Transcript Slide 1
Coxiella burnetti
Q FEVER
Overview
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Organism
Transmission
Epidemiology
Disease in Humans
Case Studies
Disease in Animals
Medical Surveillance
Laboratory Procedures
Respiratory Protection (N95)
Emergency Procedures
Prevention and Control
ORGANISM
The Organism
Coxiella burnetii
Obligate
intracellular, gram negative bacterium
Forms spore-like structures
Highly resistant to heat, drying, & some disinfectants
Can survive for months in dust & feces particles
Killed by pasteurization
Exists in two antigenic phases
Phase
1: virulent-infected animals/humans and in nature
Phase 2: less pathogenic- found after multiple lab passages in eggs
or cell cultures
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Q stands for Query
Discovered in 1937 in Queensland, Australia (slaughterhouse
workers)
1938- Montana, USA (isolated from ticks)
Outbreaks
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Largest outbreak 2007-2010 more than 4,000 cases in the
Netherlands; required euthanizing 50,000 goats
2011- Northwestern US-involved 21 goat farms and resulted in 20
human infections
Military troops
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In areas with infected animals
Cities and towns
Downwind from farms
Near roads traveled by animals
TRANSMISSION
Transmission
Inhalation (most common)
Dust, droplets
Birthing fluids/amniotic fluid/placenta
109 bacteria released per gram of placenta
Urine, feces, raw milk
Direct or indirect contact with infected animal
Contaminated surfaces, equipment, bedding, etc
Arthropods (ticks)
Person to person transmission is rare
EPIDEMIOLOGY
Epidemiology
Worldwide
Except
New Zealand
Primary reservoirs
Ruminants-Sheep,
cattle, goats
Pregnant females, fetuses, females that have just
delivered/aborted, newborns
Cats, dogs, rabbits
Birds
Reptiles
Wildlife species: moose, white-tailed deer, black bears
Epidemiology
Who’s at risk?
Farmers
Veterinarians
Meat
processors/ abattoir workers
Laboratory workers/animal laboratory workers
Immunocompromised
Pregnant women
Q Fever in the U.S.:
*CDC 2011
*CDC-2011
DISEASE IN
HUMANS
Human Disease
Incubation: 2 to 4 weeks
Disease
50%-Asymptomatic
Acute
Chronic
Acute Infection
Flu like symptoms: high fever (up to 104-105◦F),
headache, sore throat, vomiting, nausea, fatigue
Pneumonia with mild cough (50%)
Less common
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Hepatitis, myocarditis, central nervous system complications
Self-limiting-38%
>50% asymptomatic
2-4% require hospitalization
<1% mortality rate
Chronic Disease (> 6 months)
1-5% of acutely infected individuals
Pre existing heart conditions, pregnant women,
immunocompromised
Endocarditis (60-70%)
Other
Aortic aneursyms
Osteomyelitis
50% relapse rate despite antibiotic therapy
Mortality rate >50%
Endocarditis-
fatality rate 25-60% if untreated
Risk to Pregnant Women
Most asymptomatic (98%)
Transplacental transmission
Reported complications
Premature
birth
Low birth weight
Miscarriage
Placentitis
Greatest
risk during 1st trimester
Diagnosis
Serology (most common method)
IFA,
CF, ELISA, microagglutination
DNA detection methods
PCR
Isolation of organism
Not
recommended
Poses risks to laboratory personnel
BLS 3- Select Agent
Treatment
Treatment –ideal to begin first 3 days of illness
Acute
disease
Doxycycline
Chronic
disease
Doxycycline
(2-3 weeks)
and hydroxychloroquine (~18 months)
Immunity
Long
lasting (possibly lifelong)
CASE STUDIES
Dairy Farmer Case
2001
Dairy Cow Farmer (Georgia)
Sudden
onset of flu-like symptoms: fever, chills, cough
Diagnosed as influenza
2 weeks later presented to emergency room-again diagnosed
as flu
Dairy Farmer Case
Referred to infectious disease specialist
Tested
positive for Q fever (phase II)
5 day course anitibiotics-symptoms resolved in 2 weeks
Epidemiology
No
recent animal births on his farm
Two beef cattle herds of approximately 35 animals each
were across the road
2
out of 14 tested were positive for Q fever
MMWR 10/2002
Poker Player’s Pneumonia
March 5-16, 1987
Nova Scotia, Canada
12
individuals who often played poker together were
infected with Q fever.
Symptoms: headache, pneumonia, cough
Cat gave birth to kittens, 1 stillborn on 2/14/87 in the
room where poker was played
Direct contact not required
Military Personnel
Reports of US military personnel deployed in Iraq
and Afghanistan, including some without any known
animal exposure.
Since 2003, more than 200 cases of acute Q fever
have been reported among US military personnel
deployed to Iraq.
May 2010- CDC issued a health advisory warning
about the potential of Q fever among travelers
returning from Iraq and the Netherlands.
Q FEVER IN
ANIMALS
Animal Disease
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Sheep, goats, cattle
▫ Often asymptomatic
▫ Reproductive failure
Abortions
Stillbirths
Low birth weight
Weak newborns
Infertility
Carrier state
Other animal species
▫ Dogs, cats, horses, rabbits, birds
Morbidity and Mortality
Prevalence information is limited
Endemic areas
18
to 55% of sheep with antibodies
82% of dairy cattle with antibodies
Death is rare
MEDICAL SURVEILLANCE
Prior to working with sheep
The following should contact the University Employee
Occupational Health Clinic (UEOHC) for a medical
screening/risk assessment:
Immunocompromised
individuals and those with pre-existing
heart valve conditions are at higher risk of infection and should
be fully informed of the increased risks.
Pregnant women or women who are considering becoming
pregnant should also be fully informed of the increased risks.
UEOHC
Monday- Friday (8:30am-4:30pm)
919-966-9119
Exposure Procedures
Percutaneous exposure (needlesticks, cuts, animal
bites or scratches)
Remove
contaminated gloves and if possible, allow the
wound to bleed freely for a minute.
Wash the wound with soap and water for 5 minutes
and apply sterile gauze or a bandage, if necessary.
Remove protective lab clothing and follow reporting
procedures.
Exposure Procedures
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Mucous membrane exposure.
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Rinse tissue surface with copious amounts of water.
Eyes will be irrigated for at least 5 minutes using the
emergency eye wash station.
Remove protective lab clothing and follow reporting
procedures.
Inhalation exposure
Remove protective lab clothing and follow reporting
procedures.
Reporting Exposure Events
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Employees must be seen by UEOHC 919-966-9119
(M-F, 8:30am-4:30pm) for treatment and
documentation of exposure immediately following the
incident during work hours or on the next business day
if the incident happens after hours.
If the injury required first-aid after hours, go to the
UNC Hospital Emergency Room.
An Exposure Incident Report (Form 19) must be
completed by the employee at UEOHC.
EHS will also complete a report that includes how the
incident was addressed.
Reporting Signs and Symptoms of
Exposure
Employees experiencing any of the symptoms
associated with exposure (even without an
identified exposure incident) must report it to the PI,
UEOHC, and EHS.
If you have worked in the lab within the last two
weeks of experiencing any of the symptoms
associated with Q fever, report it to the PI, UEOHC,
and EHS.
Post Exposure Treatment/Testing
If prophylactic antibiotic treatment is considered
appropriate by clinic or ER medical staff,
doxycycline is generally given for 2-3 weeks (acute)
or doxycycline and hydroxychloroquine for at least
18 months (chronic) unless otherwise
contraindicated.
LABORATORY
PROCEDURES
PPE
Biohazardous Waste
Laboratory Standard Operating
Procedure
Safe handling procedures, including:
Personal
protective equipment
Engineering controls
Reporting injuries and occupational exposures
Reviewed annually by PI, EHS, IBC, and employees
Laboratory/Animal Housing Entry
Don PPE
Latex/nitrile
gloves
Tyvek (disposable jumpsuit)
Bonnet
Shoe covers
Eye protection (lab)
N95 or PAPR
Laboratory/Animal Housing Exit
Wash hands after removing gloves and prior to
leaving area.
Minimize the creation of droplets, splashes, aerosols,
and dust
Decontaminate work surfaces immediately following
spills, elimination from sheep
Sharps Precautions
Needles should only be used when there is no other
alternative
Injection
of animals and blood draws
Do not break, bend, re-sheath or reuse syringes or
needles.
When needles are required, safe needle devices
should be used
Passive
safety features recommended
Needles & Sharps Precautions
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Contaminated sharps must be
placed in hard walled plastic
containers labeled with the
biohazard symbol as shown.
When the container is no
more than 2/3 full, place
autoclave indicator tape over
the biohazard symbol in an
“X” pattern as shown.
Containers must be placed in
biohazard bag prior to
autoclaving.
Biohazardous Waste
All biohazardous waste (including liquids) must be
autoclaved prior to disposal.
Place
waste in autoclave bags.
Autoclave tape over biohazard label.
After treatment, seal bags with tape.
Place in lined Rubbermaid container.
Autoclaves must be tested weekly with a bioindicator to
insure proper function.
RESPIRATORY
PROTECTION
N95/PAPR
Respiratory Protection Program Requirements
29 CFR 1910.134
Procedures for selecting respirators for use in the
workplace.
Medical evaluations of employees required to use
respirators.
Fit testing procedures for tight-fitting respirators.
Procedures and schedules for cleaning, disinfecting,
storing, inspecting, repairing, discarding, and
otherwise maintaining respirators.
Respiratory Protection Program Requirements
29 CFR 1910.134
Training of employees in respiratory hazards to
which they are potentially exposed during routine
and emergency situations.
Training of employees in the proper use of
respirators, including putting on and removing, any
limitations on their use, and the maintenance of the
respirator.
Procedures for regularly evaluating the
effectiveness of the program.
Q Fever:
Respiratory Protection
PAPR respirators or N95 masks are required to enter
the animal housing area and laboratory
Annual training and respiratory clearance required
(clearance is done at the UEOHC)
Annual fit testing for N95 is required.
Medical Surveillance
Required to determine the employee’s ability to use
a respirator.
Medical evaluation can be conducted through a
questionnaire, and then through a medical
examination if a positive response is received for
certain questions.
There is a physiological burden on employees that
varies with the type of respirator worn, the job, the
workplace conditions in which the respirator is used,
and the medical status of the employee.
EMERGENCY
PROCEDURES
Biohazardous Spills
Animal bedding
Sheep urine, fecal material, blood
Spill procedures are posted in the facility.
Where
is the spill
kit located in
your facility?
Spills (Sheep body fluids, blood)
Secure sheep.
Assess personal exposure and remove & replace any
contaminated gloves, coveralls or shoes,
Use the disinfectant solution located in the facility or spill kit to
carefully dilute the spill from the outside edges.
Use an absorbent pad or paper towel to collect the spill.
Dispose in biohazard bag.
Spray and wipe the area once more with approved disinfectant.
Discard of paper towels and contaminated PPE in biohazard
bag.
Wash your hands and don fresh PPE.
Sharp objects must be handled by mechanical means (forceps,
dust pan and squeegee).
Spills- Sheep Waste
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Once sheep are secured, don fresh PPE, if necessary.
Place an absorbent pad/paper towel over the urine.
Spray pad/paper towels with Vimoba.
Gather the spill with paper towels. Discard in biohazardous bag.
Spray and wipe the area once more with Vimoba.
Discard of paper towels and contaminated PPE in biohazard
bag.
Wash hands and don fresh PPE.
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If sheep defecates, pick up with paper towels or absorbent pad,
spray & wipe area with Vimoba, discard in biohazard bag, and
don fresh PPE.
Potential Exposure
Employees involved in spills and accidents
determined by PI and EHS to result in overt or
potential exposures to infectious materials must be
seen by UEOHC.
Appropriate medical evaluation, surveillance, and
treatment are provided and written records are
maintained.
An Exposure Incident Report must be completed
Injuries Requiring Emergency Medical
Assistance
Call 911
PREVENTION AND
CONTROL
Prevention and Control
Ensure that new, sick, and animals about to give birth are
kept separate from one another
Monitor sheep’s behavior/health
If
you notice a difference in sheep’s appearance/behavior,
report to DLAM personnel.
Maintain sanitary conditions in sheep room and lab
Clean
and disinfect spills as they occur
Pest management (tick prevention) procedures are in place
Wash your hands after PPE removal and any animal work
Q Fever as a Biological Weapon
Extremely virulent
A single bacterium can cause infection
Highly resistant in the environment
Aerosol transmission
WHO estimates if
50
kg of C burnetii was released along a 2-km line
upwind of a population of 500,000
- 150 deaths
125,000 cases of acute illness
9,000 cases of chronic illness
Questions???
Contact EHS 919-962-5507