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Published Date: 2013-05-24 15:30:47
Subject: PRO/AH/EDR> Campylobacteriosis - USA (06): (AK) unpasteurized milk, 2nd cluster
Archive Number: 20130524.1735823

CAMPYLOBACTERIOSIS - USA (06): (ALASKA), UNPASTEURIZED MILK, SECOND CLUSTER
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Date: Thu 23 May 2013
Source: Alaska Section of Epidemiology [edited]
http://www.epi.hss.state.ak.us/phan/AKPHAN_20130523_CampyOutbreakRawMilk.pdf

The purpose of this Health Advisory is to inform Alaska health care providers of a new and potentially ongoing outbreak of _Campylobacter jejuni_ infections associated with consumption of raw milk distributed by a Kenai Peninsula cow-share program. This is the same Kenai Peninsula cow-share program that was linked to the _Campylobacter coli_ outbreak that sickened at least 31 people earlier in 2013.

On 22 May 2013, the Alaska State Public Health Laboratory notified the Alaska Section of Epidemiology (SOE) of 2 _C. jejuni_ isolates with an indistinguishable pulsed-field gel electrophoresis (PFGE) pattern. These 2 isolates came from stool samples of 2 unrelated persons living on the Kenai Peninsula. Both persons indicated that their diarrheal illness started within 10 days after consuming raw milk from the same Kenai Peninsula cow-share farm (Farm A). Nationally, this PFGE pattern has only been seen once before, from a _C. jejuni_ isolate obtained from cow manure collected on Farm A in February 2013 (see: http://www.epi.alaska.gov/bulletins/docs/b2013_12.pdf). In addition to the 2 laboratory-confirmed cases, 3 other persons have also been identified as having developed acute diarrheal illness within 10 days after consuming Farm A raw milk. These individuals did not seek medical attention.

_Campylobacter_ are bacteria that can cause diarrhea (sometimes bloody), abdominal cramping/pain, nausea, vomiting, and fever within 2 to 5 days after exposure. The illness typically lasts about a week. Sometimes campylobacteriosis infections can lead to more serious health consequences, including reactive arthritis (as occurred in several cases during the February 2013 _C. coli_ outbreak), and Guillain-Barre syndrome. In persons with compromised immune systems, the bacterium occasionally spread to the bloodstream and cause a serious life-threatening infection.

Sources of campylobacter include undercooked meat or cross-contamination of other foods by raw meat or by feces from an infected animal. Outbreaks are often associated with consumption of unpasteurized milk or contaminated water. Animals can also be infected, and some people have acquired their infection from contact with the stool of an infected or colonized animal. The organism does not commonly spread from person-to-person, but this can happen if the infected person is producing a large volume of diarrhea.

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[This sounds like deja vu all over again.

Classical zoonotic organisms such as _Brucella abortus_, _Brucella melitensis_, _Mycobacterium bovis_, _Salmonella_ species, _Listeria monocytogenes_, _Campylobacter_ species, _Yersinia_ species, _Coxiella burnetii_, and _E. coli_ O157:H7 are associated with raw milk ingestion.

Non-zoonotic organisms such as _Streptococcus pyogenes_, _Salmonella_ Typhi, _Corynebacterium diphtheriae_, _Shigella_ species, _Salmonella_ Paratyphi A, _Salmonella_ Paratyphi B, enterotoxins from _Staphylococcus aureus_, and hepatitis A virus have also been associated with raw milk ingestion.

Other diseases that can be related to unpasteurized milk are highlighted in these paragraphs extracted from
Leedom JM: Milk and infectious diseases in humans.
Clin Infect Dis 2006;43: 610-5 (http://www.journals.uchicago.edu/doi/full/10.1086/507035)
with the citations renumbered to be consecutive starting from 1:

In 1996 and 1998, there were 2 episodes involving rabid cows that occurred in Massachusetts (1). Milk from rabid cows can contain rabies virus, and transmission via unpasteurized milk is theoretically possible. Temperatures reached during pasteurization kill the virus. 80 persons consumed unpasteurized milk that was collected from the 2 cows, and 9 more had contact with saliva from the cows. All 89 persons received postexposure rabies prophylaxis, and no human cases of rabies eventuated. A similar report in Oklahoma of possible rabies exposure associated with the consumption of raw milk or cream from a rabid cow was circulated in 2006 (2).

Tickborne encephalitis, a zoonotic arbovirus infection usually transmitted to humans by the bite of an _Ixodes persulcatus_ or _Ixodes ricinus_ tick, is endemic to Central Europe, Eastern Europe, and Russia (3). However, the virus can be found in the milk of cows and goats with tickborne encephalitis and was reported to be transmissible to humans by the consumption of unpasteurized milk (4). A case-control study failed to confirm oral transmission (5).

A diarrhea syndrome (later named Brainerd diarrhea) occurred among 122 residents of Brainerd, Minnesota during the period December 1983-July 1984 (6). It was characterized by acute onset, marked urgency, lack of systemic symptoms, failure to respond to conventional antimicrobial agents, and a long median duration of illness (median duration, 16.5 months). The syndrome was linked to consumption of raw milk from a single dairy (6). No etiologic agent was ever isolated. The outbreak of Brainerd diarrhea stopped when all of the dairy's output was diverted and pasteurized (6, MT Osterholm, personal communication).

Subsequent outbreaks in Illinois and Texas were not directly associated with milk, although cattle had been in the vicinity of an Illinois well that had its water implicated as a vehicle of transmission (7). Another outbreak of Brainerd-like diarrhea, although not associated with raw milk, affected 58 (15 per cent) of 394 passengers aboard a cruise ship visiting the Galapagos Islands in Ecuador (8).

References
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1. CDC. Mass treatment of humans who drank unpasteurized milk from rabid cows -- Massachusetts, 1996-1998. JAMA 1999; 281: 1371-2 [available at http://jama.ama-assn.org/cgi/content/full/281/15/1371].
2. Rabies, bovine, human exposure - USA (OK). 2006 [ProMED-mail archive no. 20060101.0005. Accessed 26 Jul 2006].
3. Dumpis U, Crook D, Oksi J. Tick-borne encephalitis. Clin Infect Dis 1999; 28(4): 882-90 [available at http://cid.oxfordjournals.org/content/28/4/882.full.pdf+html].
4. Matuszczyk I, Tarnowska H, Zabica J, Gut W. The outbreak of an epidemic of tick-borne encephalitis in Kielec province induced by milk ingestion [in Polish]. Przegl Epidemiol 1997; 51(4): 381-8 [abstract available at http://www.ncbi.nlm.nih.gov/pubmed/9562785].
5. Rieger MA, Nubling M, Kaiser R, et al. Tick-borne encephalitis transmitted by raw milk -- what is the significance of this route of infection? Studies in the epidemic region of Southwest Germany. Gesundheitswesen 1998; 60(6): 348-56 [abstract available at http://www.ncbi.nlm.nih.gov/pubmed/9697358].
6. Osterholm MT, MacDonald KL, White KE, et al. An outbreak of a newly recognized chronic diarrhea syndrome associated with raw milk production. JAMA 1986; 256(4): 484-90 [abstract available at http://jama.ama-assn.org/content/256/4/484.abstract].
7. Mintz ED, Parsonnet J, Osterholm MT. Chronic idiopathic diarrhea [letter]. N Engl J Med 1993; 328(23): 1713-4.
8. Mintz ED, Weber JT, Guris D, et al: An outbreak of Brainerd diarrhea among travelers to the Galapagos Islands. J Infect Dis 1998; 177: 1041-5 [available at http://jid.oxfordjournals.org/content/177/4/1041.full.pdf+html]. - Mod.LL]

[Powassan virus is another North American tick-borne virus rarely causing encephalitis in humans. It has been found experimentally in raw goat milk, but in spite of serological evidence of wide-spread infection in New York goats, no case of human Powassan virus infection has been traced to their milk. Ref: Woodall JP, Roz A.(1977) Experimental milk-borne transmission of Powassan virus in the goat. Am J Trop Med Hyg. Jan;26(1):190-2. - Mod.JW]

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