Chris Whiteside, CCDC, North Wales NPHS Staff Conference 23 rd October 2008

1. Q fever Chris Whiteside, CCDC, North Wales NPHS Staff Conference 23rd October 2008

2. Q fever • What is it? • How do you catch it? • Symptoms • Case studies from North Wales • Summary • Queries and concerns

3. What is Q fever Infection caused by a bacterium called Coxiella burnetii It is a zoonosis, i.e. can be transmitted from animals to humans Called Q (Query) fever for many years, as the cause was unknown Around 50 cases of Q fever reported each year Infection can cause a range of illness from no symptoms to severe disease May cause outbreaks of illness

4. Bacterium Coxiella burnetii Carried by a wide range of animals: sheep, cattle, goats; birds, bats; domestic animals; rodents and ticks Can survive as a highly resistant spore-like form in the environment for many months or years Found in almost every country in the world apart from New Zealand

5. Q fever in animals • Usually asymptomatic • Prevalence in UK herds and flocks unknown • Can cause inflammation of the placenta and abortions • Not a common cause of abortion, but may cause outbreaks • No formal vaccine programmes for livestock • Written advice for farmers is available (Defra and HPA websites)

6. How to catch it - transmission to humans Infectious dose can be as low as one organism The most infectious materials are amniotic fluid of sheep, goats, cattle and cats; also their milk, blood, urine and faeces Transmission occurs through inhalation of contaminated aerosols, or infectious dust Often transmitted through contaminated bedding or litter directly from placenta or amniotic fluid dried windborne material especially from burning animal bedding via tick bites Human to human transmission very rare

7. Symptoms - Q fever in humans Incubation period usually 2-3 weeks (up to 40 days) Often asymptomatic Seroprevalence in country-dwellers has been shown to be up to 27% Acute Q fever - self-limiting febrile illness, hepatitis or community-acquired pneumonia Flu-like symptoms of varying degree, with myalgia, fever, headaches, sweats, joint and muscle pains, weight loss, dry cough, pneumonia, chest / abdo pain Chronic Q fever - endocarditis, hepatitis, infection of vascular grafts or aneurysms, chronic chest infection Acute:chronic cases 100:1

8. Diagnosis and treatment Serological tests as soon as possible during the acute illness, and again three weeks from onset Usually no treatment required For more severe symptoms, doxycycline 200mg o.d. for 2 weeks Early treatment gives a better outcome

9. Prevention and control Farmers: good hygiene at lambing, effective composting of waste, safe disposal of bedding materials, separation of infected animals No formal vaccine programme for animals A vaccine (Q Vax) for humans is available to at-risk groups in Australia Tick control Avoidance: people in high risk groups - pregnant women, immunosuppressed, valvular heart disease, should stay away from sheep giving birth, and avoid occupations with risk of exposure

10. Case 1, aged 47 Steve, aged 47, lives near Mold

11. Case 1 Lives near Mold Digital telephone engineer, works all over England and Wales Past history - vit B12 deficiency - pleurisy x2 late 1980s and early 1990s - high blood pressure since 2002 Tues 29th April 2008 developed flu-like symptoms, headache and anorexia while away on a course Wed 30th felt worse and drove home, feeling very weak, having to stop and rest several times on the way back Arrived home pouring sweat, also diarrhoea and vomiting Rang NHSD who advised paracetamol Thurs 1st May pm developed pains in back and went to A&E Wrexham Maelor

12. Case 1 Clinical examination at A&E: fever, expiratory wheeze, and enlarged liver Investigations: normal CXR, ?abnormal ECG, blood tests +++ Initial diagnosis: pericarditis, admitted under cardiologist Friday 2nd May – remained very poorly, looked awful, temp 39.6. CXR – shadow R lung Diagnosis: atypical pneumonia? mycoplasma / legionella ….. Rx iv antibiotics clarithromycin and cefotaxime Admitted to High Dependency Unit Mycoplasma/legionella – urine tests negative Sunday 4th May – antibiotics changed to levofloxacin, clarithromycin and rifampicin Transferred to respiratory ward and improved over next few days Discharged once mobile

13. Case 1 Back at home, still felt very weak, wobbly, unable to lift heavy objects, slept a lot, thrush on tongue, noticed his skin reacted to sunlight 27th June - follow up appt resp physician, serology tests carried out 1st Aug - results rung through to HPT office from CoCH lab Q fever antibodies positive IgG > 1280 IgM > 1280 Phase 1 CFT < 16 Phase 2 CFT > 512

14. Case 1 13th Aug, interview carried out at home (CW) Purpose: To give information on Q fever Discussion of clinical progression of his disease Exploration of possible sources of infection Identification of other linked cases Control measures if needed Steve lives in a rural area with his partner, two dogs, chickens and two horses

16. Case 1 Animal contacts : Sheep and lambs in surrounding fields Goats kept by neighbours 2 dogs, 2 horses, chickens at home Horses are fed hay, 200 bales per year He bought fresh hay on 18th April 2008, which was kept in stables Old hay was kept in the ‘small room’ next to the stable, and usually taken to the tip for disposal

20. Case 1 Steve had been on holiday during winter 2007, and a neighbour had (over-) fed the chickens Excess chicken feed strewn around the property Rats came in and nested in the old hay

21. Case 1 • The old hay was not useable as horse fodder, and so he decided to give it to the neighbours to build a goat house • 12th May: lifted and transferred the hay bales in his trailer • Onset of illness 29th May fits with incubation period (17 days)

22. Case 2, aged 32 Computer technician, works in peoples homes in Anglesey and Conwy Lived in Anglesey for 8 years Partner aged 29, and was 20 weeks pregnant 16th April 2008 he became ill with headache Next few days became worse with malaise, aching legs, feverish, dry cough and sob, anorexia, muscle and joint pains 20th April increasing weakness and noticed he had brown urine

23. Case 2 999 call, admitted to hospital Diagnosed with rhabdomyolysis and respiratory failure and admitted to ITU Intubated and ventilated for 8 days On haemofiltration for several weeks Q fever serology positive, notified to HPT on 16th May Interviewed on renal ward 20th May

24. Case 2 - possible sources of infection Pets: a cat and a bull terrier 30 sheep kept in field 10 metres from house, where they lambed in early April He walked past one sheep in labour Fits in with incubation period for onset of disease (16th April)

25. Case 3, aged 59 Lives near Wrexham, works as a hospital maintenance electrician 24th June: sudden onset of flu-like illness while away on a course Symptoms – fever, sweats, cough, sob, chest pains 3rd July: admitted to Wrexham Maelor Pneumonia diagnosed Discharged without a specific diagnosis Serology showed acute Q fever 1st August

26. Case 3 - possible sources of infection

27. Q fever summary Zoonosis Highly resistant organism Under-reported illness Difficult to diagnose clinically Often there are no symptoms Source often not found It is important to consider Q fever in cases of flu-like illness or atypical pneumonia May cause severe illness, particularly in vulnerable groups

28. Potential as a bioterrorism agent • Easy to obtain • Present worldwide in farm animals • Potential agroterrorism agent – no clinical signs in animals • Environmental persistence > 1 year • Resistant to common disinfectants • Airborne dissemination • Easily inhaled by humans • Low infective dose • Naïve target population – no vaccine outside Australia • Not usually life-threatening, but potential for life-threatening sequelae • Major impact – Panic !

29. Source Queries Receptor What are the animal reservoirs? Why is it not more common? What is the prevalence in these animals? How is it transmitted to humans? Pathway How is it spread in the environment? Why are some people unaffected? Others are seriously ill