Zoonotic Diseases

Diseases discussed here have a history of use as an agent for biological warfare, either in the U.S. or abroad. Its use may have been experimental or actual, and any detrimental consequences upon humans, animals or the environment may have been intentional or not, depending on the circumstances, the point in time, and the nature of the disease.

Monday, February 14, 2011

Q Fever Epidemic in Netherlands Continues to Grow: More Humans Infected Than Ever

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A ProMED-mail post

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International Society for Infectious Diseases

Date: Sat 12 Feb 2011
Source: Examiner.com [edited]

The outbreak that started in 2007 continues into its 5th year in the
Netherlands. As of 2 Feb 2011, there were 8 more confirmed cases so
far in 2011.

Since 2007, there have been more than 4000 cases and several deaths,
including 11 deaths in 2010.

Though the cases have been seen throughout the country, the US
Centers for Disease Control and Prevention (CDC) notes that most of
these cases have been in Noord (North) Brabant, Gelderland, Limburg,
and Utrecht Provinces in the southern part of the country. The CDC
offers the following prevention recommendations for US travelers to
the Netherlands:
- Avoid farms in the affected areas.
- If you cannot avoid visiting farms, avoid going near areas where
animals are kept, such as barns and pens, and avoid direct contact
with animals.
- Breathing in soil and dust contaminated by animals can make you
- Eat only milk and dairy products that have been pasteurized. Do not
drink raw milk or eat raw milk products.
- Wash your hands often with soap and water, especially if you have
been near animals. If soap and water are not available, use an
alcohol-based hand gel with at least 60 percent alcohol.
- Pay attention to your health after your trip. People can become
sick with Q fever 2-5 weeks after being exposed to the disease. If you
feel sick, go to the doctor and tell him or her that you have traveled
to The Netherlands.

Q fever is caused by the obligate intracellular pathogen, _Coxiella
burnetii_. The disease is usually transmitted to people through either
infected milk or through aerosols. This disease is found on most
continents with the reported incidence probably much lower than the
actual because so many cases are so mild. Animal reservoirs of _C.
burnetii_ include sheep, cattle, goats, dogs and cats. In areas where
these animals are present, Q fever affects veterinarians, meatpacking
workers and farmers. Q fever is also considered a potential agent of

The symptoms of Q fever according to the CDC are an unexplained
febrile illness, sometimes accompanied by pneumonia and/or hepatitis,
the most common clinical presentation. Illness onset typically occurs
within 2-5 weeks after exposure. The mortality rate for acute Q fever
is low (1-2 percent), and the majority of persons with mild illness
recover spontaneously within a few weeks, although antibiotic
treatment will shorten the duration of illness and lessen the risk of
complications. Chronic Q fever is uncommon (less than one percent of
acutely infected patients) but may cause life-threatening heart valve
disease (endocarditis).

[Byline: Robert Herriman]

Communicated by:

Date: Sun 6 Feb 2011
Source: IMED 2011, Vienna, Austria, 4-7 Feb 2011. Session 17 "Q Fever
in the Netherlands," abstract 17.001 [edited]

Q fever in the Netherlands: The animal health aspects. By Christianne
Bruschke, CVO, Ministry of Economic Affairs, Agriculture and
Innovation, The Hague, Netherlands

Up to 2007, some 20 people became infected yearly with Q fever, a
zoonotic disease. Suddenly in 2007, 170 people fell ill, and in 2008
there were 1000 cases. In 2009, there were more than 2300 known cases
of people becoming infected. Experts believed that there was a
relationship between Q fever abortions on milking goat and milking
sheep farms and the sharp increase in the numbers of human

In the Netherlands, several measures were taken between June 2008 and
December 2009 to control Q-fever in animals. Measures were directed in
particular at the dairy goat and sheep sector, but measures were also
taken for small ruminants that come into close contact with the
general public. Q fever in sheep and goats was made notifiable in June
2008. Hygiene measures, transport restrictions and restrictions for
visitors were implemented. Vaccination with a non-licensed vaccine was
performed in a restricted area in 2008 (voluntary) and 2009

In October 2009, monitoring based on bulk milk PCR was started to
detect infected farms. Knowing that the vaccine was not fully
efficacious in infected or pregnant animals, and having the
possibility to detect infected farms at the end of 2009, the
responsible ministers took the following decisions:
1. cull all pregnant animals on infected farms
2. a nationwide breeding ban for dairy sheep and goats
3. a compulsory vaccination program for the whole country in 2010.

With these very drastic measures, further contamination of the
environment during the lambing season would be prevented. Breeding
would be only allowed thereafter with animals coming from non-infected
vaccinated farms.

In 2010, the number of human patients with Q-fever was 382. As of
now, the focus of the measures is to prevent another outbreak, with
yearly vaccination of the dairy goat and sheep population.

[Byline: C. Bruschke]

Communicated by:

Date: Sun 6 Feb 2011
Source: IMED 2011, Vienna, Austria, 4-7 Feb 2011. Session 17 "Q Fever
in the Netherlands," abstract 17.002 [edited]

Q fever in the Netherlands: The public health aspects. By J. Van
Steenbergen, W. V. D. Hoek, D. Notermans, C. Wijkmans & T. Oomen.

Background: From 2007 through 2009, The Netherlands faced a series of
multiple Q fever outbreaks in the southern part of the country. Q
fever was specifically seen in the vicinity of dairy goat farms where
abortion waves due to _Coxiella burnetii_ occurred.

Methods and Materials: Seroprevalence of antibodies against _Coxiella
burnetii_ was tested in 2006 in a random sample of the population
(ELISA phase I and II). Hospital discharge data were used in
retrospect to find previously undetected clusters in time and space.
Incidence of acute Q fever was calculated using notification data.
Smoothing incidence lines were calculated using 6 digit area codes. A
case control study was performed in 2007. A sample of blood donors
originating from the areas with highest incidence was tested twice in
2009 with IFA. A sample of sera from the pregnancy screening (e.g.
HBsAg, lues) was tested for antibodies against _Coxiella burnetii_.

Results: In 2006, the seroprevalence of antibodies against _Coxiella
burnetii_ in The Netherlands was low (less than 2.7 percent). Before
2007, small clusters of lower respiratory tract infections went
undetected. Incidence of Q fever increased from 192 in 2007, to 1000
in 2008 and over 2300 in 2009. Risk for acute Q fever was increased
for males in age group 45-55 yrs and living in proximity of infected
goat farms, not living near infected sheep farms. In areas where blood
donor infection rate could be ascertained, only an estimated 12
percent of infections are leading to microbiologically confirmed
disease. Preliminary data show no serious adverse events of infection
during pregnancy on pregnancy outcome.

Conclusion: The total number of reported acute Q fever cases
approaches 4000. Living near infected dairy goat farms was the major
risk factor. The number of chronic infections with serious
complications remains unknown.

[Byline: J. Van Steenbergen, W. V. D. Hoek, D. Notermans, C. Wijkmans
& T. Oomen]

Communicated by:

Date: Sun 6 Feb 2011
Source: IMED 2011, Vienna, Austria, 4 - 7 Feb 2011. Session 17 "Q
Fever in the Netherlands," abstract 17.003 [edited]

Q fever in the Netherlands: _Coxiella burnetii_, laboratory aspects.
By: H.-J. Roest, Central Veterinary Institute of Wageningen, Lelystad,

Background: _Coxiella burnetii_ is a Gram-negative intracellular
bacterium, which belongs to the family of the Coxiellaceae and the
order of the Legionellales. Two phases of the bacterium can be
distinguished: phase I, associated with full length lipopolysaccharide
(LPS) and phase II, associated with truncated LPS. In the life cycle
of _C. burnetii_, 2 stages can be distinguished. The Large Cell
Variant (LCV), which is able to multiply, and the Small Cell Variant
(SCV), the spore-like form in which _C. burnetii_ is resistant to
outside influences.

Methods and Materials: Genotyping was performed by MLVA [Multiple
Loci Variable Number of Tandem Repeats Analysis].

Results: The link between dairy goats as the source of human Q fever
cases in the Netherlands has been made on the basis of epidemiological
evidence. Genotyping of _C. burnetii_ is a tool to further investigate
the connection between source and host. Using MLVA, the connection
between sheep and humans in a small Q fever outbreak in the
Netherlands could be made. MLVA was also used to type a considerable
number of goat samples from goats that were considered to be the
source of the Q fever outbreak in the Netherlands. Results show that
one MLVA type is predominantly present on all dairy goat farms in the
epidemic area in the south of the Netherlands.

_C. burnetii_ contaminated goat manure is considered to be a major
factor in the transmission to humans. Little is known about the
temperature build-up in goat manure piles and the influence of the
composting process on _C. burnetii_. In a joint effort of national
research institutes, temperatures and numbers of _C. burnetii_ in goat
manure and the decimal reduction time of _C. burnetii_ under these
conditions were assessed. Results of this study [have been

Conclusion: Results on genotyping show that one MLVA type is
predominantly present on all dairy goat farms in the epidemic area in
the south of the Netherlands. This MLVA type should also be found in
infected humans. Research on this in ongoing. Conclusions on the
results of the survival of _C. burnetii_ [have been] given during the

[Byline: H.J. Roest]

Communicated by:

[The IMED 2011 International Meeting on Emerging Diseases and
Surveillance, held in Vienna, Austria, 4-7 Feb 2011, was organized by
the International Society for Infectious Diseases. It was co-sponsored
by ProMED-mail, EcoHealth Alliance, European Centre for Disease
Prevention and Control (ECDC), European Commission (EC), European
Society of Clinical Microbiology and Infectious Diseases (ESCMID),
HealthMap, Wildlife Conservation Society (WCS) and the World
Organisation for Animal Health (OIE).

Though the exceptionally high number of human infections in the
affected Dutch districts during 2008-2009, was mainly attributed to
the development of dairy-goat mega-farms during recent years, the
possibility that this epizootic was caused by a strain of the
bacterium with particular characteristics deserves attention. Final
results are anticipated with great interest. - Mod.AS]

[see also:
Q fever - Netherlands (31): (NB) investigation report 20100930.3546
Q fever - Netherlands (30): peaked, mitigation measures
Q fever - Netherlands (29): update 20100716.2382
Q fever - Netherlands (27): risk assessment, Europe 20100525.1742
Q fever - Netherlands (26): update, EFSA 20100512.1544]
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