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

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 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’

3. 333 meldingen in 2010 tegenover 692 in 2009

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

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

6. Coxiella burnetii Microbiology • gram-negative • obligate intracellular • related to Legionella

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

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

9. Transmission (humans) • Dominant: • contaminated aerosols • Less frequent • food, tick-bite • Very rare: • via sex, blood transfusion, healthcare Study in 2008/09 ca. 1000 Dutch ticks: all negative

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

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

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

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, • […]

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

15. Basic serologic principle

16. Serology Q-fever

17. Earlier large outbreaks Literature: 53 outbreaks: 26 by sheep, 6 by goats, 3 by cats

18. Q fever history in NL • Mandatory notification since 1979 • Before 2007:- 1968-1983: Q fever low-endemic in serosurveys- 2005-2007: 8 retrospective syndromic clusters (hep, LRI)- 2006: blood donor seroprevalence = 2.4%- about 10-20 cases notified annually- no screening for Q fever in pneumonia cases • 2007:- major cluster in and around village in Brabant province

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

20. New infections by month

21. Characteristics patients2007-nov 2009 • Most patients: • 35-65 years • 62% man Hospital admission: • 50% in 2007 • 21% in 2008 • 20% in 2009

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

23. Control measures • 2009: - mandatory veterinary notification: bulk milk PCRAffected premises:- culling of pregnant goats/sheep- animal transport restrictions- life-long breeding banAdditonal 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

24. Stand van zaken 31 mei 2010 • 88 besmette bedrijven • 50.319 drachtige dieren geruimd • 54293 vrouwelijke dieren levenslang fokverbod • 1455 bokken geruimd (van 1530, rest getest) • 441 melkleverende bedrijven (>50 dieren) • 287 bedrijven gevaccineerd

25. Q fever in South Limburg 2009 2010 tot 31 maart

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- 220 miscarriages- veterinary diagnosis Q fever

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)

28. Dep. of Communicable Disease Control, PHS South Limburg:Volker HackertRick BoestenElleke LeclercqHenriette ter WaarbeekNicole Dukers National Institute for Public Health and the Environment, RIVM:Yvonne van DuynhovenWim 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 NeubauerKlaus HenningSascha Al-Dahouk GP office Voerendaal:Petra Pasman Acknowledgments: