Original Article

The role of unpasteurized “hawked” milk in the transmission of brucellosis

in Eldoret municipality, Kenya

Augustine Taban Namanda1, Rose Kakai2, Mary Otsyula3

1
Moi University, School of Public Health, P.O. Box 4606 - 30100, Eldoret, Kenya
2
Maseno University, School of Public Health and Community Development, P.O. Box 333 - 40105, Maseno, Kenya
3
Moi University, School of Science, P.O. Box 1125 - 30100, Eldoret, Kenya

Abstract
Background: Brucellosis is a zoonotic disease that continues to infect many people worldwide. Though its mortality rate is low, long
convalescent periods associated with brucellosis translate into reduced socio-economic capacity of the people affected. Human brucellosis is
mostly transmitted from animals. In Kenya, the prevalence of the disease has increased recently, along with the increased hawking of
unpasteurized milk. The extent of the risk such raw milk poses to human health with respect to brucellosis is unknown. This study
investigates the possibility of brucellosis being transmitted through unprocessed milk sold by hawkers in Eldoret municipality.
Methodology: In this cross-sectional study, 130 samples of unpasteurized pooled milk from hawkers and 14 pasteurized milk samples were
collected from shops in selected estates using cluster and simple random sampling techniques. All samples were subjected to the Brucella
Milk Ring Test (MRT) for screening. A milk consumption questionnaire was administered to households in the selected estates to establish
their milk sources and consumption patterns. Data analysis involved comparing computed percentages of different variables. Results: A high
proportion of households (77.5%) consume unpasteurized milk from hawkers. However, no antibody to Brucella was detected in any of the
milk samples collected.
Conclusion: We find no evidence that hawked milk in Eldoret is responsible for transmitting brucellosis to consumers. More research in the
potential transmission of brucellosis through milk consumption is recommended.

Key words: brucellosis, pasteurization, transmission, hawking

J Infect Developing Countries 2009; 3(4):260-266.

Received 2 November 2008 - Accepted 17 March 2009

Copyright © 2009 Namanda et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction and poorly understood of all infectious diseases.

Brucellosis remains one of the world’s most Kenya has no vaccination policy on the control of
common public health problems [1]. Worldwide, brucellosis in either animals or humans. Some years
more than 500,000 human cases of brucellosis are ago, farmers opted to have their cattle vaccinated
reported annually. This zoonotic disease is caused by with B. abortus strain 19, but the practice has
various species of Brucella that infect many domestic declined due to the high vaccine costs. The vaccine
animals, which act as reservoirs for human infection. remains useful at research and learning institutions.
The disease has evolved to establish itself as an Decision-making is urgently required to determine
occupational, as well as a food-borne, illness. The the importance of brucellosis control relative to other
transmission of brucellosis through food ingestion is public concerns and to select what brucellosis control
becoming more recognised in comparison to its strategies should be applied [5].
occupational transmission, as less and less evidence Many people may be at the risk of being infected
associates it with occupational risks from exposure to with brucellosis because of their milk consumption
organisms [2,3]. Probably for this reason, the disease habits. A study conducted on HIV patients in
is considered a re-emerging food-borne disease Nairobi, Kenya, with negative routine brucellosis
transmitted through contaminated raw milk and microbiological culture had sera with large quantities
cheese [4]. Most milk is consumed in liquid form as of Brucella-specific IgM and IgG antibodies,
compared to milk products. Despite the growing suggesting a relatively high level of exposure to
recognition of the importance of zoonoses in human Brucella organisms in the cohort. This observation
health, these diseases are among the most neglected implies that brucellosis is probably under-diagnosed
Namanda et al. - Role of unpasteurized milk in the transmission of brucellosis J Infect Dev Ctries 2009; 3(4):260-266.

in Kenya. Brucella serology may be helpful in the Administration of the household milk consumption
diagnosis of patients with non-specific symptoms [7]. questionnaire also features the cross-sectional design.
The purpose of this study was to determine the role
of unpasteurized hawked milk in the transmission of Sample Size
brucellosis in the study area. This may guide The sampling period was set for June to
strategies that can be used to prevent further September 2004. Samples that satisfied the inclusion
transmission. criteria during the study period were included. A total
of 130 samples from milk hawkers and 14 packaged
Methods milk samples from shops were collected across the
Study Area town. Up to 200 households distributed equitably in
Eldoret municipality and its surrounding areas the estates of Eldoret were sampled as respondents to
are well known for milk production and are the main the household milk consumption questionnaire.
sources of hawked milk. Both large-scale and small-
scale dairy farming contribute greatly to household Inclusion Criteria
income within these areas. This region is located in The following criteria were used to justify
Uasin Gishu District, Rift Valley Province, in Kenya. inclusion of samples and households responding to
In 1999, Eldoret municipality had an area of 147.9 the questionnaire:
km2. Its size has been increasing with time due to 1. Samples were from selected estates only.
population pressure and business expansion. Spatial 2. Samples were from milk presented for sale.
expansion of the municipality seems to follow the 3. Samples were handled in the same way as the
main roads radiating from the town. According to the milk which is sold to consumers prior to their
1999 Kenya National Census, Eldoret had a collection.
population of 197,449 people, with a growth rate of 4. Pasteurized milk was obtained from the same
4.9%. area and time as the hawked milk samples.
For the purpose of this study, the population of 5. Respondents to the household milk consumption
Eldoret was estimated to be 226,474 in the year 2002, questionnaire were immediate family members
assuming an annual population growth rate of 4.9% (father, mother or children), aged 18 years and
determined during the population census of 1999. above, from households belonging to the selected
However, the actual population could be lower than estates.
this figure considering the socio-economic dynamics
that have taken place. These include the collapse of Sampling Procedure
the textile industry, which was a major employer for The study used the cluster sampling technique, in
the inhabitants in Eldoret and may have contributed which the population of Eldoret was divided into four
significantly to the population level at the time of the clusters based on relative positions of the estates to
census. Many industry personnel who were laid off the town centre. Clusters were comprised of estates to
may have migrated out of the municipality since then. the South, West, North and Town centre (Table 1).
The town is mostly inhabited by people from From each cluster, estates were listed and milk
different parts of the country who have come because hawking points identified. Hawking points and
of employment in both the private and public sectors. hawkers to supply the samples from each estate were
These people provide a market for both pasteurized identified by simple random selection. Where the
and unpasteurized milk sold within the municipality. milk hawkers in a selected hawking point did not
have milk on a particular day, the nearest hawking
Study Population point was selected as an alternative. Apart from
Unpasteurized milk hawkers and consumers of supplying the milk samples, hawkers were requested
the hawked milk who are residents of Eldoret to provide information for the samples they supplied,
municipality comprise this population. including the milk’s area of origin. This information
was recorded by sample code, but it was not
Study Design disclosed to the laboratory technician who performed
This was a cross-sectional study based on the tests.
samples of unpasteurized hawked milk and One packaged pasteurised milk sample was
pasteurized packaged milk from the local market. bought from a shop at each selected estate or cluster,
removed from the packet and put in a container

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Namanda et al. - Role of unpasteurized milk in the transmission of brucellosis J Infect Dev Ctries 2009; 3(4):260-266.

similar to those that the unpasteurized milk samples result in agglutination. Stained aggregates of the
were placed in, and then coded before being carried Brucella bacilli would rise with the cream, giving a
to the laboratory. These processes ensured adequate blue cream line above a white column of milk. A
blinding in sample handling at the laboratory. weak positive would show a blue cream line and a
blue colour in the milk. If no antibodies were present,
Milk Sample Collection and Transportation a white cream line would appear above the normal
Hawked milk samples were collected three days white milk column. Positive and negative controls
every week. After hawkers gave their informed were included for each test.
consent, half-litre milk samples were purchased in
the paper bags that consumers used. Each day that Interviews of Milk Hawkers and Household
milk samples were collected, a half-litre sample of Respondents
packaged pasteurized milk was also bought from a Each milk hawker from whom milk samples
shop in the same locality and subjected to the same were collected was requested to give information on
laboratory treatment as the hawked milk samples. where the milk originated, who their customers were,
All milk samples were immediately placed in and what they knew about the use of the milk by their
sterile paper bags similar to the ones milk is sold in to customers. This information was recorded by sample
ensure the same conditions in which hawked milk is code on a check list form.
sold to consumers. Samples were coded with A household milk consumption questionnaire
identification stickers, immediately placed in vaccine was administered to capture information relating to
carriers with ice packs to prevent decomposition, and use and sources of their milk, any health
transported to Veterinary Investigation Laboratories complications encountered as a result of milk
(VIL) in Eldoret where they were temporarily stored consumption, and the occupation of those affected.
in the refrigerator, awaiting onward transportation to
Analabs in Nairobi. Data Analysis
Data was entered into the computer-based
Processing of Samples for Laboratory Investigation Statistical Package for Social Scientists (SPSS,
At the VIL laboratory, 10 ml of milk was taken version 11) and analysed for frequencies and
from each sample using small sterile measuring percentages.
cylinders and placed in sterile test tubes, which were
sealed with stoppers, labelled with their Ethical Considerations
corresponding sample codes, and temporarily stored Approval to conduct this study was sought from the
in a refrigerator at 0-4°C. Within 12 hours, these Institutional Research and Ethics Committee (IREC)
were transported in a vaccine carrier with ice packs to at the faculty of Health Sciences, Moi University.
Analabs for processing. After removing the 10-ml Verbal informed consent was obtained from the
samples, the remaining milk was discarded. hawkers and household consumers before being
included in the study. All information was kept
Laboratory Analysis of Milk Samples confidential.
At Analabs, the "Brucella Milk Ring Test”
(MRT) was performed to screen each milk sample for Results
Brucella antibody. Milk samples were stored Brucella Antibody in Unpasteurized and Pasteurized
overnight at 4°C before testing, according to the Milk
procedure described by Collins et al. [8]. During As indicated in Table 2, there was no positive
testing, one ml of the well-mixed raw milk stored reaction between the MRT and all milk samples.
overnight was placed in a narrow wintrobe tube, to These results show that the sampled milk did not
which one drop of the stained antigen (milk ring test have Brucella antibodies.
reagent) was added using sterile droppers. These
were immediately mixed by inverting the wintrobe Consumers of Hawked Milk
tubes several times. Placed on small test-tube racks, Over 99% of hawkers sampled (129/130) sold
the tubes were allowed to stand for one hour at 37°C milk to households, and 10% of milk hawkers
in a water bath before observation. If Brucella (13/130) sold to hotels. Thus 9.2% of the hawkers
antibodies were present in milk, they would react (12/130) sold milk to both hotels and household
with homologous antigens in the test reagent and

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Namanda et al. - Role of unpasteurized milk in the transmission of brucellosis J Infect Dev Ctries 2009; 3(4):260-266.

Table 1. Number of milk samples collected per culture estates

Cluster Description Estate No. (%) of hawking No. (%) of samples
points collected
1 South of the Town (South of Hill School 15 (3.9) 3 (2.1)
River Sosiani) Kipkaren 36 (9.3) 24 (16.7)
Langas 44 (11.3) 29 (20.1)
2 West of the Town Bacon 14 (3.6) 4 (2.8)
Boma 14 (3.6) 4 (2.8)
Bondeni 21 (5.4) 7 (4.9)
Bridge Camp 7 (1.8) 2 (1.4)
Hurruma 42 (10.8) 14 (9.7)
Kahoya 14 (3.6) 4 (2.8)
Kidiwa 15 (3.9)) 2 (1.4)
Mwanzo 10 (2.6) 3 (2.1)
Road Block 10 (2.6) 3 (2.1)
Komongo 10 (2.6) 3 (2.1)
Keroka 3 (0.8) 1 (0.7)
Mwenderi 14 (3.6) 4 (2.8)
Shauri 7 (1.8) 2 (1.4)
3 North of the Town Forest 8 (2.1) 1 (0.7)
Jerusalem 10 (2.6) 4 (2.8)
Kapsoya 14 (3.6) 5 (3.5)
Kimumu 14 (3.6) 5 (3.5)
Munyaka 15 (3.9) 5 (3.5)
Prisons 9 (2.3) 1 (0.7)
4 Town centre Kampi Somali 11 (2.8) 4 (2.8)
CBD* 31 (8.0) 10 (6.9)
Grand Total 24 388 100 144 100
Mean 16.2 4.2 6.0 4.2
Standard deviation 10.9 2.8 7.0 4.8
*CBD = Central Business District

Hawkers’ Sources of Milk

Table 2. Results of Brucella antibody by MRT analysis
Hawkers were supplied with milk by middlemen
MRT results Number (%) of milk samples: Total from different places both within and outside Uasin
Unpasteurized Pasteurized Gishu district (Fig. 1). Milk was delivered in the
Positive 0 0 0
Weak positive 0 0 0
Negative 130 (100) 14 (100) 144
Total 130 14 144

clients, while only 0.8% of hawkers (1/130) reported

to have only hotel customers. Hawkers’ perception of
milk use by their customers was as follows: of the
130 hawkers interviewed, 110 (84.6%) said the milk
was used for unspecified domestic purposes, 20
(15.4%) said it was for making household tea, and 14
(10.8%) said it was for hotel tea. Domestic milk use
may also include making tea for households.

Figure 1. Unpasteurized milk hawkers and a middle-man.

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Namanda et al. - Role of unpasteurized milk in the transmission of brucellosis J Infect Dev Ctries 2009; 3(4):260-266.

morning to the hawking points, from which the Health Complications Related to Milk Consumption
consumers could access it the whole day. According to the perception of the respondents,
Most of the milk was supplied to hawkers 10/200 (5%) reported that their households’ members
through middlemen from Ndalat (17.7%) and had suffered complications related to milk
Tanning (17.7%) in Eldoret, followed by Soy consumption while the remaining 190 (95%) did not
(11.5%) and Kapsabet (8.5%) about 40km away on report complications. These were general
the outskirts of Eldoret town. Outside Uasin Gishu complications which included three reports of
District, milk was supplied to hawkers from as far diarrhoea (30%), two reports of vomiting and
away as Trans Nzoia, Keiyo, Eldama Ravine, and diarrhoea (20%), two reports of allergy (20%), two
Nandi North districts. reports of brucellosis (20%), and one report of
stomach upsets (10%). Eight (80%) respondents
Sources and Uses of Household Milk reported that only one member of the household had
Selected in proportions corresponding to the suffered complications, while the remaining two
number of milk samples and the population of each households reported that two (10%) or three (10%)
estate, 200 respondents from Eldoret estates were household members suffered complications.
interviewed. Langas (19.5%) had the highest number One hundred and sixty five respondents (82.5%)
of respondents, followed by Kipkaren (16%) and knew about brucellosis, while 35 (17.5%) did not.
Huruma (14%). The lowest number of respondents Among respondents who knew about brucellosis, 13
was 1 (0.8%) each for Forest, Kamukunji, Keroka (7.9%) knew of a household member, neighbour, or
and Prisons. themselves who had suffered from the disease. Out of
Out of the 200 respondents, 99% reported that these, the occupation of people whom they knew had
they used either packaged or unpasteurized milk, suffered from brucellosis was that of housewife in
while only 2/200 (1%) did not use any milk in their eight cases (61.5%), a student in two cases (15.4%),
households. Three sources of milk were named by farmer in two cases (15.4%), and shopkeeper in one
respondents: packaged milk from shops or kiosks, case (7.7%). Thus the disease seems to be more
unpackaged milk from hawkers, and milk from the common among housewives.
respondents’ own cows. Among the 198 households
that used milk, the majority (84.8%) obtained it from Discussion
only one source, 9.6% from two sources, and 5.6% Brucellae are among the many pathogenic
from three sources. Only 51/200 (25.5%) microorganisms that are spread through milk of
respondents owned cows from which they received infected animals, and they can occasionally be
milk at one time or another. Thus a large proportion detected in milk and milk products [9,10]. Other
of the population (74.5%) relied on other sources for studies have shown that there appears to be a positive
their milk supply. At the time of the study, out of the correlation between the prevalence of brucellosis in
200 respondents, 155 (77.5%) used hawked animals and in humans [11]. In Kenya, according to
unpasteurized milk, while 45 (22.5%) did not. Thirty monthly reports from the Trans-Nzoia district
respondents gave reasons for preferring the veterinary office, the average case prevalence rate for
commonly used hawked milk sources. These bovine brucellosis was among the top ten cattle
included affordability and accessibility (66.7%), diseases with 8.5% prevalence. Consumption of raw
hygienic properties (20%), large family (6.7%), or unpasteurized milk can be a source of human
allergy to other sources (3.3%), and lack of other infection [12]. Other sources of infection may include
alternatives (3.3%). direct contact with contaminated milk or carcasses,
Respondents reported that their households used consumption of improperly cooked meat from
milk for one or more domestic purposes. Making tea infected carcasses, or handling of milk that is sold
was the predominant use, reported by 194 directly by farmers to consumers without going
respondents (97%). This was followed by feeding through the hawking channel. In spite of its potential
children, reported by 64 respondents (32%); making to transmit brucellosis, milk is one of the animal
fermented milk (mala), reported by 35 respondents products consumed by many families, most of whom
(17.5%); and drinking milk the way it was bought, are not producers of the commodity, especially those
reported by only 25 respondents (12.5%) who did not residing in towns and urban centres [13]. In our
specify the source of such milk directly consumed. study, a majority (77.5%) of the households used
unpasteurized milk sold by hawkers. The peri-urban

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Namanda et al. - Role of unpasteurized milk in the transmission of brucellosis J Infect Dev Ctries 2009; 3(4):260-266.

areas and parts of Eldoret municipality are known for laboratory confirmation are brucellosis positive,
milk production. Inhabitants of the town provide a indicating the necessity of organizing epidemiologic
ready market for both processed and unprocessed surveillance on brucellosis [18].
milk sold within the municipality. Knowledge of brucellosis among respondents
Whereas the market for crop products has been was high. This may have contributed to the absence
consistent, that of milk has been on the downward of antibodies from the milk. In Saudi Arabia, 79% of
trend, especially after the collapse of the Kenya patients with acute brucellosis who were admitted at
Cooperative Creameries (KCC) in the early 1990s. the King Fayad National Hospital were illiterate [19].
This left the dairy farmers and especially the small About 97% of the consumers used milk for making
scale milk producers to resort to alternative milk tea, a process that subjects the milk to high
marketing strategies such as hawking, middlemen temperatures and destroys most of the inherent
and independent milk processors. This was also the microorganisms, including Brucella species. A study
time when inflation rate was highest in the country, carried out in Nakuru and Narok within Kenya
with price increases being felt on all other revealed that 96% of rural milk consumers boiled
commodities required by households. These multiple milk either in tea or otherwise prior to consumption
factors encouraged consumers who may have found [13,20]. It is possible that hawkers also boil the milk
this source relatively cheaper than processed milk. before sale in order to extend its shelf-life. Regarding
Convenient delivery and lower prices are the association of brucellosis with occupation,
principal benefits for poor consumers [13]. In this housewives seemed to be the most affected.
study, most of the clients were household consumers, Transmission through contact can be associated with
67% of whom preferred hawked milk because it was one’s occupation. It was not stated what roles the
affordable and available. housewives were carrying out that exposed them to
About 56% of milk produced by small holder risk of brucellosis infection. Probably they were
farmers is sold raw in an unregulated informal directly involved in activities such as milking cows
market; both the product and delivery method raise and tea preparation in which they are likely to come
public health concerns about its purity and safety into direct contact with Brucellae contaminated milk.
(14). Since milk from different sources is usually The Milk Ring Test (MRT) is a reliable means of
pooled together by hawkers, one source may screening herds of cattle for Brucella organisms [21].
contaminate all the milk in the pool. Eldoret Pooling of milk from Brucella infected and clean
municipality is one of the towns in Kenya where herds has a dilution effect that could reduce the
hawking of unpasteurized milk and its products, concentration of antibodies in the milk to
especially fermented milk (“mala”) is common, undetectable levels. It is not clear if this had an effect
probably exposing its residents to milk-borne on the results of this study. Previous studies in rural
zoonotic diseases such as brucellosis. According to and urban areas of Nakuru, Narok, Nairobi, and
the local people’s perception, brucellosis has become Kiambu detected 3-5% of Brucella antibodies from
a disease of great public health concern in this area samples drawn at both consumer households and
and its transmission is to a great extent linked to the markets using MRT and enzyme-linked
consumption of hawked milk. In Kenya, there have immunosorbent assay (ELISA) [22,23]. In this study,
been no meaningful epidemiological studies no antibody was detected by MRT from any of the
conducted on human brucellosis, but evidence from milk samples. It is therefore concluded that there is
anecdotal reports showed that the disease is common no evidence to suggest that unpasteurized milk sold
among pastoralists in Narok district with a prevalence in Eldoret by hawkers is responsible for transmission
of 13.7% (15). Agglutinin for Brucellae antigens in of human brucellosis. Further studies are
blood sera among healthy people in Nairobi and recommended to perform culture and/or ELISA
Naivasha was 4% and 7% reactivity, respectively testing concurrently with MRT when examining
[16]. The reactivity among participants from milk, or to screen livestock herds to identify the
Naivasha was associated with high contact with source, so as to control the disease in animals, and
unsterilized milk as compared to those from Nairobi. ultimately among human populations.
Mosoriot health facility on the outskirts of Eldoret
recorded a prevalence rate of 35% by Brucella test
[17]. Records at a local hospital in Eldoret show that
in a month, an average of 40/174 (23%) requests for Acknowledgements

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Namanda et al. - Role of unpasteurized milk in the transmission of brucellosis J Infect Dev Ctries 2009; 3(4):260-266.

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