Q Fever in a Family

Carol Gilliam, RN, MSN, CIC– Community Health Nurse

Khrist Roy, MPH– Epidemiologist

Gene Arvin, RS– Environmentalist

Madison County Health Department Staff

Q Fever in a Family

Chasing the elusive case-defining test

And

What do you do when you know?

What Is Q Fever

Zoonotic disease caused by Coxiella brunetii - You get it from animals

Cattle, sheep and goats are primary reservoirs

It is endemic to these animals – Assume that they have it. Most animals show no symptoms

Coxiella burnetiibacteria

Found all over the world Resistant to heat, drying and many

common disinfectants Lives for long periods in soil

How is Q Fever spread?

Breathing in the organisms from air and dust contaminated by

– Dried placental material

– birth fluids

– excreta of infected herd animals

How is Q Fever spread?(continued)

Other modes of transmission possible but not common

– Tick bites– Ingestion of contaminated

unpasteurized milk

Human to Human transmission is

very rare

Q Fever

Incubation Period

Most patients become ill within 2-3 weeks after exposure

Those who recover fully from infection may possess lifelong immunity against re-infection

Clinical Types How does it look?

No symptoms – 60% Flu-like illness Liver problems – most common Respiratory or lung problems May involve nervous system Chronic Q Fever Endocarditis Miscellaneous complications:

– Inflammation of cartilage or bone, abortion, brucellosis like illness

Our cue to get involved

The State Office of Epidemiology faxed us a copy of a positive lab report they had received directly from LabCorps

Note: Resulted from computer flag at reference lab that automatically kicks out a report to the state for reportable diseases

Q Fever in a Family Cluster

Father – 48 years old – First + Lab test

Mother – 44 years old

Son – 15

Son - 11

Q Fever in a Family Cluster Father, mother, and older son helped in

birthing of goat on April 27, 04 Father became ill on May 16 and was

hospitalized on May 20 Mother became ill on May 20, treated for

bronchitis by PCP and was not hospitalized Older son became ill on May 22 and was not

hospitalized Younger son was not present in birthing area

and did not get ill

Father

Fever of Unknown Origin (complicated by past history of UTI, proctitis, prostatitis)

Hospitalized for 7 days in May, 04

In hospital, Infectious Disease Spec– Ruled out Lyme Disease, Ehrlicosis– Diagnosed Q Fever based on clinical

presentation and positive test for Q fever antibody titer

Mother Early – Fever, cough, slight chest pain

treated for bronchitis

Later – “Drop Down” attacksreferred to Neurologist

– MRI, nerve conduction tests, etc negative– Q Fever antibody titer +

Referrred to Infectious Disease Specialist– Second titer >fourfold increase

CONFIRMED CASE – Meets CDC criteria

Older Son

Flu Like illness Short duration Fever, body aches Cough and stuffy nose, mild chills Did not see doctor, but went for

testing at our suggestion 8 weeks after birthing of goat

Environmental Conditions

No dust conditions at present time Barn enclosed Dirt floor covered with hay Environmental disinfectant not present House within 100 yards of birthing area No more than 3 homes within ½ mile radius Tarred or gravel roads leading to farm No goats on nearby farms, some cattle Does not sell milk and has not sold or eaten the

goat meat yet

Environmental Assessment

Q Fever epidemic unlikely this year Whole family most likely immune Farmer now using appropriate

personal protective equipment– Shoulder length gloves– Mask

Impact on Family

Personal – Significant morbidity– Illness, fear, inconvenience

– Father felt he nearly died Economic –

– Father was not able to go to his “Day Job” for 2 months

– Expensive hospitalization, referral to specialists, MRI, etc.

How can it be prevented?

Education on sources of infection Personal protection during birthing Proper disposal of birthing materials Use only pasteurized milk and milk

products Holding areas for sheep, cattle & goats

located away from populated areas

What we did:

Community Education

Info to family - verbal and written

E-mail notification to health care facilities

Memo to Veterinarians

Supplied info to County Extension Agent for weekly newspaper column

What we did:(continued)

Assessed environment

Discussed at Nurses Work Group– An inter-county coalition of hospital

infection control nurses, members of MCHD epidemiology team, physician office staff and EOC staff

What went well

Good support to circulate educational materials locally

Accessability to KY State Epidemiology team for discussion

Able to talk to vet at CDC for technical question

Enhanced relationships with local physicians

Challenges

Difficulty getting good history from family members

Difficulty convincing practitioners for second test in 3-4 weeks (nearly did not succeed)

Maintaining privacy of family Hesitation to do environmental assessment

until case confirmed Lack of specific guidance on “proper

disposal of birthing materials”

…provides replacement income for tobacco.

We are likely to see more of it

…and possibly more Q Fever

Goat farming in Kentucky

But it’s not just the goats…

It’s the cows

It’s the sheep

And Q Fever is on some lists as a minor agent of bioterrorism