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The Seroprevalence of Coxiella Burnetii in Erzincan, Turkey: Identification of the Risk Factors and Their Relationship with Geographical Features

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The Seroprevalence of Coxiella Burnetii in Erzincan, Turkey: Identification of the Risk Factors and Their Relationship with Geographical Features [Downloaded free from http://www.jvbd.org on Tuesday, July 28, 2020, IP: 5.180.77.27] J Vector Borne Dis 54, June 2017, pp. 157–163 The seroprevalence of Coxiella burnetii in Erzincan, Turkey: Identification of the risk factors and their relationship with geographical features Aytekin Cikman1, Merve Aydin1, Baris Gulhan1, Faruk Karakecili2, Adalet Ozcicek3, Ozan Arif Kesik4, Mehmet Parlak5, Fatih Ozcelik6 & Bilge Gültepe7 1Department of Medical Microbiology; 2Department of Infectious Diseases; 3Department of Internal Medicine, Faculty of Medicine; 4Depart- ment of Geography, Faculty of Arts and Sciences, Erzincan University, Erzincan; 5Department of Medical Microbiology, Faculty of Medicine, Yuzuncu Yil University, Van; 6Clinical Biochemistry Laboratory, Erzincan Military Hospital, Erzincan; 7Department of Medical Microbiology, Faculty of Medicine, Bezmi-Alem University, Istanbul, Turkey ABSTRACT Background & objectives: Coxiella burnetii (C. burnetii) bacterium, the causative agent of Q fever has regained importance due to the increasing cases of infections and outbreaks. A cross-sectional descriptive study was conducted to investigate the seroprevalence of C. burnetii in human populations of Erzincan province located in the eastern Turkey, identify the risk factors, and to explore the relationship between geographical features. Methods: A total of 368 people residing in the rural (306) and urban (62) areas of the province were included in the study. Serum samples were analyzed for the presence of C. burnetii phase II IgG antibody using ELISA (Virion/ Serion, Wurzburg, Germany). Spatial analyses were performed to evaluate correlations between seroprevalence and geographical features. Results: The overall seroprevalence of C. burnetii was found to be 8.7% (32/368). In rural residents it was 8.5% (26/306), while in urban population it was 9.7% (6/62). Cattle breeding and contact with animal afterbirth waste were found to be major risk factors, and were significantly correlated with seropositive cases (p<0.05). The seropositive cases were only observed in the areas between 1067 and 1923 masl. Of the total seropositive cases, 65.6% were within 1000 m and 87.5% within 4000 m of rivers and their main tributaries. Around 59.4% cases were observed in areas with a slope of 0 to 5°. Interpretation & conclusion: The results of the study showed that C. burnetii seroprevalence was higher than expected, and significantly differs according to geographical features of a region. Significant risk factors include raising cattle and exposure to infected animals or their birth products/secretions. It is also more frequent in areas with higher number of rivers and streams, higher altitude and lower slope. Key words Coxiella burnetii; geographical features; Q fever; risk factors; seroprevalence INTRODUCTION directly transmitted directly through contact with infected sheeps, goats or cattles, or indirectly through contact with Coxiella burnetii (C. burnetii) is a small, pleomor- their urine, faeces and afterbirth wastes6. It has also been phic, non-motile, non-encapsulated, gram-negative obli- reported that C. burnetii infections can be acquired from gate intracellular bacterium1. According to the new clas- unpasteurized milk products, blood transfusion and un- sification based on the phylogenetic analysis of the gene protected sexual intercourse7. sequences, C. burnetii species are now included in the The largest reported Q fever outbreak affecting gamma (γ) subgroup, order Legionellales of the Proteo- > 3500 people in the Netherlands from 2007 to 2010, at- bacteria family2. Coxiella burnetii is the causative agent tracted its attention and regaining importance among the of Q fever, a zoonotic disease in humans3. The C. burnetii health agencies7. The World Health Organization (WHO) infection in humans can be asymptomatic or symptomatic has defined Q fever as an “infection of increasing im- with three different clinical forms; namely self-limited fe- portance”2. The C. burnetii is widely present throughout brile illness, acute Q fever (atypical pneumonia, hepatitis) the world, with its seroprevalence differing according to and chronic Q fever (endocarditis)4. regions8-12. Several investigatory studies have been con- The disease is transmitted to humans mostly by the ducted in different regions of Turkey, and reported C. inhalation of air contaminated with C. burnetii5. It is also burnetii positivity in different percentages8, 13-17. Further- [Downloaded free from http://www.jvbd.org on Tuesday, July 28, 2020, IP: 5.180.77.27] 158 J Vector Borne Dis 54, June 2017 more, despite the higher prevalence reported in the rural Ethical approval areas in the past, the more recent studies have indicated The study was approved by the Ethics Committee that the rural areas do not actually present a significant risk of Erzincan University (Approval No: 24.02.2014–1/7). factor10, 18. However, the relationship between the prev- Written informed consent was obtained from all partici- alence of C. burnetii and geographical features has not pants using the relevant forms. been described in earlier studies and still remains unclear. Therefore, this study investigated the seroprevalence of Antibody detection using ELISA C. burnetii in Erzincan province in eastern Turkey, and The serum samples were examined for the presence explored the associated risk factors and its relationship of C. burnetii phase II IgG antibodies using a commercial with geographical features of the study area. ELISA kit (Virion/Serion, Wurzburg, Germany), accord- ing to the manufacturer’s instructions. The serum samples MATERIAL & METHODS were diluted in antibody dilution buffer (1: 500) and each serum sample was examined twice. Study area The absorbance values were determined at 450 nm Erzincan province is located in the northwest of the (reference wavelength of 620–690 nm) using an Epoch Eastern Anatolia Region in the Upper Euphrates basin ELISA reader (BioTek Instruments, Inc., Winooski, VT, between 39° 44' 21.084'' N and 39° 29' 24.54" E coordi- USA), on the Gen5TM data analysis software (BioTek In- nates. The province comprises of nine districts; Refahiye, struments, Inc., Winooski, VT, USA). The cut-off values Kemah, Kemaliye, Tercan, Cayirli, Ilic, Otlukbeli, Uzum- of all the samples and the optical density of control samples lu and the Erzincan City center. The climate of Erzincan were recorded. Antibody activity was calculated in IU/ml displays a transition between the climates of the Black Sea using a standard curve in accordance with the manufac- and the Eastern Anatolia regions. The province has a sur- turer’s recommendations. The results were quantitatively face area of 11,623 km2 and is surrounded by mountains evaluated (<20 IU/ml–Negative; 20–30 IU/ml–Weak and plateaus. The Karasu River divides the region into Positive; and >30 IU/ml– Positive). The weak-positive east and west, with a dam in the Tercan area. The Kelkit samples were re-tested. Valley in the province has favourable vegetation and cli- matic conditions for a large tick population. The study Mapping area contains several rivers, streams and wetlands; thus, ArcGIS 10.1 (ESRI, Redlands, CA) and Google Earth agriculture and animal husbandry are common practices. (Google, Mountain View, CA) software packages were used to draw the maps of Erzincan province, districts, Blood sample collection rivers and their tributaries for performing spatial analy- This study was based on a descriptive cross-sectional sis. The data-sets were created using the “Open Street design to determine the seroprevalence of C. burnetii in Map” service on ArcGIS Basemap. Then, the location Erzincan. The study comprised of 368 participants; 306 of seropositive cases was positioned on Google Earth were rural residents and 62 were living in the urban part and exported to ArcMap. The relationship between the of the province. The demographic information about the number of seropositive cases and the altitude along with participants, such as their gender, age, education level, the slope gradient of the study area was also explored. occupations (cattle breeding in particular) and residen- The necessary data for this analysis was obtained from tial address were recorded. All participants were asked the Advanced Spaceborne Thermal Emission and Reflec- to complete a short questionnaire to determine their his- tion Radiometer Global Digital Elevation Model (ASTER tory concerning animal farming, tick bites (within the last GDEM), the National Aeronautics and Space Adminis- five years), contact with ticks, milking and contact with tration (NASA, US), and the Ministry of Economy, Trade animal afterbirth wastes. A face-to-face interview meth- and Industry (METI, Japan). In addition, buffer analyses od was used for the completion of the questionnaire. The were performed for the rivers and their tributaries (Buf- participants were divided into three groups according to fer/Multiple Ring Buffer) for the spatial analysis of the age; <29, 30–59 and >60 to evaluate the positivity of C. study area. burnetii. A 10-ml of venous blood sample was collected from each participant. The samples were centrifuged at Statistical analysis 1610 × g for 10 min and serum was separated and stored The data obtained from all participants were analyzed in different aliquots at –20 °C until assayed. using Microsoft Excel (Microsoft Corporation, Redmond, [Downloaded free from http://www.jvbd.org on Tuesday, July 28, 2020, IP: 5.180.77.27] Cikman et al: The seroprevalence of Coxiella burnetii in Erzincan, Turkey 159 WA, USA) and SPSS version 15.0 (SPSS, Inc., Chicago, urban areas, 9.7% (6/62). Four out of six people residing IL, USA). The risk factors for the seroprevalence of in Erzincan city center reported a history of contact with C. burnetii identified from the questionnaire were as- ticks or tick-bites. Among the C. burnetii positive cases, sessed using the Mann-Whitney U-test and the Kruskal- 40.6% (13/32) had a history of tick-bites and 59% (19/32) Wallis ANOVA test for non-parametric and independent reported previous contact with ticks. However, no statis- groups, and the unpaired t-test for the parametric and tically significant relationship was found between the independent groups.
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