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Home Eurosurveillance Monthly Release  1997: Volume 2/ Issue 2 Article 3
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Eurosurveillance, Volume 2, Issue 2, 01 February 1997
Research Articles
Q fever in Europe

Citation style for this article: Editorial Committee. Q fever in Europe . Euro Surveill. 1997;2(2):pii=138. Available online:

In order to give a European overview, members of the editorial board of Eurosurveillance were asked a few questions about the surveillance of Q fever in the countries they represent and the possible occurrence of similar outbreaks in recent years.

We received reports from Belgium, Denmark, England and Wales, France, Germany, Ireland, Italy, the Netherlands, Portugal, Scotland, and Spain. Four representatives gave additional comments.

Belgium and the Netherlands have two surveillance systems: mandatory notification by physicians and a laboratory reporting system. In Belgium, cases of Q fever are included in notifications of rickettsiosis. England and Wales, Scotland, and Spain collect data on Q fever only through laboratory reports of Coxiella burnetii infections. Germany has a specific mandatory notification system for Q fever. Italy and Portugal have a mandatory notification system for all rickettsial infections including Q fever (in Italy thyphus exanthematicus and in Portugal Boutonneuse fever are notified separately). Ireland, Denmark, and France have no reporting scheme for Q fever. In Denmark, however, requests for serological tests are collated at a national laboratory and in France they are centralised at a national reference centre for rickettsiosis.

Only a few cases of Q fever occurred each year in Belgium, Denmark, Ireland, the Netherlands, Portugal, and Scotland, and no outbreaks similar to those described in this issue were identified in recent years. In England and Wales, four outbreaks were reported (June to August 1981, 29 cases in Gwent (1); April to June 1983, 25 cases in Oxfordshire (2); Spring 1989, 147 cases in the West Midlands (3); March 1992, 4 cases (4)). In Spain, between 1990 to 1996, ten outbreaks were reported among which three were quite large (14, 11, and 48 cases). In Italy, an outbreak occurred in the Veneto region (summer and autumn 1993, 58 cases (5)). In Germany since 1990, 27 to 100 cases are reported each year and two outbreaks occurred in recent years (1992, 80 cases in Berlin; 1993, 121 cases in Hessen).

Some additional information was received about possible modes of transmission. Two Q fever outbreaks in England and Wales and one in Italy were investigated using case control studies (1,3,5). In Gwent, Wales, the likeliest explanation was that farm vehicles spread contaminated straw, manure, or dust, and residents of the affected area became infected by inhaling infected dust particles. In the West Midlands, the geographical distribution of cases in an urban area close to many farms where lambs and calves were being born suggested that infected aerosols from parturient sheep were spread by the wind. In the Veneto region, Italy, the case control study showed a significant association with exposure to flocks of sheep. Three flocks of sheep, which passed through the outbreak area between late May and early June in the annual transmigration, were shown to be infected. Birth products were not incriminated since this outbreak began months after the birthing season. Contamination of soil through infected urine and faeces and dry season may have played a role in airborne transmission. In Spain, cases in most outbreaks were suspected to have been infected by contact with contaminated livestock: in 1990, 14 cases were found among workers in a slaughterhouse, and in 1992, 48 cases were found in a military community that camped in a cowshed. In Germany, two outbreaks were investigated; in 1992 one occurred in a Berlin research facility where sheep were kept and the other in 1993 in a rural area in Hessen. In both outbreaks infected sheep were suspected to be the source of the outbreaks.


K de Schrijver (Gezondheidsinspectie, Antwerpen, Belgium): Four cases were identified by the laboratory system in 1995. The low level of reporting may be explained by the fact that symptoms of Q fever are quite non specific and clinicians rarely request serological tests for this illness.

R Pebody (writing for England and Wales, EPIET fellow currently based at the National Public Health Institute, Helsinki, Finland): Large outbreaks of Q fever have rarely been detected. The source of infection often remains speculative. Although both of the outbreaks detected in England and Wales were thought to be related to the inhalation of infected particles from nearby areas, the evidence was inconclusive. In the German outbreak reported here the combination of the descriptive epidemiology and a cohort study, positive coxiella serology in the sheep flock, and appropriate weather conditions provided strong evidence that the outbreak was related to airborne transmission of sheep birth products from a neighbouring farm. This article is an important addition to documenting the epidemiology of Coxiella burnetii infection. Coxiellosis is often asymptomatic in farm animals, but can cause considerable morbidity in humans. Control and eradication measures require a multidisciplinary approach from farmers, veterinarians, and public and environmental health workers (6).

M Esveld (Infectieziekten Bulletin, The Netherlands): In some human cases no relation with “classical” sources can be found and possible new sources must be sought. In a serological study of dogs and cats, 13.2% (91/688) of dogs and 10.4% (46/441) of cats were found to be positive for specific antibodies against C. burnetii (7). This implies that cats and dogs may be a source of infection. Special attention to hygiene during parturition may be needed.

G Salamina (Istituto Superiore di Sanità, Italy): In Italy the case definition for rickettsiosis used for surveillance purposes specifies both clinical symptoms and serological confirmation. Therefore, it would be possible, in theory, to identify cases of Q fever among notifications of rickettsiosis to the Ministry of Health. However to date this information has not been published.


1. Salmon MM, Howells B, Glencross EJG, Evans AD, Palmer SR. Q fever in an urban area. Lancet 1982; i: 1002-4.

2. Winner SJ, Eglin RP, Moore VIM, Mayon-White RT. An outbreak of Q fever affecting postal workers in Oxfordshire. J Infect 1997; 14:255-61.

3. Smith DL, Ayres JG, Blair I, Burg PS, Carpenter MJ, Caul EO, et al. A large Q fever outbreak in the West Midlands: clinical aspects. Resp Med 1993; 87: 509-16.

4. Q fever in the isle of Wight. Commun Dis Rep CDR Wky 1992; 2:65.

5. Manfredi Selvaggi T, Rezza G, Scagnelli M et al. Investigation of a Q fever outbreak in Northern Italy. European Journal of Epidemiology. 1996; 12:403-8.

6. Pebody RG, Wall PG, Ryan MJ, Fairley C. Epidemiological features of Coxiella burnetii infection in England and Wales: 1984 to 1994. Commun Dis Rep CDR Rev 1996; 6:R128-32.

7. Houwers DJ, Meer van der M, Dijk van AAHM. Prevalence and incidence of C. burnetii infections in dogs and cats in the Netherlands and the region Midden-Holland. Utrecht: Rijksuniversiteit Utrecht, Faculteit Diergeneeskunde, 1992.

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