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223 juni 20103 juni 20101 Queries over Q-Koorts: Q-koorts in Nederland en Zuid-Limburg Dr. Christian JPA Hoebe arts-epidemioloog infectieziektebestrijding,

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Presentation on theme: "223 juni 20103 juni 20101 Queries over Q-Koorts: Q-koorts in Nederland en Zuid-Limburg Dr. Christian JPA Hoebe arts-epidemioloog infectieziektebestrijding,"— Presentation transcript:

1 223 juni juni 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

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

3 3 juni meldingen in 2010 tegenover 692 in 2009

4 3 juni 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

5 3 juni 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

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

7 3 juni 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

8 22 juni Transmission Release of Coxiella during lambing: shedding in high concentrations highest concentrations in abortion waves 10 9 bacteria per gram of placenta long-term persistence in environment transmission: aerogenic one bacterium enough for infection

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

10 3 juni 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

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

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

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

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

15 3 juni Basic serologic principle

16 3 juni Serology Q-fever

17 3 juni Earlier large outbreaks LandYearNumber (lab confirmed) Source Switserland Sheep herd England ? city, wind Germany Sheep on market Germany Sheep herd Literature: 53 outbreaks: 26 by sheep, 6 by goats, 3 by cats

18 3 juni 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

19 3 juni 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

20 3 juni New infections by month

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

22 3 juni : - 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 Control measures

23 3 juni : - 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 Control measures

24 Stand van zaken 31 mei 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

25 3 juni Q fever in South Limburg tot 31 maart

26 3 juni 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

27 3 juni 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)

28 3 juni 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

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