Parisi A, Spasiano D. A Preliminary Evaluation of the Public Risk Perception Related to the COVID-19 Health Emergency in Italy. International Journal of Environmental Research and Public Health. 2020;17(9): 3024. https://doi.org/10.3390/ijerph17093024.
Riccò M, Vezzosi L, Cella C, Pecoraro M, Novembre G, Moreo A, et al. Tetanus vaccination status in construction workers: Results from an institutional surveillance campaign. Acta Biomedica. 2019;90(2): 269–278. https://doi.org/10.23750/abm.v90i2.6759.
Riccò M, Vezzosi L, Balzarini F, Bragazzi NL. Inappropriate risk perception for SARS-CoV-2 infection among italian HCWs in the eve of COVID-19 pandemic. Acta Biomedica. 2020;91(3): 1–2. https://doi.org/10.23750/abm.v91i3.9727.
Yates FJ, Stone ER. The Risk Construct. In: Yates FJ (ed.) Risk-Taking Behaviour. 1st Edition. Chichester, UK: John Wiley & Sons.; 1992. p. 1–25.
Article SC, Papagiannis D, Rachiotis G, Malli F, Papathanasiou I v, Kotsiou O, et al. Acceptability of Covid-19 Vaccination among Greek health. 2021;(December 2020): 1–9.
Waltenburg MA, Victoroff T, Rose CE, Butterfield M, Jervis RH, Fedak KM, et al. COVID-19 Among Workers in Meat and Poultry Processing Facilities — United States, April–May 2020. MMWR: Morbidity & Mortality Weekly Report. 2020;69(27): 888–892.
Yekta R, Vahid-dastjerdi L, Norouzbeigi S, Mortazavian AM. Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID- 19 . The COVID-19 resource centre is hosted on Elsevier Connect , the company ’ s public news and information . 2020;(January).
Groenewold MR, Burrer SL, Ahmed F, Uzicanin A, Free H, Luckhaupt SE. Increases in Health-Related Workplace Absenteeism Among Workers in Essential Critical Infrastructure Occupations During the COVID-19 Pandemic —. MMWR: Morbidity & Mortality Weekly Report. 2020;69(27): 854–858.
Sarwar A, Abdullah MI, Imran MK, Fatima T. When fear about health hurts performance: COVID-19 and its impact on employee’s work. Review of Managerial Science. 2022; https://doi.org/10.1007/s11846-022-00536-6.
Aguilar E, Roberts NJ, Uluturk I, Kaminski P, Barlow JW, Zori AG, et al. Adaptive staffing can mitigate essential worker disease and absenteeism in an emerging epidemic. PNAS. 2021;118(34): e2105337118. https://doi.org/10.1073/pnas.2105337118/-/DCSupplemental.y.
Waltenburg MA, Rose CE, Victoroff T, Butterfield M, Dillaha JA, Heinzerling A, et al. Coronavirus disease among workers in food processing, food manufacturing, and agriculture workplaces. Emerging Infectious Diseases. 2021;27(1): 243–249. https://doi.org/10.3201/eid2701.203821.
Gibbins JD, Hale C, Silver M, Fischer M, Steinberg J, Basler CA, et al. COVID-19 Among Workers in Meat and Poultry Processing Facilities —. Report, Mortality Weekly. 2020;69(18): 557–561.
INAIL - Italian National Institute for Insurance against Accidents at Work. Trend in Occupational Injuries and Work-related Diseases - Agri-food industry (Andamento degli Infortuni sul Lavoro e delle Malattie Professionali - L’industria Agroalimentare tra consumi e occupazione). 2021 Apr [Accessed 12th December 2022]. https://www.inail.it/cs/internet/docs/alg-dati-inail-2021-aprile-pdf.pdf [Accessed 12th December 2022].
Matteo Riccò. Excess mortality in Mountain Areas of Emilia Romagna Region during the first months of SARS-CoV-2 pandemic: a ‘canary in the coal mine’? Acta Biomed. 2022;93(4): e20222247. https://doi.org/10.23750/abm.v93i4.13190.
Caranci N, di Girolamo C, Bartolini L, Fortuna D, Berti E, Sforza S, et al. General and COVID-19-related mortality by pre-existing chronic conditions and care setting during 2020 in Emilia-Romagna region, Italy. International Journal of Environmental Research and Public Health. 2021;18(24). https://doi.org/10.3390/ijerph182413224.
Chirico F, Sacco A, Bragazzi NL, Magnavita N. Can Air-Conditioning Systems Contribute to the Spread of SARS / MERS / COVID-19 Infection ? Insights from a Rapid Review of the Literature. International Journal of Environmental Research and Public Health. 2020;17: 6052.
Sterud T, Tynes T, Mehlum IS, Veiersted KB, Bergbom B, Airila A, et al. A systematic review of working conditions and occupational health among immigrants in Europe and Canada. BMC Public Health. 2018. https://doi.org/10.1186/s12889-018-5703-3.
Moyce SC, Schenker M. Migrant Workers and Their Occupational Health and Safety. Annual Review of Public Health. 2018;39: 351–365. https://doi.org/10.1146/annurev-publhealth-040617-013714.
De Jesus-Rivas M, Conlon HA, Burns C. The impact of language and culture diversity in occupational safety. Workplace Health and Safety. 2016;64(1): 24–27. https://doi.org/10.1177/2165079915607872.
Valeriani G, Vukovic IS, Mollica R. Unconventional Answers to Unprecedented Challenges: The Swedish Experience During the COVID-19 Outbreak. Journal of preventive medicine and public health = Yebang Uihakhoe chi. 2020;53(4): 233–235. https://doi.org/10.3961/jpmph.20.235.
Barbato M, Thomas J. Far from the eyes, close to the heart: Psychological Impact of COVID-19 in a Sample of Italian foreign workers. Psychiatry Research. 2020;290(May): 113113. https://doi.org/10.1016/j.psychres.2020.113113.
Liem A, Wang C, Wariyanti Y, Latikin CA, Hall BJ. The neglected health of international migrant workers in the COVID-19 epidemic. Lancet Psychiatry. 2020;7(4): e20.
Falkenbach M, Greer SL. Denial and Distraction: How the Populist Radical Right Responds to COVID-19 Comment on "A Scoping Review of PRR Parties’ Influence on Welfare Policy and its Implication for Population Health in Europe". International Journal of Health Policy and Management. 2020;2019(x): 1–3. https://doi.org/10.34172/ijhpm.2020.141.
Falkenbach M, Bekker M, Greer SL. Do parties make a difference? A review of partisan effects on health and the welfare state. European Journal of Public Health. 2019; 1–10. https://doi.org/10.1093/eurpub/ckz133.
Riccò M, Ferraro P, Gualerzi G, Ranzieri S, Henry BM, Said Y ben, et al. Point-of-Care Diagnostic Tests for Detecting SARS-CoV-2 Antibodies : A Systematic Review and Meta-Analysis of Real-World Data. Journal of Clinical Medicine. 2020;9: 1515. https://doi.org/10.3390/jcm9051515.
To KKW, Tsang OTY, Leung WS, Tam AR, Wu TC, Lung DC, et al. Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. The Lancet Infectious Diseases. 2020;20(5): 565–574. https://doi.org/10.1016/S1473-3099(20)30196-1.
Richmond CS, Sabin AP, Jobe DA, Lovrich SD, Kenny PA. Interregional SARS-CoV-2 spread from a single introduction outbreak in a meat-packing plant in northeast Iowa. medRxiv. 2020; 2020.06.08.20125534. https://doi.org/10.1101/2020.06.08.20125534.
Gan Y, Tan F, Yi R, Zhou X, Li C, Zhao X.
Research Progress on Coronavirus Prevention and Control in Animal-Source Foods
. Journal of Multidisciplinary Healthcare. 2020;Volume 13: 743–751. https://doi.org/10.2147/jmdh.s265059.Rubenstein BL, Campbell S, Meyers AR, Crum DA, Mitchell CS, Hutson J, et al. Factors That Might Affect SARS-CoV-2 Transmission Among Foreign-Born and U.S.-Born Poultry Facility Workers — Maryland, May 2020. MMWR. Morbidity and Mortality Weekly Report. 2020;69(50): 1906–1910. https://doi.org/10.15585/mmwr.mm6950a5.
Heiervang E, Goodman R. Advantages and limitations of web-based surveys : evidence from a child mental health survey. Soc Psychiat Epidemiol. 2011;(123): 69–76. https://doi.org/10.1007/s00127-009-0171-9.
Huang Y, Xu S, Lei W, Zhao Y, Liu H, Yao D, et al. Knowledge, Attitudes, and Practices Regarding Zika: Paper and Internet ¬ Based Survey in Zhejiang, China. JMIR Public Health Surveill. 2017;3(4): e81. https://doi.org/10.2196/publichealth.7663.
Bonanni P, Ferrero A, Guerra R, Iannazzo S, Odone A, Pompa M, et al. Vaccine coverage in Italy and assessment of the 2012-2014 National Immunization Prevention Plan. Epidemiol Prev. 2015;39(1): 1–158. https://doi.org/10.1371/currents.outbreaks.d37b61bceebae5a7a06d40a301cfa819.
Alicino C, Iudici R, Barberis I, Paganino C, Cacciani R, Zacconi M, et al. Influenza vaccination among healthcare workers in Italy: The experience of a large tertiary acute-care teaching hospital. Human Vaccines and Immunotherapeutics. 2015;11(1): 95–100. https://doi.org/10.4161/hv.34362.
Ricco M, Signorelli C. Personal and occupational risk factors for carpal tunnel syndrome in meat processing industry workers in northern italy. Medycyna Pracy. 2017; https://doi.org/10.13075/mp.5893.00605.
Çalışkan F, Mıdık Ö, Baykan Z, Şenol Y, Tanrıverdi EÇ, Tengiz Fİ, et al. The knowledge level and perceptions towards COVID-19 among Turkish final year medical students. Postgraduate Medicine. 2020; https://doi.org/10.1080/00325481.2020.1795486.
Downloads
Published
Issue
Section
License
Copyright (c) 2023 Matteo Riccò, Antonio Baldassarre, Pietro Ferraro, Pietro Melodia, Manuel Stocchi, Prof. Nicola Magnavita
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Transfer of Copyright and Permission to Reproduce Parts of Published Papers.
Authors retain the copyright for their published work. No formal permission will be required to reproduce parts (tables or illustrations) of published papers, provided the source is quoted appropriately and reproduction has no commercial intent. Reproductions with commercial intent will require written permission and payment of royalties.