Q FEVERCoxiella burnetti

Overview

• Organism

• Transmission

• Epidemiology

• Disease in Humans

• Case Studies

• Disease in Animals

• Medical Surveillance

• Laboratory Procedures

• Respiratory Protection (N95)

• Emergency Procedures

• Prevention and Control

ORGANISM

The Organism

Coxiella burnetii

Obligate intracellular, gram negative bacterium

Forms spore-like structures

Highly resistant to heat, drying, & some disinfectants

Can survive for months in dust & feces particles

Killed by pasteurization

Exists in two antigenic phases

Phase 1: virulent-infected animals/humans and in nature

Phase 2: less pathogenic- found after multiple lab passages in eggs

or cell cultures

• Q stands for Query

• Discovered in 1937 in Queensland, Australia (slaughterhouse workers)

• 1938- Montana, USA (isolated from ticks)

• Outbreaks

▫ Largest outbreak 2007-2010 more than 4,000 cases in the Netherlands; required euthanizing 50,000 goats

▫ 2011- Northwestern US-involved 21 goat farms and resulted in 20 human infections

▫ Military troops In areas with infected animals

▫ Cities and towns Downwind from farms

Near roads traveled by animals

TRANSMISSION

Transmission

Inhalation (most common)

Dust, droplets

Birthing fluids/amniotic fluid/placenta

109 bacteria released per gram of placenta

Urine, feces, raw milk

Direct or indirect contact with infected animal

Contaminated surfaces, equipment, bedding, etc

Arthropods (ticks)

Person to person transmission is rare

EPIDEMIOLOGY

Epidemiology

Worldwide

Except New Zealand

Primary reservoirs

Ruminants-Sheep, cattle, goats

Pregnant females, fetuses, females that have just

delivered/aborted, newborns

Cats, dogs, rabbits

Birds

Reptiles

Wildlife species: moose, white-tailed deer, black bears

Epidemiology

Who’s at risk?

Farmers

Veterinarians

Meat processors/ abattoir workers

Laboratory workers/animal laboratory workers

Immunocompromised

Pregnant women

Q Fever in the U.S.:

*CDC 2011

*CDC-2011

DISEASE IN

HUMANS

Human Disease

Incubation: 2 to 4 weeks

Disease

50%-Asymptomatic

Acute

Chronic

Acute Infection

Flu like symptoms: high fever (up to 104-105◦F),

headache, sore throat, vomiting, nausea, fatigue

Pneumonia with mild cough (50%)

Less common

• Hepatitis, myocarditis, central nervous system complications

Self-limiting-38%

>50% asymptomatic

2-4% require hospitalization

<1% mortality rate

Chronic Disease (> 6 months)

1-5% of acutely infected individuals

Pre existing heart conditions, pregnant women,

immunocompromised

Endocarditis (60-70%)

Other

Aortic aneursyms

Osteomyelitis

50% relapse rate despite antibiotic therapy

Mortality rate >50%

Endocarditis- fatality rate 25-60% if untreated

Risk to Pregnant Women

Most asymptomatic (98%)

Transplacental transmission

Reported complications

Premature birth

Low birth weight

Miscarriage

Placentitis

Greatest risk during 1st trimester

Diagnosis

Serology (most common method)

IFA, CF, ELISA, microagglutination

DNA detection methods

PCR

Isolation of organism

Not recommended

Poses risks to laboratory personnel

BLS 3- Select Agent

Treatment

Treatment –ideal to begin first 3 days of illness

Acute disease

Doxycycline (2-3 weeks)

Chronic disease

Doxycycline and hydroxychloroquine (~18 months)

Immunity

Long lasting (possibly lifelong)

CASE STUDIES

Dairy Farmer Case

2001

Dairy Cow Farmer (Georgia)

Sudden onset of flu-like symptoms: fever, chills, cough

Diagnosed as influenza

2 weeks later presented to emergency room-again diagnosed

as flu

Dairy Farmer Case

Referred to infectious disease specialist

Tested positive for Q fever (phase II)

5 day course anitibiotics-symptoms resolved in 2 weeks

Epidemiology

No recent animal births on his farm

Two beef cattle herds of approximately 35 animals each

were across the road

2 out of 14 tested were positive for Q fever

MMWR 10/2002

Poker Player’s Pneumonia

March 5-16, 1987

Nova Scotia, Canada

12 individuals who often played poker together were infected with Q fever.

Symptoms: headache, pneumonia, cough

Cat gave birth to kittens, 1 stillborn on 2/14/87 in the room where poker was played

Direct contact not required

Military Personnel

Reports of US military personnel deployed in Iraq

and Afghanistan, including some without any known

animal exposure.

Since 2003, more than 200 cases of acute Q fever

have been reported among US military personnel

deployed to Iraq.

May 2010- CDC issued a health advisory warning

about the potential of Q fever among travelers

returning from Iraq and the Netherlands.

Q FEVER IN

ANIMALS

Animal Disease

• Sheep, goats, cattle▫ Often asymptomatic▫ Reproductive failure Abortions Stillbirths Low birth weight Weak newborns Infertility

• Carrier state

• Other animal species

▫ Dogs, cats, horses, rabbits, birds

Morbidity and Mortality

Prevalence information is limited

Endemic areas

18 to 55% of sheep with antibodies

82% of dairy cattle with antibodies

Death is rare

MEDICAL SURVEILLANCE

Prior to working with sheep

The following should contact the University Employee

Occupational Health Clinic (UEOHC) for a medical

screening/risk assessment:

Immunocompromised individuals and those with pre-existing

heart valve conditions are at higher risk of infection and should

be fully informed of the increased risks.

Pregnant women or women who are considering becoming

pregnant should also be fully informed of the increased risks.

UEOHC

Monday- Friday (8:30am-4:30pm)

919-966-9119

Exposure Procedures

Percutaneous exposure (needlesticks, cuts, animal

bites or scratches)

Remove contaminated gloves and if possible, allow the

wound to bleed freely for a minute.

Wash the wound with soap and water for 5 minutes

and apply sterile gauze or a bandage, if necessary.

Remove protective lab clothing and follow reporting

procedures.

Exposure Procedures

• Mucous membrane exposure.

▫ Rinse tissue surface with copious amounts of water.

▫ Eyes will be irrigated for at least 5 minutes using the

emergency eye wash station.

▫ Remove protective lab clothing and follow reporting

procedures.

Inhalation exposure

Remove protective lab clothing and follow reporting

procedures.

Reporting Exposure Events

• Employees must be seen by UEOHC 919-966-9119 (M-F, 8:30am-4:30pm) for treatment and documentation of exposure immediately following the incident during work hours or on the next business day if the incident happens after hours.

• If the injury required first-aid after hours, go to the UNC Hospital Emergency Room.

• An Exposure Incident Report (Form 19) must be completed by the employee at UEOHC.

• EHS will also complete a report that includes how the incident was addressed.

Reporting Signs and Symptoms of

Exposure

Employees experiencing any of the symptoms

associated with exposure (even without an

identified exposure incident) must report it to the PI,

UEOHC, and EHS.

If you have worked in the lab within the last two

weeks of experiencing any of the symptoms

associated with Q fever, report it to the PI, UEOHC,

and EHS.

Post Exposure Treatment/Testing

If prophylactic antibiotic treatment is considered

appropriate by clinic or ER medical staff,

doxycycline is generally given for 2-3 weeks (acute)

or doxycycline and hydroxychloroquine for at least

18 months (chronic) unless otherwise

contraindicated.

LABORATORY

PROCEDURESPPE

Biohazardous Waste

Laboratory Standard Operating

Procedure

Safe handling procedures, including:

Personal protective equipment

Engineering controls

Reporting injuries and occupational exposures

Reviewed annually by PI, EHS, IBC, and employees

Laboratory/Animal Housing Entry

Don PPE

Latex/nitrile gloves

Tyvek (disposable jumpsuit)

Bonnet

Shoe covers

Eye protection (lab)

N95 or PAPR

Laboratory/Animal Housing Exit

Wash hands after removing gloves and prior to

leaving area.

Minimize the creation of droplets, splashes, aerosols,

and dust

Decontaminate work surfaces immediately following

spills, elimination from sheep

Sharps Precautions

Needles should only be used when there is no other

alternative

Injection of animals and blood draws

Do not break, bend, re-sheath or reuse syringes or

needles.

When needles are required, safe needle devices

should be used

Passive safety features recommended

Needles & Sharps Precautions40Contaminated sharps must be

placed in hard walled plastic containers labeled with the biohazard symbol as shown.

When the container is no more than 2/3 full, place autoclave indicator tape over the biohazard symbol in an “X” pattern as shown.

Containers must be placed in biohazard bag prior to autoclaving.

Biohazardous Waste

All biohazardous waste (including liquids) must be

autoclaved prior to disposal.

Place waste in autoclave bags.

Autoclave tape over biohazard label.

After treatment, seal bags with tape.

Place in lined Rubbermaid container.

Autoclaves must be tested weekly with a bioindicator to

insure proper function.

RESPIRATORY

PROTECTIONN95/PAPR

Respiratory Protection Program Requirements29 CFR 1910.134

Procedures for selecting respirators for use in the

workplace.

Medical evaluations of employees required to use

respirators.

Fit testing procedures for tight-fitting respirators.

Procedures and schedules for cleaning, disinfecting,

storing, inspecting, repairing, discarding, and

otherwise maintaining respirators.

Respiratory Protection Program Requirements29 CFR 1910.134

Training of employees in respiratory hazards to

which they are potentially exposed during routine

and emergency situations.

Training of employees in the proper use of

respirators, including putting on and removing, any

limitations on their use, and the maintenance of the

respirator.

Procedures for regularly evaluating the

effectiveness of the program.

Q Fever:

Respiratory Protection

PAPR respirators or N95 masks are required to enter

the animal housing area and laboratory

Annual training and respiratory clearance required

(clearance is done at the UEOHC)

Annual fit testing for N95 is required.

Medical Surveillance

Required to determine the employee’s ability to use

a respirator.

Medical evaluation can be conducted through a

questionnaire, and then through a medical

examination if a positive response is received for

certain questions.

There is a physiological burden on employees that

varies with the type of respirator worn, the job, the

workplace conditions in which the respirator is used,

and the medical status of the employee.

EMERGENCY

PROCEDURES

Biohazardous Spills

Animal bedding

Sheep urine, fecal material, blood

Spill procedures are posted in the facility.

Where is the spill

kit located in

your facility?

Spills (Sheep body fluids, blood)

Secure sheep.

Assess personal exposure and remove & replace any contaminated gloves, coveralls or shoes,

Use the disinfectant solution located in the facility or spill kit to carefully dilute the spill from the outside edges.

Use an absorbent pad or paper towel to collect the spill.

Dispose in biohazard bag.

Spray and wipe the area once more with approved disinfectant.

Discard of paper towels and contaminated PPE in biohazard bag.

Wash your hands and don fresh PPE.

Sharp objects must be handled by mechanical means (forceps, dust pan and squeegee).

Spills- Sheep Waste

• Once sheep are secured, don fresh PPE, if necessary.

• Place an absorbent pad/paper towel over the urine.

• Spray pad/paper towels with Vimoba.

• Gather the spill with paper towels. Discard in biohazardous bag.

• Spray and wipe the area once more with Vimoba.

• Discard of paper towels and contaminated PPE in biohazard

bag.

• Wash hands and don fresh PPE.

▫ If sheep defecates, pick up with paper towels or absorbent pad,

spray & wipe area with Vimoba, discard in biohazard bag, and

don fresh PPE.

Potential Exposure

Employees involved in spills and accidents determined by PI and EHS to result in overt or potential exposures to infectious materials must be seen by UEOHC.

Appropriate medical evaluation, surveillance, and treatment are provided and written records are maintained.

An Exposure Incident Report must be completed

Injuries Requiring Emergency Medical

Assistance

Call 911

PREVENTION AND

CONTROL

Prevention and Control

Ensure that new, sick, and animals about to give birth are

kept separate from one another

Monitor sheep’s behavior/health

If you notice a difference in sheep’s appearance/behavior,

report to DLAM personnel.

Maintain sanitary conditions in sheep room and lab

Clean and disinfect spills as they occur

Pest management (tick prevention) procedures are in place

Wash your hands after PPE removal and any animal work

Q Fever as a Biological Weapon

Extremely virulent

A single bacterium can cause infection

Highly resistant in the environment

Aerosol transmission

WHO estimates if

50 kg of C burnetii was released along a 2-km line

upwind of a population of 500,000

- 150 deaths

125,000 cases of acute illness

9,000 cases of chronic illness

Questions???

Contact EHS 919-962-5507