Contamination of milk and dairy products by Brucella species: A global systematic review and meta-analysis

Journal Pre-proofs Contamination of milk and dairy products by Brucella species: a global systematic review and meta-analysis Maryam Dadar, Yadolah Fakhri, Youcef Shahali, Amin Mousavi Khaneghah PII: DOI: Reference:

S0963-9969(19)30661-1 https://doi.org/10.1016/j.foodres.2019.108775 FRIN 108775

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Food Research International

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Please cite this article as: Dadar, M., Fakhri, Y., Shahali, Y., Mousavi Khaneghah, A., Contamination of milk and dairy products by Brucella species: a global systematic review and meta-analysis, Food Research International (2019), doi: https://doi.org/10.1016/j.foodres.2019.108775

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Contamination of milk and dairy products by Brucella species: a global systematic review and meta-analysis Maryam Dadar1, Yadolah Fakhri2,* Youcef Shahali1,** Amin Mousavi Khaneghah3 1

Razi Vaccine and Serum Research Institute (RVSRI); Agricultural Research, Education and Extension Organization (AREEO), Karaj, Iran 2

Department of Environmental Health Engineering, Student Research Committee,

School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Department of Food Science, Faculty of Food Engineering, University of Campinas

3

(UNICAMP), Rua Monteiro Lobato, 80. Caixa Postal: 6121.CEP: 13083-862, Campinas, São Paulo, Brazil.

*,** Correspondence: *Email: [email protected] , Phone: +989216737245 **[email protected], Phone : +982634502834

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Abstract Brucellosis is known as an influential zoonosis in different regions worldwide, with significant effects on the reproductive performance of livestock. Considering the high incidence of brucellosis in dairy products and further negative impacts on food safety, the present study was aimed to systematically investigate prevalence worldwide among published data regarding the identification of Brucella spp. in dairy products. In this regard, some databases, i.e., Scopus, PubMed, Embase, and Web of Science to retrieve all related articles regarding the incidence of Brucella contaminations in dairy products from 1 January 1983 to 1 April 2019. The prevalence of Brucella spp. in unpasteurized dairy products based on countries, WHO regions, and dairy product subgroups were evaluated and statistically compared. Based on the findings, the prevalence of Brucella spp. in dairy products increased while the GDP (C = 0.17, P-value < 0.001) and HDI (C = 0.19, P-value < 0.001) ranking decreased. Also, the highest prevalence of Brucella contamination in dairy products was noted in buffalo (25.91%) and goat (17.90%), respectively. The lowest and highest prevalence of Brucella spp. were observed in the Western Pacific (15.32%) and the Southeast Asia region (25.55%), respectively. Also, the rank order of WHO regions based on odds ratio (OR) was Southeast Asia region (2.84) > Eastern Mediterranean (2.41) > Region of America (1.65) > European Region (1.54) > Africa region (1.46) > Western Pacific (reference). The results of this study showed that decreasing poverty and an increase in the level of education in societies could reduce the 2

prevalence of Brucella spp. in dairy products. The outcome of the current investigation can be used for the implementation of sustainable intervention and prevention strategies in affected regions. Keywords: Prevalence; Brucella spp.; milk; zoonosis, dairy products; a meta-analysis.

1. Introduction Brucellosis, also named as “Mediterranean fever”, “Malta fever”, or “undulant fever”, is one of the major zoonotic infections which can be caused by several Gram-negative virulent species belonging to the genus Brucella (Corbel, 1997; Negrón et al., 2019). This zoonosis transmitted to humans through the consumption of contaminated raw milk and dairy products, although direct contact with infected animals and working in medical laboratories are among other important sources of contamination (Dadar et al., 2019a; Alamian and Dadar, 2019; Kaynak-Onurdag et al., 2016; Verraes et al., 2015). It has been categorized as one of the most important neglected occupational hazards worldwide by the Office International des Epizootics (OIE), the World Health Organization (WHO) and the Food and Agriculture Organization of the United Nations (FAO) (Franc et al., 2018; Musallam et al., 2016) with critical economic impacts on animal farming and industry such as abortion, lost draught power, poor weight gain, reduced fertility and milk production in sheep, goats, cattle, camels, and swine (Franc et al., 2018; McLeod, 2011). In 3

humans, brucellosis is known as a serious, life-threatening disease that typically generates different chronic and recurring febrile conditions with non-specific clinical signs such as arthralgia, abdominal pain, sweats, back pain, hepatomegaly, undulant fever, myalgia, headaches, as well as personality changes (Dadar et al., 2019b; Franc et al., 2018). It is one of the most important zoonosis worldwide, with 500,000 new human infections reported annually. The decline in the socioeconomic status and significant loss of workdays have been reported as the consequences for infected persons (Aloufi et al., 2016). Among Brucella spp., Brucella melitensis strains are responsible for the majority of infections in humans, however, B. canis, B. abortus, B. suis (Whatmore, 2009) and, at lower extent, marine Brucella species including B. pinnipedialis and B. ceti (Dawson et al., 2008; McDonald et al., 2006) as well as B. inopinata (Scholz et al., 2010), can induce severe bacterial infections. Some high-income countries have succeeded in eradicating brucellosis following the establishment of effective vaccination programs and control strategies including the regular testing, surveillance, and slaughter of infected livestock (Falenski et al., 2011). However, this zoonosis remains one of the most important diseases in the Middle East, Latin America, South, and Central Asia and North and East Africa (Oliveira et al., 2017). In these regions, the consumption of raw dairy products still represents an important risk for population (Dadar et al., 2019; Oliver et al., 2009), which is exacerbate with the recent 4

trends in the consumption of raw milk obtained from a wide range of animals e.g. cows, goats, sheep, camels, donkeys, llamas, buffaloes, horses, yaks, and reindeer (Falenski et al., 2011). In recent years, several studies have been conducted regarding the prevalence of Brucella spp. in dairy products (Cadmus et al., 2008; Chand et al., 2005; El-Razik et al., 2008; FAO, 2018; Gupta et al., 2006; Hamdy and Amin, 2002; Ilhan et al., 2008; Kasimoğlu, 2002; Marianelli et al., 2008; Patel et al., 2008; Rivera et al., 2003; Romero et al., 1995; Zowghi et al., 1990). Therefore, a comprehensive analysis of the brucellosis epidemiology could be performed to design appropriate preventive approaches, helping to the implementation of future control programs and efficient eradication strategies in endemic regions. In this regard, the present meta-analysis was aimed to estimate the prevalence of Brucella spp. in dairy products based on defined subgroups including type of dairy product, country and W.H.O regions (i.e. African, American, South-Eastern Asia, European, Eastern Mediterranean, and Western Pacific regions). Also, the estimation of the odds ratio (OR) of contaminated dairy products by Brucella spp. based on WHO regions, abortion, type of animal, microbial species, contact with the animal, sources of sampling and vaccinate subgroups. Finally, the correlation between the prevalence of dairy products contaminated by Brucella spp. with gross domestic product (GDP) and human development index (HDI) ranking were evaluated via meta-regression analysis.. 5

2. Material and method 2.1. Search strategy

This systematic review was carried out following the Cochrane guidelines (Higgins and Green, 2011) and the subsequent screening of relevant studies was based on PRISMA guidelines (Figure 1) (Liberati et al., 2009). A search was first conducted across four main international databases, i.e., PubMed, Scopus, Embase, and Web of Science to obtain all related articles regarding the prevalence of Brucella spp. in dairy products between 1 January 1983 to 1 April 2019. The following keywords were used to search databases: "milk" OR "cheese"OR "yogurt"OR "cream"OR"butter" OR "dairy products" AND "prevalence" OR "occurrence" AND "Microbe" OR "bacteria" OR "Brucella spp." OR "B. abortus" OR "Brucella" OR "B. melitensis" OR "B. ovis." All references list of obtained articles were reviewed to retrieve additional articles.

2.2. Data extraction and inclusion/exclusion criteria The inclusion criteria were 1) full-text in the English language; 2) descriptive or crosssectional study; 3) studies on the incidence of Brucella spp. in dairy products, 4) conducted on dairy products, 5) providing information regarding positive and total 6

sample sizes and 6) available online and/or published from 1 January 1983 to 1 April 2019; Hence, books, workshops, and clinical trial were excluded due to lack of peer review process (Fakhri et al., 2019c; Keramati et al., 2018b; Khaneghah et al., 2018a; Khaneghah et al., 2018b; Rahmani et al., 2018a; Rahmani et al., 2018b). Case reports have been excluded from this meta-analysis according to the Cochrane guidelines because of their small sample size and high probability of bias. Afterward, based on similar conducted study (Fakhri et al., 2019a; Fakhri et al., 2019b; Khaneghah et al., 2019) , the required data including year of the study, total and positive sample sizes, country, WHO region, type of animal, type of dairy products, detection method, human development index (HDI) ranking, gross domestic product (GDP) ranking, vaccinated animal condition, animal contact condition, abortion condition, implicated Brucella species, and source of sampling were extracted. 2.3. Synthesis and meta-analysis of data In the current study, the prevalence is expressed as a ratio of the positive sample size (pi) to the total sample size (ni) (Keramati et al., 2018a; Khaneghah et al., 2018a). To detect heterogeneity among studies, a Chi-squared test was performed to define the I2 index for heterogeneity. When the I2 index is above 50%, heterogeneity is considered as significant (Higgins. and Thompson, 2002) and therefore, the random effect model (REM) was used to calculate the pooled prevalence of Brucella spp. in dairy products for defined

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subgroups including W.H.O regions; type of dairy product; WHO regions; abortion; type of animal; microbial species; contact with animal; sources of sampling; vaccine status and year of each study (Higgins. and Thompson, 2002; Kuroki et al., 2017). The prevalence odds ratio (OR) of Brucella spp. in defined subgroups was calculated by the aid of a univariate-analysis. It is noteworthy that, the lowest prevalence in any category of the subgroup was selected as the reference and/or baseline. The meta-regression between the prevalence of dairy products contaminated by Brucella spp. with GDP and HDI rankings were also carried out (Jackson et al., 2015; Stanley and Jarrell, 1989). No publication bias is considered when the prevalence rate is obtained based on the ratio of positive sample size to total sample size (Fakhri et al., 2018; Haghighi et al., 2018; Sabbagh et al., 2018). STATA software, version 12.0 (STATA Corp, College Station, TX, USA) was used and P-value < 0.05 was considered as significant.

3. Results and discussion Bacterial contamination of dairy products is a global concern worldwide (Heredia and García, 2018). Contamination of milk by pathogenic bacteria may directly occur from infected animals or from the farm environment and/or during storage, transport and manufacturing processes (Fysun et al., 2019). Some pathogens like Salmonella spp., Escherichia coli, Listeria spp. and Campylobacter spp. are still responsible for a large number

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of foodborne illnesses cases (Fox et al., 2018). While eradication programs along with milk pasteurization considerably reduced the prevalence of brucellosis and bovine tuberculosis in developed countries, the consumption of unpasteurized products still represents a major risk factor among developing countries (Godfroid, 2017). Commonly, Brucella spp. could contaminate raw milk through two principal routes, i.e., through contaminations which may occur during or after milking (exogenous agents) or through shedding due to the blood of animals infected (endogenous contamination)(Dadar et al., 2019; Verraes et al., 2015). Although it has been repeatedly emphasized that some virulent Brucella species are transmitted to humans through the consumption of contaminated raw milk or derived products (Mick et al., 2014), some factors such as the physiological status of the animal, the route of infection and the animal species could determine the level of contamination of milk samples from different infected animals (Jansen et al., 2019). In most infected animals B. abortus shed less than 103  CFU /ml from blood to raw milk and few animals referred to as super shedders appeared to shed up to 10 4  CFU/ml of B. abortus (Capparelli et al., 2009). The procedure and criteria used for the inclusion and exclusion of articles were presented in Figure 1. In this context, 1,080 articles were retrieved from databases including Scopus (n = 354), Web of Science (n = 245), PubMed (n = 324) and Embase (n = 157) publications from 1 January 1983 to 1 April 2019. In the first step, 728 articles were excluded due to repetition with the aid of Endnote 7x (Clarivate Table Analytics; 9

Philadelphia, PA, USA). Based on their titles, 96 articles were recognized as potentially suitable, and 256 articles were excluded due to their irrelevant content. The 96 remaining articles were reviewed, and 16 articles were excluded based on their abstracts. Full texts of the last 80 articles with 169 studies were included in the meta-analysis (Figure 1). The eradication of brucellosis in livestock has been achieved successfully in several high-income countries, including Canada, Australia, New Zealand and in most countries of Northern Europe (McDermott et al., 2013; Pappas et al., 2006). Recently, because of strict eradication programs, the brucellosis became a rare zoonosis in Western Europe. Kuwait and Saudi Arabia are highly income countries that are still suffered by this zoonotic disease with highly endemic levels of brucellosis (Dadar et al., 2019; Elmoslemany et al., 2016; Paul et al., 2017). This fact stresses the importance of the geographic situation in the epidemiology of this disease. Our results showed that the rank of W.H.O regions affected by the contamination of dairy products with different Brucella species, in a descending order, was Southeast Asia region (25.55%) > Eastern Mediterranean (22.56%) > region of America (16.64%) > European region (15.63%) > Africa region (15.32%) > Western Pacific (10.54%) (Table 1). Furthermore, the rank order of W.H.O regions based on OR was Southeast Asia region (2.84) > Eastern Mediterranean (2.41) > Region of America (1.65) > European Region (1.54) > Africa region (1.46) > Western Pacific (reference) (Table 2). However, it is important to note that prevalence data presented in this meta-analysis are based on works available in the literature and the lack 10

or the scarcity of representative researches in many countries may generate a misconception about the real prevalence of this zoonosis, particularly in regions not benefiting from adequate control and screening policies. Brucellosis remains a neglected disease in many developing countries and the occurrence of Brucella contamination in dairy products is still underestimated in many areas worldwide (Franc et al., 2018). In contrast, some other regions such as European countries exert strict surveillance policies in the context of eradication programs and most available works report sporadic outbreaks. Thus, cross-country comparisons should be interpreted with due caution, owing to regulatory, available laboratory equipment and methodological differences. According to extracted literature data published between 1983 and 2019, the high prevalence of brucellosis in Kosovo, Kuwait, Qatar, Venezuela, Syria, and Iraq was noted while specific national veterinary programs and different management systems still are needed to be reinforced. For example, in Kosovo, only 10% of milk produced by goats and sheep passes the processing routes. The rest is used by farmers for own consumption and feeding calves or sold as white cheese or raw milk without any pasteurization on the different local unregulated markets (Hamidi et al., 2016). Other important constraints for controlling Brucella spp. spread comprised improper management for unprotected animal transportation, lack of veterinary assistances , and poor cross-border veterinary collaboration (Godfroid et al., 2013). These factors also explain why brucellosis is still spreading in a substantial part of the world, especially in near- and Middle-Eastern 11

countries where this zoonosis represents a major health concern in rural and peri-urban areas (Pappas and Memish, 2007; Refai, 2002). The north- and sub-Saharan Africa, as well as South-eastern Asia, central and South America, are also constantly affected (Kline et al., 2013). By the end of 2016, among European Union, the United Kingdom (Guernsey and Channel Islands Jersey), Hungary, Italy, Greece, Cyprus, Croatia, Bulgaria, Portugal, and Spain were not yet officially brucellosis-free (Jansen et al., 2019). In endemic regions, findings of the current investigation revealed that the overall prevalence of Brucella spp. in dairy products remains high (Figure 2). In Tanzania, the brucellosis prevalence in cattle was around 8% (95% CI 6.5–10.2)(Alonso et al., 2016). In Venezuela, the prevalence among buffalo and cattle reached 10%(Memish and Balkhy, 2004) (Figure 2). In some countries including Syria, Iraq, Tanzania, and Uganda, brucellosis still spreads as an endemic zoonotic disease without adequate control approaches in dairy animals, thereby making a realistic prevalence estimation difficult (Kamwine et al., 2017) (Figure 2). According to results, in endemic regions, a higher prevalence of Brucella spp. contamination in raw milk (16.97%) while compared with cheese (7.10%) was reported which could be correlated with the role of fermenting bacteria in cheese, thus lowering the pH and reducing the of Brucella spp. growth due to nutrient competition (Verraes et al., 2015). Interestingly, the prevalence of Brucella spp. in dairy products originating from mothers who had an abortion (11.25 %) was lower than those without prior abortion 12

(13.06%) (Figure 3 A). The OR in mothers without abortion was equal to 1.20 (Table 2) which can be explaining by the fact that many herds without typical brucellosis symptoms such as abortion remain undiagnosed, leading to

further decrease in

surveillance due to lack of herd management. Also, a higher prevalence of Brucella spp. contamination in milk and milk products were noted in buffalo (25.91%) and goat (17.90%), respectively (Figure 3 B). According to the findings, the most prevalent Brucella spp. contaminating dairy products was B. melitensis (29.48%) (Figure 4A). The high prevalence of contamination of dairy products derived from goat is consistent with previous experimental findings showing that up to 60% of virulent Gram-negative Brucella spp. are excreted in the milk of infected goats. It also explains how B. melitensis has become the most prevalent Brucella species in dairy products due to its elevated shedding in goat milk (Capparelli et al., 2009). Another reason for this issue could be a large number of sheep and goat flock, which are husbanded and transported without any control. Besides, many goats and sheep farms in small-scale, produce milk for their own consumption without any further processing. Our data also suggested that the prevalence of Brucella spp. in milk samples collected during milking (16.81 %) was higher than those randomly selected from the market (10.15%) (Figure 5 A). The OR of samples collected during milking was equal to 1.84 representing the important role of dairy processing in reducing the risks of Brucella spp. transmission to consumers. 13

Dairy products derived from vaccinated animals showed a higher prevalence of Brucella contamination (15.98 %) while compared with those originating from nonvaccinated ones (10.46%) (Figure 5 B). The OR in vaccinated animals reached 1.74 (Table 2) which can be associated with the late and post-infection vaccination of herds, the inefficiency of certain vaccines giving a false sense of security and the shedding of vaccine strains in milk (Bardenstein et al., 2002; Moreno, 2014). Moreover, the implementation of global vaccination programs, including pregnant animals, considerably increases the risk of isolation of vaccine strains from mothers’ milk (Bardenstein et al., 2002). The Gross Domestic Product (GDP) is known as the market value of all services and final goods from a nation in a given year. Besides, the Human Development Index (HDI) is considered as a statistic composite index of education, life per capita income indicators, and expectancy which are applied to rank countries according to human development criteria. The results of meta-regression analyses demonstrated that the prevalence of dairy products contaminated by Brucella spp. increased with decreasing in GDP (C = 0.17, P-value < 0.001) (Figure 6 A) and HDI (C = 0.19, P-value < 0.001) ranking (Figure 6 B). These results showed that low GPD and HDI indices strongly impact hygiene education programs, veterinary supports as well as regional efforts to control brucellosis transmission through unpasteurized dairy products (Figure 6 A and B). Conclusion

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In the current systematic review, the prevalence and odds ratio of Brucella spp. in dairy products based on defined subgroups were meta-analyzed and also the correlation between the prevalence of Brucella spp. with GDP and HDI was determined. This metaanalysis highlights the need for appropriate management programs to prevent Brucella contamination in milk produced from animals acting as “super shedders” for Brucella spp., such as buffalo and goat. This could be achieved by appropriate culling, vaccination, selection, and clustering of preferred hosts for different Brucella species and may have a profound impact on the outcome of Brucellosis in endemic regions. Milk pasteurization and proper processing are other key factors in reducing the prevalence of Brucella spp. in dairy products and raw milk has by far the highest rates of Brucella contamination among milk products. As well, there is a negative relationship between GDP/HDI rankings and the prevalence of Brucella contamination. This reflects the fact that decreasing poverty and increasing the level of education in societies could reduce the prevalence of Brucella spp. in dairy products. The implementation of control plans are of overwhelming importance and appeared to be highly effective in reducing the prevalence of Brucella spp. in dairy products, especially in developing countries. The outcome of this metaanalysis will undeniably give an in-depth overview of the existing reports on Brucella spp. contamination of various dairy products in different experimental conditions and from various animal species including cows, buffalos, goats, camels, and sheep. Statistically, these data will be of great value for future research activities in the field, 15

bringing to the major light issues, trends and challenges in the view of the implementation of appropriate multi-faceted control plans in endemic regions. Acknowledgements This research was supported by grant #2-18-18-036-960504 from the Razi Vaccine and Serum Research Institute.

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39

Highlights



Brucella melitensis is the most prevalent Brucella spp. detected in dairy products



Southeastern Asia (25%) and the Eastern Mediterranean (22%) are most affected



Milk products derived from buffalo (26%) and goat (8%) are the most contaminated



The prevalence of Brucella spp. is higher in raw milk (17%) than in cheese (7%)



Brucella contamination of milk products has a negative relationship with GDP/HDI

40

Table 1. Meta-analysis regarding the prevalence of Brucella contamination of dairy products based on country, type of dairy product and WHO regions subgroups (results from 168 studies performed in the world). Subgroups

Number study

Pooled

(95%CI)

Weight (%)

Heterogeneity

Degree of freedom

P value

I2 (%)

0.59

NE1

0.00

NE

NE

1.25 0.63 1.11

NE NE NE

1.00 0.00 1.00

NE NE NE

NE NE NE

2.21 1.80 0.61 5.34

38.26 NE NE 26.94

4.00 2.00 0.00 9.00

<0.001 NE NE <0.001

89.54% NE NE 66.59%

4.85

467.24

7.00

<0.001

98.50%

16.34

1751.70

26.00

<0.001

98.52%

4.79

108.61

7.00

<0.001

93.56%

5.99

667.75

9.00

<0.001

98.65%

0.61 1.00 0.59

NE NE NE

0.00 1.00 0.00

NE NE NE

NE NE NE

0.61 2.34 2.13

NE 0.62 0.00

0.00 3.00 3.00

NE <0.001 <0.001

NE 0.00% 0.00%

5.51

114.34

8.00

<0.001

93.00%

8.54

257.34

13.00

<0.001

94.95%

2.11

14.02

3.00

<0.001

78.60%

0.60 1.83 1.18

NE NE NE

0.00 2.00 1.00

NE NE NE

NE NE NE

3.15

744.21

4.00

<0.001

99.46%

0.63

NE

0.00

NE

NE

0.59

NE

0.00

NE

NE

17.46

1621.94

28.00

<0.001

98.27%

Country

1

Algeria

1

Bangladesh Belgium Brazil

2 1 2

China Colombia Ecuador Egypt

5 3 1 10

India

8

Iran

27

Iraq

8

Italy

10

Kenya Kosovo Kuwait

1 2 1

Mexico Mongolia Morocco

1 4 4

Nigeria

9

Pakistan

14

Qatar

4

Saudi Arabia South Africa Spain

1 3 2

Syria

5

Tajikistan

1

Tanzania

1

Turkey

29

3.08(0.3710.68) 4.72(3.27-6.41) 3.27(2.68-3.94) 17.02(9.3826.16) 0(0-0) 26(0-78.52) 9(4.2-16.4) 10.71(5.9616.38) 28.92(14.5745.78) 12.96(8.5618.07) 30.03(18.6942.73) 20.91(4.6644.22) 0(0-2.8) 100(93.61-100) 61.67(48.2173.93) 1(0.03-5.45) 0.14(0-1.47) 14.29(7.1223.08) 18.79(13.2225.06) 6.61(2.4312.49) 46.62(24.4169.48) 10(4.42-18.76) 6.06(3.94-8.58) 87.5(80.5693.16) 34.38(23.3146.4) 10.28(7.913.09) 15.87(7.8827.26) 10.07(3.8518.58)

Not estimated

41

Uganda

6

Venezuela

2

Zimbabwe Overall

1 169

18.9(10.129.65) 41.14(38.1344.18) 1.68(1.32-2.11) 15.65(12.7918.71)

3.72

144.44

5.00

<0.001

96.54%

1.25

NE

1.00

NE

NE

0.63 100.00

NE 15947.24

0.00 168.00

NE <0.001

NE 98.95%

29.22

3149.63

48.00

<0.001

98.48%

6.10

5532.64

74.00

<0.001

98.66%

6.09

557.46

9.00

<0.001

98.39%

5.99

1624.88

9.00

<0.001

99.45%

5.28 7.21

1133.46 38.26

19.00 4.00

<0.001 <0.001

98.32% 89.54%

100.00

15947.24

168.00

<0.001

98.95%

89.84

15371.31

150.00

<0.001

99.02%

8.86

199.12

14.00

<0.001

92.97%

0.39 0.33 0.58 100.00

NE NE NE 15947.24

0.00 0.00 0.00 168

NE NE NE <0.001

NE NE NE 98.95%

WHO regions European Region

50

Eastern Mediterranean Southeast Asia region Region of America Africa region Western pacific

74

Overall

169

Type of dairy product Milk

151

Cheese

15

Yogurt Cream Butter Overall

1 1 1 169

10 10 20 5

15.63 (9.6422.68) 22.56 (11.7235.64) 25.55 (11.7135.64) 16.64 (2.6138.57) 15.32 (9.5-22.2) 10.54 (7.6518.65) 15.65 (12.7918.71)

16.97 (13.8620.30) 7.10 (3.1412.31) 0.00 (0-0.93) 0 (0-60.24) 0 (0-7.11) 15.65 (12.7918.710)

Table 2. The Odds ratio of contaminated dairy products by Brucella spp. in defined subgroups by univariate analysis WHO regions Southeast Asia region Eastern Mediterranean Region of America European Region Africa region Western pacific Abortion No Yes Type of animal Cow Goat Camel Buffalo Sheep

OR (95% confidence interval) 2.84 (95%CI:1.31-6.13) 2.41 (95%CI:1.12-5.27) 1.65 (95%CI:0.73-3.74) 1.54 (95%CI:0.67-3.51) 1.46 (95%CI:0.63-3.35) Reference 1.20 (95%CI:0.51-2.84) Reference 1.19 (95%CI:0.52-2.79) 1.62 (95%CI:0.73-3.54) 1.18 (95%CI:0.54-2.75) 2.57 (95%CI:1.21-5.45) Reference 42

Microbial species B. abortus B. melitensis B. abortus, B. melitensis and B. ovis B. abortus and B. melitensis B. melitensis and B. ovis Contact with animal No Yes Sources of sampling Lactating Animal Market Vaccinate Yes No

43

2.07 (95%CI:0.87-4.89) 1.24 (95%CI:0.49-3.16) 4.12 (95%CI:1.83-9.24) 1.51 (95%CI:0.61-3.71) Reference 1.47 (95%CI:0.53-4.04) Reference 1.84 (95%CI:0.79-4.25) Reference 1.71 (95%CI:0.83-3.79) Reference

Figure 1. Schematic protocol for the selection and extraction of relevant studies.

44

Figure 2. Prevalence of the dairy products contaminated by Brucella spp. worldwide based on relevant studies published from January 1983 to 1 April 2019.

45

A

B

Figure 3. Forest plots of the comparative meta-analysis on the prevalence of contaminated dairy products by Brucella spp. based on abortion data (A) and different types of animals (B).

46

A

B

Figure 4. Forest plots of the meta-analysis data on the prevalence of contaminated dairy products based on Brucella species (A) and contact with animal (B) subgroups.

47

A

B

Figure 5. Forest plots of the meta-analysis results on the prevalence of contaminated dairy products based on sampling conditions (A) and vaccination status (B).

48

A

B

Figure 6. Scatterplots of the meta-regression analysis on the prevalence of dairy products contaminated by Brucella spp. according to the GDP (A) and HDI (B) ranking of different countries.

49