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Microbial risks to humans in Estonia in association with non-pasteurised milk consumption Risk profile Authors: Prof. Arvo Viltrop, Department of Infectious Diseases, Institute of Veterinary Medicine and Animal Sciences, Estonian University of Life Sciences Prof. Mati Roasto, Department of Food Hygiene and Food Science, Institute of Veterinary Medicine and Animal Sciences, Estonian University of Life Sciences Tartu 2013 1 Introduction According to the Veterinary and Food Board (VTA), there were 32 dairy companies in Estonia on 16 April 2013 that had been issued with veterinary certificates for marketing raw milk outside the farm (markets, vending machines, shops, retail outlets). Eleven of these companies define themselves as organic producers. Small quantities of raw milk are also sold to consumers directly from farms or via various smaller marketing schemes. Consumption of unprocessed raw milk is becoming increasingly popular among the population due to its promotion in public channels and the expansion of marketing opportunities. This gives reason to assume that the population’s exposure to raw milk-borne pathogens is potentially growing. It is therefore necessary to describe the threats related to raw milk and evaluate the adequacy of the requirements and measures for guaranteeing the safety of raw milk. This risk profile was prepared within the scope of the research project Raw Milk Safety Pilot Study in Estonia, which was commissioned by the Ministry of Agriculture of the Republic of Estonia. Its goal is to give an overview of the microbial pathogens present in Estonia that can infect people via non-pasteurised milk, to describe the possible risks to people’s health associated with this (risk characterisation), to summarise existing information about the transmission of said microbes in Estonian dairy cattle and infection of people in recent years (evaluation of exposure) and to give an overview of the presently effective official measures for managing the risks related to raw milk (risk management methods). The data published in scientific literature, the official statistics of Estonia and the results of scientific research concerning Estonia, mainly for the last five years, were used to prepare the risk profile. The information concerning disease outbreaks registered in foreign countries also concerns earlier years. 2 Potentially raw milk-borne zoonotic pathogens in Estonia and characterisation of associated threats Microbes usually get into raw milk from the environment surrounding dairy cows. Infected animals also excrete many pathogens with milk. Microbes from the environment mainly gets into milk during the milking process either directly from the udder skin or the milking equipment. A less common reason is the unhygienic treatment of milk that has already been obtained by milking. In dairy farms, pathogens can also be spread by flies. Pathogens are mainly excreted into the environment by infected animals, but also by synanthropic birds, animals and insects. The microbes excreted with milk are mainly those that can cause inflammation of the udder tissue. Several microbes that cause systematic infections in animals are also excreted with milk. 2.1 Microbes from the environment 1) Escherichia coli. The E. coli strains found in cattle that are the most dangerous to humans are enterohaemorrhagic or EHEC strains that cause bloody diarrhoea and the most significant of which is E. coli O157:H7. The list of EHEC strains also includes other serotypes of E. coli (O26, O91, O103, O104, O111, O113, O117, O118, O121, O128 and O145) (Spickler, 2009). In the European Union, the cases of disease caused by E. coli O157 comprise ca 52% of all EHEC infections (ECDC, 2011). It is characterised by an extremely small infectious dose: it only takes 10-100 bacteria to infect a human (Spickler, 2009). The infection can therefore spread to people even with food that complies with all microbiological requirements. EHEC infections in humans are most often associated with meat and meat products, but it is not rare to become infected via milk and dairy products also (Gillespie et al., 2005; Spickler, 2009; Farrokh et al., 2013). 1 The EHEC infection may run its course in humans without symptoms, but it can result in bloody diarrhoea and haemorrhagic colitis. A possible complication of the latter is permanent renal failure as a result of hemolytic uremic syndrome (HUS), especially among children under the age of 10, the elderly and other people with weakened immunity. 5-10% of patients suffering from haemorrhagic colitis develop HUS. The lethality of HUS is 3-10% among children and up to 50% among the elderly (Spickler, 2009). In Europe, complication with HUS have been most often associated with E. coli O157 and O26 infections (ECDC, 2011). The incidence of E. coli O157:H7 in the skin surface samples of cattle at slaughter in Estonia has been studied within the scope of a monitoring plan of the VTA since 2011. Information about other EHEC serotypes in cattle has been collected irregularly. According to the Veterinary and Food Laboratory (VTL), the incidence of EHEC in the tested skin surface samples (serotype O157 by the culture method) is 3.5-5.5% (Kramarenko, 2013). However, EHEC was detected in 64% of the tested 120 skin surface samples when the PCR method was used. In addition to serotype O157, which was found in 44 samples (37%), a number of other serotypes were found: O145 in 57 samples (48%), O103 in 42 samples 35%, O026 in 36 samples (30%) and O111 in 8 samples (7%) (Roasto et al., 2013). Official statistics of the incidence of EHEC among people in Estonia indicate that overall incidence from 2005-2009 was 0.2-1.4 causes per 100,000 residents (3-19 laboratoryconfirmed cases per year). No cases of HUS caused by EHEC were registered in Estonia during this period (ECDC, 2011). In 2006 there was a registered case in Estonia where EHEC was most probably transmitted with raw milk (EFSA, 2012). The number of EHEC cases registered from 2010-2012 was 5, 4 and 3, respectively. Four cases had been registered as at September 2013 (Health Board, 2013 c). 2) Soil and the intestines of infected animals (incl. wild animals) are the reservoir of Listeria monocytogenes. Listeria is very resistant, can survive freezing and is also capable of reproducing at low temperatures above zero. Infected animals excrete listeria in their faeces, milk and uterine secretions. There are 13 serotypes of L. monocytogenes. Among them, 4b, 1/2b and 1/2a are the main ones that cause illness among people and animals (Spickler, 2005). The pathogen enters the human body primarily with contaminated food of animal origin. The foetus of an infected mother can become infected via the placenta during pregnancy. In the case of late listeriosis, the newborn is infected during childbirth when passing though the birth canal (Health Board, 2013). Listeriosis is a serious problem mainly for pregnant women, newborns, elderly people and those with weakened immunity. Pregnant women may develop light influenza-like symptoms, or the illness may be subclinical. A few days or weeks later, it may be followed by miscarriage, stillbirth, premature birth or septicaemia in the newborn. Babies may suffer septicaemia, respiratory tract disorders, granulomatosis or meningitis, which can often result in death. The elderly and people with weakened immunity usually develop meningitis or meningoencephalitis; less frequently septicaemia. The formation of any symptoms is rare for healthy adults. The new syndrome associated with foodborne listeria infection in adults is gastroenteritis with a fever, which is usually self-limiting and passes in one to three days (Spickler, 2005). According to the Veterinary and Food Laboratory, clinical listeriosis in Estonian cattle was diagnosed in 3-13 herds per year from 2008-2012. Sporadic cases have also been registered in goat herds (Veterinary and Food Laboratory, 2009-2013). 2 L. monocytogenes has permanently been present in the raw milk samples collected on Estonian dairy farms. It was found in 4.8-20.0% of samples from 2007-2011 (EFSA, 2012). In humans, listeriosis has been sporadically diagnosed in Estonia (3-8 cases per year from 2007-2011) and there have been no major outbreaks (EFSA, 2012). Three cases of listeriosis were registered in Estonia in 2012 and the number of cases as at September 2013 was two (Health Board, 2013). Listeria enteritis has not been registered in Estonia. 3) Salmonella enterica The most important S. enterica serotypes in cattle in terms of zoonoses are S. Dublin, S. Typhimurium and S. Newport (Costa et al., 2012; Cummings et al., 2012). In developed countries, salmonella infections in people are primarily related to consumption of salmonella-contaminated food, including milk and dairy products (Flint et al., 2005; Mazurek et al.,2003; De Valk et al., 2000). It is also possible to become infected via direct contact with infected animals (Costa et al., 2012). Infection results in acute enterocolitis with diarrhoea, fever, abdominal pain and headache, plus nausea and sometimes vomiting, which results in fluid loss. The symptoms persist for four to seven days. Septicaemia and organ damage may develop in serious cases (arthritis, meningitis, endo- and pericarditis, pneumonia, pyelonephritis, etc.), which can result in the patient’s death (Health Board, 2013). The disease is often more serious in children under five years of age, elderly people and those with weakened immunity (Cummings, 2012). Salmonellae are the food pathogens that cause the biggest number of deaths (Flint et al., 2005). According to the Veterinary and Food Laboratory, salmonellosis was detected as a clinical disease in 1-12 cattle herds per year from 2008-2012. In addition to this, infection has been detected every year in 1-12 herds sampled as part of a salmonellosis surveillance program (VTA, 2009-2013). In 2011 and 2012 the surveillance programme carried out by the VTA, detected salmonellosis in 4.4% and 3.7% of herds, respectively (VTA, 2012; 2013). Salmonella has not been found in raw milk samples in Estonia in recent years. The most common salmonella serotypes transmitted in cattle herds in Estonia are S. Dublin and S. Typhimurium. S. Enteritidis infection is also often detected (VTA, 2012; 2013). The serotypes most prevalent in humans are S. Enteritidis and S. Typhimurium (VTA, 2012). Approximately 350-650 cases of salmonellosis are registered in Estonia per year. There have been several outbreaks of food origin. Published data of the epidemiological studies carried out by the Health Board do not specify whether or how many outbreaks can be associated with the consumption of milk or dairy products (Health Board, 2013c). 4) Campylobacter spp. Campylobacteria are the most frequent causes of human gastroenteritis in developed countries (Flint et al., 2005). The zoonotic campylobacteria found in cattle include C. jejuni, C. coli (Spickler, 2005) and C. ureolyticus which was recently defined as a possible cause of gastroenteritis (Bullman et al., 2011; Koziel et al., 2012). So far, C. ureolyticus has only been detected among animals - in cattle (Koziel et al., 2012). In many European countries, cattle are a significant source of C. jejuni and C. coli in humans. The share of infections originating from cattle in humans ranges from 10-20% (Mughini Gras et al., 2012; Roux et al., 2013). People can become infected by consuming contaminated food (chicken and other poultry, raw milk, mussels, etc.) or water, or as a result of contact with infected pets or agricultural animals. Flies are effective mechanical transmitters of campylobacteria (Spickler, 2005). Most cases of campylobacteriosis in humans in developed countries are sporadic. Outbreaks are mostly associated with consumption of contaminated chicken or raw milk, or infection 3 received from water (DuPont, 2007; Sahin et al., 2012). Campylobacteria usually spread into water with faecal contamination, but in rarer cases they can also colonise a cow’s udder and excrete directly into milk from there (Hutchinson et al., 1985). The forms of campylobacteriosis in people vary from mild indigestion that self-limits in 24 hours to extremely acute and chronic colitis. Symptoms may include watery or sticky diarrhoea (faeces may contain blood), fever, nausea and vomiting, headache and muscle pain and severe abdominal pain with cramping. It may also cause enlargement of the spleen and/or liver. Complications are rare, but the disease may result in reactive arthritis, HUS and septicaemia, also meningitis, acute gall bladder infection and Guillain-Barré syndrome (rapidly progressing polyneuropathy). Isolated cases of miscarriage caused by C. jejuni have been registered (Spickler, 2005). Since C. coli and C. jejuni do not ordinarily cause clinical illness in cattle, no attention is given to their incidence in herds. This is why there is no data about their spread in Estonian cattle herds. The incidence of Campylobacter has not been studied as part of a food safety surveillance programme either, which is the reason why there is no information about its prevalence in milk. In Estonia, campylobacteriosis is one of the most prevalent diarrhoeal diseases among people. 154-214 cases per year were registered from 2008-2012 (VTA, 2012; Health Board, 2013c). No official data about the food that was the source of the infection have been published. 5) Yersiniosis, which is caused by Yesrsinia enterocolitica, is one of the most frequently registered foodborne zoonoses in developed countries, especially in the temperate zone (ranking third after campylobacteriosis and salmonellosis). The strains of Y. enterocolitica, which cause illness in people, belong to the bioserotypes of 1B/O:8, 2/O:5,27, 2/O:9, 3/O:3 and 4/O:3 (Atiqur et al., 2011). Most Y. enterocolitica infections in people are sporadic whereby the source of the infection cannot be identified. Pigs are still considered the main source of infection for people (Fredriksson-Ahomaa et al., 2006). The bioserotypes of Y. enterocolitica that are pathogenic for people are detected in cattle less often and in smaller quantities than in pigs (McNally et al., 2004; Galindo et al., 2011). Irrespective of this, cases of the illness among humans related to the consumption of contaminated dairy products, primarily pasteurised dairy products, have been registered in Europe and North America (McNally et al., 2004; Ackers et al., 2000). The latter mainly refers to mistakes made in milk handling in food businesses and/or the contamination of products after pasteurisation. Pathogenic Y. enteroclitica strains in raw milk have been detected in Europe and the rest of the world (Schiemann, 1978; Shahram, et al., 2012). However, no pathogenic strains were found in raw milk during the study recently carried out in Finland (Ruusunen et al., 2013). Rodents are probably also reservoirs of the infection and flies play an important role in the transmission of the disease (Galindo, 2011). People become infected when they consume food contaminated with the microbes. The disease is most prevalent among babies and infants. Symptoms include diarrhoea (often bloody), fever and abdominal pain. Complications (itching, joint pain, bacteriaemia) are rare (Rahman, 2011). Yersinia enterocolitica does not ordinarily cause clinical illness in animals, which is why it is rarely identified in diagnostic tests. However, it has been found in cattle and goats sporadically in Estonia. In cattle, Y. enterocolitica infection is often found due to serological cross-reactivity with the antigens of Brucella abortus. In 2008 the infection was registered in one cattle herd; in 2009 in 12 cattle herds and one goat herd (VTL, 2009-2010). 47-69 cases per year were registered in people in Estonia from 2010-2012 (3.5-5.1 cases/100,000 residents) (Health Board, 2013c). The sources of the infection are not known. 4 6) Yersinia pseudoruberculosis belongs among enteropathogenic yersina alongside Y. enterocolitica and causes infections of the intestinal tract in many animal species. The illness may not have any symptoms in animals, but in the case of cattle it has been associated with miscarriage, pneumonia and mastitis in addition to enteritis (Shwimmer et al., 2007). Y. pseudotuberculosis also causes mastitis among goats (Jones et al., 1982). Y. pseudotuberculosis can get into milk from the environment as well as directly from the infected udder. There are many registered cases of people becoming infected via milk (Shwimmer et al., 2007). In people, pseudotuberculosis usually manifests itself with symptoms of gastroenteritis (fever, abdominal pain) and mesenteric lymphadenitis. Most common complications include reactive arthritis, erythema nodosum and itching. High-risk persons, i.e. those with a weakened immune system, may develop sepsis and various associated complications (e.g. chronic liver disease) (Rihmanen-Finne et al., 2009; Schwimmer et al., 2007). There are no data from recent years about the incidence of Yersinia pseudotuberculosis among ruminants. However, in Estonia it has been detected in pigs (Martinez et al., 2009), which gives reason to assume that the infection can also be found in ruminants. Pseudotuberculosis has also been registered in people in Estonia (Zolotuhhina et al., 1996). 7) Clostridium perfringens is an anaerobic spore-forming bacterium that is widely spread in the environment and can often be found in the intestines of people and animals. It is often found in raw animal meat and poultry, but also in raw milk (CDC, 2013; Rea et al., 1992). Some strains of C. perfringens produce toxins that cause illness. All toxin-producing C. perfringens Type A strains are associated with food poisoning (The Merck Manual, 2013). People fall ill when a large quantity of C. perfringens bacteria gets into the intestines. The spores of C. perfringens become active at temperatures from 12°C - 60°C and the bacteria start reproducing (the reproduction rate being particularly high at 43°C - 47°C). This means that preservation of food contaminated with a small amount of spores can lead to C. perfringens reproduction at such a rate that the food can make a person ill (CDC, 2013). Infected people suffer acute gastroenteritis, which manifests itself as diarrhoea and abdominal cramps. Signs of the disease usually disappear in 24 hours. Severe illness and death are rare (The Merck Manual, 2013). In Estonia, C. perfringens has been registered in cattle in isolated cases (VTL, 2013). Intestinal infections caused by C. perfringens in people are registered in Estonia every year (Health Board, 2013 c). Data on the sources of infection have not been published. 8) Bacillus cereus is a spore-forming facultatively anaerobic bacterium that is widely distributed environmentally. It is able to colonise the intestines of animals for a short time. The spores of B. cereus in dairy products come from the farm environment or have spread there in the course of cross-pollution during the handling process (Vissers et al., 2007). B. cereus causes two types of illness in people: (1) the emetic form with a short incubation period (1-6 hours) characterised by nausea, vomiting and abdominal cramps, and which is caused by a thermostable emetic toxin; (2) the diarrhoeal form with a longer incubation period (8-16 hours) characterised by severe, watery diarrhoea, caused by the thermolabile, diarrhoeal enterotoxins Nhe and/or hemolytic enterotoxin HBL (Todar, 2013). Since B. cereus does not cause ordinary clinical symptoms in cattle, it is not investigated in routine diagnostic procedures. There are also no official statistics about incidence among humans in Estonia. 5 9) Cryptosporidium spp. Cryptosporidia are protozoan intracellular parasites that are transmitted via the faecal-oral route. Cryptosporidium parvum is the cryptosporidium in cattle that is the most dangerous to people. The sporulated oocysts excreted in faeces are immediately infective. In a damp environment, they remain infective for 2-6 months (Spickler, 2005). The infection spreads both by direct contact from animals to people as well as via the environment, with contaminated water and food, including milk (Fayer et al., 2000; Fretz et al.; 2003). Cryptosporidiosis in people is characterised by severe, watery diarrhoea, abdominal pain and cramps, nausea and a lack of appetite. Some people may vomit, lose weight and suffer from fever and muscle pain. The illness is usually self-limiting in healthy adults, but it may become chronic, exhausting and severe in people with weakened immunity, and cause death. The pulmonary form is characterised by a cough with fever and severe diarrhoea (Spickler, 2005). Cryptosporidia have been detected in 84% of cattle herds in Estonia (Lassen et al., 2009). Cryptosporidiosis is very rarely registered in humans in Estonia, because the disease is considered self-limiting and no tests are usually performed to identify it (Šljapnikova et al., 1994). 2.2 Microbes excreted with milk that infect humans 2.2.1 Mastitis agents 1) Staphylococcus aureus causes various inflammatory conditions in animals and people, from skin and wound infections to pneumonia and septicaemia. The toxins produced by S. aureus also cause food poisoning and toxic shock syndrome in people (Todar, 2013). S. aureus is a widely spread agent of sub-clinical mastitis in cows. S. aureus may get into the milk consumed as food directly from an infected udder or the environment (dust, equipment, etc.), as well as from people who handle milk and carry Si aureus in their nostrils or on their hands (Argudin et al., 2010). The food poisoning caused by S. aureus is an intoxication caused by the enterotoxins produced by the bacterium, which is characterised by a short incubation period (2-8 hours), nausea, severe vomiting, abdominal cramps and diarrhoea (although the latter may not occur). The symptoms usually disappear by themselves within 24-48 hours. Infants, elderly people and people with weakened immunity may sometimes require hospitalisation (Spickler, 2004; Argudin et al., 2010). Staphylococcus aureus is one of the most widely spread causal agents of mastitis in dairy cattle. From 2007-2009 it caused 11.7% of the registered cases of sub-clinical mastitis and 16.6-22.8% of clinical mastitis (Kalmus et al., 2011). Samples of raw milk where the content of S. aureus exceeds the established limit are registered by the VTL in 2-3 cases every year (Kramarenko, oral information, 2013). Cases of enteritis caused by S. aureus in humans are regularly registered in Estonia (Health Board, 2013c). 2) Streptococcus agalactiae is a Group B streptococcus which is a widely spread causal agent of clinical mastitis in cows in Estonia. Streptococci colonise the skin of the cows’ udders and cause mastitis by penetrating the udder. The infection spreads from cow to cow via milking equipment (Pyörälä, 1996). Streptococci spread into milk directly from the udder or the surface of the udder. 6 S. agalactiae causes endometritis in women; in pregnant women, it can cause sepsis, osteomyelitis, endocarditis, meningitis and septic miscarriage. Group B streptococci are also significant pathogens for newborns and the elderly, in whom they cause invasive infections such as meningitis, sepsis and pneumonia (in children), endocarditis, soft tissue inflammation and bone and muscle inflammation (in elderly people) (Spickler, 2005; Haguenoer et al., 2011). The sepsis caused by S. agalactiae is the main cause of death among newborns in the West (Apgar et al., 2005). The strains of S. agalactiae detected in people usually spread from person to person. S. agalactiae often colonise the mucous membranes of people without causing any disease (Spickler, 2005). However, there is enough proof that transmission of S. agalactiae from cattle to people has occurred, as there is a genetic link between the strains that are pathogenic to people and strains isolated from cattle (Haguenoer et al.; 2011). S. agalactiae is a common agent of mastitis in cows in Estonia, as it causes 9-14.7% of all cases of sub-clinical mastitis per year (Kalmus et al., 2011). From 2000-2002, S. agalactiae was registered in 3.3-7.8% of women tested in women’s clinics or maternity wards in Estonia (Mändar, 2011). 2.2.2 Other zoonotic pathogens excreted with milk 1) Coxiella burnetii The causative agent of Q fever is a small intracellular bacterium known as Coxiella burnetii, which forms special spore-like structures that are highly resistant in the environment. Animals mostly spread the causative agents of Q fever in faeces, but also in milk. This means that raw milk is a possible source of infection (Spickler, 2007). Q fever in cattle, goats and sheep may pass without noticeable clinical signs, but it may cause an abortion storm, still births and weak offspring as well as placentitis, endometritis and infertility (Maurin & Raoult, 1999; Eibach et al., 2012). In humans, Q fever usually occurs with influenza-like symptoms, but it may also cause pneumonia in severe cases. Chronic Q fever can lead to heart or liver damage, and cause the patient’s death (Bacci et al., 2012). C. burnetii infection has been detected in ca 25% of dairy herds in Estonia. In goat herds, the infection has not yet been detected. The infection has also been detected in 1.4% (CI95% 0.6-2.9%) of tested people in Estonia (Neare et al., 2013). In Estonia, Q fever as a clinical disease has not yet been detected in people. However, the possibilities for laboratory diagnosis of the infection were lacking in Estonia until recently. 2) Toxoplasma gondii is an obligate, intracellular, parasitic protozoan carried in many species of mammals, including ruminants. In infected animals, the disease is often sub-clinical (Järvis, 2011). Both cows and goats excrete toxoplasmas with milk; they are more frequent in goat’s milk (Dehkordi et al., 2013). Studies have indicated that the different developmental forms of toxoplasma excreted with milk are infective and can be transmitted to people (Hiramoto et al., 2001; Pereira et al., 2010). Immunocompetent people who are not pregnant usually exhibit no symptoms when infected with T. gondii. 10-20% of infected persons may develop lymphadenitis or light influenza-like symptoms. In some cases, the disease can resemble infectious mononucleosis. Symptoms usually disappear within a couple of weeks without treatment (Spickler, 2005). T. gondii is a significant pathogen for immunocompromised (and sometimes also immunocompetent) people, causing diseases of the central nervous system and the eyes. The infection may be transmitted to the foetus when a pregnant woman becomes infected for the first time. This 7 results in brain and/or eye damage in the foetus. The earlier the stage in pregnancy that the infection occurs, the more severe the damage (Pereira et al., 2010). Ocular toxoplasmosis with uveitis is sometimes also detected in youngsters and young adults. It is usually a delayed manifestation of asymptomatic foetal or postnatal infection (Spickler, 2005). In Estonia, T. gondii infection has been detected in dairy cows on 91.1% of farms and in 24.1% of dairy cows (Jokelainen et al., unpublished data, 2013). The share of persons positive for antibodies in the population is 56.4% (Janson et al., 2013). 3) Tick-borne encephalitis virus (TBEV) is an RNA virus of the genus Flavivirus in the family of Flaviviridae, which is transmitted to humans by ticks, but whose natural reservoirs include many species of wild animals and which also infects domestic animals, including cattle and small ruminants. The latter may excrete the virus with milk, which may infect people (Mansfield et al., 2009; Dobler et al., 2012). People are more commonly infected by goat’s milk, but infection by cow’s milk containing the virus has also been registered (Juceviciene, 2005; Caini et al., 2012; Hudopisk et al., 2012). Tick-borne encephalitis develops in two phases in people. The first symptoms, which last for 3-4 days, are fever, muscle pain, nausea and vomiting. These are often followed by an asymptomatic period, which lasts for 2-10 days and can end in the person’s recovery. Acute signs of damage to the central nervous system develop if the disease progresses to the second phase (Kirkmann et al., 2007; Mansfield et al., 2009). The disease most often manifests as meningitis, meningoencephalitis, polimyelitis or polyradiculoneuritis, or a combination thereof (Kirkmann et al., 2007). The poliomyelitic form may result in long-term disability. The mortality among diseased patients is 1-3% (Mansfield et al., 2009). According to our data, the tick-borne encephalitis infection has been detected in 35% of cattle herds and 56% of goat herds in Estonia (Viltrop, et al., unpublished data 2013). Transmission of the virus to people by goat’s milk and cow’s milk has repeatedly been detected in Estonia (Kerbo et al., 2005). The last case dates back to 2011, where the infection was transmitted with goat’s milk (VTA, 2012). 4) Leptospira hardjo Among the species and serovariants of leptospira that have adapted to cattle, L. hardjo is considered to be the most dangerous to people. It often spreads asymptomatically among cattle, mainly causing fertility problems and late abortions. At the same time, its zoonotic potential is high. In many countries where L. hardjo is widely spread, it is the main serotype of leptospira that infects people (Adler, de la Peña Moctezuma, 2010; Bolin, 2003). The main risk factor in human infection is direct contact with infected animals (Spickler, 2005). However, leptospiras may be excreted from the udders of infected animals straight into milk (Thiermann, 1982) or reach it via the environment. Some data suggest that L. hardjo can remain viable for at least 10 days in chilled milk, which is why its transmission to people who consume unpasteurised milk cannot be excluded (Natale et al., 2012). The course of leptospirosis in humans varies from infection without symptoms to acute illness. In most cases, the illness has minimal or no clinical manifestations. The illness usually develops in two phases. The first acute or septic phase starts suddenly with influenzalike symptoms - fever, muscle pain, photophobia and headache; in serious cases abdominal pain, vomiting and jaundice. The first phase lasts 4-9 days, after which the fever and muscle pain disappear and the person may recover. However, this can be followed by the second phase of the illness (the immune phase). This phase can manifest itself as meningitis or Weil’s disease, a severe form of leptospirosis that causes jaundice and which is characterised by headache, rash, thrombocytopenia, liver and kidney damage and jaundice. The second 8 phase of the disease can also end with the patient’s death. Lethality is 1-5% in the case of the form with meningitis and 5-10% in the case of the form with jaundice (Spickler, 2005). In Estonia, L. hardjo infection has been detected in 17% of dairy herds. In goats, the infection has not yet been detected (Viltrop, unpublished data, 2013). In Estonia, 2-8 cases of leptospirosis in humans have been registered in recent years (Health Board, 2013c). The serotypes detected in humans in 2012 were Leptospira pomona, Leptospira grippotyphosa, Leptospira bratislava and, in two cases, unidentified Leptospira spp. (VTA, 2013). Infection by milk is not probable in the case of the first three listed serotypes. However, the serotype was not identified in the case of two patients, which means that L. hardjo infection cannot be excluded. 5) Mycobacterium avium ssp paratuberculosis (MAP) belongs to the group of microorganisms known as M. avium-M. intracellulare (MAI). The reservoir hosts of the infection are cattle and small ruminants. In cattle and small ruminants, the disease causes paratuberculosis, which is a chronic disease with a very long duration. Infected animals are carriers of the infection for a long period during which they transmit the MAP to the environment via faeces and milk (Spickler, 2007). People can become infected with MAP, which is epidemiologically related to Crohn’s disease (Sechi et al., 2005; Uzoigwe et al., 2007). Crohn’s disease is a chronic inflammatory disease of the intestines, especially the colon and ileum, associated with ulcers and fistulae. The main symptoms of the disease are acute bouts of diarrhoea, abdominal pain and cramps, fever, weight loss and meteorism (Uzoigwe et al., 2007). In Estonia, seropositive animals have been detected in 3.5-9.6% of cattle in recent years (VTL, 2008-2013). 1.4 cases per 100,000 residents of Crohn’s disease have been diagnosed each year in Estonia. 6) Borrelia burgdorferi is a bacterium transmitted by ticks causes borreliosis or Lyme disease in humans. Small rodents are its main natural reservoir. Pets are incidental hosts who become infected as a result of tick bites (Spickler, 2011). Borreliae have been detected in the urine and milk of infected people and cattle (Schmidt et al., 1995; Lischer et al., 2000). However, there are no registered cases of borreliosis infection whereby infection via the environment or orally has been proven (Spickler, 2011). This means that based on existing scientific information, it cannot be claimed that B. burgdorferi can infect people via milk consumed as food. 7) In addition to the pathogens listed above, the spread of other rare infections via milk cannot be excluded in Estonia, e.g. the causal agent of anthrax Bacillus anthracis and the causal agent of human tuberculosis Mycobacterium tuberculosis, or the emergence of toxins due to the contamination of milk with toxinogenic bacteria (Cl. botulinum; other Bacillus spp. toxins). 3 Overview of outbreaks related to raw milk in the world According to different opinions, 1-3% of the population of developed countries consume raw milk and dairy products made from it that have not been heat-treated (Langer et al., 2012; CDC, 2002-2003). A number of factors determine whether or not a person who consumes raw milk gets food poisoning or an infection. These factors include the level of virulence of the microorganisms (or toxicity of the toxins) in raw milk, the micro-organism (or toxin) count, the infectious dose and the state of the person’s health (Lund & O’Brien, 2011). 9 Research into outbreaks related to milk and dairy products indicates that ca 70% of such incidents in the US (Centers for Disease Control and Prevention, 2002-2003) and 50-60% in the US and Europe (Gillespie et al., 2003; Langer et al., 2012) have been caused by infection from products that were not heat-treated. In addition to the above, it has been found that on average 16% (Claeys et al., 2013; De Buyser et al., 2001) of outbreaks of bacterial diseases in the world have been caused by the consumption of contaminated raw milk or dairy products. The statistics of different countries indicate that the share of outbreaks caused by consumption of raw milk or dairy products contaminated with pathogenic bacteria among all outbreaks was 6.1% in France, 5.7% in the Netherlands, 5.5% in Germany, 4.4% in England, 3.5% in Poland, 3.0% in Finland and 2.2% in the United States (De Buyser et al., 2001). The data above may not be complete. Namely, it has been noted that national surveillance systems do not register all diseases and outbreaks related to raw milk (Oliver et al., 2009). There may be several reasons for this, e.g. not all persons are hospitalised depending on the level of severity of the food poisoning, or not all cases are diagnosed in respect of the pathogen. However, various studies confirm that extensive consumption of raw milk can be associated with large outbreaks of food poisoning and that the frequency of outbreaks is increasing (Newkirk et al., 2011; Oliver et al., 2009). This is also confirmed in the latest report by the U.S. Centers for Disease Control and Prevention, which states that after widespread sales of raw milk were permitted in the United States, i.e. after it became freely accessible to consumers, the frequency of outbreaks caused by raw milk increased significantly (Langer et al., 2012). An overview of the outbreaks related to raw milk in the European Union and the United States from 1949-2013 is given in Table 1. The most common food pathogens that have caused outbreaks related to raw milk include Campylobacter jejuni, Listeria monocytogenes, Yersinia enterocolitica, pathogenic Escherichia coli, Salmonella spp. as well as Staphylococcus aureus (De Buyser et al., 2001; Gillespie et al., 2003; Newkirk et al., 2011; Langer et al., 2012). The data in Table 1 suggest that outbreaks related to raw milk are more frequent in the United States than in Europe. However, irrespective of the country in which the outbreak occurred, it was caused by the fact that the people who suffered from food poisoning or foodborne infection consumed raw milk or raw dairy products made without heat-treatment. Food pathogens can get into raw milk via the microflora in a cow’s udder (if the cow has mastitis) and from the external environment that surrounds the cow if strict milking hygiene requirements are not complied with. For example, it has been noted that in one case the raw milk that caused an outbreak became infected with E. coli O157 on the farm either during milking or further handling of the milk as a result of faecal contamination due to the presence of one asymptomatic cow in the dairy herd (Guh et al., 2010). This is why the conclusion made in the given study was that raw milk can become contaminated on a farm even if the overall hygiene situation there is excellent and the hygiene of raw milk production complies with requirements. The examples of outbreaks given in Table 1 became possible due to the consumption of contaminated milk that came from dairy cows kept on a small farm for own use, was purchased directly from a large farm or was accessible to people from shops. The outbreaks described in Table 1 cannot be used as a basis for highlighting the food pathogens that have caused more cases of illness, because the submitted data are not final. However, it is possible to conclude that in the United States, the biggest number of outbreaks have been associated with the presence of C. jejuni and in Europe with the presence of L. monocytogenes and Salmonella spp. in raw milk. 46 outbreaks related to raw milk were registered in the United States from 1973-1992, and in 87% of cases raw milk was sold to consumers legally (Headrick et al., 1998). There were 45 outbreaks in North America from 2000-2001 which were caused by the consumption of raw milk 10 and dairy products made from raw milk, which caused 686 people to fall ill, eight of whom died (BC Centre for Disease Control, 2012). Outbreaks have been caused by Campylobacter, Salmonella and E. coli. Based on the examples given in Table 1, the number of people who have fallen ill in outbreaks has been 2-148, but no cases have ended with death in recent years. Outbreaks related to raw milk have also been rather common in Europe. For example, drinking raw milk caused a lot of people to fall ill from 1949-1957 - ca 100 people suffered from listeriosis as a result of this (Seeliger, 1961). A major outbreak was also registered in 1981 in Scotland, when 654 people contracted salmonellosis as a result of raw milk consumption, two of whom died (De Buyser et al., 2001). In the 1990s there were ca 100 milk-related outbreaks in England and France (De Buyser et al., 2001; Gillespie et al., 2003). In 1997, for example, consumption of raw-milk cheese resulted in 113 people contracting salmonellosis (De Buyser et al., 2001). In the Netherlands, 34 people in 2005 and 16 people in 2007 contracted campylobacter enteritis after consuming raw milk (Heuvelink et al., 2009). Consumption of raw milk and raw dairy products has been associated with several outbreaks of listeriosis in Europe (Lundén et al., 2004). Said outbreaks have mostly been associated with the consumption of cheeses. The explanation for this is that L. monocytogenes can survive during the technological process of cheese production as well as during the maturation of cheese in the warehouse (Schvartzman et al., 2011). A serious risk to people’s health mainly emerges in cases where unpasteurised milk is used as the raw material for making cheese. Cheeses made from such milk have caused outbreaks mainly in France (Goulet et al., 1995). The presence of Campylobacter jejuni and C. coli in raw milk has been associated with outbreaks in Europe (Newkirk et al., 2011). For example, an outbreak of campylobacter enteritis occurred in a farmer’s family in Finland where the family members had consumed raw milk from their own farm (Schildt et al., 2006). Several studies have also confirmed the connection between salmonellosis and consumption of raw milk (Dominguez et al., 2009). In 1995, for example, 25 people in France contracted salmonellosis after eating raw-milk cheese, five of whom died (De Buyser et al., 2001). Raw milk and raw dairy products have also caused illness related to E. coli O157 (Guh et al., 2010). For example, a person in Scotland who had eaten cheese made from raw milk contaminated with E. coli O157:H7 got food poisoning. 11 Table 1. Overview of outbreaks related to raw milk Time and country April 2013 Minnesota, USA Pathogen Salmonella April 2012 Missouri, USA Escherichia coli Source Mexican-style cheese made from raw milk Raw milk April 2012, Oregon, USA Escherichia coli Raw milk January 2012 Pennsylvania, USA Campylobacter Raw milk September 2011 New York, USA Campylobacter Raw milk August - October 2011 California, USA July 2011 North Carolina, USA Escherichia coli O157:H7 Raw milk Campylobacter jejuni Raw milk June 2011 Alaska, USA Campylobacter Raw milk April 2011 Texas, USA Salmonella Raw milk April 2010 USA Salmonella Raw milk Diseased (died) Reference 25 StarTribune health: Salmonella outbreak that sickened 25 linked to raw milk http://www.startribune.com/lifestyle/health/208248661.html 14 Food Safety News: Raw milk still suspect in 14 Missouri E. coli cases. http://www.foodsafetynews.com/2012/05/missouri-says-14-e-coli-cases-may-befrom-raw-milk/#.Ui95FH9jYQM 21 KTVZ.com News: Oregon E. coli outbreak traced to raw milk. http://www.ktvz.com/news/Oregon-E-Coli-Outbreak-Traced-to-Raw-Milk//413192/15292378/-/8i28tjz/-/index.html 148 Huffpost Healthy Living: Raw milk sickened 148 in Campylobacter outbreak last year http://www.huffingtonpost.com/2013/05/06/raw-milk-outbreak-campylobacter148-sickened_n_3223199.html 2 WBNG News: Campylobacter contamination found in raw milk in Tompkins County http://www.wbng.com/news/around-the-tiers/Campylobacter-ContaminationFound-in-Raw-Milk-in-Tompkins-County-130820728.html 5 News Release. California department of food and agriculture: Organic pastures raw milk recall announced by CDFA. http://www.cdfa.ca.gov/egov/Press_Releases/Press_Release.asp?PRnum=11-064 8 FDA: Foodborne outbreak associated with raw milk from Tucker Adkins Dairy of York S.C., U.S. Food and Drug Administration, 2011 http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm263158.ht m 3 State of Alaska Epidemiology. Bulletin. Ongoing raw milk Campylobacter outbreak – southcentral Alaska, July 2011. http://www.epi.alaska.gov/bulletins/docs/b2011_22.pdf 4 WFAA Local News: Raw milk under scrutiny after North Texas illness. http://www.wfaa.com/news/local/Raw-milk-under-scrutiny-after-North-Texasillnesses-120321579.html 6 Deseret News: Salmonella outbreak linked to raw milk sold in Orem and Heber http://www.deseretnews.com/article/700032391/Salmonella-outbreak-linked-to12 January 2010 USA Campylobacter Raw milk July 2008 Connecticut, USA November 2007 Kansas, USA Escherichia coli O157 Campylobacter Raw milk 2007 The Netherlands October 2007 Kansas, USA Campylobacter jejuni Campylobacter Raw milk 2006 USA 2005 The Netherlands 2003 USA 2001 USA 1997 France Campylobacter jejuni Campylobacter jejuni Campylobacter jejuni Campylobacter jejuni Salmonella Raw milk 1997 India 1997 France Yersinia enterocolitica Listeria monocytogenes Raw milk 1996 France Salmonella Raw milk Raw milk raw-milk-sold-in-Orem-and-Heber.html 5 New York State Department of Health: Campylobacter contamination found in raw milk http://www.health.ny.gov/press/releases/2010/2010-0129_campylobactor_contamination_in_raw_milk.htm 14 Guh et al., 2010 19 Kansas Department of Health and Environment: KDHE and KDA remind consumers of health risks tied to raw milk http://www.kdheks.gov/news/web_archives/2007/12042007a.htm 16 Heuvelink et al., 2009 Raw milk 67 Centers for Disease Control and Prevention Campylobacter jejuni infection associated with unpasteurized milk and cheese, MMWR 57(51&52):1377-1379. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5751a2.htm?s_cid=mm5751a 2_x 6 Teufel, P. 2003. Campylobacter spp. In: Roginski, H., Fuquay, J.W., Fox, P.F. (Eds.), Encyclopedia of Dairy Sciences. Academic Press, pp. 237-243. 34 Heuvelink et al., 2009 Raw milk 13 Teufel, 2003. Raw milk 75 Teufel, 2003. Raw-milk Morbier cheese Raw-milk Livarot, PontL’évêque cheese Raw-milk Mont d’Or cheese 113 De Buyser, M.-L., Dufor, B., Maire M., Lafarge, V. 2001. Implication of milk and milk products in food-borne diseases in France and in different industrialised countries.-International Journal of Food Microbiology 67:1-17. 25 Barton, M.D. 2002. Yersinia enterocolitica. In: Roginski, H., Fuquay, J.W., Fox, P.F. (Eds.), Encyclopedia of Dairy Sciences. Academic Press, pp. 2770-2776. 14 De Buyser et al., 2001 14 (1) De Buyser et al., 2001 13 1995 France 1995 France 1994 Canada 1993 France Listeria monocytogenes Salmonella 1994 Scotland 1992/1994 USA 1991 Japan Escherichia coli O157:H7 Escherichia coli O157:H7 Bacillus cereus 1990 France Salmonella 1989 England and Wales 1988 England Salmonella 1986 England and Wales 1986 Canada 1985 Finland 1985 Scotland 1985 USA 1985 Switzerland Salmonella Raw milk Escherichia coli O157:H7 Salmonella Salmonella Salmonella Staphylococcus aureus Staphylococcus aureus Campylobacter jejuni Salmonella 35 (4) De Buyser et al., 2001 Raw-milk Brie de Meaux cheese Raw-milk Mont d’Or cheese Raw-milk soft cheese Cheese made from raw goat’s milk Raw-milk soft cheese Raw milk UHT milk, pasteurisation process failed Cheese made from raw goat’s milk Raw-milk soft cheese Raw-milk cheese 25 (5) De Buyser et al., 2001 35 De Buyser et al., 2001 273 (1) De Buyser et al., 2001 1 De Buyser et al., 2001 14 De Buyser et al., 2001 201 Christiansson, A. 2002. Bacillus cereus. In: Roginski, H., Fuquay, J.W., Fox, P.F. (Eds.), Encyclopedia of Dairy Sciences. Academic Press, pp. 123-127. 277 De Buyser et al., 2001 42 De Buyser et al., 2001 155 300 Maguire, H.C.F., Boyle, M., Lexis, M.J., Pankhurst, J., Wieneke, A.A., Jacob, M., Bruce, J., O’Mahony, M., (1991). A large outbreak of food poisoning of unknown aetiologic associated with Stilton cheese. Epidemiol. Infect. 106, 497-505. De Buyser et al., 2001 Raw milk 46 De Buyser et al., 2001 Raw-milk farm cheese Raw goat’s milk 35 De Buyser et al., 2001 2 De Buyser et al., 2001 Raw milk 23 Raw milk 215 Teufel, P. 2003. Campylobacter spp. In: Roginski, H., Fuquay, J.W., Fox, P.F. (Eds.), Encyclopedia of Dairy Sciences. Academic Press, pp. 237-243. De Buyser et al., 2001 14 1984 England and Wales 1984 USA 1984 Canada 1984 Scotland Salmonella Raw milk 106 De Buyser et al., 2001 Campylobacter jejuni Salmonella Raw milk 12 > 1700 27 De Buyser et al., 2001 1983 France Staphylococcus aureus 20 De Buyser et al., 2001 1983 England and Wales 1982 Canada 1982 England and Wales 1982 England and Wales 1981 Scotland 1976 Canada 1972 Romania 1970-1979 Scotland 1949-1957 Germany Salmonella Raw-milk Cheddar cheese Cheese made from raw sheep’s milk Cheese made from raw sheep’s milk Raw milk Teufel, P. 2003. Campylobacter spp. In: Roginski, H., Fuquay, J.W., Fox, P.F. (Eds.), Encyclopedia of Dairy Sciences. Academic Press, pp. 237-243. De Buyser et al., 2001 182 De Buyser et al., 2001 Unknown De Buyser et al., 2001 Salmonella Raw-milk Cheddar cheese Raw milk 77 De Buyser et al., 2001 Salmonella Raw milk 68 (1) De Buyser et al., 2001 Salmonella Yersinia enterocolitica Bacillus cereus Raw milk Raw milk 654 (2) 138 Raw milk 221 Salmonella Raw milk 29 De Buyser et al., 2001 Barton, M.D. 2002. Yersinia enterocolitica. In: Roginski, H., Fuquay, J.W., Fox, P.F. (Eds.), Encyclopedia of Dairy Sciences. Academic Press, pp. 2770 2776. Christiansson, A. 2002. Bacillus cereus. In: Roginski, H., Fuquay, J.W., Fox, P.F. (Eds.), Encyclopedia of Dairy Sciences. Academic Press, pp. 123-127. Sharp et al., 1980 Listeria monocytogenes Raw milk ~100 Seeliger, H. P. R. 1961. Listeriosis. Hafner, New York. Staphylococcus aureus Salmonella 15 4 4.1 Risk management measures Measures applied in Estonia for managing zoonotic risks associated with raw milk Requirements for milk to be marketed in the European Union are established with Regulation (EC) No 853/2004 laying down specific hygiene rules for food of animal origin (Annex III, Section IX). Such requirements are also specified in Commission Regulation (EC) No 2073/2005 on microbiological criteria for foodstuffs. In Estonia, requirements for raw milk were established with Minister of Agriculture Regulation No 71 ‘Hygiene requirements for handling raw milk’ of 15 June 2006 (Riigi Teataja, 2006). Pursuant to this regulation, a milk producer who wishes to market raw milk directly to consumers must hold an animal-health certificate (issued for up to six months by an authorised veterinarian). The certificate is issued on condition that the milk producer has carried out the following analyses within the scope of selfinspection (the acceptability criteria of results are given in brackets): 1) determining the number of bacteria in 1 ml of bulk tank milk at a temperature of 30 o C – twice a month (≤ 100,000 *). * Rolling geometric average over two months, at least two samples per month 2) determining the somatic cell count per 1 ml of bulk tank milk – once a month (≤ 400,000**) ** Rolling geometric average over three months, at least one sample per month 3) Staphylococcus aureus count in bulk tank milk – once every two months (< 500/m) 4) determining antibiotic residue – once a month (does not exceed permitted maximum) A milk producer is also obliged to inform the competent authority and take appropriate measures to improve the situation if norms are exceeded. The above requirements do not apply to the small quantities of raw milk marketed directly from farms. Pursuant to subsection 5 (1) of Regulation No 71 of the Ministry of Agriculture, marketed quantities are considered small as follows: 1) raw cow’s milk – up to 100 kg per day or 700 kg per week; 2) raw goat’s milk – up to 20 kg per day; 3) raw sheep’s milk – up to 10 kg per day. Within the scope of state supervision, additional samples of bulk tank milk are taken from directmarketing dairy farms on the basis of the risk assessment prepared by the VTA. A sample is taken once a year, and in addition to the aforementioned quality indicators, it is also tested for the presence of L. monocytogenes and the S. aureus count. The samples are tested for other pathogens in the case of suspicion or tip-offs (VTA, oral information, 2013). VTA takes samples for raw milk POS according to its monitoring plan and the tests are the same as those done on samples obtained from dairy farms – the only difference is that the presence of L. monocytogenes is determined as a total count of L. monocytogenes (VTA, oral information, 2013). Also, selling raw milk directly to consumers is prohibited according to the rules of animal disease control after certain zoonoses have been diagnosed or zoonotic pathogens have been detected in a herd. Such zoonoses are bovine tuberculosis, bovine brucellosis and bovine salmonellosis (Riigi Teataja, 2011; 2004; 2013). The sale of raw milk is also prohibited pursuant to control rules (Riigi Teataja, 2010) when animals infected with the enzootic bovine leukaemia virus are detected in a herd, although this virus is not a threat to humans. Marketing unpasteurised goat’s and sheep’s milk is prohibited if brucellosis in sheep and goats is suspected or diagnosed, or when salmonellosis is detected in the flock (Riigi Teataja, 2008). Pursuant to §§ 451-453 of the Infectious Animal Disease Control Act, restrictions can be imposed on the herd or flock if an infectious disease is detected in respect of which there are no infectious animal disease control rules, but which threatens the health of animals or people according to risk analysis. It is possible to impose restrictions on the sale of milk on the basis of the above (Riigi Teataja, 2012). 16 4.2 Overview of measures applied in some European Union Member States for managing zoonotic risks associated with raw milk We received feedback from 11 EU Member States to the survey we conducted: Finland, Italy, Sweden, Denmark, Belgium, Slovakia, Germany, Latvia, Lithuania, the Netherlands and France. Sweden, Denmark and the Netherlands are the only countries among those that gave feedback where selling raw milk via retail channels is not permitted. In Sweden, only special traditional small-scale farms have the right to produce and sell raw milk-based dairy products for sale in small quantities during a summer season through farm gate (fäbod). In addition to the safety and quality criteria for marketed milk established with Regulations (EC) No 853/2004 and 2073/2005 of the European Parliament and of the Council, national requirements have been established in the following countries: Finland, Italy, Germany, Latvia, Lithuania, the Netherlands and France. The national criteria for raw milk established in Member States are very different. The criteria of the aerobic bacteria and somatic cell count in most countries complied with Regulation (EC) No 853/2004, although they are established for raw milk meant for industrial pasteurisation. Stricter requirements of the bacteria count have been established in Finland, Germany, the Netherlands and France. The maximum aerobic bacteria count established in said countries is 50,000 per ml of raw milk (rolling geometric average), whereas several subsamples must be analysed in Germany. Even larger differences in criteria became evident in respect of pathogenic microorganisms. The list of pathogenic microorganisms and biotoxins for which raw milk is tested in various countries included the following: S. aureus (coagulase-positive staphylococci in Germany), L. monocytogenes, Campylobacter spp., EHEC, Salmonella spp and aflatoxins. 25 ml of bulk tank was usually analysed to detect pathogens, while the sampling plan required obtaining five subsamples (n=5) and their laboratory testing. None of the subsamples could contain the pathogen for which it was tested (c=0). Testing for L. monocytogenes and Salmonella and determining the S. aureus count are required in most countries. The strictest requirements of the S. aureus count have been established in Germany (m=10, M=100, n=5), which can be explained by the ability of mentioned microbe to produce toxins. L. monocytogenes was usually analysed in bulk tank farm milk, with the requirement being its absence in 25 ml (n=5, c=0), but according to received information the criterion in France is 100 CFU/ml during the shelflife period (n=5, c=0, m=M). As for the production hygiene indicator bacteria for which raw milk is tested, the E. coli count is determined in France and the enterobacteria count is determined in Finland and Germany. The frequency of sampling depends on the quantity of raw milk sold; the larger the quantities of directly marketed raw milk, the more frequently laboratory tests have to be carried out. In Belgium, the existence of the HACCP system on the farm is required in the case of very large quantities of raw milk (more than 60,000 litres per year). Sellers of raw milk in all of the countries that responded are required to inform the consumer one way or another about the need to heat-treat the milk, and in most countries the relevant information also had to be given in writing on the packaging. A detailed overview of the effective requirements in different Member States is given in Annex 1. 5 Summary There are numerous pathogens in Estonia that are hazardous to people and can potentially be found in milk. The majority of widespread pathogens in Estonia that are transmitted by milk do not cause serious illness or a high number of death among people. The exceptions here are EHEC and salmonellas, which are 17 potentially very dangerous, especially to risk groups (children, elderly people, ill people), and whose prevalence in cattle herds in Estonia is relatively high. The prevalence of pathogens in appropriately produced milk is usually small and their count is low. However, the infective dose of some pathogens is so small that even if raw milk complies with the highest quality requirements, it may still be infectious (e.g. EHEC). It is important to keep in mind that several microbes can reproduce in milk and become infectious when preserved at temperatures higher than in a refrigerator, or produce toxins that pose a threat to people’s health. Also, some significant food pathogens are psychrotrophic, i.e. able to reproduce at low temperatures above zero (e.g. Listeria monocytogenes and Yersinia enterocolitica). In addition, it is impossible to check the risks related to viruses and parasites (e.g. tick-borne encephalitis virus, Toxoplasma gondii) with bacteriological quality and safety criteria. The registered incidence of potentially milk-borne zoonoses among people is low in Estonia in the case of most infections. Salmonellosis and campylobacteriosis are the exceptions here, as their incidence is relatively high. The way the pathogens were transmitted has often not been clarified in the case of foodborne zoonoses. Illnesses can only rarely be connected to the consumption of raw milk. The connections have been clearest when people are infected with tick-borne encephalitis (mainly due to the consumption of infected goat’s milk). A connection between the consumption of raw milk and the EHEC infection has also been identified. However, there are obvious shortcomings in Estonia in the system for registration of human infectious diseases and in capacity to carry out epidemiological studies to identify the sources of infection. The risk management measures presently implemented in Estonia rely mostly on self-inspection by producers, and the studies carried out within the scope of such self-inspection for determining quality and safety indicators. Studies carried out within the scope of supervision in addition to self-inspection by producers are relatively rare. The quality and safety requirements established for directly marketed raw milk do not differ significantly from the requirements of the milk sent to milk processing companies for pasteurisation. Compared to the studies of directly marketed raw milk in many other countries, the sampling scheme implemented here is relatively less sensitive (n=1) in terms of pathogen detection. The studies carried out in Estonia at present focus on studying the milk produced and do not cover the numerous significant zoonotic pathogens that are widespread in Estonia (EHEC, salmonella et al.). The potential prevalence of zoonotic pathogens in animals is also not considered as a permanent source of risk for milk contamination in herds from which raw milk for marketing is obtained. For example, proving that a herd is free of salmonella, EHEC, leptospira or another significant zoonosis is not required if the pathogen has not been found in bulk tank milk samples or the disease has not been diagnosed or detected in the herd due to a study carried out for different reasons. In conclusion, it can be said that the raw milk marketed in Estonia cannot be considered safe enough to recommend its consumption without pasteurisation. The risk management measures currently in place in Estonia are not sufficient to guarantee the safety of raw milk for consumers, but even if the efficiency of testing were boosted, it would still be impossible to fully guarantee safety. It is therefore important to inform consumers about potential risks and advise them to consume heat-treated milk, and to definitely not give unprocessed milk to people in risk groups (children, the elderly and ill people). 18 6 References 1) Ackers ML, Schoenfeld S, Markman J, Smith MG, Nicholson MA, DeWitt W, Cameron DN, Griffin PM, Slutsker L. An outbreak of Yersinia enterocolitica O:8 infections associated with pasteurized milk. J Infect Dis. 2000 May;181(5):1834-7. Epub 2000 May 15. 2) Apgar BS, Greenberg G, Yen G. Prevention of group B streptococcal disease in the newborn. Am Fam Physician. 2005 Mar 1;71(5):903-10. 3) Argudín MÁ, Mendoza MC, Rodicio MR. Food poisoning and Staphylococcus aureus enterotoxins. Toxins (Basel). 2010 Jul;2(7):1751-73. 4) Atiqur R, Bonny T S., Stonsaovapak S, and Ananchaipattana C, Yersinia enterocolitica: Epidemiological Studies and Outbreaks, Journal of Pathogens, vol. 2011, Article ID 239391, 11 pages 5) Bacci, S., S. Villumsen, P. Valentiner-Branth, B. Smith, K. A. Krogfelt, K. Mølbak, Epidemiology and Clinical Features of Human Infection with Coxiella burnetii in Denmark During 2006–07. Zoonoses Public Health. 59 (2012) 61-68 6) Barton, M.D. 2002. Yersinia enterocolitica. In: Roginski, H., Fuquay, J.W., Fox, P.F. (Eds.), Encyclopedia of Dairy Sciences. Academic Press, pp. 2770 2776. 7) Bolin, Carole A. Diagnosis and Control of Bovine Leptospirosis, Proceedings of the 6th Western Dairy Management Conference, March 12-14, 2003, Reno, NV—155 8) Bullman S, Corcoran D, O'Leary J, Lucey B, Byrne D, Sleator RD. Campylobacter ureolyticus: an emerging gastrointestinal pathogen? FEMS Immunol Med Microbiol. 2011 Mar;61(2):228-30. 9) CDC, Centre for Disease Control BC. Summary of food borne illnesses & outbreaks in North America associated with the consumption of raw milk and raw milk dairy products (2000-2011). 2012. http://www.bccdc.ca/NR/rdonlyres/628544F1-0533-48E8-9C968391952BEF96/0/RawMilkOutbreakTable2000_2011v2.pdf, accessed September 17, 2013. 10) CDC, Clostridium perfringens, Centers for Disease Control and Prevention (CDC), http://www.cdc.gov/foodsafety/clostridium-perfingens.html (26.09.2013) 11) CDC, Campylobacter jejuni infection associated with unpasteurized milk and cheese, Centers for Disease Control and Prevention MMWR 57(51&52):1377-1379. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5751a2.htm?s_cid=mm5751a2_x 12) CDC, Foodnet population survey, 2002–2003, Centers for Disease Control and Prevention, http://www.cdc.gov/foodnet/surveys/pop/2002/2002Atlas.pdf 13) Christiansson, A. 2002. Bacillus cereus. In: Roginski, H., Fuquay, J.W., Fox, P.F. (Eds.), Encyclopedia of Dairy Sciences. Academic Press, pp. 123-127. 14) Claeys, W.L., Cardoen, S., Daube, G., De Block, J., Dewettinck, K., Dierick, K., De Zutter, L., Huyghebaert, A., Imberechts, H., Thiange, P., Vandenplas, Y., Herman, L. 2013. Raw or heated cow milk consumption: review of risks and benefits. Food Control, 31, 251-262. 15) Costa LF, Paixão TA, Tsolis RM, Bäumler AJ, Santos RL. Salmonellosis in cattle: advantages of being an experimental model. Res Vet Sci. 2012 Aug; 93(1):1-6. 16) Cummings KJ, Warnick LD, Gröhn YT, Hoelzer K, Root TP, Siler JD, McGuire SM, Wright EM, Zansky SM, Wiedmann M. Clinical features of human salmonellosis caused by bovine-associated subtypes in New York. Foodborne Pathog Dis. 2012 Sep;9(9):796-802. 17) De Buyser, M.-L., Dufor, B., Maire M., Lafarge, V. 2001. Implication of milk and milk products in foodborne diseases in France and in different industrialised countries.-International Journal of Food Microbiology 67:1-17. 18) De Valk H, Delarocque-Astagneau E, Colomb G, Ple S, Godard E, Vaillant V, Haeghebaert S, Bouvet PH, Grimont F, Grimont P, Desenclos JC. A community--wide outbreak of Salmonella enterica serotype Typhimurium infection associated with eating a raw milk soft cheese in France. Epidemiol Infect. 2000 Feb;124(1):1-7. 19) Dehkordi FS, Borujeni MR, Rahimi E, Abdizadeh R. Detection of Toxoplasma gondii in raw caprine, ovine, buffalo, bovine, and camel milk using cell cultivation, cat bioassay, capture ELISA, and PCR methods in Iran. Foodborne Pathog Dis. 2013 Feb;10(2):120-5. 19 20) Deseret News: Salmonella outbreak linked to raw milk sold in Orem and Heber http://www.deseretnews.com/article/700032391/Salmonella-outbreak-linked-to-raw-milk-sold-in-Orem-andHeber.html 21) Dobler G, Gniel D, Petermann R, Pfeffer M. Epidemiology and distribution of tick-borne encephalitis. Wien Med Wochenschr. 2012 Jun;162(11-12):230-8. 22) Dominguez M, Jourdan-Da Silva N, Vaillant V, Pihier N, Kermin C, Weill FX, Delmas G, Kerouanton A, Brisabois A, de Valk H. Outbreak of Salmonella enterica serotype Montevideo infections in France linked to consumption of cheese made from raw milk. Foodborne Pathog Dis 2009; 6:121-128. 23) DuPont HL. The growing threat of foodborne bacterial enteropathogens of animal origin. Clin Infect Dis. 2007 Nov 15;45(10):1353-61. 24) Eibach, R., F. Bothe, M. Runge, S. F. Fischer, W. Philipp, M. Ganter, Q fever: baseline monitoring of a sheep and a goat flock associated with human infections. Epidemiol. Infect. (2012), 140, 1939-1949. 25) ECDC, Shiga toxin/verotoxin-producing Escherichia coli in humans, food and animals in the EU/EEA, with special reference to the German outbreak strain STEC O104, European Centre for Disease Prevention and Control and European Food Safety Authority. Stockholm: ECDC; 2011. 26) EFSA, European Food Safety Authority, Report on trends and sources of zoonoses, Estonia - 2011, EFSA 2012, http://www.efsa.europa.eu/en/scdocs/doc/zoocountryreport11ee.pdf 27) Farrokh C, Jordan K, Auvray F, Glass K, Oppegaard H, Raynaud S, Thevenot D, Condron R, De Reu K, Govaris A, Heggum K, Heyndrickx M, Hummerjohann J, Lindsay D, Miszczycha S, Moussiegt S, Verstraete K, Cerf O. Review of Shiga-toxin-producing Escherichia coli (STEC) and their significance in dairy production. Int J Food Microbiol. 2013 Mar 15;162(2):190-212. 28) Fayer R, Morgan U, Upton S J, Epidemiology of Cryptosporidium: transmission, detection and identification, International Journal for Parasitology 30 (2000) 1305-1322 29) FDA, U.S. Food and Drug Administration: Foodborne outbreak associated with raw milk from Tucker Adkins Dairy of York S.C. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm263158.htm 30) Flint JA, Van Duynhoven YT, Angulo FJ, DeLong SM, Braun P, Kirk M, Scallan E, Fitzgerald M, Adak GK, Sockett P, Ellis A, Hall G, Gargouri N, Walke H, Braam P. Estimating the burden of acute gastroenteritis, foodborne disease, and pathogens commonly transmitted by food: an international review. Clin Infect Dis. 2005 Sep 1;41(5):698-704. 31) Food Safety News: Raw milk still suspect in 14 Missouri E. coli cases. http://www.foodsafetynews.com/2012/05/missouri-says-14-e-coli-cases-may-be-from-rawmilk/#.Ui95FH9jYQM 32) Fredriksson-Ahomaa M, Stolle A, Korkeala H. Molecular epidemiology of Yersinia enterocolitica infections. FEMS Immunol Med Microbiol. 2006 Aug;47(3):315-29. 33) Fretz R, Svoboda P, Ryan UM, Thompson RC, Tanners M, Baumgartner A. Genotyping of Cryptosporidium spp. isolated from human stool samples in Switzerland. Epidemiol Infect. 2003 Aug;131(1):663-7. 34) Galindo CL, Rosenzweig JA, Kirtley ML, Chopra AK. Pathogenesis of Y. enterocolitica and Y. pseudotuberculosis in Human Yersiniosis. J Pathog. 2011;2011:182051. doi: 10.4061/2011/182051. Epub 2011 Sep 12. 35) Gillespie IA, Adak GK, O’Brien SJ, Bolton FJ. Milkborne general outbreaks of infectious intestinal disease, England and Wales, 1992-2000. Epidemiol Infect 2003; 130:461-468. 36) Gillespie IA, O'Brien SJ, Adak GK, Cheasty T, Willshaw G. Foodborne general outbreaks of Shiga toxinproducing Escherichia coli O157 in England and Wales 1992- 2002: where are the risks? Epidemiol Infect. 2005 Oct;133(5):803-8. 37) Goulet V, Jacquet C, Vaillant V, Rebière I, Mouret E, Lorente C, Maillot E, Stainer F, Rocourt J. Listeriosis from consumption of raw-milk cheese. Lancet 1995; 345;1581-1582. 38) Guh, A., Phan, Q., Nelson, R., Purviance, K., Milardo, E., Kinney, S., Mshar, P., Kasacek, W., Cartter, M. 2010. Outbreak of Escherichia coli O157 associated with raw milk, Connecticut, 2008. Clinical Infectious Diseases, 51 (12), 1411-1417. 20 39) Haguenoer E, Baty G, Pourcel C, Lartigue MF, Domelier AS, Rosenau A, Quentin R, Mereghetti L, Lanotte P. A multi locus variable number of tandem repeat analysis (MLVA) scheme for Streptococcus agalactiae genotyping. BMC Microbiol. 2011 Jul 27;11:171. 40) Headrick, M.L., Korangy, S., Bean, N.H., Angulo, F.J., Altekruse, S.F., Klontz, K.C. 1998. The epidemiology of raw milk-associated foodborne disease outbreaks reporter in the United States, 1973 through 1992. Am J Public Health, 88 (8), 1219-1221. 41) Heuvelink, A.E., van Heerwaarden, C. Zwartkruis-Nahuis, A. Tilburg, J.J.H.C., Bos, M.H., Heilmann, F.G.C., Hofhuis, A., Hoekstra, T., de Boer, E. 2009. Two outbreaks of campylobacteriosis associated with the consumption of raw cow’s milk. International Journal of Food Microbiology, 134 (1-2), 70-74. 42) Hiramoto RM, Mayrbaurl-Borges M, Galisteo AJ Jr, Meireles LR, Macre MS, Andrade HF Jr. Infectivity of cysts of the ME-49 Toxoplasma gondii strain in bovine milk and homemade cheese. Rev Saude Publica. 2001 Apr;35(2):113-8. 43) Hudopisk N, Korva M, Janet E, Simetinger M, Grgič-Vitek M, Gubenšek J, Natek V, Kraigher A, Strle F, Avšič-Županc T Tick-borne encephalitis associated with consumption of raw goat milk, Slovenia, 2012. Emerg Infect Dis. 2013 May;19(5):806-8. 44) Huffpost Healthy Living: Raw milk sickened 148 in Campylobacter outbreak last year http://www.huffingtonpost.com/2013/05/06/raw-milk-outbreak-campylobacter-148sickened_n_3223199.html 45) Hutchinson D. N., F. J. Bolton, P. M. Hinchliffe, H. C. Dawkins, S. D. Horsley, E. G. Jessop, P. A. Robertshaw, and D. E. Counter, Evidence of udder excretion of Campylobacter jejuni as the cause of milkborne campylobacter outbreak. J Hyg (Lond). 1985 April; 94(2): 205-215. 46) Janson M, Neare K, Hütt P, Orro T, Viltrop A, Lassen B, Zoonotic parasite infections among Estonian veterinarians compared with the general population, Presentation at the conference Veterinary Medicine 2013, Tartu, 24-26 October 2013. 47) Jones TO, Mair NS, Fox E. Caprine mastitis associated with Yersinia pseudotuberculosis infection. Vet Rec. 1982 Mar 6;110(10):231. 48) Juceviciene, A., Zygutiene, M., Leinikki, P., Brummer-Korvenkontio, H., Salminen, M., Han, X. & Vapalahti, O. (2005). Tick-borne encephalitis virus infections in Lithuanian domestic animals and ticks. Scand J Infect Dis 37, 742-746. 49) Järvis T, Veterinary Parasitology III Protozoan Diseases, Tartu ülikooli kirjastus, 2011, 77 pages. 50) Kalmus P, Aasmäe B, Kärssin A, Orro T, Kask K., Udder pathogens and their resistance to antimicrobial agents in dairy cows in Estonia. Acta Vet Scand. 2011 Feb 8;53:4. 51) Kansas Department of Health and Environment: KDHE and KDA remind consumers of health risks tied to raw milk http://www.kdheks.gov/news/web_archives/2007/12042007a.htm 52) Kerbo N, Donchenko I, Kutsar K, Vasilenko V. Tickborne encephalitis outbreak in Estonia linked to raw goat milk, May-June 2005. Euro Surveill. [1730 pii]. 2005;10(6):E050623. 53) Koziel M, Lucey B, Bullman S, Corcoran GD, Sleator RD. Molecular-based detection of the gastrointestinal pathogen Campylobacter ureolyticus in unpasteurized milk samples from two cattle farms in Ireland. Gut Pathog. 2012 Nov 14;4(1):14. 54) Kramarenko T, Studies of verotoxic E. coli O157 in Estonia. Presentation at the conference Veterinary Medicine 2013. http://veterinaarmeditsiin.ee/abstraktid 55) Krikmann Ü, Kalbe I, Lüüs S-M, Taba P, Õunapuu A, Tick-borne encephalitis – common viral infection of the nervous system. Eesti Arst 2007; 86 (4): 273-276 56) KTVZ.com News: Oregon E. coli outbreak traced to raw milk. http://www.ktvz.com/news/Oregon-E-ColiOutbreak-Traced-to-Raw-Milk/-/413192/15292378/-/8i28tjz/-/index.html 57) Langer, A. J., Ayers, T., Grass, J., Lynch, M., Angulo, F. J., Mahon, B. E. 2012. Nonpasteurized dairy products, disease outbreaks, and state laws - United States, 1993-2006. Emerging Infectious Diseases, 18, 385-391. 58) Lassen B, Viltrop A, Raaperi K, Järvis T. Eimeria and Cryptosporidium in Estonian dairy farms in regard to age, species, and diarrhoea. Vet Parasitol. 2009 Dec 23;166(3-4):212-9. 21 59) Lischer CJ, Leutenegger CM, Braun U, Lutz H. Diagnosis of Lyme disease in two cows by the detection of Borrelia burgdorferi DNA. Vet Rec. 2000 Apr 22;146(17):497-9. 60) Lund, B. M., & O’Brien, S. J. 2011. The occurrence and prevention of foodborne disease in vulnerable people. Foodborne Pathogens and Disease, 8, 961-973. 61) Lundén J, Tolvanen R, Korkeala H. Human listeriosis outbreaks linked to dairy products in Europe. J Dairy Sci 2004; 87:E6-E11. 62) Maguire, H.C.F., Boyle, M., Lexis, M.J., Pankhurst, J., Wieneke, A.A., Jacob, M., Bruce, J., O’Mahony, M., (1991). A large outbreak of food poisoning of unknown aetiologic associated with Stilton cheese. Epidemiol. Infect. 106, 497-505. 63) Mansfield KL, Johnson N, Phipps LP, Stephenson JR, Fooks AR, Solomon T. Tick-borne encephalitis virus a review of an emerging zoonosis. J Gen Virol. 2009 Aug;90(Pt 8):1781-94 64) Martínez PO, Fredriksson-Ahomaa M, Sokolova Y, Roasto M, Berzins A, Korkeala H. Prevalence of enteropathogenic Yersinia in Estonian, Latvian, and Russian (Leningrad region) pigs. Foodborne Pathog Dis. 2009 Jul-Aug;6(6):719-24. 65) Mazurek J, Salehi E, Propes D, Holt J, Bannerman T, Nicholson LM, Bundesen M, Duffy R, Moolenaar RL. A multistate outbreak of Salmonella enterica serotype typhimurium infection linked to raw milk consumption-Ohio, 2003. J Food Prot. 2004 Oct;67(10):2165-70. 66) Maurin, M. D. Raoult, Q Fever.Clinical Microbiology Reviews, 0893-8512/99/$04.0010, Oct. 1999, p. 518553 67) McNally A, Cheasty T, Fearnley C, Dalziel RW, Paiba GA, Manning G, Newell DG. Comparison of the biotypes of Yersinia enterocolitica isolated from pigs, cattle and sheep at slaughter and from humans with yersiniosis in Great Britain during 1999-2000. Lett Appl Microbiol. 2004;39(1):103-8. 68) Mughini Gras L, Smid JH, Wagenaar JA, de Boer AG, Havelaar AH, Friesema IH, French NP, Busani L, van Pelt W. Risk factors for campylobacteriosis of chicken, ruminant, and environmental origin: a combined casecontrol and source attribution analysis. PLoS One. 2012;7(8):e42599 69) Mändar R, Microbiology of Reproductive Tract Infections, E-course material, University of Tartu 2011, http://dspace.utlib.ee/dspace/bitstream/handle/10062/18409/suguteede_infektsioonide_mikrobioloogia_slaidid .pdf?sequence=2 (26.10.2013) 70) Natale A, Giurisato I, Marchione S, Bosello S, Di Martino G, Bonfanti L, Ceglie L. Viability of Leptospira interrogans serovar Hardjo in refrigerated raw milk, The 2nd Prato Conference on the Pathogenesis of Bacterial Diseases of Animals 2012, Abstracts, http://vetpath-2012prato.p.asnevents.com.au/event/abstract/2026 (05.10.2013) 71) Neare K, Kooskora, M, Aleksejev A, Jeremejeva J, Hütt P, Lassen B, Orro T, Viltrop A, First evidence of Qfever in ruminants and humans in Estonia, Poster presentations, Annual meeting of the Society for Veterinary Epidemiology and Preventive Medicine, Madrid, 2013. 72) New York State Department of Health: Campylobacter contamination found in raw milk http://www.health.ny.gov/press/releases/2010/2010-01-29_campylobactor_contamination_in_raw_milk.htm 73) Newkirk R, Hedberg C, Bender J. Establishing a milkborne disease outbreak profile: potential food defense implications. Foodborne Pathog Dis 2011; 8:433-437. 74) News Release. California department of food and agriculture: Organic pastures raw milk recall announced by CDFA. http://www.cdfa.ca.gov/egov/Press_Releases/Press_Release.asp?PRnum=11-064 75) Oliver SP, Boor KJ, Murphy SC, Murinda SE. Food safety hazards associated with consumption of raw milk. Foodborne Pathog Dis 2009; 6:793-806. 76) Pereira KS, Franco RM, Leal DA.Transmission of toxoplasmosis (Toxoplasma gondii) by foods. Adv Food Nutr Res. 2010;60:1-19. Shwimmer A, Freed M, Blum S, Khatib N, Weissblit L, Friedman S, Elad D. Mastitis caused by Yersinia pseudotuberculosis in Israeli dairy cattle and public health implications. Zoonoses Public Health. 2007;54(9-10):353-7. 77) Pyörälä S, Staphylococcal and Streptococcal Mastitis, in the book: Sandholm M, Honkanen-Buzalski T, Kaartinen L, Pyörälä S, Cow’s Udder and Udder Diseases, Estonian Veterinary Association, 1996, 295 pages. 22 78) Rea MC, Cogan TM, Tobin S. Incidence of pathogenic bacteria in raw milk in Ireland. J Appl Bacteriol. 1992 Oct;73(4):331-6. 79) Riigi Teataja, Infectious Animal Disease Control Act, RT I, 18.12.2012, 23 80) Riigi Teataja, Regulation No 71 of the Minister of Agriculture of 15.06.2006, Hygiene Requirements for Handling Raw Milk, RTL 2006, 49, 897 81) Riigi Teataja, Regulation No 39 of the Minister of Agriculture of 20.05.2013, Rules of Salmonellosis Control, RT I, 24.05.2013, 2 82) Riigi Teataja, Regulation No 120 of the Minister of Agriculture of 21.07.2004, Rules of Bovine Brucellosis Control, RTL 2004, 103, 1678 83) Riigi Teataja, Regulation No 61 of the Minister of Agriculture of 23.04.2004, Rules of Bovine Tuberculosis Control, RT I, 07.07.2011, 8 84) Riigi Teataja, Regulation No 16 of the Minister of Agriculture of 27.02.2008, Rules of Controlling Brucellosis in Sheep and Goats, RTL 2008, 19, 277 85) Riigi Teataja, Regulation No 17 of the Minister of Agriculture of 28.02.2007, Rules of Bovine Enzotic Leukosis Control, RT I, 07.07.2011, 9 86) Rimhanen-Finne R, Niskanen T, Hallanvuo S, Makary P, Haukka K, Pajunen S, Siitonen A, Ristolainen R, Pöyry H, Ollgren J, Kuusi M. Yersinia pseudotuberculosis causing a large outbreak associated with carrots in Finland, 2006. Epidemiol Infect. 2009 Mar;137(3):342-7. 87) Roasto M, Kramarenko T, Mäesaar M, Meremäe K, Serogroups of verotoxic E. coli in Estonia. Applied research project of the Ministry of Agriculture “Assessment of food safety risks associated with Campylobacter spp., Listeria monocytogenes and verotoxic Escherichia coli in Estonia” (Contract No T13057VLTH) 2013 annual report. 88) Roux F, Sproston E, Rotariu O, Macrae M, Sheppard SK, Bessell P, Smith-Palmer A, Cowden J, Maiden MC, Forbes KJ, Strachan NJ. Elucidating the aetiology of human Campylobacter coli infections. PLoS One. 2013 May 29;8(5):e64504. 89) Ruusunen M, Salonen M, Pulkkinen H, Huuskonen M, Hellström S, Revez J, Hänninen ML, FredrikssonAhomaa M, Lindström M. Pathogenic bacteria in Finnish bulk tank milk. Foodborne Pathog Dis. 2013 Feb;10(2):99-106. 90) Sahin O, Fitzgerald C, Stroika S, Zhao S, Sippy RJ, Kwan P, Plummer PJ, Han J, Yaeger MJ, Zhang Q. Molecular evidence for zoonotic transmission of an emergent, highly pathogenic Campylobacter jejuni clone in the United States. J Clin Microbiol. 2012 Mar;50(3):680-7. 91) Salupere R, Infalmmatory bowel disease in Estonia: a prospective epidemiologic study 1993-1998. World J Gastroenterol 2001;7(3):387-388. 92) Schiemann, D A, Toma S, Isolation of Yersinia enterocolitica from raw milk. Appl Environ Microbiol. 1978 January; 35(1): 54-58 93) Schildt M, Savolainen S, Hänninen M-L. Long-lasting Campylobacter jejuni contamination of milk associated with gastrointestinal illness in a farming family. Epidemiol Infect 2006; 134:401-405. 94) Schmidt BL, Aberer E, Stockenhuber C, Klade H, Breier F, Luger A. Detection of Borrelia burgdorferi DNA by polymerase chain reaction in the urine and breast milk of patients with Lyme borreliosis. Diagn Microbiol Infect Dis. 1995 Mar;21(3):121-8. 95) Schvartzman MS, Maffre A, Tenenhaus-Aziza F, Sanaa M, Butler F, Jordan K. Modelling the fate of Listeria monocytogenes during manufacture and ripening of smeared cheese made with pasteurised or raw milk. Int J Food Microbiol 2011; 145:S31-38. 96) Sechi LA, Scanu AM, Molicotti P, Cannas S, Mura M, Dettori G, Fadda G, Zanetti S. Detection and Isolation of Mycobacterium avium subspecies paratuberculosis from intestinal mucosal biopsies of patients with and without Crohn's disease in Sardinia. Am J Gastroenterol. 2005 Jul;100(7):1529-36.Adler B, de la Peña Moctezuma A. Leptospira and leptospirosis, Vet Microbiol. 2010 Jan 27;140(3-4):287-96. 97) Shahram Hanifian, Sajjad Khani, Prevalence of virulent Yersinia enterocolitica in bulk raw milk and retail cheese in northern-west of Iran, International Journal of Food Microbiology, Volume 155, Issues 1–2, 2 April 2012, Pages 89-92. 23 98) Sharp, J.C.M., Paterson, G.M., Forbes, G.I. 1980. Milk-borne salmonellosis in Scotland. Journal of Infection, 2 (4), 333-340. 99) Spickler, Anna Rovid. Campylobacteriosis. May 2005 (Last Updated). At http://www.cfsph.iastate.edu/DiseaseInfo/factsheets.php (16.09.2013) 100) Spickler, Anna Rovid. Cryptosporidiosis. May 2005 (Last Updated)." At http://www.cfsph.iastate.edu/DiseaseInfo/factsheets.php (16.09.2013) 101) Spickler, Anna Rovid. Enterohemorrhagic Escherichia coli Infections. May 2009 (Last Updated). At http://www.cfsph.iastate.edu/DiseaseInfo/factsheets.php (16.09.2013) 102) Spickler, Anna Rovid. Leptospirosis, May 2005 (Last Updated). At http://www.cfsph.iastate.edu/DiseaseInfo/factsheets.php (16.09.2013) 103) Spickler, Anna Rovid. Listeriosis. May 2005 (Last Updated). At http://www.cfsph.iastate.edu/DiseaseInfo/factsheets.php (12.09.2013) 104) Spickler, Anna Rovid. Paratuberculosis, April 2007 (Last Updated). At http://www.cfsph.iastate.edu/DiseaseInfo/factsheets.php (16.09.2013) 105) Spickler, Anna Rovid. Q-fever, April 2007 (Last Updated). At http://www.cfsph.iastate.edu/DiseaseInfo/factsheets.php (16.09.2013) 106) Spickler, Anna Rovid. Staphylococcal Enterotoxin B. May 2004 (Last Updated)." At http://www.cfsph.iastate.edu/DiseaseInfo/factsheets.php (16.09.2013) 107) StarTribune health: Salmonella outbreak that sickened 25 linked to raw milk http://www.startribune.com/lifestyle/health/208248661.html 108) State of Alaska Epidemiology. Bulletin. Ongoing raw milk Campylobacter outbreak – southcentral Alaska, July 2011. http://www.epi.alaska.gov/bulletins/docs/b2011_22.pdf 109) Šljapnikova L, Pirožkova L, Peetso R, Sudakova R, Zolotuhhina I, Zilmer K, Neiman R, Cryptosporidiosis in Children with Diarrhoeal Syndrome, Eesti Arst 1994;3190-193 110) Zolotuhhina I, Laan I, Aaremäe M, Peetso R, Erythrema nodosum and reactive arthritis as clinical manifestations of the immunological complications of yersiniosis and pseudotuberculosis in Estonian children. Eesti Arst 1996;2:119-124 111) Health Board (a), Communicable Diseases, Listeriosis, http://www.terviseamet.ee/nakkushaigused/nakkushaigused-a-u/l.html (16.09.2013) 112) Health Board (b), Communicable Diseases, Salmonellosis, http://www.terviseamet.ee/nakkushaigused/nakkushaigused-a-u/l.html (16.09.2013) 113) Health Board (c), Incidence of Communicable Diseases, http://www.terviseamet.ee/nakkushaigused/nakkushaigustesse-haigestumine.html (14.10.2013) 114) Teufel, P. 2003. Campylobacter spp. In: Roginski, H., Fuquay, J.W., Fox, P.F. (Eds.), Encyclopedia of Dairy Sciences. Academic Press, pp. 237-243. 115) The Merck Manual, Clostridium perfringens. Food Poisoning, Last full review/revision May 2013 by Joseph R. Lentino, http://www.merckmanuals.com/professional/infectious_diseases/anaerobic_bacteria/clostridium_perfringens_ food_poisoning.html?qt=cl perfringens&alt=sh (26.09.2013) 116) Thiermann AB. Experimental leptospiral infections in pregnant cattle with organisms of the Hebdomadis serogroup. Am J Vet Res. 1982 May;43(5):780-4. 117) Tick-borne encephalitis transmitted by unpasteurised cow milk in western Hungary, September to October 2011. Euro Surveill. 2012 Mar 22;17(12) 118) Todar Kenneth, Todar's Online Textbook of Bacteriology www.textbookofbacteriology.net (16.09.2013) 119) Uzoigwe JC, Khaitsa ML, Gibbs PS. Epidemiological evidence for Mycobacterium avium subspecies paratuberculosis as a cause of Crohn's disease. Epidemiol Infect. 2007 Oct;135(7):1057-68. 120) WBNG News: Campylobacter contamination found in raw milk in Tompkins County http://www.wbng.com/news/around-the-tiers/Campylobacter-Contamination-Found-in-Raw-Milk-inTompkins-County-130820728.html 24 121) Veterinary and Food Board (VTA), Zoonoses Report 2011, VTA, 2012, http://www.vet.agri.ee/static/files/1245.EESTI%20ZOONOOSIDE%20ARUANNE%202011.pdf (28.10.2013) 122) Veterinary and Food Board (VTA), Zoonoses Report 2012, VTA, 2013, http://www.vet.agri.ee/static/files/1269.EESTI%20ZOONOOSIDE%20ARUANNE%202012.pdf (28.10.2013) 123) Annual Report 2008 of Veterinary and Food Board, VTL, 2009 124) Annual Report 2009 of Veterinary and Food Board, VTL, 2010 125) Annual Report 2010 of Veterinary and Food Board, VTL, 2011 126) Annual Report 2011 of Veterinary and Food Board, VTL, 2012 127) Annual Report 2012 of Veterinary and Food Board, VTL, 2013 128) WFAA Local News: Raw milk under scrutiny after North Texas illness. http://www.wfaa.com/news/local/Raw-milk-under-scrutiny-after-North-Texas-illnesses-120321579.html 129) Vissers MM, Te Giffel MC, Driehuis F, De Jong P, Lankveld JM. Minimizing the level of Bacillus cereus spores in farm tank milk. J Dairy Sci. 2007 Jul;90(7):3286-93. 25 Annex 1. Raw milk intended for direct selling to customers. National criteria/requirements ESTONIA 33 (raw milk selling directly from farm, other selling point or at vending machine) Regulation (EC) No 853/2004 Section IX Raw milk, colostrum, dairy products and colostrumbased products Ministry of Agriculture Regulation (EE) No. 71 ≤ 100.000** ≤ 100.000 (bulk tank milk) ≤ 400.000 *** ≤ 400.000 (bulk tank milk) NR NR (ones < 500 per (ones per month; two bulk months) tank milk) Aflatoxins Enterobacteria Salmonella VTEC/STEC Campylobacter L. monocytogenes S. aureus/CPS CFU per ml Antibiotic residues Legislation Somatic cell count per ml Country Number of holdings* Aerobic plate count CFU at 30 °C per ml Criteria for raw milk Sampling frequency and location Comments Has to meet all requirements and criteria of the Regulation (EC) No 853/2004 Section IX. General hygiene rules according to Regulation (EC) No 853/2004. Veterinary certificate is needed what is given by official veterinarian after every 6 months if all requirements are fulfilled 26 Absence in 25 ml; n=1, c=0 (has been sampled in very few cases only; bulk tank milk) According to risk assessment; Regulation (EC) 2073/2005 has been considered with regard to RTE Aflatoxins Enterobacteria Salmonella VTEC/STEC Comments Campylobacter L. monocytogenes Antibiotic residues Somatic cell count per ml National legislation Plate count CFU at 30 °C per ml Country S. aureus/CPS CFU per ml < 500 (ones per year; bulk tank milk) State surveillance program Absence in 25 ml (ones per year; bulk tank milk; n=1, c=0)); 100 cfu/ml [m=M; n=1 c=0] when from selling point e.g. 27 FINLAND National requirements Ministry of Agriculture and Forestry Regulation NB: there are no vending machines in Finland yet. 50.000 (n=1, c=0) 250.00 (n=1, c=0) NR Absence in 25 ml bulk tank milk n=5, c=0 STEC O26, O103, O111, O145, O157 Absence in 25 ml bulk Absen tank milk ce in n=5, c=0 Absence in 25 ml 25 ml bulk goat O157 tank milk milk n=5, c=0 Absence in n=5, faecal material c=0 (ones in a period from July to November; dairy farm) m=100 cfu/ml; M=500 cfu/ml; n=5, c=2 Obligatory consumer information in written form: Product is the raw milk and may contain pathogenic microorganisms; heat treatment needed for risk groups (children, elderly, pregnant, diseased) Self-control program together with sampling plan and frequency; Constructional and functional demands to the building etc. 28 ≤ 400.000 NR Abs ence in 25 ml; n=5, c=0 Aflatoxins Absence in 25 ml; n=5, c=0 VTEC O157 Absence in 25 ml; n=5, c=0 Enterobacteria L. monocytogenes Absence in 25 ml; n=5, c=0 Salmonella ≤ 100.000 n=5, m=500 , M=20 00 VTEC/STEC Provisions of ISR 2007 (Intesa Stato Regioni, 2007a): Regional Competent Authority is responsible for devising and implementing monitoring plans for raw milk safety and hygiene and for continuous control of microbiologica l criteria Comments Campylobacter The sale of raw milk for human consumption by self-service vending machines has been allowed in Italy since 2004. 1032 dairy herds in 2010. Each herd can supply one or more vending machines; 1424 authorized vending machines (02.11.2012); Vending machines can be installed at farm or market S. aureus/CPS CFU per ml Ordinance by the Ministry of Health: vending machine should display information that raw milk should be boiled Antibiotic residues ITALY Somatic cell count per ml National legislation Plate count CFU at 30 °C per ml Country ≤ 50 ppm 29 SWEDEN DENMARK Aflatoxins Enterobacteria Salmonella VTEC/STEC Campylobacter L. monocytogenes S. aureus/CPS CFU per ml Antibiotic residues Somatic cell count per ml National legislation Plate count CFU at 30 °C per ml Country Comments Traditional production in small scale farms during the summer season is possible for direct sales at the farm gate (fäbod). It is related with unpasteurised milk products (cheese stored at least 60 days, whey products and butter). Based on traditional farming where the dairy cows are kept on pastures away from the main farm and dairies. Not allowed to sell raw milk through the normal retail channels Not allowed to sell BELGIUM National Regulation will be soon introduced, based on Reg. No 853/2004 and 852/2004 NR ≤ 100.000** ≤ 400.000 *** Rapid test may be used Sales channels: On the production site; Itinerant trade; Milk vending machine; Local retail trade (selling directly to final consumers). Sampling frequency is based on raw milk quantities – smaller quantities frequency reduced by half (to once a month). 30 Aflatoxins Enterobacteria Salmonella NR VTEC/STEC ≤ 400.000 Comments Campylobacter ≤ 100.000** L. monocytogenes Indication on vending machine that raw milk should be boiled prior consumption S. aureus/CPS CFU per ml SLOVAKIA Antibiotic residues National legislation Somatic cell count per ml Country Plate count CFU at 30 °C per ml Smaller quantities: up to 15.000 litres of cow milk and 2000 litres from other species per year. Larger quantities: up to 60.000 litres cow milk and 8.000 litres from other species per year. If unlimited quantities than HACCP is required. *** 31 Bottled raw milk shelflife max 96 hours at +8 °C (max.) Tierische LebensmittelHygieneverord nung (TierLMHV), §17, 18 and Annex 2 m=20.000 M=50.000 n=5 c=2 m=200.0 00 M=300.0 00 n=5 c=2 NR Coagulas epositive Staphyl o cocci (CPS) m=10 M=100 n=5 c=2 Aflatoxins Enterobacteria Salmonella VTEC/STEC Comments Campylobacter L. monocytogenes S. aureus/CPS CFU per ml Generally not allowed but farmer may request specialty to sell raw milk (Vorzugsmilch) directly to retail stores or from farm Antibiotic residues GERMANY Somatic cell count per ml National legislation Plate count CFU at 30 °C per ml Country Sampling monthly basis and all conformities with criteria have to be verified within farm selfcontrol program Absence in bulk tank milk Absence in bulk tank milk Absence in bulk tank milk m=0 M=0 n=5 c=0 Enterob acteriac eae m=10 M=100 n=5 c=2 Abse nce in bulk tank milk No foodborne pathogens and their toxins No mastitis pathogens Phosphatase test has to be positive Sensory control Haemolytic streptococcus bacteria (ones per months) Absence in 1 ml 32 Instruction of Cabinet of Ministers No. 123/2010 Regarding raw milk and raw milk products. This national legislation act has direct bond with Veterinary Law in Latvia as well as with Regulation (EC) No 853/2004 Section IX (raw milk) Aflatoxins Enterobacteria Salmonella VTEC/STEC NR Campylobacter ≤ 400.000 L. monocytogenes ≤ 100.000 Comments S. aureus/CPS CFU per ml Antibiotic residues LATVIA Somatic cell count per ml National legislation Plate count CFU at 30 °C per ml Country On the vending machine it should be the following information: Raw milk, boil before consumption, use by date (no longer than 48h after milking); address and name of the producer. If the machine is fully automatic the same information should be on bottle too. Milk in vending machine should be only from one farm. Some rules just for vending machines: material, temperature requirements etc. Farmer can also sell the raw milk directly to consumers but requirements related with Act No. 123/2010 should be fulfilled. 33 ≤ 100.000 ≤ 400.000 NR n=5; c=2; m=500 cfu/ml; M=2000 cfu/ml Aflatoxins Enterobacteria Salmonella VTEC/STEC Comments Campylobacter L. monocytogenes S. aureus/CPS CFU per ml Regulation (EC) No 853/2004 Also 1661/2009 regulation III annex IX section. Hygiene Norm HN 26:2006 “Microbiologi c al criteria for food products” Antibiotic residues LITHUANIA Somatic cell count per ml National legislation Plate count CFU at 30 °C per ml Country n=5; c=0; abse nt in 25 ml 34 NETHERLAN DS Warenwetbeslu it hygiene van levensmiddele n, Artikel 8 ≤ 50.000** NR m=100 M=500 n=5 c=2 Abs ence in 25g n=5 c=0 Aflatoxins Enterobacteria Salmonella VTEC/STEC Comments Campylobacter L. monocytogenes S. aureus/CPS CFU per ml Antibiotic residues Somatic cell count per ml National legislation Plate count CFU at 30 °C per ml Country Raw milk (cow), intended for direct selling to customers, is only present: 1st on the farm where the milk is collected; 2nd in a recipient not suitable to sell directly to the customer. (So not bottled.) When the raw milk isn’t sold within 2 hours after milking, it is chilled: a) When sold within 24 hours: 8 ºC or lower. b) When sold after 24 hours: 6 ºC or lower. On or in the direct environment of the recipient is displayed the following information: RAW MILK, BOIL BEFORE USE (Rauwe melk voor gebruik koken.) 35 For sheep and goats ≤ 500.000 rolling geometric average while sampling frequency is based on risk analyse Bulk tank milk Abse nce in 25g n=5 c=0 durin g selflife For sheep and goat milk E. coli n=5 c=0 m=10 cfu/ml M=100 cfu/ml Bulk tank milk Aflatoxins For cattle milk E. coli n=5 c=0 m=10 cfu/ml M=100 cfu/ml Bulk tank milk Enterobacteria Salmonella Campylobacter L. monocytogenes For cattle milk: n=5, c=0 m=M 100 cfu/ml during product self-life Comments VTEC/STEC For cattle milk ≤ 50.000 rolling geometric average while sampling frequency is based on risk analyse Bulk tank milk S. aureus/CPS CFU per ml Recent national regulation: Arrete of 13/07/2012 Applicable to raw milk of cows, sheep, goats Antibiotic residues FRANCE Somatic cell count per ml National legislation Plate count CFU at 30 °C per ml Country Need of approval from district vet services. Cooling of raw milk immediately after milking, kept at 0-4 ºC, except if selling less than 2 h after milking. Only milks of 2 successive milking or milking within 24 h can be mixed. Selling in hermetically sealed individual packages or vending machines, with requirements described in Article 7. Microbiological criteria for L.m.; Salmonella; E. coli and total count. 36 * The number of holdings with permission of raw milk selling for direct consumption purpose in big quantity, except selling in small quantity (up to 100 kg cow’s milk per day or 700 kg per week; goat milk up to 20 kg per day; ewe raw milk up to 10 kg per day). ** Rolling geometric average over a two month period with at least two samples per months *** Rolling geometric average over a three-month period, with at least one sample per month NR, no residues [Raw milk is not placed on the market if either: it contains antibiotic residues in a quantity that, in respect of any one of the substances referred to in Annexes I and III to Regulation (EEC) No 2377/90, exceeds the levels authorised under that Regulation; or the combined total of residues of antibiotic substances exceeds any maximum permitted value]. NB: Information from different countries has been collected through contact persons at veterinary authorities. 37