Evaluation of Patients with Community-Acquired Pneumonia Caused by Zoonotic Pathogens in an Area with a High Density of Animal Farms

Increased risk of pneumonia amongst residents living near goat farms in different livestock-dense regions in the Netherlands

BACKGROUND

Previous studies, performed between 2009-2019, in the Netherlands observed an until now still unexplained increased risk for pneumonia among residents living close to goat farms. Since data were collected in the provinces Noord-Brabant and Limburg (NB-L), an area with relatively high air pollution levels and proximity to large industrial areas in Europe, the question remains whether the results are generalizable to other regions. In this study, a different region, covering the provinces Utrecht, Gelderland, and Overijssel (UGO) with a similar density of goat farms, was included to assess whether the association between goat farm proximity and pneumonia is consistently observed across the Netherlands.

METHODS

Data for this study were derived from the Electronic Health Records (EHR) of 21 rural general practices (GPs) in UGO, for 2014-2017. Multi-level analyses were used to compare annual pneumonia prevalence between UGO and data derived from rural reference practices ('control area'). Random-effects meta-analysis (per GP practice) and kernel analyses were performed to study associations of pneumonia with the distance between goat farms and patients' home addresses.

RESULTS

GP diagnoses of pneumonia occurred 40% more often in UGO compared to the control area. Meta-analysis showed an association at a distance of less than 500m (~70% more pneumonia compared to >500m) and 1000m (~20% more pneumonia compared to >1000m). The kernel-analysis for three of the four individual years showed an increased risk up to a distance of one or two kilometers (2-36% more pneumonia; 10-50 avoidable cases per 100,000 inhabitants per year).

CONCLUSIONS

The positive association between living in the proximity of goat farms and pneumonia in UGO is similar to the previously found association in NB-L. Therefore, we concluded that the observed associations are relevant for regions with goat farms in the entire country.

Zoonotic Disease Risks of Live Export of Cattle and Sheep, with a Focus on Australian Shipments to Asia and the Middle East

The growing human and livestock populations in the world today and increased international transport of livestock is increasing the risk of both emerging and endemic zoonotic diseases. This review focuses on the potential for the live export trade to transmit zoonotic diseases. Both cattle and sheep are exposed to major stresses during the transport process, which are described, together with the impact of these stresses on the immune function of transported animals. Heat stress, overcrowding, inanition, ship and vehicle motion and accumulation of noxious gases are analysed for their ability to potentiate infectious diseases. The major zoonoses are described: pustular dermatitis, pneumonia, salmonellosis, as well as some common conditions, such as conjunctivitis, with specific reference to stressors associated with each disorder. Historical precedents exist for restriction of the trade based on disease risks. Finally, the economic and regulatory frameworks are considered to evaluate ways in which the spread of zoonotic diseases can be controlled.

Q Fever as a Cause of Community-Acquired Pneumonia in French Guiana

In French Guiana, community-acquired pneumonia (CAP) represents over 90% of Coxiella burnetii acute infections. Between 2004 and 2007, we reported that C. burnetii was responsible for 24.4% of the 131 CAP hospitalized in Cayenne. The main objective of the present study was to determine whether the prevalence of Q fever pneumonia remained at such high levels. The secondary objectives were to identify new clinical characteristics and risk factors for C. burnetii pneumonia. A retrospective case-control study was conducted on patients admitted in Cayenne Hospital, between 2009 and 2012. All patients with CAP were included. The diagnosis of acute Q fever relied on titers of phase II IgG ≥ 200 and/or IgM ≥ 50 or seroconversion between two serum samples. Patients with Q fever were compared with patients with non-C. burnetii CAP in bivariate and multivariate analyses. During the 5-year study, 275 patients with CAP were included. The etiology of CAP was identified in 54% of the patients. C. burnetii represented 38.5% (106/275; 95% CI: 31.2-45.9%). In multivariate analysis, living in Cayenne area, being aged 30-60 years, C-reactive protein (CRP) > 185 mg/L, and leukocyte count < 10 G/L were independently associated with Q fever. The prevalence of Q fever among CAP increased to 38.5%. This is the highest prevalence ever reported in the world. This high prevalence justifies the systematic use of doxycycline in addition to antipneumococcal antibiotic regimens.

The air we breathe: understanding the impact of the environment on pneumonia

An increased risk of community-acquired pneumonia has been shown in residents of rural livestock farming areas in the Netherlands and United States, probably due to air pollution exposure or zoonotic infections. Spatial epidemiological analyses have particularly implicated poultry and goat farms in the increased risk-an observation that warrants further research. Studying the viral or bacterial etiology of community-acquired pneumonia using traditional microbiological methods or metagenomic sequencing could help to fathom to what extent environmental factors and causative pathogens contribute to spatial differences in the incidence of severe acute respiratory infections.

Predisposing factors to acquisition of acute respiratory tract infections in the community: a systematic review and meta-analysis

Background

Preventing respiratory tract infections (RTIs) could have profound effects on quality of life, primary care workload, antibiotic prescribing and stewardship. We aimed to identify factors that increase and decrease RTI acquisition within Organisation for Economic Cooperation and Development (OECD) member countries.

Methods

Systematic search of Medline, Embase, Cochrane and ISI Web of Knowledge for studies conducted up to July 2020 reporting predisposing factors for community RTI acquisition. Pooled odds ratios were calculated using a random-effects model.

Results

23 studies investigated risk factors associated with community-acquired pneumonia (n = 15); any RTI (n = 4); influenza like illness (n = 2); and lower RTI (n = 2). Demographic, lifestyle and social factors were: underweight BMI (pooled odds ratio (OR_p 2.14, 95% CI 1.58 to 2.70, p = 0.97); male sex (OR_p 1.30, 95% CI 1.27 to 1.33, p = 0.66); contact with pets (OR_p 1.35, 95% CI 1.16 to 1.54, p = 0.72); contact with children (OR_p 1.35, 95% CI 1.15 to 1.56, p = 0.05); and ex-smoking status (OR_p 1.57, 95% CI 1.26 to 1.88, p = 0.76). Health-related factors were: chronic liver condition (OR_p 1.30, 95% CI 1.09 to 1.50, p = 0.34); chronic renal condition (OR_p 1.47, 95% CI 1.09 to 1.85, p = 0.14); and any hospitalisation in previous five years (OR_p 1.64, 95% CI 1.46 to 1.82, p = 0.66).

Conclusions

We identified several modifiable risk factors associated with increased likelihood of acquiring RTIs in the community, including low BMI, contact with children and pets. Modification of risk factors and increased awareness of vulnerable groups could reduce morbidity, mortality and antibiotic use associated with RTIs.

PROSPERO registration

CRD42019134176.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06954-3.

Applicability of a sheep model for training in plastic surgery of eyelids and orbit

OBJECTIVE

To test the applicability of a fresh tissue model for teaching facial plastic techniques and approaches to the eyelids and orbit.

DESIGN

Observational animal experiments.

SUBJECTS

Ten prepubescent sheep heads harvested following humane euthanasia at the completion of unrelated live animal research.

METHODS

Young sheep were saline perfused at the end of an in vivo protocol. Head and neck tissues were harvested and refrigerated for 3-7 days. An experienced oculoplastic surgeon and an otolaryngologist explored the feasibility of common oculoplastic procedures in the ovine model.

RESULTS

The model has potential for teaching basic principles in eyelid surgery including upper lid blepharoplasty, aponeurotic ptosis repair, upper lid gold weight lid loading for facial paralysis, lateral canthotomy and inferior limb cantholysis, lower lid tightening, and transconjunctival approach to the orbital floor. Eye muscle advancement, optic nerve sheath fenestration, and enucleation also accurately simulated human surgery. Anatomic variations limit the sheep model for orbital floor reconstruction and lacrimal drainage procedures.

CONCLUSIONS

The sheep head and neck provide an inexpensive, safe model for developing skills in several oculoplastic procedures. Formal simulation testing is needed to confirm these expert opinions.

Current Status of Putative Animal Sources of SARS-CoV-2 Infection in Humans: Wildlife, Domestic Animals and Pets

SARS-CoV-2 is currently considered to have emerged from a bat coronavirus reservoir. However, the real natural cycle of this virus remains to be elucidated. Moreover, the COVID-19 pandemic has led to novel opportunities for SARS-CoV-2 transmission between humans and susceptible animal species. In silico and in vitro evaluation of the interactions between the SARS-CoV-2 spike protein and eucaryotic angiotensin-converting enzyme 2 (ACE2) receptor have tentatively predicted susceptibility to SARS-CoV-2 infection of several animal species. Although useful, these data do not always correlate with in vivo data obtained in experimental models or during natural infections. Other host biological properties may intervene such as the body temperature, level of receptor expression, co-receptor, restriction factors, and genetic background. The spread of SARS-CoV-2 also depends on the extent and duration of viral shedding in the infected host as well as population density and behaviour (group living and grooming). Overall, current data indicate that the most at-risk interactions between humans and animals for COVID-19 infection are those involving certain mustelids (such as minks and ferrets), rodents (such as hamsters), lagomorphs (especially rabbits), and felines (including cats). Therefore, special attention should be paid to the risk of SARS-CoV-2 infection associated with pets.

On the interpretation of bioaerosol exposure measurements and impacts on health

Bioaerosols are recognized as one of the main transmission routes for infectious diseases and are responsible for other various types of health effects through inhalation and potential ingestion. Associating exposure with bioaerosol and health problems is challenging, and adequate exposure monitoring is a top priority for aerosol scientists. The multiple factors affecting bioaerosol content, the variability in the focus of each bioaerosol exposure study, and the variations in experimental design and the standardization of methods make bioaerosol exposure studies very difficult. Therefore, the health impacts of bioaerosol exposure are still poorly understood. This paper presents a brief description of a state-of-the-art development in bioaerosol exposure studies supported by studies on several related subjects. The main objective of this paper is to propose new considerations for bioaerosol exposure guidelines and the development of tools and study designs to better interpret bioaerosol data. The principal observations and findings are the discrepancy of the applicable methods in bioaerosol studies that makes result comparison impossible. Furthermore, the silo mentality helps in creating a bigger gap in the knowledge accumulated about bioaerosol exposure. Innovative and original ideas are presented for aerosol scientists and health scientists to consider and discuss. Although many examples cited herein are from occupational exposure, the discussion has relevance to any human environment. This work gives concrete suggestions for how to design a full bioaerosol study that includes all of the key elements necessary to help understand the real impacts of bioaerosol exposure in the short term. The creation of the proposed bioaerosol public database could give crucial information to control the public health. Implications: How can we move toward a bioaerosol exposure guidelines? The creation of the bioaerosol public database will help accumulate information for long-term association studies and help determine specific exposure biomarkers to bioaerosols. The implementation of such work will lead to a deeper understanding and more efficient utilization of bioaerosol studies to prevent public health hazards.

Associations between pneumonia and residential distance to livestock farms over a five-year period in a large population-based study

In a recent study of electronic health records (EHR) of general practitioners in a livestock-dense area in The Netherlands in 2009, associations were found between residential distance to poultry farms and the occurrence of community-acquired pneumonia (CAP). In addition, in a recent cross-sectional study in 2494 adults in 2014/2015 an association between CAP and proximity to goat farms was observed. Here, we extended the 2009 EHR analyses across a wider period of time (2009–2013), a wider set of health effects, and a wider set of farm types as potential risk sources. A spatial (transmission) kernel model was used to investigate associations between proximity to farms and CAP diagnosis for the period from 2009 to 2013, obtained from EHR of in total 140,059 GP patients. Also, associations between proximity to farms and upper respiratory infections, inflammatory bowel disease, and (as a control disease) lower back pain were analysed. Farm types included as potential risk sources in these analyses were cattle, (dairy) goats, mink, poultry, sheep, and swine. The previously found association between CAP occurrence and proximity to poultry farms was confirmed across the full 5-year study period. In addition, we found an association between increased risk for pneumonia and proximity to (dairy) goat farms, again consistently across all years from 2009 to 2013. No consistent associations were found for any of the other farm types (cattle, mink, sheep and swine), nor for the other health effects considered. On average, the proximity to poultry farms corresponds to approximately 119 extra patients with CAP each year per 100,000 people in the research area, which accounts for approximately 7.2% extra cases. The population attributable risk percentage of CAP cases in the research area attributable to proximity to goat farms is approximately 5.4% over the years 2009–2013. The most probable explanation for the association of CAP with proximity to poultry farms is thought to be that particulate matter and its components are making people more susceptible to respiratory infections. The causes of the association with proximity to goat farms is still unclear. Although the 2007–2010 Q-fever epidemic in the area probably contributed Q-fever related pneumonia cases to the observed additional cases in 2009 and 2010, it cannot explain the association found in later years 2011–2013.

Ex vivo ovine model for teaching open laryngotracheal surgery

Objective

To develop an animal model for teaching open laryngotracheal surgical procedures.

Methods

The heads and necks from 5 pre-pubescent sheep were harvested after humane anesthesia. After 2–5 days to allow for rigor mortis to resolve, a specimen was supported with sandbags on an operating table. Operative procedures including tracheotomy, medialization laryngoplasty, anterior cartilage grafting, tracheal resection with primary anastomosis, and laryngectomy with closure of the pharynx were attempted.

Results

The ovine head and neck provided an accurate model for simulation of all attempted procedures. Ovine tissue resembled that of humans in mechanical properties and handling. Postsurgical endoscopy confirmed graft alignment.

Conclusions

The sheep head and neck provides an inexpensive, realistic, and safe model for surgical training for a variety of open laryngotracheal procedures. This is particularly relevant given the recent emphasis on surgical simulation and the relative rarity of some of these procedures in residency training.

Data Science Priorities for a University Hospital-Based Institute of Infectious Diseases: A Viewpoint

Automation of laboratory tests, bioinformatic analysis of biological sequences, and professional data management are used routinely in a modern university hospital-based infectious diseases institute. This dates back to at least the 1980s. However, the scientific methods of this 21st century are changing with the increased power and speed of computers, with the "big data" revolution having already happened in genomics and environment, and eventually arriving in medical informatics. The research will be increasingly "data driven," and the powerful machine learning methods whose efficiency is demonstrated in daily life will also revolutionize medical research. A university-based institute of infectious diseases must therefore not only gather excellent computer scientists and statisticians (as in the past, and as in any medical discipline), but also fully integrate the biologists and clinicians with these computer scientists, statisticians, and mathematical modelers having a broad culture in machine learning, knowledge representation, and knowledge discovery.

A systematic review of the public health risks of bioaerosols from intensive farming

BACKGROUND

Population growth, increasing food demands, and economic efficiency have been major driving forces behind farming intensification over recent decades. However, biological emissions (bioaerosols) from intensified livestock farming may have the potential to impact human health. Bioaerosols from intensive livestock farming have been reported to cause symptoms and/or illnesses in occupational-settings and there is concern about the potential health effects on people who live near the intensive farms. As well as adverse health effects, some potential beneficial effects have been attributed to farm exposures in early life. The aim of the study was to undertake a systematic review to evaluate potential for adverse health outcomes in populations living near intensive livestock farms.

MATERIAL AND METHODS

Two electronic databases (PubMed and Scopus) and bibliographies were searched for studies reporting associations between health outcomes and bioaerosol emissions related to intensive farming published between January 1960 and April 2017, including both occupational and community studies. Two authors independently assessed studies for inclusion and extracted data. Risk of bias was assessed using a customized score.

RESULTS

38 health studies met the inclusion criteria (21 occupational and 1 community study measured bioaerosol concentrations, 16 community studies using a proxy measure for exposure). The majority of occupational studies found a negative impact on respiratory health outcomes and increases in inflammatory biomarkers among farm workers exposed to bioaerosols. Studies investigating the health of communities living near intensive farms had mixed findings. All four studies of asthma in children found increased reported asthma prevalence among children living or attending schools near an intensive farm. Papers principally investigated respiratory and immune system outcomes.

CONCLUSIONS

The review indicated a potential impact of intensive farming on childhood respiratory health, based on a small number of studies using self-reported outcomes, but supported by findings from occupational studies. Further research is needed to measure and monitor exposure in community settings and relate this to objectively measured health outcomes.

Detection of respiratory bacterial pathogens causing atypical pneumonia by multiplex Lightmix® RT-PCR

Pneumonia is a severe infectious disease. In addition to common viruses and bacterial pathogens (e.g. Streptococcus pneumoniae), fastidious respiratory pathogens like Chlamydia pneumoniae, Mycoplasma pneumoniae and Legionella spp. can cause severe atypical pneumonia. They do not respond to penicillin derivatives, which may cause failure of antibiotic empirical therapy. The same applies for infections with B. pertussis and B. parapertussis, the cause of pertussis disease, that may present atypically and need to be treated with macrolides. Moreover, these fastidious bacteria are difficult to identify by culture or serology, and therefore often remain undetected. Thus, rapid and accurate identification of bacterial pathogens causing atypical pneumonia is crucial. We performed a retrospective method evaluation study to evaluate the diagnostic performance of the new, commercially available Lightmix^® multiplex RT-PCR assay that detects these fastidious bacterial pathogens causing atypical pneumonia. In this retrospective study, 368 clinical respiratory specimens, obtained from patients suffering from atypical pneumonia that have been tested negative for the presence of common agents of pneumonia by culture and viral PCR, were investigated. These clinical specimens have been previously characterized by singleplex RT-PCR assays in our diagnostic laboratory and were used to evaluate the diagnostic performance of the respiratory multiplex Lightmix^® RT-PCR. The multiplex RT-PCR displayed a limit of detection between 5 and 10 DNA copies for different in-panel organisms and showed identical performance characteristics with respect to specificity and sensitivity as in-house singleplex RT-PCRs for pathogen detection. The Lightmix^® multiplex RT-PCR assay represents a low-cost, time-saving and accurate diagnostic tool with high throughput potential. The time-to-result using an automated DNA extraction device for respiratory specimens followed by multiplex RT-PCR detection was below 4 h, which is expected to significantly improve diagnostics for atypical pneumonia-associated bacterial pathogens.

Impacts of Intensive Livestock Production on Human Health in Densely Populated Regions

In several regions worldwide, the presence of livestock in close proximity to residential areas raises questions about public health implications. The rapid expansion of large-scale livestock farms, increasingly interwoven with urbanized areas, and its potential impact on neighboring residents' health has hardly been accompanied by any research. The current situation in densely populated livestock farming areas could be regarded as a "natural experiment." Most scientific and public health initiatives have focused on emerging zoonoses and antimicrobial resistance as potential health threats. In this commentary, we emphasize the importance of respiratory health effects of noninfectious air pollutant emissions from livestock farms.

Updated systematic review: associations between proximity to animal feeding operations and health of individuals in nearby communities

OBJECTIVE

The objective of this review was to update a systematic review of associations between living near an animal feeding operation (AFO) and human health.

METHODS

The MEDLINE® and MEDLINE® In-Process, Centre for Agricultural Biosciences Abstracts, and Science Citation Index databases were searched. Reference lists of included articles were hand-searched. Eligible studies reported exposure to an AFO and an individual-level human health outcome. Two reviewers performed study selection and data extraction.

RESULTS

The search returned 3702 citations. Sixteen articles consisting of 10 study populations were included in the analysis. The health outcomes were lower and upper respiratory tracts, MRSA, other infectious disease, neurological, psychological, dermatological, otologic, ocular, gastrointestinal, stress and mood, and other non-infectious health outcomes. Most studies were observational and used prevalence measures of outcome. An association between Q fever risk and proximity to goat production was reported. Other associations were unclear. Risk of bias was serious or critical for most exposure-outcome associations. Multiplicity (i.e., a large number of potentially correlated outcomes and exposures assessed on the same study subjects) was common in the evidence base.

CONCLUSIONS

Few studies reported an association between surrogate clinical outcomes and AFO proximity for respiratory tract-related outcomes. There were no consistent dose-response relationships between surrogate clinical outcome and AFO proximity. A new finding was that Q fever in goats is likely associated with an increased Q fever risk in community members. The review results for the non-respiratory health outcomes were inconclusive because only a small number of studies were available or the between-study results were inconsistent.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014010521.

Livestock-associated risk factors for pneumonia in an area of intensive animal farming in the Netherlands

Previous research conducted in 2009 found a significant positive association between pneumonia in humans and living close to goat and poultry farms. However, as this result might have been affected by a large goat-related Q fever epidemic, the aim of the current study was to re-evaluate this association, now that the Q-fever epidemic had ended. In 2014/15, 2,494 adults (aged 20–72 years) living in a livestock-dense area in the Netherlands participated in a medical examination and completed a questionnaire on respiratory health, lifestyle and other items. We retrieved additional information for 2,426/2,494 (97%) participants from electronic medical records (EMR) from general practitioners. The outcome was self-reported, physician-diagnosed pneumonia or pneumonia recorded in the EMR in the previous three years. Livestock license data was used to determine exposure to livestock. We quantified associations between livestock exposures and pneumonia using odds ratios adjusted for participant characteristics and comorbidities (aOR). The three-year cumulative frequency of pneumonia was 186/2,426 (7.7%). Residents within 2,000m of a farm with at least 50 goats had an increased risk of pneumonia, which increased the closer they lived to the farm (2,000m aOR 1.9, 95% CI 1.4–2.6; 500m aOR 4.4, 95% CI 2.0–9.8). We found no significant associations between exposure to other farm animals and pneumonia. However, when conducting sensitivity analyses using pneumonia outcome based on EMR only, we found a weak but statistically significant association with presence of a poultry farm within 1,000m (aOR: 1.7, 95% CI 1.1–2.7). Living close to goat and poultry farms still constitute risk factors for pneumonia. Individuals with pneumonia were not more often seropositive for Coxiella burnetii, indicating that results are not explained by Q fever. We strongly recommend identification of pneumonia causes by the use of molecular diagnostics and investigating the role of non-infectious agents such as particulate matter or endotoxins.

Current and future prospects for nanotechnology in animal production

Nanoparticles have been used as diagnostic and therapeutic agents in the human medical field for quite some time, though their application in veterinary medicine and animal production is still relatively new. Recently, production demands on the livestock industry have been centered around the use of antibiotics as growth promoters due to growing concern over microbial antibiotic resistance. With many countries reporting increased incidences of antibiotic-resistant bacteria, laws and regulations are being updated to end in-feed antibiotic use in the animal production industry. This sets the need for suitable alternatives to be established for inclusion in feed. Many reports have shown evidence that nanoparticles may be good candidates for animal growth promotion and antimicrobials. The current status and advancements of nanotechnological applications in animal production will be the focus of this review and the emerging roles of nanoparticles for nutrient delivery, biocidal agents, and tools in veterinary medicine and reproduction will be discussed. Additionally, influences on meat, egg, and milk quality will be reviewed.

Increased risk of pneumonia in residents living near poultry farms: does the upper respiratory tract microbiota play a role?

BACKGROUND

Air pollution has been shown to increase the susceptibility to community-acquired pneumonia (CAP). Previously, we observed an increased incidence of CAP in adults living within 1 km from poultry farms, potentially related to particulate matter and endotoxin emissions. We aim to confirm the increased risk of CAP near poultry farms by refined spatial analyses, and we hypothesize that the oropharyngeal microbiota composition in CAP patients may be associated with residential proximity to poultry farms.

METHODS

A spatial kernel model was used to analyze the association between proximity to poultry farms and CAP diagnosis, obtained from electronic medical records of 92,548 GP patients. The oropharyngeal microbiota composition was determined in 126 hospitalized CAP patients using 16S-rRNA-based sequencing, and analyzed in relation to residential proximity to poultry farms.

RESULTS

Kernel analysis confirmed a significantly increased risk of CAP when living near poultry farms, suggesting an excess risk up to 1.15 km, followed by a sharp decline. Overall, the oropharyngeal microbiota composition differed borderline significantly between patients living <1 km and ≥1 km from poultry farms (PERMANOVA p = 0.075). Results suggested a higher abundance of Streptococcus pneumoniae (mean relative abundance 34.9% vs. 22.5%, p = 0.058) in patients living near poultry farms, which was verified by unsupervised clustering analysis, showing overrepresentation of a S. pneumoniae cluster near poultry farms (p = 0.049).

CONCLUSION

Living near poultry farms is associated with an 11% increased risk of CAP, possibly resulting from changes in the upper respiratory tract microbiota composition in susceptible individuals. The abundance of S. pneumoniae near farms needs to be replicated in larger, independent studies.

The Epidemiology and Characteristics of Q fever and Co-infections with Scrub Typhus, Murine Typhus or Leptospirosis in Taiwan: A Nationwide Database Study

Q fever (QF) is a worldwide zoonosis associated with outbreaks. Only a few nationwide studies regarding the surveillance and epidemiology of human QF have been reported. Although QF is endemic in Taiwan, a nationwide database investigation of the epidemiology and characteristics of QF and its associations with scrub typhus (ST), murine typhus (MT) and leptospirosis (LS) has never been reported. We analysed nationwide databases of suspected QF, ST, MT and LS cases from October 2007 to December 2014 obtained from the Centers for Disease Control, Taiwan. A total of 468 (4.2%) QF cases were identified among 11 109 suspected QF cases. QF cases were mainly distributed in the southern and Kaohsiung-Pingtung regions but rarely in the eastern region. Compared to non-QF cases, QF cases had significantly higher percentages of males (88.7 versus 66.2%) and high-risk occupations (farming, animal husbandry or veterinary medicine) (16.2 versus 10.5%). But the percentages of specific animal contact, including cattle (0.6 versus 0.8%) and goats (0.9 versus 1.0%), were low in both. The majority of suspected QF cases (89.4%) were simultaneously suspected with ST, MT or LS, and the combinations of suspected diseases differed between regions. The number of suspected QF cases from the eastern region decreased since 2009, which was not observed in other regions. A total of 1420 (12.8%) cases had confirmed diseases, including QF (453, 4.1%), QF+ST (7, 0.06%), QF+MT (4, 0.04%), QF+LS (4, 0.04%), MT (186, 1.7%), ST (545, 4.9%), ST+LS (11, 0.1%) and LS (210, 1.9%). Compared to cases of unknown disease, QF cases had larger percentages of high-risk occupations (16.2 versus 9.6%) but similar histories of animal contact (29.8 versus 25.1%). QF is an endemic disease in southern Taiwan. It is difficult to differentiate QF from ST, MT or LS only by high-risk occupations and history of animal contact, and co-infection of QF with these diseases should be considered.

Ex vivoovine model for suspension microlaryngoscopy training

Objective:

To develop an ovine model for teaching suspension laryngoscopy and phonosurgery.

Methods:

The head and neck from 10 pre-pubescent sheep were harvested following humane euthanasia at the end of anin vivoprotocol. No live animals were used in this study. The tissues were saline-perfused and refrigerated for 1–5 days. Suspension laryngoscopy was performed using adolescent Parsons and adult Kantor-Berci laryngoscopes suspended with a Benjamin-Parsons laryngoscope holder. Visualisation was achieved with 0° and 30° telescopes, and a three-chip camera and video system. Shapshay-Ossoff microlaryngeal instruments were used for endolaryngeal dissection.

Results:

Experienced laryngologists led a second year medical student through several procedures including injection laryngoplasty, hydrodissection and incision, endolaryngeal suturing, and partial cordectomy. Despite expected anatomical differences, the model proved highly realistic for suspension microlaryngoscopy.

Conclusion:

The sheep head and neck model provides an inexpensive, safe model for developing skills in suspension laryngoscopy and basic phonosurgery.

Increased respiratory symptoms in COPD patients living in the vicinity of livestock farms

Several studies have investigated the effect of livestock farm emissions on the respiratory health of local residents, but results are inconsistent. This study aims to explore associations between the presence of livestock farms and respiratory health in an area of high-density livestock farming in the Netherlands. We focused especially on associations between farm exposures and respiratory symptoms within subgroups of potentially susceptible patients with a pre-existing lung disease.In total, 14 875 adults (response rate 53.4%) completed a questionnaire concerning respiratory health, smoking habits and personal characteristics. Different indicators of livestock farm exposures relative to the home address were computed using a geographic information system.Prevalence of chronic obstructive pulmonary disease (COPD) and asthma was lower among residents living within 100 m of a farm (OR 0.47, 95% CI 0.24-0.91 and OR 0.65, 95% CI 0.45-0.93, respectively). However, >11 farms in 1000 m compared to fewer than four farms in 1000 m (fourth quartile versus first quartile) was associated with wheezing among COPD patients (OR 1.71, 95% CI 1.01-2.89). Using general practitioners' electronic medical records, we demonstrated that selection bias did not affect the observed associations.Our data suggest a protective effect of livestock farm emissions on the respiratory health of residents. Nonetheless, COPD patients living near livestock farms reported more respiratory symptoms, suggesting an increased risk of exacerbations.