Occurrence and levels of mycotoxins and their metabolites in human breast milk associated to dietary habits and other factors: A systematic literature review, 1984–2015

A Comprehensive Systematic Review and Meta-Analysis on the Prevalence of Aflatoxin M1 in Dairy Products in Selected Middle East Countries

BACKGROUND

Human consumption of dairy products contaminated with aflatoxin (AF) M1 can lead to severe health issues. This AF's significance and impact on health necessitate a thorough investigation of its prevalence in dairy products.

OBJECTIVES

This study aims to determine the prevalence of AFM1 in dairy products through a systematic review and meta-analysis, focusing on data from Middle Eastern countries.

METHODS

We identified relevant studies through electronic database searches (PubMed, Scopus and Web of Science) up to August 2023. We employed a random-effects model to derive an overall estimate and used 95% confidence intervals to determine pooled prevalence rates.

RESULTS

The meta-analysis included 193 studies encompassing 297,530 samples of dairy products. The results showed that AFM1 contaminated 87% of dairy products. The following is a ranking of countries based on the prevalence of AFM1 in their dairy products: Iran > Jordan > Turkey > Kuwait > Lebanon > Syria > Egypt > Cyprus > the United Arab Emirates. The current meta-analysis indicated that Middle Eastern countries exhibited a high prevalence of AFM1 in dairy products. The prevalence rates for AFM1 in various dairy products were as follows: milk (87%), yogurt (68.9%), cheese (63.6%), kashk (62.9%), doogh (55.6%) and ice cream (54%). Pasteurized milk (99.5%), ultra-high temperature (91.3%), raw milk (73%) and traditional milk (51%), among other milk types, had the highest contamination rates.

CONCLUSION

The study reveals a high prevalence of AFM1 in dairy products, particularly in Middle Eastern countries. Given the critical importance of milk and dairy products in the diet, special measures are needed to safeguard their quality and protect consumers from AF contamination.

Biomonitoring and determinants of mycotoxin exposures from pregnancy until post-lactation in HIV-infected and HIV-uninfected women from Harare, Zimbabwe

The human immunodeficiency virus (HIV) heavily affects women from resource-limited settings who are vulnerable to potentially harmful mycotoxins including aflatoxin B1 (AFB1), fumonisin B1 (FB1) and ochratoxin A (OTA). We aimed to conduct biomonitoring and ascertain the determinants of maternal mycotoxin exposure in pregnancy, lactation and post-lactation periods. We conducted a retrospective longitudinal study in HIV-infected and HIV-uninfected women from Harare, Zimbabwe. 175 and 125 random urine samples in pregnancy and 24 months after delivery (post-lactation) respectively were analysed for aflatoxin M1 (AFM1) and FB1 by ELISA. 6 weeks after delivery (lactation), 226 and 262 breast milk (BM) samples were analysed for AFM1 and OTA respectively by ELISA. The association of demographics and food consumption with mycotoxins was evaluated using multivariable logistic regression. In HIV-infected, urinary AFM1 was detected in 46/94 (Median: 0.05; Range: 0.04-0.46 ng mL-1) in pregnancy and 47/66 (Median: 0.05; Range: 0.04-1.01 ng mL-1) post-lactation. Urinary FB1 was detected in 86/94 (Median: 1.39; Range: 0.17-6.02 ng mL-1) in pregnancy and 56/66 (Median: 0.72; Range: 0.20-3.81 ng mL-1) post-lactation. BM AFM1 was detected in 28/110 (Median: 7.24; Range: 5.96-29.80 pg mL-1) and OTA in 11/129 (Median: 0.20; Range: 0.14-0.65 ng mL-1). In HIV-uninfected, urinary AFM1 was detected in 48/81 (Median: 0.05; Range: 0.04-1.06 ng mL-1) in pregnancy and 41/59 (Median: 0.05; Range: 0.04-0.52 ng mL-1) post-lactation. Urinary FB1 was detected in 74/81 (Median: 1.15; Range: 0.17-6.16 ng mL-1) in pregnancy and 55/59 (Median: 0.96; Range: 0.20-2.82 ng mL-1) post-lactation. BM AFM1 was detected in 38/116 (Median: 7.70; Range: 6.07-31.75 pg mL-1) and OTA in 4/133 (Median: 0.24; Range: 0.18-0.83 ng mL-1). Location, wealth, and peanut butter consumption were determinants of AFB1 exposure. HIV infection, BMI, location, rainy season, unemployment, and age were determinants of FB1 exposure. Women especially those pregnant and/or HIV-infected are at risk of adverse effects of mycotoxins.

Prevalence and concentration of aflatoxin M1 in breast milk in Africa: a meta-analysis and implication for the interface of agriculture and health

Breast milk is one of the many distinct forms of food that can be contaminated with aflatoxin M1 (AFM1). They may be consumed by eating contaminated foods, such as contaminated meat and crops, which would then be present in breast milk and cause health problems, including nervous system disorders and cancers of the lungs, liver, kidneys, and urinary tract. However, the prevalently inconsistent explanation of prevalence and concentration remains a big challenge. Thus, this meta-analysis was conducted to determine the prevalence and concentration of harmful chemicals in breast milk in an African context. The databases MEDLINE, PubMed, Embase, SCOPUS, Web of Science, and Google Scholar were searched for both published and unpublished research. To conduct the analysis, the collected data were exported to Stata version 18. The results were shown using a forest plot and a prevalence with a 95% confidence interval (CI) using the random-effects model. The Cochrane chi-square (I2) statistics were used to measure the studies' heterogeneity, and Egger's intercept was used to measure publication bias. This review included twenty-eight studies with 4016 breast milk samples and newborns. The analysis showed the overall prevalence and concentration of aflatoxin M1 in breast milk were 53% (95% CI 40, 65; i2 = 98.26%; P = 0.001). The pooled mean aflatoxin M1 concentration in breast milk was 93.02 ng/l. According to this study, the eastern region of Africa was 62% (95% CI 39-82) profoundly affected as compared to other regions of the continent. In subgroup analysis by publication year, the highest level of exposure to aflatoxins (68%; 95% CI 47-85) was observed among studies published from 2010 to 2019. This finding confirmed that more than half of lactating women's breast milk was contaminated with aflatoxin M1 in Africa. The pooled mean aflatoxin M1 concentration in breast milk was 93.02 ng/l. According to this study, the eastern region of Africa was profoundly affected compared with other regions. Thus, the government and all stakeholders must instigate policies that mitigate the toxicity of aflatoxins in lactating women, fetuses, and newborns.

Determination of aflatoxin M1 and ochratoxin A in breast milk in rural centers of Yazd, Iran: Exposure assessment and risk characterization

Breast milk (BM) is considered as the best source of nutrition which could have prevention effects on various diseases in the first years of a child. Along with nutritive compounds, presence of contaminants such as mycotoxins in BM could be transmitted into neonate. The aim of this study was to determine the occurrence, levels, and factors associated with the presence of aflatoxin M1 (AFM1) and ocratoxin a (OTA) in BM samples of nursing mothers in rural centers of Yazd, Iran. The presence and average AFM1 and OTA concentration in 72 BM samples was measured by competitive ELISA. The demographic and diet parameters of nursing mothers were collected by a questionnaire and were analyzed using SPSS 18 software. AFM1 and OTA were detected in 63 (87.5%) and 47 (65.2%) samples with the mean concentration levels of 19.46 ± 13.26 ng/L (ranges from 5.1 to 53.9) and 200 ± 160 ng/L (ranges from 100 to 2460), respectively. Of these, 32 samples (50.7%) for AFM1 and 23 samples (48.9%) for OTA had values exceeding the limit set by the European Union regulation for infant foods (25 ng/L for AFM1 and 500 ng/L for OTA). It was also found that the risk of AFM1 and OTA occurrence in BM increased significantly with the consumption of beans, bread, cereals, fruit juice and crackers, and cream, respectively. This study showed that the estimated daily intake for AFM1 and OTA by 1 month of age infants was 2.7 and 28.5 ng/kg bw/day, respectively, while, as the age of the infant increased, the values were lower and close to 0.9 and 9.9 ng/kg bw/day for AFM1 and OTA in 12 months of age infants, respectively. The high occurrence and noticeable levels of AFM1 and OTA detected in this study indicated that some infants receive undesirable exposures to AFM1 and OTA with breast milk. Therefore, it is recommended that mothers are advised to avoid certain foods during pregnancy and breastfeeding that are likely sources of mycotoxins.

Occurrence of ochratoxin A in breast milk and urine samples of nursing mothers in Bangladesh

The mycotoxin ochratoxin A (OTA) is a potent nephrotoxin with carcinogenic properties and, thus, of concern as a food contaminant. Since food contaminant data are scarce in Bangladesh, we applied human biomonitoring to gain more insights into OTA exposure in the country's population. OTA concentrations in human milk and urine samples of nursing mothers were determined with the aim to assess also exposure to this mycotoxin in breastfed infants. Breastfeeding mothers (n = 74) from three districts of Bangladesh (Sylhet, Cumilla, and Mymensingh region) participated in this study. They provided demographic data, along with breast milk and urine samples. OTA levels were measured by a competitive enzyme-linked immunosorbent assay (ELISA) with a detection limit of 60 ng/L for milk and 30 ng/L for urine.OTA was detected in 62.2% of all breast milk samples (mean 74.8 ± 49.0 ng/L, range < LOD-243.3 ng/L) and in 51.4% of all urine samples (mean 44.3 ± 63.5 ng/L, range < LOD-519.3 ng/L). The differences observed between regions for mean breast milk or for urinary OTA levels were relatively small. No significant correlation was observed between OTA levels in breast milk and food consumption patterns among nursing mothers. Regarding infant exposure, the estimated average daily intake of OTA for all was 15.0 ng/kg bw/day (range 4.5-45 ng/kg bw/day). In 34.5% of these infants, their estimated daily OTA intake exceeded a preliminary TDI value set by EFSA (17 ng/kg bw/day). The mean OTA intake was slightly higher (16.2 ± 7.8 ng/kg bw/day) in 1-2 months babies than in older infants (< 2 to 12 months), although the difference was not significant. Presence of OTA in most milk and urine samples of nursing mothers documents their widespread dietary mycotoxin exposure. Although based on a relatively small number of participants, the present analysis indicates non-negligible exposure of some nursed infants in Bangladesh. Therefore, further biomonitoring studies and investigations on major sources of OTA in food commodities are encouraged.

Longitudinal follow-up of zearalenone and deoxynivalenol mycotoxins in breast milk in the first five months of life

OBJECTIVES

There is a possibility for exposed lactating mammalians to transfer some contaminants to their milk. This study aimed to determine the levels and changes of Zearalenone (ZEN), Deoxynivalenol (DON) mycotoxins for the first five months in human milk.

METHODS

Voluntary lactating mothers having infants with gestational length ≥ 37 weeks were enrolled between August 2017 and June 2018 in Şanlıurfa. Mothers and infants with chronic health problems were not included in the study. Human milk samples were taken at three different times; on enrollment (Day 6-10, visit 1), between 4 and 6 weeks postpartum (visit 2), and between 14 and 19 weeks postpartum (visit 3). Mycotoxin levels in human milk were measured utilizing Helica brand commercial kit.

RESULTS

Nineteen voluntary mothers and their breastfed infants with three human milk samples completed the study. The mean ages of mothers and infant (± SD) were 27.4 (± 5.4) years and 7.6 (± 0.9) days on enrollment. Median levels of ZEN and DON in human milk samples were 0.39 and 16.7 ng/mL, respectively. None of the cases had a ZEN daily intake higher than 250 ng/kg bw per day. However, three fourth of the cases had DON intake higher than > 1000 ng/kg bw per day. When adjusted for infant weight for age and sex, both ZEN levels and daily intake were decreased progressively from visit 1 to visit 3 (p < 0.001). DON levels and daily intake at visit 2 were found to be significantly lower in samples of visit 3 than that taken in visit 2 (p = 0.004 and p < 0.001, respectively).

CONCLUSIONS

Breast milk monitoring study revealed that ZEN and DON mycotoxins were present in the mother-infant environment. Contamination levels changed during the lactation period.

Prevalence and concentration of Aflatoxin M1 in human breast milk in sub-Saharan Africa: a systematic review and meta-analysis, and cancer risk assessment

This study aimed to assess the prevalence, concentration of AFM1 in human breast milk, and to determine the risk of cancer for infants in sub-Saharan Africa. A systematic literature search was performed using PubMed, CINAHL, Web of science, global health, Cochrane, and Google Scholar electronic databases. A random-effects model was used to estimate the pooled prevalence and concentration of AFM1 in breast milk. The meta-analysis of 8 articles containing 9 studies showed the pooled prevalence of AFM1 in breast milk to be 56.18% (95% CI: 29.65-82.71) and the pooled concentration to be 31.12 ng/L (95% CI: 25.97-36.25). The cancer risk assessment indicated for both male and female 1-month infants in Sierra Leone (HI > 1) is high, and all the rest of the infants are free of risk (HI < 1). The pooled prevalence and mean concentration of AFM1 in breast milk is high. Monitoring of AFB1 concentration of commonly used foods will be of high value in reducing the burden of AFM1.

Determination of aflatoxin M1 in breast milk and related factors

OBJECTIVE:

Breastfeeding in women with aflatoxin M1 exposure may be a risk factor for the newborn. Thus, it is crucial to determine aflatoxin M1 levels in breast milk and raise mothers’ awareness about nutrition in lactation and other periods. This study was carried out to determine aflatoxin M1 contamination in milk samples taken from mothers who gave birth.

METHODS:

The study was carried out in the postpartum department of Training and Research Hospital between December 31, 2018, and June 31, 2019, and 90 breastfeeding mothers were included in the study.

RESULTS:

A total of 75 (83.3%) of the examined samples were found positive. The mean aflatoxin M1 ratio in positive samples was 12.16 pg/mL (5.00–23.18 pg/mL). Mothers’ consumption of processed food was associated with aflatoxin M1 levels (p=0.043). It was determined that the aflatoxin M1 levels of mothers who consumed processed food products 1 or 2 times a month were 3.22 times lower than those who consumed 1–2 times a week.

CONCLUSIONS:

This study emphasized the importance of monitoring aflatoxin M1 levels in breast milk for infant health. It is thought that nutrition education given to mothers during pregnancy will significantly impact aflatoxin M1 results. In addition, the dangers of mycotoxins in mother-infant nutrition should be emphasized regularly in health education.

Express high-sensitive detection of ochratoxin A in food by a lateral flow immunoassay based on magnetic biolabels

We present an easy-to-use lateral flow immunoassay for rapid, precise and sensitive quantification of one of the most hazardous mycotoxins - ochratoxin A (OTA), which is widely present in food and agricultural commodities. The achieved limit of detection during the 20-min OTA registration is 11 pg/mL. The assay provides accurate results in both low- and high-concentration ranges. That is due to the extraordinary steepness of the linear calibration plot: 5-order dynamic range of concentrations causes almost a 1000-fold change in the signal obtained by electronic detection of magnetic biolabels using their non-linear magnetization. High specificity, repeatability, and reproducibility of the assay have been verified, including measuring OTA in real samples of contaminated corn flour. The developed assay is a promising analytical tool for food and feed safety control; it may become an express, convenient and high-precision alternative to the traditional sophisticated laboratory techniques based on liquid chromatography.

Mycotoxins Exposure in Cabinda, Angola-A Pilot Biomonitoring Survey of Breastmilk

Breast milk is considered the ideal form of nutrition for newborns and infants. However, it can carry over contaminants, namely mycotoxins, with biological effects to which this population is particularly vulnerable. Human biomonitoring and surveillance programs are particularly scarce in low-income countries, where food security is a more urgent priority in comparison with food safety. This pilot survey aims to assess exposure of breastfed infants to aflatoxin M1 (AFM1), zearalenone (ZEN), and ochratoxin A (OTA) in Angola, and to evaluate the main socio-demographical and food consumption determinants of lactating mothers. All 37 breast milk samples analyzed are found to be contaminated with ZEN and OTA, although none are found contaminated with AFM1. Contamination levels are lower than previously reported for ZEN but higher in the case of OTA. A significant association between ZEN levels in breast milk and the consumption of cookies by the lactating mothers is found. As for OTA, higher levels are observed in the milk from mothers with younger infants, for which high estimated daily intake (EDI) is determined. As far as the authors are aware, this is the first survey of the occurrence of mycotoxins in breast milk in Angola, so further human biomonitoring works should follow, given that mycotoxins are a global health issue that directly impact the health of populations.

Mycotoxin exposure biomonitoring in breastfed and non-exclusively breastfed Nigerian children

A multi-specimen, multi-mycotoxin approach involving ultra-sensitive LC-MS/MS analysis of breast milk, complementary food and urine was applied to examine mycotoxin co-exposure in 65 infants, aged 1-18 months, in Ogun state, Nigeria. Aflatoxin M₁ was detected in breast milk (4/22 (18%)), while six other classes of mycotoxins were quantified; including dihydrocitrinone (6/22 (27%); range: 14.0-59.7 ng/L) and sterigmatocystin (1/22 (5%); 1.2 ng/L) detected for the first time. Seven distinct classes of mycotoxins including aflatoxins (9/42 (21%); range: 1.0-16.2 µg/kg) and fumonisins (12/42 (29%); range: 7.9-194 µg/kg) contaminated complementary food. Mycotoxins covering seven distinct classes with diverse structures and modes of action were detected in 64/65 (99%) of the urine samples, demonstrating ubiquitous exposure. Two aflatoxin metabolites (AFM₁ and AFQ₁) and FB₁ were detected in 6/65 (9%), 44/65 (68%) and 17/65 (26%) of urine samples, respectively. Mixtures of mycotoxin classes were common, including 22/22 (100%), 14/42 (33%) and 56/65 (86%) samples having 2-6, 2-4, or 2-6 mycotoxins present, for breast milk, complementary food and urine, respectively. Aflatoxin and/or fumonisin was detected in 4/22 (18%), 12/42 (29%) and 46/65 (71%) for breast milk, complimentary foods and urine, respectively. Furthermore, the detection frequency, median concentrations and occurrence of mixtures were typically greater in urine of non-exclusively breastfed compared to exclusively breastfed infants. The study provides novel insights into mycotoxin co-exposures in early-life. Albeit a small sample set, it highlights transition to higher levels of infant mycotoxin exposure as complementary foods are introduced, providing impetus to mitigate during this critical early-life period and encourage breastfeeding.

Urinary Biomarkers of Mycotoxin Induced Nephrotoxicity-Current Status and Expected Future Trends

The intensifying world-wide spread of mycotoxigenic fungal species has increased the possibility of mycotoxin contamination in animal feed and the human food chain. Growing evidence shows the deleterious toxicological effects of mycotoxins from infants to adults, while large population-based screening programs are often missing to identify affected individuals. The kidney functions as the major excretory system, which makes it particularly vulnerable to nephrotoxic injury. However, few studies have attempted to screen for kidney injury biomarkers in large, mycotoxin-exposed populations. As a result, there is an urgent need to screen them with sensitive biomarkers for potential nephrotoxicity. Although a plethora of biomarkers have been tested to estimate the harmful effects of a wide spectrum of toxicants, β₂-microglobulin (β₂-MG) and N-acetyl-β-D-glucosaminidase (NAG) are currently the dominant biomarkers employed routinely in environmental toxicology research. Nevertheless, kidney injury molecule 1 (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL) are also emerging as useful and informative markers to reveal mycotoxin induced nephrotoxicity. In this opinion article we consider the nephrotoxic effects of mycotoxins, the biomarkers available to detect and quantify the kidney injuries caused by them, and to recommend biomarkers to screen mycotoxin-exposed populations for renal damage.

Occurrence of aflatoxin M1 in human breast milk in Bangladesh

Breast milk is the best, most complete form of nutrition for newborns and infants. However, human milk can contain aflatoxin M₁ (AFM₁) upon ingestion of dietary mycotoxin contaminants, namely, aflatoxin B₁ (AFB₁), by lactating mothers. AFB₁ and its hydroxylated metabolite AFM₁ are potent carcinogens and thus an important issue in food safety and public health. This study is the first to explore the presence of AFM₁ in breast milk samples from Bangladesh and assess infant exposure to this toxin, as a consequence of maternal mycotoxin intake. A total of 62 breast milk samples were collected from nursing mothers in Sylhet region of Bangladesh. The milk samples were collected between October 2019 and March 2020 and analyzed by a sensitive enzyme-linked immunosorbent assay. AFM₁ was detected in 51.6% of the breast milk samples (colostrum, transitional and mature milk), with a mean concentration of 4.42 ± 0.56 pg/mL, and in the range between LOD (4.0 pg/mL) and 6.66 pg/mL. The frequent detection of AFM₁ in breast milk indicates widespread dietary exposure to mycotoxins in our cohort. The estimated average daily intake of AFM₁ for all nursed infants was 0.49 ng/kg b.w./day. No significant correlations were observed between AFM₁ levels in human milk and food items regularly consumed by nursing women. Overall, AFM₁ levels in breast milk samples from the Sylhet region of Bangladesh are moderate, and lower than the permissible levels established for AFM₁ in dairy milk or infant formulae (50 and 25 ng/kg, respectively). Yet, this first data for AFM₁ breast milk contaminant levels just reflect the recent situation in one cohort, and monitoring should be continued.

Mycotoxin occurrence in breast milk and exposure estimation of lactating mothers using urinary biomarkers in São Paulo, Brazil

In this study, the occurrence of aflatoxins (AFs), fumonisins (FBs), ochratoxin A (OTA), deoxynivalenol (DON), zearalenone (ZEN) and some of their metabolites were assessed in breast milk and urine of lactating women (N = 74) from Pirassununga, São Paulo, Brazil. Exposure estimations through urinary mycotoxin biomarkers was also performed. Samples were collected in four sampling times (May and August 2018, February and July 2019) and analyzed by liquid chromatography coupled to tandem mass spectrometry. Aflatoxin M₁ (AFM₁) was not detected in breast milk. However, two samples (3%) presented FB₁ at 2200 and 3400 ng/L, while 4 samples (5%) had OTA at the median level of 360 ng/L. In urine, AFM₁ and aflatoxin P₁ (AFP₁) were found in 51 and 11% of samples, respectively (median levels: 0.16 and 0.07 ng/mg creatinine, respectively). Urinary DON (median level: 38.59 ng/mg creatinine), OTA (median level: 2.38 ng/mg creatinine) and ZEN (median level: 0.02 ng/mg of creatinine) were quantified in 18, 8 and 10% of the samples, respectively. Mean probable daily intake (PDI) values based on urinary biomarkers were 1.58, 1.09, 5.07, and 0.05 μg/kg body weight/day for AFM₁, DON, OTA, and ZEN, respectively. Although a low mycotoxin occurrence was detected in breast milk, the PDI for the genotoxic AFs was much higher than those reported previously in Brazil, while PDI values obtained for OTA and DON were higher than recommended tolerable daily intakes. These outcomes warrant concern on the exposure of lactating women to these mycotoxins in the studied area.

Prevalence and concentration of fumonisins in cereal-based foods: a global systematic review and meta-analysis study

Cereal-based foods are utilized as an essential food segment worldwide. Nevertheless, their contamination by mycotoxins, also fumonisins, could pose a critical health risk. The present research provides the first systematic review regarding the prevalence and concentration of fumonisins in cereal-based food with the aid of a meta-analysis. In this regard, some international databases PubMed, Web of Science, Google Scholar, and Scopus were explored during the last 30 years. Among 9729 screened articles, 73 articles (which meet the proposed inclusion criteria), including 11,132 data, were incorporated in the performed meta-analysis. The overall rank order regarding the concentration of fumonisins in cereal-based foods was corn-based foods > wheat-based foods > other cereal foods > barley-based foods > rice-based foods > oat-based foods. Based on the prevalence of fumonisins, the overall rank order was other cereal foods > corn-based foods > rice-based foods > wheat-based foods > oat-based foods > barley-based food. The present meta-analysis results can be a beneficial database for risk assessment model progress, which can help industries and organizations decrease the presence of fumonisins in cereal-based food.

Risk of dietary and breastmilk exposure to mycotoxins among lactating women and infants 2-4 months in northern India

Mycotoxins are carcinogenic secondary metabolites of fungi that have been linked to infant growth faltering. In this study, we quantified co-occurring mycotoxins in breast milk and food samples from Haryana, India, and characterized determinants of exposure. Deterministic risk assessment was conducted for mothers and infants. We examined levels of eight mycotoxins (Aflatoxin B1 , B2 , G1 , G2 , M1 , M2 ; Ochratoxin A, B) in 100 breast milk samples (infants 2-4 months) using ultra-high-performance liquid chromatography tandem mass spectrometry. Aflatoxin B1 (AFB1 ), fumonisin B1 (FB1 ) and deoxynivalenol (DON) were detected in several food items (n = 298) using enzyme-linked immunosorbent assays. We report novel data on the presence of mycotoxins in breast milk samples from India. Whereas breast milk concentrations (AFM1 median: 13.7; range: 3.9-1200 ng/L) remain low, AFM1 was detected above regulatory limits in 27% of animal milk samples. Additionally, 41% of infants were above provisional maximum tolerable daily intake (PMTDI) limits for AFM1 due to consumption of breast milk (mean: 3.04, range: 0.26-80.7 ng kg-1 bw day-1 ). Maternal consumption of breads (p < 0.05) was associated with breast milk AFM1 exposure. AFB1 (μg/kg) was detected in dried red chilies (15.7; 0-302.3), flour (3.13; 0-214.9), groundnuts (0; 0-249.1), maize (56.0; 0-836.7), pearl millet (1.85; 0-160.2), rice (0; 0-195.6), wheat (1.9; 0-196.0) and sorghum (0; 0-63.5). FB1 (mg/kg) was detected in maize (0; 0-61.4), pearl millet (0; 0-35.4) and sorghum (0.95; 0-33.2). DON was not detected in food samples. Mothers in our study exceeded PMTDI recommendations for AFB1 due to consumption of rice and flour (mean: 75.81; range: 35.2-318.2 ng kg-1 bw day-1 ). Our findings show the presence of Aflatoxin B1 and M1 at various levels of the food chain and in breast milk, with estimated intakes exceeding PMTDI recommendations. Aflatoxins are known carcinogens and have also been linked to stunting in children. Their presence across the food system and in breast milk is concerning, thus warranting further research to replicate and expand on our findings and to understand implications for maternal and child health.

Aflatoxin M1 in Africa: Exposure Assessment, Regulations, and Prevention Strategies - A Review

Aflatoxins are the most harmful mycotoxins causing health problems to human and animal. Many acute aflatoxin outbreaks have been reported in Africa, especially in Kenya and Tanzania. When ingested, aflatoxin B1 is converted by hydroxylation in the liver into aflatoxin M1, which is excreted in milk of dairy females and in urine of exposed populations. This review aims to highlight the AFM1 studies carried out in African regions (North Africa, East Africa, West Africa, Central Africa, and Southern Africa), particularly AFM1 occurrence in milk and dairy products, and in human biological fluids (breast milk, serum, and urine) of the populations exposed. Strategies for AFM1 detoxification will be considered, as well as AFM1 regulations as compared to the legislation adopted worldwide and the assessment of AFM1 exposure of some African populations. Egypt, Kenya, and Nigeria have the highest number of investigations on AFM1 in the continent. Indeed, some reports showed that 100% of the samples analyzed exceeded the EU regulations (50 ng/kg), especially in Zimbabwe, Nigeria, Sudan, and Egypt. Furthermore, AFM1 levels up to 8,000, 6,999, 6,900, and 2040 ng/kg have been reported in milk from Egypt, Kenya, Sudan, and Nigeria, respectively. Data on AFM1 occurrence in human biological fluids have also shown that exposure of African populations is mainly due to milk intake and breastfeeding, with 85-100% of children being exposed to high levels. Food fermentation in Africa has been tried for AFM1 detoxification strategies. Few African countries have set regulations for AFM1 in milk and derivatives, generally similar to those of the Codex alimentarius, the US or the EU standards.

Aflatoxin M1 prevalence in breast milk in Morocco: Associated factors and health risk assessment of newborns "CONTAMILK study"

The aim of this study was to assess the contamination of breast milk by aflatoxin M1 among nursing mothers from Rabat, Morocco, and to explore its association with several maternal parameters and dietary habits. In addition, the health risk assessment of the newborns by the estimation of the daily intake. A competitive Enzyme Linked Immunosorbent Assay method was used for the analysis of aflatoxin M1 in breast milk samples. Analytical results indicate that out of 82 total samples, 43 samples (52.4%) of milk were positive. Aflatoxin M1 levels ranged from undetectable to 13.33 ng/L, while the mean level was 5.75 ± 3.44 ng/L. Besides, several factors and foodstuffs seem to increase the level of AFM1 in breast milk. As regards the estimated daily intake of aflatoxin M1, it varies between immeasurable and a maximum of 1.16 ng/kg.bw. The degree of exposure to AFB1 and the levels of its metabolite AFM1 in breast milk were low, compared to some studies from other countries. Further investigations and periodic monitoring programs are recommended in large samples and in many cities of morocco to assess the level of exposure of the Moroccan population.

Ochratoxin a in breast milk in Morocco: the affecting dietary habits of the lactating mothers and the degree of exposure of newborns "CONTAMILK study"

The aim of the present study is to evaluate the level of contamination of breast milk (BM) by ochratoxin A, among Moroccan lactating mothers in the city of Rabat, and to identify the associated factors of exposure, also to estimate the degree of exposure of the breastfeed infant. The analysis of ochratoxin A (OTA) was accomplished by ELISA method on 82 colostrum samples. OTA was detectable (>0.08 ng/mL) in 55% of samples with a maximum concentration of 10.04 ng/mL, and the levels exceeded 0.5 ng /mL in 50 % of the samples. In addition, several factors and dietary habits affect significantly the level of OTA in the analyzed samples of breast milk including, the consumption of industrial dairy products, the frequency of consumption of canned foods, dried fruits and legumes, also the period of breast milk collection. Besides, OTA was higher than the tolerable daily intake for 49% newborns. However, these results need to be confirmed by multicenter studies to more broadly estimate the levels of exposition of Moroccan population to OTA. Furthermore, awareness campaigns are recommended to inform the public, especially pregnant women and lactating women about appropriate preventive measures to limit exposure to this mycotoxin.

Occurrence of and Factors Associated With the Presence of Aflatoxin M1 in Breast Milk of Mothers in Fethiye, Turkey

Aflatoxins comprise a group of mycotoxins that are found in the environment. Exposure to aflatoxins has been reported to cause serious health problems in humans. Since aflatoxin M₁ (AFM₁) is secreted in breast milk, the exposure of infants to this toxin is an important concern. The aim of this study was to determine the prevalence, levels of, and factors associated with the presence of AFM₁ in breast milk of mothers in Fethiye, Turkey. Breast milk samples were taken from 100 mothers who had given birth over the period of October-November 2017. The AFM₁ content of the samples was determined via enzyme-linked immunosorbent assay. The lowest limit for milk samples in the Ridascreen® AFM₁ commercial test kit is 5 ng/L. Because of this, AFM₁ levels below 5 ng/L in the breast milk samples were assessed as negative. Of the breast milk samples tested, 53 were positive. The average AFM₁ amount in the positive samples was 6.36 ng/L (ppt; range 5.10-8.31 ng/L). Mothers who were housewives, lived in damp, humid houses, or ate spices or dried fruits and vegetables had significantly greater prevalence of AFM₁ in their breast milk than those who were employed, did not report dampness or mold in the home, or did not eat spices or dried fruits and vegetables. AFM₁ in breast milk could be an important risk factor for infant health. Informing the public about food safety could reduce the amount of AFM₁ being transferred into breast milk via food channels.

Combined (d)SPE-QuEChERS Extraction of Mycotoxins in Mixed Feed Rations and Analysis by High Performance Liquid Chromatography-High-Resolution Mass Spectrometry

The objective of this work was the development of a methodology capable of simultaneously determine 26 mycotoxins in mixed feed rations collected in 20 dairy farms. A sample preparation methodology based on a combination of (d)SPE and QuEChERS extractions was used. Liquid chromatography-high resolution mass spectrometry was employed for both identification and quantification purposes. To this respect, a powerful workflow based on data-independent acquisition, consisting of fragmenting all precursor ions entering the mass spectrometer in narrow m/z isolation windows (SWATH), was implemented. SWATH data file then contains all the information that would be acquired in a multitude of different experimental approaches in a single all-encompassing dataset. Analytical method performance was evaluated in terms of linearity, repeatability and matrix effect. Relative recoveries were also measured, giving values above 80% for most compounds. Matrix-matched calibration was carried out and enabled reaching the low ng mL-1 level for many mycotoxins. The observed matrix effect, in most cases suppressive, reached even values higher than 60%. The repeatability was also adequate, showing a relative standard deviation lower than 10%. All unified samples analyzed showed co-occurrence of two or more mycotoxins, recurrently zearalenone, fumonisin B1, and β-zearalenol, with an occurrence frequency ranging from 60% to 90%.

Risk assessment of aflatoxins in food

EFSA was asked to deliver a scientific opinion on the risks to public health related to the presence of aflatoxins in food. The risk assessment was confined to aflatoxin B1 (AFB1), AFB2, AFG1, AFG2 and AFM1. More than 200,000 analytical results on the occurrence of aflatoxins were used in the evaluation. Grains and grain-based products made the largest contribution to the mean chronic dietary exposure to AFB1 in all age classes, while 'liquid milk' and 'fermented milk products' were the main contributors to the AFM1 mean exposure. Aflatoxins are genotoxic and AFB1 can cause hepatocellular carcinomas (HCCs) in humans. The CONTAM Panel selected a benchmark dose lower confidence limit (BMDL) for a benchmark response of 10% of 0.4 μg/kg body weight (bw) per day for the incidence of HCC in male rats following AFB1 exposure to be used in a margin of exposure (MOE) approach. The calculation of a BMDL from the human data was not appropriate; instead, the cancer potencies estimated by the Joint FAO/WHO Expert Committee on Food Additives in 2016 were used. For AFM1, a potency factor of 0.1 relative to AFB1 was used. For AFG1, AFB2 and AFG2, the in vivo data are not sufficient to derive potency factors and equal potency to AFB1 was assumed as in previous assessments. MOE values for AFB1 exposure ranged from 5,000 to 29 and for AFM1 from 100,000 to 508. The calculated MOEs are below 10,000 for AFB1 and also for AFM1 where some surveys, particularly for the younger age groups, have an MOE below 10,000. This raises a health concern. The estimated cancer risks in humans following exposure to AFB1 and AFM1 are in-line with the conclusion drawn from the MOEs. The conclusions also apply to the combined exposure to all five aflatoxins.

Toxicological and Medical Aspects of Aspergillus-Derived Mycotoxins Entering the Feed and Food Chain

Due to Earth's changing climate, the ongoing and foreseeable spreading of mycotoxigenic Aspergillus species has increased the possibility of mycotoxin contamination in the feed and food production chain. These harmful mycotoxins have aroused serious health and economic problems since their first appearance. The most potent Aspergillus-derived mycotoxins include aflatoxins, ochratoxins, gliotoxin, fumonisins, sterigmatocystin, and patulin. Some of them can be found in dairy products, mainly in milk and cheese, as well as in fresh and especially in dried fruits and vegetables, in nut products, typically in groundnuts, in oil seeds, in coffee beans, in different grain products, like rice, wheat, barley, rye, and frequently in maize and, furthermore, even in the liver of livestock fed by mycotoxin-contaminated forage. Though the mycotoxins present in the feed and food chain are well documented, the human physiological effects of mycotoxin exposure are not yet fully understood. It is known that mycotoxins have nephrotoxic, genotoxic, teratogenic, carcinogenic, and cytotoxic properties and, as a consequence, these toxins may cause liver carcinomas, renal dysfunctions, and also immunosuppressed states. The deleterious physiological effects of mycotoxins on humans are still a first-priority question. In food production and also in the case of acute and chronic poisoning, there are possibilities to set suitable food safety measures into operation to minimize the effects of mycotoxin contaminations. On the other hand, preventive actions are always better, due to the multivariate nature of mycotoxin exposures. In this review, the occurrence and toxicological features of major Aspergillus-derived mycotoxins are summarized and, furthermore, the possibilities of treatments in the medical practice to heal the deleterious consequences of acute and/or chronic exposures are presented.

Concentration and Prevalence of Aflatoxin M1 in Human Breast Milk in Iran: Systematic Review, Meta-Analysis, and Carcinogenic Risk Assessment: A Review

This meta-analysis was designed to review the published reports regarding the concentration and/or prevalence of aflatoxin M₁ (AFM₁) in human breast milk in Iran. The carcinogenic risk for Iranian infants consuming this milk was estimated with the hazard index. The PubMed and Scopus databases and the Scientific Information Database were screened for relevant studies between 1995 and 2017, and 11 of the 112 collected studies were included in the systematic review and meta-analysis. The mean (95% confidence interval) concentration of AFM₁ was 5.85 ng/L (4.54 to 7.15 ng/L), which was lower than the European Union standard (25 ng/L). The mean prevalence of AFM₁ in breast milk in Iran was 42% (11 to 77%). The estimated daily intakes for male and female infants were 0.02 to 5.57 ng/kg and 0.02 to 3.68 ng/kg of body weight per day, respectively. The rank order of estimated daily intake for both male and female infants according to age was 1 week > 1 month > 6 months > 12 months. The hazard index for all age groups of infants in all provinces in Iran was less than 1. Therefore, infants in Iran were not considered at carcinogenic risk from AFM₁ in human breast milk.

Fluoride in Iranian Drinking Water Resources: a Systematic Review, Meta-analysis and Non-carcinogenic Risk Assessment

A systematic review, meta-analysis, and non-carcinogenic risk considering fluoride content of drinking water resources of 31 provinces of Iran among some international databases such as Science Direct, Scopus, PubMed, and national databases including SID and Irandoc (2011 to July 2017) were conducted. In this context, 10 articles (40 studies) with 1706 samples were included in meta-analyses and risk assessment studies. The pooled concentration of fluoride in the cold, mild, and warm weather provinces were calculated as 0.39 mg/L (95% CI 0.32-0.48 mg/L), 0.52 (95% CI 0.43-0.61 mg/L), and 0.75 (95% CI 0.56-0.94 mg/L), respectively. The pooled concentration of fluoride in Iranian drinking water resources was 0.51 (95% CI 0.45-0.57 mg/L). The minimum and maximum concentrations of fluoride content were related to Kermanshah (0.19 mg/L) and Kerman (1.13 mg/L) provinces, respectively. The HQ of fluoride in the children and adults were 0.462 and 0.077, respectively as children are more vulnerable than adults. The HQ for children and adults was lower than 1 value. Therefore, there is no considerable non-carcinogenic risk for consumers due to drinking water in Iran. Although the non-carcinogenic of fluoride in drinking water was not significant, fluoride entry from other sources, such as food or inhalation, could endanger the health of the residents of Kerman and Bushehr provinces.

Contamination and Prevalence of Histamine in Canned Tuna from Iran: A Systematic Review, Meta-Analysis, and Health Risk Assessment

Histamine is one of the most important health issues associated with consumption of canned tuna because of possible allergic and anaphylactic reactions in consumers. Although the concentrations of histamine in tuna in Iran have been investigated in several studies, definitive conclusions are elusive. This study was undertaken as a systematic review and meta-analysis of the concentration and prevalence of histamine in Iranian canned tuna, and the related health risk was assessed. An extensive search of articles in the databases Scopus, PubMed, and Scientific Information Database resulted in 11 articles and a total of 693 samples for inclusion in this review. The minimum and maximum concentrations of histamine were determined as 8.59 ± 14.24 and 160.52 ± 87.59 mg kg⁻¹, respectively. The mean concentration was calculated as 77.86 mg kg⁻¹ (95% confidence interval [CI], 47.51 to 108.21 mg kg⁻¹), which was lower than the 200 mg kg⁻¹ recommended limit by the U.S. Food and Drug Administration (FDA). The mean prevalence of histamine was 9.19% (95%; CI, 6.88 to 11.5%). The 95% value of the target hazard quotient for adult consumers was calculated as 0.10. In all studies performed in Iran, the concentration of histamine in canned tuna was lower than FDA standard. Health risk assessment indicated low histamine risk (target hazard quotient < 1) for adults in Iran from consumption of canned tuna.

Overview on the Mycotoxins Incidence in Serbia in the Period 2004⁻2016

With an average annual production of 6.9 M tonnes and 2.5 M tonnes of maize and wheat respectively, Serbia is one of the main grain producers and exporters in Europe. Cereals are also the major staple food in Serbian diet. In view of the high cereal consumption, for human and animal nutrition, the presence of mycotoxins entails a high public health risk of chronic exposure to mycotoxins. This study provides an overview of the incidence of predominant mycotoxins, mainly in cereal and dairy products, in Serbia, in the 2004⁻2016, using data reported in the scientific literature. The study demonstrated that the total prevalence of aflatoxins was 62.9% (n = 12,517) with 26.2% of the samples exceeding the EU limits during this period. Results obtained for T-2/HT-2 (n = 523), deoxynivalenol (n = 2907), fumonisins (n = 998), zearalenone (n = 689) and ochratoxin A (n = 740) indicated the prevalence of 45.5%, 42.9%, 63.3%, 39.3% and 28.1%, respectively. For these mycotoxins, the EU limits were less frequently exceeded. Comprehensive collection and analysis of all accessible information reviewed in this paper showed moderate incidence and prevalence of mycotoxins in Serbia, with an exception of the 2012 drought year and the 2014 flood year.

A review of the current situation of aflatoxin M1 in cow's milk in Serbia: risk assessment and regulatory aspects

The aim of this systematic review is to provide information regarding the incidence and levels of aflatoxin M₁ (AFM₁) in raw and heat processed cow's milk in Serbia during 2015-16 and to compare these with collected data on the occurrence of AFM₁ in raw milk and dairy products during the last decade in our region. Estimation of dietary exposure (EDI) and hazard index (HI) calculations for different age groups of the population were also carried out, based on the AFM₁ content of milk samples and on available food consumption data in Serbia. AFM₁ was detected in 69.9% (984/1408) of raw milk samples in 2015 versus 84.9% (3094/3646) in 2016, while in heat-processed milk, AFM₁ was detected in 77.8% (364/468) in 2015 versus 98.5% (753/765) in 2016. On the basis of the obtained results, 450 (9%) of raw and 14 (1.1%) of heat-processed milk samples were contaminated with AFM₁ levels above the maximum permitted level in Serbia (0.25 μg kg^-1). However, a large percentage of raw and heat processed milk in Serbia (30.1% and 17.3%, respectively) was contaminated with AFM₁ levels above the maximum permitted level regulated in the European Union (0.05 μg kg^-1). Therefore, in order to protect consumer health, it is extremely important to further control the level of aflatoxins in milk, and this should be considered as a high priority for risk management actions.

Daily uptake of mycotoxins - TDI might not be protective for nursed infants

Exclusive breast feeding is recommended by international bodies for the first six months of life. Because of the presence of contaminants, breast feeding might lead to toxicologically relevant exposure of the nursed child. Exposure towards mycotoxins is of specific interest because of their widespread occurrence in food and of their toxicological profile. We calculated the relationship between maternal intake at the level of the existing TDIs and the exposure in the nursed infants of several mycotoxins to evaluate whether maternal exposure at the TDI is also safe for the nursed infant. If published information was not available we used in silico methods for estimating toxicokinetic parameters and the lactational transfer. A single dose and a continuous daily intake scenario were considered. Maternal intake at the TDI exceeds the age-adjusted TDI (TDI/3) values for infants in case of deoxynivalenol and patulin in the single dose scenario. Exceedance is particularly pronounced for ochratoxin A in the continuous daily intake scenario (29.2 fold above the child adjusted TDI). According to published data in infants impaired kidney function may result from this exceedance. When setting a TDI, the safety of the exclusively nursed infant should be considered in the continuous daily intake scenario.

Aflatoxin M1 in human breast milk in Shahrekord, Iran and association with dietary factors

This survey was conducted to determine the occurrence and levels of aflatoxin M₁ (AFM₁) in 250 breast milk samples of lactating mothers, obtained from urban and rural regions of Shahrekord, Iran. Moreover, the association between AFM₁ occurrence levels and dietary factors was assessed. AFM₁ analysis was carried out using the competitive enzyme-linked immunosorbent assay technique for screening and high-performance liquid chromatography with fluorescence detection (HPLC-FLD) for confirmatory purposes. The toxin was detected in 39 samples (15.6%), ranging from 11.1 to 39.3 ng/l, of which 8 samples (3.2%) had levels above the Iranian national standard limit (25 ng/l). AFM₁ occurrence and levels in breast milk samples obtained from rural regions were significantly higher (P ≤ 0.05) than those obtained from urban ones. It might be due to the different dietary patterns in these regions. It was found that dietary habits with more tendencies to consume bread, rice and non-alcoholic beer beverage significantly increased (P ≤ 0.05) the risk of AFM₁ occurrence in breast milk. In addition, higher consumption of bread, olive and traditional cream significantly increased (P ≤ 0.05) the levels of AFM₁ in breast milk samples. Further investigations should be performed to determine more precisely the association between AFM₁ occurrence and dietary factors and also the risk of infant exposure to this mycotoxin.