title: The Epidemiology and Characteristics of Q fever and Co-infections with Scrub Typhus, Murine Typhus or Leptospirosis in Taiwan: A Nationwide Database Study.
abstract: Q fever (QF) is a worldwide zoonosis associated with outbreaks. Only a few nationwide studies regarding the surveillance and epidemiology of human QF have been reported. Although QF is endemic in Taiwan, a nationwide database investigation of the epidemiology and characteristics of QF and its associations with scrub typhus (ST), murine typhus (MT) and leptospirosis (LS) has never been reported. We analysed nationwide databases of suspected QF, ST, MT and LS cases from October 2007 to December 2014 obtained from the Centers for Disease Control, Taiwan. A total of 468 (4.2%) QF cases were identified among 11 109 suspected QF cases. QF cases were mainly distributed in the southern and Kaohsiung-Pingtung regions but rarely in the eastern region. Compared to non-QF cases, QF cases had significantly higher percentages of males (88.7 versus 66.2%) and high-risk occupations (farming, animal husbandry or veterinary medicine) (16.2 versus 10.5%). But the percentages of specific animal contact, including cattle (0.6 versus 0.8%) and goats (0.9 versus 1.0%), were low in both. The majority of suspected QF cases (89.4%) were simultaneously suspected with ST, MT or LS, and the combinations of suspected diseases differed between regions. The number of suspected QF cases from the eastern region decreased since 2009, which was not observed in other regions. A total of 1420 (12.8%) cases had confirmed diseases, including QF (453, 4.1%), QF+ST (7, 0.06%), QF+MT (4, 0.04%), QF+LS (4, 0.04%), MT (186, 1.7%), ST (545, 4.9%), ST+LS (11, 0.1%) and LS (210, 1.9%). Compared to cases of unknown disease, QF cases had larger percentages of high-risk occupations (16.2 versus 9.6%) but similar histories of animal contact (29.8 versus 25.1%). QF is an endemic disease in southern Taiwan. It is difficult to differentiate QF from ST, MT or LS only by high-risk occupations and history of animal contact, and co-infection of QF with these diseases should be considered.
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine and Division of Infection Control Laboratory, E-Da Hospital and I-Shou University, Kaohsiung, Taiwan.
authors.forename: C-H
authors.initials: CH
authors.lastname: Lai
authors.affiliation: Infection Control Department, Pao-Chien Hospital, Pingtung, Taiwan.
authors.forename: W
authors.initials: W
authors.lastname: Sun
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.|College of Medicine, Chang Gung University, Kaohsiung, Taiwan.
authors.forename: C-H
authors.initials: CH
authors.lastname: Lee
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine and Department of Critical Care Medicine, E-Da Hospital, Kaohsiung, Taiwan.|School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.
authors.forename: J-N
authors.initials: JN
authors.lastname: Lin
authors.affiliation: Department of Veterinary Medicine, College of Veterinary Medicine, National Pingtung University of Science and Technology, Pingtung, Taiwan.
authors.forename: M-H
authors.initials: MH
authors.lastname: Liao
authors.affiliation: Department of Veterinary Medicine, College of Veterinary Medicine, National Pingtung University of Science and Technology, Pingtung, Taiwan.
authors.forename: S-S
authors.initials: SS
authors.lastname: Liu
authors.affiliation: Division of Infectious Diseases, Pingtung Christian Hospital, Pingtung, Taiwan.
authors.forename: T-Y
authors.initials: TY
authors.lastname: Chang
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
authors.forename: K-F
authors.initials: KF
authors.lastname: Tsai
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
authors.forename: Y-C
authors.initials: YC
authors.lastname: Chang
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine and Division of Infection Control Laboratory, E-Da Hospital and I-Shou University, Kaohsiung, Taiwan.
authors.forename: H-H
authors.initials: HH
authors.lastname: Lin
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.|School of Medicine, Graduate Institute of Medicine, Sepsis Research Center, Center for Dengue Fever Control and Research, Kaohsiung Medical University, Kaohsiung, Taiwan.|Department of Biological Science and Technology, College of Biological Science and Technology, National Chiao Tung University, HsinChu, Taiwan.
authors.forename: Y-H
authors.initials: YH
authors.lastname: Chen
mesh_terms: D000328:Adult; D000368:Aged; D000818:Animals; D060085:Coinfection / Q000453:epidemiology* / Q000382:microbiology; D016208:Databases, Factual; D005260:Female; D006801:Humans; D007922:Leptospirosis / Q000150:complications* / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D011778:Q Fever / Q000150:complications*; D012612:Scrub Typhus / Q000150:complications* / Q000453:epidemiology; D013624:Taiwan / Q000453:epidemiology*; D014437:Typhus, Endemic Flea-Borne / Q000150:complications* / Q000453:epidemiology; D015047:Zoonoses
keywords: Q fever; Taiwan; co-infection; leptospirosis; murine typhus; scrub typhus