Q fever: Evidence of a massive yet undetected cross-border outbreak, with ongoing risk of extra mortality, in a Dutch-German border region.

BACKGROUND: Following outbreaks in other parts of the Netherlands, the Dutch border region of South Limburg experienced a large-scale outbreak of human Q fever related to a single dairy goat farm in 2009, with surprisingly few cases reported from neighbouring German counties. Late chronic Q fever, with recent spikes of newly detected cases, is an ongoing public health concern in the Netherlands. We aimed to assess the scope and scale of any undetected cross-border transmission to neighbouring German counties, where individuals unknowingly exposed may carry extra risk of overlooked diagnosis. METHODS: (A) Seroprevalence rates in the Dutch area were estimated fitting an exponential gradient to the geographical distribution of notified acute human Q fever cases, using seroprevalence in a sample of farm township inhabitants as baseline. (B) Seroprevalence rates in 122 neighbouring German postcode areas were estimated from a sample of blood donors living in these areas and attending the regional blood donation centre in January/February 2010 (n = 3,460). (C) Using multivariate linear regression, including goat and sheep densities, veterinary Q fever notifications and blood donor sampling densities as covariates, we assessed whether seroprevalence rates across the entire border region were associated with distance from the farm. RESULTS: (A) Seroprevalence in the outbreak farm's township was 16.1%. Overall seroprevalence in the Dutch area was 3.6%. (B) Overall seroprevalence in the German area was 0.9%. Estimated mean seroprevalence rates (per 100,000 population) declined with increasing distance from the outbreak farm (0-19 km = 2,302, 20-39 km = 1,122, 40-59 km = 432 and ≥60 km = 0). Decline was linear in multivariate regression using log-transformed seroprevalence rates (0-19 km = 2.9 [95% confidence interval (CI) = 2.6 to 3.2], 20 to 39 km = 1.9 [95% CI = 1.0 to 2.8], 40-59 km = 0.6 [95% CI = -0.2 to 1.3] and ≥60 km = 0.0 [95% CI = -0.3 to 0.3]). CONCLUSIONS: Our findings were suggestive of widespread cross-border transmission, with thousands of undetected infections, arguing for intensified cross-border collaboration and surveillance and screening of individuals susceptible to chronic Q fever in the affected area.

Perioperative Occupational Exposure to Coxiella burnetii-Infected Thoracic Endovascular Aneurysm Stent Graft.

We conducted this study to determine the risk of transmission of Q fever to health care workers (HCWs) during perioperative exposure to Coxiella burnetii-infected thoracic endovascular aneurysm stent graft. Pre-operative and 6-week post-operative phase I and II IgG Q fever antibody titers were determined in 14 staff members of an operation room. The room had a negative pressure and all the members of the surgical team wore either a fitted N-95 mask or a powered purified air respirator. Phase I and II IgG antibody titers were <1:16 for 11 of the 14 studied HCWs; 2 HCWs did not follow up at 6 weeks and 1 had a pre-exposure phase II IgG titer of 1:128 with no change 6 weeks later. We concluded that risk of transmission of C. burnetii in the operating room from infected patient to HCWs who wore appropriate personal protective equipment is low.

Treatment of an Abdominal Aortic Aneurysm Infected by Coxiella Burnetii Using a Cryopreserved Allograft.

Q fever is a worldwide zoonosis caused by an intracellular bacillus named Coxiella burnetii (CB) and is a rare cause of vascular infections. We report a case of abdominal aortic aneurysm infected by CB with bilateral paravertebral abscesses and contiguous spondylodiscitis treated by open repair using a cryopreserved allograft and long-term antibiotic therapy by oral doxycycline and oral hydroxychloroquine for a duration of 18 months. Twenty months after the operation, the patient had no infections signs and vascular complication.

Soroprevalência de Bartonella sp., Coxiella burnetii e Hantavirus em Pessoas que Injetam Drogas Ilícitas no Estado do Rio de Janeiro nos anos de 1999 a 2001 / Seroprevalence of bartonella sp., coxiella burnetti and hantavirus in intravenous illicit drug users in the state of Rio de Janeiro in the years of 1999-2001

O aumento do consumo de drogas ilícitas na atualidade vem acompanhado não apenas do impacto social e econômico, como também na saúde. As pessoas que injetam drogas apresentam maior susceptibilidade a infecções por diversos agentes, devido ao uso da droga e à subsequente imunossupressão, como também pelo risco de maior exposição a agentes transmitidos por artrópodes e reservatórios vertebrados em ambientes insalubres. São muitos os estudos correlacionando o consumo de drogas à infecção pelo HIV, VHB e VHC, porém raros investigam outros agentes. No presente estudo transversal e retrospectivo, selecionamos aleatoriamente 300 amostras de um estudo multicêntrico da década de 1990 e fizemos a pesquisa sorológica para Bartonella spp., Coxiella burnetii e Hantavirus. O perfil demográfico e social encontrado mostrou-se em concordância com a literatura: homens, jovens, de baixa renda e com histórico de prisão. A maior parte apresentava situações de risco por injetar drogas com dispositivos previamente usados e por injetar em local público. Alguns fatores foram discordantes da literatura internacional e podem ter influenciado os resultados, uma vez que são considerados situações de risco, como escassez de pessoas que injetaram drogas enquanto presas, que residem em instituições, ou sem-tetoA evidência de infecção por C. burnetii foi de 9,3 porcento, praticamente o dobro da observada na população geral brasileira, embora, em comparação com dados internacionais, a prevalência tenha sido menor. Não houve diferença estatística significativa em relação às variáveis demográficas entre os grupos sororeativos e soronegativos para febre Q. A presença de anticorpos anti-Bartonella foi de 1 porcento, bem discrepante dos estudos nacionais e internacionais. Pode ser justificado pela não inclusão no teste sorológico de antígeno de B. elizabethae e de B. quintana e pela reduzida frequência de sem-tetos...

The increased consumption of illicit drugs today is followed not only by a social and economic impact, as well as in health. People who inject drugs are more susceptible to infections by various agents due to drug use and subsequent immunosuppression, as well as the risk of increased exposure to agents transmitted by arthropods and vertebrate reservoirs in unhealthy environments. Many studies link drug use to HIV, HBV and HCV,however only a few investigate other agents. In this retrospective cross-sectional study, we selected randomly 300 samples from a multicenter study from the 1990s and made aserological survey for Bartonella spp., Coxiella burnetii and hantavirus. The demographic and social profile was found in agreement with the literature: men, young age, low incomeand with a history of imprisonment. The majority was exposed to risk situations by injecting drugs with previously used devices and by injecting in a public places. Some factors were disagreeing with the international literature and may have influenced theresults, since they are considered high-risk situations, such as shortage of people whoinjected drugs while imprisoned, residing in institutions, or homeless. Evidence of C.burnetii infection was 9.3 percent, almost double the rate in the general Brazilian population,although in comparison with international data, the prevalence was lower. There was nostatistically significant difference in relation to demographic variables among seroreactiveand seronegative groups for fever Q. The presence of antibodies to Bartonella was 1percent, significantly discrepant from national/international studies. Possibly justified by the noninclusion of antigen B. elizabethae and B. quintana in the serological test, and the reduced frequency of homelessness. There was no correlation between high alcohol consumption with higher seroprevalence of Bartonella spp., probably for the reasons mentioned above...

[Q fever, a zoonosis often overlooked]. / Fievre Q: une zoonose souvent méconnue.

Q fever is a zoonosis caused by an intracellular Gram-negative bacteria, Coxiella burnetii. Animals are the main reservoir and transmission to men generally is occurring by inhalation of contaminated aerosols. Acute Q fever generally is benign and usually resolves spontaneously. When symptomatic, the clinical presentation typically includes one of the following three syndromes: a flu-like illness, a granulomatous hepatitis or an atypical pneumonia. Individuals presenting risk factors such as patients with valvular heart diseases and vascular prostheses, as well as pregnant women and immuno-suppressed patients represent a population at risk of chronic infection, with endocarditis as the most common clinical form.

[Zoonoses as occupational diseases].

The article represents materials on risk for animal husbandry workers of being infected with Coxiella and Leptospira. The authors describe contemporary difficulties in diagnosis and epidemiologic surveillance for these diseases. The materials demonstrate that undiagnosed infected (ill) animals on veterinary objects, with violated biologic safety rules, could promote contraction of zoonotic infection by susceptible subjects (workers engaged into animal husbandry and enterprises on animal materials processing). Contemporary laboratory methods and professional skills enable opportune and complete diagnosis of infections and diseases, with further possibility to apply preventive measures efficiently.

Screening-level risk assessment of Coxiella burnetii (Q fever) transmission via aeration of drinking water.

A screening-level risk assessment of Q fever transmission through drinking water produced from groundwater in the vicinity of infected goat barnyards that employed aeration of the water was performed. Quantitative data from scientific literature were collected and a Quantitative Microbial Risk Assessment approach was followed. An exposure model was developed to calculate the dose to which consumers of aerated groundwater are exposed through aerosols inhalation during showering. The exposure assessment and hazard characterization were integrated in a screening-level risk characterization using a dose-response model for inhalation to determine the risk of Q fever through tap water. A nominal range sensitivity analysis was performed. The estimated risk of disease was lower than 10(-4) per person per year (pppy), hence the risk of transmission of C. burnetii through inhalation of drinking water aerosols is very low. The sensitivity analysis shows that the most uncertain parameters are the aeration process, the transport of C. burnetii in bioaerosols via the air, the aerosolization of C. burnetii in the shower, and the air filtration efficiency. The risk was compared to direct airborne exposure of persons in the vicinity of infected goat farms; the relative risk of exposure through inhalation of drinking water aerosols was 0.002%.

Influence of the environment and occupational exposure on the occurrence of Q fever.

Q fever, which is caused by Coxiella bumetii, is a worldwide zoonotic infectious disease and ruminants are the main reservoir for human infections. Humans become infected primarily by inhaling aerosols that are contaminated with C. bumetii. Ingestion (particularly drinking raw milk) and person-to-person transmission are minor routes. Animals shed the bacterium in urine and faeces, and in very high concentrations in birth by-products. The bacterium persists in the environment in a resistant spore-like form which may become airborne and transported long distances by the wind. Q fever is considered primarily an occupational disease of workers in close contact with farm animals or processing their products, however, it may occur also in persons without direct contact. To prevent the introduction and spread of Q fever infection, preventive measures should be implemented including immunisation with currently available vaccines of domestic animals and humans at risk.

Estudo da febre Q em seres humanos, animais domésticos e artrópodes em uma área no Município de Itaboraí, Rio de Janeiro / Study of Q fever in humans, domestic animals and arthropods in an area in the municipality of Itaboraí, Rio de Janeiro

Febre Q é uma zoonose cosmopolita causada por Coxiella burnetii, pequena bactéria intracelular obrigatória gram-negativa e pleomórfica da ordem Legionellales. A doença, que ocorre como pequenos surtos ou como casos isolados, tem amplo espectro de manifestações clínicas, desde uma doença febril limitada, pneumonia, hepatite a endocardite e meningoencefalite. Carrapatos, animais de fazenda, domésticos e selvagens são reservatórios da infecção. A transmissão para o homem ocorre por inalação de aerossóis provenientes de urina, fezes, leite e produtos de abortamento ou menos comumente pela ingestão de leite cru de animais infectados. No Brasil, desde a primeira descrição de febre Q em 1953, em São Paulo, todos os casos têm sido identificados com base em teste sorológico e os poucos estudos soroepidemiológicos em população de risco apontam para a circulação de C. burnetii. Em 2008 foi possível confirmar um caso de febre Q em um paciente, a partir de análise sorológica e molecular. Com o objetivo de rastrear um foco de infecção por C. burnetii, um estudo epidemiológico descritivo foi desenvolvido na área de ocorrência do primeiro caso no Brasil de febre Q confirmado, em 2008, por análise molecular, no Município de Itaboraí, Rio de Janeiro. Análises sorológicas e moleculares foram realizadas em amostras biológicas de familiares e de cães, gatos, cabras e equinos existentes na área estudada, em 2009. Amostras de soro foram submetidas ao teste comercial de imunofluorescência indireta (PANBIOTM), título de corte de 64, para a pesquisa de anticorpo anti-C. burnetii, fases I e II. Amostras de sangue dos familiares e dos animais, assim como de leite, fezes e de secreção nasal, vaginal, além dos artrópodes, coletados nos animais, foram submetidas à PCR (reação em cadeia da polimerase) para a presença da bactéria, utilizando oligonucleotídeos para o gene alvo htpAB. Reatividade foi identificada em amostras de soro da esposa, de 2 dos 13 caninos, 05 de 10 caprinos e 02 das 03 ovinos. O genoma foi recuperado em amostra de sangue e/ou leite ou swab anal de 02 cães e 06 cabras. O sequenciamento dos produtos de PCR amplificados, do soro dos cães e do leite das cabras, mostraram identidade de 99 por cento para as sequências depositadas no GenBank. Embora não seja uma doença de notificação, os dados obtidos confirmam a circulação deste agente zoonótico e servem de alerta para a necessidade de vigilância epidemiológica da febre Q, em especial em Itaboraí, devido, entre outros fatores, ao crescente desmatamento com ocupação de vastas áreas e da criação, informal e de caráter familiar, de cabras leiteiras por pequenos proprietários nas diversas áreas do território nacional.

Intracellular life of Coxiella burnetii in macrophages.

Coxiella burnetii, the agent of Q fever, is an obligate intracellular bacterium that is considered a potential biological weapon of category B. C. burnetii survives within myeloid cells by subverting receptor-mediated phagocytosis and preventing phagosome maturation. The intracellular fate of C. burnetii also depends on the functional state of myeloid cells. This review describes the mechanisms used by C. burnetii to circumvent uptake and trafficking events, and the role of cytokines on C. burnetii survival in myeloid cells.

Investigation of a Q fever outbreak in a rural area of The Netherlands.

A Q fever outbreak occurred in the southeast of The Netherlands in spring and summer 2007. Risk factors for the acquisition of a recent Coxiella burnetii infection were studied. In total, 696 inhabitants in the cluster area were invited to complete a questionnaire and provide a blood sample for serological testing of IgG and IgM phases I and II antibodies against C. burnetii, in order to recruit seronegative controls for a case-control study. Questionnaires were also sent to 35 previously identified clinical cases. Limited environmental sampling focused on two goat farms in the area. Living in the east of the cluster area, in which a positive goat farm, cattle and small ruminants were situated, smoking and contact with agricultural products were associated with a recent infection. Information leaflets were distributed on a large scale to ruminant farms, including hygiene measures to reduce the risk of spread between animals and to humans.

Q fever in the Southern California desert: epidemiology, clinical presentation and treatment.

Despite the absence of a natural reservoir for Q fever in the desert of Southern California, six cases have been identified during the past 32 years. During that period of time, two areas have been used by northern sheep ranchers from Idaho and Wyoming to import sheep to an area in the Coachella Valley through 1985. Thereafter, because of housing development, the sheep area was moved to Blythe along the Colorado River. All but two of these patients probably acquired infection by Coxiella burnetii by living or working in close proximity to these grazing areas but not directly involved with the sheep. The shift of infected patients from the Coachella Valley to Blythe (100 miles distant) seems to support that supposition. All patients with acute Q fever developed antibodies primarily to phase II antigen, whereas the only person with chronic Q fever developed phase I antibodies. All patients presented with granulomatous hepatitis. One also had a pulmonary infiltrate, and the single individual with chronic Q fever also had a mitral valve prosthesis, although echocardiography could not define endocarditis. All patients with acute infections responded to 3-5 weeks of therapy with doxycycline, whereas the patient with chronic disease failed 3 years of therapy with combination regimens. Further studies at the Eisenhower Medical Center on the prevalence of infection in Blythe, CA, and elsewhere are anticipated.

[Q Fever in pregnancy: a case report and review of the literature]. / Q-Fieber in der Schwangerschaft: Therapie und Handling des Krankheitsbildes anhand eines Fallberichtes.

Endemic occurrence of Q fever among persons in close contact with domestic animals is well known in some rural regions of Germany. The prevalence of antibodies indicating acute Q fever in pregnancy reported in the literature varies between 0.2 % and 4.7 % of the screened population. Q fever in pregnancy initially manifests as placentitis and often leads to premature birth (30 %), growth restriction (46 %), spontaneous abortion (22 %) or fetal death in utero (7 %). Some impairment of pregnancy is observed in over 70 % of cases with seroconversion during pregnancy. Thus Q fever serology should be tested in all pregnant women presenting with atypical pneumonia and/or prolonged fever of unknown etiology. It is of interest that medical staff members in contact with Cociella burnetii infected pregnant women are also at risk of acquiring an acute Q fever infection. We report about a patient presenting with confirmed acute and later chronic Q fever during pregnancy in whom antibiotic treatment with rifampicin and clarithromycin proved to be effective and led to the vaginal delivery of a premature but healthy infant. We believe that maternal serum screening for transmissible infections should also include Q fever serology in certain rural regions.

[Sheep, chills and "doughnut granuloma"--an atypical course of Coxiella infection]. / Schafe, Schüttelfrost und "Doughnut-Granulome"--atypischer Verlauf einer Coxiellen Sepsis.

Q fever usually presents with high fever, headache and an atypical pneumonia. A case report of a 47-year-old patient with an atypical course of a coxiella infection is described. The dominant clinical symptoms were a liver and bone marrow involvement, whereas pulmonary manifestations were absent. The diagnosis of Q fever in this patient was based on the detection of cytoplasmatic inclusion bodies in macrophages and granulocytes. Furthermore fibrin-ring granulomas ("doughnut lesions") were found in liver tissue specimen and epitheloid-cell granulomas were detected in bone marrow specimen. Complement-fixation antibody titers and PCR resulted unspecific or negative on different occasions during the course of the disease. A confirmation of the diagnosis by complement-fixation antibody test was possible only after recovery from the disease. In Q fever with atypical clinical and serological presentation the screening of blood cells for inclusion bodies and liver or bone marrow tissue for granulomas may be important for establishing the diagnosis.

[Q fever with endocarditis: clinical presentation and serologic follow-up of 21 patients]. / Fièvre Q avec endocardite: présentation clinique et suivi sérologique de 21 patients.

AIM OF THE STUDY: The purpose of this study was to analyse the clinical and serological follow-up in 21 patients with Q fever endocarditis in Switzerland from 1981 to 1993. PATIENTS AND METHODS: Criteria for Q fever endocarditis were the following: Coxiella burnetii phase I IgG > 1 : 2560 and IgA > 1 : 20 by indirect immunofluorescence. Methods to confirm the diagnosis include immunohistochemical demonstration of C. burnetii by microscopy in valvular material (1 case) and inoculation of this material in experimental animals (10 cases). Information on clinical course of the disease, laboratory abnormalities and treatment were obtained by chart review and a questionnaire sent to physicians who requested the serological tests for Q fever. RESULTS: The average age of the patients was 47 years (15 men and 6 women). 64% of patients had a history of environmental exposure to C. burnetii. The median time of symptomatology before diagnosis was 5 months (1-108). 19/21 patients had valvular lesions, and 2/21 vascular Dacron prosthesis. Most patients presented with fever (18/21), congestive cardiac failure (14/21), weight loss (12/21), anemia (6/19), or thrombocytopenia (6/19). All the patients required antibiotic treatment. Cardiac surgery was performed in 15/21 patients. For 10 patients the geometric mean serological follow-up included at least titers at time of diagnosis (IgG anti-phase I antibodies 1 : 27024, IgA anti-phase I antibodies 1 : 685), at the end of therapy (IgG anti-phase I antibodies 1 : 2941, IgA anti-phase I antibodies 1 : 153) and 6 months after the end of therapy (IgG anti-phase I antibodies 1 : 368, IgA anti-phase I antibodies 1 : 40). The fall in anti-phase I titers was significant. During the clinical and serological outcome (median of 60 months and 69 months respectively) there was no recurrence of endocarditis and antibody titers to C. burnetii phase I remained low. Two patients died during the observation period, one from lung cancer, while the cause of death in the other was unknown. CONCLUSIONS: Serology is the key to Q fever diagnosis. The duration of treatment, and the values to be used to establish cure of endocarditis, are not clearly defined. During the clinical and serological outcome (median of 60 months and 69 months respectively) there was no recurrence of endocarditis and antibody titers to C. burnetii phase I remained low.

Reseña de las principales enfermedades transmitidas por garrapatas en Panamá / Review of the most important diseases transmitted by ticks in Panamá

Se ha comprobado que en Panamá las garrapatas intervienen en diversos problemas de la salud humana y de los animales, no obstante, poca es la información que sobre dichos artrópodos y su ecología está a disposición del personal médico nacional. En este trabajo se exponen algunos conceptos generales sobre la biología de las garrapatas; y, asimismo, se describe someramente la epidemiología de las enfermedades que son transmitidas por ellas al ser humano en el país