1. Investigation of a Q Fever Outbreak in the Texas Panhandle James L. Alexander, DVM, MPVM Zoonosis Control Division Texas Department of Health Canyon, Texas Investigating A Suspected Q Fever Outbreak

2. Background December 2006 Environmental survey for presence of Coxiella burnetii conducted in the Panhandle, South Plains and West Texas Results:  Non- agriculturally related sites: 69% +  Agriculturally related sites: 50% +

3. Coxiella burnetii Birthing fluids, urine and feces of livestock and cats and dogs Source of Organism

4. The Panhandle has an abundance of livestock Coxiella burnetii

5. The Panhandle has an abundance of wind Coxiella burnetii

6. A Light Breeze in the Panhandle

7. West Texas has plenty of aerosolized dust and soil Coxiella burnetii Spreads by aerosolization of contaminated dust/soil

8. June 12, 2008 Late in the day began receiving calls about an illness at an ethanol plant construction site at Hereford, Texas Symptoms reported were more consistent with food-poisoning Workers were going to the hospital to be tested for q fever

9. Hereford, Texas – ~ 40 miles SW of Amarillo You are here

10. June 13, 2008 Met with personnel from the company that owned the ethanol plant Met with Hereford City Officials Participated in media interviews Visited Infection Control Nurse @ hospital

11. Hereford is known for feedlots “The Beef Capital of the World”

14. Manure-fueled Ethanol Plant

21. N

23. Companies 14 were on site during the 60 days prior to the “discovery” of q fever titers in the work force The majority left that Friday or in the next week Interviews and follow-up testing delayed Many returned in late July but some were lost to follow-up

24. Case-Control Study Desired Attempted to match age and sex Due to departure of personnel the match was not very successful A second test was obtained on some people to determine if sero-conversion was still occurring

26. Investigation 198 people received at least 1 test 36 people received at least 2 tests 5 people were tested 3 times 239 samples collected No one that did not already have a titer of >128 developed a higher titer

27. Surveyed Population Of 198 People Tested  17 had titers > 128 (8.6%)  1:4096 was the highest titer based on a retest of index case

28. 122 of the “Tested” people were interviewed (62%)  15 of the 17 with titers 5 asymptomatic (33.3%) 10 symptomatic (67.7%)  42 interviewees with compatible symptoms (32 w/o titers)  80 interviewees without compatible symptoms (5 with titers)  4 people without tests were interviewed Surveyed Population

29. Tested Population 14 Females (7%)  Age: 22 - 52 2 with > 128 (14.3%)  Ages 22 and 48 (mean = 35) 12 without titers  Ages 23-52 (mean = 38.7)

30. 184 Males (93%)  Age: 1 - 69 15 with > 128 (8.2%)  Age: 19-61 (mean = 43.6) 169 without titers  Ages 1 - 69 (mean = 39.4) Tested Population

31. Information Obtained Demographics and health history Work location on site Job title/occupation Past livestock exposure Animal exposure in past 60 days Exposure to aborting animal Illness and symptoms Use of PPE Proximity to manure

32. Predominant Symptoms of “Cases” and Non-titered People Reporting Illness Weakness 10 (100%)24 (75%) Malaise 8 (80%)22 (69%) Chills 7 (70%)22 (69%) Sweating 7 (70%)21 (66%) Headache 6 (60%)27 (75%) Myalgia 4 (40%)17 (53%) Lymphadenitis 3 (30%) 4 (12.5%) “10 Cases”“32 Non-cases”

33. Evaluated Proximity to manure – not significant Employer – not significant Prior contact with livestock – not significant

34. Plant Owner Modifications Tarp to block wind at unloading site Water misting during manure unloading Removal of grinder from manure processing system Halting manure delivery when wind direction was from the manure site toward areas occupied b y personnel

35. Actions Taken by Contractor Invited OSHA to visit - declined Invited NIOSH to visit – accepted Required Tyvek © suits and respirators Established PPE zones

36. General Contractor’s Action Plan

38. NIOSH Recommendations No Tyvek suits Shower and laundry facilities on-site No work clothes or footwear to leave the site Move the contractor office trailers and install running water to improve hand sanitation Medical screening for symptomatic personnel Cleaning shoes at office doorways and proper cleaning techniques for offices Appropriate respiratory-protection equipment based on the job function

39. The Next Steps Continue to Analyze These Data Complete the sero-survey initiated in 2009  500-600 samples from blood donors  CDC will test to see if the prevalence of antibodies to C. burnetii in a “normal” population in the Panhandle can be determined

40. As the late Paul Harvey used to say, “Stay tuned for the rest of the story”

41. James L. Alexander, DVM, MPVM Regional Zoonosis Control Veterinarian Texas Department of State Health Services Health Service Region 1 Canyon, Texas james.alexander@dshs.state.tx.us