2. 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

3. Q Fever in a Family Chasing the elusive case-defining test And What do you do when you know?

4. 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

5. Coxiella burnetii bacteria  Found all over the world  Resistant to heat, drying and many common disinfectants  Lives for long periods in soil

6. 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

7. How is Q Fever spread? (continued)  Other modes of transmission possible but not common – Tick bites –Ingestion of contaminated unpasteurized milk

8. Human to Human transmission is very rare Q Fever

9. 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

10. 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

11. 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

12. Q Fever in a Family Cluster  Father – 48 years old – First + Lab test  Mother – 44 years old  Son – 15  Son - 11

13. 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

14. 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

15. Mother  Early – Fever, cough, slight chest pain treated for bronchitis  Later – “Drop Down” attacks referred 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

16. 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

17. 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

18. Environmental Assessment  Q Fever epidemic unlikely this year  Whole family most likely immune  Farmer now using appropriate personal protective equipment –Shoulder length gloves –Mask

19. 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.

20. 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

21. 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

22. 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

23. 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

24. 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”

25. …provides replacement income for tobacco. We are likely to see more of it …and possibly more Q Fever Goat farming in Kentucky

26. 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