The rise and control of the 2007–2012 human Q fever outbreaks in the Netherlands

A systematic review of global Q fever outbreaks

Q fever is an important zoonotic disease with a worldwide distribution. Outbreaks of Q fever are unpredictable and can affect many people, resulting in a significant burden on public health. The epidemiology of the disease is complex and substantial efforts are required to understand and control Q fever outbreaks. The purpose of this study was to systematically review previous investigations of outbreaks and summarise important epidemiological features. This will improve knowledge of the factors driving the occurrence of Q fever outbreaks and assist decision makers in implementing mitigation strategies. A search of four electronic databases identified 94 eligible articles published in English between 1990 and 2022 that related to 81 unique human Q fever outbreaks. Outbreaks were reported across 27 countries and mostly in industrialised nations. Documented Q fever outbreaks varied in size (2 to 4107 cases) and duration (4 to 1722 days). Most outbreaks (43/81) occurred in communities outside of traditional at-risk occupational settings and were frequently associated with living in proximity to livestock holdings (21/43). Indirect transmission via environmental contamination, windborne spread or fomites was the most common route of infection, particularly for large community outbreaks. Exposure to ruminants and/or their products were confirmed as the principal risk factors for infection, with sheep (28/81) as the most common source followed by goats (12/81) and cattle (7/81). Cooperation and data sharing between human and animal health authorities is valuable for outbreak investigation and control using public health and veterinary measures, but this multisectoral approach was seldom applied (14/81). Increased awareness of Q fever among health professionals and the public may facilitate the early detection of emerging outbreaks that are due to non-occupational, environmental exposures in the community.

Molecular epidemiology of Coxiella burnetii infection in sheep and goats in Henan province, China

Q fever is a significant zoonotic disease caused by Coxiella burnetii, an obligate intracellular gram-negative bacterium. Although C. burnetii infection has been identified in various animal species, domestic ruminants serve as the primary reservoirs and main sources of human infection. Understanding of the epidemiology of C. burnetii in domestic ruminants is crucial for preventing and controlling of C. burnetii infection in humans. In this study, spleen tissues from sheep and goats were collected in Hennan province, China. Through PCR screening, C. burnetii was detected in sheep and goats in Henan province with an overall infection rate of 6.8 %. Sequence comparison and phylogenetic analysis revealed that all newly identified C. burnetii strains shared a close genetic relationship with those found in humans worldwide. These findings highlight the high risk of C. burnetii infection among slaughterhouse workers and emphasize the importance of epidemiological studies that investigate samples from both humans and animals within the "One Health" framework. Such surveillance will contribute to a better understanding of the epidemic situation and aid in the development of effective prevention and control strategies for C. burnetii infections in humans.

Data analysis supports monitoring and surveillance of goat health and welfare in the Netherlands

Monitoring and surveillance systems have an increasingly important role in contemporary society ensuring high levels of animal health and welfare, securing export positions, and protecting public health by ensuring animal health and product safety. In the Netherlands, a voluntary monitoring and surveillance system is in place since 2003 to provide a broad overview of livestock trends in addition to disease-specific surveillance systems, including insight into the occurrence and prevalence of new and emerging non-notifiable diseases and disorders. Being a major surveillance component of this monitoring and surveillance system for small ruminant health in the Netherlands, an annual data analysis on routine census data is performed to retrospectively monitor trends and developments regarding goat health and welfare. This paper aims to describe the process of the data analysis on goat farms in the Netherlands in 2020 and subsequent results are discussed. The data analysis provides key monitoring indicators such as animal and farm density, mortality, animal movements, and numbers and origin of imported small ruminants. Trends were analysed over a five-year, period and associations between herd characteristics and herd health are evaluated. Results showed that in 2020 the Dutch goat population consisted of 670,842 goats, distributed over 14,730 unique herds and increased by 2.3 % compared to 2019. Between 2016 and 2020, although probably underestimated, recorded mortality rates showed a decline on both small-scale and professional farms, with a strongest decrease on farms with herd sizes over more than 200 animals. Seventy-five percent of all professional farms registered animal introductions, in addition to 63 % of small-scale farms, including 2439 imported goats. Performing risks analyses requires demographic knowledge of the goat industry. During and after several disease outbreaks, such as bluetongue and Schmallenberg virus disease, the data analysis proved to function as a valuable tool, however, appeared just as important for recording outbreak-free data. Since its start in 2006, the concept of the data-analysis has continuously been improved, and will in the future be further developed, especially if more complete data sets become available. Subsequently, data analysis will increasingly support monitoring and surveillance of goat health and welfare.

Loss of Caprine Arthritis Encephalitis Virus (CAEV) Herd Accreditation: Characteristics, Diagnostic Approach, and Specific Follow-Up Scenarios on Large Dairy Goat Farms

The retrovirus causing caprine arthritis encephalitis (CAE), a slowly progressive inflammatory disease in goats, belongs to the group of small ruminant lentiviruses (SRLVs) which cause lifelong infections that ought to be avoided for animal welfare as well as economic reasons. SRLV accreditation has been in place for forty years in The Netherlands and is based on the screening of small ruminant sera for specific antibodies. This paper evaluates 38 dairy goat herds that lost CAEV accreditation between 2012 and 2022. The characteristics of these herds are discussed, and specific follow-up scenarios, depending on desired goals, are introduced. The herd size of the participating herds varies from approximately 400 to 4600 adult dairy goats. The larger herds tended to be more prone to lose herd accreditation and had more difficulties regaining accreditation. Possible routes of introduction are lined up. The Royal GD's tailor-made approach and advice to support livestock farmers with herds that have lost CAE accreditation are discussed in detail. Specific emphasis is placed on the strategic deployment of various diagnostic tests (such as antibody ELISAs and PCR) in different media, such as (pooled) sera, (bulk)milk and tissue samples. Special attention is paid to the added value of retrospective bulk milk testing or the specific testing of groups based on housing and management, which enables the investigation of the moment of viral introduction and route of transmission into a herd. Furthermore, the prospective implementation of bulk milk and strategic pooled milk sample testing in the Dutch SRLV accreditation programs intensifies surveillance and enables the taking of swift action to prevent further transmission within and between herds. An appeal is made to share experiences to improve programs collectively, and to start research into the underlying mechanisms.

Q Fever—A Neglected Zoonosis

Q fever remains a neglected zoonosis in many developing countries including Pakistan. The causing agent Coxiella (C.) burnetii is resistant to environmental factors (such as drying, heat and many disinfectants), resulting in a long-lasting infection risk for both human and animals. As the infection is usually asymptomatic, it mostly remains undiagnosed in animals until and unless adverse pregnancy outcomes occur in a herd. In humans, the infection leads to severe endocarditis and vascular infection in chronic cases. Limited data are available on molecular epidemiology and evolution of this pathogen, especially in ruminants. Genomic studies will help speculating outbreak relationships in this scenario. Likewise, pathogenesis of C. burnetii needs to be explored by molecular studies. Awareness programs and ensuring pasteurization of the dairy milk before human consumption would help preventing Q fever zoonosis.

Identifying scenarios and risk factors for Q fever outbreaks using qualitative analysis of expert opinion

Q fever is an important zoonotic disease perceived to be an occupational hazard for those working with livestock. Outbreaks involving large numbers of people are uncommon, but the increasing case incidence coupled with changing environmental and industry conditions that promote transmission of Q fever has raised concerns that large and serious outbreaks could become more frequent. The aim of this study was to use expert opinion to better understand how large Q fever outbreaks might occur in an Australian context and to document factors believed to be drivers of disease transmission. Focus groups were conducted with human and animal health professionals across several Australian states. All discussions were recorded, transcribed verbatim and imported into NVIVO for thematic analysis. Four anthropogenic risk factors (disease awareness, industry practices, land use, human behaviour) and three ecological risk factors (physical environment, agent dissemination, animal hosts) emerged from the data. Analysis of expert opinions pointed to the existence of numerous scenarios in which Q fever outbreaks could occur, many of which depict acquisition in the wider community outside of traditional at-risk occupations. This perception of the expansion of Q fever from occupational-acquisition to community-acquisition is driven by greater overarching economic, political and socio-cultural influences that govern the way in which people live and work. Findings from this study highlight that outbreaks are complex phenomena that involve the convergence of diverse elements, not just that of the pathogen and host, but also the physical, political and socioeconomic environments in which they interact. A review of the approaches to prevent and manage Q fever outbreaks will require a multisectorial approach and strengthening of community education, communication and engagement so that all stakeholders become an integrated part of outbreak mitigation and response.

Monitoring and Surveillance of Small Ruminant Health in The Netherlands

In contemporary society and modern livestock farming, a monitoring and surveillance system for animal health has become indispensable. In addition to obligations arising from European regulations regarding monitoring and surveillance of animal diseases, The Netherlands developed a voluntary system for the monitoring and surveillance of small ruminant health. This system aims for (1) early detection of outbreaks of designated animal diseases, (2) early detection of yet unknown disease conditions, and (3) insight into trends and developments. To meet these objectives, a system is in place based on four main surveillance components, namely a consultancy helpdesk, diagnostic services, multiple networks, and an annual data analysis. This paper describes the current system and its ongoing development and gives an impression of nearly twenty years of performance by providing a general overview of key findings and three elaborated examples of notable disease outbreaks. Results indicate that the current system has added value to the detection of various (re)emerging and new diseases. Nevertheless, animal health monitoring and surveillance require a flexible approach that is able to keep pace with changes and developments within the industry. Therefore, monitoring and surveillance systems should be continuously adapted and improved using new techniques and insights.

Dairy Sheep Played a Minor Role in the 2005-2010 Human Q Fever Outbreak in The Netherlands Compared to Dairy Goats

Q fever is an almost ubiquitous zoonosis caused by Coxiella burnetii. This organism infects several animal species, as well as humans, and domestic ruminants like cattle, sheep and goats are an important animal reservoir of C. burnetii. In 2007, a sudden rise in notified human Q fever cases occurred in The Netherlands, and by the end of 2009, more than 3500 human Q fever patients had been notified. Dairy sheep and dairy goats were suspected to play a causal role in this human Q fever outbreak, and several measures were taken, aiming at a reduction of C. burnetii shedding by infected small ruminants, in order to reduce environmental contamination and thus human exposure. One of the first measures was compulsory notification of more than five percent abortion within thirty days for dairy sheep and dairy goat farms, starting 12 June 2008. After notification, an official farm inspection took place, and laboratory investigations were performed aiming at ruling out or demonstrating a causal role of C. burnetii. These measures were effective, and the number of human Q fever cases decreased; levels are currently the same as they were prior to 2007. The effect of these measures was monitored using a bulk tank milk (BTM) PCR and an antibody ELISA. The percentage PCR positive dairy herds and flocks decreased over time, and dairy sheep flocks tested PCR positive significantly less often and became PCR negative earlier compared to dairy goat herds. Although there was no difference in the percentage of dairy goat and dairy sheep farms with a C. burnetii abortion outbreak, the total number of shedding dairy sheep was much lower than the number of shedding dairy goats. Combined with the fact that Q fever patients lived mainly in the proximity of infected dairy goat farms and that no Q fever patients could be linked directly to dairy sheep farms, although this may have happened in individual cases, we conclude that dairy sheep did not play a major role in the Dutch Q fever outbreak. BTM monitoring using both a PCR and an ELISA is essential to determine a potential C. burnetii risk, not only for The Netherlands but for other countries with small ruminant dairy industries.

Multispecies Q Fever Outbreak in a Mixed Dairy Goat and Cattle Farm Based on a New Bovine-Associated Genotype of Coxiella burnetii

A Q fever outbreak on a dairy goat and cattle farm was investigated with regard to the One Health concept. Serum samples and vaginal swabs from goats with different reproductive statuses were collected. Cows, cats, and a dog were investigated with the same sample matrix. The farmer's family was examined by serum samples. Ruminant sera were analyzed with two phase-specific enzyme-linked immunoassays (ELISAs). Dominant immunoglobulin G (IgG) phase II levels reflected current infections in goats. The cows had high IgG phase I and II levels indicating ongoing infections. Feline, canine, and human sera tested positive by indirect fluorescent antibody test (IFAT). Animal vaginal swabs were analyzed by qPCR to detect C. burnetii, and almost all tested positive. A new cattle-associated C. burnetii genotype C16 was identified by the Multiple-Locus Variable-number tandem repeat Analysis (MLVA/VNTR) from ruminant samples. Additionally, a possible influence of 17ß-estradiol on C. burnetii antibody response was evaluated in goat sera. Goats in early/mid-pregnancy had significantly lower levels of phase-specific IgGs and 17ß-estradiol than goats in late pregnancy. We conclude that the cattle herd may have transmitted C. burnetii to the pregnant goat herd, resulting in a Q fever outbreak with one acute human case. The influence of placentation and maternal pregnancy hormones during pregnancy on the immune response is discussed.

Applied Proteomics in 'One Health'

‘One Health’ summarises the idea that human health and animal health are interdependent and bound to the health of ecosystems. The purpose of proteomics methodologies and studies is to determine proteins present in samples of interest and to quantify changes in protein expression during pathological conditions. The objectives of this paper are to review the application of proteomics technologies within the One Health concept and to appraise their role in the elucidation of diseases and situations relevant to One Health. The paper develops in three sections. Proteomics Applications in Zoonotic Infections part discusses proteomics applications in zoonotic infections and explores the use of proteomics for studying pathogenetic pathways, transmission dynamics, diagnostic biomarkers and novel vaccines in prion, viral, bacterial, protozoan and metazoan zoonotic infections. Proteomics Applications in Antibiotic Resistance part discusses proteomics applications in mechanisms of resistance development and discovery of novel treatments for antibiotic resistance. Proteomics Applications in Food Safety part discusses the detection of allergens, exposure of adulteration, identification of pathogens and toxins, study of product traits and characterisation of proteins in food safety. Sensitive analysis of proteins, including low-abundant ones in complex biological samples, will be achieved in the future, thus enabling implementation of targeted proteomics in clinical settings, shedding light on biomarker research and promoting the One Health concept.

Ovine abortion and stillbirth investigations in Australia

Fetal loss and lamb mortality between mid-pregnancy and weaning are important economic and welfare issues for the Australian sheep industry. The aim of this study was to determine common causes of ovine abortion and stillbirths based on submissions to veterinary laboratories and identify factors that impact the determination of an aetiological diagnosis. Data for 529 investigations on abortion or stillbirth between 2000 and 2018 were retrieved from four state veterinary laboratories in Western Australia, South Australia, Victoria and Tasmania. An aetiological diagnosis was made for 57% of investigations. Investigations that included placental tissue samples were more than twice as likely to have an aetiological diagnosis compared to investigations without placenta (P = 0.017, 95% confidence interval 1.1, 4.5). Of the investigations where an aetiological diagnosis was made, 81% involved infectious abortion, with Campylobacter spp. (32%), Listeria spp. (25%) and Toxoplasma gondii (9%) being the three most common abortigenic pathogens implicated. The remaining 19% of investigations with an aetiological diagnosis included a wide range of infectious and non-infectious diseases. Diagnoses made varied year to year and between states. No evidence of exotic abortigenic pathogens were reported. Veterinary practitioners can improve the probability of an aetiological diagnosis by emphasising to farmers the importance of collecting any aborted material, especially placenta, and appropriate storage of the tissues until they can be submitted to the laboratory. Some diseases that cause abortion in Australian sheep have zoonotic potential, and veterinary practitioners play an important role in educating clients about appropriate hygiene when handling pregnant and lambing ewes or any aborted material.

Risk factors for an infection with Coxiella burnetii in German sheep flocks

In Germany, sheep are the main source of human Q fever epidemics, but data on Coxiella burnetii (C. burnetii) infections and related risk factors in the German sheep population remain scarce. In this cross-sectional study, a standardised interview was conducted across 71 exclusively sheep as well as mixed (sheep and goat) farms to identify animal and herd level risk factors associated with the detection of C. burnetii antibodies or pathogen-specific gene fragments via univariable and multivariable logistic regression analysis. Serum samples and genital swabs from adult males and females of 3367 small ruminants from 71 farms were collected and analysed using ELISA and qPCR, respectively. On animal level, univariable analysis identified young animals (<2 years of age; odds ratio (OR) 0.33; 95% confidence interval (CI) 0.13–0.83) to reduce the risk for seropositivity significantly (p < 0.05). The final multivariable logistic models identified lambing all year-round (OR 3.46/3.65; 95% CI 0.80–15.06/0.41–32.06) and purchases of sheep and goats (OR 13.61/22.99; 95% CI 2.86–64.64/2.21–239.42) as risk factors on herd level for C. burnetii infection detected via ELISA and qPCR, respectively.

Comparison of Coxiella burnetii Excretion between Sheep and Goats Naturally Infected with One Cattle-Associated Genotype

The main reservoir of Coxiella (C.) burnetii are ruminants. They shed the pathogen through birth products, vaginal mucus, faeces and milk. A direct comparison of C. burnetii excretions between naturally infected sheep and goats was performed on the same farm to investigate species-specific differences. The animals were vaccinated with an inactivated C. burnetii phase I vaccine at the beginning of the study period for public health reasons. Vaginal and rectal swabs along with milk specimens were taken monthly during the lambing period and once again at the next lambing season. To estimate the environmental contamination of the animals' housings, nasal swabs from every animal were taken simultaneously. Moreover, dust samples from the windowsills and straw beddings were collected. All samples were examined by qPCR targeting the IS1111 gene and the MLVA/VNTR typing method was performed. Whole genome sequencing was applied to determine the number of IS1111 copies followed by a calculation of C. burnetii genome equivalents of each sample. The cattle-associated genotype C7 was detected containing 29 IS1111 copies. Overall, goats seem to shed more C. burnetii through vaginal mucus and in particular shed more and for longer via the rectal route than sheep. This is supported by the larger quantities of C. burnetii DNA detected in caprine nasal swabs and environmental samples compared to the ovine ones. Transmission of C. burnetii from cattle to small ruminants must also be considered.

Relationship between Coxiella burnetii (Q fever) antibody serology and time spent outdoors

BACKGROUND/AIM

From 2007 through 2010, the Netherlands experienced the largest recorded Q fever outbreak to date. People living closer to Coxiella burnetii infected goat farms were at increased risk for acute Q fever. Time spent outdoors near infected farms may have contributed to exposure to C. burnetii. The aim of this study was to retrospectively evaluate whether hours/week spent outdoors, in the vicinity of previously C. burnetii infected goat farms, was associated with presence of antibodies against C. burnetii in residents of a rural area in the Netherlands.

METHODS

Between 2014-2015, we collected C. burnetii antibody serology and self-reported data about habitual hours/week spent outdoors near the home from 2494 adults. From a subgroup we collected 941 GPS tracks, enabling analyses of active mobility in the outbreak region. Participants were categorised as exposed if they spent time within specified distances (500m, 1000m, 2000m, or 4000m) of C. burnetii infected goat farms. We evaluated whether time spent near these farms was associated with positive C. burnetii serology using spline analyses and logistic regression.

RESULTS

People that spent more hours/week outdoors near infected farms had a significantly increased risk for positive C. burnetii serology (time spent within 2000m of a C. burnetii abortion-wave positive farm, OR 3.6 (1.2-10.6)), compared to people spending less hours/week outdoors.

CONCLUSIONS

Outdoor exposure contributed to the risk of becoming C. burnetii serology positive. These associations were stronger if people spent more time near C. burnetii infected farms. Outdoor exposure should, if feasible, be included in outbreak investigations.

One Health approach to controlling a Q fever outbreak on an Australian goat farm

A recent outbreak of Q fever was linked to an intensive goat and sheep dairy farm in Victoria, Australia, 2012-2014. Seventeen employees and one family member were confirmed with Q fever over a 28-month period, including two culture-positive cases. The outbreak investigation and management involved a One Health approach with representation from human, animal, environmental and public health. Seroprevalence in non-pregnant milking goats was 15% [95% confidence interval (CI) 7-27]; active infection was confirmed by positive quantitative PCR on several animal specimens. Genotyping of Coxiella burnetii DNA obtained from goat and human specimens was identical by two typing methods. A number of farming practices probably contributed to the outbreak, with similar precipitating factors to the Netherlands outbreak, 2007-2012. Compared to workers in a high-efficiency particulate arrestance (HEPA) filtered factory, administrative staff in an unfiltered adjoining office and those regularly handling goats and kids had 5·49 (95% CI 1·29-23·4) and 5·65 (95% CI 1·09-29·3) times the risk of infection, respectively; suggesting factory workers were protected from windborne spread of organisms. Reduction in the incidence of human cases was achieved through an intensive human vaccination programme plus environmental and biosecurity interventions. Subsequent non-occupational acquisition of Q fever in the spouse of an employee, indicates that infection remains endemic in the goat herd, and remains a challenge to manage without source control.

Coxiella burnetii infections in sheep or goats: an opinionated review

Q fever is an almost ubiquitous zoonosis caused by Coxiella burnetii, which is able to infect several animal species, as well as humans. Cattle, sheep and goats are the primary animal reservoirs. In small ruminants, infections are mostly without clinical symptoms, however, abortions and stillbirths can occur, mainly during late pregnancy. Shedding of C. burnetii occurs in feces, milk and, mostly, in placental membranes and birth fluids. During parturition of infected small ruminants, bacteria from birth products become aerosolized. Transmission to humans mainly happens through inhalation of contaminated aerosols. In the last decade, there have been several, sometimes large, human Q fever outbreaks related to sheep and goats. In this review, we describe C. burnetii infections in sheep and goats, including both advantages and disadvantages of available laboratory techniques, as pathology, different serological tests, PCR and culture to detect C. burnetii. Moreover, worldwide prevalences of C. burnetii in small ruminants are described, as well as possibilities for treatment and prevention. Prevention of shedding and subsequent environmental contamination by vaccination of sheep and goats with a phase I vaccine are possible. In addition, compulsory surveillance of C. burnetii in small ruminant farms raises awareness and hygiene measures in farms help to decrease exposure of people to the organism. Finally, this review challenges how to contain an infection of C. burnetii in small ruminants, bearing in mind possible consequences for the human population and probable interference of veterinary strategies, human risk perception and political considerations.

A probably minor role for land-applied goat manure in the transmission of Coxiella burnetii to humans in the 2007-2010 Dutch Q fever outbreak

In 2007, Q fever started to become a major public health problem in the Netherlands, with small ruminants as most probable source. In order to reduce environmental contamination, control measures for manure were implemented because of the assumption that manure was highly contaminated with Coxiella burnetii. The aims of this study were 1) to clarify the role of C. burnetii contaminated manure from dairy goat farms in the transmission of C. burnetii to humans, 2) to assess the impact of manure storage on temperature profiles in dunghills, and 3) to calculate the decimal reduction time of the Nine Mile RSA 493 reference strain of C. burnetii under experimental conditions in different matrices. For these purposes, records on distribution of manure from case and control herds were mapped and a potential relation to incidences of human Q fever was investigated. Additionally, temperatures in two dunghills were measured and related to heat resistance of C. burnetii. Results of negative binomial regression showed no significant association between the incidence of human Q fever cases and the source of manure. Temperature measurements in the core and shell of dunghills on two farms were above 40°C for at least ten consecutive days which would result in a strong reduction of C. burnetii over time. Our findings indicate that there is no relationship between incidence of human Q fever and land applied manure from dairy goat farms with an abortion wave caused by C. burnetii. Temperature measurements in dunghills on two farms with C. burnetii shedding dairy goat herds further support the very limited role of goat manure as a transmission route during the Dutch human Q fever outbreak. It is very likely that the composting process within a dunghill will result in a clear reduction in the number of viable C. burnetii.