Brucellosis in dairy herds: Farm characteristics and practices in relation to likely adoption of three potential private– public partnership (PPP) vaccination control strategies in West and Central Africa

Brucellosis is regarded as one of the highest burden zoonotic diseases to persist in many regions globally. While sustained vaccination against B . abortus in an endemic setting can markedly reduce the prevalence of large ruminant and human brucellosis and benefit local livelihoods, the implementation of effective and sustainable con trol programmes has often failed in the worst affected areas. In a cross- sectional study of 728 peri- urban dairy farmers in nine areas of six West and Central African countries, levels of commercialization and farm characteristics were examined alongside B. abortus seroprevalence estimates to hypothesize the most appropriate

. In humans, brucellosis causes flu-like symptoms and chronic debilitating illness. It often manifests as recurrent bouts of fever, which can be misdiagnosed as drug-resistant malaria and lead to underestimation of its incidence (Chabasse et al., 1983;Dean et al., 2012). The main routes for human infection are consumption of contaminated dairy products and contact with infected ruminants (Charters, 1980). In livestock, brucellosis decreases productivity by causing abortions, reducing fertility and decreasing milk yield (Corbel, 1988).
It is widely accepted that sustained vaccination of animals in an endemic setting can markedly reduce the prevalence of ruminant and human brucellosis and benefit local livelihoods. The vaccine endorsed by the World Organisation for Animal Health (OIE) for the prevention of brucellosis in cattle is B. abortus S19, which remains the reference vaccine with which any other vaccines must be compared (OIE, 2018). It is used as a live vaccine and is normally given to female calves aged between 3 and 6 months as a single subcutaneous dose. A reduced dose can be administered subcutaneously to adult cattle but is often avoided as animals can develop persistent antibody titres and may abort following vaccination and excrete the vaccine strain in the milk posing a human health risk. Alternatively, the vaccine can be administered to cattle of any age as either one or two doses, given by the conjunctival route, which induces immunity without a persistent antibody response and reduces the risks of abortion and excretion in the milk when vaccinating adult cattle (OIE, 2018).
There is historical serological evidence of widespread brucellosis infection in cattle in the West and Central African region (Akakpo & Ndour, 2013), but there is limited availability or use of Science and Technology Laboratory (DSTL), Department for International Development (DFID), Economic and Social Research Council (ESRC), Medical Research Council (MRC) and Natural Environment Research Council (NERC). This project represents one of 11 programmes funded in total and was funded under the title, 'Establishment of a multi-sectoral strategy for the control of brucellosis in the main peri-urban dairy production zones of West and Central Africa'. The funders had no input in the design, collection, analysis and interpretation of data, the writing of the report or the decision to submit the article for publication. model for brucellosis vaccination delivery in each country. Demographic and economic data were collated and used to describe the farming systems currently in place.
Furthermore, these data were utilized in a likelihood assessment to generate a quantitative score to hypothesize which of three private-public partnership (PPP) vaccine delivery models, that is 1) transformative, 2) transactional or 3) collaborative, would be most appropriate in each setting. The study sites had substantial differences in their levels of dairy commercialization and the farming practices employed; the heterogeneity across the study sites was evident in the conclusions of which models would be appropriate for vaccination delivery. While Lomé (Togo) had a strong indication for a transformative PPP model, Burkina Faso had strong indication for the collaborative PPP model. Of the remaining study sites, the scores were less dominant for any one model with Cameroon and Ivory Coast sites only just scoring highest on the transformative model and Senegal and Mali sites only just scoring highest on the collaborative model. Interestingly, none of the countries included in the study scored highest on the transactional model which currently is the most commonplace delivery model in the majority of sub-Saharan African countries.

K E Y W O R D S
brucellosis control, cattle, dairy herds, private-public partnership, vaccination, West and Central Africa brucellosis vaccination (Craighead et al., 2018). Extensive human population growth and high rates of urbanization mean this region is globally one of the most rapidly evolving (Craighead et al., 2018).
This changes food consumption practices, and therefore, farming systems which are becoming increasingly intensive (Ducrotoy et al., 2015). In a recent study in the region, herds still practising transhumance were found to be at lower risk of being brucellosis seropositive than those that were sedentary; it was suggested that a decrease in transhumant herds is occurring in evolving peri-urban settings (Musallam et al., 2019). It is important to consider the nature and speed at which these farming systems are evolving in order to evaluate the impact on the epidemiology of disease. This in turn will facilitate a better understanding of what control strategies are warranted, feasible and sustainable. As challenges and demands on dairy production evolve, farmers' practices and behaviours will alter accordingly. Understanding and incorporating these changes into planning is paramount for efficient and effective policy development which will be fit for purpose.
Health service utilization is a well-studied area. Since its first inception some sixty years ago, multiple theories, models and frameworks have been developed and expanded to investigate factors that affect personal and societal use of particular services for both preventative and curative medicine in the human and veterinary service (Batista Ferrer et al., 2015;De Vries et al., 1988;Hardaker & Lien, 2010;Hopman et al., 2011;Looijmans-van den Akker et al., 2009;Rat-Aspert & Fourichon, 2010;Sok et al., 2014Sok et al., , 2016Velde et al., 2018). Commonly used theories in healthcare utilization research are the theory of planned behaviour which is an expansion of the reasoned action approach (Ajzen & Fishbein, 1980) and the health belief model (Rosenstock, 1974). There has been extensive work developing social psychological decision models within these theories, but one major criticism is that they do not fully account for the broader impacts of extrinsic factors such as political, economic or environmental or inter-and intrapersonal influences (Velde et al., 2018). In their theoretical framework, Andersen and Newman (1973) addressed this problem to a degree; they identified three important areas to consider when assessing health service utilization these being (1) characteristics of the health services delivery system, (2) changes in medical technology and social norms, and (3) individual determinants of utilization. To assess the third area, they developed a behavioural model under the assumption that a sequence of conditions contributes to the type and volume of health service a person uses. In their model, Andersen and Newman identified factors in three categories (predisposing factors, enabling factors and need level) which they deemed influential on people's utilization of human health services in America. Although not extensively used in veterinary healthcare research, we propose that this framework is appropriate to investigate vaccine uptake by cattle farmers.
Many sub-Saharan African countries were placed under structural adjustment programmes (SAPs) in the 1980s as a pre-condition of the International Monetary Fund and the World Bank providing debt relief and loans. These programmes involved adjustment of many government services and legislation to enhance economic performance by allowing unbridled market forces to drive the economy (Amoako-Tuffour et al., 2018;Hollinger & Staatz, 2015).
Combinations of different policies were adopted such as privatization, fiscal austerity, free trade and deregulation. These policies and changes were indeed successful in some circumstances where often government provision of livestock services came under increasing criticism for high costs and limited effectiveness. However, it was often only the high potential areas and market-orientated systems such as intensive dairy farming that were adequately served by these markets while marginalized areas and poorer livestock keepers continued to lack adequate access to animal health services (David, 2003;Ilukor et al., 2015;Magnani et al., 2019). In many sub-Saharan African countries, these negative effects coupled with high burdens of endemic diseases means that the resources to carry out effective brucellosis control and surveillance are frequently lacking.
When disease control programmes are entirely managed and funded by government or NGOs, they often become unsustainable when competing demands on resources arise and may suffer from inadequate execution or abruptly come to a halt when funds end (Angba et al., 1987;Camus, 1995;Thys E. et al., 2005). Through the effects of SAPs and in response to limited resources of government bodies, privatization and decentralization of animal health services have occurred to varying degrees in many countries. While in some circumstances this has led to more consistent and accessible services there are many examples where certain livestock keepers are disadvantaged as they experience high transaction costs to access such services and less profitable regions or health issues are neglected in a profit-driven private sector (Pica-Ciamarra, 2005).
Looking at inadequacies of past programmes and considering the widespread effects of urbanization on demand and consequently production practices as well as the penetration of Internet technologies and commercial suppliers, the need for design and implementation of new delivery models for brucellosis control in livestock is becoming evident. There are many examples of different models for service delivery in both agricultural and livestock systems globally where the need to align public and private partnerships has been recognized as a corner stone for effective and sustainable delivery of services and goods (Holden, 1999). Indeed, the promotion of publicprivate partnerships (PPP) by organizations such as the Food and Agriculture Organization of the United Nations (FAO) and OIE has been at the forefront of both animal health provision and agricultural development globally (OIE, 2019). In relation to veterinary services a PPP is defined as 'a collaborative approach in which the public and private sector share resources, responsibilities and risks to achieve common objectives and mutual benefits in the field of veterinary services in a sustainable manner' (Thevasegayam et al., 2017).
Recently, Galière et al., (2019) defined a typology for PPPs in the veterinary field; they proposed three types of PPP by performing multiple correspondence analysis (MCA) on data gathered from PPP programmes running globally. They found two factors to be highly significant in defining the types, namely (1) the category of the main private partner collaborating with the public sector and (2) the type of interaction between the partners. They define transactional PPPs as those often seen as the traditional understanding of PPPs which are initiated and funded by the public sector who contract out certain service delivery to private veterinarians under a client/ private provider contract agreement. Collaborative PPPs were defined as partnerships between consortia or producer associations and the public veterinary services and driven by trade interests. The last type was the transformative PPP which represents joint programmes initiated and funded by private companies, often large aid donors or NGOs, to establish sustainable capability to deliver otherwise unattainable major programmes. Examples of transactional PPPs are found in many sub-Saharan African countries such as in Mali where for more than 20 years the veterinary services have delegated certain service provision such as peste des petits ruminants and contagious bovine pleuropneumonia vaccination through the Animal Health Mandate to private veterinarians. This has resulted in improved vaccine coverage, better animal health and therefore food security (OIE, 2019). For the last 10 years, a transformative PPP has been in place between the Ethiopian Ministry of Agriculture and its private partner Ethiochicken. This agreement has increased chicken production in Ethiopia; the private partner produces quality chicks, The aim of this study was to describe the commercialization and farming practices in peri-urban dairy cattle farms in six West and Central African countries where cattle brucellosis is endemic and to evaluate the appropriateness of brucellosis vaccination programmes through the three different delivery models outlined above.

| Study sites and data collection
Data for this study were collected in conjunction with a wider study to estimate brucellosis herd seroprevalence in cattle in the region; details of the full methodology are described elsewhere (Musallam et al., 2019) and a short summary is provided here. Cross-sectional studies were conducted in nine peri-urban dairy production zones across six West and Central Africa countries between February 2017 and January 2018, namely in Burkina Faso (Ouagadougou), Cameroon (Bamenda and Ngaoundere), Ivory Coast (Abidjan), Mali (Bamako), Senegal (Dakar, Thies and Niakhar) and Togo (Lomé) (Figure 1).
The target population was defined as 'all bovine dairy herds present in the predefined peri-urban zone'. The study unit was defined as 'any herd where lactating cows are managed together as a unit regardless of herd size'. The boundaries for each 'peri-urban zone' were defined through consultation with personnel from the veterinary and livestock production services, dairy farm associations and private veterinarians in each zone.
A structured questionnaire was designed under the principles of the Andersen-Newman behaviour model (Andersen & Newman, 1973) applied to the utilization of cattle vaccination by farmers (Table 1). In the behavioural model, three categories are identified as being important contributors to an individual's utilization of a service. The first category was defined as predisposing factors, stating 'Some individuals have a propensity to use services more than other individuals, where propensity toward use can be predicted by individual characteristics which exist prior to the onset of specific episodes of illness'. We suggest that the type of farm and the farmer's current behaviour around biosecurity and preventative care fit into this category (Table 1) and would identify if a farmer is more likely to uptake vaccination for brucellosis. The second category encompasses enabling factors under the assumption that 'even though individuals may be predisposed to use health services, some means must be available for them to do so'.
Under this category, there are three factors associated with finance as a farmer must have available cash flow to fund vaccination unless it is under a free service; breeding practices have also been included here under the assumption that those farmers who are utilizing artificial insemination will have suppliers/technicians visiting them which could be utilized as an important information and vaccine delivery component under a collaborative model (Table 1). The -third category is defined as need (or illness level) which broadly covers the level of illness either in perception by individuals or the probability of its occurrence.
Here, we include the seroprevalence level as a proxy for the threat of brucellosis infection, and we also include dairy output assuming that farmers who have a higher output and more reliance on dairy income will have more need to maintain or improve their production through control of the production limiting effects of brucellosis. The questionnaire data were utilized to provide summary statistics and to perform logistic regression to evaluate the theoretical reasoning for including certain variables in the behavioural model and likelihood assessment.

| Data analysis
All questionnaire data were uploaded to Stata 12.2 in order to produce summary statistics and perform logistic regression (see below).

| Private-public partnership models
Three PPP types were used to hypothesize potential vaccine delivery models for brucellosis vaccination in the study areas. We did not include a fully public service as in the setting of our study all government services would require the private sector at some point in order to deliver a full coverage of service nationally.
The three model types for vaccination delivery were defined as follows based on OIE (2019): 1. Transformative: Initiated by the private sector but sanctioned by, and working with the public sector to establish an otherwise unattainable major programme. Funded initially by international development assistance or national/international philanthropic or charitable organisations. Joint governance such as a Memorandum of Understanding between the private and public partners.
2. Transactional: Government procurement of vaccination services from private veterinary service providers (veterinarians/paravets).
Initiated and funded by the public sector with further payment from the farmers for service. Governance is a client/private provider relationship. The private provider is contracted and trained/monitored by the public sector. The activities and intended outcomes are primarily defined by the public sector and contracts set out effective monitoring and evaluation mechanisms for remedial action if needed.
3. Collaborative: Joint commitment between the public sector and beneficiaries, for example producer associations, consortia or mutual societies. Jointly resourced between the public sector and private entities including dairies, milk associations, feed merchants, artificial insemination companies, agricultural suppliers and supermarkets. Governance may range from legislative to light touch and decision making is shared between the collaborating parties.

| Likelihood assessment
The likelihood assessment was conceptualized to give a quantitative output score for each PPP vaccine delivery model in each country. Guided by the three categories of the Andersen-Newman behavioural model, we hypothesized what farm and farmer characteristics could be expected to influence a farmer's utilization of a paid-for brucellosis vaccination service. These assumptions were further investigated by means of univariate logistic regression of the data testing the association between individual variables and a farmer's reported use of any vaccination in their cattle accounting for aggregation of observations within study areas by stratification.
Consideration of the regression output (effect and strength of evidence) combined with the rationale for a variable's inclusion based on Andersen-Newman principles led to the inclusion of 9 questionnaire variables in the likelihood assessment (Table 1). Additionally, the seroprevalence levels (Musallam et al., 2019) from the wider project were included as a variable in the need category of the behavioural model. For each setting and factor, a three-point score (0 = not conducive to model, 1 = moderately conducive, 2 = most conducive) was awarded individually for each of the three vaccine delivery models (Table 2). To define the level for each variable, assessment of the distributions of questionnaire data was first performed and three levels were proposed. These levels were presented to regional veterinary researchers from the Veterinary School of Dakar who gave their expert opinion on both the level and rationale. The three-point score for each study setting and variable was then awarded on the basis of the data analysed from the questionnaire. The total score for each setting and vaccine delivery model was summed, and the model with the highest total score was deemed as most likely to succeed in that setting.

| Participant demographics and farm characteristics
In total, 728 farmers agreed to participate in the study by answering the questionnaire and allowing bulk milk from their cattle to be sampled (Table 3). In all sites other than Ouagadougou (Burkina Faso), the majority of respondents were the household head or the farm owner. Nearly all respondents were male with only a few females in the Cameroon and Senegal sites (Table 3). All seroprevalence estimates referred to were presented by Musallam et al., (2019).
In Lomé (Togo), large subsistence herds of indigenous breeds ( Figure 2) with low milk output were predominant (Table 4). The  (Table 4) with large herds of predominantly local breed cattle ( Figure 2). In contrast to the Togo site, most farmers in Abidjan reported receiving some income from dairy farming (Table 6) and there was widespread reporting of vaccine use with 95% saying they used vaccines in their herds (Table 5). The herd TA B L E 2 Likelihood assessment-parameters and levels utilized for assigning scores to indicate best-fit vaccine delivery model Farmers practising modern techniques are more likely to use different inputs into their animals to increase productivity and to be driven by profit; the higher the proportion in the population therefore the more likely paid-for inputs are to succeed.
10%-20% of modern farmers 1 1 1 <10% of modern farmers 2 0 0 Breed type <50% keeping local breeds only 0 2 4 Farmers keeping imported breed types do so mainly to increase productivity and profit and therefore are more likely to spend on inputs and to be receptive to interventions to increase productivity and profit. Double weight is given in the collaborative model as breeding and buying imported cattle represents a potential market avenue for vaccine delivery.
seroprevalence estimate was lower in Abidjan than in Lomé but still considerable at 23% (Figure 4). In contrast to Lomé, Ouagadougou (Burkina Faso) had a large proportion of farmers who identified as modern 2 - (Table 4), keeping imported high-producing cattle ( Figure 2) with relatively smaller herds and higher input spends per cow (Table 6). Artificial insemination was widely used (Figure 3), and all farmers generally partook in some disease control measures already (  (Table 5). There was only minimal use of artificial insemination in Cameroon (10%); around a quarter of farmers utilized it in Mali while in Senegal it was slightly higher at around 35% of farmers (Figure 3). While Senegal had low levels of herd seroprevalence in all three areas tested, Cameroon had more moderate levels at 14% in one site and Mali had a higher estimate of 33% herds showing signs of exposure (Figure 4). In all study sites, farmers identified diseases and access to grazing lands as the predominant barriers to farming ( Figure 5).

| Logistic regression and likelihood assessment
In the univariate logistic regression (Table 7) Consequently, there were not enough data points on brucellosis knowledge to include this in the analysis.
The quantitative scores for the likelihood assessment (

| D ISCUSS I ON
In this study, we aimed to characterize the commercialization levels and farming practices in selected peri-urban farming areas in six West and Central African countries and evaluate how these characteristics might influence which PPP delivery models may fit best to implement brucellosis control through vaccination. The results indicate a heterogeneity over the nine study sites in the structure and operation of the peri-urban dairy sector. There is a clear distinction between Lomé (Togo) where the sector seems much less  Only a quarter of farmers utilize this service which highlights either the limited coverage of the service or the limited uptake and demand from the farmer side which may be due to a perceived low risk of disease or lack of awareness about the disease, its consequences or available control options.
In countries such as Togo and Ivory Coast where commercialization of farms is less prominent but disease burden appears to be high, the transformative model scored highest. There is an obvious need to control the disease not least from a public health standpoint.
Farmers may not be driven to control the disease on the basis of improving production and they also may not have the financial cash flow to invest in vaccination for their herds; they also have little interaction with other livestock extension workers or suppliers as their systems are low input. A transformative agreement where it is in the government's or NGO's interest to control an important disease could see the employment, training and engagement of private community animal healthcare workers (CAHW). This method of outreach to engage and reach farmers to supply free or heavily subsidized vaccines has proved successful where there is little incentive for private veterinarians to deliver the service (Catley et al., 2004;Ilukor, 2017).
In order to engage farmers, it is important to understand the issues they face and incorporate vaccine delivery within other programmes that will lead to eventual self-sufficiency after initial heavy invest- While the notion of PPPs and evaluation of animal health as either a public or private good is nothing new and indeed well published (Ahuja, 2004), the practice of incorporating these theories and research within the design and research outputs of epidemiological studies is less common. Our study provides a novel approach for assessing healthcare service delivery at the early conception phases and highlights areas for further research. The comparative demographic and production data presented are useful to parameterize cost-benefit models designed on the basis of the proposed vaccine delivery models.

TA B L E 5
Practices on farms that relate to disease risks and disease control

Buying points Number of herds (% of herds)
Rarely (

| CON CLUS ION
In this paper, we have examined farmer-specific factors to hypothesize methods of vaccine-based brucellosis control in peri-urban dairy areas where brucellosis is endemic. The findings across sites in the six countries have highlighted the diversity of factors that may hinder or assist in implementing appropriate control strategies in each of these settings. As is evidenced in these findings, each of the study sites examined lies on a spectrum of transformation to more intensive commercially driven systems. The evolving nature of these farming systems provides opportunities for new and innovative routes for animal health services and disease control strategies to be implemented in a successful and sustainable manner. By assessing the current characteristics of each county's dairy sector and considering the future directions, exploration of the suggested delivery models can be undertaken by means of a  cost-benefit analysis to inform policy in this important emerging field.

ACK N OWLED G EM ENTS
Authors acknowledge all farmers who participated in this study, field technicians and laboratory technicians for their help and support.

CO N FLI C T O F I NTE R E S T
Declarations of interest: none.

DATA AVA I L A B I L I T Y S TAT E M E N T
Research data are not shared at this time. The data are part of a large and ongoing study, and once complete all data will be published as one data in brief article. 2 The term 'modern' was identified by farmers during qualitative work within the wider project and refers to commercially driven practices such as cross-breeding, artificial insemination and utilizing milk parlours. Ivory Coast 12 7 7

TA B L E 7 Logistic regression output
Mali 11 11 12 Senegal 8 9 11 Togo 19 6 6 The numbers in bold highlight the highest scores for each country. Name of the interviewer :

Country :
Please begin by obtaining GPS co-ordinates aŌer introducing the study to the parƟcipant and gaining consent. If you are inside the building, please go outside to record the GPS by pressing 'Record locaƟon' To be completed by the interviewer before the start of the interview: The person agreed to do the interview is :

PART 1 SECTION A -FARM STRUCTURE AND TYPE
1. The farm type is; (Ɵck all those that apply) ☐ Single ownership (all animals are owned by one household) ☐Mixed ownership (animals are kept/managed together but belong to people from different households) 2. How will you describe movement of your herd?
☐ The cows are always kept around this area (they are never moved to an area that is further away than half a day walking distance or requires staying overnight to find food or water) ☐ The animals are someƟmes moved to a different area that is too far to be reached and return from within a day.
3. How many people are involved with the farm animals including family members and/or addiƟonal staff?
Family: ……………………. In the next quesƟon you need to use the animal pictures that have been provided If veterinarian-in-charge is answering the quesƟons then go to secƟon I, if not proceed to secƟon G If the answer to quesƟon 32 is "No", then go to secƟon I. if the answer to quesƟon 32 is "YES", conƟnue to quesƟon 33 36. Please pass the animal pictures to the interviewee and ask him/her: Could you please order the pictures from the species that are most likely to have brucellosis to the species that are least likely to have brucellosis? (Do not interfere with the interviewee, let the interviewee arrange the pictures as he / she wants and register below the posiƟon of each species, from the first one; number 1: the one that is more likely to have the disease called brucellosis, number 5: the one that is least likely to have the disease called brucellosis). CaƩle: _____________ (write posiƟon number) Sheep: _____________ (write posiƟon number) Goats: _____________ (write posiƟon number) Donkeys: ___________ (write posiƟon number) Poultry: ____________ (write posiƟon number) 37. Do you think brucellosis can be transmiƩed from animals to people? (Please choose one opƟon only, depending on the interviewee answer). ☐ Yes, I am sure this disease can be transmiƩed from animals to people ☐ I am not sure whether this disease can be transmiƩed from animals to people ☐ No, I am sure this disease cannot be transmiƩed from animals to people If the answer to quesƟon 37 is "c", then go to quesƟon 40.
38. In your opinion, which ways brucellosis can be transmiƩed from animals to humans? (Please do not tell anything else to the interviewee, simply read the quesƟon, listen and Ɵck below on the basis of what the interviewee answers; you can Ɵck as many opƟons as the interviewee answers). Contact with animals ☐ Contact with infected people ☐ Contact with foetus or foetal membranes ☐ ConsumpƟon of milk ☐ ConsumpƟon of meat ☐ ConsumpƟon of dairy products ☐ Contact with faeces ☐ Others (Please specify)…………………………….. 39. In your opinion, how likely it is that a person acquires brucellosis in the following situaƟons? (Please Ɵck one box only for each row depending on the answer of the interviewee)

SituaƟon High
Moderate Low contact (touching, walking with, entering pens etc.) with infected animals AssisƟng the parturiƟon of infected animal Drinking raw (non-boiled) milk from infected animals EaƟng dairy products (cheese, cream etc.) made from milk of infected animals EaƟng meat of infected animals Contact (eaƟng together, being in the same room etc.) with infected person Contact with foetuses or foetal membranes of infected animals 40. In your opinion, what would most people in this area do if they suspect or find out that some of their animals may have brucellosis? (Please Ɵck one box only for each row depending on the answer of the interviewee) AcƟon Never SomeƟmes Always Ask the local veterinarian/ paravet/pharmacy for advice Buy vaccine Try to treat infected animals Sell suspected animals directly to neighbours Sell suspected animals in the market Sell suspected animals to the butcher | 27 CRAIGHEAD Et Al.
10. How frequently do you consume the following products in your household?
Curdled milk = milk fermented at room temperature without adding any lacƟc acid bacteria and/or enzymes, Fermented milk = milk fermented by adding lacƟc acid bacteria and/or enzymes. 11. Do you produce the following products in your house from milk produced by your animals? Curdled milk = milk fermented at room temperature without adding any lacƟc acid bacteria and/or enzymes, Fermented milk = milk fermented by adding lacƟc acid bacteria and/or enzymes. Please note the milk sample ID and use the same to label the boƩle.