Outbreaks Due to Unpasteurized Dairy Products in the United States Casey Barton Behravesh, DVM, DrPH, DACVPM LCDR, US Public Health Service Enteric Diseases Epidemiology Branch National Center for Zoonotic, Vectorborne, and Enteric Diseases July, 009 The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
Pasteurization and Public Health Late 800s Developed by Louis Pasteur Originally intended to prevent wine spoilage Early 900s Introduced to eliminate milkborne pathogens 948 First statewide requirement (Michigan) 987 FDA bans interstate sale of unpasteurized dairy products
Current State of Regulations Interstate sale prohibited by FDA Intrastate sale regulated by states 5 states permitted sale during 993 006 Challenges to regulations Attempts to circumvent rules Attempts to seek legislative nullification
Policy Analysis Do restrictions on state raw milk sales reduce raw milk outbreaks? 87% of raw milk outbreaks during 973 99 in states that permitted intrastate sale CDC expanded analysis for 993 006
Policy Analysis Methods Outbreak summary data reported to CDC Foodborne Outbreak Reporting System All outbreaks that implicated milk or cheese Conducted descriptive analysis of outbreak data Surveyed states to determine legal status Calculated incidence of outbreaks in states Compared incidence by states legal status
Outbreaks 3 Dairy Product Outbreaks,837 Cases 3 Hospitalizations 3 Deaths 74 Unpasteurized,600 Cases 0 Hospitalizations Deaths 48 Pasteurized,3 Cases 30 Hospitalizations Death
Etiologies Unpasteurized Brucella, 3 (4%) Listeria, 3 (4%) Shigella, (3%) STEC, 0 (4%) Salmonella 6 (%) Campylobacter 4 (55%)
Etiologies Pasteurized Listeria,, 3% Bacillus cereus,, 3% Shigella,, 3% Clostridium perfringens,, 7% Staphylococcus aureus, 3, 0% Norovirus, 3, 44% Campylobacter, 3, 0% Salmonella, 6, 0%
Reports by Year 5 0 5 0 5 0 Enhanced Surveillance Implemented 993 994 995 996 997 998 999 000 00 00 003 004 005 006 Unpasteurized Pasteurized
Seasonal Distribution Outbreaks 6 4 0 8 6 4 0 3 4 5 6 7 8 9 0 Months Brucella spp. Campylobacter spp. Listeria monocytogenes Salmonella enterica Shigella spp. STEC Norovirus Toxic Other/Unknown
Unpasteurized product outbreaks, by state 993 006 (N = 74) AK CA 4 OR 3 WA 8 NV ID 3 AZ MT WY 3 NE OH IL IN UT CO WV VA 3 KS MO KY 3 NM ND SD TX 4 OK 3 MN IA AR LA WI 5 MS MI TN AL GA VT NH SC PA FL NC NY 4 ME MD CT NJ MA RI HI
Pasteurized product outbreaks, by state 993 006 (N = 48) CA 6 OR WA NV ID AZ MT WY IA NE OH IL IN UT 3 CO 3 KS MO KY WV VA NM ND SD OK MN AR WI MI TN VT NH SC PA 3 NC NY 3 ME MD 3 CT NJ MA RI AK TX LA MS AL GA FL HI
States Legal Status Responses received from all 50 states Seven (4%) changed status during period Three legalized sales Three prohibited sales One prohibited sales and then relegalized (49%) of remaining states permitted sales
Legal Status 993 993 WA OR NV CA ID UT MT WY CO ND SD NE KS MN IA MO WI IL MI IN OH KY NH VT NY PA WV VA ME MA RI CT NJ AZ NM OK AR TN SC NC MD MS AL GA AK TX LA FL HI Permit Sale of UDP Prohibit Sale of UDP
Legal Status 999 999 WA OR NV CA ID UT MT WY CO ND SD NE KS MN IA MO WI IL MI IN OH KY NH VT NY PA WV VA ME MA RI CT NJ AZ NM OK AR TN SC NC MD MS AL GA AK TX LA FL HI Permit Sale of UDP Prohibit Sale of UDP
Legal Status 006 006 WA OR NV CA ID UT MT WY CO ND SD NE KS MN WI IA IL MO MI OH IN KY NH VT NY PA WV VA ME MA RI CT NJ AZ NM OK AR TN SC NC MD MS AL GA AK TX LA FL HI Permit Sale of UDP Prohibit Sale of UDP
Unpasteurized Product Incidence (993 006) Sum of Annual Population of U.S. during 993 006 = 3.9 Billion Person-Years Sale Permitted. Billion Person-Years 56 Outbreaks 045 Cases Sale Prohibited.7 Billion Person-Years 5 Outbreaks 44 Cases
Unpasteurized Product Incidence Sale Permitted 56 /.B =.54* 045 /.B = 47.45* (993 006) Sale Prohibited 5 /.7B = 0.88* 44 /.7B = 4.8* Incidence Density Ratios Outbreaks:.54 / 0.88 =.90 (95% CI =.67 5.0) Cases: 47.45 / 4.8 =.96 (95% CI =.70.4) * per 00 million person-years
Conclusions Unpasteurized product consumption continues to cause illness and outbreaks Outbreaks are associated with inadequate regulations restricting unpasteurized products Unpasteurized product outbreaks are more common and cause more severe illness than pasteurized product outbreaks
Limitations Outbreak surveillance data limited Outbreaks likely underreported Some outbreaks have limited information Data not adjusted for prevalence of unpasteurized product consumption
Recommendations Further restrict/prohibit distribution of unpasteurized dairy products Educate consumers about health risks of consuming unpasteurized products Local, state, and federal public health partners Clinicians Consumer and advocacy groups
CDC. Campylobacter jejuni infection associated with unpasteurized milk and cheese--kansas, 007. MMWR Morb Mortal Wkly Rep 009;57:377-379. CDC. Escherichia coli 057:H7 infections in children associated with raw milk and raw colostrum from cows California, 006. MMWR Morb Mortal Wkly Rep 008;57:65-68. CDC. Outbreak of multidrug-resistant Salmonella enterica serotype Newport infections associated with consumption of unpasteurized Mexican-style aged cheese--illinois, March 006-April 007. MMWR Morb Mortal Wkly Rep 008;57:43-435. CDC. Salmonella Typhimurium Infection Associated with Raw Milk and Cheese Consumption --- Pennsylvania, 007. MMWR Morb Mortal Wkly Rep 56;6-64. CDC. Escherichia coli O57:H7 Infection Associated with Drinking Raw Milk --- Washington and Oregon, November--December 005. MMWR Morb Mortal Wkly Rep 56;65-67. CDC. Multistate Outbreak of Salmonella Serotype Typhimurium Infections Associated with Drinking Unpasteurized Milk --- Illinois, Indiana, Ohio, and Tennessee, 00 003. MMWR Morb Mortal Wkly Rep 5;63-65. CDC. Outbreak of Campylobacter jejuni Infections Associated with Drinking Unpasteurized Milk Procured through a Cow-Leasing Program --- Wisconsin, 00. MMWR Morb Mortal Wkly Rep 5;548-549. CDC. Outbreak of Listeriosis Associated With Homemade Mexican-Style Cheese --- North Carolina, October 000--January 00. MMWR Morb Mortal Wkly Rep 50;560-. CDC. Outbreak of Escherichia coli O57:H7 Infection Associated With Eating Fresh Cheese Curds --- Wisconsin, June 998. MMWR Morb Mortal Wkly Rep 49;9-3. CDC. Campylobacteriosis Associated with Raw Milk Consumption Pennsylvania. MMWR Morb Mortal Wkly Rep 3;337-8,344. www.cdc.gov/mmwr
Acknowledgments Adam Langer Frederick Angulo Tracy Ayers Julian Grass Michael Lynch Patricia Griffin Gail Stennies Jeff Lybarger John Sheehan Morrie Potter (FDA) State and local health departments The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
Questions? The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention