investigation of a q fever outbreak in the texas panhandle james l. alexander, dvm, mpvm zoonosis...
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Investigation of a Q Fever Outbreak in the
Texas Panhandle
James L. Alexander, DVM, MPVMZoonosis Control Division
Texas Department of HealthCanyon, Texas
Investigating A Suspected Q Fever Outbreak
BackgroundDecember 2006
Environmental survey for presence of Coxiella burnetii conducted in the Panhandle, South Plains and West Texas
Results: Non- agriculturally related sites: 69% + Agriculturally related sites: 50% +
Coxiella burnetii
Birthing fluids, urine and feces
of livestock and cats and dogs
Source of Organism
The Panhandle has an abundance of livestock
Coxiella burnetii
The Panhandle has an abundance of wind
Coxiella burnetii
A Light Breeze in the Panhandle
West Texas has plenty of aerosolized dust and soil
Coxiella burnetii Spreads by aerosolization of contaminated dust/soil
June 12, 2008
Late in the day began receiving calls about an illness at an ethanol plant construction site at Hereford, Texas
Symptoms reported were more consistent with food-poisoning
Workers were going to the hospital to be tested for q fever
Hereford, Texas – ~ 40 miles SW of Amarillo
You are here
June 13, 2008 Met with personnel from the company that
owned the ethanol plant
Met with Hereford City Officials
Participated in media interviews
Visited Infection Control Nurse @ hospital
Hereford is known for feedlots
“The Beef Capital of the World”
Manure-fueled Ethanol Plant
N
Companies
14 were on site during the 60 days prior to the “discovery” of q fever titers in the work force
The majority left that Friday or in the next week
Interviews and follow-up testing delayed Many returned in late July but some were lost
to follow-up
Case-Control Study Desired Attempted to match age and sex
Due to departure of personnel the match was not very successful
A second test was obtained on some people to determine if sero-conversion was still occurring
Investigation
198 people received at least 1 test
36 people received at least 2 tests
5 people were tested 3 times
239 samples collected
No one that did not already have a titer of >128 developed a higher titer
Surveyed Population
Of 198 People Tested
17 had titers > 128 (8.6%)
1:4096 was the highest titer based on a retest of index case
122 of the “Tested” people were interviewed (62%) 15 of the 17 with titers
5 asymptomatic (33.3%) 10 symptomatic (67.7%)
42 interviewees with compatible symptoms (32 w/o titers)
80 interviewees without compatible symptoms (5 with titers)
4 people without tests were interviewed
Surveyed Population
Tested Population
14 Females (7%)
Age: 22 - 52 2 with > 128 (14.3%)
Ages 22 and 48 (mean = 35)
12 without titers Ages 23-52 (mean = 38.7)
184 Males (93%) Age: 1 - 69
15 with > 128 (8.2%) Age: 19-61 (mean = 43.6)
169 without titers Ages 1 - 69 (mean = 39.4)
Tested Population
Information Obtained
Demographics and health history Work location on site Job title/occupation Past livestock exposure Animal exposure in past 60 days Exposure to aborting animal Illness and symptoms Use of PPE Proximity to manure
Predominant Symptoms of “Cases” and
Non-titered People Reporting Illness
Weakness 10 (100%) 24 (75%) Malaise 8 (80%) 22 (69%) Chills 7 (70%) 22 (69%) Sweating 7 (70%) 21 (66%) Headache 6 (60%) 27 (75%) Myalgia 4 (40%) 17 (53%) Lymphadenitis 3 (30%) 4 (12.5%)
“10 Cases” “32 Non-cases”
Evaluated
Proximity to manure – not significant
Employer – not significant
Prior contact with livestock – not significant
Plant Owner Modifications Tarp to block wind at unloading site
Water misting during manure unloading
Removal of grinder from manure processing system
Halting manure delivery when wind direction was from the manure site toward areas occupied b y personnel
Actions Taken by Contractor
Invited OSHA to visit - declined
Invited NIOSH to visit – accepted
Required Tyvek© suits and respirators
Established PPE zones
General Contractor’s Action Plan
NIOSH Recommendations
No Tyvek suits Shower and laundry facilities on-site No work clothes or footwear to leave the site Move the contractor office trailers and install
running water to improve hand sanitation Medical screening for symptomatic personnel Cleaning shoes at office doorways and proper
cleaning techniques for offices Appropriate respiratory-protection equipment
based on the job function
The Next Steps
Continue to Analyze These Data
Complete the sero-survey initiated in 2009 500-600 samples from blood donors CDC will test to see if the prevalence of
antibodies to C. burnetii in a “normal” population in the Panhandle can be determined
As the late Paul Harvey used to say, “Stay tuned for the rest of the story”
James L. Alexander, DVM, MPVMRegional Zoonosis Control Veterinarian
Texas Department of State Health ServicesHealth Service Region 1
Canyon, [email protected]