© International Epidemiological Association 1999
International Journal of Epidemiology 1999;28:179–188
Printed in Great Britain
REVIEW ARTICLE
Worldwide trends in DDT levels
in human breast milk
Daniel Smith
Background Concern over human breast milk contamination with the pesticide DDT (1,1,1trichloro-2,2-bis(chlorodiphenyl)ethane) has prompted numerous studies around
the world during the last five decades. This article examines trends in reported
DDT levels, and the apparent effect of restrictions on DDT use.
Methods
More than 130 published values for DDT in human milk since 1951 were
compiled, and trend lines were fit for regions of the world.
Results
Population means have declined in much of the world, from 5000–10 000 µg
DDT/kg milk fat to around 1000 today in many areas. Although different regions
have different means, the decline seen in various countries corresponds to their
restricting DDT use.
Discussion
DDT concentrations in human milk have declined in most areas of the world,
consistent with restrictions on its use. Nevertheless, levels can be high in areas
still using DDT, even higher than the World Health Organization’s recommended
limit for infants. These results indicate that population averages can be reduced
by a predictable amount as DDT use is restricted.
Keywords
DDT, DDE, human milk, breastfeeding, trends
Accepted
31 July 1998
From its first use in the 1940s for controlling wartime typhus
and agricultural pests, the pesticide DDT (1,1,1-trichloro-2,2bis(chlorodiphenyl)ethane) enjoyed worldwide popularity.1,2
Its deleterious effects on wildlife primarily led to its eventual
ban on routine use in the US and many other countries in the
1970s.1 Nevertheless, concerns exist today over its persistence
in the environment, its bioaccumulation, and its potential for
causing cancer2,3 and reproductive problems.4 Despite its ban
throughout much of North America and Europe, and the availability of alternatives, DDT continues to be used, mainly for
controlling malaria-carrying mosquitoes.5 Total global use may
be as great in the 1990s as it was in the 1970s.6
Human breast milk is a convenient medium for monitoring
levels of lipophilic organochlorine compounds such as DDT, first
because of obvious concern over exposure to the suckling infant,
but also because it is easier to obtain than, for example, adipose
tissue.7 Several earlier reviews of DDT levels in breast milk have
been published e.g. the extensive compilations by Jensen.8,9
The purpose of this note is to update these reviews, examine
population trends in DDT breast milk levels around the world,
Environmental Health Investigations Branch, California Department of Health
Services, 1515 Clay Street, Suite 1700, Oakland, CA 94612-1404, USA.
and estimate changes that can be ascribed to banning or restricting DDT.
Methods
Published reports on DDT levels in breast milk from around the
world were obtained for a regional trend analysis. Many early
citations (from the 1970s and before) were gleaned from the
reviews by Jensen8,9 and Polishuk et al.10 A computerized literature search was conducted to identify more recent papers. Some
of these papers were inaccessible, such as those from Eastern
European journals. The studies were restricted to those that
purported to reflect the ordinary population in a locale, not specialized groups with extreme exposures (such as a local source
of contamination). While we cannot claim to have produced an
exhaustive listing, we believe we have summarized a sufficient
number of papers, especially spanning the years DDT has been
banned or restricted in many countries, to provide an accurate
picture of trends.
As expected when summarizing the literature from several
continents over five decades, there is considerable variation in
how authors report their results. First, we converted all reported
concentrations into consistent units: µg/kg total DDT compounds
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INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
in milk fat (equivalent to parts per billion). Most authors report
results in terms of total DDT compounds. This is the sum
of isomers of DDT and its metabolites DDE (1,1-dichloro-2,
2-bis(p-chlorophenyl)ethylene, typically the predominant DDT
compound in human tissues), and DDD (1,1-dichloro-2,2-bis(pchlorophenyl)ethane).11 When results for specific metabolites
were given, we summed these to derive a total. Some authors
reported concentrations only in whole milk, but also provided the
average per cent of milk fat for their series; these we used to estimate the fat normalized concentration. When the per cent fat was
not reported, we followed Rogan et al.,12 and took it to be 2.5%.
Like many biological quantities, these concentrations are not
necessarily normally distributed. Hence medians or geometric
means might ordinarily be preferred as measures of central
tendency, while arithmetic means may overestimate the
median.13 However, most papers reported only arithmetic mean
values. As the focus of this analysis is on differences and trends,
we have maintained the use arithmetic means where possible
for consistency across studies and regions. Occasionally, when
concentrations were reported in categories, we used midpoints
of the category. If results from a panel of women were reported
over several months of lactation, we took the earliest reported
post-partum values to mitigate the decline in levels during lactation.7 For the dates the samples represent, we used the year of
sampling when given, or midpoint if the samples spanned >2
years. If no date could be inferred from the paper, we used the
year of the publication. Information on when DDT was restricted
or banned in different countries was obtained from various
sources, in most cases the articles themselves.
Trends in the data were assessed using a non-parametric
smoothing cubic spline.14 Regression slopes were fit by weighted
least squares, with the dependent variable the natural log of the
reported mean concentration, and the weight proportional to
the number of samples making up the reported mean. A few
studies that did not report the number of samples were excluded
from the weighted regression. The analyses were performed
using SAS JMP.14
Results
The studies used for this analysis appear in Table 1, grouped by
location and sorted by year. The data are plotted in Figure 1,
using a log scale for the ordinate. All reported levels before 1970
(starting with the first report in the US in 195015) are .2000
µg/kg. Many are several times that amount. Non-parametric
smoothing lines have been fit separately to the points from five of
the regions in Table 1. The plots reveal considerable differences
in means, but all show a downward trend after about 1970.
A closer view of the 28 cited values from the US and Canada
(Figure 2) indicates an average of about 4000–5000 µg/kg
through the earlier years, then a steady decline by 1975. The
smoothed line during this decline is approximately straight.
For the 13 studies from 1975 and later, the weighted least
squares regression line is: ln(DDT) = 8.497 – 0.179(Year – 1975),
with R2 = 0.80. The 95% confidence interval (CI) for this slope
is –0.240 to –0.119 lnDDT/yr. This translates into an 11% to
21% per year reduction in average DDT in breast milk during
this time (1 – exp{slope}). The decline during this period coincides with the DDT restrictions in place in the US and Canada
by 1972.16,17
A similar analysis of the 38 averages reported 1975 and later
from Western European countries (Figure 1) gives an R2 of
0.73, and a slope of –0.114 lnDDT/yr (95% CI : –0.138, –0.090)
corresponding to a 9% to 13% reduction per year. The flatter
slope and lower R2 compared to the US and Canada may be
attributable to the greater variation among European nations as
to when DDT use was restricted during this period (see below).
In order to examine the effect of DDT restrictions on breast
milk levels, it is necessary to account for the difference across
countries in the year DDT was restricted. Figure 3 plots reported
means from the studies in Table 1 for each country by the number of years since that country restricted DDT use. Information
on country-specific dates of DDT restriction was difficult to obtain.
The countries and dates used in Figure 3 (and their sources)
were: Canada, 1969;17 Sweden, 1970;11 Norway, 1970;18
Australia, 1971;19 Finland, 1971;20 Poland, 1971;21 US,
1972;16 Italy, 1973;22 Germany, 1974;16 Portugal, 1974;23
Czechoslovakia, 1977;24 Spain, 1977;25 Hong Kong, 1983;26
and Mexico, 1990.27 Data from other countries in Table 1 are
omitted. Reports from countries where DDT was in use at the
time of the report (e.g. US before 1972) are plotted at time zero.
A weighted regression for the 94 points in Figure 3 gives
ln(DDT) = 8.626 – 0.135 (years since restriction), with R2 = 0.71
(95% CI : –0.164, –0.123 lnDDT/yrs since restriction, or 11% to
14% decline per year.
Discussion
This analysis involves some uncertainty in trying to summarize
these disparate reports. There undoubtedly exist some differences between studies in characteristics of the women, e.g. age,
parity, and duration of lactation, that can influence the DDT
concentrations.7 Some studies may have individuals with
some unusually high exposures, e.g. occupational, that bring
the average up. Then too, there is some uncertainty in the dates
used in the analysis. Dates of sampling were not provided in
some citations, making it necessary to use the date of the publication, which might be several years later. Further, countries’
bans of DDT have typically been phased in over several years,
starting with restricting DDT use in agriculture, while still
allowing it for special purposes. For example, despite Mexico’s
restricting DDT use to anti-malaria campaigns since 1990,
Mexico still uses more tons per year than other Latin American
countries.28 Even after a complete ban, DDT can still find its way
into the food chain in small quantities through its persistence in
the soil for years,29,30 or through imported produce.31,32 These
residual sources of DDT exposure would be expected to ‘flatten’
the estimated slope of the decline one might see if exposure
could be stopped suddenly and completely. In spite of these
potential variations between studies and across regions, it is
perhaps surprising that these simple models fit the data as well
as they do.
Another way to look at this decline is to calculate a half-life,
according to the formula half-life = ln2 ÷ slope of the regression
on log concentration.33 The result can be thought of as the
‘population-level’ half-life of DDT in breast milk, or the number
of years for a population’s average to decline to half its value
following DDT restriction. This is distinct from the half-life in an
individual, as these population studies are conducted on various
cross-sectional samples of women, and hence provide the
DDT TRENDS IN HUMAN MILK
181
Table 1 Reported concentrations of total DDT compounds in breast milk, µg/kg in milk fat
Year
Total DDT (µg/kg in milk fat)a
No. of samples
District of Columbia
1950
5200
32
Laug et al.15
Chicago
1961
5300
4
Quinby et al.43
Washington State
1961
3300
5
Quinby et al.43
California
1962
7400b
7
West44
US, 1 City
1967
2800
5
Curley and Kimbrough45
Canada
1968
5500
147
Ritcey et al.46
Canada
1970
2960
90
Mes et al.47
Pennsylvania
1970
2400
53
Kroger48
US, 7 Cities
1971
6800
101
Wilson et al.49
Arizona
1973
11 900
6
Hagyard et al.50
St Louis
1973
880
51
Jonsson et al.51
Mississippi
1974
2360
6
Barnett et al.52
New Brunswick
1974
3570
6
Musial et al.53
Nova Scotia
1974
2410
9
Musial et al.53
US, Southern
1974
13 760
57
Strassman and Kutz54
Pennsylvania
1975
4560
42
Bradt and Herrenkohl55
US, Northeast
1976
2300
149
Savage et al.56
US, Southwest
1976
6000
388
Savage et al.56
Canada
1978
1087
154
Dillon et al.57
Canada
1978
1870
100
Mes and Davies58
N Carolina
1980
2500b
734
Rogan et al.12
Canada
1982
990
210
Mes et al.59
Canada
1983
1200
21
Mes et al.37
Ontario
1984
1200
16
Mes et al.37
Arkansas
1986
990
942
Mattison et al.60
Canada
1986
385
412
Mes et al.47
New York
1989
550
8
Shechter et al.61
Quebec
1989
340
536
Dewailly et al.62
Great Britain
1963
5040
19
Egan et al.63
Belgium
1969
4800
20
Siyali64
Norway
1970
3270
42
Brevik and Bjerk65
Portugal
1972
7776
10
Graca et al.23
Sweden
1972
2930
75
Noren et al.66
Finland
1974
1570
49
Vuori et al.20
Finland
1974
2320
–
Wickstrom et al.67
Norway
1975
3270
50
Bakken and Seip68
Italy
1976
3840
61
Dommarco et al.69
Norway
1976
1758
44
Brevik and Bjerk65
Sweden
1976
1840
153
Noren et al.66
Netherlands
1979
1230c
15
Eckenhausen et al.70
Norway
1979
1404
133
Skaare71
Spain
1979
7200
45
Hernandez et al.25
Sweden
1979
1500
41
Hofvander et al.72
Germany
1980
2040
836
Somogyi and Beck73
Germany
1980
1840
1873
Somogyi and Beck73
Great Britain
1980
1710
102
Collins et al.74
Sweden
1980
1240
199
Noren et al.66
Spain
1981
10 240
20
Baluja et al.75
Sweden
1981
1060d
46
Vaz et al.76
Finland
1982
890
50
Wickstrom et al.67
Norway
1982
1000
14
Skaare and Polder18
Location
Reference
US/Canada
Western Europe
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INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
Table 1 Continued
Location
Year
Total DDT (µg/kg in milk fat)a
No. of samples
Reference
Norway
1982
910
34
Skaare et al.77
Sweden
1983
1220
–
Mes et al.59
Germany
1984
978
144
Furst et al.78
Germany
1984
1380
–
Mes et al.59
Italy
1984
1880
65
Dommarco et al.69
Finland
1985
570
165
Mussalo-Rauhamaa et al.79
Germany
1985
922
220
Furst et al.78
Italy
1985
2200
93
Di Muccio et al.80
Sweden
1985
561
102
Noren et al.66
Germany
1986
771
157
Furst et al.78
Germany
1987
806
144
Furst et al.78
Germany
1988
675
196
Furst et al.78
Germany
1989
703
145
Furst et al.78
Germany
1989
800
167
Shechter et al.61
Germany
1990
561
286
Furst et al.78
Sweden
1990
320d
13
Vaz et al.76
Sweden
1990
421
40
Noren et al.66
France
1991
2283
20
Bordet et al.81
Germany
1991
531
113
Furst et al.78
Norway
1991
338
28
Johansen et al.82
Spain
1991
660
51
Hernandez et al.25
Sweden
1991
296
40
Noren et al.66
Wales
1991
490
115
Duarte-Davidson et al.38
Sweden
1992
283
20
Noren et al.66
Poland
1970
11 500
32
Sikorski et al.21
Yugoslavia (Slovenia)
1973
3850
14
Krauthacker et al.83
Czechoslovakia
1974
7300
–
Prachar et al.24
Yugoslavia (Croatia)
1976
1790
27
Krauthacker et al.83
Yugoslavia (Croatia)
1978
1360c
34
Krauthacker et al.83
Poland
1980
6800
106
Sikorski et al.21
Poland
1987
4600
54
Sikorski et al.21
Yugoslavia, island
1987
1080d
33
Krauthacker84
Turkey
1988
2800
51
Üstünbas et al.85
Yugoslavia, rural
1989
550d
20
Krauthacker84
Czechoslovakia
1993
1845
26
Prachar et al.24
Poland
1996
1072
108
Czaja et al.86
Turkey
1996
2357
104
Çok et al.87
Israel
1975
5774
29
Polishuk et al.10
Hong Kong
1976
18 870
21
Ip and Phillips26
Japan
1977
1938
30
Nakayama and Aoki88
India
1980
4800
25
Siddiqui et al.89
India
1982
6060
50
Jani et al.90
India
1984
7900
6
Ramakrishnan et al.91
India
1984
1890
6
Ramakrishnan et al.91
India
1984
4750
6
Ramakrishnan et al.91
India
1984
8000
6
Ramakrishnan et al.91
Israel
1984
2720
100
Weisenberg et al.92
Hong Kong
1985
13 800
25
Ip and Phillips26
India
1988
1200
25
Tanabe et al.93
India
1989
3740
20
Nair and Pillai94
Tajikistan
1989
2600b
43
Lederman95
Eastern Europe
Asia/Middle East
DDT TRENDS IN HUMAN MILK
183
Table 1 Continued
Year
Total DDT (µg/kg in milk fat)a
No. of samples
Reference
Thailand
1989
4340
3
Shechter et al.61
Turkmenistan
1989
1300b
24
Lederman95
Vietnam
1989
11 400
12
Shechter et al.61
Jordan
1990
6420
15
Alawi et al.96
Kazakstan
1996
2260
76
Hooper et al.97
Guatemala City
1971
19 200
15
de Campos and Olszyna-Marzys98
Guatemala, rural
1971
76 800
46
de Campos and Olszyna-Marzys98
El Salvador
1974
32 640
40
de Campos and Olszyna-Marzys98
Guatemala
1974
15 120
290
Winter et al.99
Mexico
1976
13 180
15
Albert et al.100
Brazil
1984
1000
30
Matuo et al.101
Brazil, rural
1989
770
21
Sant’Ana et al.102
Brazil, urban
1989
1800
21
Sant’Ana et al.102
Mexico, rural
1989
6250b
229
Gladen and Rogan103
Mexico
1995
6440
43
Waliszewski et al.41
Mexico City
1995
594
–
Lopez-Carrillo et al.28
Australia, rural
1970
4630
36
Newton and Greene104
Australia, urban
1970
3730
26
Newton and Greene104
Australia, rural
1971
16 900
20
Miller and Fox40
Australia, urban
1971
2660
23
Stacey and Thomas105
Australia, urban
1971
8600
20
Miller and Fox40
Australia
1972
2560
45
Siyali64
Australia, rural
1979
1281
95
Stacey et al.19
Australia, urban
1979
1277
45
Stacey et al.19
Australia
1980
1680
14
Stacey and Tatum106
Kenya
1986
4800
8
Kanja et al.107
South Africa
1987
690
88
Bouwman et al.108
South Africa
1987
15 830
129
Bouwman et al.108
New Zealand, north
1988
1100
21
Bates et al.109
New Zealand, south
1988
3000
17
Bates et al.109
Papua New Guinea
1990
890
41
Spicer and Kereu110
Zimbabwe
1990
6000
40
Chikuni et al.111
Kenya
1991
473
216
Kinyamu et al.112
Location
Latin America
Other regions
a All values are arithmetic means unless otherwise indicated.
b Category midpoint.
c Geometric mean.
d Median.
prevalence of milk DDT in the population of women lactating
at a particular time. Applying this formula to the confidence
limits of the slope from Figure 3 gives an estimated population
half-life of 4.2 to 5.6 years. This compares to a half-life of
5.8 years estimated for DDE in similar cross-sectional samples
of cow’s milk from Canadian dairy herds between 1970 and
1986.34
The most direct concern with toxic compounds in breast milk,
of course, relates to potential exposure to the infant. While breastfeeding is usually considered to have overwhelming advantages,35
there has been concern that breastfed infants in some areas could
be exceeding recommended limits of various organochlorine compounds.36 The current World Health Organization’s Acceptable
Daily Intake (ADI) for DDT, established in 1984,2 is 20 µg/kg-day.
Making some assumptions about an infant’s intake and body
mass, this ADI can be translated into an allowable breast milk
concentration, as follows:
ADI µg/kg-day
kg milk/day × fat/milk × child/kg
concentration of DDT
= µg/kg milk fat
Values for these quantities used by others include: for milk
intake, 0.8 kg/day37 to 0.85 kg/day;38 body mass, 5 kg,25
6.5 kg,17 and 7 kg;38 and proportion of fat in milk 0.025.12
Given these constants, the 20 µg/kg-day ADI translates into
approximately 5000–6000 µg/kg allowable DDT in breast
milk fat. Population average levels can clearly exceed this in
regions where DDT is actively used (Figure 3), a point made by
184
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
Figure 1 Mean total DDT compounds in breast milk reported by region and year of study, with spline fit
Figure 2 Mean total DDT compounds in breast milk by year reported in studies from the US and Canada,
with spline fit
others.39–41 And of course, even where the population average
falls below the ADI, individuals in the upper tail of the distribution can exceed it.
Numerous organohalogen compounds (PCBs, dioxins, pesticides) have been studied in human milk, fat, and blood. Where
concentrations in breast milk approach or exceed levels of concern, continued monitoring of milk has been recommended to
examine trends and verify pollution controls.36 Where DDT is
still in use, we can perhaps use population-derived estimates of
trends to make predictions about future concentrations. In
DDT TRENDS IN HUMAN MILK
185
Figure 3 Mean total DDT compounds in breast milk reported in various countries by year since country
banned or restricted DDT use
Mexico, for example, which plans to reduce DDT usage by 80%
over the next 5 years, and eliminate it by 2007,42 Waliszewski
et al.41 reported mean breast milk concentrations of 11 000 µg/kg
in women from the swampy area of Veracruz, roughly double
the ADI. They suggest continued monitoring in this area. Our
results would predict that five or so years after the ban is complete, the Veracruz average should be at or below the ADI.
DDT is but one of many organohalogen compounds that
are biologically persistent, possibly carcinogenic, possibly hormonally active.3 As these compounds are restricted, banned, or
reduced around the world, the evidence from DDT can help us
anticipate the results. It would appear bans of the type placed
on DDT can successfully reduce the population burdens of
these compounds, and produce a noticeable decline albeit after
several years.
8 Jensen AA. Chemical contaminants in human milk. Residue Rev
1983;89:1–128.
9 Jensen AA. Levels and trends of environmental chemicals in human
milk. In: Jensen AA, Slorach SA (eds). Chemical Contaminants in
Human Milk. Boca Raton: CRC Press, 1991, pp.45–207.
10 Polishuk ZW, Ron M, Wassermann M, Cucos S, Wassermann D,
Lemesch C. Organochlorine compounds in human blood plasma and
milk. Pest Monit J 1977;10:121–29.
11 WHO. DDT and its derivatives. In: Environmental Health Criteria 9.
Geneva: World Health Organization, 1979, pp.11–15.
12 Rogan WJ, Gladen BC, McKinney JD et al. Polychlorinated biphenyls
(PCBs) and dichlorodiphenyl dichloroethene (DDE) in human milk:
effects on growth, morbidity, and duration of lactation. Am J Public
Health 1987;77:1294–97.
13 Armitage P, Berry G. Statistical Methods in Medical Research. 2nd Edn.
Oxford: Blackwell Scientific Publications, 1987, pp.358–64.
14 SAS Institute. JMP Statistics and Graphics Guide, Version 3. Cary, NC: SAS
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