Diagnosis and Management of Q Fever United States 2013

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Recommendations and Reports,CONTENTS Disclosure of Relationship. CDC our planners and our content experts disclose that. Introduction 1, they have no financial interests or other relationships with. Methods 2 the manufacturers of commercial products suppliers of. Epidemiology 3 commercial services or commercial supporters Presentations. will not include any discussion of the unlabeled use of a product. Assessment of Clinical Signs and Symptoms 4 or a product under investigational use CDC does not accept. Diagnosis 9 commercial support,Treatment and Management 12. Occupational Exposure and Prevention 16,Surveillance and Reporting 19. Acknowledgments 20,References 20,Appendix A 24,Appendix B 26.
Appendix C 27,Appendix D 28, Front cover photo A girl plays with goats one of the primary reservoirs of Coxiella burnetii the bacterium that causes the zoonotic disease Q fever. The MMWR series of publications is published by the Office of Surveillance Epidemiology and Laboratory Services Centers for Disease Control and Prevention CDC. U S Department of Health and Human Services Atlanta GA 30333. Suggested Citation Centers for Disease Control and Prevention Title MMWR 2013 62 No RR inclusive page numbers. Centers for Disease Control and Prevention,Thomas R Frieden MD MPH Director. Harold W Jaffe MD MA Associate Director for Science. James W Stephens PhD Director Office of Science Quality. Denise M Cardo MD Acting Deputy Director for Surveillance Epidemiology and Laboratory Services. Stephanie Zaza MD MPH Director Epidemiology and Analysis Program Office. MMWR Editorial and Production Staff, Ronald L Moolenaar MD MPH Editor MMWR Series Martha F Boyd Lead Visual Information Specialist. Christine G Casey MD Deputy Editor MMWR Series Maureen A Leahy Julia C Martinroe. Teresa F Rutledge Managing Editor MMWR Series Stephen R Spriggs Terraye M Starr. David C Johnson Lead Technical Writer Editor Visual Information Specialists. Catherine B Lansdowne MS Project Editor Quang M Doan MBA Phyllis H King. Information Technology Specialists,MMWR Editorial Board. William L Roper MD MPH Chapel Hill NC Chairman, Matthew L Boulton MD MPH Ann Arbor MI Timothy F Jones MD Nashville TN.
Virginia A Caine MD Indianapolis IN Rima F Khabbaz MD Atlanta GA. Barbara A Ellis PhD MS Atlanta GA Dennis G Maki MD Madison WI. Jonathan E Fielding MD MPH MBA Los Angeles CA Patricia Quinlisk MD MPH Des Moines IA. David W Fleming MD Seattle WA Patrick L Remington MD MPH Madison WI. William E Halperin MD DrPH MPH Newark NJ John V Rullan MD MPH San Juan PR. King K Holmes MD PhD Seattle WA William Schaffner MD Nashville TN. Recommendations and Reports, Diagnosis and Management of Q Fever United States 2013. Recommendations from CDC and the Q Fever Working Group. Alicia Anderson DVM1,Henk Bijlmer MD PhD2,Pierre Edouard Fournier MD PhD3. Stephen Graves MD PhD4,Joshua Hartzell MD5,Gilbert J Kersh PhD1. Gijs Limonard MD6,Thomas J Marrie MD7,Robert F Massung PhD1. Jennifer H McQuiston DVM1,William L Nicholson PhD1.
Christopher D Paddock MD1,Daniel J Sexton MD8, 1National Center for Emerging and Zoonotic Infectious Diseases CDC Atlanta Georgia. 2National Institute for Public Health and the Environment The Netherlands. 3French National Center for the Study and Diagnosis of Q Fever Facult de M decine Marseille France. 4Australian Rickettsial Reference Laboratory Foundation Victoria Australia. 5Walter Reed National Military Medical Center Washington DC. 6Canisius Wilhelmina Hospital Nijmegen The Netherlands. 7Dalhousie University Nova Scotia Canada, 8Duke University Medical School Durham North Carolina. Q fever a zoonotic disease caused by the bacterium Coxiella burnetii can cause acute or chronic illness in humans Transmission occurs. primarily through inhalation of aerosols from contaminated soil or animal waste No licensed vaccine is available in the United States. Because many human infections result in nonspecific or benign constitutional symptoms establishing a diagnosis of Q fever often is. challenging for clinicians This report provides the first national recommendations issued by CDC for Q fever recognition clinical and. laboratory diagnosis treatment management and reporting for health care personnel and public health professionals The guidelines address. treatment of acute and chronic phases of Q fever illness in children adults and pregnant women as well as management of occupational. exposures These recommendations will be reviewed approximately every 5 years and updated to include new published evidence. Introduction tick bites ingestion of unpasteurized milk or dairy products. and human to human transmission are rare 1 Laboratory. Q fever first described in 1937 is a worldwide zoonosis that diagnosis relies mainly on serology and doxycycline is the most. has long been considered an underreported and underdiagnosed effective treatment for acute illness No vaccine is available. illness because symptoms frequently are nonspecific making commercially in the United States. diagnosis challenging 1 3 The causative organism Coxiella Q fever was designated a nationally notifiable disease in. burnetii is an intracellular bacterium that tends to infect the United States in 1999 Since then reports of Q fever. mononuclear phagocytes but can infect other cell types as have increased with 167 cases reported in 2008 an increase. well Infection in humans usually occurs by inhalation of greater than ninefold compared with 2000 in which 17 cases. bacteria from air that is contaminated by excreta of infected were reported 4 The national seroprevalence of Q fever is. animals Other modes of transmission to humans including estimated to be 3 1 based on data from the National Health. and Nutrition Examination Survey 2003 2004 and human. infections have been reported from every state in the United. The material in this report originated in the National Center for Emerging. and Zoonotic Infectious Diseases Beth P Bell MD Director and the. States 5 Q fever infections in humans and animals have. Division of Vector Borne Diseases Lyle R Petersen MD Director been reported from every world region except Antarctica 6. Corresponding preparer Alicia Anderson DVM Division of Vector Q fever has acute and chronic stages that correspond to two. Borne Diseases National Center for Emerging and Zoonotic Infectious distinct antigenic phases of antibody response During an acute. Diseases CDC 1600 Clifton Road MS A 30 Atlanta GA 30333. Telephone 404 639 4499 Fax 404 639 2778 E mail aha5 cdc gov infection an antibody response to C burnetii phase II antigen. is predominant and is higher than the response to the phase I. MMWR March 29 2013 Vol 62 No 3 1,Recommendations and Reports. antigen whereas a chronic infection is associated with a rising Prompt diagnosis and appropriate treatment shortens the. phase I immunoglobulin G IgG titer Although acute Q fever illness and reduces the risk for severe complications 15 16. symptoms in humans vary the condition typically is characterized In patients with chronic Q fever illness early treatment might. by a nonspecific febrile illness hepatitis or pneumonia be lifesaving Physician awareness of the epidemiologic and. Asymptomatic infections followed by seroconversion have clinical characteristics of Q fever is required to make a prompt. been reported in up to 60 of cases identified during outbreak and correct diagnosis Information in this report is designed. investigations 6 8 Onset of symptoms usually occurs within to assist U S clinicians with the following. 2 3 weeks of exposure and symptomatic patients might be ill Recognize common epidemiologic features and clinical. for weeks or months if untreated manifestations of Q fever. Chronic Q fever can manifest within a few months or Consider Q fever as the cause of a patient s illness if. several years after acute infection and can follow symptomatic appropriate. or asymptomatic infections Chronic disease is rare 5 of Obtain relevant history e g medical history and. patients with acute infections and typically is characterized exposure and diagnostic tests for Q fever. by endocarditis in patients with preexisting risk factors such Identify the limitations and utility of laboratory diagnostic. as valvular or vascular defects 9 Unlike acute Q fever testing. which has a low mortality rate 2 chronic Q fever Make treatment decisions based on epidemiologic and. endocarditis is always fatal if untreated 10 Routine blood clinical evidence. cultures are negative in patients with chronic Q fever Recognize that doxycycline is the treatment of choice for. endocarditis Diagnosis of chronic Q fever endocarditis can patients of any age with severe illness. be extremely difficult because vegetative lesions are visualized Recognize potential severe manifestations of acute and. by echocardiography in approximately 12 of patients 6 chronic Q fever and understand appropriate strategies to. Q fever is an occupational disease in persons whose work monitor and manage these patients. involves contact with animals such as slaughterhouse workers Manage infected children and pregnant women. veterinarians and farmers although infection is not limited appropriately. to these groups Urban outbreaks and cases with no known Provide effective risk communication for persons at high. exposure or close proximity to livestock have been reported risk for Q fever exposure. as have nonoccupational exposures such as through a hobby Report suspect and confirmed cases to appropriate public. farm a small farm that is not a primary source of income 11 health officials. Data collected from Q fever case report forms submitted to A compilation of the key point summaries for Q fever clinical. CDC during 2000 2010 indicate that 320 of 405 79 cases features diagnosis treatment occupational exposures and. in patients who reported occupational status are recognized surveillance and reporting are provided Appendix A. in patients who are not in previously defined high risk. occupations and 243 of 405 60 cases are in patients who. do not report livestock contact CDC unpublished data Methods. 2010 These findings underscore the need for health care This report provides the first national guidelines for. professionals to consider Q fever in the differential diagnosis the diagnosis and management of Q fever in the United. in patients with a compatible illness even in the absence of States The recommendations were prepared by the Q Fever. occupational risk or history of direct contact with animal Working Group which includes CDC scientists infectious. reservoirs Approximately 200 cases of acute Q fever were disease specialists laboratorians epidemiologists and clinical. reported in U S military personnel who had been deployed practitioners with expertise in the diagnosis and management. to Iraq since 2003 Investigations of these cases linked illness of Q fever These recommendations were developed through. to tick bites sleeping in barns and living near helicopter expert consultation and consensus and represent the best. zones with environmental exposure resulting from helicopter judgment of Q fever subject matter experts many of whom. generated aerosols 12 13 are international experts because of the low number of. The largest known reported Q fever outbreak involved Q fever clinical subject matter experts in the United States In. approximately 4 000 human cases and occurred during 2009 CDC created the first draft using previously published. 2007 2010 in the Netherlands This outbreak was linked to guidelines review articles and multiple search strategies of. dairy goat farms near densely populated areas and presumably medical and professional computerized databases During. involved human exposure via a windborne route 14 2010 2012 each member of the Q Fever Working Group. 2 MMWR March 29 2013 Vol 62 No 3,Recommendations and Reports. reviewed revised and refined the recommendations In to physical stresses including heat and desiccation and can. 2012 the CDC National Institute of Occupational Safety survive in the environment for months to years The bacteria. and Health reviewed the recommendations When possible can become airborne traveling on wind currents for miles. recommendations were based on existing recommendations resulting in outbreaks 35 36 In one outbreak Q fever cases. or guidelines referenced within the text with emphasis on were documented in persons who lived 10 miles from the farm. U S populations Published guidelines and the peer reviewed that was the source of the outbreak In a recent outbreak in. literature were reviewed to ensure the relevance completeness the Netherlands living within 2 km of an infected farm was. and accuracy of the recommendations If no adequate a significant risk factor for infection 36 38 Less common. guidelines existed the guidelines and recommendations were routes of transmission include ingestion of raw milk and dairy. based on the experience and expertise of the Q Fever Working products or contact with contaminated clothing 39 40. Group members Person to person transmission of Q fever is possible but. rarely reported Persistent infection of the genital tract has. been documented both in animals and humans and sexual. Epidemiology transmission and transplacental transmission of disease have. been reported 41 44 Rare cases of transmission caused by. Overview blood transfusion or bone marrow transplantation from infected. Cattle sheep and goats are the primary reservoirs for human donors have been reported 45 46 C burnetii has been. the diagnosis and management of Q fever in the United States The recommendations were prepared by the Q Fever Working Group which includes CDC scientists infectious disease specialists laboratorians epidemiologists and clinical practitioners with expertise in the diagnosis and management of Q fever These recommendations were developed

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