July 2007

Q Fever
Q. What is Q fever? A. Q fever is an infection caused by Coxiella burnetii (COX-ee-ELL-ah burn-ETT-eye), a type of bacteria that is distributed worldwide. Q (for “query”) fever was first described in Australia in 1935 among slaughterhouse workers and cattle farmers. Q fever became a notifiable disease in the United States in 1999. Due to the highly infectious and persistent nature of the organism, the potential for its use as a biological warfare agent is a concern. The Centers for Disease Control and Prevention (CDC) categorizes C. burnetti as a Category B agent (i.e., those that are moderately easy to disseminate). Q. How is Q fever spread? A. Cattle, sheep, and goats are the primary reservoirs of C. burnetii, although camels, other livestock, domesticated animals such as dogs and cats, and wild animals such as rodents, other mammals, birds, and ticks can also be carriers. Transovarial and transstadial transmission are common in ticks and likely help maintain the organism in the environment by circulating the pathogens between ticks and rodents, larger animals and birds. Organisms are shed in the milk, urine, and feces of infected animals. This is a situation that can go unnoticed, since animals rarely show any clinical symptoms of Q fever. During birthing, the organisms are dispersed in very high numbers within the amniotic fluids and the placenta. The organisms are resistant to heat, drying, and many common disinfectants, thereby permitting the bacteria to survive for long Photo: U.S. Air Force, Tallil Air Base, Dec 2006 periods of time in the environment. Infection of humans usually occurs by inhalation of these organisms from airborne particles of contaminated barnyard dust. Humans are very susceptible to the disease and very few organisms are required to cause infection. In rare instances, people may acquire Q fever via the ingestion of contaminated milk or dairy products, by tick bites, or by human-to-human transmission. Q. How common is Q fever? A. Q fever is found in every country except New Zealand. Approximately 50-60 cases of Q fever are reported from across the United States each year, although it is thought to be underdiagnosed and under-reported. Worldwide, the incidence varies from country to country. Since 2003, over 30 cases of Q fever have been reported in U.S. soldiers serving in Iraq and Afghanistan. Q. Who is at risk for Q fever? A. Q fever occurs mainly by occupational exposure among veterinarians, workers at slaughterhouses and meat processing plants, sheep and diary workers, livestock farmers, researchers, and military personnel who are deployed to areas where herd animals are present. Although exposure generally occurs via direct contact with infected animals, infection may also take place when contaminated manure, straw, or dust is stirred up by vehicles, such as trucks or helicopters.

Photo: U.S. Army, Baghdad, Sep 2006

Q. What are the symptoms of Q fever? A. Only about half of the people who are infected with C. burnetii get sick. However, as few as 1-10 C. burnetii organisms can cause disease in a susceptible person. Infection with greater numbers of organisms will result in shorter incubation periods. Most acute cases of Q fever begin suddenly after an incubation period of 2-3 weeks with flu-like symptoms including one or more of the following: high fever, severe headache, muscle aches, confusion, sore throat, chills, sweats, non-productive cough, nausea, vomiting, diarrhea, abdominal pain, and chest pain. Fever usually lasts for 1-2 weeks. Thirty to fifty percent of symptomatic patients develop pneumonia, and some develop hepatitis. Most patients recover to good health within several

months. Only 1-2% of people with acute Q fever die of the disease. Chronic Q fever, which is disease that lasts for 6 months or longer, is rare, but much more serious. Persons who have had acute Q fever may develop the chronic form 1-20 years after the initial infection. This is most likely to occur in people who are immunocompromised or have a history of heart disease. The most serious complication of chronic Q fever is endocarditis (heart inflammation). Infection with C. burnetii usually provides lifelong immunity against re-infection. Q. How is Q fever diagnosed? A. Since the clinical symptoms of Q fever are often non-specific and flu-like, it is difficult to make an accurate diagnosis without appropriate laboratory testing. Confirming Q fever requires serologic testing to detect the presence of antibodies to C. burnetii antigens. Indirect immunofluorescence assay (IFA) is the most widely used method. Recent studies have shown that greater accuracy in the diagnosis of Q fever can be achieved by looking not only at IgM and IgG antibodies, but IgA as well. Q fever should be considered in the differential diagnosis of deployed, or recently redeployed, soldiers with a febrile illness, especially when hepatitis or pneumonia is present. Q. What is the treatment for Q fever? A. Doxycycline is the treatment of choice for acute Q fever. Antibiotic therapy is most effective when initiated within the first 3 days of illness. A dose of 100 mg of doxycycline taken orally twice daily for 15-21 days is frequently the prescribed regimen. Quinolone antibiotics have demonstrated good in vitro activity against C. burnetii and may also be considered by the physician. Therapy should be started again if the disease relapses. Although Q fever is often self-limiting, treatment is recommended to shorten duration of symptoms and prevent more severe complications and chronic disease. Chronic Q fever endocarditis is very difficult to treat effectively and often requires the use of multiple drugs such as doxycycline in combination with quinolones for at least 4 years, or doxycycline in combination with hydroxychloroquine for 1 ½-3 years. Surgery to replace damaged heart valves may be required. Q. Is there a Q fever vaccine? A. A vaccine for Q fever is not commercially available in the United States, although a human vaccine (Q-VAX®) is used in Australia. In the U.S., Q fever vaccine may only be used under an Investigational New Drug license. Although the Department of Defense (DoD) manages such a license, it has not currently approved use of that vaccine for troops. Animal vaccines are available in Europe, but not in the U.S. Q. How can Q fever be prevented? A. During deployments, especially to developing countries or rural areas, help protect yourself against Q fever by practicing these preventive measures: Avoid barnyard dust or other materials, such as straw, that may be contaminated with manure, urine, feces, milk, or animal birthing products and fluids (e.g., blood, placentas, or aborted fetuses). Avoid direct contact with animals, especially sheep, cattle, goats, and other livestock such as camels. Avoid bivouacking in areas where livestock or other animals are present, such as barns or stables, or in the vicinity of livestock slaughtering facilities. Avoid handling unprocessed wools or animal hides, such as sheepskins. Avoid inhalation of dust that is kicked up by vehicles or by other activities, especially in areas where herd animals have been present. Do not adopt camp animals or mascots. Avoid ingestion of raw milk or cheese. Use only pasteurized milk and milk products. Practice good hygiene techniques (frequent hand washing, etc.). Protect yourself from tick bites; use the DoD Insect Repellent System: • Wear the proper clothing: long pants tucked into boots or socks; long sleeves; shirt tucked into pants; light-colored clothing makes it easier to spot ticks. • Treat clothing with permethrin repellent. For military uniforms, order the impregnation (IDA) kit (NSN 6840-01345-0237, effective through approximately 50 washes), or aerosol spray (NSN 6840-01-278-1336, effective through 5-6 washes). • Apply DEET repellent to all exposed skin. Military personnel should order NSN 6840-01-284-3982; one application lasts up to 12 hours. • Check yourself for ticks routinely; use the buddy system. Remove any attached ticks immediately.

Q-VAX is a registered trademark of CSL Limited, ABN 99 051d 588 348, 45 Poplar Road, Parkville, Victoria 3052 Australia U.S. Army Center for Health Promotion and Preventive Medicine Entomological Sciences Program,5158 Blackhawk Road, Aberdeen Proving Ground, Maryland 21010-5403 http://chppm-www.apgea.army.mil DSN 584-3613; CM (410) 436-3613; FAX -2037