Public Health Risks in Asia s Growing Dairy Sector Joachim Otte (FAO, Bangkok) Dairy Asia Towards Sustainability Bangkok, Thailand, 22 May 2014
Building Bridges, Supporting Livelihoods Hazards and characteristics Prevalence and exposure Human health impacts / burden Conclusions and recommendations Menu 2
Microbial Brucella spp. Mycobacterium spp. Campylobacter spp. Escherichia coli (STEC) Listeria monocytogenes Salmonella spp. Staphylococcus aureus Yersinia enterocolitica Cryptosporidium, etc 22/May/2014 3 Milk Contaminants Chemical Heavy metals (lead, copper, cadmium, etc.) Aflatoxins / mycotoxins Pesticides and other agrochemicals Drug residues (antibiotics, anti-inflammatories, etc.) Preservatives (formalin) Etc. 3
Building Bridges, Supporting Livelihoods Contamination Routes Systemic cow diseases (e.g. bovine tuberculosis, brucellosis) Infection of the cow's udder (mastitis) Bacteria that live on the skin of cows Environment (e.g. feces, dirt, processing equipment) Insects, rodents, and other animal vectors Human actions accidental deliberate 4
Building Bridges, Supporting Livelihoods Exposure: Milk Consumption 175 150 125 75 50 25 0 kg/capita/year (2009) Product Whole 22/May/2014 South Asia East Asia Southeast Asia Source: FAOSTAT 5 5
Building Bridges, Supporting Livelihoods Brucella spp. Agent: Gram-, non-motile, cocco-bacillus Ecology: Concentration in milk, urine and genital fluids of infected animals Manifestation: Undulating fever, arthralgia, arthritis, orchitis, endocarditis Illness: severe, not selflimiting 6
Endemic: Bangladesh, China, India, Iran, Indonesia, Malaysia, Mongolia, Myanmar, Nepal, Pakistan (sero-prev. 5%) Sporadic: Bhutan, Cambodia, Lao PDR, ROK, Thailand, Viet Nam (seroprev. < 1%) Absent: Australia, Japan, NZ 22/May/2014 7 Brucellosis in Cattle 7
Human cases /,000 / year 10 to 50: Iran (15), Mongolia (16) 2 to 10: China (3), India, Pakistan <0.1: Aust., Japan, Malaysia, NZ, Thailand, ROK 0.1 to 2: Others? 22/May/2014 8 Brucellosis in Humans Brucellosis risk factors in Pakistan: - Drinking of un-boiled milk OR = 2.25 - Handling of cows OR = 5.73 (Mukhtar 2010) 40 35 30 25 20 15 10 5 0 C-B of 10-year vaccination in Mongolia Cost Benefits Priv. income Priv. health exp. Pub. health exp. Ag. Sector Vaccination 8
Building Bridges, Supporting Livelihoods Listeria monocytogenes Agent: Gram+, motile rod Ecology: ubiquitous in the environment, saprophytic in animals, can grow at 0 o C Manifestation: meningitis, meningo-encephalitis, brain abscess, cerebritis often preceded by diarrhea or other g.i. symptoms Illness: severe, not selflimiting 9
IRA1 IRA2 IRA3 IRA4 IRA5 IND1 IND2 MAL CHI IRA1 IRA2 IRA3 IRA4 IRA5 IRA6 IRA7 IRA8 IRA9 IRA10 IRA11 IRA12 % positive samples 80 60 L. monocytogenes Raw milk (various species) Milk products (various) 80 60 40 40 Cheese Ice cream 20 20 0 0 22/May/2014 10 10
Building Bridges, Supporting Livelihoods Agent: Gram- motile rod, high genetic diversity Escherichia coli Ecology: Commensal in lower intestine of warm-blooded animals Manifestation: (STEC, e.g. O157) severe acute haemorrhagic diarrhea, abdominal cramps, no fever Illness: severe but usually self-limiting 11
IRA1 IRA2 IRA3 IND1 IND2 IND3 PAK1 PAK2 PAK3 MAL1 MAL2 IRA1 IRA2 IND1 IND2 IND3 NEP PAK THA % positive samples E. coli, all Serotypes Raw milk (various species) Past. milk & products (various) 80 60 40 80 60 40 20 20 Past. Past. 0 0 22/May/2014 12 12
IRA1 IRA2 IRA3 IRA4 IRA5 IND MAL1 MAL2 MAL3 MAL4 % positive samples 80 60 Raw milk (various species) E. coli O157 Milk products (various) Iran: 3 of 45 (7%) samples positive (Momtaz et al., 2012) 40 20 0 22/May/2014 13 13
Building Bridges, Supporting Livelihoods Salmonella enterica Agent: Gram-, motile rod Ecology: intestinal tract of many animal species (warm and cold-blooded), environment Manifestation: diarrhea, fever, vomiting, and abdominal cramps Illness: serious but usually self-limiting 14
IND1 IND2 IND3 IND4 PAK MAL1 MAL2 CHI % positive samples Salmonella enterica spp. Raw milk (various species) Pasteurized milk and milk products (various) 80 60 40 20 0 India: 0 of 12 samples of past. milk Nepal: 1 of 72 ice cream samples from shops in Kathmandu Thailand: 0 of samples of past. milk 22/May/2014 15 15
Building Bridges, Supporting Livelihoods Campylobacter jejuni & coli Agent: Gram-, motile spiral bacteria within host, coccal outside host Ecology: Gut commensal of birds, transient infection of mammals, environment Manifestation: diarrhea with cramps, fever and pain Illness: severe but usually self-limiting, Guillain-Barré 16
IRA1 IRA2 IRA3 IRA4 PAK THA IRA1 IRA2 IRA3 IRA4 IRA5 IRA6 IRA7 IRA8 IRA9 IRA10 IRA11 IRA12 PAK % positive samples 80 60 40 20 Campylobacter Raw milk (various species) Milk products (various) 80 60 40 20 0 0 22/May/2014 17 17
Building Bridges, Supporting Livelihoods Staphylococcus aureus Agent: Gram+, clustered coccal bacteria Ecology: Found on skin of humans and cause of mastitis Manifestation: toxin-induced abdominal pain, cramping, diarrhea, vomiting and fever Illness: moderate, usually self-limiting 18
IRA1 IRA2 IRA3 IND1 IND2 IND3 IND4 IND5 IND6 IND7 MAL1 MAL2 MAL3 MAL4 MAL5 IND IRA1 IRA2 IRA3 IRA4 IRA5 IRA6 IRA7 IRA8 IRA9 MAL1 MAL2 % positive samples 80 60 Staphylococcus aureus Raw milk (various species) Milk products (various) 80 60 40 20 0 40 20 0 Ice cream 22/May/2014 19 19
Building Bridges, Supporting Livelihoods Cryptosporidium spp. Agent: protozoa, subclass coccidiasina Ecology: completes lifecycle in one host and persists as oocysts in environment (water) Manifestation: watery diarrhea 2 to 10 days after infection, camps, low fever Illness: moderate, usually self-limiting 20
Bhutan Nepal India Pakistan Iran Mongolia China ROK Japan Myanmar Lao PDR Philippines Thailand Indonesia Viet Nam Malaysia Diarrhea DALYs /,000-500 1,000 1,500 2,000 22/May/2014 21 Burden of GI disease Source: GBD 2004 Attribution??? Pathogen / Agent Virus (e.g. norovirus) Bacteria (e.g. vibrio) Protozoa (e.g. amoeba) Toxin Source Water Environment Food 21
GI and Milk, Minnesota Reported GI pathogens, Minnesota 2001-2010 12% Campylo E coli O157 Campylo Non O157 Cryptosp Exposure to raw milk 31% 3% 7% 14,399 cases 47% Non O157 STEC Salmonella Cryptosp 22/May/2014 22 E coli O157 Salmonella 0 2 4 6 8% Exposure: in all patients: 3.7% 5 years: 76%!!! Source: Robinson et al., 2014 22
Building Bridges, Supporting Livelihoods Aflatoxins Class of toxins produced by molds Aspergillus flavus and A. parasiticus App. 20, of which B 1, B 2, G 1 and G 2 most common Aflatoxins M 1, M 2 - metabolites of B 1 and B 2 - in the milk of animals fed on moldy grain MRL in milk: USA 500 nanogram/l; EU 50 ng/l Damage the liver leading to necrosis, cirrhosis and cancer Suppress the immune system Acute poisoning: Abdominal pain, vomiting, convulsions, edema, hemorrhaging Chronic poisoning: Growth and development impairment, liver cancer 23
IRA1 IRA2 IRA3 PAK1 PAK2 PAK3 PAK4 CHI1 CHI2 THA1 THA2 THA3 IDO1 IDO2 % samples > EU MRL Building Bridges, Supporting Livelihoods AFM 1 in Milk 80 60 40 20 0 24
MRL EC MRL US IRA1 IRA2 IRA3 IRA4 IND1 IND2 PAK1 PAK2 PAK3 PAK4 PAK5 THA CHI Nanogram/L Max AFM 1 concentrations found,000 AFM 1 in Milk 10,000 1,000 10 1 22/May/2014 25 25
IRA1 IRA2 IRA3 IRA4 IRA5 IND1 IND2 PAK1 PAK2 PAK3 PAK4 PAK5 PAK6 PAK7 PAK8 PAK9 THA IDO1 IDO2 CHI 90 80 70 60 50 40 30 20 10 0 % Samples > US MRL AFM 1 in Milk 22/May/2014 26 26
Burden of Liver Cancer Liver cancer DALYs /,000 Pakistan Nepal Bhutan Iran India Sri Lanka Mongolia ROK China Japan 1,500 Thailand Lao PDR Viet Nam Cambodia Indonesia Philippines Myanmar Malaysia - 200 300 400 500 22/May/2014 27 27
Building Bridges, Supporting Livelihoods Heavy metals Cadmium, copper, chromium, lead (Pb), etc. Sources: industrial production processes, road traffic, coal and gas-fired power stations Accumulation in kidneys, liver and bone-marrow, Interferes with development of nervous system (children!!) Symptoms: abdominal pain, headache, anemia, seizures, coma Effects on kidneys and blood reversible, those on nervous system not MRL in milk: 20 micro-gram per liter 28
MRL IRA1 IRA2 IRA3 PAK1 PAK2 PAK3 PAK4 PAK5 PAK6 PAK7 PAK8 IRA1 IRA2 PAK1 PAK2 PAK3 PAK4 PAK5 PAK6 IND Micro-gram per liter Pb Contamination of Milk Mean Pb concentration in milk % samples exceeding MRL,000 10,000 80 1,000 60 40 10 20 1 0 22/May/2014 29 29
Building Bridges, Supporting Livelihoods Control brucellosis in dairy animals Improve hygiene along entire dairy chain, including feed Monitoring of chemical residues (hot spots) Spot checks for milk adulteration Conclusions 30
Building Bridges, Supporting Livelihoods www.aphca.org 22/May/2014 31 31
CHI1 CHI2 LAO PHL ROK THA1 THA2 THA3 THA4 THA5 THA6 THA7 VIE % positive samples Pork Salmonella spp. 80 60 40 20 0 22/May/2014 32 32