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Hart voor Brabant

Of goats and humans; the societal costs of the Dutch Q fever saga

Gabriëlla Morroy [1,2], Juriaan Prins [3], Ron Bergevoet [4], Peter Schneeberger [5], Hans H.J Bor [2], Wim van der Hoek[6], Jeaninne Hautvast [2], Clementine J. Wijkmans [1,2], Jeannette B. Peters [7,8], Johan J. Polder [9]

Background Results In the , more than 4.000 human Q fever cases and Following acute Q fever 40% of working 24 deaths were notified between 2007 and 2010 during an Dutch patients reported long-term (>1 unprecedented outbreak, implicating dairy goats as the main month) sick-leave. One to two years after

source. Veterinary control measures were taken reluctantly initial infection 40% of patients reported as economic damage was feared. Measures were introduced persisting physical symptoms and 60% a late, gradually increased and culminated in the culling of severely affected health status. The general approximately 60.000 goats, 3 years after the outbreak began. Quality of Life was affected in 44.9% of Growing numbers of Dutch patients are reported to develop late cases and 43.5% suffered from persisting complications; Q fever fatigue syndrome or chronic Q fever, with fatigue. implicit high costs to society. We estimated the societal cost of the outbreaks by combining data from veterinary and human The estimated societal costs of the Q fever health sector sources. outbreak are approximately 250-600 million Euros. Human costs account for 85%, are Methods spread out over a decade and delayed. The All patients notified in 2007 and 2008 received a questionnaire largest costs are due to loss of QoL followed 12 to 26 month after the onset of initial illness. Human by productivity loss. Veterinary costs are costs were based on real cost data of sick leave, health care much smaller but immediate. consumption and estimated costs of Quality of Life (QoL) loss, from patients notified in 2007 and 2008 and Dutch veterinary data. Cost data were extrapolated to other outbreak years also incorporating duration of illness information from literature.

Notified Q fever patients per week and costs 2007 -2012 Notified Q fever patients per week and human and veterinary costs per year 2007-2012 Costs Q fever outbreaks 2007- 2012 aprox 600 million euro Million euro 80 250 2007: N=194 n 2008: N=982 Costs Q fever outbreak 2007-2012 2009: N=2.313 2010: N=407 2011: N=75 Culling 200 2012: N=5 60

number notificatio New livestock

Start culling Tankmilkcontroll & vaccination 150 40 85% Sick leave

100 Treatment

20 Outbreak controll

50 Loss Quality of life

Loss Quality of life Deaths 0 0 1 6 11 16 21 26 31 36 41 46 51 4 9 14 19 24 29 34 39 44 49 2 7 12 17 22 27 32 37 42 47 52 4 9 14 19 24 29 34 39 44 49 2 7 12 17 22 27 32 37 42 47 52 5 10 15 20 25 2007 2008 2009 2010 2011 2012

Conclusions Q-fever poses a serious long-term burden on patients and society. The real impact of a zoonosis outbreak only becomes apparent when combining both human health and veterinary costs.

Veterinary cost are proportionally small but more apparent as they are immediate. Because of a slow trickle down effect human cost and societal implications tend to be hidden and underestimated. Finding the balance between economic veterinary interests and human health remains a challenge when dealing with future outbreaks of zoonotic diseases. The then ministers of health and agriculture faced with the goat issue. 1.MD, CCD, Department of Infectious Disease Control, Municipal Health Service Hart voor Brabant, ‘s-Hertogenbosch. 2.AMPHI, Department of Primary and Community Care, Radboud University Medical Centre (RUMC), Nijmegen.3.SEO Economisch Onderzoek, . 4.LEI Wageningen UR, Wageningen. 5.Laboratory of Medical Microbiology, Jeroen Bosch Hospital, ’s-Hertogenbosch. 6.Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven. 7. Department of Medical Psychology, RUMC, Nijmegen. 8.Department of Pulmonary Diseases, RUMC, Nijmegen. 9. RIVM and University. All institutes are in the Netherlands

Corresponding author: Gabriella Morroy; [email protected]