Only a few cases have been reported in the United States, and outbreaks in countries outside the Indo-Pacific area are rare. In Haiti, tetrodotoxin is thought to have been used in voodoo preparations, in so-called zombie poisons, where subsequent careful analysis has repeatedly called early studies into question on technical grounds, and have failed to identify the toxin in any preparation, such that discussion of the matter has all but disappeared from the primary literature since the early 1990s. Kao and Yasumoto concluded in the first of their papers in 1986 that "the widely circulated claim in the lay press to the effect that tetrodotoxin is the causal agent in the initial zombification process is without factual foundation.”