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From the Centers for Disease Control and Prevention
April 21, 1999

Mass Treatment of Humans Who Drank Unpasteurized Milk From Rabid Cows— Massachusetts, 1996-1998

JAMA. 1999;281(15):1371-1372. doi:10.1001/jama.281.15.1371-JWR0421-3-1

MMWR. 1999;48:228-229

Rabies is a viral zoonosis that is usually transmitted by the bite of an infected mammal. However, in Massachusetts, two incidents have been reported since 1996 of potential mass exposures to rabies through drinking unpasteurized milk. This report presents the investigations of these two incidents.

Incident 1

On November 12, 1998, the Virology Laboratory of the Massachusetts Department of Public Health (VLMDPH) diagnosed rabies in a 6-year-old Holstein dairy cow from a farm in Worcester County. Further analysis of the cow's brain tissue with monoclonal antibodies revealed the cow was infected with a variant of the rabies virus associated with raccoons in the eastern United States.

The cow had loss of appetite beginning November 4 and hypersalivation beginning November 6. An intestinal obstruction was suspected initially as the cause of illness. However, the cow became ataxic and aggressive and died on November 8.

The cow had been milked 12 times during the week before death. Milk from the cow had been pooled with milk collected from other cows, and an unpasteurized portion was distributed for human consumption. Public health investigations identified 66 persons who drank unpasteurized milk collected from this dairy during October 23-November 8. All 66 received rabies postexposure prophylaxis (PEP). In addition, five persons received PEP because of exposure to the cow's saliva during the 15 days preceding her death. Neither milk nor mammary tissue from the rabid cow was available for examination for the presence of rabies virus.

Incident 2

On November 12, 1996, the VLMDPH diagnosed rabies in a 14-year-old Jersey dairy cow from a different farm in Worcester County. Analysis with monoclonal antibodies revealed the cow was infected with a variant of the rabies virus associated with raccoons in the eastern United States.

The cow developed tenesmus and depression on November 6 and was euthanized on November 10. The cow had been milked during October 26-November 2. An investigation identified 14 persons who drank unpasteurized milk collected from this cow during this period. All 14 persons received rabies PEP. In addition, four persons received PEP because of exposure to the rabid cow's saliva during the 15 days preceding her death.

Reported by:

M McGuill, DVM, B Matyas, MD, B Werner, PhD, A DeMaria, Jr, MD, State Epidemiologist, Massachusetts Dept of Public Health. Viral and Rickettsial Zoonoses Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; and an EIS Officer, CDC.

CDC Editorial Note:

Management of mass human exposures to rabid animals requires public health officials to balance knowledge of rabies epidemiology, risk for transmission, and pathogenesis with the perceived risk for death among exposed persons. Because of the nearly 100% case-fatality ratio of human rabies and the virtually complete effectiveness of PEP, many mass exposure incidents prompt administration of rabies immune globulin and vaccine, even if the circumstances do not meet the criteria for exposure.13

During 1990-1996, CDC received reports of 22 incidents of mass human exposures to rabid or presumed-rabid animals in the United States, resulting in 1908 persons receiving PEP (median: 33 persons per incident).4 In Massachusetts during 1991-1995, the median cost for PEP was $2376 per person, including physician and facility charges.5 Prolific administration of PEP in response to these incidents strains the availability of rabies biologics, especially human rabies immune globulin, which has a short shelf-life and tightly controlled distribution by the manufacturers.

An average of 150 rabid cattle have been reported to CDC in the United States each year since 1990.6 In addition to concerns about rabies transmission from animals to humans through bites, rabid livestock raise the potential for foodborne transmission. The National Association of State Public Health Veterinarians recommends against consuming tissues and milk from rabid animals.2 However, because rabies virus is inactivated by temperatures below those used for cooking and pasteurization, eating cooked meat or drinking pasteurized milk from a rabid animal is not an indication for PEP.

Rabies virus can be transmitted by direct contact with infected material, such as saliva from an animal infected with rabies, and mucous membranes, including the oral and gastric mucosae.7 In addition to saliva and neural tissue, rabies virus also has been detected in the kidney, prostate, pancreas, and other tissues and body fluids.8 However, saliva and neural tissue are the primary proven vehicles for rabies virus in naturally occurring cases. Anecdotal reports exist of rabies transmission by ingestion of milk from rabid animals (e.g., from a rabid sheep to a nursing lamb).7 In these reports, the more conventional routes (e.g., bite or mucous membrane exposure) could not be completely excluded.

Transmission of rabies virus in unpasteurized milk is theoretically possible. The risk could be defined better if samples of milk and mammary tissue were collected from rabid livestock and assayed for the presence, viability, and infectivity of rabies virus. Regardless of the amount of viable rabies virus that may be shed in cows' milk, the theoretical risk for transmission of rabies from this route can be eliminated if all dairy products are pasteurized before consumption.

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National Association of State Public Health Veterinarians, Inc, Compendium of animal rabies control, 1999. J Am Vet Med Assoc. 1999;214198- 202
CDC, Human rabies prevention—United States, 1999: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 1999;48 ((no. RR-1))
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Kreindel  SMMcGuill  MMeltzer  MRupprecht  CDeMaria Jr  A The cost of rabies postexposure prophylaxis: one state's experience. Public Health Rep. 1998;113247- 51
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