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Published Date: 2008-08-02 17:00:28
Subject: PRO/AH/EDR> Q fever - Netherlands (03): (NBR, GEL)
Archive Number: 20080802.2367

Q FEVER - NETHERLANDS (03): (NOORD BRABANT, GELDERLAND)
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[1] Human, Eurosurveillance report
[2] Ministry of Agriculture, Nature and Food Quality Press Release
[3] Animal Health Service

*****
[1] Human, Eurosurveillance report
Date: Thu 31 Jul 2008
Source: Eurosurveillance [edited]
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=18939>

Q fever is a worldwide zoonosis caused by the
bacterium _Coxiella burnetii_ which is common in
a wide range of wild and domestic animals. Cattle
and small ruminants, in particular sheep and
goats, have been associated with large human
outbreaks. Humans become infected primarily by
inhaling aerosols that are contaminated by _C.
burnetii_. Most infections remain asymptomatic
but in about 40 percent lead to a febrile
disease, pneumonia and/or hepatitis. Chronic
infections, mainly endocarditis, are observed in
3 to 5 percent of cases, with an increased risk
for pregnant women and persons with heart valve
disorders or impaired immunity. Q fever in
pregnancy, whether symptomatic or asymptomatic,
may also result in adverse pregnancy outcomes
(1). Q fever in humans is a notifiable disease in
The Netherlands. The notification criteria for a
confirmed case is a positive serology defined by
immunofluoresence assay (IFA) test or a _C.
burnetii_ complement fixation test (2). Also
clinical patients diagnosed by PCR are considered
as confirmed cases. Between 1997 and 2006, Q
fever was notified rarely with an average of 11
(range 5-16) cases annually [3). In 2007, we
reported in this journal the 1st community
outbreak of Q fever in the south of The
Netherlands (4).

Current situation
-----------------
We report a 2nd large outbreak of Q fever that
started in the 1st half of 2008. Since the spring
of 2008, a marked increase in notified Q fever
cases has been observed with a total of 677 cases
notified up to 24 Jul 2008 in OSIRIS, an
internet-based reporting system for notifiable
infectious diseases in The Netherlands. Of these
cases, 17 had illness onset in 2007, 546 in 2008,
while for the remaining 114 recently notified
cases the date of illness onset is still unknown.
The majority of cases reported illness onset
between week 18 and 24, similar to the outbreak
in 2007 (Figure 1 [for figures see original URL -
Mod. LL]). The overall female to male ratio is
1:1.7. The age distribution in 2008 ranges
between 7 to 87 years (IQR 41-60 years, median 51
years) and is similar to the age distribution in
2007 (Figure 2). The preliminary hospitalization
rate of cases in 2008 was 22 percent compared
to 43 percent during the same period (week 1-28)
in 2007.

Of the cases with illness onset in 2008 for whom
information on symptoms was available (n=300), 94
percent reported fever, followed by fatigue (89
percent), night sweating (78 percent), headache
(71 percent) and general malaise (63 percent). 65
percent of the cases with known symptoms had
pneumonia. So far, no pregnancy has been reported
among notified cases.

Although the 2008 epidemic is located in the same
part of the country as the outbreak in 2007, it
is more widespread in the province of
Noord-Brabant and expanded to the adjacent
province of Gelderland (Figure 3). This area is
known for its large density of dairy goats. 75
percent of the cases notified in 2008 reside in
one municipal health service region. Within this
region, several distinct clusters of Q fever have
been observed in rural municipalities with
cumulative incidences as high as 14 acute _C.
burnetii_ infections per 1000 inhabitants (Figure
3). The outbreak is ongoing but the numbers seem
to decrease in the entire Q fever affected area.

Control measures and new legislation
------------------------------------
Since 2007, Q fever has become an important
public health problem in The Netherlands,
warranting a continuous enhanced surveillance.
Efficient data sharing between public health
institutions and veterinary health partners on
regional and national level is a prerequisite for
timely and thorough source tracing and
identification. Following the 2007 outbreak, an
informal agreement was made that the veterinary
and the public health sectors would exchange
information on farms with newly diagnosed animal
cases of Q fever to allow for an adequate
response and control. On 3 Jun 2008, an outbreak
management team was convened and recommended a
mandatory notification of Q fever in ruminants.
In the same month this recommendation was
implemented by the Dutch Ministry of Agriculture
and the Ministry of Health; farmers and
veterinarians have to report symptoms compatible
with Q fever, usually abortion waves, in small
ruminants held in deep litter houses. In
addition, a ban to spread manure during the 3
months following the detection of Q fever at the
farm and a restriction for visitors at the and
farm were imposed (5,6).

The current situation has also led to public
health questions about the need for screening of
pregnant women for Q fever and exclusion of blood
donations from individuals in affected regions.
On 22 Jul 2008, an international expert meeting
was organized by the National Institute for
Public Health and the Environment (RIVM) and the
Health Council of The Netherlands, with
participation of the European Centre for Disease
Prevention and Control (ECDC), to address these
important issues. The outcome of this meeting
will be reported separately.

Discussion
----------
This is by far the largest community outbreak of
Q fever ever reported in the literature. Other
European countries such as Denmark and Germany
have also reported a changing epidemiology of Q
fever and an increase in cases in 2008 but not to
the same extent as in The Netherlands (7,8). The
sharp increase in cases in the spring and the
widespread pattern of this community outbreak
with more than 600 cases reported in 2008 is
alarming. This high number of notified cases is
partly explained by an increased awareness of Q
fever among general practitioners (GP),
specialists and medical microbiological
laboratories, especially in the region where the
2007 outbreak occurred. We hypothesize that this
has also led to a different diagnostic approach
and earlier diagnosis of suspected cases, leading
to less hospital admissions in the notified
cases. Signals from rural GP practices indicate,
however, that there is an unprecedented marked
and striking increase in pneumonia and signs and
symptoms associated with Q fever in their patient
population [personal communication].

To date there has been no conclusive evidence as
for the source(s) of the epidemic. Although a
single animal source can cause many human Q fever
cases (9), the larger geographic area in which
cases occur in 2008, compared to 2007, points at
multiple sources. Several studies to assess the
risk factors for Q fever in the general
population, high-risk groups, and in ruminants
are ongoing or starting in the near future
including source investigations focusing mainly
at small ruminant farms and pet farms.

We hope through this paper to raise awareness of
this problem and inspire colleagues from other
European countries to report whether they have
observed similar increase in Q fever case numbers
and share their experience.

References
----------
1. Carcopino X, Raoult D, Bretelle F, Boubli L,
Stein A: Managing Q fever during pregnancy: the
benefits of long-term cotrimoxazole therapy. Clin
Infect Dis. 2007;45: 548-555.
2. RIVM. Q fever. Available from:
<http://www.rivm.nl/cib/infectieziekten-A-Z/infectieziekten/Q_koorts/index.jsp>.
3. van Gageldonk-Lafeber AB, Koopmans MPG,
Bosman A, Heijnen MLA: Surveillance of Q fever in
the Netherlands. Infectieziektebulletin 2003; 14:
173-177. Available from:
<http://www.rivm.nl/infectieziektenbulletin/bul1405/art_qkoorts.html>
4. Karagiannis I, Morroy G, Rietveld A, et al: A
Q fever outbreak in the Netherlands: a
preliminary report. Euro Surveill. 2007.
Available from:
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=3247>.
5. [Q-fever designated as an infectious
reportable animal disease] Staatscourant 10 June
2008, nr. 109, page 15. Available from:
<http://overheid-op.sdu.nl/cgi/login>.
6. [Regulation containing measures for
prevention of Q-fever] Staatscourant 13 June
2008, nr. 112, page 18. Available from:
<http://overheid-op.sdu.nl/cgi/login>.
7. Villumsen S, Nielsen HI: [Q fever Äì a new
zoonotic disease in Denmark? The Danish Society
for Infectious Diseases] Ugeskr Laeger. 2008;170:
1033.
8. Robert Koch Institute. Increased occurrence
in Q-fever in spring 2008. Epidemiologisches
Bulletin 25/2008, 20 June 2008, Germany.
Available from:
<http://www.rki.de/cln_091/nn_494986/DE/Content/Infekt/EpidBull/Archiv/2008/25__08,templateId=raw,property=publicationFile.pdf/25_08.pdf>.
9. Porten K, Rissland J, Tigges A, et al: A
super-spreading ewe infects hundreds with Q fever
at a farmers' market in Germany. BMC Infect Dis.
2006; 6:147.

[Byline: Schimmer B, Morroy G, Dijkstra F, et al.]

--
Comunicated by:
ProMED Rapporteur Brent Barrett

[This Eurosurveillance report further documents
this large Q fever outbreak in southern
Netherlands. The location of the southern
provinces of Noord-Brabant (North Brabant) and
Gelderlnad can be found on map at
<http://www.amsterdam.co.kr/general/maps/nl_map_provinces.gif>. - Mod. LL]

*****
[2] Ministry of Agriculture, Nature and Food Quality Press Release
Date: Wed 31 Jul 2008
Source: Press release, Ministry of Agriculture,
Nature and Food quality [trans. from Dutch by
Mod.AS, edited]
<http://www.minlnv.nl/portal/page?_pageid=116,1640333&_dad=portal&_schema=PORTAL&p_news_item_id=23507>

New measures Q-fever outbreak Brabant
-------------------------------------
An executive consultation on the Q-fever outbreak
in Brabant has been held today [31 Jul 2008].
Representatives of the ministries of Agriculture
and Health, Animal Health Services (GD), National
Institute of Health and Environment (RIVM), the
Food and Consumer Product Safety Authority (VWA)
and administrators from the region discussed
measures to be taken in order of controlling the
outbreak.

During today's [31 Jul 2008] administrative
consultations, the following 4 short-term
decisions were made:

- Recently, the GD (Animal Health Services) have
issued guidelines for goat farms about the
prevention of Q-fever dissemination. The VWA will
carry out, during the coming 2 weeks, visits to
all goat holdings in the affected areas in order
to follow up the implementation of the said
guidelines.

- The Ministry of Agriculture will work with the
VWA to ensure that hobby goat farmers are updated
about the hygienic requirements.

- The Ministry of Agriculture will consult
shortly manure-treatment experts about possible
measures to limit the dissemination of the
bacterium during the withdrawal process of the
manure from the animal dwellings [pen barns].

- The Ministry of Agriculture will investigate,
in a short term, whether the vaccination of goats
against Q fever is useful and possible.
Subsequently, the efficacy, safety and
availability of vaccines will be addressed.

For the longer term, it was decided that RIVM
will make proposals for further studies into the
routes of transmission to man from the
environment and from animals.

At present, the accumulated number of Q fever
cases in humans is 686 [since Jan 2008]. The
cases have been reported from the eastern half of
Noord Brabant and from south Gelderland [Map at
<http://www.map-of-netherlands.co.uk/images/netherlands-politcal-map.jpg>
- Mod.AS].

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******
[3] Animal Health Service
Date: Fri 1 Aug 2008
Source: Agrarisch Dagblad [trans. and abridged from Dutch by Mod.AS, edited]
<http://www.agd.nl/1057833/Nieuws/Artikel/Overal-antistoffen-Q-koorts.htm>

Antibodies against the bacterium _Coxiella
burnetii_, the causative agent of Q fever, are
found throughout the country in sheep and goats.
This is evident from the 1st results of an
investigation of the Animal Health Service (GD).
However, the percentage of animals with
antibodies [outside the infected provinces, in
the South] has been low, as demonstrated by the
results of blood tests. "These preliminary
results have been expected," says veterinarian
Piet Vellema of the GD. The final results are
expected early next year [2009].

Vellema calls it remarkable that only in the
south of the country there are [heavily] infected
farms, and that human infections are limited to
that area. "It is not clear how the
contamination on holdings took place. Possibly,
an animal carrier had been present in the flock
for extended period before wider spread occurred"
[This is indeed a possible mechanism of Q fever's
dynamics, when wider infection follows a
parturition or abortion of a single or few
infected silent carrier(s). - Mod.AS]

There are also holdings that have not suffered
abortions in spite of the presence of animals
infected with _Coxiella burnetii_. "The
possibility exists that other species play a role
in the dissemination of the bacterium, since it
is not species-specific. But here we know too
little."

The knowledge about Q-fever deserves to be intensified, said Vellema.

[Byline: Mariska Vermaas]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[Additional background and data on the 2 major Q
fever outbreaks in the Netherlands, in 2007 and
2008, are available on-line at:

1. Q fever outbreak in the Netherlands: a
preliminary report. Eurosurveillance, Volume 12,
Issue 32, 09 August 2007
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=3247#0>

2. Large ongoing Q fever outbreak in the south
of The Netherlands, 2008. Eurosurveillance,
Volume 13, Issue 31, 31 July 2008 [1 above]
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=18939>

According to OIE's WAHID interface, Q fever in
animals became notifiable in the Netherlands
since 2006. Though such disease-status should
enable quantitative information on the incidence
of the disease, the Dutch report for 2006, while
indicating that the disease was present, did not
provide figures. The interface does not include
any information on Q fever in the Netherlands,
since Jan 2007.

Article 1.1.2.3. of OIE's Terrestrial Animal
Health Code says that a member country is obliged
to notify, within 24 hours, any of the following
(6) events:

- the 1st occurrence of a listed disease listed
disease and/or infection in a country, a zone or
a compartment;

- re-occurrence of a listed disease and/or
infection in a country, a zone or a compartment
following a report declared the outbreak ended;

- the 1st occurrence of a new strain of a
pathogen of an OIE listed disease in a country, a
zone or a compartment;

- a sudden and unexpected increase in the
distribution, incidence, morbidity or mortality
of a listed disease prevalent within a country, a
zone or a compartment;

- an emerging disease with significant morbidity
or mortality, or zoonotic potential;

- evidence of change in the epidemiology of a
listed disease (including host range,
pathogenicity, strain) in particular if there is
a zoonotic impact.

Notifications, follow-up reports, and 6-monthly
summaries to the OIE are long due. - Mod.AS]

See Also