Integrating interdisciplinary methodologies for One Health: goat farm re-implicated as the probable source of an urban Q fever outbreak, the Netherlands, 2009.
BACKGROUND
In spring 2008, a goat farm experiencing Q fever abortions ("Farm A") was identified as the probable source of a human Q fever outbreak in a Dutch town. In 2009, a larger outbreak with 347 cases occurred in the town, despite no clinical Q fever being reported from any local farm.


METHODS
Our study aimed to identify the source of the 2009 outbreak by applying a combination of interdisciplinary methods, using data from several sources and sectors, to investigate seventeen farms in the area: namely, descriptive epidemiology of notified cases; collation of veterinary data regarding the seventeen farms; spatial attack rate and relative risk analyses; and GIS mapping of farms and smooth incidence of cases. We conducted further spatio-temporal analyses that integrated temporal data regarding date of onset with spatial data from an atmospheric dispersion model with the most highly suspected source at the centre.


RESULTS
Our analyses indicated that Farm A was again the most likely source of infection, with persons living within 1 km of the farm at a 46 times larger risk of being a case compared to those living within 5-10 km. The spatio-temporal analyses demonstrated that about 60 - 65 % of the cases could be explained by aerosol transmission from Farm A assuming emission from week 9; these explained cases lived significantly closer to the farm than the unexplained cases (p = 0.004). A visit to Farm A revealed that there had been no particular changes in management during the spring/summer of 2009, nor any animal health problems around the time of parturition or at any other time during the year.


CONCLUSIONS
We conclude that the probable source of the 2009 outbreak was the same farm implicated in 2008, despite animal health indicators being absent. Veterinary and public health professionals should consider farms with past as well as current history of Q fever as potential sources of human outbreaks.
Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), PO Box 1, , 3720 BA, Bilthoven, The Netherlands. gladbury@gmail.com.|European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control, Tomtebodavägen 11a, 171 83, Stockholm, Sweden. gladbury@gmail.com.
Georgia A F
GA
Ladbury
Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), PO Box 1, , 3720 BA, Bilthoven, The Netherlands. jeroen.van.leuken@rivm.nl.|Institute for Risk Assessment Sciences (IRAS), Utrecht University, Domplein 29, 3512 JE, Utrecht, The Netherlands. jeroen.van.leuken@rivm.nl.
Jeroen P G
JP
Van Leuken
Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), PO Box 1, , 3720 BA, Bilthoven, The Netherlands. arno.swart@rivm.nl.
Arno
A
Swart
Department of Small Ruminant Health, Animal Health Service (GD), Arnsbergstraat 7, 7418 EZ, Deventer, The Netherlands. p.vellema@tiscali.nl.
Piet
P
Vellema
Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), PO Box 1, , 3720 BA, Bilthoven, The Netherlands. barbara.schimmer@rivm.nl.
Barbara
B
Schimmer
Municipal Health Service Brabant-Zuidoost, Clausplein 10, 5611 XP, Eindhoven, The Netherlands. r.terschegget@ggdbzo.nl.
Ronald
R
Ter Schegget
Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), PO Box 1, , 3720 BA, Bilthoven, The Netherlands. wim.van.der.hoek@rivm.nl.
Wim
W
Van der Hoek
D000034:Abortion, Veterinary / Q000453:epidemiology* / Q000382:microbiology; D000383:Agriculture; D000822:Animal Husbandry; D000818:Animals; D002947:Cities; D016997:Coxiella burnetii; D004196:Disease Outbreaks; D005260:Female; D015511:Goat Diseases / Q000453:epidemiology* / Q000382:microbiology; D006041:Goats / Q000382:microbiology; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D011247:Pregnancy; D011634:Public Health; D011778:Q Fever / Q000453:epidemiology / Q000662:veterinary*; D062211:Spatio-Temporal Analysis