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