Q Fever Outbreak in the Province of Noord-Brabant: Overview and Measures

Author(s): R. Dumont*1, C. Wijkmans2, P. Schneeberger3, S. Lutgens4
Affiliation(s): 1Healthcare department, Province of Noord-Brabant, 2Infectious diseases department, Public health service GGD Hart voor Brabant, 3Microbiology department, Jeroen Bosch hospital, ‘s-Hertogenbosch, 4Microbiology department, Maastricht University Medical Centre, Maastricht, Netherlands
Keywords: Coxiella burnetii, Q fever, zoonosis, outbreak, one medicine concept, the Netherlands
Background:

Since the year 2007, three consecutive outbreaks of Q fever have been reported in the Netherlands. The ongoing 2009 outbreak in the north-eastern part of the province of Noord-Brabant is the largest community outbreak ever, with 2,204 cases reported until October 8, 2009. The hospitalisation rate of cases was 20,4%. Six patients died as a result of this infection. The changing epidemiology of Q fever has not yet been clarified, but it is highly suspected that many of the cases are associated with infected goats and sheep living in intensive farms. Agricultural and public health ministries, branches, health services, and the province work together intensively in order to stem the tide of the disease, and ultimately prevent human cases in the future. This is an example of the “one medicine concept”, which focuses on the commonality of human and veterinary medicine.

Results/Conclusions: This is by far the largest community outbreak of Q fever ever reported in scientific literature. The severe increase in cases and the widespread pattern of this outbreak with more than 2,200 cases reported from January until October 2009 is alarming. This high number of notified cases is partly due to an increased awareness of Q fever among general practitioners (GP), specialists, public health services and medical microbiological laboratories, especially in the region where the outbreaks have occurred. Presumably, this has also led to a different diagnostic approach and earlier diagnosis of suspected cases. Signals from rural GP practices indicate, however, that there is an unprecedented, striking increase in pneumonia and signs and symptoms associated with Q fever amongst their patients. Conclusive evidence as for the sources of the epidemic has yet to be discovered. Although a single animal source can cause many human Q fever cases, the larger geographic area in which cases occur in 2009, compared to 2007 and 2008 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 in progress or starting in the near future. Currently more than 3 million Euros is available for the research agenda, nationwide. The measures are expected to control the disease but must not deserve too much optimism in the short term. A reduction of Q fever patients is not expected in 2010, at most stabilized. This is due to the scarcity of vaccines in 2009 and the large scale of the outbreak. Another reason is that C. burnetii survives in the environment between particles. This year, over 2,204 people with Q fever are reported. Six people in the Netherlands deceased due to Q fever. All had a different underlying condition. Despite the expected positive effects of the measures, people will still fall ill in 2010. However, national, regional and local administrators, human and veterinary experts increasingly work together to solve the questions regarding the Q fever outbreak. The battle continues. All organizations invest heavily in cooperation although they have conflicting interests. The public health is important in the choice of measures. But the expected effectiveness, feasibility and proportionality of the proposed measures have to be balanced before a decision is taken. New knowledge is continuously becoming available, thus the measures are continuously being adjusted. It is important to take verifiable measures which have the support of parties and can be enforced. This requires agreement on the measures to be taken. Some organizations characterize the discussions and compromises as swimming against the tide.

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