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, Texasjames.alexander@dshs.state.tx.us