Q Fever in Rural Australia: Education Versus Vaccination

Introduction

Q fever is an infectious disease caused by Coxiella burnetii. This zoonotic disease is acquired from wild and domestic animals with common reservoirs including sheep, cattle, and kangaroos (Gikas et al. 2010). Communities living and working in rural Australia, including the North Coast of New South Wales (NSW), are at an increased risk of exposure to this organism (Hutson et al. 2000). Transmission occurs in the vast majority of cases through inhalation of contaminated aerosols from infected animals. Asymptomatic infection is common, whereas acute Q fever presents usually as an acute febrile illness with pneumonitis and/or hepatitis (Parker et al. 2006). Although the clinical manifestations of Q fever are diverse, its diagnosis can be challenging due to a clinical overlap with other respiratory infections (Gikas et al. 2010).

Chronic Q fever can develop from ineffective treatment of an acute episode or after asymptomatic acute infection and usually presents as endocarditis (and less commonly as osteomyelitis, chronic hepatitis, or pneumonitis) (Parker et al. 2006, Gikas et al. 2010). Endocarditis may develop in 60–80% of patients with chronic Q fever and carries up to 5% mortality despite treatment (Eldin et al. 2017). Post-Q fever chronic fatigue syndrome can present after symptomatic acute infection, even if the infection resolves (Gikas et al. 2010). Chronic fatigue syndrome may result in patients being unable to perform independent activities of daily living and lead to absenteeism from work. This can have substantial economic impact, in terms of increased worker's compensation, medical costs, decreased quality of life, and permanent disability (Kermode et al. 2003).

The Australian government implemented the National Q fever Management Program in 2001–2002, which subsidized vaccination to high-risk occupational groups (abattoir workers, farmers and those in contact with livestock, etc); this was followed by decrease of the incidence of Q fever from 800 to 300 annual cases (Gidding et al. 2009), but this decline stopped since the program was terminated in 2006 (Palmer et al. 2007, Gidding et al. 2009).

Given the consequences of delayed diagnosis and the absence of a prevention policy, there is a reliance on front line healthcare workers to recognize, diagnose, and manage Q fever early, to minimize the risk of chronic disease. We surveyed physicians in rural communities at risk on their understanding of the disease. Our objective was to determine the current level of awareness and to identify knowledge gaps to inform targeted education policies.

Materials and Methods

We used a cross-sectional study design to evaluate the current knowledge base of clinicians on the epidemiology, presentation, and diagnosis of Q fever on the Northern New South Wales Local Health District. An electronic survey was developed on the SurveyMonkey™ platform. The questionnaire included closed-ended questions targeting clinicians understanding of Q fever epidemiology, presentation, diagnosis, and long-term complications.

Surveys were provided to the hospitals in the Northern New South Wales Local Health District through an online link, which was provided to local health district directors. The directors then disseminated the survey to their respective hospital house staff.

We adopted several techniques to maximize the response rates according to a modified Dillman survey design (Hoddinott and Bass 1986). The link to the online survey was sent in a cover letter outlining the purpose of the survey, followed by two additional correspondences at 1-month intervals. The results were analyzed using descriptive statistics.

Results

The survey was active from November 2014 to February 2015. During this time, 45 participants responded to the survey out of a target of 100. Among the 43 participants who completed the survey, 35 participants (78%) were hospital based and 10 (22%) from doctors working in the community. Results of the survey are displayed in Table 1.

Thirty-one (72%) clinicians answered bacteria as the cause of Q fever, 34 (79.1%) participants selected animals as the reservoir of Q fever infection, and 22 (51%) identified inhalation as the form of transmission (Table 1).

The majority (84%) identified livestock rearing occupations as a high-risk group, with 65–70% identifying stock yard and meat workers as groups also at risk. Furthermore, 23 (51%) of the participants considered those living in rural and remote communities as high risk.

Less than half (47%) of the participants were aware of the long-term complications associated with Q fever. Finally, 28 (63%) of respondents were aware of the existence of a vaccine.

Discussion

The results of this study demonstrate knowledge gaps in epidemiology, diagnosis, clinical course, and prevention of Q fever among clinicians practicing in an area prevalent of the disease. Almost one-third of responders incorrectly identified Q fever to be caused by organisms other than bacteria. Many participants did not consider animals as reservoir for disease, those living in rural and remote areas at high risk, and only half were aware that the infection is transmitted through inhalation.

To our best knowledge, there have been no studies evaluating physician knowledge in known high-risk regions for Q fever. In the United States, Q fever has been seen as an underestimated and under-reported disease (Dahlgren et al. 2015). There have been concerted efforts to encourage education of physicians to consider this treatable disease (Dahlgren et al. 2015). Similar to our article, these studies suggest that further education is required to be able to correctly diagnose the disease and appreciate outcomes of Q fever in high-risk regions.

Identifying patients at high risk is central to diagnosis (Gikas et al. 2010). Being unaware of these groups, in addition to the lack of understanding of the pathogenesis of Q fever, may result in missed opportunities of treating acute Q fever episodes, hence increasing the risk of chronic complications of Q fever; this may be preventable through improved clinician education (Parker et al. 2006). With the majority of patients diagnosed with Q fever being from rural and remote communities, having a high index of clinical suspicion to identify the diagnosis and treat early is of great importance. Given that the high costs may dissuade patients from receiving unsubsidized vaccination, educating clinicians in areas of high incidence and risk becomes increasingly important. The findings of this survey provide justification for an alternative strategy to vaccination, which may lie in educating and improving resources for doctors to become more equipped at recognizing and managing Q fever.

A notable limitation of this study is the low response rate that may be related to access to the online format, leading to self-reporting risk bias, lack of incentive to respond, and relevance to physicians' unique practice type.

Conclusion

Our results identified gaps in knowledge of clinicians in the epidemiology and diagnosis of acute Q fever infection. With the termination of sponsored vaccination programs, this study highlights the need for education programs that can increase Q fever awareness to effectively treat acute episodes and prevent long-term complications.