Estimation of Urinary Concentration of Aflatoxin

M1 in Chinese Pregnant Women

Yajing Lei, Lizheng Fang, Muhammad Sajid Hamid Akash, Kanwal Rehman, Zhiming Liu, Weixing Shi, and Shuqing Chen

Abstract: Aflatoxin M1 (AFM1 ) is a main cause of hepatocarcenogenoma in Chinese population. Measurement of

aflatoxin exposure in human may help in providing clear evidence for the exposure of specific environmental pollutants
in certain population. “One child policy” in China offered parents more careful to choose safe food during pregnancy, but
no reports published on the efficacy of their endeavor. In present study, we aimed to assess the exposure of AFM1 in
Chinese pregnant women. The urine samples were collected from 600 volunteers from Zhejiang province, China and
the urinary concentration of AFM1 was measured using ELISA kit. AFM1 was detected in 84% of the pregnant women.
The geometric mean and 95th percentile concentration of AFM1 in pregnant women were 50.3 ng/L and 633.5 ng/L,
respectively. Our results point out that pregnant women especially are at the high risk of exposure to AFM1 . Our results
also indicate that although “one child policy” offered parents to pay more attention for the selection of safe food, but
detection of AFM1 in urine of pregnant women indicate that more foods containing AFM1 still need to be detected.
Highest exposure of AFM1 in pregnant women indicates that awareness campaigns must be started especially in the rural
areas of China regarding the possible hazardous effects of AFM1 exposure in pregnant women.

Keywords: aflatoxin M1, milk products, pregnant women, urine samples

Introduction more susceptible to the potential carcinogenic effects of aflatoxins

Aflatoxins belong to the group of mycotoxins, which are harm-
ful contaminants of food and are usually produced from As-
pergillus flavus and Aspergillus parasiticus (Frisvad and others 2005).
These contaminants are mostly present in a wide range of agri-
cultural products and foodstuffs such as wheat, rye, corn, soy,
sorghum, rice, cottonseed, grains, moldy peanuts, milk, and dairy
products (Hussein and Brasel 2001; Sassahara and others 2005;
Unusan 2006; Tabari and others 2013). AFG1 , AFG2 , AFB1 , AFB2
are considered the major aflatoxins, among which AFB1 and its
metabolite aflatoxin M1 (AFM1 ) are recognized as most dominant
hepatotoxic aflatoxins (Everley and others 2007).
Among the milk and dairy products, milk has the greatest poten-
tial for exposure of AFM1 in human (Rahimi and others 2010).
The exposure of AFM1 in human is partly from the consump-
tion of contaminated milk and dairy products, and partly from
its endogenous production from AFB1 via biotransformation at
the hepatic level through microsomal enzyme cytochrome P450.
Once AFM1 is produced, it can be secreted into the milk of
mammals (Neal and others 1998; Fallah 2010). AFM1 also has
carcinogenic potency (Creppy 2002) and has been classified as
a probable human carcinogen (IARC 1993). As milk and other
dairy products are mostly consumed by the women during their
pregnancy, therefore, the potential exposure of AFM1 in these
products indicates the worldwide concern as pregnant women are
MS 2013-0885 Submitted 6/29/2013, Accepted 8/15/2013. Authors Lei, Akash,
Rehman, and Chen are with Inst. of Pharmacology, Toxicology and Biochemical Phar-
maceutics, College of Pharmaceutical Sciences, Zhejiang Univ., Hangzhou 310058,
China. Author Fang is with Sir Run Run Shaw Hospital, School of Medicine,
Zhejiang Univ., Hangzhou 310016, China. Author Akash is also with College
of Pharmacy, Government College Univ. Faisalabad, Faisalabad, Pakistan. Author
Liu is with Hangzhou EPIE Bio-detection Technology Limited, Hangzhou 310051,
China. Author Shi is with Inst. of Public Health, College of Medical Science, Zhe-
jiang Univ., Hangzhou 310058, China. Direct inquires to author Chen (E-mail:
(Boudra and others 2007). Therefore, Food and Drug Admin-
istration (US FDA 1996) and the European Union (European
Commission 2001) have established a maximum admissible levels
of AFM1 of 50 ng/kg in milk and milk products but FDA has
set an action level of 500 ng/kg in whole, low fat, and skimmed
milk with the attention of decreasing this limit to 10 ng/kg (FDA
2005).
Due to over population, China adopted a one child policy
to control the population rate. After the implementation of one
child policy in China, the foods used during the fetal develop-
ment period are selected very carefully for the good health of
baby. However, it cannot provide absolutely contamination-free
food, even though government has made efforts to detect the
concentration of aflatoxins in various kind of foods. Biomonitor-
ing or measurement of internal exposure of AFM1 is the mea-
surement of the body burden of toxic chemical compounds or
their metabolites in biological substances. Often, these measure-
ments are done in blood and/or urine (Azziz-Baumgartner and
others 2005; Lewis and others 2005; Angerer and others 2007).
Internal exposure measurement can provide a real situation for
the exposure of AFM1 in certain population. “One child policy” in
China makes parents more cautious to choose safe food, but no
reports published on the efficacy of their endeavor. Therefore it
would be of much importance for the determination of internal
exposure of AFM1 in Chinese population especially in pregnant
women.
Despite the potential risk exposure of AFM1 in pregnant
women, no sufficient data are available online regarding the poten-
tial exposure of AFM1 in the urine samples of pregnant women in
Chinese population. Therefore, the purpose of our present study
was to estimate the concentration of AFM1 in urine samples of
pregnant women in Zhejiang province of the People’s Republic
of China. This study also reports the data of a 1st survey on the
Chemical Food Safety

chenshuqing@zju.edu.cn). presence of AFM1 in the urine samples of pregnant women in

T: Toxicology &

Zhejiang province of the People’s Republic of China.



C 2013 Institute of Food Technologists
R

doi: 10.1111/1750-3841.12259 Vol. 78, Nr. 11, 2013 r Journal of Food Science T1835
Further reproduction without permission is prohibited
 Exposure of AFM1 . . .

Materials and Methods Table 1–Frequency distribution of percentile levels and GM of

urinary AFM1 in a China population (ng/L).
Participants and study area
Percentile
The present study took place during January 2010 to January
2012 in the Zhejiang Province of Peoples Republic of China. The Parameters Nr GM Min 10th 25th 50th 75th 90th 95th Max
study participants were recruited randomly both from the rural and
Total 600 50.5 <LOD <LOD 17 55 120 349 729.5 4900
urban areas of Zhejiang Province. Zhejiang province is an eastern Age group (years)
coastal province of China where exposure to dietary mycotoxins <18 295 48.4 <LOD <LOD 15 55 120 344 744 4900
is widespread. Total 600 participants were recruited for this study 18–28 235 54.6 <LOD <LOD 27 57 130 344 636 2400
out of which 512 were pregnant women and 88 were males. >28 70 46.2 <LOD <LOD 11.7 51.5 130 380 945 1800
Male samples were set here to compare the AFM1 concentrations Place of residence
Rural 291 51.3 <LOD <LOD 12 56 140 480 1040 3500
between pregnant women and men. Prior to sample collection,
Urban 309 49.8 <LOD <LOD 22 53 110 290 515 4900
sociodemographic characteristics were also recorded such as age, Gender
place of residence, occupational contact to AFM1 , trimester of Male 88 51.5 <LOD <LOD <LOD 70.5 230 704 1455 4900
pregnancy, and health status. Female 512 50.3 <LOD <LOD 21 53 110 320 633.5 3500

GM = geometric mean; Min = minimum; Max = maximum; LOD = limit of

Ethical considerations detection.
Present study was approved by the Ethics Committee of School
of medicine, Zhejiang Univ., Hangzhou, China and informed
of residence). On the basis of questionnaire responses, age was
written consent was obtained from the participants before inclu-
categorized in 3 groups (<18, 18 to 28, and >28 y) and residence
sion in this study and for publication of their data in the form of
was divided into 2 groups (Rural and Urban). Statistical significant
article.
difference was set at P <0.05.
Sample collection and preparation for analysis
Each participant collected urine sample in polyethylene tubes. Results
After urine collection, all samples were identified and immediately Main characteristics of study participants
sent to the laboratory. All urine samples were centrifuged and the The enrolment, sociodemographic characteristics, and urine
supernatants were stored at –20 ◦ C in metal-free polypropylene collection were performed from January 2010 to January 2012.
tubes till further analysis. Urine dilution was corrected by the All the participants were reported as nonoccupational contact to
adjustment of specific gravity using urinometer. AFM1 . All the pregnant women were in the last trimester of
their pregnancy. Sociodemographic characteristics of study partic-
AFM1 analysis in urine ipants are represented in Table 1. About 48.50% participants were
For the determination of urinary concentration of AFM1 , a recruited from the rural area, whereas 51.50% participants were
competitive ELISA kit (Food-Safe, Guangzhou, China) was used recruited from the urban area of Zhejiang Province. We also noted
as described previously (Zhu and others 1987) with some mod- the age of all participants of our study. Almost 49.20% participants
ifications. A 96-well plate had been coated with anti-AFM1 an- were under 18 y of their age, whereas 39.20% were in the range
tibody. Briefly, the plates were 1st incubated with 10 μL urine of 18 to 28 y and only 11.60% were above 28 y old.
samples and/or standard samples, followed by the addition of 100
μL horseradish peroxidase-labeled AFM1 . The mixture was then Occurrence of AFM in urine samples
1
incubated at room temperature for 1 h. After 3 washes with wash In our study, the distributions of AFM1 in 600 urine samples
 
buffer, the 3,3 ,5,5 -Tetramethylbenzidine substrate were added analyzed are shown in Figure 1. We also calculated the GM and
and the mixture incubated for next 30 min. One N H2 SO4 so-
lution was then added to the wells to stop the enzyme reaction.
Finally, the absorbance was read at 450 nm by a microplate reader.
AFM1 concentrations were calculated from a standard curve. Stan-
dard urine samples were prepared by spiking blank urine with a
series of AFM1 dilutions. The detection limit was set to 100 ng/L.

Statistical analysis
Statistical analyses was performed using SPSS 17 (SPSS Inc.,
Chicago, Ill., U.S.A.) and imputed the concentrations of AFM1
below the limit of detection (LOD) by the value of LOD divided
by the square root of 2 if the geometric standard deviation was less
than 3; otherwise, we imputed the LOD divided by 2. Because the
frequency of detection of AFM1 was <60%, therefore, geometric
mean (GM) was calculated. We also calculated median, range, and
distribution of different percentiles for concentration of AFM1 .
Data were conducted on log-transformed values as the transformed
values were less skewed than the nontransformed values. Analysis
of variance (ANOVA) test was used to examine the associations
Chemical Food Safety

with the logarithmic transformation of AFM1 concentrations in Figure 1–Distribution of urinary concentration of AFM1 in 600
T: Toxicology &

urine samples between selected variables (age, gender, and place participants.

T1836 Journal of Food Science r Vol. 78, Nr. 11, 2013

Exposure of AFM1 . . .
Table 2–Observed statistically significant values for differences others 2005; Lewis and other 2005). These studies obtained the
between GM concentrations of urinary AFM1 from participants significant relationship between food intake and urinary excretion
in a Chinese population.
Variable Pa
Age
<18 compared with 18–28 0.309
<18 compared with >28 0.834
18–28 compared with >28 0.431
Place of residence
Rural compared with urban 0.761
Gender
Male compared with female 0.682
different percentiles of urinary concentrations of AFM1 that are
represented in Table 1. AFM1 was detected in 85% of partici-
pants with the range from LOD to 4900 ng/L. The detection
frequency of AFM1 in pregnant women and males were 84% and
16%, respectively. In the all participants, the median concentra-
tion of AFM1 was 55.0 ng/L, whereas the GM and 95th percentile
concentration of AFM1 were 50.0 ng/L and 729.5 ng/L, respec-
tively.
We also compared the exposure of AFM1 among the participants
on the basis of questionnaire responses such as age, residence, and
gender (Table 1). In case of age, although, the GM and median
concentration of AFM1 were found to be high in the age group of
18 to 28 y old, but on contrary, the 95th percentile concentration
of AFM1 was found to be significantly very high in the age group
of more than 28 y old. Similarly, when we compared the exposure
of AFM1 on the basis of place of residence of participants, we
found that the highest value of the 95th percentile concentration
of AFM1 was found in the urine samples of participants that were
from the rural areas as compared to that from the urban areas.
In the pregnant women, the median concentration of AFM1 was
53.0 ng/L, whereas in males, it was 70.50 ng/L. The GM and
95th percentile concentration of AFM1 for pregnant women were
50.3 ng/L and 633.5 ng/L, respectively, whereas in males, GM
and 95th percentile concentration of AFM1 were 51.5 ng/L and
1455 ng/L.
For the multiple regression models, we used ANOVA to exam-
ine the association of selected variables such as age, place of resi-
dence, and gender with the log-transformed GM concentrations
of AFM1 in urine samples. We considered all possible two-way in-
teractions between these covariates and did not find any significant
difference among these variables (Table 2).
Discussion
It is very essential to focus the attentions of government officials
and concerned departments about the problem of AFM1 exposure
in human population generally and pregnant women especially. In
order to prevent the exposure of human population to AFM1
exposure, it is very necessary to assess and evaluate the potential
risk factors that may cause the exposure of AFM1 in human.
These factors may include unsuitable farming managements and
unhygienic conditions during transportation and storage of milk
which could lead to high risk of AFM1 contamination. Several
studies have confirmed the presence of AFM1 in milk and other
dairy products (Kim and others 2000; Hussein and Brasel 2001;
Rastogi and others 2004; Sassahara and others 2005; Unusan 2006;
Zinedine and others 2007; Fallah 2010; Khlangwiset and others
2011; Fallah and others 2011; Tabari and others 2013). Different
studies have been conducted in Asia and Africa to investigate the
exposure of AFM1 (Lye and others 1995; Azziz-Baumgartner and
of aflatoxin. In the region of China, it has been estimated that
the daily ingestion of aflatoxin is between 6.5 and 2027 ng/kg/d,
whereas in Africa, the daily consumption of aflatoxin is between
3.5 and 183.7 ng/kg/d (Williams and others 2004). As human
beings generally and pregnant women especially consume milk
and various other dairy products as an essential part of food in
their daily life, they are continuously at high risk to the exposure
of AFM1 .
Coulter and colleagues (Coulter and others 1986) found that
the urinary concentration of aflatoxin in Sudanese children was
28%. Another hospital-based study was conducted on children in
the rural areas of Kenya and urinary concentration of aflatoxin
was detected in 75% of the study participants (De Vries and oth-
ers 1987). One study was conducted on Nigerian population to
estimate the urinary concentration of aflatoxins (Bean and Others
1989). Aflatoxins were detected in 53.8% of the urine samples
of study participants. Polychronaki and colleagues (Polychronaki
and others 2008) estimated the urinary concentration of AFM1
in Egyptian and Guinean children. The urine levels of AFM1 in
study participants were positively detected but significantly lower
than that reported in our study. One study was conducted to eval-
uate the exposure of AFM1 in milk powder consumed by the
infants using commercially available ELISA kit and 11% samples
were detected as positive for exposure of AFM1 (Oliveira and oth-
ers 1997). Another study was also conducted on boys and girls of
Sierra Leone to estimate the urinary concentration of aflatoxin ex-
posure (Jonsyn-Ellis 2001) and found that children were frequently
at the high risk of aflatoxin exposure.
Thereby, we estimated the possible exposure of pregnant women
to AFM1 by detecting urinary concentration of AFM1 with
ELISA, which is an effective method to directly measure the
exposure of AFM1 in human. We found that the detection fre-
quency in pregnant women and males were 84% and 16%, re-
spectively, suggesting that the general population in common and
pregnant women especially was widely exposed to AFM1 . The
GM and 95th percentile concentrations of AFM1 for females were
50.3 ng/L and 633.5 ng/L, respectively. Recently, one study has
been conducted in Egypt to estimate the urinary concentration
of AFM1 in pregnant women (Piekkola and others 2012). In this
study, it has been found that the GM of AFM1 was 19.7 ng/mL,
whereas in our study the value of GM is 50.3 ng/mL which is
significantly very high. AFM1 has shown the potential to cause
morbidity in neonates and abnormal fetal development during
pregnancy (Abdulrazzaq and others 2004; Wangikar and others
2005). The levels of AFM1 in urine observed in our study are also
significantly very high than those reported previously in differ-
ent studies for other countries (Cheng and others 1997; Jolly and
others 2006; Malir and others 2006; Romero and others 2009).
The results of our present study indicate that if the levels of AFM1
are not controlled considerably in milk and dairy products, then
this may lead to the high risk of exposure of AFM1 to pregnant
women leading birth defects. The observation of high frequencies
of AFM1 exposure in our present study clearly indicates the alarm-
ing levels of aflatoxin exposure in pregnant women of rural areas
of Zhejiang Province of China, confirming the need for relevant
studies in future.
Moreover, no significant difference was observed between GM
concentrations of urinary AFM1 from participants as evident from
Chemical Food Safety
Table 2. It has been found that no significance difference was found
T: Toxicology &
between males and pregnant women. Due to over population,
Vol. 78, Nr. 11, 2013 r Journal of Food Science T1837
 Exposure of AFM1 . . .
China adopted a “one child policy” to control the population rate.
After the implementation of “one child policy” in China, the foods
used during the fetal development period are selected very care-
fully for the good health of baby. Thus, the pregnant women
would have had little opportunity for the exposure of AFM1 -
contaminated food. However, the results of our study indicate
that no significance difference was found between males and preg-
nant women, and still the pregnant women are highly exposed to
AFM1 which indicate that many AFM1 -contaminated foods have
not been detected by relevant departments and highly selective
food cannot protect the pregnant women from the exposure of
AFM1 .
From the results of our present study, we have also come to know
that pregnant women who belonged to the rural areas of Zhejiang
Province were at the highest risk of AFM1 exposure. Therefore, it
is the responsibility of the concerned department to start awareness
campaigns especially in the rural areas of China regarding the
possible hazardous effects of AFM1 exposure in pregnant women.
Further efforts should be taken to find the source of exposure to
AFM1 for the better health of pregnant women and fetus.
Conclusion
Detection of AFM1 concentration in urine is a useful tool to es-
timate the ingestion of AFB1 as AFM1 is the most potent metabo-
lite of AFB1 . In present study, we estimated the frequency and
the levels of AFM1 exposure in the urine samples of pregnant
women in Chinese population. To conclude, our results indicate
that AFM1 was significantly detected in the urine samples of nor-
mal person and pregnant women therefore; pregnant women as
compared to normal persons are at higher risk of exposure of
AFM1 . Therefore, it is the responsibility of the government and
concerned department to control the levels of AFM1 in the milk
and other dairy products in order to prevent the carcinogenic
complications during the fetal development induced by AFM1
exposure in the pregnant women. Moreover, further studies on
AFB1 exposure should also be conducted for better estimation of
the actual levels of aflatoxin exposure that would quantitatively
correspond to the actual levels of AFM1 excretion among individ-
uals. Moreover, to protect the pregnant women from the potential
carcinogenic effects of AFM1 , there is a need to establish a legis-
lation to regulate the levels of AFM1 in milk and dairy products
and awareness campaigns must also be started in the rural areas in
People’s Republic of China.
Conflict of Interest
The authors declare that they do not have any conflict of interest
for this article.
Acknowledgments
This project was supported by Major Science and Technology
Projects and Special Priority Themes of Zhejiang Province of
China (Grants Nr 2010C13030).
References
Abdulrazzaq YM, Osman N, Yousif ZM, Trad O. 2004. Morbidity in neonates of mothers who
have ingested aflatoxins. Ann Trop Paediatr 24:145–51.
Angerer J, Ewers U, Wilhelm M. 2007. Human biomonitoring: state of the art. Int J Hyg
Environ Health 210:201–28.
Azziz-Baumgartner E, Lindblade K, Gieseker K, Rogers HS, Kieszak S, Njapau H, Schleicher
R, McCoy LF, Misore A, DeCock K, Rubin C, Slutsker L; Aflatoxin Investigative Group.
2005. Case-control study of an acute aflatoxicosis outbreak, Kenya, 2004. Environ Health
Perspect 113:1779–83.
Chemical Food Safety
Bean TA, Yourtee DM, Akande B, Ogunlewe J. 1989. Aflatoxin metabolites in the urine of
Nigerians: comparison of chro-matographic methods. J Toxicol Toxin Reviews 8:43–52.
T: Toxicology &
T1838 Journal of Food Science r Vol. 78, Nr. 11, 2013
Boudra H, Barnouin J, Dragacci S, Morgavi DP. 2007. Aflatoxin M1 and ochratoxin A in raw
bulk milk from French dairy herds. J Dairy Sci 90:3197–201.
Cheng Z, Root M, Pan W, Chen J, Campbell TC. 1997. Use of improved method for analysis of
urinary aflatoxin M1 in a survey of Mailand China and Taiwan. Cancer Epidemiol Biomarkers
Prev 6:523–9.
Coulter JBA, Hendrickse RG, Lamplugh SM, Macfarlene SBJ, Moody JB, Omer MIA, Suliman
GI, Williams TE. 1986. Aflatoxins and kwashiorkor: clinical studies in Sudanese children.
Trans Roy Soc Trop Med Hyg 80:945–51.
Creppy EE. 2002. Update of survey, regulation and toxic effects of mycotoxins in Europe. Toxicol
Lett 127:19–28.
De Vries HR, Lamplugh SM, Hendrickse RG. 1987. Aflatoxin and kwashiorkor in Kenya: a
hospital based study in a rural area of Kenya. Ann Trop Paediatr 7:249–57.
European Commission. 2001. Regulation (EC), No 466/2001 of 8 March 2001. Setting maxi-
mum levels for certain contaminants in foodstuffs. Official Journal L77:1–13.
Everley RA, Ciner FL, Zhan D, Scholl PF, Groopman JD, Croley TR. 2007. Measurement of
aflatoxin and aflatoxin metabolites in urine by liquid chromatography-tandem mass spectrom-
etry. J Anal Toxicol 31:150–6.
Fallah AA. 2010. Aflatoxin M1 contamination in dairy products marketed in Iran during winter
and summer. Food Control 11:1478–81.
Fallah AA, Rahnama M, Jafari T, Saei-Dehkordi SS. 2011. Seasonal variation of aflatoxin M1
contamination in industrial and traditional Iranian dairy products. Food Control 22:1653–6.
FDA. 2005. Sec. 527.400 whole milk, low fat milk, skim milk-aflatoxin M1 (CPG7106.10).
Washington, D.C.: FDA Compliance Policy Guides, 219.
Frisvad JC, Skouboe P, Samson RA. 2005. Taxonomic comparison of three different groups
of aflatoxin producers and a new efficient producer of aflatoxin B1, sterigmatocystin and
3-O-methylsterigmatocystin, Aspergillus rambellii sp. nov. Syst Appl Microbiol 28:442–53.
Hussein HS, Brasel JM. 2001. Toxicity, metabolism, and impact of mycotoxins on humans and
animals. Toxicology 167:101–34.
International Agency for Research on Cancer (IARC). 1993. Some naturally occurring sub-
stances: food items and constituents, heterocyclic aromatic amines and mycotoxins. In: IARC
Monographs on the Evaluation of Carcinogenic Risk to Humans, Vol. 56, Lyon: IARC
Scientific publications. p. 245–395.
Jolly P, Jiang Y, Ellis W, Awuah R, Nnedu O, Phillips T, Wang JS, Afriyie-Gyawu E, Tang L,
Person S, Williams J, Jolly C. 2006. Determinants of aflatoxin levels in Ghanaians: sociode-
mographic factors, knowledge of aflatoxin and food handling and consumption practices. Int
J Hyg Environ Health 209:345–58.
Jonsyn-Ellis FE. 2001. Seasonal variation in exposure frequency and concentration levels of
aflatoxins and ochratoxins in urine samples of boys and girls. Mycopathologia1 52:35–40.
Khlangwiset P, Shephard GS, Wu F. 2011. Aflatoxins and growth impairment: a review. Crit
Rev Toxicol 41:740–55.
Kim EK, Shon DH, Ryu D, Park JW, Hwang HJ, Kim YB. 2000. Occurrence of aflatoxin M1
in Korean dairy products determined by ELISA and HPLC. Food Addit Contam 17:59–64.
Lewis L, Onsongo M, Njapau H, Schurz-Rogers H, Luber G, Kieszak S, Nyamongo J, Backer
L, Dahiye AM, Misore A, DeCock K, Rubin C; Kenya Aflatoxicosis Investigation Group.
2005. Aflatoxin contamination of commercial maize products during an outbreak of acute
aflatoxicosis in eastern and central Kenya. Environ Health Perspect 113:1763–7.
Lye MS, Ghazali AA, Mohan J, Alwin N, Nair RC. 1995. An outbreak of acute hepatic
encephalopathy due to severe aflatoxicosis in Malaysia. Am J Trop Med Hyg 53:68–72.
Malir F, Ostry V, Grosse Y, Roubal T, Skarkova J, Ruprich J. 2006. Monitoring the mycotoxins
in food and their biomarkers in the Czech Republic. Mol Nutr Food Res 50:513–8.
Neal GE, Eaton DL, Judah DJ, Verma A. 1998. Metabolism and toxicity of aflatoxins M1 and
B1 in human-derived in vitro system. Toxicol Appl Pharmacol 151:152–8.
Oliveira CA, Germano PM, Bird C, Pinto CA. 1997. Immunochemical assessment of aflatoxin
M1 in milk powder consumed by infants in São Paulo, Brazil. Food Addit Contam 14:7–10.
Piekkola S, Turner PC, Abdel-Hamid M, Ezzat S, El-Daly M, El-Kafrawy S, Savchenko E,
Poussa T, Woo JC, Mykkänen H, El-Nezami H. 2012. Characterisation of aflatoxin and
deoxynivalenol exposure among pregnant Egyptian women. Food Addit Contam Part A
Chem Anal Control Expo Risk Assess 29:962–71.
Polychronaki N, Wild CP, Mykkänen H, Amra H, Abdel-Wahhab M, Sylla A, Diallo M, El-
Nezami H, Turner PC. 2008. Urinary biomarkers of aflatoxin exposure in young children
from Egypt and Guinea. Food Chem Toxicol 46:519–26.
Rahimi E, Bonyadian M, Rafei M, Kazemeini HR. 2010. Occurrence of aflatoxin M1 in raw
milk of five dairy species in Ahvaz, Iran. Food Chem Toxicol 48:129–31.
Rastogi S, Dwivedi PD, Khanna, SK, Das M. 2004. Detection of Aflatoxin M1 contamination
in milk and infant milk products from Indian markets by ELISA. Food Control 15:287–90.
Romero AC, Ferreira TRB, Dias CTS, Calori-Domingues MA, Gloria EM 2009. Occurrence
of AFM1in urine samples of a Brazilian population and association with food consumption.
Food Control 21:554–8.
Sassahara M, Pontes Netto D, Yanaka EK. 2005. Aflatoxin occurrence in foodstuff supplied to
dairy cattle and aflatoxin M1in raw milk in the North of Paraná state. Food Chem Toxicol
43:981–4.
Tabari M, Tabari K, Tabari O. 2013. Aflatoxin M1 determination in yoghurt produced in Guilan
province of Iran using immunoaffinity column and high-performance liquid chromatography.
Toxicol Ind Health 29:72–6.
Unusan N. 2006. Occurence of aflatoxin M1 in UHT milk in Turkey. Food Chem Toxicol
44:1897–1900.
US FDA. 1996. CPG Sec. 527.400 whole milk, low fat milk, skim milk-aflatoxin M1. FDA
Compliance Policy Guides. Washington, D.C.: FDA.
Wangikar PB, Dwivedi P, Sinha N, Sharma AK, Telang AG. 2005. Effects of aflatoxin B1 on
embryo fetal development in rabbits. Food Chem Toxicol 43:607–15.
Williams JH, Phillips TD, Jolly PE, Stiles JK, Jolly CM, Aggarwal D. 2004. Human aflatoxicosis
in developing countries: a review of toxicology, exposure, potential health consequences, and
interventions. Am J Clin Nutr 80:1106–22.
Zhu JQ, Zhang LS, Hu X, Xiao Y, Chen JS, Xu YC, Fremy J, Chu FS. 1987. Correlation
of dietary aflatoxin B1 levels with excretion of aflatoxin M1 in human urine. Cancer Res
47:1848–52.
Zinedine A, González-Osnaya L, Soriano JM, Moltó JC, Idrissi L, Mañes J. 2007. Presence of
aflatoxin M1 in pasteurized milk from Morocco. Int J Food Microbiol 114:25–9.