Published Date: 2007-08-09 16:00:13
Subject: PRO/AH/EDR> Q fever - Netherlands (Noord-Brabant, Gelderland)
Archive Number: 20070809.2592
Q FEVER - NETHERLANDS (NOORD-BRABANT, GELDERLAND)
*************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>
Date: Thu 9 Aug 2007
Source: Eurosurveillance weekly release 2007; 12(8) [edited]
<http://www.eurosurveillance.org/ew/2007/070809.asp#2>
On 29 May 2007, a general practitioner (GP) from a rural village in the
province of Noord-Brabant, in the south of the Netherlands, alerted the
municipal health service about an unusual increase in pneumonia cases among
adults in his practice. Cases presented with one or more of the following
symptoms: fever, night sweating, muscle pain, cough, and fatigue. A 2nd GP
from a nearby village reported a similar alert soon thereafter and this led
to a further investigation of the cases.
Earlier in the month [May 2007], the same municipal health service received
an alert by a regional medical microbiologist regarding an increase in
severe pneumonias that did not respond well to antibiotics. This 1st
cluster of cases was initially attributed to _Mycoplasma pneumoniae_, but
more in-depth diagnostics revealed that the majority of these patients had
a positive serology for acute _Coxiella burnetii_ infection. Also, 6
sporadic Q fever cases were reported from the same province through the
mandatory notification system from January to April 2007. An investigation
was launched to describe the outbreak, find the source and route of
transmission, identify symptomatic and asymptomatic pregnant patients who
are more likely to contract chronic Q fever (1) in the most affected area,
and investigate possible links to animal reservoirs in the region in order
to decide on appropriate control measures.
As Q fever is a rarely reported disease in the Netherlands, a broad case
definition was used:
- a confirmed case of Q fever was defined as any inhabitant of the
Netherlands presenting to a GP with clinical symptoms consistent with Q
fever since 1 Jan 2007 and who had laboratory confirmed positive serology
defined as a seroconversion or 4-fold increase of antibody titre using a
_C. burnetii_ CFT (home-made complement fixation test using phase 1 and 2
antigens) in samples taken at least 14 days apart, or showing positive for
phase 2 IgM antibodies in the _C. burnetii_ IFA (Focus diagnostics) with a
1:64 or greater dilution.
- a probable case definition was also introduced only for an area in the
east of the Noord Brabant region, where more cases were clustered, to
better describe the outbreak there. Probable cases had clinical symptoms
consistent with Q fever and either a less than 4-fold increase in phase 2
IgM within 14 days, or a single serum sample positive for phase 2 IgM
antibodies in a dilution of 1:20 or greater.
- in all cases, infection with _Legionella_ spp. was excluded.
Q fever is caused by _Coxiella burnetii_, an intracellular bacterium. It is
an almost worldwide appearing zoonosis whereby goats, sheep, and cattle
have been described as the most common animal reservoir for human
infections. Many Q fever outbreaks worldwide are temporally linked to the
lambing season, as birth products from infected animals can be an important
source of environmental contamination and transmission to humans via the
aerosol route (2). At least 3 outbreaks of Q fever have been documented
worldwide since January 2007: in the United Kingdom (3), Slovenia (4), and
Australia (5).
In the Netherlands, 5-20 cases of Q fever have been reported annually
between 2000 and 2006 (6). From 1 Jan 2007 until 2 Aug 2007, 63 confirmed
and probable cases with Q fever have been reported to the municipal health
services throughout the Netherlands; 59 of them were in the provinces of
Noord Brabant and Gelderland, of which 36 were confirmed according to the
used case definition. Among the 59 cases in these provinces, 27 were living
in a well-defined area in the eastern part of Noord Brabant. It should be
noted that retrospective active case finding was initiated in the latter
area for patients with a GP consultancy after 15 May 2007 to better
describe the cluster of cases there. The overall male to female ratio is
1.67 and the median age is 50 years. Date of symptoms onset is currently
available for 47 of all patients. The peak of case occurrence was in week
21 [21-27 May] of 2007. According to the data available including week 30
[23-29 Jul 2007], the last case had a symptoms onset in week 26 (figure,
see original URL. - Mod.LL)
A trawling questionnaire was used to generate hypotheses about the possible
source of the outbreak in eastern Noord Brabant area. The municipal health
service undertook active case finding through the GP offices in this area,
where about 11 500 inhabitants reside. The area is highly agricultural with
a large population of ruminants (cattle, sheep, and goats). The number of
goats has been reported to be increasing during the last decade in this
region, as has the degree of intensive goat farming (7); moreover, there
have been active reports of abortion waves due to _C. burnetii_ infection
among the goat population in 2006 and 2007. Meteorological factors may also
have played a role in this outbreak setting, but this remains to be
investigated. April [2007] was a very dry month; only 1.5 mm (0.06 in) of
precipitation fell in the nearby weather station of Eindhoven between 22
Mar 2007 and 6 May 2007, while the average precipitation value for April
alone is 42 mm (1.7 in). Weather conditions, such as dry weather and wind,
have been documented to play an important role in other Q fever outbreaks
(8,9).
This is the 1st documented outbreak of Q fever in the Netherlands, and it
is currently under investigation. So far, only sporadic cases and family
clusters related to direct animal contact had been observed here. It is
also an example of local GPs signalling an outbreak in the Netherlands,
underlining their role in early warning of outbreaks, before
laboratory-confirmed cases are reported to the health services. Further
studies are planned.
References:
1. Raoult D, Marrie TJ, Mege JL. Natural history and pathophysiology of Q
fever. Lancet Infect Dis 2005; 5: 219-26.
2. Cutler SJ, Bouzid M, Cutler RR. Q Fever. J Infect 2007; 54: 313-8.
3. Q Fever Cluster in Cheltenham. Health Protection Report 1(29). HPA.
Available from
<http://www.hpa.org.uk/hpr/archives/2007/news2007/news2907.htm>.
4. Grilc E, Socan M, Koren N, et al. Outbreak of Q fever among a group of
high school students in Slovenia, March-April 2007. Euro Surveill 2007;
12(7): E070719.1. Available from
<http://www.eurosurveillance.org/ew/2007/070719.asp#1>
5. ProMED-mail. Q Fever - Australia. ProMED-mail 2007; 30 Jul:
20020713.2244. Available from <http://www.promedmail.org> (accessed 1
August 2007).
6. Van Lier EA, Rahamat-Langendoen JC, van Vliet JA. Staat van
Infectieziekten in Nederland 2006. RIVM Rapport 210211002/2007 (in Dutch).
7. Vellema P. Nieuwkomers Q-fever en pasteurellose duiken op.
Geitenhouderij: tweemaandelijks blad voor alle geitenhouders 2006; 10(5):
14-5. Boerhaar: Stichting Vakblad Geitenhouderij (in Dutch).
8. Hawker JI, et al. A large outbreak of Q fever in the West Midlands:
windborne spread into metropolitan area? Commun Dis Public Health 1998;
1(3): 180-7.
9. Robert Koch Institute. Grosser Q-Fieber-Ausbruch in Jena, Juni 2005:
Epidemiologisches Bulletin 2006; 45: 391-8. Available online at
<http://www.gpk.de/downloadp/STIKO_Bulletin45_061110_Q_Fieber2005.pdf> (in
German).
[The references in the original URL are actually numbered incorrectly. The
numbering is corrected here. - Mod.LL]
[Karagiannis I (<Ioannis.Karagiannis@rivm.nl>), Morroy G, Rietveld A, et al]
--
communicated by:
ProMED-mail
<promed@promedmail.org>
[The epidemic curve shown in the figure shows a dramatic upswing in cases
during week 21 and a slower downswing towards the baseline numbers during
weeks 22-26 [28 May-4 Jun and 25 Jun-1 Jul 2007]. Clearly an event occurred
in the affected area during this time and the ongoing investigation should
been useful in delineating the event and then how the transmission of this
airborne infection occurred.
A map of the 2 provinces mentioned can be found, bordering upon one another
in the south of the Netherlands at
<http://www.amsterdam.co.kr/general/maps/nl_map_provinces.gif>. - Mod.LL]
See Also
Q fever - Australia (SA) (04) 20070731.2458Q fever - UK (England): alert, RFI 20070723.2367
Q fever, veterinary students - Slovenia 20070720.2332
Q fever - Australia (SA) 20070624.2038
2006
---
Q fever - USA (IA,IL): RFI 20061130.3391
Q fever, meat processing plant - UK (Scotland) (02) 20060825.2394
Q fever, meat processing plant - UK (Scotland) 20060721.2001
2005
---
Q fever, calving - Australia (NSW) 20051103.3222
Q fever, contaminated wool - Russia (Moscow) 20051025.3118
Q fever - Israel 20050814.2378
Q fever - USA (CO) 20050810.2329
Q fever, human - USA (TX) 20050701.1861
2004
---
Q fever, farmers - Australia (S. Australia) 20041214.3309
Q fever - Bulgaria (Botevgrad) 20040829.2413
Q fever - Bosnia & Herzegovina (Banja Luka) 20040513.1291
2002
---
Q fever - UK (Wales) 20021027.5653
Q fever - France (Chamonix) (02) 20020911.5283
Q fever - France (Chamonix) 20020903.5224
Q fever, human, sheep, vaccine - Germany (02) 20020629.4632
Q fever, human, sheep, vaccine - Germany: RFI 20020626.4607
Q fever - Bosnia & Herzegovina (Livno) 20020328.3832
2001
---
Q fever - Australia (Queensland) 20010129.0204
.................ll/mj/sh
*##########################################################*
************************************************************
ProMED-mail makes every effort to verify the reports that
are posted, but the accuracy and completeness of the
information, and of any statements or opinions based
thereon, are not guaranteed. The reader assumes all risks in
using information posted or archived by ProMED-mail. ISID
and its associated service providers shall not be held
responsible for errors or omissions or held liable for any
damages incurred as a result of use or reliance upon posted
or archived material.
************************************************************
Become a ProMED-mail Premium Subscriber at
<http://www.isid.org/ProMEDMail_Premium.shtml>
************************************************************
Visit ProMED-mail's web site at <http://www.promedmail.org>.
Send all items for posting to: promed@promedmail.org
(NOT to an individual moderator). If you do not give your
full name and affiliation, it may not be posted. Send
commands to subscribe/unsubscribe, get archives, help,
etc. to: majordomo@promedmail.org. For assistance from a
human being send mail to: owner-promed@promedmail.org.
############################################################
############################################################