Q fever in an occupational setting: a preventable public health challenge Heidi Lord BN MPH South Western Sydney Local Health District Public Health Unit WCPH - April 2017

Outline Background Cluster investigation Public health challenge Recommendations for the way forward

Background Highly infectious and efficient pathogen Humans predominately infected through inhalation of airborne dust or droplets Clinical presentation: acute, chronic, asymptomatic (60%) Q fever is notifiable in all Australian jurisdictions Approximately 550 cases notified in Australia in 2016 Males represent 70% of notifications

Investigation SWS PHU notified of two Q fever cases in September 2015 Case investigations revealed both had been employed at the same abattoir during their incubation period Cases reported that co-workers had experienced similar symptoms

Methods Field Investigation Risk factor survey Active case finding

Results: 8 cases, 7 confirmed and 1 suspected Case No. Age, Sex Onset date Notification Date Laboratory evidence Investigation classification Method for identification 1 17, M 24/11/2014 10/12/2014 Definitive seroconversion Confirmed Notification; linked after Retrospective Review 2 28, M 27/11/2014 09/01/2015 Definitive – nucleic acid testing 3 28/11/2014 08/09/2015 Notification to Public Health Unit 4 22, M 11/01/2015 13/10/2015 Suspected case (no convalescent sample available) Retrospective Review 5 27, M 27/07/2015 30/11/2015 6 31/08/2015 21/10/2015 Abattoir line listing 7 60, M 7/09/2015 (deceased 30/9/2015) 18/09/2015 8 45, M

Results – Active case finding 6 additional cases identified 4 cases were identified through retrospective review of laboratory results 2 through the abattoir line listing

Results – Risk factor surveys Conducted between October – November 2015 All 8 cases had high risk exposures during their current employment None identified risk factors outside of their occupational setting Attempts to interview or have asymptomatic staff complete the risk factor survey were unsuccessful

Results - Field investigation 33 staff employed at the abattoir 23/33 employed as kill staff and 10/33 management, maintenance and stock handling High-risk exposures: - animals aborting/giving birth in the holding yards - foetuses pulled out and dumped into a slops chute - kill floor staff exposed to aerosolisation of birthing products - inconsistent PPE, staff smoking during their breaks High staff turnover Inadequate record keeping

Implications for the abattoir Reported to SafeWork NSW - enforcing body for Work Health and Safety Regulations in NSW Abattoir issued with a strict warning and a recommendation to implement a vaccination program for existing and future staff Action not comparable to restrictions place on abattoirs in previously reported outbreaks

Public health challenge Legislative authority lies with other agencies High turnover of staff and ongoing pressure to start staff immediately Absence of a pre-screening and vaccination program Lack of knowledge: abattoir management and staff Timely notification Improving adoption of prevention strategies

Way forward Tighter regulation and increased monitoring Mandatory pre-screening and vaccination programs for high-risk occupations Multi-agency collaboration: human health, animal health, industry, and work, health and safety regulatory bodies Education: industry and GP’s Research: non-compliance of work, health and safety legislation in abattoirs across NSW

Acknowledgement South Western Sydney Local Health District Public Health Unit NSW Health Greater Sydney Local Land Services SafeWork NSW Publication: Lord H, Fletcher-Lartey S, Weerasinghe G, Chandra M, Egana N, Schembri N, et al. A Q fever cluster among workers at an abattoir in south-western Sydney, Australia, 2015. Western Pac Surveill Response J. 2016 Nov 10;7(4). doi:10.5365/wpsar.2016.7.2.012