Q FEVER IN THE PANHANDLE Q FEVER IN THE PANHANDLE THE SAGA CONTINUESTHE SAGA CONTINUES

James L. Alexander, DSHSJames L. Alexander, DSHSKelly Fitzpatrick, CDCKelly Fitzpatrick, CDCLindsay Oliver, CDCLindsay Oliver, CDCGilbert Kersh, CDCGilbert Kersh, CDC

Robert Massung, CDCRobert Massung, CDCKevin McClaran, DSHSKevin McClaran, DSHS

2006 Environmental Survey2006 Environmental Survey

50% of agriculturally-50% of agriculturally-related sites positiverelated sites positive

69% of non-69% of non-agriculturally-related agriculturally-related sites positivesites positive

59% of all sites 59% of all sites positivepositive

3 areas of West Texas sampled3 areas of West Texas sampled

Tested for Presence of Tested for Presence of Coxiella burnetii Coxiella burnetii DNA in dirt/dust/manureDNA in dirt/dust/manure

2008 Construction Site Incident2008 Construction Site Incident 17/199 (8.5%) sero-positive 17/199 (8.5%) sero-positive >> 128 128

10/15 (66.7%) interviewees 10/15 (66.7%) interviewees symptomaticsymptomatic

Why?Why?

““What is the prevalence of antibodies What is the prevalence of antibodies to q fever in the Panhandle to q fever in the Panhandle

population?”population?”

NetherlandsNetherlands

2009: 2357 new human q fever cases2009: 2357 new human q fever cases– US 43,855 (109)US 43,855 (109)

Slaughtered about 62,500 pregnant goats Slaughtered about 62,500 pregnant goats and sheepand sheep

455,000 doses of vaccine distributed455,000 doses of vaccine distributed

90% of sheep/goat herds vaccinated90% of sheep/goat herds vaccinated

““What is the prevalence of antibodies What is the prevalence of antibodies to q fever in the Panhandle to q fever in the Panhandle

population?”population?”

DSHS collaborated with the local blood bankDSHS collaborated with the local blood bank

IRB approval obtainedIRB approval obtained

Donors were apprised of the project, given a fact sheet Donors were apprised of the project, given a fact sheet and asked if they would participateand asked if they would participate

DSHS provided a vacuum tube which the phlebotomists DSHS provided a vacuum tube which the phlebotomists used when collecting the routine samples for screening used when collecting the routine samples for screening tests.tests.

A questionnaire was administered by a DSHS A questionnaire was administered by a DSHS representative.representative.

2009 Sero-survey for Q-fever 2009 Sero-survey for Q-fever

2009 Sero-survey for Q-fever 2009 Sero-survey for Q-fever

600 serum samples were collected600 serum samples were collected– 591 from blood donors591 from blood donors– 9 from people who could not donate, or who chose 9 from people who could not donate, or who chose

not to donate, but desired to participatenot to donate, but desired to participate– 4 regular donors who were unable to donate blood 4 regular donors who were unable to donate blood

participated in the surveyparticipated in the survey– 589 donors in the study589 donors in the study

19 blood drive events in 17 counties19 blood drive events in 17 counties

Residents from 26 counties and 2 states participatedResidents from 26 counties and 2 states participated

Samples from a New Mexico resident and 3 residents Samples from a New Mexico resident and 3 residents of non-Panhandle counties in Texas were removed.of non-Panhandle counties in Texas were removed.

Samples from 5 non-donors, 1 without a Samples from 5 non-donors, 1 without a questionnaire, and a 17 y.o. were also removedquestionnaire, and a 17 y.o. were also removed

Tubes were centrifuged, serum was pipetted and Tubes were centrifuged, serum was pipetted and samples were stored on dry ice until they could be samples were stored on dry ice until they could be placed in a Revcoplaced in a Revco®® @ -80 @ -80oo C C

Held @ -80Held @ -80o o C until shipped to CDC for testing.C until shipped to CDC for testing.

2009 Sero-survey for Q-fever2009 Sero-survey for Q-fever

2009 Sero-survey for Q-fever2009 Sero-survey for Q-fever

All samples screened by ELISAAll samples screened by ELISA

All ELISA positive/equivocal samples All ELISA positive/equivocal samples tested by IFA @ 1:16tested by IFA @ 1:16

Samples reactive @ 1:16 were titrated Samples reactive @ 1:16 were titrated to their endpoint to their endpoint

CDC Test Protocol

PrevalencePrevalence

589 samples utilized in the study589 samples utilized in the study

Antibody prevalence:Antibody prevalence:

10.7% in 589 people 10.7% in 589 people from 23 Countiesfrom 23 Counties

CountiesCounties Donation SitesDonation Sites

6 Counties with 0% 6 Counties with 0% 2 Sites with 0% 2 Sites with 0%

1-6 donors (14)1-6 donors (14) 8 and 35 donors (43)8 and 35 donors (43)

9 Counties with 3-8%9 Counties with 3-8% 10 Sites with 3-8%10 Sites with 3-8%

19-99 donors (385)19-99 donors (385) 12-80 donors (350) 12-80 donors (350)

8 Counties with 16-50%8 Counties with 16-50% 8 Sites with 19-43% 8 Sites with 19-43%

5-68 donors (190)5-68 donors (190) 4-72 donors (196) 4-72 donors (196)

PrevalencePrevalence

SymptomsSymptoms

Do you recall having an illness, possibly lasting 7 days or more, that began suddenly with fever, chills, profuse sweating, muscle and joint pains,

severe headache and fatigue for which a definitive diagnosis was not made?

SymptomsSymptoms

11.1% of people with sero-11.1% of people with sero-positive results said “Yes”positive results said “Yes”

Male (6):Male (6): 14%14%

Female (1):Female (1): 5% 5%

All White Non-HispanicAll White Non-Hispanic

SymptomsSymptoms

10.3% of people with negative 10.3% of people with negative results also said “Yes” results also said “Yes”

Male (23):Male (23): 8.7%8.7%

Female (31):Female (31): 12%12%

Age DataAge Data

Positives:Positives:

AllAll PosPos NegNeg

RangeRange 18-82 18-82 18-7618-76 18-8218-82

MeanMean 46.3 46.3 46.4 46.4 46.2 46.2

Median Median 48 48 49 49 48 48

ModeMode 53, 55 53, 55 38, 49, 51 38, 49, 51 55 55

DemographicsDemographicsRacial Percentages Racial Percentages

White Non-Hispanic 85.6 62.8

Hispanic 12.7 29.3

Black Non-Hispanic 0.3 5.4

Amer. Indian/Alaskan Native 0.7 1.0

Asian-Pacific Islander 0.2 1.4

Black Hispanic 0.2 NA

None Provided 0.3 NA

Survey Popn

US Sero-prevalence StudyUS Sero-prevalence Study

Seroprevalence of Q Fever in the United Seroprevalence of Q Fever in the United States, 2003–2004, States, 2003–2004, Anderson, et alAnderson, et al

2003-20042003-2004

Stratified for ageStratified for age

Part of the National Health and Nutrition Part of the National Health and Nutrition Examination Survey programExamination Survey program

Comparison of StudiesComparison of StudiesAnderson, et alAnderson, et al11

PanhandlePanhandle ((> > 20 y.o.)20 y.o.) ((>> 18 18

y.o.)y.o.)

Sample SizeSample Size 44374437 589 589

Sero-prevalenceSero-prevalence 3.1%*3.1%* 10.7%10.7%((>>1:16)1:16) ((>>1:128)1:128)

* * Weighted popWeighted popn n estimateestimate

1 Seroprevalence of Q Fever in the United States, 2003–20041 Seroprevalence of Q Fever in the United States, 2003–2004

Comparison of StudiesComparison of Studies

Anderson, et alAnderson, et alPanhandlePanhandle

Male +Male + 3.8%3.8% 14%14%

Female +Female + 2.4%2.4% 7% 7%

Male:FemaleMale:Female 1.5:11.5:1 2:12:1

AgeAge Age Risk Age Risk No EffectNo Effect

Seroprevalence of Q Fever in the United States, 2003–2004Seroprevalence of Q Fever in the United States, 2003–2004

Anderson, et alAnderson, et al PanhandlePanhandle

Male vs FemaleMale vs Female 1.5 OR (1.0-2.3)1.5 OR (1.0-2.3) 2.1 OR (1.2-2.1 OR (1.2-3.8)3.8)

White Non-HispanicWhite Non-Hispanic 2.8%2.8% 10.4%10.4%

HispanicsHispanics 7.4%7.4% 10.7%10.7%

Geometric meanGeometric mean 95 (16 - 4096)95 (16 - 4096) 597 (64 - 597 (64 - 65536)65536)

(Phase II IgG)(Phase II IgG)

Comparison of StudiesComparison of Studies

Panhandle Study LimitationsPanhandle Study Limitations

Of 19 counties with more than 1 participant, 5 Of 19 counties with more than 1 participant, 5 were under-represented and 14 were over-were under-represented and 14 were over-represented.represented.

Residents of 4 counties provided 50% of the Residents of 4 counties provided 50% of the samplessamples

2 of those counties (large pop2 of those counties (large popn)n) were over were over represented and 2 (moderate poprepresented and 2 (moderate popn)n) were were under representedunder represented

Used healthy blood donorsUsed healthy blood donors

Racial/ethnic representation did not match Racial/ethnic representation did not match the area’s diversitythe area’s diversity

Convenience sampleConvenience sample

Not stratified for ageNot stratified for age

Study LimitationsStudy Limitations

ConclusionsConclusions Exposure to Exposure to Coxiella burnetii Coxiella burnetii appears to be appears to be

significant in some parts of the Texas significant in some parts of the Texas PanhandlePanhandle

If the healthy, blood donor population has a If the healthy, blood donor population has a 10.7% prevalence, it is logical to suspect that 10.7% prevalence, it is logical to suspect that a random sample across our population a random sample across our population might detect a higher prevalence might detect a higher prevalence

Analysis continues to examine risk factors, Analysis continues to examine risk factors, including occupation, association with including occupation, association with livestock and location of residence livestock and location of residence

Thanks to:Thanks to:

HSR 1 Zoonosis Control teamHSR 1 Zoonosis Control team Kevin McClaran, DSHS EpidemiologistKevin McClaran, DSHS Epidemiologist HSR 1 Immunization, PHP and Social HSR 1 Immunization, PHP and Social

Programs StaffPrograms Staff Coffee Memorial Blood Center StaffCoffee Memorial Blood Center Staff CDC teamCDC team Patrick Hunt, DSHS Zoonosis ControlPatrick Hunt, DSHS Zoonosis Control