Sie sind auf Seite 1von 7

wkw Outbreak of staphylococcal food intoxication after consumption of pasteurized milk products 34/2009

original article
125
Wien Klin Wochenschr (2009) 121: 125131
DOI 10.1007/s00508-008-1132-0
Printed in Austria
Springer-Verlag 2009
Wiener klinische Wochenschrift
The Middle European Journal of Medicine
Outbreak of staphylococcal food intoxication
after consumption of pasteurized milk products,
June 2007, Austria
Daniela Schmid
1
, Rainer Fretz
1
, Petra Winter
1
, Michaela Mann
1
, Gerda Hger
1
, Anna Stger
1
,
Werner Ruppitsch
1
, Johann Ladsttter
1
, Norbert Mayer
2
, Alfred de Martin
2
, Franz Allerberger
1
1
Austrian Agency for Health and Food Safety, Vienna, Austria
2
European Programme for Intervention Epidemiology Training (EPIET), Stockholm, Sweden
3
Public Health Authority, St. Plten, Austria
Ausbruch von Staphylokokken-Enterotoxikosen
nach Genuss pasteurisierter Schulmilch,
Juni 2007, sterreich
Zusammenfassung. Am 13. Juni 2007 wurde die ster- Am 13. Juni 2007 wurde die ster- Juni 2007 wurde die ster-
reichische Agentur fr Gesundheit und Ernhrungs-
sicherheit von einer lokalen Gesundheitsbehrde ber
das gehufte Auftreten von Bauchkrmpfen und Erbre-
chen am 8. Juni bei 40 Kindern zweier benachbarter
Volksschulen unterrichtet. Die am 8. Juni konsumierten
Schulmilchgetrnke wurden als Quelle des Ausbruchs
vermutet. Die Schulmilchgetrnke stammten von einer
lokalen Molkerei X, die am 8. Juni acht Volksschulen
und zwei Kindergrten belieferte. Die kurze Inkubati-
onszeit alle Flle erkrankten noch am Tag der Konsu-
mation und die kurze Krankheitsdauer von 12 Tagen
lieen eine Lebensmittelvergiftung vermuten. Deskrip-
tiv-epidemiologische und mikrobiologische Untersu-
chungen sowie eine retrospektive Kohortenstudie wur-
den zur Ermittlung des urschlichen Agens, dessen Re-
servoirs und des bertragungsmodus durchgefhrt.
Von 1025 Kindern der 10 Einrichtungen erfllten 166 die
Falldenition (16,2%). Nach den Ergebnissen der Kohor-
tenanalysen war die Konsumation von Milch, Kakao-
milch oder Vanillemilch der Molkerei X mit einem 37,8
fach hherem Risiko zu erkranken, assoziiert (95% CI:
2,3116,5). In den verbliebenen orginal-verschlossenen
Milchprodukten wurden Staphylokokken-Enterotoxin A
und D nachgewiesen. Sechs von 64 Viertelgemelkspro-
ben von 3 von 16 der Molkerei X zuliefernden Khen er-
brachten in der bakteriologischen Untersuchung Ente-
rotoxin A und D produzierenden Staphylococcus aureus
des spa Typs t2953. Ein aus einem Nasenabstrich des
Molkereibetreibers gewonnenes S. aureus Isolat war
vom spa Typ t635 und wies Gene fr Enterotoxin C, G, H
und I auf.
Die Ausbruchsuntersuchung belegte, dass die am
7. Juni in der Molkerei X hergestellten Milchprodukte
die Quelle des Ausbruches einer Staphylokokken-Ente-
rotoxikose am 8. Juni waren. Die Khe der Molkerei X
und nicht der Molkereibetreiber waren das wahr-
scheinliche Reservoir des Enterotoxin-produzierenden
S. aureus-Stammes. Eine Risikoanalyse des Produk-
tions-Prozesses lie vermuten, dass die Toxinprodukti-
on whrend Lagerung von berschssiger pasteurisier-
ter Milch ber 3 Tage stattfand, bevor diese am 7. Juni
neuerlich pasteurisiert und zu den inkriminierten
Schulmilchgetrnken verarbeitet wurde.
Summary. On June 13, 2007, the public health authority
informed the Austrian Agency for Health and Food
Safety about 40 children from two neighboring elemen-
tary schools who had fallen ill with abdominal cramps
and vomiting on June 8. School milk products consumed
on June 8 were suspected as the source of the outbreak.
On June 8, the milk products were provided by local
dairy X to eight elementary schools and two nurseries.
The short incubation period all cases fell ill on the day
on which the products were consumed and the short
duration of illness (12 days) strongly suggested intoxi-
cation. In order to identify the causative pathogen, its
reservoir and the mode of transmission, a descriptive-
epidemiological and microbiological investigation and
a retrospective cohort study were conducted. Six of the
10 institutions served by dairy X completed question-
naires on demographics and food consumption. One
school had a 79% response rate (203/258) and was cho-
sen as the basis for our cohort study. A total of 166 of the
1025 children (16.2%) at the 10 institutions fullled the
case denition. Consumption of milk, cacao milk or va-
nilla milk originating from dairy X was associated with
a 37.8 times higher risk of becoming a case (95% CI:
2.3116.5). Unopened milk products left over at the af-
fected institutions yielded staphylococcal enterotoxins
A and D. Six out of 64 quarter milk samples from three
of 16 cows producing milk for dairy X tested positive for
S. aureus. The isolates produced enterotoxins A and D,
yielded genes encoding enterotoxins A and D, and
showed spa type t2953. S. aureus isolated from the nasal
Correspondence: Dr. Daniela Schmid, sterreichische Agentur
fr Gesundheit und Ernhrungssicherheit (AGES), Whringer-
strae 25a, 1090 Wien, Austria, E-mail: Daniela.Schmid@ages.at
wkw 34/2009 Outbreak of staphylococcal food intoxication after consumption of pasteurized milk products
original article
126
swab of the dairy owner harbored genes encoding en-
terotoxins C, G, H and I, and showed spa type t635. Our
investigation revealed that the milk products produced
in dairy X on June 7 were the source of the outbreak on
June 8. The cows not the dairy owner were the likely
reservoir of the enterotoxin-producing S. aureus. From
the risk assessment of the production process at the
dairy, we hypothesize that staphylococcal toxin pro-
duction took place during a 3-day period of storage of
pasteurized milk prior to repasteurization for the pro-
duction batch of June 7.
Key words: Outbreak, staphylococcal food intoxication,
pasteurized, milk.
Introduction
Outbreaks of staphylococcal food poisoning are usually
associated with foods of high protein content, such as
ham, poultry, potato salad, egg salad or cream-lled
pastries, which are thought to be contaminated during
preparation by a food handler. In the majority of staph-
ylococcal foodborne outbreaks described, purulent skin
lesions on food handlers hands were the reservoir of
the pathogen [1, 2]. Food handlers, and not the food an-
imals, are the main source of bacterial contamination
in outbreaks of staphylococcal food poisoning [3]. How-
ever, staphylococci are frequently found in animals and
are therefore likely contaminants of milk, especially if
mastitis is present in the herd. On the other hand,
staphylococci are poor competitors against other bacte-
rial constituents of the normal ora [3].
We report on an outbreak caused by pasteurized
milk products, where milk cows without clinical overt
mastitis were the most likely reservoir of the enterotox-
in-producing Staphylococcus aureus.
On June 13, 2007, the public health authority report-
ed on 40 children from two neighboring elementary
schools in the Austrian province of Lower Austria who
had fallen ill with abdominal cramps, vomiting and
prostration on June 8. An initial case series investiga-
tion identied consumption of school milk products
during the 09:30 recess as the only potential common
link among the cases. The prompt clinical onset, 34
hours after consumption of the dairy products, the typ-
ical symptoms and the short duration of illness (12
days) indicated food intoxication associated with the
school milk products.
All milk products were provided by local dairy X,
which usually supplies about 92 institutions with di-
verse milk products (milk, vanilla milk, cacao milk, or-
ange whey, apricot yoghurt whey) and apple juice. On
Friday 8 June, only 10 institutions, including two day
nurseries, were operational and supplied with dairy
products from dairy X. Only one person, the owner, was
working in dairy X on that day. The delivery of milk
products from the dairy was stopped by the public
health authority in the afternoon of June 8. Samples
from unopened milk products left over at the affected
institutions and samples from raw milk, milk-products
and environmental surfaces (swabs, Rodac plates) at the
dairy were subjected to microbiological investigation.
Materials and methods
Descriptive epidemiological investigation
In this outbreak a case was dened as a child who (a) was pres-
ent in one of the 10 institutions on June 8, 2007 and (b) devel-
oped vomiting, prostration or abdominal cramps after the
09:30 recess on that day. Active case nding was performed by
interviewing the directors of the eight schools and the two
daycare centers on occurrence of cases fullling the outbreak
case denition.
Analytical epidemiological investigation
A cohort study was performed to test the hypothesis that the
milk products produced by dairy X were the vehicle of infec-
tion. Questioning was via self-lled questionnaires sent to the
patients parents. Data were obtained on demographics, dis-
ease status, clinical onset, symptoms, duration of illness, re-
sults of microbiological stool examinations, and exposure to
milk products originating from dairy X (milk, vanilla milk,
cocoa milk, orange whey, apricot yoghurt whey) and to the
apple juice. Six of the 10 schools served by dairy X completed
questionnaires on demographics and food consumption. One
school (elementary school A) had a 79% response rate (203/258)
and was the basis for our cohort study. The selection process
of the study population is illustrated in Fig. 1.
Microbiological investigation
Food samples were tested for staphylococcal enterotoxin us-
ing an enzyme-linked immunosorbent assay (R-Biopharm)
and by culture for presence of staphylococci, Bacillus cereus,
Clostridium perfringens, Campylobacter, Salmonella and Es-
cherichia coli, and for presence and enumeration of enterobac-
teriaceae (coliforms). Samples tested from the June 7 pro-
duction batch (ntotal = 7) were milk (n = 1), vanilla milk (n = 3),
cacao milk (n = 1), orange whey (n = 1) and apricot yoghurt
whey (n = 1), and from the June 8 production batch (ntotal = 5)
one sample each from milk, vanilla milk, cacao milk and from
the two whey beverages. In addition, one sample each from
vanilla powder and cacao powder and one from raw milk were
obtained at the dairy on June 8.
Stool samples available from 13 of the outbreak cases were
cultured for Shigella, Salmonella, Campylobacter, Yersinia and
enterohemorrhagic Escherichia coli, as described elsewhere
[4]. A nasal swab taken from the dairy farmer on June 14 was
cultured for S. aureus.
The cows producing milk for the dairy were sampled two
times as follows: on June 15, quarter milk samples from 19 cows
(76 specimens), and on July 24 quarter milk samples from 16
out of these 19 cows (64 specimens). The California mastitis
test (CMT) a screening test for subclinical mastitis was used
for all quarter milk samples (CMT scoring: no precipitate ()
corresponding to a somatic cell count (SCC) of < 150,000 cells/
ml; slight precipitate (+) corresponding to an SCC range
100,000250,000 cells/ml; distinct precipitate (1+) correspond-
ing to an SCC range 200,000700,000 cells/ml; gel formation
(2+) corresponding to an SCC range 500,0001,500,000 cells/ml;
thick gel (3+) corresponding to an SCC > 1,000,000 cells/ml) [5,
6]. A CMT score 1+ was considered to indicate intramammary
infection (i.e. subclinical mastitis) [710]. All quarter milk
samples were cultured for the presence of mastitis-causing
pathogens using methods described elsewhere [11, 12].
Environmental samples, swabs (n = 10) and Rodac-plates
(n = 3) were obtained at the dairy on June 12. The swab samples
were collected as follows and cultured for the presence of staph-
ylococci, Bacillus cereus and enterobacteriaceae: one specimen
from the inside of the lling cap of the bottle carousel, six sam-
ples from the lling tank of the bottle carousel (1 from inside
wkw Outbreak of staphylococcal food intoxication after consumption of pasteurized milk products 34/2009
original article
127
the wall, 2 from inside the tank lid, 2 from the milk pipeline
entry, 1 from the tank outlet), one sample from each of the two
bowls in which pasteurized milk was mixed with vanilla pow-
der or cacao powder and one sample from inside the milk ho-
mogenizer. The three Rodac plates, one sample taken from in-
side each of the two mixing bowls and one taken from the oor
of the lling tank, were tested for the presence of enterobacteri-
aceae. S. aureus isolates were tested by PCR for enterotoxin
genes sea to see and seg to sei [13] and subjected to spa typing.
Spa types were determined by sequencing the variable repeat
region of the Staphylococcus protein A (spa) gene [14].
Results
Descriptive epidemiological investigation
A total of 166 of the 1025 children at the 10 institutions
provided with milk products from dairy X on June 8,
2007, fullled the case denition (16.2%). The sex distri-
bution was 1:1 and the median age was 8 years (range
613). Nine of the ten institutions were affected by cases
(Table 1).
Analytical epidemiological investigation
All cases in the cohort study consumed at least one of
the dairy products provided during the school recess on
June 8. Consumption of milk, cacao milk or vanilla milk
provided by dairy X on June 8 was associated with a 37.8
times higher risk of becoming a case (95% CI: 2.3116.5)
(Table 2). The consumption of whey was not associated
with a risk of staphylococcal intoxication and the con-
sumption of apple juice had a 0.14 times lower risk of the
illness.
Microbiological investigation
Five of the seven samples of milk products from the
June 7 production batch (1 sample from milk, 3 samples
from vanilla milk, 1 sample from cacao milk) yielded
staphylococcal enterotoxins A and D, and enterobacte-
riaceae with 2500755,000 colony forming units (cfu)/
ml. E. coli was recovered from all four specimens of va-
nilla and cacao milks (vanilla milk sample No. I, 300
cfu/ml; vanilla milk sample No. II, 600 cfu/ml; vanilla
Source population
10 institutions
institutions AJ
6 institutions willing to participate in the questioning
institutions AF
A
response rate:
78.7%
(203/258)
B
response rate:
0%
(0/43)
C
response rate:
11,5%
(11/96)
D
response rate:
16%
(34/213)
E
response rate:
0%
(0/74)
F
response rate:
59,3%
(51/68)
1/6 institutions with response to questionnaire > 75%
institution A
Institution A providing the
study population
N = 203
Fig. 1. Recruitment of the study population from the school population of the 10 involved institutions (A-J);
institution-specic response rates to questioning (%)
Table 1. Number of cases per institution in the
institutions AJ (%)
Institution Number of cases (%) Total number of children
at the institution
A 57 (22.1%) 258
B 3 (7%) 43
C 10 (10.4%) 96
D 32 (15%) 213
E 6 (8.1%) 74
F 33 (38.4%) 86
G 10 (20%) 50
H 5 (5%) 100
I 10 (15.4%) 65
J 0 (0) 40
Total
166 (16.2%) 1025
wkw 34/2009 Outbreak of staphylococcal food intoxication after consumption of pasteurized milk products
original article
128
milk sample No. III, 1900 cfu/ml; cacao milk sample,
500 cfu/ml). All seven samples of milk products from
the June 7 production batch were negative for S. aureus
culture. Five samples of milk products from the June 8
production batch (sample of raw milk and samples of
vanilla powder and cacao powder) also tested negative
for staphylococcal enterotoxins and for S. aureus.
Twelve (16%) of the 76 quarter milk samples taken
on June 15 grew S. aureus; of the 19 cows tested, seven
(36.8%) yielded at least one milk sample positive for S.
aureus. For four of these seven cows, the CMT score of
1+ indicated the presence of subclinical mastitis.
The S. aureus isolates from the milk samples of July
15 were not available for molecular typing or toxigenic-
ity testing and therefore further samples were collected
from 16 of these 19 cows on July 24. Six (11%) of the
64 quarter milk samples from three of these 16 cows
tested positive for S. aureus; all three cows yielded so-
matic cell counts of > 1,000,000 cells/ml. All six isolates
tested positive for enterotoxins A and D, yielded genes
encoding enterotoxin A and D, and showed spa type
t2953. Five other cows among the 16 animals tested pos- Five other cows among the 16 animals tested pos- tested pos-
itive for Streptococcus dysgalactiae and coagulase-nega-
tive staphylococci.
S. aureus isolated from the nasal swab of the dairy
owner harbored genes encoding enterotoxins C, G, H
and I, and showed spa type t635.
The 13 stool samples from outbreak cases tested
negative for Shigella, Salmonella, Campylobacter, Yers-
inia and enterohemorrhagic E. coli.
Four of the 10 environmental swab samples (1 from
inside the lling cap of the bottle carousel, 1 of the six
swabs from the lling tank of the bottle carousel,
2 swabs from the two mixing bowls) were positive for
enterobacteriaceae, and one of the four samples (from a
mixing bowl) grew E. coli. All 10 environmental samples
were negative for S. aureus. The Rodac plates from in-
side the two mixing bowls and from the oor inside the
lling tank yielded no growth of enterobacteriaceae.
Veterinary medical investigation
Among the 19 cows tested on June 15, the CMT revealed
the following maximum SCC ranges: for one cow
100,000250,000 cells/ml (one quarter milk sample), for
two cows 200,000700,000 cells/ml (one quarter milk
sample each), for ve cows 500,0001,500,000 cells/ml
(one quarter milk sample each in three cows, two quarter
milk samples each in two cows), and for three cows
> 1,000,000 cells/ml (one quarter milk sample each in two
cows, two quarter milk samples in one cow). Thus, in 10
of the 19 cows the CMT result indicated the presence of
subclinical mastitis (CMT score 1+). Among the 16 cows
retested on July 24, the CMT revealed the following max-
imum SCC ranges: for two cows 200,000700,000 cells/ml
(one quarter milk sample for each cow), for three cows
500,0001,500,000 cells/ml (one quarter milk sample
each in two cows, two quarter milk samples in one cow),
and for three cows > 1,000,000 cells/ml (one quarter milk
sample each in two cows, three quarter milk samples in
one cow). Thus, in 8 of the 16 cows the CMT result indi-
cated the presence of subclinical mastitis.
The cows showed no clinical signs of mastitis on
either sampling day.
Public health intervention
The measures taken following the outbreak were to im-
plement increased quality control requests for thermal
disinfection of the milk mixing bowls and the lling car-
ousel; that is, the obligation for regular testing and re-
cording of the water temperature used for hot ushing.
In addition, the rubber feeding pipes on the bottle carou-
sel had to be exchanged for metal pipes, a material more
amenable to cleaning and disinfection than rubber. The
use of disposable drinking cups instead of reuseable
glassware on the bottle carousel was mandated; the car-
ousel therefore was remodeled for disposable drinking
cups. Following implementation of these measures, re-
peated microbiological investigation of samples from
milk bowls, the bottle carousel and dairy products re-
vealed no further bacterial contamination. The cows
with CMT results indicating subclinical mastitis received
dry cow therapy with local application of antibiotic.
Discussion
S. aureus is an occasional contaminant of raw milk and,
if present, is usually due to mastitis within the herds of
cows, goats or sheep that produce milk for human con-
sumption [15]. When S. aureus is the causative organism
of mastitis in cattle, up to 15% of S. aureus strains prove
to be enterotoxin producing [16, 17]. S. aureus entero-
toxin is of concern to the dairy industry because of the
toxins ability to withstand pasteurization time and
temperature combinations commonly used for a wide
range of dairy products.
Studies in Austria and Germany reported that levels
of S. aureus in bovine milk samples ranged from 39.6%
with < 500 cfu/ml to 7.2% with > 2000 cfu/ml [15]. An- < 500 cfu/ml to 7.2% with > 2000 cfu/ml [15]. An- 500 cfu/ml to 7.2% with > 2000 cfu/ml [15]. An- > 2000 cfu/ml [15]. An- 2000 cfu/ml [15]. An-
other study reported that 522% of milk samples were
positive for S. aureus [18]. A Wisconsin study found 9.7%
of bulk tank milk samples positive for S. aureus, and a
study from Virginia reported that in 30% of herds tested
10% of the cows were infected with S. aureus [19, 20].
These rates compare well with the rates found in the
cows providing milk for dairy X, where 16% of the quar-
Table 2. Results of food-specific cohort analyses in 203
children at school A
RR (95% CI) P
Products from the dairy 37.8 (12.3116.5) 0.000
Milk 2.9 (1.84.6) 0.001
Vanilla milk 3.2 (2.14.9) 0.000
Cacao milk 7.7 (4.912.1) 0.000
Whey 1.9 (0.477.73) n. s.
Apple juice 0.14 (0.020.97) 0.008
wkw Outbreak of staphylococcal food intoxication after consumption of pasteurized milk products 34/2009
original article
129
ter milk samples were positive for S. aureus, with 36.8%
of the cows having at least one positive milk sample. A
low incidence (014.6%) of enterotoxin producers in
staphylococci isolated from raw bovine milk has gener-
ally been recorded, with a distinct preponderance of
strains producing enterotoxins C, D or both [2126].
The udders of cows with mastitis constitute a major
reservoir for staphylococci. In Austria, surveillance pro-
grams for mastitis in cow herds are operated by the in-
dustry. The farmer is legally obliged to perform a daily
screening test for subclinical mastitis (the CMT) on
quarter milk samples prior to milking; any indecisive or
positive results require further bacteriological investi-
gation by culture. In addition, an external person (usu-
ally a dairy employee) determines monthly SCCs from
composite milk samples. We were unable to elucidate
why these precautionary measures failed to detect the
presence of subclinical mastitis in the cows providing
the milk for dairy X.
This problem affects not only bovine milk. Staphy-
lococcal intoxications after consumption of cheese
made from sheep milk have occurred in France and the
UK [27, 28], where enterotoxins A or D were found in the
cheeses causing the outbreaks. Bautista et al. reported
that of 124 staphylococcal strains isolated from sheep
milk, 78 produced enterotoxins A, B, C or D; enterotox-
ins A and D, elaborated by 44 and 43 strains, respec-
tively, showed the highest incidence [29].
S. aureus is regarded as a poor competitor against
the normal microora in unpasteurized dairy products
and is typically found to cause problems in foods with
lower water content, where it outcompetes other bacte-
ria [30]. Growth of S. aureus, with toxin production, has
been reported in pasteurized milk [31]. Donnelly et al.
[33] reported toxin production of 10 ng within 12 hours
in pasteurized milk at 35C, starting with an initial
S. aureus population of 1 10
4
1 10
6
cfu/ml. Fujikawa
et al. reported toxin production in raw milk within 12
hours at 37C; however, an initial inoculum of 1 10
6

cells of S. aureus was needed before toxin production
was observed [34].
We hypothesize that in dairy X staphylococcal en-
terotoxins accumulated in pasteurized milk prior to the
production of the school milk items. Pasteurized milk,
remaining from production on June 4, was stored for a
period of 72 hours in a refrigerated storage tank. (On
June 5 and 6 the dairy produced only fresh cheese, using
a different production line.) The milk was repasteurized
and used, together with fresh pasteurized milk, for the
June 7 production (Fig. 2).
Raw milk tank
Herd of cows
producing milk for dairy X
Pasteurizer Storage tank for
pasteurized milk
Milk
Mixing Bowl
for vanilla milk
Mixing Bowl
for cacao milk
Bottle carousel
Left over milk transferred
Plastics hose
Fig. 2. Schematic illustration of the production process for the June 7 batch of milk products
wkw 34/2009 Outbreak of staphylococcal food intoxication after consumption of pasteurized milk products
original article
130
The connection tube between pasteurizer and stor-
age tank, a plastic hose 6 m long, could have been the
site of S. aureus growth and toxin production (Fig. 3),
favored by the unusually warm summer with ambient
temperatures up to 36C during the incriminated time
period (data not shown). This hypothesis remains un-
proven, as no samples of the stored pasteurized milk
were available for microbiological testing.
The mode of inoculation of S. aureus into the stored
pasteurized milk could not be elucidated. Nevertheless,
detection of enterobacteriaceae in the environmental
samples from the bottle carousel and the milk mixing
bowls and also in the samples taken on June 8 from left-
over products (produced on June 7), including the de-
tection of E. coli in the vanilla and cacao milks, indicate
severe failures in appropriate cleaning and disinfection
in the dairy at least for this production process.
Because of the short incubation time before the on-
set of symptoms, foods contaminated with staphylococ-
cal enterotoxins are more readily identied than many
other foodborne illnesses with longer onset times. How-
ever, over the past 30 years, only a handful of S. aureus
enterotoxin poisoning outbreaks involving milk prod-
ucts have been reported [32, 3536]. The primary cause
of contamination in the few cases reported was always
post-pasteurization because of faulty equipment and
poor product-handling practices [32, 36]. In an outbreak
of S. aureus food poisoning due to tainted milk products
in Osaka (Japan) and neighboring prefectures in June/
July 2000 (the Snow Brand low-fat milk incident), a total
of 13,420 cases were notied [36], the largest outbreak
since the end of World War II.
The increase in organic farming and direct retail at
farm level implies an even higher risk than with indus-
trial production of milk. Outbreaks involving relatively
small organic dairies have been reported repeatedly; for
example, 25 laboratory-conrmed cases of enterohem-
orrhagic E. coli O157 infection in Denmark in 2004 [38].
Highly automated dairy production plants usually guar-
antee a higher degree of good hygienic practice than at
small production units such as the one involved in the
outbreak reported.
References
1. Schmid D, Gschiel E, Mann M, Huhulescu S, Ruppitsch W,
Bhm G, Pichler J, Lederer I, Hger G, Heuberger S, Aller-
berger F (2007) Outbreak of acute gastroenteritis in an
Austrian boarding school, September 2006. Euro Sur-
veill12: 224. Available online: www.eurosurveillance.org/
em/v12n03/1203-224.asp
2. Wei HL, Chiou CS (2002) Molecular subtyping of Staphylo-
coccus aureus from an outbreak associated with a food
handler. Epidemiol Infect 128: 1520
3. Stewart GC (2005) Staphylococcus aureus. In: Fratamico
PM, Bhunia AK, Smith JL (eds) Foodborne pathogens: mi-
crobiology and molecular biology. Caister Academic
Press, Norfolk, pp 273284
4. Anonymus (2001) Standardisierung und Qualittssiche-
rung in mikrobiologischer Labordiagnostik. Richtlinien.
Liebeswar G, Editor. Innsbruck: Bundesministerium fr
soziale Sicherheit und Generationen. ISBN 3-86123-126-0
5. Sargeant JM, Leslie KE, Shirley JE, Pulkrabek BJ, Lim GH
(2001) Sensitivity and specicity of somatic cell count and
California mastitis test for identifying intramammary in-
fection in early lactation. J Dairy Sci 84: 20182024
6. Winter P, Baumgartner W (1999) Evaluation of CMT reac-
tions in goat milk. Dtsch Tierrztl Wochenschr 106: 30
34
7. McDermott MP, Erb HN, Natzke RP (1982) Predictability
by somatic cell count related to prevalence of intramam-
mary infection within herds. J Dairy Sci 65: 15351539
8. Dohoo IR, Leslie KE (1991) Evaluation of changes in so-
matic cell counts as indicators of new intramammary in-
fections. Prev Vet Med 10: 225237
9. Doherr MG, Roesch M, Schaeren W, Schallibaum M, Blum
JW (2007) Risk factors associated with subclinical mastitis
in dairy cows on Swiss organic and conventional produc-
tion system farms. Veterinarni Medicina 52: 487495
10. Leslie KE, Schukken YH, Sargeant JM, Timms LL (2003)
Evaluation of the California mastitis test to detect an in-
tramammary infection with a major pathogen in early
lactation dairy cows. Can Vet J 44: 413416
11. Roesch M, Doherr MG, Blum JW (2006) Management,
feeding, production, reproduction and udder health on
organic and conventional Swiss dairy farms. Schweizer
Archiv fr Tierheilkunde 148: 387395
12. Deutz A, Obritzhauser W (1995) Eutergesundheit und
Milchqualitt. Leopold Stocker-Verlag, Graz-Dsseldorf.
ISBN 3-7020-0987-6
13. Jarraud S, Cozon G, Vandenesch F, Bes M, Etienne J, Lina
G (1999) Involvement of enterotoxins G and I in staphylo-
coccal toxic shock syndrome and staphylococcal scarlet
fever. J Clin Microbiol 37: 24462449
14. Ruppitsch W, Indra A, Stger A, Mayer B, Stadlbauer S,
Wewalka G, Allerberger F (2006) Classifying spa types in
complexes improves interpretation of typing results for
methicillin-resistant Staphylococcus aureus. J Clin Micro- J Clin Micro- Clin Micro-
biol 44: 24422448
15. International Dairy Federation (1994) Staphylococcus au-
reus. In: The signicance of pathogenic microorganisms
in raw milk, pp 2442. ISBN: 92 9098 016 8
16. Cenci-Goga BT, Karama M, Rossitto PV, Morgante RA,
Cullor JS (2003) Enterotoxin production by Staphylococcus
aureus isolated from mastitic cows. J Food Protect 66:
16931696
17. Joshi R, Purohoit SK (1997) Studies on important patho-
gens of public health signicance from marketed raw milk
and cream in Bikaner City. Indian Vet Med J 21: 197200
Fig. 3. Plastic hose between pasteurizer and storage tank for
pasteurized milk
wkw Outbreak of staphylococcal food intoxication after consumption of pasteurized milk products 34/2009
original article
131
18. International Dairy Federation (1980) Factors inuencing
the bacteriological quality of raw milk. Bulletin 120
19. Jones GM (1991) Analysis of DHI cow and herd bulk tank
milk samples for Staphylococcus aureus antibody levels. J
Dairy Sci 74: 161167
20. Makovec JA, Ruegg PL (2003) Results of milk samples sub-
mitted for microbiological examination in Wisconsin
from 1994 to 2001. J Dairy Sci 86: 34663472
21. Casman EP (1965) Staphylococcal enterotoxin. Ann N Y
Acad Sci 128: 124131
22. Casman EP, Bennett RW, Dorsey AE, Issa JA (1967) Identi-
cation of a fourth staphylococcal enterotoxin, enterotxin
D. J Bacteriol 94: 18751882
23. Harvey J, Gilmour A (1985) Application of current meth-
ods for isolation and identication in raw bovine milk. J
Appl Bacteriol 59: 207221
24. Abbar FM, Mohammed MT, Arslain SH (1986) Selected
biological properties of enterotoxigenic staphylococci iso-
lated from milk. J Food Prot 49: 871873
25. Garcia ML, Moreno B, Bergdoll MS (1980) Characteriza- Characteriza-
tion of staphylococci isolated from mastitic cows in Spain.
Appl Environ Microbiol 39: 548553
26. Olson JC, Casman EP, Baer EF, Stone JE (1970) Enterotoxige-
nicity of Staphylococcus aureus cultures isolated from acute
cases of bovine mastitis. Appl Microbiol 20: 605607
27. De Buyser ML, Janin F, Dilasser F (1985) Contamination of
ewe cheese with Staphylococcus aureus: study of an out-
break of food poisoning. In: Jelkaszewicz J (ed) The Staph-
ylococci. Zbl Bakt Suppl 14, Gustav Fisher Verlag, Stutt-
gart, pp 677678
28. Wieneke AA, Gilbert RJ (1987) Comparison of our methods
for the detection of staphylococcal enterotoxin in foods
from outbreaks of food poisoning. Int J Food Microbiol 4:
135143
29. Bautista L, Gaya P, Medina M, Nunez M (1988) A quantita- A quantita-
tive study of enterotoxin production by sheep milk staph-
ylococci. Appl Environ Microb 54: 566569
30. Microorganisms in foods 5: Characteristics of microbial
pathogens (food safety). Roberts TA, et al (eds) Interna-
tional Commission on Microbiological Specications of
Foods (ICMSF) (1996). London, Blackie Academic & Pro-
fessional. ISBN: 041247350X. Available from Springer
31. Halprin-Dohnalek MI, Marth EH (1989) Growth of Staphy-
lococcus aureus in milks and creams with various amounts
of milk fat. J Food Protect 52: 540543
32. Milk Safety Branch. Staphylococcus enterotoxin produc-
tion in foam and current dairy industry balance tank
practices (M-I-04-5). U.S. Food and Drug Administration,
June 2, 2004, accessed June 15, 2008 at www.cfsan.fda.
gov/~ear/mi-04-5.html
33. Donelly CB, Leslie JE, Black LA (1968) Production of en-
terotoxin A in milk. Appl Microbiol 16: 917924
34. Fujikawa H, Morozumi S (2006) Modeling Staphylococcus
aureus growth and enterotoxin production in milk. Food
Microbiol 23: 260267
35. Everson ML, Hinds MW, Bernstein RS, Bergdoll MS
(1988) Estimation of human dose of staphylococcal en- Estimation of human dose of staphylococcal en-
terotoxin A from a large outbreak of staphylococcal food
poisoning involving chocolate milk. Int J Food Microbiol
7: 311316
36. Asao T, Kumeda Y, Kawai T, Shibata T, Oda H, Haruki K,
Nakazawa H, Kozaki S (2003) An extensive outbreak of
staphylococcal food poisoning due to low-fat milk in Ja-
pan: estimation of enterotoxin A in the incriminated milk
and powdered skim milk. Epidemiol Infect 130: 3340
37. Soejima T, Nagao E, Yano Y, Yamagata H, Kagi H, Shina-
gawa K (2007) Risk evaluation for staphylococcal food
poisoning in processed milk produced with skim milk
powder. Int J Food Microbiol 115: 2934
38. Helwigh B, Borck B, Hald Danish T (2005) Annual report
on zoonoses in Denmark 2004. Ministry of Family and
Consumer Affairs. Edited by Zoonosis Centre, Danish
Institute for Food and Veterinary Research. ISSN 0909-
4172