Q fever in the Netherlands - 2007-2010: what we learned from the largest outbreak ever

Treatment of persistent focalized Q fever: time has come for an international randomized controlled trial

Q fever is a worldwide zoonosis due to Coxiella burnetii, responsible for endocarditis and endovascular infections. Since the 1990s, the combination hydroxychloroquine + doxycycline has constituted the curative and prophylactic treatment in persistent focalized Q fever. This combination appears to have significantly reduced the treatment's duration (from 60 to 26 months), yet substantial evidence of effectiveness remains lacking. Data are mostly based on in vitro and observational studies. We conducted a literature review to assess the effectiveness of this therapy, along with potential alternatives. The proposed in vitro mechanism of action describes the inhibition of Coxiella replication by doxycycline through the restoration of its bactericidal activity (inhibited in acidic environment) by alkalinization of phagolysosome-like vacuoles with hydroxychloroquine. So far, the rarity and heterogeneous presentation of cases have made it challenging to design prospective studies with statistical power. The main studies supporting this treatment are retrospective cohorts, dating back to the 1990s-2000s. Retrospective studies from the large Dutch outbreak of Q fever (>4000 cases between 2007 and 2010) did not corroborate a clear benefit of this combination, notably in comparison with other regimens. Thus, there is still no consensus among the medical community on this issue. However insufficient the evidence, today the doxycycline + hydroxychloroquine combination remains the regimen with the largest clinical experience in the treatment of 'chronic' Q fever. Reinforcing the guidelines' level of evidence is critical. We herein propose the creation of an extensive international registry, followed by a prospective cohort or ideally a randomized controlled trial.

A systematic review of global Q fever outbreaks

Q fever is an important zoonotic disease with a worldwide distribution. Outbreaks of Q fever are unpredictable and can affect many people, resulting in a significant burden on public health. The epidemiology of the disease is complex and substantial efforts are required to understand and control Q fever outbreaks. The purpose of this study was to systematically review previous investigations of outbreaks and summarise important epidemiological features. This will improve knowledge of the factors driving the occurrence of Q fever outbreaks and assist decision makers in implementing mitigation strategies. A search of four electronic databases identified 94 eligible articles published in English between 1990 and 2022 that related to 81 unique human Q fever outbreaks. Outbreaks were reported across 27 countries and mostly in industrialised nations. Documented Q fever outbreaks varied in size (2 to 4107 cases) and duration (4 to 1722 days). Most outbreaks (43/81) occurred in communities outside of traditional at-risk occupational settings and were frequently associated with living in proximity to livestock holdings (21/43). Indirect transmission via environmental contamination, windborne spread or fomites was the most common route of infection, particularly for large community outbreaks. Exposure to ruminants and/or their products were confirmed as the principal risk factors for infection, with sheep (28/81) as the most common source followed by goats (12/81) and cattle (7/81). Cooperation and data sharing between human and animal health authorities is valuable for outbreak investigation and control using public health and veterinary measures, but this multisectoral approach was seldom applied (14/81). Increased awareness of Q fever among health professionals and the public may facilitate the early detection of emerging outbreaks that are due to non-occupational, environmental exposures in the community.

Efficacy and Safety of an Inactivated Phase I Coxiella burnetii Vaccine to Control Q Fever in Ruminants: A Systematic Review

Q fever is a disease caused by Coxiella burnetii that affects many animal species and humans. In ruminants, the disease is responsible for several reproductive disorders (such as abortions, stillbirths, premature births, weak offspring, retained foetal membranes and infertility). An inactivated vaccine based on a phase I antigen of C. burnetii is available for cattle, goats and sheep. This review aims to summarise the scientific literature regarding the efficacy and safety of this vaccine to control the infection in these three domestic ruminant species. Forty-five publications and one experimental veterinary thesis reporting on experimental studies, case reports, mathematical modelling and intervention studies were selected according to the PRISMA guidelines. Although some studies lack control groups or statistical analyses, for all three species, published data show that vaccination often results in a reduction in abortions and an improvement in reproductive performance in comparison with absence of vaccination. There is also evidence, including in infected herds and animals, that vaccination is associated with a reduction in bacterial shedding, both in intensity and duration in comparison with absence of vaccination. For these reasons, in case of human outbreaks, vaccination is one of the pillars of control measures. Vaccination is generally well tolerated, despite the rare occurrence of mild, transient side-effects, such as hyperthermia and reduction in milk yield.

Work participation, social roles, and empowerment of Q-fever fatigue syndrome patients ≥10 years after infection

OBJECTIVE

To determine work participation, social roles, and empowerment of QFS patients ≥10-year after infection.

METHODS

QFS patients ≥10-year after acute infection, who were of working age, participated in a cross-sectional survey study. Work participation, fulfilment of social roles, and empowerment outcomes were studied for the total population, as well as for subgroups based on employment type and current work status. Associations between empowerment, work and social roles were examined.

RESULTS

291 participants were included. Of the 250 participants who had paid work before Q-fever, 80.4% stopped working or worked less hours due to QFS. For each social role, more than half of the participants (56.6-87.8%) spent less time on the role compared to before Q-fever. The median empowerment score was 41.0 (IQR: 37.0-44.0) out of 60. A higher empowerment score was significantly associated with lower odds of performing all social roles less due to QFS (OR = 0.871-0.933; p<0.001-0.026), except for parenting and informal care provision (p = 0.070-0.460). No associations were found between empowerment and current work status.

CONCLUSION

Work participation and fulfilment of social roles is generally low in QFS patients. Many of the participants stopped working or are working less hours due to QFS, and most spent less time on social roles compared to before Q-fever. Minor variation was seen in total empowerment scores of participants; however, these slight differences were associated with the fulfilment of social roles, but not work participation. This new insight should be further explored in future studies.

Metabolism and physiology of pathogenic bacterial obligate intracellular parasites

Bacterial obligate intracellular parasites (BOIPs) represent an exclusive group of bacterial pathogens that all depend on invasion of a eukaryotic host cell to reproduce. BOIPs are characterized by extensive adaptation to their respective replication niches, regardless of whether they replicate within the host cell cytoplasm or within specialized replication vacuoles. Genome reduction is also a hallmark of BOIPs that likely reflects streamlining of metabolic processes to reduce the need for de novo biosynthesis of energetically costly metabolic intermediates. Despite shared characteristics in lifestyle, BOIPs show considerable diversity in nutrient requirements, metabolic capabilities, and general physiology. In this review, we compare metabolic and physiological processes of prominent pathogenic BOIPs with special emphasis on carbon, energy, and amino acid metabolism. Recent advances are discussed in the context of historical views and opportunities for discovery.

Molecular survey of hemoplasmas and Coxiella burnetii in vampire bats from northern Brazil

In addition to zoonotic viral pathogens, bats can also harbor bacterial pathogens, including hemoplasmas (hemotropic mycoplasmas) and Coxiella burnetii. The present study aimed to investigate, using molecular techniques, the presence of hemoplasmas and C. burnetii in spleen samples from vampire bats in northern Brazil. For this purpose, between 2017 and 2019, spleen samples were collected from Desmodus rotundus (n = 228) and Diaemus youngii (n = 1) captured in the states of Pará (n = 207), Amazonas (n = 1), Roraima (n = 18) and Amapá (n = 3). DNA samples extracted from the bat spleen and positive in PCR for the endogenous gapdh gene were subjected to conventional PCR assays for the 16S rRNA, 23S rRNA and RNAse P genes from hemoplasmas and to qPCR based on the IS1111 gene element for C. burnetii. All spleen samples from vampire bats were negative in the qPCR for C. burnetii. Hemoplasmas were detected in 10 % (23/229) of spleen samples using a PCR based on the 16S rRNA gene. Of these, 21.73 % (5/23) were positive for the 23S rRNA gene and none for the RNAseP gene. The seven hemoplasma 16S rRNA sequences obtained were closely related to sequences previously identified in vampire bats from Belize, Peru and Brazil. The 23S rRNA sequence obtained revealed genetic proximity to hemoplasmas from non-hematophagous bats from Brazil and Belize. The analysis revealed different circulating genotypes among Brazilian vampire bats, in addition to a trend towards genera-specific hemoplasma genotypes. The present study contributes to the knowledge of the wide diversity of hemoplasmas in vampire bats.

Molecular detection and MST genotyping of Coxiella burnetii in ruminants and stray dogs and cats in Northern Algeria

Aiming at identifying the reservoir and contamination sources of Coxiella burnetii in Northern Algeria, we investigated the molecular presence of the bacterium in 599 samples (blood, placenta, liver, spleen, and uterus) collected from cattle, sheep, dogs and cats. Our qPCR results showed that 15/344 (4.36%) blood samples and six/255 (2.35%) organ specimens were positive for C. burnetii. In cattle, three (4%) blood and liver samples were positive. In sheep, one blood (1.19%) and 3 (8.57%) placenta samples were positive. At the Algiers dog pound, 8 (10%) and 3 (5%) blood samples were qPCR positivein dogs and cats, respectively. In addition, MST genotyping showed that MST 33 was present in cattle and sheep, MST 20 in cattle,andMST 21 in dogs and cats.

Controlling Coxiella burnetii in naturally infected sheep, goats and cows, and public health implications: a scoping review

Q fever is a worldwide zoonotic disease which domestic ruminants are the main source of infection for humans. This scoping review summarizes the control measures currently available to reduce Coxiella burnetii (Cb) infection in naturally infected sheep, goat and cattle herds. A total of 28 articles were included in the review. A lack of methodological standardization was noted in the articles analyzed. The results indicated that long-term vaccination in cows reduces bacterial excretion in milk and environmental contamination. In small ruminants, the results of vaccination in terms of efficacy are variable. In goats, there is a reduction in bacterial excretion, unlike in sheep, where a long-term vaccination program is necessary to reduce bacterial excretion. Moreover, the high persistence of viable Cb in the environment means that control measures for sheep are needed for several years. The use of antibiotics as a control measure in cows and sheep was not found to reduce excretion. However, the combination of vaccination with antibiotic therapy appears to have positive effects in small ruminants in terms of controlling outbreaks of Q fever. Hygiene and biosecurity measures are the basic means for controlling Cb infection on ruminant farms and ensuring public health.

First report of an outbreak of "Q" fever IN an abattoir from Argentina

In late October 2021, one of the veterinarians and the occupational physician of a bovine and swine abattoir from Entre Ríos Province, Argentina were alerted about workers with atypical pneumonia symptoms, raising suspicious of a possible Q fever outbreak. An outbreak epidemiological investigation was carried out. Analysis was based on the description of the study population, according to gender, age, symptoms, and position within the abattoir, as well as on outbreak epidemic curve and its probable origin. Cases of Q fever in the workers were confirmed by serology. Measurements of the association between the evaluated variables and the risk of exposure were investigated and calculated as attack rates. The outbreak occurred between October and November 2021, symptomatically affecting 11 workers, out of a total exposed population of 49 individuals. The index case was a 33-year-old male who started with symptoms on 27 October 2021, and the outbreak extended for at least 17 days. Workers in the clean zone of the slaughter floor had a 4.68 times higher risk of contracting Q fever than people located in other areas. Importantly, two pregnant cows were slaughtered a few days before the outbreak began, which could have been the origin of the outbreak. The present study demonstrates the urgent need to consider Q fever when diagnosing abortive diseases of ruminants in Argentina, as well as in zoonotic disease epidemiological surveillance to inform all actors of the health system.

Scenario tree modelling to inform surveillance design for maintaining freedom from Coxiella burnetii infection in Australian commercial dairy goat herds

We used scenario tree methods to determine how different disease detection methods might be used to provide quantitative evidence that Australian dairy goat herds are free of coxiellosis. The aim of our proposed C. burnetii surveillance programme is to find evidence of the absence of antigen as well as evidence of an absence of an immune response to C. burnetii infection in individual dairy goat herds. We defined a C. burnetii infected dairy goat herd as a herd in which at least one doe was showing evidence of either active infection or past C. burnetii exposure using four candidate surveillance system components (SSCs): (1) testing of individual doe whole blood using the C. burnetii com1 PCR; (2) testing of individual doe whole blood using the C. burnetii ELISA; (3) testing bulk tank milk (BTM) using the com1 PCR and the C. burnetii ELISA; and (4) investigations of abortions and stillborn kids submitted to a diagnostic laboratory for testing. Of eight candidate surveillance strategies (combinations of the SSCs listed above) individual doe ELISAs every six months combined with monthly BTM PCR and ELISA testing returned the highest surveillance system sensitivity of 0.963 (95% probability interval [PI] 0.911-0.982) for the lowest cost, at AUD 28.94 (95% PI 28.38-30.59) over a 12-month period, for every one percent increase in surveillance system sensitivity. Assuming a probability of disease freedom of 0.10 at the start of the surveillance program and a probability of C. burnetii introduction per month of 0.01 we estimate that 95% confidence that C. burnetii was absent from a herd could be achieved after a single round of individual doe ELISAs followed by period of 6 consecutive monthly BTM PCR and ELISA tests. The results of this study show that selection of the most efficient combination of surveillance system components requires a good understanding of initial herd C. burnetii status and the probability of introduction of infection and how this may change over time. Scenario tree analyses results have provided insight into the key determinants of C. burnetii detection ability.

Two Years after Coxiella burnetii Detection: Pathogen Shedding and Phase-Specific Antibody Response in Three Dairy Goat Herds

The infection dynamics of Coxiella (C.) burnetii were investigated in three dairy goat herds (A, B, and C) 2 years after the first pathogen detection. A total of 28 and 29 goats from herds A and B, and 35 goats from herd C, were examined. Sera were analyzed on three sampling dates using phase-specific serology. Pathogen shedding was assessed using post-partum vaginal swabs and monthly bulk tank milk (BTM) samples. Dust samples from a barn and milking parlor were also collected monthly. These samples were analyzed with PCR (target IS1111). In herd A, individual animals tested seropositive, while vaginal swabs, BTM, and most dust samples tested negative. Herds B and C exhibited high IgG phase I activity, indicating a past infection. In herd B, approximately two-thirds of the goats shed C. burnetii with vaginal mucus, and irregular positive results were obtained from BTM. Herd C had two positive goats based on vaginal swabs, and BTM tested positive once. Dust samples from herds B and C contained C. burnetii DNA, with higher quantities typically found in samples from the milking parlor. This study highlights the different infection dynamics in three unvaccinated dairy goat herds and the potential use of dust samples as a supportive tool to detect C. burnetii at the herd level.

Epidemiology of Pathogens Listed as Potential Bioterrorism Agents, the Netherlands, 2009‒2019

We provide incidences (cases/10 million persons) in the Netherlands during 2009-2019 for pathogens listed as potential bioterrorism agents. We included pathogens from the highest categories of the European Medicines Agency or the US Centers for Disease Control and Prevention. Notifiable diseases and recently published data were used to calculate the average annual incidence. Coxiella burnetii had the highest incidence because of a Q fever epidemic during 2007-2010. Incidence then decreased to 10.8 cases/. Pathogens with an incidence >1 were Brucella spp. (2.5 cases), Francisella tularensis (1.3 cases), and Burkholderia pseudomallei (1.1 cases). Pathogens with an incidence <1 were hemorrhagic fever viruses (0.3 cases), Clostridium botulinum (0.2 cases), and Bacillus anthracis (0.1 cases). Variola major and Yersinia pestis were absent. The generally low incidences make it unlikely that ill-meaning persons can isolate these pathogens from natural sources in the Netherlands. However, the pathogens are stored in laboratories, underscoring the need for biosecurity measures.

Prerequisites, barriers and opportunities in care for Q-fever patients: a Delphi study among healthcare workers

BACKGROUND

Q-fever is a zoonotic disease that can lead to illness, disability and death. This study aimed to provide insight into the perspectives of healthcare workers (HCWs) on prerequisites, barriers and opportunities in care for Q-fever patients.

METHODS

A two-round online Delphi study was conducted among 94 Dutch HCWs involved in care for Q-fever patients. The questionnaires contained questions on prerequisites for high quality, barriers and facilitators in care, knowledge of Q-fever, and optimization of care. For multiple choice, ranking and Likert scale questions, frequencies were reported, while for rating and numerical questions, the median and interquartile range (IQR) were reported.

RESULTS

The panel rated the care for Q-fever patients at a median score of 6/10 (IQR = 2). Sufficient knowledge of Q-fever among HCWs (36%), financial compensation of care (30%) and recognition of the disease by HCWs (26%) were considered the most important prerequisites for high quality care. A lack of knowledge was identified as the most important barrier (76%) and continuing medical education as the primary method for improving HCWs' knowledge (76%). HCWs rated their own knowledge at a median score of 8/10 (IQR = 1) and the general knowledge of other HCWs at a 5/10 (IQR = 2). According to HCWs, a median of eight healthcare providers (IQR = 4) should be involved in the care for Q-fever fatigue syndrome (QFS) and a median of seven (IQR = 5) in chronic Q-fever care.

CONCLUSIONS

Ten years after the Dutch Q-fever epidemic, HCWs indicate that the long-term care for Q-fever patients leaves much room for improvement. Facilitation of reported prerequisites for high quality care, improved knowledge among HCWs, clearly defined roles and responsibilities, and guidance on how to support patients could possibly improve quality of care. These prerequisites may also improve care for patients with persisting symptoms due to other infectious diseases, such as COVID-19.

Efficacy of Phase I and Phase II Coxiella burnetii Bacterin Vaccines in a Pregnant Ewe Challenge Model

The bacterium Coxiella burnetii can cause the disease Q-fever in a wide range of animal hosts. Ruminants, including sheep, are thought to play a pivotal role in the transmission of C. burnetii to humans; however, the only existing livestock vaccine, namely, Coxevac® (Ceva Animal Health Ltd., Libourne, France), a killed bacterin vaccine based on phase I C. burnetii strain Nine-Mile, is only approved for use in goats and cattle. In this study, a pregnant ewe challenge model was used to determine the protective effects of Coxevac® and an experimental bacterin vaccine based on phase II C. burnetii against C. burnetii challenge. Prior to mating, ewes (n = 20 per group) were vaccinated subcutaneously with either Coxevac®, the phase II vaccine, or were unvaccinated. A subset of pregnant ewes (n = 6) from each group was then challenged 151 days later (~100 days of gestation) with 106 infectious mouse doses of C. burnetii, Nine-Mile strain RSA493. Both vaccines provided protection against C. burnetii challenge as measured by reductions in bacterial shedding in faeces, milk and vaginal mucus, and reduced abnormal pregnancies, compared to unvaccinated controls. This work highlights that the phase I vaccine Coxevac® can protect ewes against C. burnetii infection. Furthermore, the phase II vaccine provided comparable levels of protection and may offer a safer and cost-effective alternative to the currently licensed vaccine.

MLVA and com1 genotyping of Coxiella burnetii in farmed ruminants in Great Britain

Coxiella burnetii, the causative agent of the zoonotic disease Q fever, has been shown to be endemic in Great Britain, but information on the prevailing genomic lineages or Genomic Groups (GGs) of Coxiella burnetii is limited. The aim of this study was to genotype C. burnetii isolates from infected farmed ruminants by Multiple Locus Variable Number Tandem Repeat Analysis (MLVA) and identify their associated Genomic Group. A total of 51 Coxiella-containing abortion samples from farmed ruminants (sheep, goats, and cattle), which were collected in Great Britain during 2013-2018, were included in the study, 34 of which returned a C. burnetii MLVA genotype. All bovine samples (n = 18), 5/7 of the ovine samples, and 3/9 of the caprine samples belonged to an MLVA cluster which we could link to the MST20 genotype of GG III, whereas 6/9 of the caprine samples and 2/7 of the ovine samples belonged to MLVA clusters which we could link to the MST33 or MST32 genotypes of GG II (7 vs 1 sample(s), respectively). We also noted that the Coxiella-specific com1 gene contained unique mutations that could genomotype isolates, i.e. assign them to a Genomic Group. In conclusion, both goats and sheep in Great Britain (from 2014 onward) were found to carry the same MLVA genotypes (MST33-like; GG II) that were linked to a human Q fever outbreak in the Netherlands. This knowledge in combination with the usage of genotyping/genomotyping methods should prove useful in future surveillance programs and in the management of outbreaks.

Coxiella burnetii (Q-fever) outbreak associated with non-occupational exposure in a semi-urban area of western Croatia in 2022

In March 2022, an outbreak of Q fever (Coxiella burnetii) with non-occupational exposure was confirmed in a semi-urban area in Čavle, Croatia. Veterinary and human epidemiological investigations were conducted to identify the source of the outbreak and to implement appropriate control measures. Three farms were settled next to each other near the homes of the first human cases at the end of the street. The closest farm was less than 500 meters away. These farms contained 161 adult sheep and goats. Among the animal samples analysed, all 16 goats (100%) and 24/50 sheep (48%) tested positive for C. burnetii IgM/IgG antibodies, phase I and II. One out of five sheeps' vaginal swabs were C. burnetti DNA positive. Human testing revealed 20 confirmed and three probable cases (9/23 pneumonia, 2/23 hepatitis, 21/23 fever), with three hospitalizations, and one death. Twenty-seven cases were discarded following negative laboratory results. The epidemiological investigation revealed airborne transmission as the most likely route of transmission. Multiple logistic regression analyses were used to evaluate risk factors for Q fever infection. Persons who were near the farms (≤750 m) (OR 4.5; 95% CI = 1.1-18.3) and lived in the nearest street to the farms had the highest risk of contracting Q fever (OR 3.7; 95% CI = 1.1-13.6). Decreased rainfall compared to monthly averages was recorded in the months prior to the outbreak with several days of strong wind in January preceding the outbreak. This was the largest Q fever outbreak in the county in the last 16 years, which was unexpected due to its location and non-occupational exposure. To stop the outbreak, numerous intensive biosecurity measures were implemented. The outbreak highlights the importance of urban development strategies to limit the number of animal housing near residential areas while providing regular biosecurity measures to prevent infections in livestock.

Coxiella burnetii in cattle and their human contacts in a gaushala (cattle shelter) from India and its partial com1 gene sequence-based phylogenetic analysis

Q fever caused by Coxiella burnetii is an important zoonosis and has great public health significance. A total of 905 clinical samples from 387 cattle [serum (n = 387); vaginal swabs (n = 387); milk (n = 131)] and 59 serum samples from humans were collected from gaushala (cattle shelter) and screened for anti-C. burnetii IgG antibodies in the sera using an indirect-ELISA kit. Further, the samples were tested for C. burnetii DNA employing TaqMan real-time and conventional PCR assays targeting the com1 gene. In ELISA, 9.56% and 6.78% of animal and human sera samples were positive for anti-C. burnetii antibodies, respectively. Upon pathogen detection, 3.87% sera, 1.81% vaginal swabs, and 6.87% milk samples from cattle tested positive in TaqMan real-time PCR and 1.55% sera, 0.52% vaginal swabs, and 3.05% milk samples were found positive in conventional PCR. In humans, one serum sample was positive in both the PCR assays. The PCR positive samples (n = 12) were partially sequenced and the phylogenetic tree was constructed using com1 gene sequences (n = 42) from a different host and geographical areas. The study highlights infection of cattle and their human contacts in gaushala and identifies relationships between strains identified in the gaushala and those in other parts of the globe.

Q fever and coxiellosis in Brazil: an underestimated disease? A brief review

Q fever, caused by the γ-proteobacterium Coxiella burnetii, is a zoonosis of great importance and global impact. This agent has high transmissibility and can spread over long distances via wind, in which a small number of aerosolized particles are needed to infect susceptible hosts. The clinical diagnosis of Q fever is difficult owing to the variety of clinical signs shared with other diseases. In Brazil, studies related to C. burnetii are constantly being conducted, and this review aims to increase the number of approaches already studied, leading to the following question: is Q fever an unknown, neglected disease, or does it have a focal occurrence in certain areas (exotic/rare) in the country?

Tick-Borne-Agents Detection in Patients with Acute Febrile Syndrome and Ticks from Magdalena Medio, Colombia

Acute febrile illness (AFI) is a morbid condition with a sudden onset of fever with at least seven days of evolution, where no signs or symptoms related to an apparent infection have been identified. In Latin America, a high proportion of disease is typically due to malaria and arboviruses. However, among the infectious etiologies, tick-borne diseases (TBDs) should also be considered, especially in areas where people come into direct contact with these arthropods. This study aims to describe the etiology and epidemiology related to tick-borne agents in patients with AFI and the tick’s natural infection by agents of TBD in the rural tropical Magdalena Medio region in Colombia, and explore the factors associated with the presence of Coxiella burnetii infection. We conduct a cohort study enrolling 271 patients with AFI to detect the bacteria of the genera Anaplasma, Ehrlichia, Coxiella, Rickettsia, Borrelia, and Francisella through molecular techniques, and additionally evaluate the presence of IgG antibodies with commercially available kits. We also conduct tick collection in the patient’s households or workplaces for the molecular screening of the same bacterial genera. Seropositivity to IgG antibodies was obtained for all the bacteria analyzed, with Francisella being the most common at 39.5% (107/271), followed by R. rickettsii at 31.4% (85/271), Ehrlichia at 26.9% (73/271), R. typhi at 15.5% (42/271), Anaplasma at 14.4% (39/271), and Borrelia at 6.6% (18/271). However, these bacteria were not detected by the molecular techniques used. Coxiella burnetii infection was detected in 39.5% of the patients: 49.5% only by phase I and II IgG antibodies, 33.6% only by real-time PCR, and 16.8% had a concordant positive result for both techniques. A total of 191 adult ticks, 111 females and 80 males, were collected and identified as Rhipicephalus sanguineus s.l. and Rhipicephalus microplus. In the 169 adult ticks in which natural infection was evaluated, Ehrlichia spp. was detected in 21.3% (36/169), Coxiella spp. in 11.8% (20/169), and Anaplasma spp. in 4.7% (8/169). In conclusion, we identified the prior exposition to Francisella, Anaplasma, Ehrlichia, Rickettsia, Borrelia, and Coxiella in patients through serological tests. We also detected the infection of C. burnetii using molecular techniques. In the ticks, we identified bacteria of the genera Coxiella, Anaplasma, and Ehrlichia. These results suggest the importance of these zoonotic agents as possible causes of AFI in this region.

Natural Exposure- and Vaccination-Induced Profiles of Ex Vivo Whole Blood Cytokine Responses to Coxiella burnetii

Q fever is a zoonotic disease caused by the highly infectious Gram-negative coccobacillus, Coxiella burnetii (C. burnetii). The Q fever vaccine Q-VAX® is characterised by high reactogenicity, requiring individuals to be pre-screened for prior exposure before vaccination. To date it remains unclear whether vaccine side effects in pre-exposed individuals are associated with pre-existing adaptive immune responses to C. burnetii or are also a function of innate responses to Q-VAX®. In the current study, we measured innate and adaptive cytokine responses to C. burnetii and compared these among individuals with different pre-exposure status. Three groups were included: n=98 Dutch blood bank donors with unknown exposure status, n=95 Dutch village inhabitants with known natural exposure status to C. burnetii during the Dutch Q fever outbreak of 2007-2010, and n=96 Australian students receiving Q-VAX® vaccination in 2021. Whole blood cytokine responses following ex vivo stimulation with heat-killed C. burnetii were assessed for IFNγ, IL-2, IL-6, IL-10, TNFα, IL-1β, IP-10, MIP-1α and IL-8. Serological data were collected for all three cohorts, as well as data on skin test and self-reported vaccine side effects and clinical symptoms during past infection. IFNγ, IP-10 and IL-2 responses were strongly elevated in individuals with prior C. burnetii antigen exposure, whether through infection or vaccination, while IL-1β, IL-6 and TNFα responses were slightly increased in naturally exposed individuals only. High dimensional analysis of the cytokine data identified four clusters of individuals with distinct cytokine response signatures. The cluster with the highest levels of adaptive cytokines and antibodies comprised solely individuals with prior exposure to C. burnetii, while another cluster was characterized by high innate cytokine production and an absence of C. burnetii-induced IP-10 production paired with high baseline IP-10 levels. Prior exposure status was partially associated with these signatures, but could not be clearly assigned to a single cytokine response signature. Overall, Q-VAX® vaccination and natural C. burnetii infection were associated with comparable cytokine response signatures, largely driven by adaptive cytokine responses. Neither individual innate and adaptive cytokine responses nor response signatures were associated retrospectively with clinical symptoms during infection or prospectively with side effects post-vaccination.

Coxiella burnetii Plasmid Effector B Promotes LC3-II Accumulation and Contributes To Bacterial Virulence in a SCID Mouse Model

Coxiella burnetii, the causative agent of zoonotic Q fever, is characterized by replicating inside the lysosome-derived Coxiella-containing vacuole (CCV) in host cells. Some effector proteins secreted by C. burnetii have been reported to be involved in the manipulation of autophagy to facilitate the development of CCVs and bacterial replication. Here, we found that the Coxiella plasmid effector B (CpeB) localizes on vacuole membrane targeted by LC3 and LAMP1 and promotes LC3-II accumulation. Meanwhile, the C. burnetii strain lacking the QpH1 plasmid induced less LC3-II accumulation, which was accompanied by smaller CCVs and lower bacterial loads in THP-1 cells. Expression of CpeB in the strain lacking QpH1 led to restoration in LC3-II accumulation but had no effect on the smaller CCV phenotype. In the severe combined immune deficiency (SCID) mouse model, infections with the strain expressing CpeB led to significantly higher bacterial burdens in the spleen and liver than its parent strain devoid of QpH1. We also found that CpeB targets Rab11a to promote LC3-II accumulation. Intratracheally inoculated C. burnetii resulted in lower bacterial burdens and milder lung lesions in Rab11a conditional knockout (Rab11a^-/- CKO) mice. Collectively, these results suggest that CpeB promotes C. burnetii virulence by inducing LC3-II accumulation via a pathway involving Rab11a.

A cross-sectional survey of risk factors for the presence of Coxiella burnetii in Australian commercial dairy goat farms

The largest Australian farm‐based outbreak of Q fever originated from a dairy goat herd. We surveyed commercial dairy goat farms across Australia by testing bulk tank milk (BTM) samples using a commercial indirect enzyme‐linked immunosorbent assay and two quantitative polymerase chain reactions (PCRs). Of the 66 commercial dairy goat herds on record, managers from 61 herds were contacted and 49 provided BTM samples. Five of the surveyed herds were positive on at least one of the diagnostic tests, thus herd‐level apparent prevalence was 10% (95% confidence interval [CI] 4 to 22). True prevalence was estimated to be 3% (95% credible interval: 0 to 18). Herd managers completed a questionnaire on herd management, biosecurity and hygiene practices and risk factors were investigated using multivariable logistic regression. Herds with >900 milking does (the upper quartile) were more likely to be Coxiella burnetii positive (odds ratio = 6.75; 95% CI 1.65 to 27.7) compared with farms with ≤900 milking does. The odds of BTM positivity increased by a factor of 2.53 (95% CI 1.51 to 4.22) for each order of magnitude increase in the number of goats per acre. C. burnetii was not detected in samples from the majority of the Australian dairy goat herds suggesting there is an opportunity to protect the industry and contain this disease with strengthened biosecurity practices. Intensification appeared associated with an increased risk of positivity. Further investigation is required to discriminate the practices associated with an increased risk of introduction to disease‐free herds, from practices associated with maintenance of C. burnetii infection in infected dairy goat herds.

Illuminating the bacterial microbiome of Australian ticks with 16S and Rickettsia-specific next-generation sequencing

Next-generation sequencing (NGS) studies show that mosquito and tick microbiomes influence the transmission of pathogens, opening new avenues for vector-borne pathogen control. Recent microbiological studies of Australian ticks highlight fundamental knowledge gaps of tick-borne agents. This investigation explored the composition, diversity and prevalence of bacteria in Australian ticks (n = 655) from companion animals (dogs, cats and horses). Bacterial 16S NGS was used to identify most bacterial taxa and a Rickettsia-specific NGS assay was developed to identify Rickettsia species that were indistinguishable at the V1-2 regions of 16S. Sanger sequencing of near full-length 16S was used to confirm whether species detected by 16S NGS were novel. The haemotropic bacterial pathogens Anaplasma platys, Bartonella clarridgeiae, “Candidatus Mycoplasma haematoparvum” and Coxiella burnetii were identified in Rhipicephalus sanguineus (s.l.) from Queensland (QLD), Western Australia, the Northern Territory (NT), and South Australia, Ixodes holocyclus from QLD, Rh. sanguineus (s.l.) from the NT, and I. holocyclus from QLD, respectively. Analysis of the control data showed that cross-talk compromises the detection of rare species as filtering thresholds for less abundant sequences had to be applied to mitigate false positives. A comparison of the taxonomic assignments made with 16S sequence databases revealed inconsistencies. The Rickettsia-specific citrate synthase gene NGS assay enabled the identification of Rickettsia co-infections with potentially novel species and genotypes most similar (97.9–99.1%) to Rickettsia raoultii and Rickettsia gravesii. “Candidatus Rickettsia jingxinensis” was identified for the first time in Australia. Phylogenetic analysis of near full-length 16S sequences confirmed a novel Coxiellaceae genus and species, two novel Francisella species, and two novel Francisella genotypes. Cross-talk raises concerns for the MiSeq platform as a diagnostic tool for clinical samples. This study provides recommendations for adjustments to Illuminaʼs 16S metagenomic sequencing protocol that help track and reduce cross-talk from cross-contamination during library preparation. The inconsistencies in taxonomic assignment emphasise the need for curated and quality-checked sequence databases.

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Bacterial pathogens identified in ticks from companion animals with 16S NGS.

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Sanger sequencing confirmed novel Coxiellaceae gen. sp. and Francisella.

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“Candidatus Rickettsia jingxinensis” was identified with Rickettsia-specific NGS.

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Comparison of taxonomic assignments in 16S sequence databases revealed errors.

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Modifications to the 16S metagenomic library protocol (Illumina) are provided.

Identifying scenarios and risk factors for Q fever outbreaks using qualitative analysis of expert opinion

Q fever is an important zoonotic disease perceived to be an occupational hazard for those working with livestock. Outbreaks involving large numbers of people are uncommon, but the increasing case incidence coupled with changing environmental and industry conditions that promote transmission of Q fever has raised concerns that large and serious outbreaks could become more frequent. The aim of this study was to use expert opinion to better understand how large Q fever outbreaks might occur in an Australian context and to document factors believed to be drivers of disease transmission. Focus groups were conducted with human and animal health professionals across several Australian states. All discussions were recorded, transcribed verbatim and imported into NVIVO for thematic analysis. Four anthropogenic risk factors (disease awareness, industry practices, land use, human behaviour) and three ecological risk factors (physical environment, agent dissemination, animal hosts) emerged from the data. Analysis of expert opinions pointed to the existence of numerous scenarios in which Q fever outbreaks could occur, many of which depict acquisition in the wider community outside of traditional at-risk occupations. This perception of the expansion of Q fever from occupational-acquisition to community-acquisition is driven by greater overarching economic, political and socio-cultural influences that govern the way in which people live and work. Findings from this study highlight that outbreaks are complex phenomena that involve the convergence of diverse elements, not just that of the pathogen and host, but also the physical, political and socioeconomic environments in which they interact. A review of the approaches to prevent and manage Q fever outbreaks will require a multisectorial approach and strengthening of community education, communication and engagement so that all stakeholders become an integrated part of outbreak mitigation and response.

Molecular detection of Coxiella burnetii in aborted bovine fetuses in Brazil

In the past decade, cases of Q fever have been reported in Brazil. Although the previous report of Coxiella burnetii in humans and animals, the knowledge about the occurrence of this pathogen in livestock in Brazil is scarce. This study aimed to search C. burnetii and possible coinfections in tissues of aborted bovine fetuses from Brazil. Tissue samples from seventy-six aborted bovine fetuses sent to the laboratory of molecular diagnosis of infectious diseases from 2013 to 2019 were evaluated by real-time PCR for C. burnetii. Overall, 9.2% (7/76) of the samples were positive for C. burnetii. Moreover, the molecular diagnostic history of our lab revealed the coinfection with Neospora spp. in three fetuses and the presence of histopathological features suggestive with fetal neosporosis in another one. The previous report of C. burnetii in humans and animals in the country, with the detection of C. burnetii from tissues of aborted bovine fetuses reported here, reinforces the neglected state of the disease in Brazil and raises the question of the role of the pathogen in reproductive disorders in national livestock.

Exposure of South African Abattoir Workers to Coxiella burnetii

Abattoir workers may contract Q fever by inhalation of Coxiella burnetii bacteria in aerosols generated by slaughtering livestock, or in contaminated dust. We estimated the seroprevalence of C. burnetii and examined the associated factors in a survey of South African abattoir workers. Coxiella burnetii seropositivity was determined by detection of IgG antibodies against C. burnetii phase II antigen. Logistic regression, adjusted for clustering and sampling fraction, was employed to analyze risk factors associated with C. burnetii seropositivity. Among 382 workers from 16 facilities, the overall seroprevalence was 33% (95% confidence interval (CI): 28–38%) and ranged from 8% to 62% at the facility level. Prolonged contact with carcasses or meat products (odds ratio (OR): 4.6, 95% CI: 1.51–14.41) and prior abattoir or butchery work experience (OR: 1.9, 95% CI: 1.13–3.17) were associated with C. burnetii seropositivity. In contrast, increasing age and livestock ownership were inversely associated. Precautions to protect abattoir personnel from Q fever are discussed.

Characterisation of putative lactate synthetic pathways of Coxiella burnetii

The zoonotic pathogen Coxiella burnetii, the causative agent of the human disease Q fever, is an ever-present danger to global public health. Investigating novel metabolic pathways necessary for C. burnetii to replicate within its unusual intracellular niche may identify new therapeutic targets. Recent studies employing stable isotope labelling established the ability of C. burnetii to synthesize lactate, despite the absence of an annotated synthetic pathway on its genome. A noncanonical lactate synthesis pathway could provide a novel anti-Coxiella target if it is essential for C. burnetii pathogenesis. In this study, two C. burnetii proteins, CBU1241 and CBU0823, were chosen for analysis based on their similarities to known lactate synthesizing enzymes. Recombinant GST-CBU1241, a putative malate dehydrogenase (MDH), did not produce measurable lactate in in vitro lactate dehydrogenase (LDH) activity assays and was confirmed to function as an MDH. Recombinant 6xHis-CBU0823, a putative NAD+-dependent malic enzyme, was shown to have both malic enzyme activity and MDH activity, however, did not produce measurable lactate in either LDH or malolactic enzyme activity assays in vitro. To examine potential lactate production by CBU0823 more directly, [13C]glucose labelling experiments compared label enrichment within metabolic pathways of a cbu0823 transposon mutant and the parent strain. No difference in lactate production was observed, but the loss of CBU0823 significantly reduced 13C-incorporation into glycolytic and TCA cycle intermediates. This disruption to central carbon metabolism did not have any apparent impact on intracellular replication within THP-1 cells. This research provides new information about the mechanism of lactate biosynthesis within C. burnetii, demonstrating that CBU1241 is not multifunctional, at least in vitro, and that CBU0823 also does not synthesize lactate. Although critical for normal central carbon metabolism of C. burnetii, loss of CBU0823 did not significantly impair replication of the bacterium inside cells.

Seroprevalence estimate and risk factors for Coxiella burnetii infections among humans in a highly urbanised Brazilian state

BACKGROUND

Q fever is among the top 13 global priority zoonoses, however, it is still neglected and under-reported in most of the world, including Brazil. Thus, we evaluated the seroprevalence of and the risk factors for Coxiella burnetii infections in humans from Minas Gerais, a highly urbanised Brazilian state.

METHODS

Coxiella burnetii was searched for patient samples (n=437), which were suspected of then later confirmed as negative for dengue fever, by the indirect immunofluorescence technique and real-time PCR. Risk factors for infections and spatial clusters for both C. burnetii-seropositive individuals and livestock concentration were evaluated.

RESULTS

We found that 21 samples (4.8%; 95% CI 3.0 to 7.2%) were reactive for at least one class of anti-C. burnetii antibodies (titer of ≥64), with rural residence (p=0.036) being a risk factor. Also, two spatial clusters of seropositivity were found within a significant area by Scan, and a probable relationship between the Scan result and the livestock concentration by area was found.

CONCLUSIONS

Seropositive individuals were associated with rural residence, with a likely relationship with the livestock concentration. Thus, this study establishes baseline figures for C. burnetii seroprevalence in humans in a state of Brazil, allowing the monitoring of trends and setting of control targets, as well as more representative longitudinal and risk analysis studies.

[Management of Adult Community-Acquired Pneumonia and Prevention - Update 2021 - Guideline of the German Respiratory Society (DGP), the Paul-Ehrlich-Society for Chemotherapy (PEG), the German Society for Infectious Diseases (DGI), the German Society of Medical Intensive Care and Emergency Medicine (DGIIN), the German Viological Society (DGV), the Competence Network CAPNETZ, the German College of General Practitioneers and Family Physicians (DEGAM), the German Society for Geriatric Medicine (DGG), the German Palliative Society (DGP), the Austrian Society of Pneumology Society (ÖGP), the Austrian Society for Infectious and Tropical Diseases (ÖGIT), the Swiss Respiratory Society (SGP) and the Swiss Society for Infectious Diseases Society (SSI)]

The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.

Epidemiological investigation and physician awareness regarding the diagnosis and management of Q fever in South Korea, 2011 to 2017

BACKGROUND

In South Korea, the number of Q fever cases has rapidly increased since 2015. Therefore, this study aimed to characterize the epidemiological and clinical features of Q fever in South Korea between 2011 and 2017.

METHODS/PRINCIPAL FINDINGS

We analyzed the epidemiological investigations and reviewed the medical records from all hospitals that had reported at least one case of Q fever from 2011 to 2017. We also conducted an online survey to investigate physicians' awareness regarding how to appropriately diagnose and manage Q fever. The nationwide incidence rate of Q fever was annually 0.07 cases per 100,000 persons. However, there has been a sharp increase in its incidence, reaching up to 0.19 cases per 100,000 persons in 2017. Q fever sporadically occurred across the country, with the highest incidences in Chungbuk (0.53 cases per 100,000 persons per year) and Chungnam (0.27 cases per 100,000 persons per year) areas. Patients with acute Q fever primarily presented with mild illnesses such as hepatitis (64.5%) and isolated febrile illness (24.0%), whereas those with chronic Q fever were likely to undergo surgery (41.2%) and had a high mortality rate (23.5%). Follow-up for 6 months after acute Q fever was performed by 24.0% of the physician respondents, and only 22.3% of them reported that clinical and serological evaluations were required after acute Q fever diagnosis.

CONCLUSIONS

Q fever is becoming an endemic disease in the midwestern area of South Korea. Given the clinical severity and mortality of chronic Q fever, physicians should be made aware of appropriate diagnosis and management strategies for Q fever.

Molecular detection of Theileria sergentii/orientalis/buffeli and Ehrlichia canis from aborted ovine and caprine products in Sardinia, Italy

The economic impact and losses caused by abortion of small ruminants represent an important threat to livestock industry worldwide. Infectious agents are the most commonly causes of small ruminant abortion and many of which pose a serious threat to human health. The management of abortion outbreaks is essential to understand the transmission, prevention and control of the zoonotic diseases. This study aimed to increase the knowledge about the common known zoonotic pathogens causing abortion (Coxiella burnetii, Chlamydia abortus and Toxoplasma gondii) circulating in Sardinia. In addition, the occurrence of other infectious agents that, until now, had never been identified in abortion samples and which might be cocirculating during the abortion outbreaks were also considered. In this study, 125 abortion samples collected from 91 small ruminant farms were screened for the presence of Babesia/Theileria spp., Ehrlichia canis, Anaplasma spp., Chlamydia spp., C. burnetii and T. gondii by PCR analyses and sequencing. This is the first evidence on the presence of Theileria sergenti/orientalis/buffeli group and Eh. canis in 22 (22/125; 18%) and 26 (26/125; 21%) abortion products from small ruminants, respectively. Chlamydia abortus, C. burnetii and T. gondii were also detected in brain, liver, spleen and placentae at 46% (58/125), 34% (42/125) and 2% (2/125), respectively. This study highlights that pathogens with epizootic and zoonotic potential are circulating in the island and could be involved directly or in association with other pathogens as possible cause of ruminant abortion. Further studies are needed to fully assess the impact of Theileria sergenti/orientalis/buffeli group and Eh. canis on ruminant abortion and their real zoonotic risk in the island.

National Seroprevalence of Coxiella burnetii in Chile, 2016-2017

Coxiella burnetii is an intracellular bacterium and the cause of the zoonotic infection, Q fever. National surveillance data on C. burnetii seroprevalence is currently not available for any South American country, making efforts of public health to implement strategies to mitigate infections in different at-risk groups within the population extremely challenging. In the current study, we used two commercial anti-C. burnetii immunoassays to screen sera collected from a sample of the Chilean population as part of a 2016–2017 national health survey (n = 5166), nationwide and age-standardized. The seroprevalence for C. burnetii for persons ≥ 15 years was estimated to be 3.0% (95% CI 2.2–4.0), a level similar to national surveys from The Netherlands (2.4%) and USA (3.1%), but lower than Australia (5.6%). A linear increase of C. burnetii seropositivity was associated with an individual’s age, with the peak seroprevalence 5.6% (95% CI 3.6–8.6) observed in the ≥65 years’ group. C. burnetii seropositivity was significantly higher in the southern macro-zone 6.0% (95% CI 3.3–10.6) compared to metropolitan region 1.8% (95% CI 0.9–3.3), the former region being home to significant livestock industries, particularly dairy farming. These data will be useful to inform targeted strategies for the prevention of Q fever in at-risk populations in Chile.

The Prevalence of Coxiella burnetii in Hard Ticks in Europe and Their Role in Q Fever Transmission Revisited-A Systematic Review

The zoonosis Q fever is caused by the obligate intracellular bacterium Coxiella burnetii. Besides the main transmission route via inhalation of contaminated aerosols, ticks are discussed as vectors since the first isolation of the pathogen from a Dermacentor andersonii tick. The rare detection of C. burnetii in ticks and the difficult differentiation of C. burnetii from Coxiella-like endosymbionts (CLEs) are questioning the relevance of ticks in the epidemiology of Q fever. In this review, literature databases were systematically searched for recent prevalence studies concerning C. burnetii in ticks in Europe and experimental studies evaluating the vector competence of tick species. A total of 72 prevalence studies were included and evaluated regarding DNA detection methods and collection methods, country, and tested tick species. Specimens of more than 25 different tick species were collected in 23 European countries. Overall, an average prevalence of 4.8% was determined. However, in half of the studies, no Coxiella-DNA was detected. In Southern European countries, a significantly higher prevalence was observed, possibly related to the abundance of different tick species here, namely Hyalomma spp. and Rhipicephalus spp. In comparison, a similar proportion of studies used ticks sampled by flagging and dragging or tick collection from animals, under 30% of the total tick samples derived from the latter. There was no significant difference in the various target genes used for the molecular test. In most of the studies, no distinction was made between C. burnetii and CLEs. The application of specific detection methods and the confirmation of positive results are crucial to determine the role of ticks in Q fever transmission. Only two studies were available, which assessed the vector competence of ticks for C. burnetii in the last 20 years, demonstrating the need for further research.

Epidemiological study of Coxiella burnetii in dairy cattle and small ruminants in Québec, Canada

The bacterium Coxiella burnetii (C. burnetii) can infect a wide range of animals, most notably ruminants where it causes mainly asymptomatic infections and, when clinical, it is associated with reproductive disorders such as abortion. It is also the etiological agent of Q fever in humans, a zoonosis of increasingly important public health concern. A cross-sectional study was performed to estimate the apparent prevalence and spatial distribution of C. burnetii positivity in dairy cattle and small ruminant herds of two regions of Québec, Canada, and identify potential risk factors associated with positivity at animal and herd levels. In dairy cattle herds, individual fecal samples and repeated bulk tank milk samples (BTM) were collected. In small ruminant herds, serum and feces were sampled in individual animals. ELISA analyses were performed on serum and BTM samples. Real-time quantitative PCR (qPCR) was done on fecal and BTM samples. An animal was considered C. burnetii-positive when at least one sample was revealed positive by ELISA and/or qPCR, while a herd was considered C. burnetii-positive when at least one animal inside that herd was revealed positive. None of the 155 cows had a qPCR-positive fecal sample, whereas 37.2 % (95 % CI = 25.3-49.1) of the 341 sheep and 49.2 % (95 % CI = 25.6-72.7) of the 75 goats were C. burnetii-positive. The apparent prevalence of C. burnetii-positive herds was 47.3 % (95 % CI = 35.6-59.3) in dairy cattle herds (n = 74), 69.6 % (95 % CI = 47.1-86.8) in sheep flocks (n = 23) and 66.7 % (95 % CI = 22.3-95.7) in goat herds (n = 6). No spatial cluster of positive herds was detected. At the individual level, the only significant association with positivity in multivariable regressions was higher parity number in small ruminants. At the herd level, the use of calving group pen, the distance to the closest positive bovine herd, and small ruminant herd density in a 5 km radius were associated with dairy cattle herd positivity, whereas small ruminant herds with more than 100 animals and with a dog on the farm had greater odds of C. burnetii positivity. Our study shows that the infection is frequent on dairy cattle and small ruminant herds from the two studied regions and that some farm and animal characteristics might influence the transmission dynamics of the C. burnetii infection.

Multi-Scale Airborne Infectious Disease Transmission

Airborne disease transmission is central to many scientific disciplines including agriculture, veterinary biosafety, medicine, and public health. Legal and regulatory standards are in place to prevent agricultural, nosocomial, and community airborne disease transmission. However, the overall importance of the airborne pathway is underappreciated, e.g.,, US National Library of Medicine's Medical Subjects Headings (MESH) thesaurus lacks an airborne disease transmission indexing term. This has practical consequences as airborne precautions to control epidemic disease spread may not be taken when airborne transmission is important, but unrecognized. Publishing clearer practical methodological guidelines for surveillance studies and disease outbreak evaluations could help address this situation.To inform future work, this paper highlights selected, well-established airborne transmission events - largely cases replicated in multiple, independently conducted scientific studies. Methodologies include field experiments, modeling, epidemiology studies, disease outbreak investigations and mitigation studies. Collectively, this literature demonstrates that airborne viruses, bacteria, and fungal pathogens have the capability to cause disease in plants, animals, and humans over multiple distances - from near range (< 5 m) to continental (> 500 km) in scale. The plausibility and implications of undetected airborne disease transmission are discussed, including the notable underreporting of disease burden for several airborne transmitted diseases.

The European Union One Health 2019 Zoonoses Report

This report of the EFSA and the European Centre for Disease Prevention and Control presents the results of zoonoses monitoring activities carried out in 2019 in 36 European countries (28 Member States (MS) and eight non-MS). The first and second most reported zoonoses in humans were campylobacteriosis and salmonellosis, respectively. The EU trend for confirmed human cases of these two diseases was stable (flat) during 2015-2019. The proportion of human salmonellosis cases due to Salmonella Enteritidis acquired in the EU was similar to that in 2017-2018. Of the 26 MS reporting on Salmonella control programmes in poultry, 18 met the reduction targets, whereas eight failed to meet at least one. The EU prevalence of Salmonella target serovar-positive flocks has been stable since 2015 for breeding hens, laying hens, broilers and fattening turkeys, with fluctuations for breeding turkey flocks. Salmonella results from competent authorities for pig carcases and for poultry tested through national control programmes were more frequently positive than those from food business operators. Shiga toxin-producing Escherichia coli (STEC) infection was the third most reported zoonosis in humans and increased from 2015 to 2019. Yersiniosis was the fourth most reported zoonosis in humans in 2019 with a stable trend in 2015-2019. The EU trend of confirmed listeriosis cases remained stable in 2015-2019 after a long period of increase. Listeria rarely exceeded the EU food safety limit tested in ready-to-eat food. In total, 5,175 food-borne outbreaks were reported. Salmonella remained the most detected agent but the number of outbreaks due to S. Enteritidis decreased. Norovirus in fish and fishery products was the agent/food pair causing the highest number of strong-evidence outbreaks. The report provides further updates on bovine tuberculosis, Brucella, Trichinella, Echinococcus, Toxoplasma, rabies, West Nile virus, Coxiella burnetii (Q fever) and tularaemia.

A Novel Marmoset (Callithrix jacchus) Model of Human Inhalational Q Fever

Common marmosets (Callithrix jacchus) were shown to be susceptible to inhalational infection with Coxiella burnetii, in a dose-dependent manner, producing a disease similar to human Q fever, characterized by a resolving febrile response. Illness was also associated with weight loss, liver enzyme dysfunction, characteristic cellular activation, circulating INF-γ and bacteraemia. Viable C. burnetii was recovered from various tissues during disease and from 75% of the animal's lungs on 28 days post challenge, when there were no overt clinical features of disease but there was histological evidence of macrophage and lymphocyte infiltration into the lung resulting in granulomatous alveolitis. Taken together, these features of disease progression, physiology and bacterial spread appear to be consistent with human disease and therefore the common marmoset can be considered as a suitable model for studies on the pathogenesis or the development of medical counter measures of inhalational Q fever.

Molecular prevalence of Coxiella burnetii in bulk-tank milk from bovine dairy herds: Systematic review and meta-analysis

Coxiella burnetii is an obligate intracellular zoonotic bacterium that causes Q fever. Ruminants, including cattle, are broadly known to be reservoirs for this bacterium. Since 2006, many research groups have evaluated the herd-level prevalence of C. burnetii in cattle by molecular techniques on composite milk samples. This study explored the global C. burnetii herd-level prevalence from studies done on bovine bulk-tank milk (BTM) samples using PCR-based analysis. Also, moderators were investigated to identify sources of heterogeneity. Databases (CAB Abstracts, Medline via Ovid, PubMed, Web of Science and Google Scholar) were searched for index articles on C. burnetii prevalence in BTM samples by PCR published between January-1973 and November-2018. Numerous studies (1054) were initially identified, from which seventeen original publications were included in the meta-analysis based on the pre-defined selection criteria. These studies comprised 4031 BTM samples from twelve countries. A random-effects model was used because of considerable heterogeneity (I² = 98%) to estimate the herd-level prevalence of C. burnetii as 37.0%(CI_95%25.2–49.5%). The average herd size appeared to account for a high level of the heterogeneity. No other moderators (geographic location, gross national income or notification criteria for Q fever) seemed to be determinant. This systematic evaluation demonstrated a high molecular prevalence of C. burnetii in BTM samples both in European and non-European countries, evidencing a widespread herd-level circulation of this agent in bovine dairy farms around the world. Meta-regression showed herd size as the most relevant moderator with the odds of a BTM sample testing positive doubling with every unit increase.

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First meta-analysis of the PCR-based prevalence of C. burnetii in bovine milk

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Results showed a high molecular prevalence of C. burnetii in bulk-tank milk samples.

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C. burnetii is widely distributed in dairy farms in Europe and the wider world.

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Current results reinforce the need for further investigations on this zoonosis.

Validation of a Novel Commercial ELISA Test for the Detection of Antibodies against Coxiella burnetii

Q fever is a zoonosis caused by Coxiella burnetii, a Gram-negative pathogen with a complex life cycle and a high impact on public and animal health all over the world. The symptoms are indistinguishable from those belonging to other diseases, and the disease could be symptomless. For these reasons, reliable laboratory tests are essential for an accurate diagnosis. The aim of this study was to validate a novel enzyme-linked immunosorbent assay (ELISA) test, named the Chorus Q Fever Phase II IgG and IgM Kit (DIESSE, Diagnostica Senese S.p.A), which is performed by an instrument named Chorus, a new device in medical diagnostics. This diagnostic test is employed for the detection of antibodies against C. burnetii Phase II antigens in acute disease. Our validation protocol was performed according to the Italian Accreditation Body (ACCREDIA) (Regulation UNI CEI EN ISO/IEC 17025:2018 and 17043:2010), OIE (World Organization for Animal Health), and Statement for Reporting Studies of Diagnostic Accuracy (STARD). Operator performance was evaluated along with the analytical specificity and sensitivity (ASp and ASe) and diagnostic accuracy of the kit, with parameters such as diagnostic specificity and sensitivity (DSp and DSe) and positive and negative predictive values (PPV and NPV), in addition to the repeatability. According to the evaluated parameters, the diagnostic ELISA test was shown to be suitable for validation and commercialization as a screening method in human sera and a valid support for clinical diagnostics.

Proteomic Identification of Coxiella burnetii Effector Proteins Targeted to the Host Cell Mitochondria During Infection

Modulation of the host cell is integral to the survival and replication of microbial pathogens. Several intracellular bacterial pathogens deliver bacterial proteins, termed "effector proteins" into the host cell during infection by sophisticated protein translocation systems, which manipulate cellular processes and functions. The functional contribution of individual effectors is poorly characterized, particularly in intracellular bacterial pathogens with large effector protein repertoires. Technical caveats have limited the capacity to study these proteins during a native infection, with many effector proteins having only been demonstrated to be translocated during over-expression of tagged versions. Here, we developed a novel strategy to examine effector proteins in the context of infection. We coupled a broad, unbiased proteomics-based screen with organelle purification to study the host-pathogen interactions occurring between the host cell mitochondrion and the Gram-negative, Q fever pathogen Coxiella burnetii. We identify four novel mitochondrially-targeted C. burnetii effector proteins, renamed Mitochondrial Coxiella effector protein (Mce) B to E. Examination of the subcellular localization of ectopically expressed proteins confirmed their mitochondrial localization, demonstrating the robustness of our approach. Subsequent biochemical analysis and affinity enrichment proteomics of one of these effector proteins, MceC, revealed the protein localizes to the inner membrane and can interact with components of the mitochondrial quality control machinery. Our study adapts high-sensitivity proteomics to study intracellular host-pathogen interactions, providing a robust strategy to examine the subcellular localization of effector proteins during native infection. This approach could be applied to a range of pathogens and host cell compartments to provide a rich map of effector dynamics throughout infection.

Detection of Coxiella burnetii antibodies in sheep and cattle on a veterinary campus in St. Kitts: Implications for one health in the Caribbean region

Coxiella burnetii is a ubiquitous zoonotic bacterium reported worldwide that causes Q-fever. Infections result in profound economic losses to livestock producers by causing abortions and low birth weights. Current information about the disease in the Caribbean region is scarce. With multiple small islands and territories, it is often considered that the bacterium is absent or circulates at a low prevalence. Our study aimed to determine whether sheep and cattle housed at a veterinary campus in St Kitts had previous exposure to C. burnetii. Blood samples were taken from cattle (n = 63; 72% of the herd) and sheep (n = 133; 71% of the flock). Antibodies to C. burnetii were detected by a commercial indirect enzyme-linked immunosorbent assay (IDvet® ELISA) test. The seroprevalence was estimated at 26.3% (95% CI: 19.1–34.7%) in sheep and 0% (95% CI: 0–5.7%) in cattle. Sheep importation to St. Kitts is very rare, thus, these results suggest that C. burnetii is present on the island. The seronegativity of all the cattle highlights the absence of the bacterium on the veterinary campus. The high seroprevalence in sheep, however, has potentially important implications for animal health and public health as well as for wildlife conservation. Further investigation about animal seroprevalence and human exposure are warranted in St. Kitts and in the Caribbean region.

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Seroprevalence in sheep from a veterinary university was 26.3%

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No cattle from the university were seropositive

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Risk for human and animal health is likely to be important in St. Kitts

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There is a need to investigate the prevalence of Coxiella burnetii in Caribbean region

Coxiella burnetii utilizes both glutamate and glucose during infection with glucose uptake mediated by multiple transporters

Coxiella burnetii is a Gram-negative bacterium which causes Q fever, a complex and life-threatening infection with both acute and chronic presentations. C. burnetii invades a variety of host cell types and replicates within a unique vacuole derived from the host cell lysosome. In order to understand how C. burnetii survives within this intracellular niche, we have investigated the carbon metabolism of both intracellular and axenically cultivated bacteria. Both bacterial populations were shown to assimilate exogenous [¹³C]glucose or [¹³C]glutamate, with concomitant labeling of intermediates in glycolysis and gluconeogenesis, and in the TCA cycle. Significantly, the two populations displayed metabolic pathway profiles reflective of the nutrient availabilities within their propagated environments. Disruption of the C. burnetii glucose transporter, CBU0265, by transposon mutagenesis led to a significant decrease in [¹³C]glucose utilization but did not abolish glucose usage, suggesting that C. burnetii express additional hexose transporters which may be able to compensate for the loss of CBU0265. This was supported by intracellular infection of human cells and in vivo studies in the insect model showing loss of CBU0265 had no impact on intracellular replication or virulence. Using this mutagenesis and [¹³C]glucose labeling approach, we identified a second glucose transporter, CBU0347, the disruption of which also showed significant decreases in ¹³C-label incorporation but did not impact intracellular replication or virulence. Together, these analyses indicate that C. burnetii may use multiple carbon sources in vivo and exhibits greater metabolic flexibility than expected.

Isolation of Coxiella burnetii in patients with nonspecific febrile illness in South Korea

Background

The number of human Q fever cases in South Korea has been rapidly increasing since 2015. We report the first isolation of Coxiella burnetii in Korea in two patients who initially presented with non-specific febrile illness and were finally diagnosed with acute Q fever in South Korea.

Case presentation

Two adult patients with fever had serologic tests against C. burnetii initially negative, and polymerase chain reaction against 16S rRNA using whole blood was also negative. After bacterial amplification of C. burnetii in immune-depressed mice, we isolated C. burnetii from patients with acute Q fever. The isolates KZQ2 and KZQ3 were confirmed by polymerase chain reaction, nucleotide sequence analysis, and morphologic observation using a transmission electron microscope.

Conclusions

These results can help us understand the clinical and epidemiologic features of Q fever in South Korea.

Evidence of Q Fever and Rickettsial Disease in Chile

Q fever and rickettsial diseases occur throughout the world and appear to be emergent zoonoses in Chile. The diagnosis of these diseases is currently uncommon in Chile, as their clinical presentations are non-specific and appropriate diagnostic laboratory assays are of limited availability. During a recent outbreak of undiagnosed human atypical pneumonia, we serologically investigated a series of 357 cases from three regions of southern Chile. The aim was to identify those caused by Coxiella burnetii and/or Rickettsia spp. Serological analysis was performed by ELISA and an immunofluorescence assay (IFA) for acute and convalescence sera of patients. Our results, including data from two international reference laboratories, demonstrate that 71 (20%) of the cases were Q fever, and 44 (15%) were a likely rickettsial infection, although the rickettsial species could not be confirmed by serology. This study is the first report of endemic Q fever and rickettsial disease affecting humans in Chile.

Molecular detection of Coxiella burnetii in livestock farmers and cattle from Magdalena Medio in Antioquia, Colombia

Coxiella burnetii causes Q fever in humans and coxiellosis in animals. In humans, it causes acute febrile illnesses like influenza, pneumonia, hepatitis, and chronic illnesses such as endocarditis, vascular infection, and post-infectious fatigue syndrome. It is widely distributed worldwide, and its main reservoirs are sheep, goats, and cattle. This study aimed to determine the frequency of C. burnetii infection using molecular detection and to identify the associated factors in livestock farmers and cattle from the Magdalena Medio region of Antioquia, Colombia. Using real-time polymerase chain reaction (PCR), molecular detection was performed for the IS1111 insertion sequence of C. burnetii using genomic DNA collected from the peripheral blood of 143 livestock farmers and 192 cattle from 24 farms located in Puerto Berrío, Puerto Nare, and Puerto Triunfo. To confirm the results, bidirectional amplicon sequencing of 16S rRNA was performed in four of the positive samples. Additionally, factors associated with C. burnetii were identified using a Poisson regression with cluster effect adjustment. Real-time PCR showed positive results in 25.9% and 19.5% of livestock farmer samples and cattle samples, respectively. For livestock farmers, factors associated with C. burnetii were the area where the farm was located [Puerto Berrío, adjusted prevalence ratio (aPR): 2.13, 95% confidence interval (CI): 1.10-4.11], presence of hens (aPR: 1.47, 95% CI: 1.21-1.79), horses (aPR: 1.61, 95% CI: 1.54-1.67), and ticks (aPR: 2.36, 95% CI: 1.03-5.42) in the residence, and consumption of raw milk (aPR: 1.47, 95% CI: 1.26-1.72). For cattle, the factors associated with Coxiella genus were municipality (Puerto Nare; aPR: 0.39, 95% CI: 0.37-0.41) and time of residence on the farm (≥49 months; aPR: 2.28, 95% CI: 1.03-5.20). By analyzing sequences of the 16S rRNA molecular marker, C. burnetii infection was confirmed in livestock farmers. However, in cattle, only the presence of Coxiella-type bacteria was identified. Further research is necessary to determine the potential role that these types of bacteria have as etiological agents for disease in livestock farmers and cattle from the study area.

EirA Is a Novel Protein Essential for Intracellular Replication of Coxiella burnetii

The zoonotic bacterial pathogen Coxiella burnetii is the causative agent of Q fever, a febrile illness which can cause a serious chronic infection. C. burnetii is a unique intracellular bacterium which replicates within host lysosome-derived vacuoles. The ability of C. burnetii to replicate within this normally hostile compartment is dependent on the activity of the Dot/Icm type 4B secretion system. In a previous study, a transposon mutagenesis screen suggested that the disruption of the gene encoding the novel protein CBU2072 rendered C. burnetii incapable of intracellular replication. This protein, subsequently named EirA (essential for intracellular replication A), is indispensable for intracellular replication and virulence, as demonstrated by infection of human cell lines and in vivo infection of Galleria mellonella The putative N-terminal signal peptide is essential for protein function but is not required for localization of EirA to the bacterial inner membrane compartment and axenic culture supernatant. In the absence of EirA, C. burnetii remains viable but nonreplicative within the host phagolysosome, as coinfection with C. burnetii expressing native EirA rescues the replicative defect in the mutant strain. In addition, while the bacterial ultrastructure appears to be intact, there is an altered metabolic profile shift in the absence of EirA, suggesting that EirA may impact overall metabolism. Most strikingly, in the absence of EirA, Dot/Icm effector translocation was inhibited even when EirA-deficient C. burnetii replicated in the wild type (WT)-supported Coxiella containing vacuoles. EirA may therefore have a novel role in the control of Dot/Icm activity and represent an important new therapeutic target.

Relationship between Coxiella burnetii (Q fever) antibody serology and time spent outdoors

BACKGROUND/AIM

From 2007 through 2010, the Netherlands experienced the largest recorded Q fever outbreak to date. People living closer to Coxiella burnetii infected goat farms were at increased risk for acute Q fever. Time spent outdoors near infected farms may have contributed to exposure to C. burnetii. The aim of this study was to retrospectively evaluate whether hours/week spent outdoors, in the vicinity of previously C. burnetii infected goat farms, was associated with presence of antibodies against C. burnetii in residents of a rural area in the Netherlands.

METHODS

Between 2014-2015, we collected C. burnetii antibody serology and self-reported data about habitual hours/week spent outdoors near the home from 2494 adults. From a subgroup we collected 941 GPS tracks, enabling analyses of active mobility in the outbreak region. Participants were categorised as exposed if they spent time within specified distances (500m, 1000m, 2000m, or 4000m) of C. burnetii infected goat farms. We evaluated whether time spent near these farms was associated with positive C. burnetii serology using spline analyses and logistic regression.

RESULTS

People that spent more hours/week outdoors near infected farms had a significantly increased risk for positive C. burnetii serology (time spent within 2000m of a C. burnetii abortion-wave positive farm, OR 3.6 (1.2-10.6)), compared to people spending less hours/week outdoors.

CONCLUSIONS

Outdoor exposure contributed to the risk of becoming C. burnetii serology positive. These associations were stronger if people spent more time near C. burnetii infected farms. Outdoor exposure should, if feasible, be included in outbreak investigations.