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What Do We Know About Q Fever in Mexico?

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What Do We Know About Q Fever in Mexico? ARTÍCULO ORIGINAL What do we know about Q fever in Mexico? Javier Araujo-Meléndez,* José Sifuentes-Osornio,* J. Miriam Bobadilla-del-Valle,* Antonio Aguilar-Cruz,** Orestes Torres-Ángeles,** José L. Ramírez-González,*** Alfredo Ponce-de-León,* Guillermo M. Ruiz-Palacios,* M. Lourdes Guerrero-Almeida* * Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. ** Jurisdicción Sanitaria No. 4, Huichapan, Hidalgo. *** Hospital General, Huichapan, Hidalgo. ABSTRACT ¿Qué sabemos acerca de la fiebre Q en México? In Mexico, Q fever is considered a rare disease among hu- RESUMEN mans and animals. From March to May of 2008, three pa- tients were referred, from the state of Hidalgo to a En México la fiebre Q se considera una enfermedad rara en- tertiary-care center in Mexico City, with an acute febrile ill- tre los humanos y los animales. Sin embargo, entre marzo y ness that was diagnosed as Q fever. We decided to undertake a mayo 2008 tres pacientes del estado de Hidalgo fueron refe- cross sectional pilot study to identify cases of acute disease in ridos a un hospital de tercer nivel en la Ciudad de México this particular region and to determine the seroprevalence of por una enfermedad febril aguda y fueron diagnosticados Coxiella burnetii among healthy individuals with known risk con fiebre Q. Se decidió llevar a cabo un estudio piloto para factors for infection with this bacteria. Q fever was defined identificar casos de enfermedad aguda en esa región y deter- according to the Centers for Disease Control and Prevention minar la prevalencia serológica de Coxiella burnetii en indi- criteria. All subjects were interviewed for signs and symptoms viduos sanos con factores de riesgo conocidos. Se definió of the disease, demographic and household characteristics and fiebre Q conforme a los criterios de los Centros de Control y occupational exposure to cattle. Blood samples were taken Prevención de Enfermedades (CDC). Todos los sujetos en es- from hospitalized and outpatients with symptoms suggestive tudio fueron entrevistados para detectar signos y síntomas of Q fever, as well as from asymptomatic individuals with di- de la enfermedad, características demográficas y de la vi- rect and daily exposure to cattle (slaughterers, butchers, far- vienda y exposición ocupacional a ganado. Se tomaron mues- mers, shepherds and veterinarians) in the five municipalities. tras sanguíneas a los pacientes hospitalizados y externos con We report the occurrence of 17 cases with positive antibodies síntomas sugerentes de fiebre Q, así como a individuos asin- against C. burnetii in a rural area of central Mexico; eight ca- tomáticos con exposición directa y cotidiana con ganado ses had clinical criteria of acute Q fever disease. Results from (granjeros, carniceros, pastores y veterinarios). Se reporta- this pilot study underscore the need for active surveillance ron 17 casos con anticuerpos positivos contra C. burnetii en programs and comprehensive studies to further define the esta área rural; ocho casos cumplieron con los criterios de prevalence and risk factors associated with the disease in enfermedad aguda. Los resultados subrayan la necesidad Mexico, to know more about its clinical presentation and to de llevar a cabo programas de vigilancia activa y la realización characterize bacterial factors involved in its pathogenesis. de estudios prospectivos poblacionales para definir la preva- lencia y factores de riesgo de la enfermedad en México, así como para caracterizar mejor la presentación clínica y los factores asociados con la patogenicidad de la bacteria. Key words. Q fever. Coxiella burnetii. Exotic diseases in Palabras clave. Fiebre Q. Coxiella burnetii. Enfermedades Mexico. Infections in the rural area. Zoonosis. exóticas en México. Infecciones en el área rural. Zoonosis. INTRODUCTION in milk, urine and feces of infected animals and most importantly, during birthing the bacteria is Q fever is a zoonotic disease caused by Coxiella shed in high numbers within the amniotic fluids burnetii, a species of bacteria with a worldwide dis- and the placenta. The organisms are resistant to tribution.1 The primary reservoirs of C. burnetii heat, drying and many common disinfectants, fea- are cattle, sheep and goats. C. burnetii is excreted tures that enable the bacteria to survive for long Revistai de Investigación gac Clínicaíni / Vol. 64, Núm. 6 (Parte I) / Noviembre-Diciembre, 2012 / pp 541-545 periods in the environment. Infection of humans in the five municipalities. Serologic assessment for usually occurs after inhalation of aerosols from specific antiphase II C. burnetii antigen type IgG an- contaminated barnyards dust, excreta and direct tibodies was performed using an ELISA test (Phase contact with birth fluids of infected herd animals. IIIgG, Virion/Serion®, Würzbur, Germany); positive The disease has also been described in abattoir results were confirmed using an indirect immu- workers.2 Only about 40% of all people infected nofluorescence assay (IFA) (BioMerieux®, Marcy with C. burnetii develop clinical disease and in cer- l’Etoile, France). Infection with C. burnetii was con- tain risk groups (immunocompromised hosts) the sidered positive by either an antiphase II C. burnetii infection (symptomatic or not) may result in chro- antigen IgG titer > 200 IU/mL or antiphase II C. nic disease (2% of cases).3-5 burnetii antigen IgM titer > 50 IU/mL in a single Since 1994, Q fever is a notifiable disease in Mexi- serum sample. Statistical analyses were performed co.6 Due to the lack of specific signs and symptoms using the STATA software® version 8:0 (College and to the difficulties of making an accurate diagno- Station, Texas, USA). Measures of central tendency sis without appropriate laboratory testing, Q fever and dispersion, frequency and proportions, chi-squa- is underreported and it is commonly referred as a re test or Fisher’s exact test were used as appro- rare, exotic disease in both, humans and animals. priate to describe the data and to determine the Interestingly, the seroprevalence of Q fever reported significance of associations between study variables. in the United States during the National Health and Odds ratios and corresponding 95% Confidence In- Nutrition Examination Survey (NHANES 2003- tervals (95% CI) were calculated using logistic re- 2004), was higher for subjects of Mexican-American gression methods. A two-tailed p value ≤ 0.05 was origin than that reported in the non-Hispanic Ame- considered as statistically significant. The Institu- rican populations. This study suggested differences tional Review Board approved the study, and all sub- in geographical or occupational exposure, but we jects signed informed consent. could not identify the source of the infection.7 RESULTS MATERIAL AND METHODS A total of 159 subjects were included in the study From March to May 2008, three patients were re- (Figure 1). Twenty three subjects reported a history ferred to this tertiary-care hospital located in Mexi- of prolonged fever during the prior year or presen- co City, with persistent high fever, chills, malaise ted with acute symptoms: the three initial sympto- and mild hepatitis. Serologic assessment of the three matic patients, five more cases of acute Q fever patients revealed positive antibodies against C. bur- detected during the study and three of 15 subjects netii and in two, a liver biopsy showed the classical with a history of prolonged fever had > 200 IU/mL granulomatous hepatitis. All of them were residents titers of anti-phase II C. burnetii antigen IgG anti- of a farming region in the state of Hidalgo, Mexico. bodies. Among the 136 asymptomatic subjects, 6 We decided to undertake a cross sectional pilot study (4.4%) subjects were infected, and 3 of them had se- to identify cases of acute disease in this particular rologic evidence of acute infection with C. burnetii region and to determine the seroprevalence of C. (specific IgG antibody titers ≥ 1:256 by IFA). The burnetii among healthy individuals with known risk median age of the 8 acutely ill subjects was 44 years, factors for infection with this bacteria. From June all had acute fever, chills, headache, fatigue, myal- through August 2009, this pilot study was conduc- gias and arthralgias; mild hepatitis was detected in ted in collaboration with the jurisdictional health 6 cases, and only 3 had daily exposure to cattle. authorities of five municipalities in the state of Hi- None developed pneumonia, endocarditis or endovascu- dalgo. Q fever was defined according to the Centers lar infections. All patients with suspected or confir- for Disease Control and Prevention (CDC) criteria.8 med diagnosis of Q fever were treated and all had All subjects were interviewed for signs and complete resolution of symptoms. Table 1 shows the symptoms of the disease, demographic and house- demographic characteristics and antibody titers of hold characteristics and occupational exposure to the 17 (10.7%) subjects with confirmed C. burnetii cattle. Blood samples were taken from hospitalized infection. and outpatients with symptoms suggestive of Q fe- Univariate analysis including the 159 subjects in ver, as well as from asymptomatic individuals with the study showed that male gender (OR 6.2, 95% CI: direct and daily exposure to cattle (slaughterers, 0.8 to 48.88, p = 0.08) and living in Huichapan/Te- butchers, farmers, shepherds and veterinarians) cozautla (OR 6.7; 95% CI: 1.47, 30.38, p = 0.014), 542 Araujo-Meléndez J, et al. Q fever in Mexico. Rev Investes ClinC 2012; 64 (6) Parte I: 541-545 159 subjects included 23 subjects with symptoms 136 subjects without or history of prolonged fever during the prior year symptoms during the prior year ELISA (+) ELISA (-) 6 subjects (4.4%) 130 subjects (95.6%) History of Clinical suspicion of Q fever 15 subjects fever and ELISA (+) 8 patients ELISA (+) ELISA (-) 3 subjects 12 subjects 3 patients were 5 patients diagnosed hospitalized during the study Figureg e 1. Population included in the study and prevalence of infection by Coxiella burnetii: 159 subjects were included in the study, 23 reported a current or previous history of fever and 136 more asymptomatic.
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