223 juni 20103 juni 2010 1

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

Dr. Christian JPA Hoebearts-epidemioloog infectieziektebestrijding, arts M&GHoofd afdeling infectieziektebestrijdingGGD Zuid Limburg

PAOG Jeugdgezondheidszorg, Maastricht 22 juni 2010

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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

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333 meldingen in 2010

tegenover 692 in 2009

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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

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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

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Coxiella burnetii

Microbiology

• gram-negative• obligate intracellular• related to Legionella

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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

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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

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• Dominant:– contaminated aerosols

• Less frequent– food, tick-bite

• Very rare:– via sex, blood

transfusion, healthcare

Transmission (humans)

Study in 2008/09 ca. 1000 Dutch ticks: all negative

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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

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symptoms Q-fever

• Symptoms– Fever– Headache– Myalgia– Lower respiratory

symptoms

• Therapy:• R/ Doxycyclin 100mg

2dd for 2 weeks

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QFS: Diminishing in time

after 1 year little subgroup 10-20%(strict definition CFS)of ‘real’ QFS

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Chronic Q-fever

• patients at risk:– hart valve anomalities– vasculair grafts– immunodeficiency– pregnancy

• Osteoarticular infection,• vascular infection,• granulomatous hepatitis• Lung fibrosis,• amyloidosis,• mixed cryoglobulinemia,• […]

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Available diagnostic tests

• Serology– Complement Binding reaction

(CBR)– Immunofluorescence (IFA)– ELISA

• Pathogen detection– Culture– Direct immunofluorescence– Polymerase chain reaction

(PCR)

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Basic serologic principle

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Serology Q-fever

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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

Germany 2005 160 Sheep herd

Literature: 53 outbreaks: 26 by sheep, 6 by goats, 3 by cats

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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

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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

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New infections by month

Nieuwe infecties per maand: januari 2007 tm oktober 2009

0

200

400

600

800

1000

1200

1400

Maand

Aa

nta

l

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Characteristics patients 2007-nov 2009

Most patients:35-65 years62% man

Hospital admission:50% in 200721% in 200820% in 2009

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• 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

Control measures

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• 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 farmsgrazing sheep

- temporary ban on dairy goat farm start- or size-ups

Control measures

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

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Q fever in South Limburg

2009 2010 tot 31 maart

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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

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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)

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Acknowledgments:

• 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 HoekJim 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