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Q fever surveillance in ruminants, Thailand, 2012.

To the Editor: Two cases of fatal endocarditis in Khon Kaen Province in northeastern Thailand were found to be caused by Coxiella burnetii (1). Although C. burnetii is known to be present in many countries, including in Thailand (2), human infection is more commonly associated with sheep and goats, possibly because these animals shed the organism more frequently in vaginal secretions and feces than do large ruminants (3).

Surveillance for Q fever, which is caused by C. burnetii, in livestock is currently based primarily on serologic or PCR testing of milk (4). However, problems in estimating prevalence include serologic assay insensitivity (5,6) or unavailability of milk from nondairy animals.

For diagnosis of Q fever, the placenta of the animal is commonly tested, but testing is usually conducted only when abortions occur, which is only likely when uninfected animals first encounter C. burnetii. Therefore, this approach might underestimate true organism distribution in a disease-endemic area (7). In addition, nearly all abortion storms have occurred in sheep or goats, which are rare in Thailand. Ruminant abortion is rarely reported to veterinary authorities in Thailand.

Comparison of paired colostrum and placental samples from sheep showed that C. burnetii was found more frequently in placental samples (8), which suggested that the placenta is a better sample than milk for surveillance purposes. Also, a placenta may be more useful because it is more likely to contaminate the farm environment. Milk is an unlikely source of Q fever in adult persons because it is seldom consumed by adults in Thailand.

The ideal surveillance strategy would include all relevant samples (serum, milk, and products of conception, both normal and abnormal). However, in practice, cost and logistical limitations dictate refinement of sampling. C. burnetii is frequently detected in normal ruminant placentas, but offspring are apparently not affected (9). We report that surveillance of normal placentas can provide useful surveillance data.

To test this hypothesis, in 2012 we asked local veterinarians in selected subdistricts in Thailand to contact farmers at their convenience to request that the veterinarians be alerted when a ruminant gave birth. Only grossly normal placentae from normal births of apparently healthy offspring were sampled. Cotyledonary (preferred) or intercotyledonary chorioallantoic tissue was obtained, chilled, and shipped cold to the National Institute for Animal health (Bangkok, Thailand) for analysis. Tissue was ground, extracted, and analyzed by PCR for IS1111 of C. burnetii in a Light Cycler 2.0 Apparatus (Roche, Basel, Switzerland) as described (10). To minimize false-positive results, we repeated the PCR with a separate portion of tissue from the original sample. Samples were considered positive if the PCR had a cycle threshold <35 for each assay, or suspected of being positive if this occurred in 1 of 2 separate assays.

Results indicate a high frequency of C. burnetii infections in some provinces (Table), which roughly match locations where fatal human cases of endocarditis have occurred (Figure, Appendix, wwwnc.cdc.gov/EID/article/19/12/13-0624-F1.htm). It is common practice among the agrarian population in Thailand to consume ruminant placenta. Although this tissue is reportedly cooked before consumption, the preparation process may result in environmental contamination sufficient to expose persons who were not in close contact with the infected animal.

This study demonstrates that sampling and PCR of grossly normal ruminant placenta is a viable stand-alone approach for surveillance of C. burnetii that might enable the generation, at a minimal cost, of a highly detailed map showing areas where humans and animals are at risk for Q fever. The results indicate that C. burnetii is highly endemic in the study region. However, in light of the extreme rarity of serious complications in human infections and lack of any indication of a serious effect on animal production, these results do not indicate a need for veterinary control measures. Nonetheless, food safety practices should be addressed. It is essential that physicians monitoring patients with underlying heart valve conditions encourage such patients to seek diagnosis of any febrile illness so that appropriate treatment may be initiated to minimize risk for complications.

We report a novel approach to Q fever surveillance, which is potentially useful for countries such as Thailand, where subclinical ruminant infections are common. Our results also provide an initial indication of risk factors associated with recent cases of fatal Q fever endocarditis in Thailand. Follow-up research should include broader reservoir species surveillance, environmental surveillance, and comparison of genotypes of organisms found in ruminant placenta with those found in persons with endocarditis. These further efforts will result in clearer understanding of Q fever ecology and potential routes of human exposure.

References

(1.) Pachirat O, Fournier PE, Pussadhamma B, Taksinachanekij S, Lulitanond V, Baggett HC, et al. The first reported cases of Q fever endocarditis in Thailand. Infectious Disease Reports. 2012;4:e7. http://dx.doi. org/10.4081/idr.2012.e7

(2.) Suputtamongkol Y, Rolain JM, Losuwanaruk K, Niwatayakul K, Suttinont C, Chierakul W, et al. Q fever in Thailand. Emerg Infect Dis. 2003;9:1186-7. http:// dx.doi.org/10.3201/eid0909.030086

(3.) Rodolakis A, Berri M, He'chard C, Caudron C, Souriau A, Bodier CC, et al. Comparison of Coxiella burnetii shedding in milk of dairy bovine, caprine, and ovine herds. J Dairy Sci. 2007;90:5352-60. http://dx.doi.org/10.3168/jds.2006-815

(4.) Lopez-Gatius F, Almeria S, Garcia-spierto I. Serological screening for Coxiella burnetii infection and related reproductive performance in high producing dairy cows. Res Vet Sci. 2012;93:67-73. http:// dx.doi.org/10.1016/j.rvsc.2011.07.017

(5.) Berri M, Souriau A, Crosby M, Rodolakis A. Shedding of Coxiella burnetii in ewes in two pregnancies following an episode of Coxiella abortion in a sheep flock. Vet Microbiol. 2002;85:55-60. http://dx.doi. org/10.1016/S0378-1135(01)00480-1

(6.) Bottcher J, Vossen A, Janowetz B, Alex M, Gangl A, Randt A, et al. Insights into the dynamics of endemic Coxiella burnetii infection in cattle by application of phase-specific ELISAs in an infected dairy herd. Vet Microbiol. 2011;151:291-300. http:// dx.doi.org/10.1016/j.vetmic.2011.03.007

(7.) Centers for Disease Control and Prevention. Notes from the field: Q fever outbreak associated with goat farms--Washington and Montana, 2011. MMWR Morb Mortal Wkly Rep. 2011;60:1393.

(8.) Runge M, Binder A, Schotte U, Ganter M. Investigations concerning the prevalence of Coxiella burnetii and Chlamydia abortus in sheep in correlation with management systems and abortion rate in Lower Saxony in 2004. Berl Munch Tierarztl Wochenschr. 2012;125:138-43.

(9.) Hansen MS, Rodolakis A, Cochonneau D, Agger JF, Christoffersen AB, Jensen TK, et al. Coxiella burnetii associated placental lesions and infection level in parturient cows. Vet J. 2011;190:e135-9. Epub 2011 Feb 2. http://dx.doi.org/10.1016/ j.tvjl.2010.12.021

(10.) Christensen DR, Hartman LJ, Loveless BM, Frye MS, Shipley MA, Bridge DL, et al. Detection of biological threat agents by real-time PCR: comparison of assay performance on the R.A.P.I.D., the Light-Cycler, and the Smart Cycler platforms. Clin Chem. 2006;52:141-5. http://dx.doi. org/10.1373/clinchem.2005.052522

Author affiliations: Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand (S.L.Yingst); National Institute of Animal Health, Bangkok (P. Opaschaitat, R. Kanitpun, S. Thammasart, M. Ekgatat, P. Wongwicharn); and Region 8 Regional Veterinary Diagnostic Center, Surat Thani, Thailand (V. Jirathanawat)

DOI: http://dx.doi.org/10.3201/eid1912.130624

Address for correspondence: Samuel L. Yingst, United States Army Materiel Command, Armed Forces Research Institute of Medical Sciences, APO AP 96546, Bangkok, Thailand; email: samuel.yingst@afrims.org
Table. PCR results for Q fever surveillance in ruminants, Thailand,
2012

                                                No. cases

Province (no. sites)       Animal     Positive  Negative   Suspected

Chaiyapum (13)          Beef cattle      3         10          0
Chaiyapum (3)           Dairy cattle     1          0          2
Chaiyapum (1)               Goat         0          0          2
Chiang Mai (1)            Buffalo        0          2          2
Kalasin (1)                 Goat         1          0          0
Khon Kaen (8)           Beef cattle      8          0          0
Khon Kaen (2)             Buffalo        2          0          0
Maha Sarakham (1)           Goat         2          6          0
Nakon Pathom (9)            Goat         1          9          0
Nakon Ratchasima (1)    Beef cattle      1          1          0
Nakon Ratchasima (17)   Dairy cattle     20        30          0
Nakon Ratchasima (3)        Goat         15        13          0
Prachuap Kiri Khan (9)  Dairy cattle     3          1          6
Ratchaburi (2)              Goat         1          9          0
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Title Annotation:LETTERS
Author:Yingst, Samuel L.; Opaschaitat, Pattarin; Kanitpun, Reka; Thammasart, Suree; Ekgatat, Monaya; Jirath
Publication:Emerging Infectious Diseases
Article Type:Letter to the editor
Geographic Code:9THAI
Date:Dec 1, 2013
Words:1383
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