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Queries over Q-Koorts: Q-koorts in Nederland en Zuid-Limburg

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Presentation on theme: "Queries over Q-Koorts: Q-koorts in Nederland en Zuid-Limburg"— Presentation transcript:

1 Queries over Q-Koorts: Q-koorts in Nederland en Zuid-Limburg
Dr. Christian JPA Hoebe arts-epidemioloog infectieziektebestrijding, arts M&G Hoofd afdeling infectieziektebestrijding GGD Zuid Limburg PAOG Jeugdgezondheidszorg, Maastricht 22 juni 2010 223 juni 2010 3 juni 2010

2 History Brisbane abattoirs Independently isolated
Australia (from patients) by Burnet & Derrick (1937) and USA (from ticks) by Davis & Cox (1938) (nine mile strain – Montana) ‘Coxiella Burnetti’ 22 juni 2010

3 333 meldingen in 2010 tegenover 692 in 2009 3 juni 2010

4 Outline Bacterium: Coxiella burnetti Clinical picture
Diagnostic possibilities Epidemiologic situation NL animals and humans Measures taken NL Epidemiologic situation ZL Other topics Environment, menure, occupational risk 3 juni 2010

5 Kernboodschappen Q-koorts
Grootste risico van februari tot juli: lammerseizoen; geen persoon tot persoon transmissie Transmissie: via lucht (incl. direct contact) Symptomen: koorts en hoofdpijn (Serologisch) testen bij acute Q-koorts. HA: Behandeling acute Q-koorts doxy 2dd 100mg 2 weken Risicogroepen: immuungecompromiteerden, zwangeren, kleplijden, vaatprotheses. Chronische ziekte = niet chronische vermoeidheid 3 juni 2010

6 Coxiella burnetii Microbiology gram-negative obligate intracellular
related to Legionella 3 juni 2010

7 Distribution Worldwide distribution
Reservoir: - mammals, above all domestic ruminants - birds - arthropods (e.g. ticks) All eukaryotes can be infected! Abortions in sheep and goat Excretion in feces, urine, milk 3 juni 2010

8 Transmission Release of Coxiella
during lambing: shedding in high concentrations highest concentrations in abortion waves 109 bacteria per gram of placenta long-term persistence in environment transmission: aerogenic one bacterium enough for infection 22 juni 2010

9 Transmission (humans)
Dominant: contaminated aerosols Less frequent food, tick-bite Very rare: via sex, blood transfusion, healthcare Study in 2008/09 ca Dutch ticks: all negative 3 juni 2010

10 Clinical picture humans
Acute: 60% asymptomatic, 20% mild (flu-like), 20% moderate to severe (pneumonia, hepatitis, rare: encephalitis); 2-5% hospitalized Chronic: 1-5%, mainly endocarditis Longterm sequelae: Q-fever fatigue syndrome 3 juni 2010

11 symptoms Q-fever Symptoms Fever Headache Myalgia
Lower respiratory symptoms Therapy: R/ Doxycyclin 100mg 2dd for 2 weeks 22 juni 2010

12 QFS: Diminishing in time
after 1 year little subgroup 10-20% (strict definition CFS) of ‘real’ QFS 3 juni 2010

13 Chronic Q-fever patients at risk: hart valve anomalities
vasculair grafts immunodeficiency pregnancy Osteoarticular infection, vascular infection, granulomatous hepatitis Lung fibrosis, amyloidosis, mixed cryoglobulinemia, […] 3 juni 2010

14 Available diagnostic tests
Serology Complement Binding reaction (CBR) Immunofluorescence (IFA) ELISA Pathogen detection Culture Direct immunofluorescence Polymerase chain reaction (PCR) 3 juni 2010

15 Basic serologic principle
3 juni 2010

16 Serology Q-fever 3 juni 2010

17 Earlier large outbreaks
Land Year Number (lab confirmed) Source Switserland 1983 415 Sheep herd England 1989 147 ? city, wind Germany 2003 167 Sheep on market 2005 160 Literature: 53 outbreaks: 26 by sheep, 6 by goats, 3 by cats 3 juni 2010

18 Q fever history in NL Mandatory notification since 1979
Before 2007: : Q fever low-endemic in serosurveys : 8 retrospective syndromic clusters (hep, LRI) : blood donor seroprevalence = 2.4% - about cases notified annually - no screening for Q fever in pneumonia cases 2007: - major cluster in and around village in Brabant province 3 juni 2010

19 Population serology RIVM: Pienter II sera: feb 2006-jun 2007
5654 national sera:0-79 yrs 2.4% adjusted overall corrected prevalence [61/5654 (1.1%) in ELISA IgG fase II, 1.2% in 505 ELISA-neg IFA-pos (1:32 – 1:128)] before 2007 NL low prevalence area for Coxiella Burnetti 3 juni 2010

20 New infections by month
3 juni 2010

21 Characteristics patients 2007-nov 2009
Most patients: 35-65 years 62% man Hospital admission: 50% in 2007 21% in 2008 20% in 2009 3 juni 2010

22 Control measures 2007: - informing clinicians and laboratories - no veterinary control measures 2008 (June): - mandatory notification of abortion waves - positive farms: - ban on spreading of manure for 90 days - voluntary vaccination - pasteurizing of milk - restrictions to visitors of affected premises 3 juni 2010

23 Control measures 2009: - mandatory veterinary notification: bulk milk PCR Affected premises: - culling of pregnant goats/sheep - animal transport restrictions - life-long breeding ban Additonal measures: - nationwide mandatory vaccination: dairy goats and sheep (farm with >50 animals) recreational and care farms grazing sheep - temporary ban on dairy goat farm start- or size-ups 3 juni 2010

24 Stand van zaken 31 mei 2010 88 besmette bedrijven
drachtige dieren geruimd 54293 vrouwelijke dieren levenslang fokverbod 1455 bokken geruimd (van 1530, rest getest) 441 melkleverende bedrijven (>50 dieren) 287 bedrijven gevaccineerd 3 juni 2010

25 Q fever in South Limburg
2009 2010 tot 31 maart 3 juni 2010

26 Q fever in South Limburg
2008: seroprevalence South Limburg 1% 2009: last week of March Veterinary notification of Q fever - dairy goat annex care farm “Voerendaal” - ~1500 animals miscarriages - veterinary diagnosis Q fever 3 juni 2010

27 Conclusions environment
Highest concentration direct after abortion storm Amount diminish with distance to farm Amount diminish in time (but positive air during months) Testing (PCR) dust and vaginal samples most positive (in contrast with manure, milk and air) Environmental samples during lambing season positive year after abortion. Risk >1 year for farmers (occupational risk) an population living in surrounding area (public health risk) 3 juni 2010

28 Acknowledgments: Dep. of Communicable Disease Control, PHS South Limburg: Volker Hackert Rick Boesten Elleke Leclercq Henriette ter Waarbeek Nicole Dukers National Institute for Public Health and the Environment, RIVM: Yvonne van Duynhoven Wim van der Hoek Jim van Steenbergen Dep. of Medical Microbiology, Maastricht University Medical Centre: Cathrien Bruggeman Petra Wolffs Dep. of Medical Microbiology, Atrium Medical Centre Heerlen: Frans Stals Resarch Cooperation Q-Fieber (Friedrich Loeffler Institut, Germany): Heinrich Neubauer Klaus Henning Sascha Al-Dahouk GP office Voerendaal: Petra Pasman 3 juni 2010

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