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Crohns Disease By Eye Online. November 2004.

Why Cow's Milk Is
Causing Concern. By James Allen - Editor.

Mycobacterium avium sub-species paratuberculosis (MAP) might be as hard to say as it is to spell, but the chances are you will be hearing a lot more about it in the coming weeks and months. Or at least I hope so, as it is something that, if certain scientists are proved correct, will make nurseries and daycare providers think twice before offering milk to children in their care.

For many years now, there has been accumulating concern that MAP, a type of bacteria that causes Johne�s disease in dairy herds, can be transmitted to humans in cow�s milk. And now evidence has been published suggesting, but not proving, that MAP, once in the human body, can lead to the development of Crohn�s disease, an often severe gastrointestinal illness that affects 100,000 Britons. Drug treatments for Crohn�s disease are limited and there is no cure.

In this month�s News Focus (page 8), Dr Tim Bull, a senior research fellow with the Crohn�s Group at St George�s Hospital Medical School in London, explains that children with a genetic disposition to Crohn�s disease might be �wise to avoid milk�. This is because the trigger for Crohn�s is thought to occur early in life � a serious cause for concern for those caring for young children.

It seems only a matter of time, then, that the issue becomes bigger news and parents and practitioners start to worry. Or does it?

As Cate Campbell explains, the government is in a tricky situation: provide lots of information and health advice and risk the fear of provoking yet another cattle scare, not long after BSE, foot and mouth and the TB controversy; say too little, say that there is no definite link between milk and Crohn�s disease � and the government would not be incorrect to say as much � and then later be accused of a cover up, or of running scared of the all-powerful pharmaceutical companies.

The answer to this conundrum might be quite clear, but it is far from straightforward. The government should be investing a lot more energy and money into establishing a link one way or the other at the same time as issuing preliminary advice to those working in education settings, if only so they can make informed responses to the worries of parents.

None of the nurseries or daycare providers EYE contacted had so far heard of MAP, and they all seemed happy to carry on offering milk as normal until further guidance is given by the Department of Health and other appropriate government agencies.

Perhaps it�s best then for everyone to keep tabs on the news, and keep a watchful eye on any further research or developments. If parents are concerned it�s always best to act on their wishes and provide other alternatives, such as soya milk.

As Dr Bull emphasises, most parents can be reassured that allowing their children to drink milk is both safe and desirable, but there is no harm in mixing a bit of knowledge with a degree of caution.

Issue November 2004.

Eye Online Article Link

Are We Sitting On The Next BSE Crisis ? By Eye Online. Nov 2004.

Are we sitting on
the next BSE crisis? By Cate Campell

Disturbing evidence suggests that a bacterium transmitted in cow�s milk might trigger Crohn�s disease in patients with a genetic predisposition. Cate Campbell investigates.

Johne�s disease in dairy herds. Never heard of it? You undoubtedly will.

It will be of special concern to early years practitioners because there is a growing belief that the bacterium which causes Johne�s disease can be transmitted to humans in cow�s milk. Once in the human body, this can lead to the development of Crohn�s disease, a chronic and debilitating bowel disorder.
The Department for Environment, Food & Rural Affairs (DEFRA) recently produced guidelines for farmers on how to control the spread of
Consequently, nurseries and daycare providers should think twice about offering milk to children with a family history of Crohn�s disease, a leading researcher into the link with Johne�s disease has told EYE. �The position that we are taking at the moment is that children with a family history of Crohn�s disease might be wise to avoid milk,� asserts Dr Tim Bull, senior research fellow with the Crohn�s Group at St George�s Hospital Medical School in London.

The incidence of Crohn�s disease has been steadily increasing, possibly as much as fivefold per decade. There have been numerous theories as to why this should be, but there is agreement that a genetic influence exists. Researchers in the St George�s Crohn�s Group suspect that sufferers have a genetic predisposition to the condition, which is triggered by the bacterium that causes Johne�s disease, mycobacterium avium sub-species paratuberculosis (MAP). MAP bacteria has been found in people with Crohn�s disease.

Professor John Hermon Taylor, head of the St George�s Crohn�s Group, affirms: �Almost everybody with Crohn�s disease is found to be infected. There is a very, very substantial probability that Crohn�s disease is due to MAP.�

Like Crohn�s disease, the incidence of Johne�s disease in cattle has been increasing during the past 20 years. Proving the link once and for all is difficult though. One problem is that the familial gene which causes Crohn�s disease varies � the susceptible gene is different in the Japanese population, for instance, so their Crohn�s disease may be triggered by something other than MAP.

The condition also takes many years to develop. Though younger children do sometimes present with Crohn�s disease, it usually occurs for the first time in adolescence or early adulthood, making a link with childhood milk consumption much harder to establish. The main sticking point, though, is that researchers have so far been unable to consistently culture � or �grow� � the bacteria found in humans.

Yet research suggests a very strong probability of a link. And there is considerable anecdotal evidence to suggest a sound association with MAP for countless Crohn�s disease sufferers, and certainly those of UK origin. Many patients have a persuasive childhood association with dairies or farms, for instance. But, though such information seems compelling, it is impossible to �test� and is consequently considered scientifically untrustworthy.

The DEFRA guidelines to farmers form part of a strategy developed by the Food Standards Agency (FSA) to reduce the likelihood of consumers being exposed to MAP in milk. Whilst acknowledging that no acceptable scientific evidence had been established to conclusively link MAP and Crohn�s disease, the FSA decided to take the possibility seriously. A study commissioned by the FSA in 2002 found that live MAP was present in about two per cent of the UK�s retail milk. As a result, it said: �The agency believes that precautionary action to reduce human exposure to MAP should start now and should not be dependent on waiting for the link to be proved or disproved.�

The DEFRA guidelines contain detailed recommendations for hygienic milking practices, higher temperatures for milk pasteurisation and reduction of MAP in dairy herds, primarily by separating diseased animals, keeping their healthy cattle off infected pastures and only feeding calves colostrum from their own mothers.

However, Johne�s disease is extremely difficult to recognise and develops over a number of years, so it can become widespread in a herd before it is identified. Besides, the DEFRA guidelines are only recommendations for best practice; they are not mandatory. Furthermore, measures to prevent the disease may cost farmers more than controlling an outbreak.

�We would like to see DEFRA�s guidelines strictly adhered to,� insists Dr Bull, but he fears that, at best, they will merely halt the disease, not eliminate it. �I think the government�s goal is to stop the disease increasing above present levels� and that would be sufficient for them to say, "Yes, we did something, we�re abating it." But we don�t believe that�s sufficient. We would like to see a more aggressive approach.�

Crohn�s disease pressure groups in this country and abroad have long been urging governments to accept the link with MAP. In the United States, the Paratuberculosis Awareness & Research Association (PARA) urged its members to take antibiotics to treat MAP infection, hoping to establish the link that way, and some sufferers found their condition did improve significantly.

In the UK, members of the Chronic Crohn�s Campaign (TCCCUK) are convinced of the link with MAP. �We all know what has happened with the BSE/CJD scandal and, in my opinion, this problem is, and will be, far worse and far bigger,� insists Tim Page, a member of TCCCUK. �A fact that keeps haunting me is the huge subsidy given to provide milk for young children.�

TCCCUK would like to see higher temperatures used for pasteurisation to ensure MAP is destroyed in the process. �Milk is certainly a part of the Crohn�s story and one that the government is jittery about. It has considered increasing the pasteurisation temperature but the dairy industry really doesn�t want to do that as it changes the flavour,� explains Dr Bull.

Offering children goat�s milk or water won�t help either. Both may be contaminated with MAP. Goat�s milk is even more likely to be infected than cow�s milk, and in countries where more goat�s milk is consumed than cow�s milk, the incidence of Crohn�s disease is correspondingly higher.

MAP has also been found in the domestic water supply, albeit at low levels. Since MAP is excreted in faeces, it is possible for water flowing through pasture land to become contaminated. For instance, the St George�s team has noticed a correlation between the incidence of Crohn�s disease in South Wales and the path of the River Taff, which flows through the centre of Cardiff.

It isn�t just cows that excrete MAP. Many other wild and farm animals can be infected. For instance, in Scotland most wild rabbits carry MAP. Since they are preyed on, and eaten by carrion, the spiral of infection continues and the chance of a cow consuming infected grass becomes almost inevitable. �The Scottish population of cattle is at least 90 per cent challenged by the organism,� declares Dr Bull.

The Crohn�s Group is busy developing a vaccine that may ultimately provide a treatment for Crohn�s disease and could prevent Johne�s disease in cattle. However, St George�s is the only UK centre carrying out such research, and progress is slower than necessary due to lack of support. It seems only a matter of time, then, before the issue becomes bigger news and parents start to worry. Because the trigger for Crohn�s disease is thought to occur early in life, it is those caring for the smallest children who will be most concerned.

It could be argued that some guidance should have been issued already, at least to prepare those working in education and health settings. It could also be argued that the government should put much more energy and cash into establishing a link one way or the other, not to mention developing a vaccine to control MAP in cattle and a treatment for Crohn�s disease.

On the other hand, the government must be keen to avoid providing too much information for fear of provoking yet another cattle scare after the BSE debacle, the foot and mouth crisis and the TB controversy. And would a new treatment for Crohn�s disease be welcomed when, as Dr Bull points out, �the pharmaceutical companies have a huge billion-dollar interest in keeping this disease abated using steroids�?

Whatever the case, none of the nurseries or daycare providers we spoke to had heard of MAP. The National Day Nurseries Association said it would not alter its advice to members until it had been advised by the Department of Health. The Professional Association of Nursery Nurses� professional officer, Tricia Pritchard, advises nurseries �to seek medical advice and to make sure they obtain information from parents about any food allergies their children may have�.

Most parents can be reassured that allowing their children to drink milk is both safe and desirable, emphasises Dr Bull: �But if you have a family history, you should consider the evidence and consider whether it is appropriate to expose your child.�

Issue November 2004.

Eye On Line Article Link

Crohns Disease By Eye Online. November 2004.

Are We Sitting On The Next BSE Crisis ? By Eye Online. Nov 2004.

What Does Your Glass of Milk Contain ?