On Jan. 25, 2007, Italy formally authorized the sale of raw milk to consumers through automatic vending devices. The decision had its legal basis in the generous interpretation of a 2004 provision in European Union hygiene law, and followed intense lobbying from farmers and local authorities.
In fact, since 2004, local authorities had permitted sales of raw milk in their territories.
The 2007 decision requires registration of vending devices with the authorities, and authorized the placing of devices not only within farms, but also elsewhere in the same province. Pooling of milk from different farms is not permitted; each device corresponds to an individual farm.
The decision also mandates two analytical controls per month, on farm (and not in the end product), on Plate count (at 30 °C , per ml, with a limit of ≤ 100 000) and somatic cell count (per ml, with a limit of 400,000), and requires compliance with the limits, set by EU law, for the average of the two measurements. An unfortunate consequence of this requirement has been that compliance with the limits has been interpreted as proof of safety of the final product.
In the technical annex to the decision, a number of mandatory procedures are named, and the legal requirement for raw milk to be safe is repeated multiple times. In language which lends itself to multiple interpretations, analytical monitoring is required for pathogens (S. aureus, Listeria monocytogenes, Salmonella spp, E. coli O157, Campylobacter) and contaminants (aflatoxins) on animals and milk, though no minimum frequency is mandated.
Moreover, fresh raw milk has to be supplied daily, and unsold milk from the previous day has to be collected and cannot be sold as such.
The vending devices can provide raw milk from tap, or automatically fill bottles, which need to carry the label “unpasteurized raw milk.” Moreover, raw milk has to be kept between 0 and 4 C (32 to 39 F) at all times, with an automatic mechanism to stop distribution if temperature exceeds the limits. A temperature data logger needs to be installed.
The decision helped boost a booming market, a growth which continues today. Unaffected by safety issues, as of 2012, more than 1,400 distribution vending machines exist in Italy.
Raw milk is promoted for its supposed health benefits and, regrettably, also to children by organizations such as Slow Food, an international movement that supports traditional and local cuisine and farming. The key touted benefit is for allergy prevention, and nutrition.
Problems became apparent early on. A 2006 survey by a consumers’ organization found 5 out of the 10 vending machines tested with distributed milk temperature above 4 C (39 F), and in one case above 10 C (50 F). The survey was performed in March, a cool month. It also found that 7 of the samples had total microbial load above statutory limits, though no pathogens were found.
In 2007, out of 39 samples from vending machines, one E. coli O157 positive sample, and three Campylobacter positive samples, were reported to a local congress. In the generally supportive climate and with misguided reading of microbiological evidence from a food safety standpoint, the authors interpreted their overall results as satisfactory.
Sadly, in 2009, a team from Italy’s Istituto Superiore di Sanità, in charge of a national registry of hemolytic uremic syndrome (HUS) cases, reported that, in a case-control study, the only food significantly associated with HUS in 60 Italian children who developed the disease was raw milk.
On Jan. 19, 2009, following cases of HUS possibly linked to raw milk, Italy’s Ministry of Health ordered temporarily all raw milk sold to carry the label “to be used only after boiling” (in red and at least 1 cm, .39 inch, high); for on-farm sales, the warning has to be given verbally.
A mandatory use-by date of three days was also set. Use of raw milk in catering premises, including school cafeterias, was also banned. It is debatable whether people would actually buy raw milk in order to then boil it. More recently, data on microbiological quality of Italian raw milk from vending machines have been reported, and are commented here.
Two years later, on March 23, 2012, the Ministry of Health formally asked pediatricians and physicians, through their associations, to warn patients and parents to boil any raw milk they intend to consume. The 2009 temporary ordinance was also reiterated.
The Ministry also reported that, since 2007, 18 children who later developed HUS have been exposed to raw milk (though a causal link has not been proven), and very recently cases have been identified. There has also been one death. If possible, the magnitude of the health burden appears also underestimated, or underreported, as aggressive identification and early investigation of sporadic cases or outbreaks is not pursued. The recent developments did attract media attention; however, the travails of children with HUS have received little publicity.
From a public health standpoint, the experience of Italy underlines the perils, and difficult reversibility, of policies that expand the availability of raw milk. It is relevant for countries, or jurisdictions, contemplating such policies. The present state is such that only an outbreak large and severe enough to be detected by Italy’s epidemiological means seems likely to question the current policy of pretending that consumers actually boil the raw milk they buy.
The experience also exemplifies the significant health burden that the Italian society – like others – is willing to shoulder as the natural/traditional discourse trumps the health/science perspective. As a consequence, the challenge for the public health community to prioritize safety and overcome cultural and communication barriers has become enormous, against perceived consensus. Even scientists who have highlighted safety issues publicly state that safe raw milk is possible, and do not dare advocate the only protective solution: ban sales of raw milk, especially through vending devices.
Luca Bucchini, a Rome-based food risk scientist and consultant, is co-founder and managing director of Hylobates, a European food safety and nutrition consultancy.
Intesa, ai sensi dell’articolo 8, comma 6, della legge 5 giugno 2003, n. 131, tra il Governo, le Regioni e le Province autonome di Trento e di Bolzano in materia di vendita diretta di latte crudo per l’alimentazione umana. 2007. Available at http://www.normativasanitaria.it/normsan-pdf/0000/26733_1.pdf (Italian).
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Scavia G., Escher M., Baldinelli F., Pecoraro C., Caprioli A. Consumption of unpasteurized milk as a risk factor for hemolytic uremic syndrome in Italian children. (2009) Clinical Infectious Diseases, 48 (11), pp. 1637-1638.
Ministero della Salute. Segnalazione casi di Sindrome emolitico-uremica pediatrica da probabile consumo di latte crudo. 2012. Available at http://www.iss.it/binary/seur/cont/NotaMinSalLatteCrudo27_3_2012.pdf (Italian)© Food Safety News