Dairy consumers' knowledge, attitudes, and practices towards zoonotic bovine tuberculosis in a country without veterinary and public health interventions: A cross-sectional study in Bhutan

Bovine tuberculosis (bTB) is a globally neglected zoonotic disease. In several low- and middle-income countries (LMIC), limited bTB surveillance and technologies to minimise milk-borne zoonoses put dairy consumers at high risk of bTB infection. Surprisingly, LMIC consumers are seldom investigated, which represents a significant knowledge gap that undermines existing efforts to mitigate zoonotic tuberculosis. We conducted a cross-sectional study in Bhutan where bTB control measures are lacking and raw dairy is widely consumed to assess dairy consumers' awareness and their knowledge, attitudes, and practices (KAP) regarding bTB. We enrolled 347 participants at the eight milk outlets operating in the capital city to determine the level of awareness about bTB among this group and characterise their KAP towards bTB. Only 17.3 % of the participants had heard of bTB. Majority (90.1 %) of them knew there is treatment of tuberculosis (TB) in Bhutan and TB is curable (72.5 %). However, 70.1 % had misconception that infected people cannot appear healthy, and only 12 % knew bTB is zoonotic. Only 26 % and 24 % perceived milk and dairy products as high risk respectively compared to 56.5 % for meat and 85.8 % for consuming diseased animals. Over 80 % of participants reported consumption of milk and dairy products daily or weekly, 25 % consuming primarily raw or insufficiently boiled milk. Only a few consumers knew of bTB and its zoonotic potential (n = 42; 12 %, Confidence Interval 95 %: 8.9 %-16 %). Regarding health practices, 60 % had annual check-ups, 15.3 % had TB testing, 5.2 % had TB treatment, and vaccination status was uncertain. Unsupervised classification of the data using Generalised Low-Ranking Models revealed that most variability was explained by three demographic factors, a few attitudes towards bTB infection risk, and milk and dairy product consumption frequency. Our findings reveal a widespread lack of awareness and low-risk perception regarding milk-borne bTB among consumers. These results are consistent with findings in other LMICs and highlight that dairy consumers likely represent a blind spot in current efforts to mitigate the adverse effects of bTB in these settings.