Open access

The impact of thermal pasteurization on viral load and detectable live viruses in human milk and other matrices: a rapid review

Publication: Applied Physiology, Nutrition, and Metabolism
10 July 2020

Abstract

Holder pasteurization (62.5 °C, 30 min) of human milk is thought to reduce the risk of transmitting viruses to an infant. Some viruses may be secreted into milk – others may be contaminants. The effect of thermal pasteurization on viruses in human milk has yet to be rigorously reviewed. The objective of this study is to characterize the effect of common pasteurization techniques on viruses in human milk and non-human milk matrices. Databases (MEDLINE, Embase, Web of Science) were searched from inception to April 20th, 2020, for primary research articles assessing the impact of pasteurization on viral load or detection of live virus. Reviews were excluded, as were studies lacking quantitative measurements or those assessing pasteurization as a component of a larger process. Overall, of 65 131 reports identified, 109 studies were included. Pasteurization of human milk at a minimum temperature of 56−60 °C is effective at reducing detectable live virus. In cell culture media or plasma, coronaviruses (e.g., SARS-CoV, SARS-CoV-2, MERS-CoV) are highly susceptible to heating at ≥56 °C. Although pasteurization parameters and matrices reported vary, all viruses studied, except parvoviruses, were susceptible to thermal killing. Future research important for the study of novel viruses should standardize pasteurization protocols and should test inactivation in human milk.
Novelty
In all matrices, including human milk, pasteurization at 62.5 °C was generally sufficient to reduce surviving viral load by several logs or to below the limit of detection.
Holder pasteurization (62.5 °C, 30 min) of human milk should be sufficient to inactivate nonheat resistant viruses, including coronaviruses, if present.

Résumé

La pasteurisation de Holder (62,5 °C, 30 min) du lait humain pourrait réduire le risque de transmission de virus à un nourrisson. Certains virus peuvent être sécrétés dans le lait – d’autres peuvent être des contaminants. L’effet de la pasteurisation thermique sur les virus dans le lait humain n’est pas encore rigoureusement documenté. L’objectif de cette étude est de caractériser l’effet des techniques de pasteurisation courantes sur les virus dans les matrices avec et sans lait humain. Des bases de données (MEDLINE, Embase, Web of Science) sont examinées du début au 20 avril 2020 pour trouver des articles de recherche primaire évaluant l’impact de la pasteurisation sur la charge virale ou la détection de virus vivants. Les analyses documentaires sont exclues tout comme les études ne présentant pas de mesures quantitatives ou celles évaluant la pasteurisation en tant que composante d’un processus plus vaste. Dans l’ensemble, 109 études sont incluses sur 65 131 rapports identifiés. La pasteurisation du lait humain à une température minimale de 56 °C à 60 °C est efficace pour diminuer les virus vivants détectables. Dans les milieux de culture cellulaire ou le plasma, les coronavirus (par exemple, SARS-CoV, SARS-CoV-2, MERS-CoV) sont très sensibles au chauffage à ≥56 ºC. Bien que les paramètres de pasteurisation et les matrices rapportées varient, tous les virus étudiés, à l’exception des parvovirus, sont sensibles à la destruction thermique. Les futures recherches importantes pour l’étude de nouveaux virus devraient normaliser les protocoles de pasteurisation et tester l’inactivation dans le lait maternel. [Traduit par la Rédaction]
Les nouveautés
Dans toutes les matrices, y compris le lait humain, la pasteurisation à 62,5 °C est généralement suffisante pour diminuer la charge virale survivante de plusieurs niveaux logarithmiques ou en dessous de la limite de détection.
La pasteurisation de Holder (62,5 °C, 30 min) du lait humain devrait être suffisante pour inactiver les virus non résistants à la chaleur, y compris les coronavirus, le cas échéant.

Introduction

Breastfeeding is associated with numerous positive health and neurocognitive outcomes: these include lower infectious morbidity and mortality, higher intelligence, and protection against the development of chronic disease later in life (Victora et al. 2016). Although clinically, breastfeeding may represent a vehicle for the transmission of infectious diseases to infants, including viral infections, its benefit typically outweighs any risk (Lawrence 2011). There are, however, circumstances when breastfeeding is contraindicated, such as maternal infection with human immunodeficiency virus (HIV)-1/2) or human t-lymphocytic virus (HTLV)-I/II in a developed country or herpes simplex virus with active lesions on the breast (Margreete et al. 2012).
While their mother’s own milk supply is being established, human donor milk is used as a bridge for hospitalized infants; among very low birth weight infants, the use of human donor milk instead of preterm formula as a bridge has been shown to reduce the incidence of necrotizing enterocolitis (Underwood 2013; Quigley et al. 2019). Since the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in late 2019, ensuring that current high-quality screening, handling and pasteurization standards are sufficient for maintaining a safe supply of human donor milk has been an ongoing challenge for milk banks (Furlow 2020). Milk banking associations, including the Human Milk Banking Association of North America (HMBANA) and the European Milk Banking Association (EMBA) have responded to the pandemic by issuing new guidelines with respect to enhanced donor screening, including asking specific questions to assess the likelihood of a potential donor being infected with SARS-CoV-2 (COVID-19: EMBA 2020; Human Milk Banking Association of North America 2020). While all donor milk from nonprofit milk banks in North America undergoes low-temperature long-time pasteurization, known as the Holder method (62.5 °C, 30 min), to inactivate potentially pathogenic bacteria and viruses, additional research is warranted to determine whether SARS-CoV-2 is inactivated by Holder pasteurization (Arslanoglu et al. 2018). It is also important to understand if other pasteurization methods can inactivate SARS-CoV-2, including high-temperature short-time, proposed as an alternative technique in human milk banking, in addition to flash-heating, a home-based method that takes place with informal milk sharing (Eats on Feets 2011).
At present, the virome of human milk has been understudied. Few studies have investigated whether or not viruses that may cause disease in preterm infants are present in human milk (Mohandas and Pannaraj 2020). Viruses may be present in human milk as a result of secretion into the milk from the mammary tissue, notably, cytomegalovirus, HTLV, and HIV, or may be present as a contaminant from skin or respiratory droplets either in the milk or on collection containers (Michie and Gilmour 2001). Regardless of origin, accurate data are needed around thermal inactivation of viruses to avoid confusion and misinformation around the safety of human donor milk.
To date, there has been no systematic review of the impact of thermal pasteurization on viral load or detectable live virus in a human milk matrix or other nonhuman milk matrices. The primary aim of this review is to characterize studies conducted in human milk to determine how certain viral families that are either present in human milk, or used as surrogates, respond to thermal pasteurization as assessed by viral load or live virus detection. To expand the scope of viruses tested, the secondary objective is to summarize studies conducted in nonhuman milk matrices that have examined the effect of thermal pasteurization on any virus. This review also aims to compare viruses that have been assessed in studies using both human milk and nonhuman milk matrices to ascertain any trends in susceptibility to thermal pasteurization.

Materials and methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in completion of this rapid review, except where indicated (Moher et al. 2009). This rapid review is in response to the COVID-19 pandemic.

Search strategy and selection criteria

References for this rapid review were identified through electronic searches of various online databases, including MEDLINE, Embase, and Web of Science, from database inception to April 20th, 2020, with the assistance of a research librarian. The search strategy focused on keywords to identify articles that assessed the effect of thermal pasteurization or heat inactivation, including Holder pasteurization, on the detection of live virus or viral load in human milk or other nonhuman milk matrices. The names of viral families, as per the current taxonomic classification, were included in the search as they may be present in human milk (by secretion or contamination) or could be used as surrogate viruses to model highly pathogenic or nonculturable viruses (King et al. 2012).
The keywords and MeSH terms included for all database searches were intended to capture all relevant research with respect to thermal pasteurization of viruses in human milk, the primary outcome of this rapid review. To increase the scope, we supplemented the search to capture research articles that tested all matrices other than human milk. Macronutrient analysis was not considered in association with viral load in any study and therefore, not considered as part of this review. The search strategy is summarized in Supplementary Table S11 and included 3 main ideas. The first concept included viral taxonomic families using keywords and MeSH terms based on the nomenclature suggested by the International Committee on Taxonomy (King et al. 2012). The second concept consisted of synonyms and phrases closely related to human milk (e.g., breast milk, donor milk, etc.). Lastly, the final concept was thermal pasteurization and its synonyms (e.g., Holder pasteurization, heat, etc.). Our initial search aimed to retrieve articles specific to human milk, which was achieved by combining all 3 concepts; by only retaining the first and last concept, a second set of articles was retrieved that theoretically involved thermal pasteurization and viruses in all other matrices, including human milk. Grey literature was searched as per the previously published guidelines, including from dissertations and Google advanced search (Natal 2019). Articles resulting from those searches and relevant references cited in those articles were reviewed.
After duplicates were removed, titles then abstracts were screened by a single reviewer. Primary research articles were included if they assessed the effect of Holder pasteurization (62.5 °C to 63 °C) or any other heat treatment on viral load or detection of live virus in human milk or other matrices. Eligible study designs included pre–post or longitudinal; in either design, the outcome, detection of live virus, or viral load was assessed before and after pasteurization or at discrete time points during a given pasteurization process. Qualitative, observational, and review studies were excluded, in addition to experimental studies that did not assess viral load (quantitative) or detectable live virus. Studies that investigated how thermal pasteurization and the addition of matrix stabilizers affects viral load or live virus detection were also excluded; the outcome of these studies may be confounded by the fact that the integrity of viruses may be different as certain stabilizers are added or removed. Studies were also excluded if thermal pasteurization was tested in combination with other processing techniques (e.g., irradiation, lyophilization during the production of plasma concentrates), unless the study was appropriately controlled. The primary rationale being that aspects of processing, other than heat, may also lead to the inactivation of viruses. Reports on clinical trials or studies published in nonscientific journals were not included. All studies irrespective of language or year published were included.
Multiple attempts were made to retrieve the full text of all articles screened on the basis of title and abstract, including interlibrary loan and/or author follow-up. Data were extracted from eligible full-text articles, including viruses tested, matrix used, thermal pasteurization parameters (temperature, time) and a measure of reduction in viral load/detectable virus. Included studies were summarized after being dichotomized into 2 groups depending on whether detectable live virus or viral load was tested in human milk or another matrix. To determine whether a human milk matrix affected the results, a subanalysis was conducted on studies that tested the same viruses in both human milk and nonhuman milk matrices. In this subanalysis, only studies that assessed virus presences by plaque reduction assay or endpoint dilution (TCID50) were included. First, viruses that were tested in both groups were determined by cross-referencing; relevant data (log-reduction, temperature, and duration of pasteurization) was then extracted and aggregated. Unless otherwise defined, complete inactivation is a concentration of virus that was below the lower detection limit of the assay. If multiple studies assessed the same virus, the pasteurization conditions used in the summary were matched as closely as possible to the data available in studies experimenting with human milk.

Results

Study selection and characteristics

The selection of studies is summarized in Fig. 1. A total of 65 131 reports were identified and assessed for eligibility. This included 23 441 citations from MEDLINE, 34 479 citations from Embase, 7200 records from Web of Science, and 11 from manual searches. Altogether, 64 949 records were excluded on the basis of title and abstracts alone, encompassing articles that did not meet the inclusion criteria (n = 44 286 records) or were duplicate records (n = 20 663). After title and abstract screening, 182 reports remained for full-text review. Upon full-text review, 73 reports were excluded: 6 were duplicate records, 2 could not be retrieved, and 65 did not meet inclusion criteria. Thus, 109 articles were included in the review and were organized according to the matrix used in testing the effect of pasteurization on viral load.
Fig. 1.
Fig. 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram describing the selection of studies for inclusion in the review.

Studies conducted in human milk

First, we summarized 17 unique studies that used human milk as the matrix to test the effect of pasteurization on 13 different viruses (Table 1). Most studies reported on viral addition experiments, while few studies subjected milk with endogenous virus to thermal pasteurization. Since human milk alone may reduce viral load and detectable live virus, 2 studies reported diluting milk samples prior to assay and 6 studies controlled for the independent effect of human milk on reducing infectivity (Dworsky et al. 1982; Orloff et al. 1993; Terpstra et al. 2007; Volk et al. 2010; Hoque et al. 2013; Donalisio et al. 2014; Hamilton Spence et al. 2017; Pfaender et al. 2017). Predominantly, the viruses tested were caspid enveloped and belonged to 7 different viral families, including filoviridae, flaviviridae, herpesviridae, papillomaviridae, picornaviridae, retroviridae, and togaviridae. Cytomegalovirus and HIV were the most common viruses studied with 8 and 7 articles, respectively. To assess surviving virus concentration following pasteurization, plaque reduction assays and endpoint titration assays (TCID50) were most frequently used, although some studies used immunofluorescence, reverse-transcriptase enzymatic assays and secreted embryonic alkaline phosphatase reporter assay.
Table 1.
Table 1. Summary of studies assessing the effect of heat, including Holder pasteurization, on viral inactivation in human milk.

Note: Complete inactivation refers to a viral load that is below the detectable limit of the assay, unless otherwise noted. GFP, green fluorescence protein; HIV, human immunodeficiency virus; IF, immunofluorescence; PBMC, reripheral blood mononuclear cell; PFU, plaque forming unit; PRA, plaque reduction assay; RT, reverse transcriptase; SEAP, secreted embryonic alkaline phosphatase; TCID50, tissue culture infectious dose 50.

Based on the literature reviewed, Holder pasteurization, defined as a temperature of 62.5−63 °C held for 30 min, resulted in complete inactivation of viruses in the herpesviridae family, including cytomegalovirus (Dworsky et al. 1982; Hamprecht et al. 2004; Donalisio et al. 2014); however, complete inactivation of herpes simplex virus did not occur, requiring a temperature of 100 °C for 5 min (Welsh et al. 1979). In fact, for cytomegalovirus specifically, studies that demonstrated complete inactivation collectively required temperatures of 60−63 °C for varying lengths of time (between 5 s to 30 min) (Friis and Andersen 1982; Klotz et al. 2018; Maschmann et al. 2019). Similarly, retroviridae were susceptible to heating in a human milk matrix whereby complete inactivation was observed after pasteurization above 60 °C, for a minimum of 5 s. In particular, flash heating (at-home pasteurization method) and Holder pasteurization completely inactivated HIV-1 in human milk (Orloff et al. 1993; Israel-Ballard et al. 2007; Volk et al. 2010; Hoque et al. 2013); high temperature short time (72 °C for 8 s) similarly yielded complete inactivation (>5.5-log reduction) (Terpstra et al. 2007). Holder pasteurization was found to inactivate (>5-log reduction) Ebola virus and Marburg virus of the filoviridae family, Zika virus (>6-log reduction) of the flaviviridae family, Semliki forest virus of the togaviridae family (4.2-log reduction), and human papillomavirus of the papillomaviridae family (Welsh et al. 1979; Hamilton Spence et al. 2017; Pfaender et al. 2017). Some nonenveloped members of the picornaviridae family were found to be more resistant to heating (Terpstra et al. 2007); high-temperature short-time treatment (72 °C for 16 s) of hepatitis A virus and porcine parvovirus yielded a 2- or 0.5-log reduction in TCID50/mL, respectively. Infectivity of coxsackievirus persisted after Holder pasteurization, although reduced by 3.6-log PFU/mL (Welsh et al. 1979).

Studies conducted in nonhuman milk matrices

Second, we summarized the remaining 92 unique studies that were identified during the literature review that assessed the effect of thermal pasteurization on viruses in a nonhuman milk matrix (Table 2). Cell culture media was the most prevalent matrix used in testing; other common matrices included bovine milk, bovine serum, human serum albumin, and human plasma. In total, 21 unique families of viruses were tested, including adenoviridae, anelloviridae, birnaviridae, caliciviridae, circonviridae, coronaviridae, flaviviridae, hepadnaviridae, hepeviridae, herpesviridae, orthomyxoviridae, paramyxoviridae, parvoviridae, picornaviridae, polymaviridae, poxviridae, reoviridae, retroviridae, rhabdoviridae, and togaviridae. The majority of studies tested nonenveloped viruses in the families of picornaviridae (n = 38), and caliciviridae (n = 25), in addition to retroviridae (n = 16).
Table 2.
Table 2. Summary of studies assessing the effect of heat on viral inactivation in matrices others than human milk.

Note: Ag, antigen; DIU, duck infectious units; ED, endpoint dilution; EID, egg infectious dose; FBS, fetal bovine serum; FFU, fluorescence-focus unit; FQ-PCR, fluorescence-quantitative polymerase chain reaction; HSA, human serum albumin; IF, immunofluorescence; IV, inactivation velocity; MERS-CoV, Middle East respiratory syndrome coronovirus; PBS, phosphate buffered saline; PFU, plaque forming unit; PRA, plaque reduction assay; qRT-PCR, quantitative reverse transcriptase (real time) polymerase chain reaction; RIFA, radio-immunofluorescence assay; RIFU, radioimmunofocus units; RT, reverse transcriptase; SARS-CoV, severe acute respiratory syndrome coronavirus; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; TCID50, tissue culture infectious dose 50.

Hepatitis A was the most commonly tested virus tested of the picornaviridae family and was seen to be particularly heat sensitive in a variety of matrices including bovine milk, cell culture media, and soft-shell clams. For example, a minimum of a 4-log reduction in infectivity of Hepatitis A was observed after different thermal pasteurization parameters such as 60−65 °C for 10–180 min (Croci et al. 1999; Bidawid et al. 2000; Gibson and Schwab 2011), 72 °C for 1–13 min (Bidawid et al. 2000; Araud et al. 2016), and 90 °C for 5 min (Sow et al. 2011). Murine norovirus, the most frequently tested virus of the caliciviridae family, was also observed to be sensitive to heat. A reduction in infectivity of greater than 5-log was observed at temperatures of 60−67 °C for 1–60 min (Gibson and Schwab 2011; Shao et al. 2018), >3.5-log reduction at 72 °C for 1 min (Hewitt et al. 2009; Araud et al. 2016), and >5-log reduction at 85−90 °C for 1–5 min (Sow et al. 2011; Park et al. 2014a). HIV was the most commonly tested of the retroviridae and was also susceptible to heat inactivation. Greater than 4-log reduction in TCID50 was observed at 60−65 °C for 10–15 min (Lelie et al. 1987; Gregersen et al. 1989); similar reductions were observed at 77−80 °C after 0.25 s (Charm et al. 1992).
Notably, viruses in the coronaviridae family, SARS-CoV and SARS-CoV-2, also show significant reductions in infectivity (>5–7-log reduction in TCID50/mL) following pasteurization in cell culture media and plasma products; complete inactivation was observed at temperatures between 56–60 °C for a 5–60-min duration (Duan et al. 2003; Darnell et al. 2004; Yunoki et al. 2004; Kariwa et al. 2006; Chin et al. 2020). Other coronaviruses, including canine coronavirus and Middle East respiratory syndrome coronovirus (MERS-CoV), show sensitivities to heating in cell culture media, bovine milk or camel milk, where a clinically relevant reduction in infectivity (>4.5–5.5-log TCID50) is attainable upon heating at 63–65 °C for 5–30 min (Pratelli 2008; Leclercq et al. 2014; van Doremalen et al. 2014). Furthermore, cytomegalovirus, a member of the herpesviridae family, was completely inactivated at temperatures between 50–65 °C for 15–30 min (Plummer and Lewis 1965; Lelie et al. 1987; Farmer et al. 1992; Mikawa et al. 2019).

Viruses tested in human milk and other matrices

Finally, the summary of the comparisons among viruses that were tested in both a human milk and a nonhuman milk matrix is shown in Table 3. Overall, the range of temperatures that yielded some degree of log reduction were consistent among viruses, irrespective of the matrix. Cytomegalovirus, for example, was a virus where there was good agreement among studies testing thermal pasteurization in either a human milk or a nonhuman milk matrix; inactivation was evident at temperatures between 50 °C and 65 °C for 10–30 min. Similarly consistent, porcine parvovirus in the parvoviridae family was found to be heat resistant in either human milk or nonhuman milk matrices (Danner et al. 1999; Terpstra et al. 2007; Sauerbrei and Wutzler 2009). There were some differences in the time required for the log reduction in infectivity depending on matrix, but there were no discernable trends identified.
Table 3.
Table 3. Comparing the log reductions in detectable live viruses pasteurized in both a human milk and a nonhuman milk matrix.

Note: UD, undetectable.

*Log-PFU or TCID50/mL.

Discussion

Pasteurization is an essential part of human donor milk banking and is practiced worldwide to reduce or eliminate the risk of transmission of viruses that may be expressed in milk or may be found as a contaminant; Holder pasteurization (62.5 °C, 30 min) is the most common method used (Arslanoglu et al. 2018). Our rapid review aimed to summarize the literature pertaining to the effect of thermal pasteurization on viral load and detectable live virus; in particular, research that has been conducted using a human milk matrix. Our rapid review also aimed to compare viruses that have been both tested in a human milk matrix and a nonhuman milk matrix to better understand any potential modulating effects.
As expected, the most commonly studied viruses in human milk in relation to thermal pasteurization included those that have been previously shown to be transmitted through breastmilk; primarily cytomegalovirus and HIV-1, which are enveloped viruses belonging to the herpesviridae and retroviridae families, respectively (Prendergast et al. 2019). Although not as common as cytomegalovirus or HIV, Ebola, Marburg, and Zika viruses have also been studied in human milk given that viral nucleic acid has been detected in milk and transmission is a potential concern (Hamilton Spence et al. 2017; Sampieri and Montero 2019). Despite differences in viral taxonomy and caspid envelope, pasteurization is effective at significantly reducing detectable virus or viral load by several log, and in many cases, to below detectable levels (Table 1).
Many studies involving human milk tested pasteurization parameters that included the Holder method (62.5 °C, 30 min) to mimic practices at milk banks; however, a variety of time and temperature combinations were tested. Although many studies reported that viruses including Ebola, Marburg, Zika, cytomegalovirus, and HIV appear to be completely inactivated after 30 min at 62.5–63 °C (Table 1), others report inactivation after a shorter duration; it remains unclear whether Holder pasteurization for shorter times might effectively inactivate these viruses. Arriving at a consensus is difficult given that a study might assess reductions in surviving virus concentrations before and after Holder pasteurization and another might assess at different time points during the pasteurization process. Moreover, high-temperature short-time pasteurization, defined here as pasteurization above 70 °C for less than 30 min, appears to be as effective as pasteurization at lower temperatures for a longer duration.
Given the limited research in a human milk matrix, the inclusion of studies that assessed viral load or detectable live virus in a range of matrices allowed us to assess a broader scope of viruses belonging to numerous taxonomic families. The matrix may influence the effectiveness of pasteurization by altering how heat is distributed; however, our results suggest that irrespective of matrix, enveloped, compared with nonenveloped viruses, generally require less input of thermal energy to achieve similar reductions in viral load or live virus concentration. This suggests that the results presented in Table 2 may, to a certain degree, be representative of how viruses could be inactivated by heat in human milk. In all matrices, including human milk, pasteurization at temperatures of 62.5 °C was generally sufficient to reduce surviving viral load by several logs or to below the limit of detection, depending on the starting concentration of virus and whether it was enveloped. To completely inactivate nonenveloped viruses, such as bovine viral diarrhea virus, hepatitis A or porcine parvovirus in human milk or in other matrices, temperatures above 63 °C (70−90 °C) or a significantly longer duration at 60−63 °C (Table 2) is generally required. Overall, the results are consistent with the logarithmic thermal death time curve where the same degree of thermal lethality can occur at varying temperatures depending on holding time; pasteurization at higher temperatures for shorter durations or lower temperatures for longer durations yielded similar results in terms of the magnitude of infectivity reductions.
Finally, while we cannot discount any differences in response to thermal pasteurization, viruses that were tested in both a human milk and nonhuman milk matrix appeared to require similar temperatures to elicit a given log reduction in infectivity. Nevertheless, there was significant variability in the duration of pasteurization tested, making it difficult to draw any conclusions as some viruses may require greater time at temperature for 1 matrix, and less time at temperature for another. In addition to there being a wide range of matrices included as part of the nonhuman milk group, differences in the time may be an artefact of the design of the respective studies; in many cases, viral infectivity or load was not always assessed longitudinally but after a predetermined length of time. Consequently, this may overestimate the amount of time required to achieve a certain degree of inactivation, making it difficult to compare and aggregate the results from different studies.
There are many strengths of this rapid review. First, we carried out a robust search strategy, in addition to manual searches of grey literature, to generate a complete list of studies, irrespective of language or year published that assessed the impact of thermal pasteurization on viral load in human milk and other matrices. The studies in this review reported on a wide range of thermal pasteurization parameters (low-temperature long-time, high-temperature short-time) across several viruses in a diverse set of matrices. Despite these, the interpretation of our results should be considered alongside its limitations. First, this review was conducted by a single reviewer, which may have introduced potential selection bias during initial screening. As a result, our review may not have captured all possible studies. Despite this, the purpose of this review was to rapidly and broadly characterize how viruses in any matrix, including human milk, might respond to thermal pasteurization. Second, the reduction in viral load or detectable live virus that was extracted was approximated if multiple strains of a given virus genus were studied, despite the potential of strain-specific variation in thermal resistance. Third, in our comparison of studies that assessed similar viruses in both a human milk and nonhuman milk matrix, we chose to aggregate the results to match, to the best of our ability, the pasteurization parameters tested in human milk. While this may have allowed us to assess the temperature and time requirements to achieve a certain log reduction, we were limited to a narrow range of pasteurization conditions.
To our knowledge, this rapid review is the first to broadly summarize the literature that has reported on the impact of any thermal pasteurization on virus survival. The results from this study highlight our limited understanding with respect to the effect of thermal pasteurization on viruses in human milk—this is especially relevant given the possibility that novel viruses, including SARS-CoV-2, may be present in human milk. Although currently there is insufficient evidence to suggest that SARS-CoV-2 is expressed in milk and could lead to vertical transmission, it may also be present as a contaminant (Lackey et al. 2020). Based on the literature review, Holder pasteurization (62.5 °C, 30 min) may be sufficient to inactivate nonheat resistant viruses that may be present in human milk, including coronaviruses. Thus clinically, standard pasteurization procedures conducted at milk banks should be adequate to ensure a safe supply of human donor milk. Though our attempt to rapidly survey all known viral families may help provide some insight into how novel viruses may respond to thermal pasteurization, additional investigation is warranted using standardized research methodology and human milk as the matrix. In addition to thermal pasteurization, research into novel and innovative pasteurization systems for human milk must also be studied to ensure they can be used to successfully inactivate potential viral pathogens.

Conflict of interest statement

All authors have no conflicts of interest to disclose.

Acknowledgements

The authors gratefully acknowledge Glyneva Bradley-Ridout at the University of Toronto who was consulted on the search strategy. This work was supported by the Ontario Graduate Scholarship; Restracomp Scholarship, The Hospital for Sick Children, and the Canadian Institutes of Health Research (FDN no. 143233).

Footnote

1
Supplementary data are available with the article at https://doi.org/10.1139/apnm-2020-0388.

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Supplementary data (apnm-2020-0388suppla.docx)

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Published In

cover image Applied Physiology, Nutrition, and Metabolism
Applied Physiology, Nutrition, and Metabolism
Volume 46Number 1January 2021
Pages: 10 - 26

History

Received: 14 May 2020
Accepted: 6 July 2020
Published online: 10 July 2020

Key Words

  1. viral infectivity
  2. viruses
  3. Holder pasteurization
  4. thermal pasteurization
  5. human milk
  6. donor milk
  7. milk banking
  8. SARS-CoV-2

Mots-clés

  1. infectiosité virale
  2. virus
  3. pasteurisation de Holder
  4. pasteurisation thermique
  5. lait humain
  6. lait de donneur
  7. banque de lait
  8. SARS-CoV-2

Authors

Affiliations

Michael A. Pitino*
Department of Nutritional Sciences, University of Toronto, Toronto, ON M5S 1A8, Canada.
Translational Medicine Program, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada.
Deborah L. O’Connor
Department of Nutritional Sciences, University of Toronto, Toronto, ON M5S 1A8, Canada.
Translational Medicine Program, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada.
Allison J. McGeer
Department of Microbiology, Sinai Health, Toronto, ON M5G 1X5, Canada.
Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5S 1A1, Canada.
Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada.
Department of Nutritional Sciences, University of Toronto, Toronto, ON M5S 1A8, Canada.
Division of Neonatology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada.
Department of Pediatrics, Sinai Health, Toronto, ON M5G 1X5, Canada.
Department of Pediatrics, University of Toronto, Toronto, ON M5G 1X8, Canada.

Notes

*
Present address: Peter Gilgan Centre for Research and Learning, 10th floor, 10.9410-Bench O, 686 Bay Street, Toronto, ON M5G 0A4, Canada.
This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

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