Environmental Surveillance During an Outbreak of Tularaemia in Hares, the Netherlands, 2015
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Surveillance and outbreak report Environmental surveillance during an outbreak of tularaemia in hares, the Netherlands, 2015 I Janse 1 2 , M Maas 1 2 , JM Rijks ³ , M Koene ⁴ , RQ van der Plaats ¹ , M Engelsma ⁵ , P van der Tas ⁶ , M Braks ¹ , A Stroo ⁷ , DW Notermans ¹ , MC de Vries ¹ , F Reubsaet ¹ , E Fanoy 1 8 , C Swaan 1 , MJ Kik ³ , J IJzer ³ , RI Jaarsma ¹ , S van Wieren ⁹ , AM de Roda- Husman 1 10 , M van Passel ¹ , H Roest ⁴ , J van der Giessen 1 4 1. Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands 2. These authors share first authorship 3. Dutch Wildlife Health Centre, Utrecht University, Utrecht, the Netherlands 4. Department of Bacteriology and Epidemiology, Wageningen Bioveterinary Research (WBVR), Lelystad, the Netherlands, 5. Department of Diagnostics and Crisis Organisation, Wageningen Bioveterinary Research (WBVR), Lelystad, the Netherlands 6. GGD Fryslân, Regional Public Health Service of Friesland, Leeuwarden, the Netherlands 7. Netherlands Food and Consumer Product Safety Authority, Wageningen, the Netherlands 8. GGD Utrecht, Regional Public Health Service of Utrecht, Zeist, the Netherlands 9. Resource Ecology Group, Department of Environmental Science, Wageningen University and Research Centre, Wageningen, the Netherlands 10. Institute for Risk Assessment Sciences (IRAS), Faculty of Veterinary Medicine, Utrecht University, Utrecht, the Netherlands Correspondence: Ingmar Janse ([email protected]) Citation style for this article: Janse I, Maas M, Rijks JM, Koene M, van der Plaats RQ, Engelsma M, van der Tas P, Braks M, Stroo A, Notermans DW, de Vries MC, Reubsaet F, Fanoy E, Swaan C, Kik MJ, IJzer J, Jaarsma RI, van Wieren S, de Roda-Husman AM, van Passel M, Roest H, van der Giessen J. Environmental surveillance during an outbreak of tularaemia in hares, the Netherlands, 2015. Euro Surveill. 2017;22(35):pii=30607. DOI: http://dx.doi.org/10.2807/1560-7917.ES.2017.22.35.30607 Article submitted on 30 August 2016 / accepted on 09 May 2017 / published on 31 August 2017 Tularaemia, a disease caused by the bacterium [6]. Small mammals contribute to the geographical Francisella tularensis, is a re-emerging zoonosis in spread of F. tularensis, but they may not constitute the the Netherlands. After sporadic human and hare cases major reservoir [5]. Although tularaemia occurrence occurred in the period 2011 to 2014, a cluster of F. tula- has been linked to particular landscape features [4,7], rensis-infected hares was recognised in a region in the the dominant environmental reservoir(s) in which F. north of the Netherlands from February to May 2015. tularensis may persist for prolonged periods are still No human cases were identified, including after active largely unknown and may vary between geographical case finding. Presence of F. tularensis was investi- areas [1]. F. tularensis has been detected in various gated in potential reservoirs and transmission routes, types of surface waters and sediments [3,8] where it is including common voles, arthropod vectors and sur- potentially hosted by free-living protozoa [9]. Multiple face waters. F. tularensis was not detected in common transmission routes exist, resulting in different clinical voles, mosquito larvae or adults, tabanids or ticks. manifestations. In humans, insect bites or direct con- However, the bacterium was detected in water and tact with infected animals generally leads to ulcerog- sediment samples collected in a limited geographical landular infections, ingestion of infected meat or water area where infected hares had also been found. These to oropharyngeal infections, and inhalation of infected results demonstrate that water monitoring could aerosols to respiratory pneumonic infections [5]. provide valuable information regarding F. tularensis spread and persistence, and should be used in addi- In the Netherlands, indigenous tularaemia had not tion to disease surveillance in wildlife. been reported for over 50 years, until a patient in the western province of Zuid-Holland was diagnosed with Introduction ulceroglandular tularaemia contracted from an uniden- Tularaemia is a zoonosis caused by the intracellular tified local source in 2011 [10]. This first human case pathogen Francisella tularensis. Disease in humans of a re-emerging disease initiated several actions. and animals is mostly caused by subspecies tularensis Medical and veterinary professionals were informed (type A) and holarctica (type B) [1]. In Europe, tularae- through a weekly surveillance report distributed by the mia is a locally emerging or re-emerging zoonosis with National Institute for Public Health and the Environment most human cases reported from Sweden, Finland and (RIVM), and Dutch medical and veterinary journals [11- Turkey [1-4]. There may be sporadic and geographically 13]. After additional cases in the following years, a confined cases, and seasonal epidemics and epizoot- procedure to make tularaemia a notifiable disease in ics [5]. F. tularensis has a wide host range, although humans began, and was implemented in November lagomorphs and rodents appear to be particularly 2016 [14]. Surveillance of brown hares (Lepus euro- susceptible to infection and symptom development paeus) started at national level in 2011 and through www.eurosurveillance.org 1 Figure Locations of dead brown hares and other tularaemia surveillance samples collected during and after a tularaemia outbreak in hares, the Netherlands, 2015–2016 ^ ma ma ma Wommels ^ J YY H Grou <= <= K W Y I1 ^ M <=Y <=Y<= <= <= I2 ma < E Y L G ma = < W D2 ^!B1 <= NWW=!Y^ ^ Bolsward R Q2W^<=!^ W ^^ <= B2 ^ Y< S<= ^<= B < C2 Q1 mc 3 =! <= O2 ^ O1 A< Y ^<= =Akkrum YY ^ C1 P ^ ^ ^ <=<=1P2 ^ <=T1 Sneek <= Y T2 mb F2 W<=F1 ^ IJlst ^ Y Heeg ^ Joure Heerenveen St Nicolaasga <=U Balk Wolvega ^ ^ ^ ^ V2 <=<=V1 <=W 0 2 4 6 Km Lemmer <=X1 ^ X2 <=J Grou ^ Y<=K <=M <=L Y ^ B< 1 W=! ^ D W 2 ^B3 =!=!Y W<==!^D1 ^ W ^^B2 ^<=N R Y <= ^ Q2 <= Q 1 mc < S C< 2 <= C1 =!=! ^ Y 0 1 km O1 O2 Akkrum ^ <=<= < =A Y ^ ^ Y ^ ^ A–X: surface water sampling locations, numbers represent multiple sampling points at one location; ma: 181 common voles captured using snap traps between February and April; mb: 38 common voles captured alive in April; mc: 38 common voles. captured dead by farmers in August The insert depicts a map of the Netherlands with the province of Friesland marked in yellow. The blue and red squares indicate the areas covered by the upper and lower maps, respectively. The lower map zooms in on the epizootic area. Locations where dead hares were found during the first and second half of 2015 are indicated by large and small stars, respectively. Yellow stars represent hares where tularaemia was confirmed as cause of death while white stars represent tularaemia-negative hares. Locations where common voles were collected during the first and second half of 2015 are indicated by large and small purple triangles, respectively. Locations where arthropods were collected during the first half of 2015 or in the second half of 2015 or later are indicated by large and small blue diamonds, respectively. Surface water sampling locations are represented by circles. Samples collected on 16 April and on 29 May are indicated by the left half and right half of the circle, respectively. Presence of F. tularensis DNA is indicated by the colours red (detected) or green (not detected). Transparency signifies that no samples were collected on that date. 2 www.eurosurveillance.org this, a hare infected with F. tularensis was identified hunters, farmers and veterinarians. Following evidence in the southern province of Limburg in May 2013 [15]. of an outbreak among hares in Friesland in 2015, sub- Two months later, ulceroglandular tularaemia was diag- mitting dead hares from this province was actively nosed in a patient from the same region. In 2014, F. encouraged by the DWHC. A convenience sample of 23 tularensis infections were detected in three humans persons, mostly hunters from different game manage- (including two family members) and two hares. The ment units, were interviewed in June after the outbreak human and hare tularaemia cases occurred in various to gain more insight into the outbreak dynamics. geographical areas of the Netherlands and in different seasons [16]. Human case finding The local public health service, GGD Fryslân, The event approached farmers and hunters who had handled On 9 February 2015, two hares were submitted to the infected hares to investigate whether these individu- Dutch Wildlife Health Centre (DWHC) for post-mortem als had developed health problems. In collaboration investigation. The case history noted that four hares with the regional laboratory for infectious diseases, had died over the weekend in a garden in the province Izore, patient records were retrospectively searched of Friesland, northern Netherlands, with death occur- from the area of the hare epizootic in the months ring abruptly after a spell of abnormal behaviour. The February, March and April 2015. The search included two animals were in fair condition and had acute severe requests for laboratory diagnosis of pathogens causing extensive necrotic hepatitis. Tularaemia was confirmed clinical manifestations mimicking those of tularaemia by real-time PCR (qPCR). Following the two index cases, (e.g. Bartonella henselae, cytomegalovirus, Epstein– four more dead hares were found east and south of Barr virus and Toxoplasma gondii), often by serology, these two cases on 27 February, 4 March and 11 March. but also including cultures of lymph node biopsies. Tularaemia was confirmed to be the cause of death, General practitioners of 13 patients who met at least and suspicion of a tularaemia outbreak was communi- one of these criteria were contacted and the possibility cated in March. Following the event, active human case of clinical tularaemia was reconsidered. Also, between finding was initiated to reveal undiagnosed tularaemia February and December 2015, lymph nodes, mesente- cases. Potential reservoirs and transmission routes rium and neck biopsy samples were submitted to Izore of F.