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Epidemiologic Notes and Reports Brucellosis --
Texas
On April 7, 1983, a case of possible brucellosis was reported
to
the city of Houston, Texas, Health Department's Bureau of
Epidemiology. Three weeks later, 12 suspected cases had been
reported, and by July 19, 29 cases were identified. Six of the
cases
were reported by physicians and nurses, and the remainder were
discovered during epidemiologic investigation in the community.
The patients ranged in age from 2 to 81 years. All were
Mexican
emigrants living in northeast Houston. Twenty-eight of the 29
patients reported eating goat cheese ("queso blanco") before the
onset
of symptoms. Twenty-three patients reported purchasing cheese from
neighborhood weekend vendors selling the product from their motor
vehicles.
None of the patients interviewed had any leftover cheese, but
one
was able to purchase additional cheese for analysis from a vendor
in
his neighborhood. The cheese was reportedly produced in Linares,
Mexico, and laboratory analysis determined that it was
unpasteurized;
all attempts to isolate Brucella sp. from the cheese were
unsuccessful. On May 6, a news release was circulated to the
media,
and the public was made aware of the potential dangers of
purchasing
cheese from unlicensed food vendors. Since that time, neighborhood
contacts reportedly have not seen the street vendors.
As of this report, 19 of the 29 patients have had blood
cultures
positive for B. melitensis, and one had B. melitensis isolated from
blood and bone marrow. Three additional cases were confirmed by a
fourfold rise or fall in agglutinating titer. Seven patients with
presumptive diagnoses displayed clinical symptoms compatible with
brucellosis in addition to agglutinating titers of
1:160.
Reported by P Perkins, MPH, A Rogers, M Key, MD, V Pappas, R Wende,
DrPH, City of Houston Health Dept, J Epstein, MD, Houston, M
Thapar,
MD, Ripley Clinic, Houston, F Jensen, MD, Harris County Health
Dept,
TL Gustafson, MD, Acting State Epidemiologist, Texas State Dept of
Health; E Young, MD, Veterans Administration Hospital, Houston; Div
of
Bacterial Diseases, Center for Infectious Diseases, CDC. Editorial Note
Editorial Note: In the 14-year period 1965-1978, 3,316 cases of
brucellosis were reported to CDC by state health departments.
Unpasteurized (raw) dairy products accounted for 268 (8%) of these
cases; 127 (47%) of the 268 cases were associated with raw dairy
products from Mexico, predominantly fresh cheese made from
unpasteurized goat milk, as in the present outbreak. Similar
outbreaks have been reported previously from Colorado (1) and Texas
(2).
An additional 50 (19%) of the 268 raw dairy product-associated
cases were traced to ingestion of products from countries in the
Mediterranean basin, Far East, Middle East, and South America.
Most
were sporadic events involving individual American travelers or
foreign visitors to the United States who consumed dairy products
acquired abroad; however, outbreaks of multiple cases have occurred
among members of tour groups to countries bordering the
Mediterranean
Sea (3). Because these individuals frequently have no vocational
or
avocational exposure to Brucella spp., other more common causes of
fever are generally ruled out before a diagnosis of brucellosis is
entertained, thereby delaying appropriate therapy. Countries
reporting more than 1,000 human cases of brucellosis per year in
their
indigenous populations include Argentina, Greece, Iran, Italy,
Mexico,
Peru, and Spain (4). The remaining 91 (34%) raw dairy
product-associated human brucellosis cases were linked to
unpasteurized milk or cheese produced in the United States.
Unpasteurized dairy products have been associated with Group C
streptococcal infections in New Mexico (5). Raw milk cheese
contaminated with staphylococcal enterotoxin is reported to be
widespread (6,7). In addition, salmonellae, which are readily
killed
by pasteurization, have been shown repeatedly to survive the
cheese-making process (6). Other organisms that have caused
cheese-associated diseases or have been shown to survive the
cheese-making process include Escherichia coli, Mycobacterium
tuberculosis, and Campylobacter jejuni.
References
Eckman MR. Brucellosis linked to Mexican cheese. JAMA
1975;232:636-7.
Young EJ, Suvannoparrat U. Brucellosis outbreak attributed to
ingestion of unpasteurized goat cheese. Arch Intern Med
1975;135:240-3.
Arnow PM. Brucellosis in a tour group. JAMA (in press).
Kaufmann AF, Martone WJ. Brucellosis. In: JM Last, ed.
Maxcy-Rosenau public health and preventive medicine. 11th ed.
New York: Appleton-Century-Crofts. 1980:419-22.
CDC. Group C streptococcal infections associated with eating
homemade cheese--New Mexico. MMWR 1983;32:510,515-6.
Keogh BP. Reviews of the progress of dairy science. Section
B.
The survival of pathogens in cheese and milk powder. J Dairy
Res
1971;38:91-111.
Bryan FL. Epidemiology of milk-borne diseases. J Food
Protection
1983;46:637-49.
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