Vaccine Preventable Diseases in Australia, 2005 to 2007

3.12 Q fever

Page last updated: 24 December 2010

Q fever is a zoonotic disease caused by Coxiella burnetii. It has been identified in a wide range of wild and domestic animal hosts, including arthropods, birds, rodents, marsupials and livestock, but the most important reservoirs as sources for human infections are cattle, sheep and goats. C. burnetii can withstand harsh environmental conditions including desiccation, and are shed in the urine, faeces, milk and particularly birth products of infected animals. Humans become infected primarily by inhaling aerosols contaminated by C. burnetii. Occupations with higher exposure risks include abattoir and farm workers and veterinarians. Windborne spread and indirect exposures in a contaminated environment account for non-occupational infections.1,2

Q fever may present with acute or chronic clinical manifestions, and there is increasing acceptance of an association with long-term sequelae, in particular the post Q fever fatigue syndrome.1,3,4 A high proportion of infected persons are asymptomatic or only experience a self-limiting febrile illness. Although Q fever infections generally respond to antibiotic treatment, they may result in significant morbidity, including pneumonitis, hepatitis, myocarditis, chronic endocarditis, and occasional fatality. Recrudescence may occur, especially in pregnant or immunocompromised persons.1,2

A whole-cell formalin-inactivated vaccine against Q fever, the Q-VAXTM developed in Australia, has been available since 1989. In the early 1990s, 90%–95% of the vaccine produced was purchased by abattoirs, but the usage was low before the manufacturer began to actively promote the vaccine in 1994.5 A National Q Fever Management Program, which was funded by the Australian Government, was implemented from 2001 in Queensland, South Australia, Victoria and Western Australia, and from 2002 in the Australian Capital Territory, New South Wales and Tasmania. (The Northern Territory opted out of the program as, until 2002, there had been no cases of Q fever recorded since 1991.6) The program consisted of systematic delivery of a subsidised Q fever vaccination service to targeted populations with a high risk of environmental exposure who did not show evidence of pre-existing immunity to Q fever (identified by clinical and laboratory screening tests). The program was delivered in two phases. Phase 1 targeted abattoir workers, workers in the meat and livestock industry, and sheep shearers. Phase 2 of the program expanded to include sheep, dairy and beef cattle farmers, their employees, and family members working on farms. The national program was concluded at different times between June 2004 and December 2006 in different jurisdictions.7

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Case definitions

Notifications

See Appendix 6.6 for pre-2004 definition

National definition from January 2004:8

Only confirmed cases are notifiable. Confirmed cases require either laboratory definitive evidence, or laboratory suggestive evidence together with clinical evidence.

  1. Laboratory definitive evidence
    • Detection of Coxiella burnetii by nucleic acid testing; or
    • Seroconversion or significant increase in antibody level to Phase II antigens in paired sera tested in parallel in absence of recent Q fever vaccination; or
    • Detection of C. burnetii by culture.
  2. Laboratory suggestive evidence
    • Detection of specific IgM in the absence of recent Q fever vaccination.
  3. Clinical evidence
    • A clinically compatible disease.

Hospitalisations and deaths

The ICD-10-AM/ICD-10 code A78 was used to identify hospitalisations and deaths.

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Secular trends

From January 2006 to December 2007, there were 852 cases of Q fever notified to the NNDSS (average annual rate 2.04 per 100,000). There were 360 hospitalisations coded with a diagnosis of Q fever (average annual rate 0.88 per 100,000) from July 2005 to June 2007. The progressive decline in the overall notification and hospitalisation rates observed in the 3 years following a peak in 20029 did not continue over the 2 years under review (Figure 3.12.1). The notification rates were 1.72 (95% CI 1.55–1.91), 1.97 (95% CI 1.78–2.17) and 2.12 (95% CI 1.93–2.32) per 100,000 in 2005, 2006 and 2007, respectively (see also Appendix 6.2). The hospitalisation rates were 0.77, 0.85 and 0.90 per 100,000 in 2004/2005, 2005/2006 and 2006/2007, respectively (see also Appendix 6.3). Over the 2-year review period, the median number of notifications per month was 35 (range 22–49), and the median number of hospitalisations per month was 15 (range 9–25). The total number of Q fever notifications and hospitalisations over the most recent 4 years for which data are available are shown by month of the year in Figure 3.12.2. There were considerable month-to-month variations in the number of notifications and hospitalisations with no consistent seasonal pattern.

Figure 3.12.1: Q fever notifications and hospitalisations, Australia, 1993 to 2007,* by month of diagnosis or admission

Figure 3.12.1:  Q fever notifications and hospitalisations, Australia, 1993 to 2007, by month of diagnosis or admission

* Notifications where the date of diagnosis was between January 1993 and December 2007; hospitalisations where the date of admission was between July 1993 and June 2007.

Figure 3.12.2: Q fever notifications and hospitalisations, Australia, for the most recent 4 years,* by month of the year

Figure 3.12.2:  Q fever notifications and hospitalisations, Australia, for the most recent 4 years, by month of the year

* Notifications where the date of diagnosis was between January 2004 and December 2007; hospitalisations where the date of admission was between July 2003 and June 2007.

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Severe morbidity and mortality

In the period July 2005 to June 2007, hospital separations for Q fever accounted for a total of 2,262 hospital bed days (1,065 in 2005/2006 and 1,197 in 2006/2007) with an annual average of 1,131 bed days per year; this was less than for the period July 2002 to June 2005 (1,269 bed days per year).9 The median length of stay was 4 days. There were no recorded hospitalisations among children aged <5 years and only 7 hospitalisations (5 with Q fever as the principal diagnosis) among children aged 5–14 years during this period. However, the median length of stay of this latter age group was longest (median 7 days, range 2–14 days), irrespective of whether Q fever was the principal diagnosis (Table 3.12.1). Overall, Q fever was the principal diagnosis for 80% (288/360) of all hospitalisations with any separation diagnosis of Q fever. This proportion does not differ significantly across different age groups.

Table 3.12.1: Q fever notifications, hospitalisations and deaths, Australia, 2005 to 2007,* by age group

Age group
(years)
Notifications
2 years
(2006–2007)
Hospitalisations
2 years
(July 2005–June 2007)
LOS per admission
(days)
Deaths
2 years
(2005–2006)
n Rate n (§) Rate (§) Median (§) n Rate
0–4
4
0.15
0
(0)
(–)
(–)
0
5–14
29
0.53
7
(5)
0.13
(0.09)
7.0
(7.0)
0
15–24
94
1.62
28
(23)
0.49
(0.40)
3.5
(3.0)
0
25–59
587
2.89
246
(204)
1.23
(1.02)
4.0
(4.0)
0
60+
138
1.84
79
(56)
1.09
(0.77)
6.0
(5.0)
0
All ages
852
2.04
360
(288)
0.88
(0.70)
4.0
(4.0)
0

* Notifications where the date of diagnosis was between January 2006 and December 2007; hospitalisations where the date of separation was between July 2005 and June 2007; deaths where the death was recorded between January 2005 and December 2006.

† LOS = length of stay in hospital.

‡ Average annual age-specific rate per 100,000 population.

§ Principal diagnosis (hospitalisations).

There were no deaths with an underlying cause coded as Q fever recorded in 2005–2006 in the AIHW National Mortality Database. There was 1 death, a female aged >75 years, among the notified cases reported to NNDSS in 2007, but, consistent with the mortality database, none in 2005 or 2006.

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Age and sex distribution

During the years 2006 and 2007, the highest average annual notification rates were seen in adult males aged 40–64 years (4.8 per 100,000), followed by males aged 15–39 years (3.3 per 100,000); this higher rate in males aged 40–64 years compared with other age/gender groups has been observed since 2000 (Figure 3.12.3). Notification rates were considerably lower in females aged 40–64 years and people aged ≥65 years (1.5 and 1.4 per 100,000, respectively) and even lower in females aged 15–39 years and children aged <15 years (1.0 and 0.4 per 100,000, respectively).

Figure 3.12.3: Q fever notification rates, Australia, 1993 to 2007,* by age group, sex and year of diagnosis

Figure 3.12.3:  Q fever notification rates, Australia, 1993 to 2007, by age group, sex and year of diagnosis

* Notifications where the date of diagnosis was between January 1993 and December 2007.

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In the 10 years prior to 2008, annual Q fever notification rates peaked in 2002 in all age groups except those aged ≥65 years (which peaked in 2001), and declined progressively until 2005 inclusive. Excluding children aged <15 years, in whom there were only a small number of cases, the percentage decreases across different age/gender groups were quite similar, and ranged from 51% to 67% when the rate in 2005 was compared with 2002. A modest increase in notification rates was observed in 2006–2007 compared with 2005 for all age/gender groups, but the increases were not statistically significant (Figure 3.12.3). A greater proportional increase was observed in those aged ≥65 years and females aged 15–39 years compared with other adults.

For Q fever hospitalisation rates in 2005/2006–2006/2007, the differentials among various age/gender groups were similar to those for notification rates, with the highest rates seen in adult males aged 40–64 years (2.2 per 100,000), followed by males aged 15–39 years (1.2 per 100,000) (Figure 3.12.4).

Figure 3.12.4: Q fever hospitalisation rates, Australia, 1993/1994 to 2006/2007,* by age group, sex and year of separation

Figure 3.12.4:  Q fever hospitalisation rates, Australia, 1993/1994 to 2006/2007, by age group, sex and year of separation

* Hospitalisations where the date of separation was between July 1993 and June 2007.

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There has been a progressive increase in the median age of Q fever notifications from 1993 to 2007 for male cases (Figure 3.12.5). The increase in the median age from 30 years in 1993 to 44 years in 2007 is substantially greater than that seen in the general Australian male population, which increased from 32.4 years in 2003 to 36.9 years in 2007.10 For notified female cases, the median age increased from 36 years to a peak of 46 years in 2004 and decreased to 41 years in 2007, while the median age of the general female population increased from 33.3 years in 1993 to 37.1 years in 2004 and 37.6 years in 2007. The median age in females tended to be higher than males prior to 1999, but has become similar to that of males since then. A similar progressive increase in the median age of Q fever hospitalisations from 1998/1999 to 2006/2007 was also observed.

Figure 3.12.5: Median age of Q fever notifications and hospitalisations, Australia, 1993 to 2007,* by sex and year of diagnosis or separation

Figure 3.12.5:  Median age of Q fever notifications and hospitalisations, Australia, 1993 to 2007, by sex and year of diagnosis or separation

* Notifications where the date of diagnosis was between January 1993 and December 2007; hospitalisations where the date of separation was between July 1998 and June 2007; hospitalisation data for each of the financial years are plotted according to the year in which the financial year began.

There was a clear male predominance for both notification and hospitalisation rates over the 2-year review period, with the male:female ratios being 2.9:1 and 3.6:1, respectively. This was consistent with previous observations since the 1990s, although the male:female ratio for notification rates was lower than that observed in the previous reporting period of 2003–2005 (3.3:1).9

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Geographical distribution

Over the respective 2-year review periods, notification and hospitalisation rates were highest in Queensland, as in previous years. This was followed by New South Wales, when jurisdictions with <5 notifications or hospitalisations were excluded (Appendix 6.2 and Appendix 6.3). Together, these two states contributed 85% (724/852) of the notifications and 81% (293/360) of the hospitalisations for Q fever during the respective 2-year review periods. Excluding the jurisdictions with <5 notifications or hospitalisations, the proportion of hospitalisations relative to notifications was lower in the two states that reported higher overall rates (Queensland, New South Wales) than in the two states that reported lower overall rates (South Australia, Victoria).

In Queensland and New South Wales, notification rates declined to a trough in 2005 (Figure 3.12.6). While the rates in Queensland remained relatively stable in 2006 and 2007, the notification rates were higher in New South Wales in 2006 and 2007 (2.6 per 100,000 [95% CI 2.2–3.0] and 3.0 per 100,000 [95% CI 2.6–3.5], respectively) compared with 2005 (2.1 per 100,000 [95% CI 1.8–2.5]). For most other jurisdictions, the notification rates remained relatively stable for these 2 reporting years, and there were no significant trends over the 6-year period 2002–2007. The exception was the Northern Territory where Q fever notification rates progressively increased from 2002 to 2006, but decreased in 2007; however, these rates were derived from a very small number of cases and a small population denominator.

Figure 3.12.6: Average annual Q fever notification and hospitalisation rates in selected jurisdictions, Australia, 2002 to 2007,* by year of diagnosis or separation

Figure 3.12.6:  Average annual Q fever notification and hospitalisation rates in selected jurisdictions, Australia, 2002 to 2007, by year of diagnosis or separation

* Notifications where the date of diagnosis was between January 2002 and December 2007; hospitalisations where the date of separation was between July 2002 and June 2007.

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In the two states with more substantial numbers of hospitalisations (Queensland and New South Wales), the magnitude of relative change over time in hospitalisation rates was less than notification rates from 2002 to 2007. In Queensland, hospitalisation rates rose in 2005/2006 and 2006/2007 after a significant decrease in 2004/2005 compared with the preceding 2 years, although rates still remained lower (with marginal statistical significance) compared with 2002/2003. In New South Wales the hospitalisation rates in these 2 recent years remained significantly lower compared with 2003/2004 (Figure 3.12.6).

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Vaccination status

Of the 852 notifications of Q fever reported to NNDSS in 2006–2007, 11 (1.3%) were reported to have been vaccinated, but only 3 had their vaccination status validated. The vaccination status was unknown or missing in 302 cases (35.4% of total). These vaccination status proportions were very similar for the cases among males aged 20–69 years (1.2% vaccinated, 36.7% unknown or missing).

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Comment

The incidence of Q fever notifications in Australia remains relatively high compared with other countries that report Q fever, which are predominantly in Europe.2 In Europe, Q fever is notified often in the context of outbreaks,11–13 although outbreaks may be prolonged and become entrenched in certain regions of a country,12 as exemplified by an ongoing outbreak in The Netherlands.14,15 In Europe in the 3 years from 2005 to 2007, notification rates were <0.5 per 100,000 in countries with higher incidence (France, Germany, the UK, Spain, Bulgaria, Greece, Cyprus),16–18 except for countries where significant outbreaks occurred (rate 1.03 per 100,000 in The Netherlands and 4.6 per 100,000 in Slovenia in 2007).18 For all countries, the reported rates of Q fever are likely to be an underestimate of the true disease incidence, as a high proportion of those infected are either asymptomatic or would have mild and non-specific clinical manifestations.2

One earlier French study reported significant seasonal prevalence in May, June and July (spring and early summer) over the years 1982–1990,19 supposedly attributed to the ‘outside’ lambing season with heavy environmental contamination with the causal bacteria.2 However, the peak season of reported Q fever in Europe varied from June–July to September–October in the 3 years from 2005 to 2007.16–18 In contrast, the Australian data do not suggest any apparent seasonality in Q fever notifications in earlier reports5 or in recent years (Figure 3.12.1 and Figure 3.12.2). This may reflect, at least in part, differences in the epidemiology in Australia, including the relative contribution of sporadic cases and of various transmission routes and environment of the reported cases.

The decline in rates of Q fever in Australia from 2002 to 2005 is likely to reflect the substantial impact of the National Q Fever Management Program (NQFMP), especially among younger adult males, consistent with the demographic profile of abattoir workers.7 However, the progressive decrease in the overall notification rates (and, to a lesser extent, the hospitalisation rates) in the 3 years following 2002 did not continue in the 2-year period under review (2006–2007 for notifications, 2005/2006–2006/2007 for hospitalisations). This trend needs to be monitored closely, while recognising that the number of cases was relatively small in some age groups, and that there are inherent limitations and variations in diagnosis and reporting of Q fever. There may also be differences in trend between different jurisdictions or regions.

The levelling, or possibly reversal, of the decreasing trend in the 2 years under review coincided with the cessation of the NQFMP. Since the conclusion of the NQFMP, anecdotal reports suggest that most well-established abattoirs have maintained access to Q fever vaccination for their new staff. However, occupational exposure still continued to contribute to a considerable proportion of cases during and after the cessation of the NQFMP,20–24 due to limitations of the program in reaching the more dispersed at-risk populations with potential exposure to Q fever in the farming environment. The vaccine manufacturer announced in late 2005 the cessation of production of the Q fever vaccine25,26 until further production could commence in a new vaccine manufacturing facility with the support of the Australian Government.27 This might possibly have impacted on the supply and general availability of the vaccine some time after 2006, and contributed to some occupationally acquired cases who would otherwise have been vaccinated. However, data on the occurrence or extent of any shortage are not available. Building work of a new facility for manufacturing the Q fever vaccine commenced in May 2007, and the facility was scheduled to be operational in 2009.28

The more rapid increase in the median age of Q fever notifications from a lower age to a higher age compared with the increase in median age of the general male population, and the diminishing gender difference in the median age of notifications in more recent years, suggest a progressively lower relative incidence in younger males, the dominant age/gender of workers in high-risk occupations. This may also suggest that exposure in environments other than the traditional high-risk occupational environment or non-occupational exposure may become more important both in absolute and relative terms. A recent analysis of New South Wales notifications showed a significant decline in the proportion of notifications in the ‘Abattoir/Meat worker’ occupational group and an increase in the ‘Farmer/Livestock’ occupational group in 2005–2007 compared with previous periods.24 In addition, as would be expected, the proportion of cases that reported community exposure rather than occupational exposure was increasing following the implementation of the NQFMP20 in which the main targets for vaccination were people with high occupational exposure risks. The extent of the absolute increase in disease rates in those with non-occupational (community) exposures is unknown. Control of non-occupational exposure to Q fever is more challenging, and the benefits of using the Q fever vaccine in those environments would be more equivocal. The existing Q fever vaccine formulation has been shown to be efficacious and effective from several published studies conducted in high-risk settings. However, there is a lack of information on its effectiveness in other settings.29

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Males aged 15–64 years continued to have the highest rates of Q fever notification and hospitalisation, which reflects the demographic profile of the workforce in the at-risk occupations. However, it should be noted that the percentage decrease in notification rates across different age/gender groups, excluding children aged <15 years in whom there were only a small number of cases, were quite similar when the rate in 2005 was compared with 2002. In addition, greater proportional increases in notification rates in 2006–2007, compared with 2005, were observed in those aged ≥65 years and females aged 15–39 years compared with other adults. This suggests that factors other than Q fever vaccination, such as local drought conditions, movements of livestock and livestock slaughter rates, and other environmental factors, might also contribute to the variation in the observed rates. This poses further challenges to the control of Q fever.

The majority of notified Q fever cases in 2006–2007 were unvaccinated. However, it is not possible to ascertain the proportion who would have been considered to be at high risk of exposure and thus should have been recommended vaccination. A similar proportion of cases among males aged 20–69 years were unvaccinated. This suggests that either a significant proportion of those at high occupational risk remained unvaccinated, or that the great majority of notified cases in males aged 20–69 years were acquired through occupational settings with lower risk, where the risks were less well recognised, or through community non-occupational exposure.

Since the early 1990s, southeast Queensland and northeast New South Wales have been the areas that report the highest Q fever incidence in Australia.5 The current data continue to reflect this geographic distribution of the disease. Q fever appears to be emerging in the Northern Territory in the past few years. The first notified case of Q fever in the Northern Territory (at least since availability of electronic records in 1991) occurred in March 2002.30 Noting that only a small number of notified cases occurred within a comparatively small population, the Q fever notification rate in the Northern Territory increased from 2002 to 2006 and exceeded that of several other jurisdictions of lower incidence (Figure 3.12.6). Occupational exposures were not identified in these cases, and clustering of cases was not observed.6 The rate increase was considered likely to represent a true increase, although increased testing and improved diagnosis might have contributed.31 Q fever notification rates decreased in 2007 in the Northern Territory; this might have resulted from changes in natural environmental factors that affected disease transmission, but further careful monitoring is warranted.

As the symptomatology of Q fever tends to be non-specific, and diagnostic practices may vary among patients of different gender and various geographic, occupational and age groups, notification data are likely to be underestimating the true burden of Q fever. Hospitalisation data are only a measure of more severe cases. Notification data in the NNDSS core dataset currently do not contain information on the occupation, probable route of exposure, or immune status of the notified cases. The vaccination status was unknown or missing in more than one-third of all notified cases in 2006–2007, a period after the conclusion of the NQFMP when reporting of vaccination status would be expected to have improved. Information on likely exposure of some notified cases is available, with varying degrees of detail, only from some jurisdictional reports based on enhanced surveillance data.20–24,32–34 More complete national surveillance data on exposure factors, occupations and immune/vaccination status of cases are highly desirable to facilitate better understanding of the epidemiology and control of Q fever in Australia.

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References

1. Parker NR, Barralet JH, Bell AM. Q fever. Lancet 2006;367(9511):679–688.

2. Maurin M, Raoult D. Q fever. Clin Microbiol Rev 1999;12(3–4):518–553.

3. Marmion BP, Shannon M, Maddocks I, Storm P, Penttila I. Protracted debility and fatigue after acute Q fever. Lancet 1996;347(9006):977–978.

4. Ayres JG, Flint N, Smith EG, Tunnicliffe WS, Fletcher TJ, Hammond K, et al. Post-infection fatigue syndrome following Q fever. QJM 1998;91(2):105–123.

5. Garner MG, Longbottom HM, Cannon RM, Plant AJ. A review of Q fever in Australia 1991–1994. Aust N Z J Public Health 1997;21(7):722–730.

6. Ralph A, Markey P, Schultz R. Q fever cases in the Northern Territory of Australia from 1991 to 2006. Commun Dis Intell 2007;31(2):222–227.

7. Gidding HF, Wallace C, Lawrence GL, McIntyre PB. Australia’s national Q fever vaccination program. Vaccine 2009;27(14):2037–2041.

8. Communicable Diseases Network Australia. Surveillance case definitions for the Australian National Notifiable Diseases Surveillance System. 2004. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/cdna-casedefinitions.htm Accessed on 24 August 2009.

9. Brotherton J, Wang H, Schaffer A, Quinn H, Menzies R, Hull B, et al. Vaccine Preventable Diseases and Vaccination Coverage in Australia, 2003 to 2005. Commun Dis Intell 2007;31(Suppl):S1–S152.

10. Australian Bureau of Statistics. Australian historical population statistics, 2008. ABS Cat. No. 3105.0.65.001. Canberra: Australian Bureau of Statistics, 2008. Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3105.0.65.0012008?OpenDocument Accessed on 8 June 2010.

11. Editorial committee. Q fever in Europe. Euro Surveill 1997;2(2):pii=138. Available from: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=138 Accessed on 8 June 2010.

12. Coulombier D. Query fever: an opportunity to understand the disease better [editorial]. Euro Surveill 2010;15(12):pii=19526. Available from: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19526 Accessed on 8 June 2010.

13. Grilc E, Socan M, Koren N, Ucakar V, Avsic T, Pogacnik M, et al. Outbreak of Q fever among a group of high school students in Slovenia, March–April 2007. Euro Surveill 2007;12(29):pii=3237. Available from: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=3237 Accessed on 8 June 2010.

14. Schimmer B, Dijkstra F, Vellema P, Schneeberger PM, Hackert V, ter Schegget R, et al. Sustained intensive transmission of Q fever in the south of the Netherlands, 2009. Euro Surveill 2009;14(19):pii=19210. Available from: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19210 Accessed on 8 June 2010.

15. van der Hoek W, Dijkstra F, Schimmer B, Schneeberger PM, Vellema P, Wijkmans C, et al. Q fever in the Netherlands: an update on the epidemiology and control measures. Euro Surveill 2010;15(12):pii=19520. Available from: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19520 Accessed on 8 June 2010.

16. European Centre for Disease Prevention and Control. Annual epidemiological report on communicable diseases in Europe. Report on the status of communicable diseases in the EU and EEA/EFTA countries. Stockholm: European Centre for Disease Prevention and Control, 2007. Available from: http://www.ecdc.europa.eu/en/publications/Publications/0706_SUR_Annual_Epidemiological_Report_2007.pdf Accessed on 8 June 2010.

17. European Centre for Disease Prevention and Control. Annual epidemiological report on communicable diseases in Europe 2008. Report on the state of communicable diseases in the EU and EEA/EFTA countries. Stockholm: European Centre for Disease Prevention and Control, 2008. Available from: http://www.ecdc.europa.eu/en/publications/Publications/0812_SUR_Annual_Epidemiological_Report_2008.pdf Accessed on 8 June 2010.

18. European Centre for Disease Prevention and Control. Annual epidemiological report on communicable diseases in Europe 2009 (revised edition). Stockholm: European Centre for Disease Prevention and Control, 2010. Available from: http://www.ecdc.europa.eu/en/publications/Publications/0910_SUR_Annual_Epidemiological_Report_on_Communicable_Diseases_in_Europe.pdf Accessed on 8 June 2010.

19. Tissot Dupont H, Raoult D, Brouqui P, Janbon F, Peyramond D, Weiller PJ, et al. Epidemiologic features and clinical presentation of acute Q fever in hospitalized patients: 323 French cases. Am J Med 1992;93(4):427–434.

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20. Palmer C, McCall B, Jarvinen K, Krause M, Heel K. “The dust hasn’t settled yet”: the National Q fever Management Program, missed opportunities for vaccination and community exposures. Aust N Z J Public Health 2007;31(4):330–332.

21. Fielding J. Surveillance report. Zoonoses. Q fever. Victorian Infectious Diseases Bulletin 2006;9(4):104.

22. Fielding J. Surveillance report. Zoonoses. Q fever. Victorian Infectious Diseases Bulletin 2007;10(2):48.

23. Fielding J. Surveillance report. Zoonoses. Q fever. Victorian Infectious Diseases Bulletin 2007;10(4):107.

24. Massey PD, Irwin M, Durrheim DN. Enhanced Q fever risk exposure surveillance may permit better informed vaccination policy. Commun Dis Intell 2009;33(1):41–45.

25. Australian Meat Industry Council. Q update – shortage of Q vaccine. National News April 2006: p. 3. Available from: http://www.amic.org.au/SiteMedia/w3svc116/Uploads/Documents/e8629a1e-6a83-42ab-8347-fbdab0baeca0.pdf Accessed on 2 June 2009.

26. Marmion B. Q fever: the long journey to control by vaccination. Med J Aust 2007;186(4):164–166.

27. Abbott T, McGauran P. Joint media release: Government acts to maintain Q fever vaccine supplies (ABB045/06). 2006. Available from: http://www.health.gov.au/internet/ministers/publishing.nsf/Content/BAF3870FCFD0010ECA25714F000BB0C0/$File/abb045.pdf Accessed on 2 June 2009.

28. CSL Limited annual report 2006–2007. CSL Biotherapies report. Available from: http://annualreport.csl.com.au/AR07/AR07_YR_BR_CSL_Biotherapies_Report.asp Accessed on 8 June 2010.

29. Chiu CK, Durrheim DN. A review of the efficacy of human Q fever vaccine registered in Australia. N S W Public Health Bull 2007;18(7–8):133–136.

30. Markey P, Fisher D. First notified case of Q fever in the NT. The Northern Territory Disease Control Bulletin 2002;9(1):10–11.

31. Centre for Disease Control Northern Territory. Comments on NT disease notification graphs (ratio of the number of notifications in 2006 to the mean of the previous 4 years: selected diseases). The Northern Territory Disease Control Bulletin 2007;14(1):36.

32. SA Health. Communicable Disease Control Branch report, 1st January 2006 to 30th June 2006. Zoonoses. Q fever. Public Health Bulletin South Australia 2006;Edition 5:40.

33. SA Health. Communicable Disease Control Branch report, 1 July to 31 December 2006. Zoonoses. Q fever. Public Health Bulletin South Australia 2007;4(1):31.

34. SA Health. Communicable Disease Control Branch surveillance report, 1 January to 31 December 2007. Zoonoses. Q fever. Public Health Bulletin South Australia 2008;5(1):46.

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