title: Outbreaks attributed to cheese: differences between outbreaks caused by unpasteurized and pasteurized dairy products, United States, 1998-2011.
abstract: BACKGROUND
  The interstate commerce of unpasteurized fluid milk, also known as raw milk, is illegal in the United States, and intrastate sales are regulated independently by each state. However, U.S. Food and Drug Administration regulations allow the interstate sale of certain types of cheeses made from unpasteurized milk if specific aging requirements are met. We describe characteristics of these outbreaks, including differences between outbreaks linked to cheese made from pasteurized or unpasteurized milk.
  
  
  METHODS
  We reviewed reports of outbreaks submitted to the Foodborne Disease Outbreak Surveillance System during 1998-2011 in which cheese was implicated as the vehicle. We describe characteristics of these outbreaks, including differences between outbreaks linked to cheese made from pasteurized versus unpasteurized milk.
  
  
  RESULTS
  During 1998-2011, 90 outbreaks attributed to cheese were reported; 38 (42%) were due to cheese made with unpasteurized milk, 44 (49%) to cheese made with pasteurized milk, and the pasteurization status was not reported for the other eight (9%). The most common cheese-pathogen pairs were unpasteurized queso fresco or other Mexican-style cheese and Salmonella (10 outbreaks), and pasteurized queso fresco or other Mexican-style cheese and Listeria (6 outbreaks). The cheese was imported from Mexico in 38% of outbreaks caused by cheese made with unpasteurized milk. In at least five outbreaks, all due to cheese made from unpasteurized milk, the outbreak report noted that the cheese was produced or sold illegally. Outbreaks caused by cheese made from pasteurized milk occurred most commonly (64%) in restaurant, delis, or banquet settings where cross-contamination was the most common contributing factor.
  
  
  CONCLUSIONS
  In addition to using pasteurized milk to make cheese, interventions to improve the safety of cheese include limiting illegal importation of cheese, strict sanitation and microbiologic monitoring in cheese-making facilities, and controls to limit food worker contamination.
authors.affiliation: 1 Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention , Atlanta, Georgia .
authors.forename: L Hannah
authors.initials: LH
authors.lastname: Gould
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Mungai
authors.forename: Casey Barton
authors.initials: CB
authors.lastname: Behravesh
mesh_terms: D002611:Cheese / Q000382:microbiology* / Q000592:standards; D004196:Disease Outbreaks; D005506:Food Contamination / Q000032:analysis*; D005511:Food Handling / Q000379:methods*; D005516:Food Microbiology; D005517:Foodborne Diseases / Q000453:epidemiology* / Q000382:microbiology; D061352:Pasteurization; D014481:United States / Q000453:epidemiology
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