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Epidemiology Of: Milk-Borne Diseases
Epidemiology Of: Milk-Borne Diseases
Journal of Food Protection. Vol. 46. No.7 Pages 637-649 (July 1983)
Copyright©. International Association 01 Milk. Food. and Environmental Sanitarians
Department of Health and Human Services. Public Health Service. Centers for
Disease Control. Atlanta, Georgia 30333
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Figure 1. Secular trends of milk-borne diseases by specific vehicle and year of occurrence, United States.
ter jejuni until laboratory procedures improved and con- for most of the ice cream-associated outbreaks (Fig. 1) dur-
cern about the problem was generated. ing the 1909 to 1925 period; staphylococcal intoxication
predominated from 1930 through the 1950s. Of the remain-
The types of milk and milk products that were impli- ing outbreaks, cheese and raw milk (including certified raw
cated as vehicles of outbreaks of specific milk-borne dis- milk) were often implicated as vehicles. The listing "milk,
eases during the 1970s are shown in Table 2. Ice cream, unspecified" refers, most likely, to raw milk; but, the re-
usually homemade and containing eggs, was the vehicle of ported data do not so specify. The pasteurized milk and
most of the outbreaks (usually of salmonellosis) reported chocolate milk were either improperly pasteurized or be-
during this period. Therefore, many of these should proba- came contaminated after being pasteurized. [For informa-
bly be omitted from the list because they would be better tion on recent milk-borne diseases that have occurred in
classified as egg-borne diseases. Typhoid fever accounted Canada, see data from the Health Protection Branch (4).]
Arizonosis
Botulism <1 1
Brucellosisa 8 4 9 1
Campylobacteriosis <1 3 40
Diphtheria 8 2 4 1
Escherichia coli
diarrhea
Haverhill fever <1
Hepatitis A <1 2
Histamine intoxication
Iron intoxication
Milk sickness <1
TABLE 2. Milk and Milk products reported as vehicles of disease outbreaks, 1970-1979.
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Raw milk 3 2 7
Milk, unspecified 2 8 12
Certified milk 2 3
Pasteurized milk 2 2
Chocolate milk 3
TABLE 3. Milk-borne arul milk-product-borne outbreaks of salmonellosis in the United States. 1965-1981.
Year Product State Number of References
cases Serotype
monella heidelberg infections, which affected at least 339 was either raw milk or certified raw milk. Three of the out-
persons, showed statistically significant association be- breaks affected farm families only. The other out-
TABLE 5. Cases of brucellosis associated with ingestion of domestic and foreign milk and milk-products (usually cheese) by year (23).
Year Total Cases related to unpasteurized milk or milk-products (cheese)
before and during the long period of cooling before the mix TABLE 6. Countries from which dairy products were processed
froze. Butter has also been implicated as a vehicle that were vehicles of Brucella, 1971-1979 (23).
(50,92,105,126). Country Number
Staphylococcus aureus is frequently found on cows ud- of cases
ders and in their teat canals. It is a common cause of mas- Mexico 115
titis. From these sources, staphylococci reach milk readily. United States 54
Milk and milk-products can also be contaminated by either Italy 12
hands or nasal discharges of dairy or processing plant Greece 5
workers. Staphylococci must multiply to produce sufficient Unspecified, Latin American countries 5
enterotoxin in foods to cause illness. Unspecified, European countries 3
India 2
Brucellosis Portugal 2
Milk-borne and milk-pro duct-borne brucellosis is a con-
Unspecified, Asian countries 2
Costa Rica
tinuing problem in the United States. Table 5 summarizes
France
reports that implicated milk and milk-products as the most Germany
probable sources of infection for approximately 10% of the Iran
known cases during the period 1971-1978 (23). Most of Kenya
the dairy product-associated cases have a history that in- Tanzania
cludes ingestion of milk products, usually raw goat-cheese, Thailand
produced in other countries. The countries in which these Unspecified, Middle-East country
products were produced are listed in Table 6. Examples of Total 208
outbreaks in which Mexican-prepared raw goat-cheese was
implicated are described (16,48,106.128). school children became ill after they ingested raw milk
Milk-producing animals-cattie, goats, sheep, and buf- which had been held at room temperature in a home for
faloes-can be reservoirs of brucellae. This organism has a about 4 h.
propensity for localizing in the uteri of females that are An outbreak of yersiniosis was discovered in New York
pregnant and in the mammary glands of lactating females. State during an investigation to uncover the reasons for an
Thereby, infected animals can for years shed brucellae in unusually high incidence of appendectomies in children
their milk. under 18 years old (12). The illness that caused the acute
Milk can also become contaminated with brucellae syndrome suggestive of appendicitis was caused by Y. en-
through contact with infected organs or fomities or from terocolitica. Chocolate milk was the epidemiologically im-
excreta or dust. Brucellae are quite resistant to environ- plicated vehicle. Chocolate syrup had been mixed and
mental stress. They survive in raw milk several hours, and added to milk after pasteurization.
in cheese several weeks, but usually not as long as a year. A report has been made of a Yersinia pseudotuberculosis
They can survive in frozen products a few years. [See septicemia and post-diarrheal, hemolytic, uremic syn-
Bryan (19) for a review of Brucella and brucellosis.] drome in a I5-month old child (93). This child and his
mother both became ill 1 d after they ingested goat's milk
Yersiniosis that had not been pasteurized.
Raw milk was suspected as a vehicle in an outbreak of Recently, Y. enterocolitica was responsible for an out-
Yersinia enterocolitica enteritis in Canada (42). Fifty-eight break affecting 148 persons from three states; most were
hospitalized, 17 underwent appendectomies, one of these either milked cows or handled milk or milking equipment
persons died. It was estimated that 857 cases may have oc- and were considered as the source.
curred. Pasteurized milk was the implicated vehicle; details Dried milk has also been implicated as a vehicle (1,94).
about the source of contamination were discovered (73). Canned milk that had been opened and diluted the evening
An investigation revealed that unsold milk was returned to before serving was responsible for three outbreaks that in-
the dairy and fed to hogs. At the hog farm, milk crates cluded 835 cases of tonsillitis and scarlet fever (l09).
were stored on the ground down slope from hog pens.
Crates were returned to the dairy and washed, but the Diphtheria
washing failed to remove some of the mud in the triangular Before pasteurization became a common practice, many
configurations on the undersurface of the crates. Aulisio et diphtheria epidemics were epidemiologically associated
al. (10) hypothesized that the mud contaminated the bot- with raw milk. These outbreaks have been summarized by
tom of the milk containers when they were put into the various authors and reviewed by Bryan (19). In many of
crates; tops of the containers could have been contaminated the outbreaks, implicated milk came from farms on which
during stacking. Animals are frequently infected with Y. dairy workers were either carriers of Corynebacterium
diphtheriae or they suffered from clinical manifestations of
Milk sickness was isolated from rectal swabs taken from 5 of 25 infants,
Grazing animals have developed trembles as a result of from the pump and from the vessel in which the pump had
eating leaves and stems of white snakeroot (Eupatorium been disinfected.
rugosum) or rayless goldenrod (Aplopappus heterophyllus
or lsocoma wrighii). Animals having this condition elimi- Listeriosis
nate tremetol ( a higher alcohol which is toxic to the liver) Foodborne transmission of listeriosis has not been con-
in their milk. Milk sickness is manifested by weakness, firmed in humans, but raw milk has been suspected to be
prostration, loss of appetite, abdominal pain, nausea, vom- a vehicle. For example, Potel (92) told about a woman
iting, muscular tremors and coma. It is frequently fatal. who had drunk milk from a cow with atypical mastitis and
Although, this disease is rare today, numerous cases and later gave birth to twins prematurely. The infants had mul-
deaths occurred among early settlers, particularly in the tiple tumors composed of granulation tissue, Listeria
midwest, before land was cleared. Significant to the occur- monocytogenes was isolated from the infants and from the
rence was that cattle foraged wooded areas and were cow's milk. In several cases of listeriosis that occurred in
milked only sporadically (81). Halle, Germany, raw milk was suspected as the vehicle,
milk, than the frequency with which these antibodies are Histamine and tyramine in cheese are usually degraded
found in the sera of persons who did not drink raw milk. in the body by monoamine oxidase. Certain drugs, how-
Epidemiologic evidence presented by Brown et al (17) ever, inhibit this enzyme. Persons who have taken one of
suggested that ingestion of raw milk from infected cattle these drugs, have experienced attacks of hypertension
resulted in a common-source outbreak; contact with ani- shortly after ingestion of cheese; cerebrovacular accidents
mals, farms, dust and insects were ruled out as possible have been reported (/3).
routes of transmission. Ingestion of raw milk that con-
tained C. burnetii by human volunteers, however, has not Arsenic poisoning
caused illness (51,73). In the summer of 1955, 12,131 children in western
c. burnetii can survive vat-pasteurization at 61.7°C Japan were poisoned because they ingested arsenic-con-
(143°F) for 30 min; pasteurization at 62.8°C (l45°F) for 30 taminated dry milk. One-hundred-thirty of these children
min or at 71. 7°C (161°F) for 15 sec is adequate to kill this died. The arsenic reached the milk from an inadequately
organism. purified "sodium phosphate" stabilizer which was used in
the manufacturing process. Fourteen years later, survivors
Hepatitis A
Farm workers who either milk animals or handle milk, those organisms that reach raw milk may be found in the
or milking or storage equipment, can contribute additional cheese. Brucellae that reach cheese and survive the cheese
organisms to the milk. Such contamination has resulted in making process have caused several cases of brucellosis.
numerous milk-borne outbreaks of typhoid fever, Salmonellae, also frequently reach milk, and they can
diphtheria, septic sore throat, scarlet fever, shigellosis, grow during cheese making and persist during ripening of
staphylococcal enterotoxicosis, hepatitis A and certain cheeses for 60 days or more.
poliomyelitis. Slow acid production (low milling acidity) by a starter
culture can allow staphylococci to grow and perhaps pro-
Certified milk duce enough entertoxin to cause disease if process temper-
Certified milk is raw milk which is produced under strict tures are favorable during curd formation. If the pH of the
conditions that comply with standards of sanitation adopted curd is higher than normal (5.2-5.3), growth of
by the American Association of Medical Milk Commis- staphylococci can even continue during pressing, but sel-
sions (3). These procedures were originated in the early dom afterwards. Their numbers decline rapidly during ri-
1800's to produce safe milk before pasteurization became pening.
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states. J. Food Prot. 45:1263. outbreaks. Public Health Rep. 75: 1025-1030.
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