Transboundary and Emerging Diseases

ORIGINAL ARTICLE

Coxiella burnetii Infections in Small Ruminants and Humans

in Switzerland
€rk3
I. Magouras1, J. Hunninghaus1, S. Scherrer2, M. M. Wittenbrink2, A. Hamburger2, K. D. C. Sta
€ pbach-Regula
and G. Schu 1

1
Veterinary Public Health Institute, Vetsuisse Faculty, University of Bern, Bern, Switzerland
2
Institute of Veterinary Bacteriology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
3
Royal Veterinary College, London, UK

Keywords: Summary
Coxiella burnetii; sheep; goats; zoonosis;
seroprevalence; abortion The recent Q fever epidemic in the Netherlands raised concerns about the poten-
tial risk of outbreaks in other European countries. In Switzerland, the prevalence
Correspondence: of Q fever in animals and humans has not been studied in recent years. In this
I. Magouras. Veterinary Public Health study, we describe the current situation with respect to Coxiella (C.) burnetii
Institute, Vetsuisse Faculty, University of Bern,
infections in small ruminants and humans in Switzerland, as a basis for future
Schwarzenburgstrasse 155, 3097 Liebefeld,
epidemiological investigations and public health risk assessments. Specific objec-
Switzerland.
Tel.: +41 31 631 57 31;
tives of this cross-sectional study were to (i) estimate the seroprevalence of
Fax: +41 31 631 57 49; C. burnetii in sheep and goats, (ii) quantify the amount of bacteria shed during
E-mail: ioannis.magouras@vetsuisse.unibe.ch abortion and (iii) analyse temporal trends in human C. burnetii infections. The
seroprevalence of C. burnetii in small ruminants was determined by commercial
Received for publication October 31, 2014 ELISA from a representative sample of 100 sheep flocks and 72 goat herds. Herd-
level seroprevalence was 5.0% (95% CI: 1.6–11.3) for sheep and 11.1% (95% CI:
doi:10.1111/tbed.12362
4.9–20.7) for goats. Animal-level seroprevalence was 1.8% (95% CI: 0.8–3.4) for
sheep and 3.4% (95% CI: 1.7–6) for goats. The quantification of C. burnetii in 97
ovine and caprine abortion samples by real-time PCR indicated shedding of >104
bacteria/g in 13.4% of all samples tested. To our knowledge, this is the first study
reporting C. burnetii quantities in a large number of small ruminant abortion
samples. Annual human Q fever serology data were provided by five major Swiss
laboratories. Overall, seroprevalence in humans ranged between 1.7% and 3.5%
from 2007 to 2011, and no temporal trends were observed. Interestingly, the two
laboratories with significantly higher seroprevalences are located in the regions
with the largest goat populations as well as, for one laboratory, with the highest
livestock density in Switzerland. However, a direct link between animal and
human infection data could not be established in this study.

rates among endocarditis cases can range from 5% in trea-

Introduction
Q fever is a zoonotic disease with a worldwide distribution.
It is caused by the gram-negative, obligate intracellular bac-
terium Coxiella burnetii. Human infections are mostly
asymptomatic but can also manifest clinically as self-limit-
ing febrile illness, atypical pneumonia or hepatitis (Maurin
and Raoult, 1999). Approximately 5% of Q fever cases pro-
gress to a chronic infection, usually manifesting as endocar-
ditis (Arricau-Bouvery and Rodolakis, 2005). Mortality
ted to >60% in untreated cases (Kampschreur et al., 2013).
The animal reservoir for C. burnetii is diverse, but small
ruminants are the most common source of human infec-
tions (EFSA 2010; Georgiev et al., 2013). Infected animals
are often asymptomatic; however, C. burnetii can cause late
abortion and stillbirths, particularly in small ruminants
(Maurin and Raoult, 1999; Guatteo et al., 2011). Infected
ruminants shed the bacteria mainly with birth products,
but also in vaginal discharges, urine, milk and faeces

204 © 2015 Blackwell Verlag GmbH • Transboundary and Emerging Diseases. 64 (2017) 204–212
I. Magouras et al.
(Hatchette et al., 2001; Arricau Bouvery et al., 2003;
Rodolakis et al., 2007; Rousset et al., 2009). C. burnetii can
survive in the environment for up to 1 year (Kersh et al.,
2013), and human infections mainly result from inhalation
of infected aerosols or dust (Welsh et al., 1958; Tissot-
Dupont et al., 1999).
During the period from 2007 to 2011, the Netherlands
experienced a major epidemic of Q fever which resulted in
more than 4000 reported human cases (Van Loenhout
et al., 2012). The outbreak was linked epidemiologically to
intensive dairy goat production units which were in close
proximity to urban areas. Aborting goats played the great-
est role in contaminating the environment. The connection
between animal and human infections was demonstrated
through molecular epidemiology (Roest et al., 2011a; Til-
burg et al., 2012).
In Switzerland, an important outbreak of Q fever in
1983 with 415 acute human cases was linked to sheep
flocks descending from alpine pastures (Dupuis et al.,
1987). The last documented sero-epidemiological survey
in domestic animals in Switzerland (excluding goats) was
conducted almost 30 years ago when 3.9% of 2806 ran-
domly selected sheep tested positive using a complement
fixation test (Metzler et al., 1983). In a later study, PCR
examination of randomly selected 81 sheep and 39 goat
bulk milk samples resulted in negative findings, which
might be attributed to the low sensitivity of the PCR test
applied (Fretz et al., 2007). In Switzerland, farmers are
obliged to report all sheep and goat abortions to veteri-
narians. In case of animals originating from traders, ani-
mals in summer pastures or any farm with more than
one animal aborting within a 4-month period, abortion
samples have to be sent by veterinarians to diagnostic
laboratories for further examinations. Specifically, abor-
tion samples are then tested for Brucella (B.) melitensis,
C. burnetii and Chlamydia spp. From 2002 to 2011, a
total of 582 (annually: mean 58.2, median 63.5, range
31–78) Q fever-related abortions in ruminants were
reported to the Swiss Federal Food Safety and Veterinary
Office (FSVO) (‘Swiss Zoonoses Report 2011’, 2011), of
which 68 (12%) originated from goats and 34 (6%) from
sheep. Why these numbers are so low remains uncertain;
however, they may be due to underreporting. In animals
with clinical signs, abortions may not be recognized by
the farmers because the majority of sheep and goats in
Switzerland are managed extensively. Furthermore, many
infections in small ruminants are subclinical and go
unnoticed (Maurin and Raoult, 1999), and shedding may
occur in subclinically infected animals that deliver nor-
mally (Roest et al., 2012). Humans serve as sentinels for
Q fever in animals, and infection in animals is often
identified following spillover into the human population
(Cutler et al., 2007).
© 2015 Blackwell Verlag GmbH • Transboundary and Emerging Diseases. 64 (2017) 204–212
Coxiella burnetii Infections in Switzerland
Mandatory reporting of human Q fever cases in Switzer-
land was introduced in November 2012; thus, only limited
data on the epidemiology of human Q fever are available
prior to that date. In the years 2013 and 2014, the total
number of human Q fever cases reported to the Federal
Office of Public Health (FOPH) was 26 and 38, respec-
tively. Furthermore, the last large-scale, countrywide Q
fever seroprevalence study among blood donors in Switzer-
land was conducted in 1986, revealing notable regional dif-
ferences with big cities having lower seroprevalences (9.5–
12.2%) than mountainous regions (23.6–31.7%) (Dupuis
et al., 1986).
In Europe, sheep and goats represent a significant risk
for human Q fever as they have been implicated in the vast
majority of reported human Q fever outbreaks (EFSA 2010;
Georgiev et al., 2013). The overall aim of this study was to
gather current information about Q fever in small rumi-
nants and humans in Switzerland, upon which future epi-
demiological investigations and public health risk
assessments may be based. Specific objectives of this study
were to (i) estimate the seroprevalence of C. burnetii in
sheep and goats, (ii) quantify the amount of bacteria shed
by aborting small ruminants and (iii) analyse temporal
trends of human C. burnetii infections in serum samples
submitted to diagnostic laboratories.
Materials and Methods
Small ruminant serum samples
According to the Swiss Federal Statistical Office (FSO) data
for the year 2011, there were 424 018 sheep in 9428 flocks
(mean flock size 45 sheep) and 86 215 goats (including
dwarf goats) in 6612 herds (mean herd size 13 goats) in
Switzerland. Blood samples from sheep and goats were col-
lected as part of the 2011 nationwide, mandatory cross-sec-
tional survey of the FSVO to document freedom from
B. melitensis infection. A representative stratified (by can-
ton), randomized sample pool was provided, with 10 998
samples from 681 sheep flocks and 5030 samples from 526
goat herds. Blood samples were collected between January
and May 2011 from animals >12 months of age. Following
centrifugation, sera were stored at 20°C until further
analysis. For the purpose of this study, only sheep flocks
with at least 10 animals were included as larger flocks are
considered to pose a greater risk for humans due to a
higher infection pressure (Schimmer et al., 2011). Because
of the small size of goat herds in Switzerland (50% of all
goat herds included in this survey had <10 animals each,
and 14% of all herds had less than five animals), only herds
with >3 goats were included in the study. A sample size to
estimate the herd-level seroprevalence with a precision of
2% in both species, with an expected herd prevalence of
5% and a confidence level of 95%, was calculated using
205
Coxiella burnetii Infections in Switzerland
WinEpiscope 2.0 (Thrusfield et al., 2001). This resulted in
a target sample size of 100 sheep flocks and 100 goat herds.
From the pool of available sera, 500 individual sheep sera
from 100 flocks and 321 individual goat sera from 72 herds
were randomly selected. Five serum samples were randomly
selected from each sheep flock and between two and five
serum samples (depending on herd size) from each goat
flock.
Abortion samples
To encourage farmers to submit abortion materials (foetus-
es and foetal membranes) for the study, an announcement
was placed in a popular goat and sheep producer journal
(April 2011 edition). In addition, 400 sheep and goat own-
ers were mailed packages containing information about the
study, directions to collect and submit abortion samples
and sample collection materials. As an incentive, participat-
ing farmers were offered a complete bacteriological exami-
nation of submitted samples for abortion-causing
pathogens. In addition, four veterinary laboratories in Swit-
zerland were also asked to submit the abortion samples
they had directly received from veterinarians. During the
period from December 2010 to February 2012, a total of 97
abortion samples, including 54 sheep samples (from 42
flocks) and 43 goat samples (from 33 herds), were submit-
ted for examination. Most abortion samples were provided
by the veterinary laboratories from the cantons of
Graub€ unden (n = 64), Schwyz (n = 14), St. Gallen
(n = 13) and Vaud (n = 1). Only 5 abortion samples were
received directly from animal owners. All abortion samples
were sent to the Institute of Veterinary Bacteriology in Zur-
ich and were kept at 20°C until further analysis.
Serological testing of small ruminants
Sera were tested in duplicates for antibodies to C. burnetii-
inactivated phase I and II antigens with a sensitivity
and specificity of 100%, using a commercial ELISA test
(CHEKITâ Q fever Antibody ELISA Test Kit, IDEXX, Lieb-
efeld, Switzerland), according to the manufacturer’s
instructions. Results were expressed as a percentage of the
optical density (% OD) reading of the test sample calculated
as % OD = 100 * (S N)/(P N), where S, N and P are the
OD values of the sample (S) and OD of negative (N) and
positive (P) controls, respectively. The OD was measured
with an ELISA reader Magellan V 6.6. Samples with % OD
> 40% were considered positive and samples with % OD
<30% negative, respectively. Samples within the interval of
30% <% OD <40% were inconclusive (intermediate), and
for estimating seroprevalence, these were considered to be
negative. A flock or herd was considered seropositive when
at least one animal had a positive test result.
206 © 2015 Blackwell Verlag GmbH • Transboundary and Emerging Diseases. 64 (2017) 204–212
I. Magouras et al.
DNA Extraction and real-time PCR of abortion samples
DNA was extracted from tissues using the DNeasy Blood
and Tissue Kit (Qiagen, Hombrechtikon, Switzerland)
according to the manufacturer’s instructions. Placental
samples (30 mg) were randomly cut out and incubated in
buffer ATL and proteinase K at 56°C until completely lysed.
Remaining contaminants and enzyme inhibitors were
removed in two wash steps, and DNA was eluted using
40 ll Qiagen AE buffer. The DNA concentration was mea-
sured using a NanoDrop 2000c Spectrophotometer
(Thermo Scientific, Wilmington, DE, USA), diluted to a
concentration of 10 ng/ll and stored at 20°C.
PCR analysis was performed using the commercial
TaqVetTM Coxiella burnetii real-time PCR kit (LSI; Labo-
ratoire Service International, Lissieu, France), according
to the manufacturer’s instructions. The test targets the
IS1111a element of C. burnetii. DNase- and RNase-free
water was used as a negative control for every 10 sam-
ples tested. A positive control containing 105 C. burnetii/
ml was delivered with the kit and was used as a quanti-
fication standard. A quantity of 2 ll of DNA extract,
corresponding to 20 ng genomic DNA, was added to
8 ll of master mix. The real-time PCR was performed
on Applied Biosystems 7500 Fast Real-Time PCR System
(ABI7500) using the following cycling program: 50°C for
2 min and enzyme activation at 95°C for 10 min, fol-
lowed by 45 cycles of 95°C for 15 s and 60°C for
1 min.
Fluorescence data were acquired during the annealing
and extension phase. C. burnetii IS1111a was measured
using the FAM detection channel on the ABI7500. All
samples presenting a typical amplification curve with a
threshold cycle (Ct) value <40 were considered positive.
As an endogenous control, samples were also tested with a
specific primer set for the goat housekeeping gene glycer-
aldehyde 3-phosphate dehydrogenase (GAPDH), and data
were obtained using the VIC detection channel on the
ABI7500. Samples having a Ct value >40 for the endoge-
nous control of GAPDH were diluted 1 : 4 and 1 : 10 to
reduce the concentration of potential inhibitors of the
reaction, retested and reanalysed. The absolute quantifica-
tion was based on the calculation of the ratio of expression
of C. burnetii IS1111a relative to the reference gene GAD-
PH. This ratio was compared to the quantified stan-
dard (delivered with the TaqVetTM C. burnetii real-time
PCR kit) reflecting the concentration of bacteria. How-
ever, as the number of IS1111a copies expressed varies
between strains (Klee et al., 2006), the obtained quantifi-
cation resulted in an approximate value of the C. burnetii
concentration. Results were interpreted as negative
(N = no bacteria), low positive (LP = 1–102 bacteria/g),
positive (P = 102–104 bacteria/g) and high positive
I. Magouras et al.
Fig. 1. Location and C. burnetii serology results of tested sheep flocks in Switzerland. The size of the triangular symbols is relative to the number of
positive sheep per flock. Grey shadows depict the density of sheep and goat population.
(HP = >104 bacteria/g) according to the manufacturer’s
instructions.
Human serology data
Human serology data were provided by five major Swiss
university or hospital laboratories (encoded as A-E) (Table
2) for the period 2007–2011. All laboratory submissions
with a request for a Q fever serological diagnostic test were
included in the study. All laboratories used immunofluo-
rescent antibody analysis (IFA), for example the laboratory
A which contributed most samples uses a Q fever IFA test
from Focus Diagnostics, Cypress, CA, USA. To avoid dupli-
cates, laboratories were asked to submit records with a
unique patient identifier; however, to ensure confidentiality
and protect the privacy of patients, all identifying informa-
tion was excluded for the records. Only the first registered
diagnosis was counted for each patient; follow-up examina-
tions were excluded. Diagnostic test results were provided
either already interpreted or as raw test results. For the lat-
ter, exact guidelines for the interpretation of the test result
as well as ongoing support were provided by qualified staff
from the corresponding laboratories.
© 2015 Blackwell Verlag GmbH • Transboundary and Emerging Diseases. 64 (2017) 204–212
Coxiella burnetii Infections in Switzerland
Statistical analysis
Descriptive statistics and other tests of statistical inference
were performed using the software NCSS 2007 (Kaysville, UT,
USA). Herd prevalence estimates are presented with accom-
panying exact 95% confidence intervals (95% CI). Differ-
ences in human seroprevalences between different years and
laboratories were tested with the Fisher’s exact test (FET).
Maps were created using ARCGIS9, ARCMAP Version 9.2 by
ESRI Inc. (Redlands, CA, USA). Quantitative interpretation
of the PCR results was performed with the Excel Quantisoft
File provided by Laboratoire Service International (LSI).
Human laboratory data were provided in Microsoft Excel
(Microsoft Corp, Redmond, WA, USA) files.
Results
Sheep and goat seroprevalence
The 172 small ruminant herds included in the study were
geographically distributed throughout Switzerland (Figs 1
and 2). The size of selected sheep flocks ranged from 10 to
810 animals. The median number of sheep per flock was 36
(mean 65). For goats, the herd sizes ranged from three to
207
Coxiella burnetii Infections in Switzerland
Fig. 2. Location and C. burnetii serology results of tested goat herds in Switzerland. The size of the triangular symbols is relative to the number of
positive goats per herd. Grey shadows depict the density of sheep and goat population.
110, and the median number of goats per herd was 9.5
(mean 19). At herd level, seroprevalence was 5% (5/100)
for sheep (95% CI: 1.6–11.3) and 11.1% (8/72) for goats
(95% CI: 4.9–20.7).
The animal-level seroprevalence was 1.8% (9/500) for
sheep (95% CI: 0.8–3.4) and 3.4% (11/321) for goats (95%
CI: 1.7–6).
The number of seropositive animals detected per sheep
flock was one in two flocks, two in two flocks and three in
one flock. Six goat herds had one seropositive animal each,
whereas one goat herd had two and another three seroposi-
tive animals. The size of seropositive sheep flocks ranged
from 12 to 43 (median 16, mean 24.6) and in seropositive
goat herds from 5 to 21 (median 11, mean 11.5) animals,
respectively. The OD of positive samples ranged from
51.1% to 91.5% for sheep (median 63.4%, mean 67.2%)
and from 50.6% to 144.6% for goats (median 76.7%, mean
82.4%).
Eight of nine seropositive sheep were detected in four
flocks from the north-eastern part of Switzerland, whereas
one seropositive animal was detected in the south-east of
the country (Fig. 1). Two inconclusive test results origi-
nated from a sheep flock located in the canton of Valais in
208
I. Magouras et al.
the south-west and one from the north-east of the country
(Fig. 1). The majority of seropositive goat herds (n = 6)
were identified in the north-eastern part of Switzerland as
well (Fig. 2). In addition, one herd with three seropositive
goats was detected in the canton of Ticino in the south and
one seropositive goat in the canton of Vaud, in the western
part of Switzerland. Four goats with inconclusive results,
each from a different herd, were detected in the north-east
of Switzerland and one additional goat in the canton of
Valais (Fig. 2).
Real-time PCR results of abortion samples
Of 97 abortion samples tested, 44.4% (24/54) of ovine and
44.2% (19/43) of caprine samples were found positive by
real-time PCR, respectively (Table 1). Positive sheep sam-
ples originated from 23 flocks and positive goat samples
from 18 herds. Quantities of C. burnetii in abortion mate-
rial were high with >104 bacteria/g detected in 13.4% (13/
97) of tested samples, of which 11.1% (6/54) originated
from sheep and 16.3% (7/43) from goats. In 16.5% (16/97)
of all abortion samples for both species, the amount of
bacteria ranged from 102 to 104 bacteria/g, whereas <102
© 2015 Blackwell Verlag GmbH • Transboundary and Emerging Diseases. 64 (2017) 204–212
I. Magouras et al. Coxiella burnetii Infections in Switzerland

Table 1. Real-time PCR results of 97 tested abortion samples from Compared to some European countries, the animal-level
sheep and goat, submitted by regional diagnostic laboratories and by seroprevalence of C. burnetii in small ruminants (1.8% of
farmers
sheep and 3.4% of goats) in this study appears to be rather
Sheep Goats Total low.
Animal-level seroprevalences in sheep were 10.4% in
Bact/ga n % n % n %
northern Greece, 11.8% in Spain and 12.3% in Northern
>10 4
6 11.1 7 16.3 13 13.4 Ireland, respectively (Pape et al., 2009; Ruiz-Fons et al.,
100–10 000 8 14.8 8 18.6 16 16.5 2010; McCaughey et al., 2010; Ryan et al., 2011). The ani-
1–100 10 18.5 4 9.3 14 14.4 mal-level seroprevalence of goats in northern Greece was
0 30 55.6 24 55.8 54 55.7 6.5%, in Spain 8.7% and 9.3% in Northern Ireland (Pape
Total 54 100 43 100 97 100
et al., 2009; McCaughey et al., 2010; Ruiz-Fons et al.,
C. burnetii bacteria per gram tissue.
a 2010). In Ireland, seroprevalence in sheep was comparable
to the Swiss situation with 0.7% of animals and 8.4% of
flocks having tested seropositive (Ryan et al., 2011). In the
bacteria/g were detected in 14.4% (14/97) of all samples. Netherlands, 2.4% of the sheep and 7.8% of the goats were
Among positive samples, the proportion of samples with found seropositive in 2008 (Van den Brom et al., 2013).
>104 bacteria/g was 25% (6/24) for sheep and 36.9% (7/19) Herd-level seroprevalence in Switzerland (5.0% in sheep
for goat samples. and 11.1% in goats) was also relatively low. In the Nether-
lands, 14.5% of the sheep flocks and 17.9% of the goat
herds were tested positive in 2008 (Van den Brom et al.,
Human serology results
2013). Herd-level seroprevalence in sheep was 74% in Spain
Human serology results for the years 2007–2011 are pre- and 62.1% in Northern Ireland, respectively (McCaughey
sented in Table 2. The largest two laboratories (A and B) et al., 2010; Ruiz-Fons et al., 2010; Ryan et al., 2011). In
contributed 47.3% and 29.0% of all samples, respectively. goats, herd-level prevalence was reported to be 45% in
The overall annual seroprevalence ranged from 1.7% (95% Spain and 42.9% in Northern Ireland (McCaughey et al.,
CI 1.0–2.7) to 3.5% (95% CI 2.5–4.7), and no trend 2010; Ruiz-Fons et al., 2010). Lower prevalences have been
was observed over the years. Laboratories B and C reported detected in Ireland, where only 0.3% of goats and 1.5% of
a significantly lower seroprevalences (P < 0.001) than goat herds were found positive in 2011 (Ryan et al., 2011).
laboratories A and D. Over the 5-year period, the overall se- Interestingly, no seropositive sheep and goats were detected
roprevalence was 4.0% (95% CI 3.3–4.9), 0.7% (95% CI in a recent serosurvey in Norway (Kampen et al., 2012). It
0.4–1.3), 0.6% (95% CI 0.2–1.5) and 5.7% (95% CI 3.8– is unclear why the seroprevalence for Switzerland as
7.9), for laboratories A, B, C and D, respectively. reported in this study was so low compared to other Euro-
pean studies. Direct comparisons between these studies
should be performed with caution as there are differences
Discussion and Conclusion
in the study populations, time of the study, sampling strat-
The current study provides recent, baseline epidemiological egies and laboratory methods used.
data on C. burnetii infections of small ruminants and Seroprevalence demonstrates previous exposure of ani-
humans in Switzerland. This is the first study that broadly mals to C. burnetii and does not necessarily indicate cur-
covers the country. rent shedding and consequently current risk of

Table 2. Positive human Q fever serology results diagnosed from 2007 to 2011 in five major Swiss laboratories

2007 2008 2009 2010 2011

Laboratory n + % n + % n + % n + % n + %

A 457 25 5.5 633 34 5.4 518 13 2.5 470 12 2.5 333 14 4.2
B 248 2 0.8 276 0 0 312 1 0.3 278 1 0.4 364 7 1.9
C 186 1 0.5 148 1 0.7 107 1 0.9 118 1 0.8 130 0 0
D 101 5 5 124 6 4.8 102 3 2.9 100 5 5 92 10 10.9
Ea – – – – – – – – – – – – 15 1 6.7
Total 992 33 3.3 1181 41 3.5 1039 18 1.7 966 19 2 919 31 3.4

n = number of samples from Q fever suspects; (+) = number of positive samples.

a
Data were available only for 2011, not included in total numbers.

© 2015 Blackwell Verlag GmbH • Transboundary and Emerging Diseases. 64 (2017) 204–212 209
Coxiella burnetii Infections in Switzerland
transmission. Several studies suggest that a significant pro-
portion of animals that shed C. burnetii can be seronegative
(Berri et al., 2001; Arricau Bouvery et al., 2003; Rousset
et al., 2009; Bellini et al., 2014). Furthermore, it has been
shown that the proportion of animals shedding C. burnetii
is independent of abortion history and half of the shedders
might represent clinically inapparent infections (Rousset
et al., 2009). Thus, C. burnetii serology alone might not
provide the most complete picture of the infection status
within the animal population as seronegative shedders will
be missed.
Outbreaks of Q fever in humans are commonly linked to
abortion episodes affecting small ruminants (Van den
Brom and Vellema, 2009; Roest et al., 2011b). Information
on shedding is indispensable when quantitative data are
required to assess the magnitude of environmental contam-
ination and consequently the risk of C. burnetii transmis-
sion to other animals and humans. However, there is
limited information in the literature on the amount of
C. burnetii shed with aborted material. One, older study
reported that >109 bacteria per gram of placenta may be
shed during an abortion (Babudieri, 1959). In the current
study, we quantified the amount of C. burnetii DNA in
aborted material using real-time PCR. The majority of the
samples tested originated from the eastern part of Switzer-
land. It is unclear why there was such a strong over-repre-
sentation of the canton of Graub€ unden (>50% of all
samples). It could be speculated that there might be a close
network between farmers and veterinary services in that
region.
Altogether, 44.5% of ovine abortion samples and 44.3%
of caprine abortion samples were found positive for C. bur-
netii DNA. Shedding was >104 bacteria/g in about 1 of 3 of
all positive samples which signifies the public health risk
posed by aborted material. It has been suggested that only
samples containing >104 bacteria/g are indicative of abor-
tion caused by C. burnetii (Rodolakis, 2006).
Lower quantities detected in our samples could have
resulted from contamination of initially negative aborted
material with C. burnetii DNA from the environment.
Alternatively, some initially strong-positive samples might
have been invariably long exposed to environmental condi-
tions; thus, amounts of C. burnetii at the time of submis-
sion to the laboratory might be lower in these. Finally,
variations in the quantities of C. burnetii could also result
from a non-homogenous distribution of bacteria in the tis-
sues, with placental trophoblasts being the main site of
multiplication (Sanchez et al., 2006).
Human serology data were collected to address the
lack of information about C. burnetti exposure and Q
fever in humans. These samples were not representative
of the human population in Switzerland. However, they
can provide some information about temporal changes in
210 © 2015 Blackwell Verlag GmbH • Transboundary and Emerging Diseases. 64 (2017) 204–212
I. Magouras et al.
human Q fever infections. Laboratories A and D had sig-
nificantly higher seroprevalences than laboratories B and
C. Interestingly, laboratory A received samples from the
region with the highest livestock density in all Switzer-
land, and laboratories A and D are both located in the
regions with the largest number of goats in Switzerland.
However, a direct link between human and animal sam-
ples could not be made in this study. Furthermore, it
was not possible to analyse human sample data from the
north-eastern part of Switzerland, where the majority of
seropositive small ruminants were detected. The raw data
format from this area differed significantly from that of
the other laboratories, making interpretation and com-
parison with the other laboratories difficult. Regional
variations in human C. burnetii seroprevalences in Swit-
zerland have been reported in the past (Dupuis et al.,
1986). The latter study reported generally much higher
seropositivity values. This was surprising, as the study
population in the latter survey included healthy blood
donors, compared to diagnostic submissions only in our
study. One possible hypothesis for these differences is
that in 1983 and earlier, the percentage of the human
population that was in contact with livestock was higher
compared to nowadays. However, it also cannot be
excluded that these differences are mainly due to
differences in the diagnostic tests used.
In our study, the percentage of positive serological diag-
noses per year for all laboratories ranged from 1.7% for the
year 2009 to 3.5% in 2008. In a similar Austrian study
involving nine participating laboratories, 3.1% (166/5361)
of samples tested positive for antibodies to C. burnetii
(Allerberger et al., 2010). Austria and Switzerland are
neighbouring alpine countries that share common hus-
bandry practices for small ruminants. In the Netherlands,
goat production is more intensive with up to 1000 animals
per farm, and their number in the country has more than
doubled between the years 2000 and 2009 (Roest et al.,
2011b). Based on these differences, it is unlikely for Swit-
zerland to experience a Q fever outbreak of the magnitude
observed in the Netherlands. However, despite the low
prevalence in animals found in our study, the large quanti-
ties of bacteria shed with abortions highlight the potential
zoonotic threat of C. burnetii for humans living in the
vicinity of small ruminant farms. This became evident by
the recent Q fever outbreak in the canton of Vaud, where
most human cases where directly linked to a specific sheep
farm (Bellini et al., 2014). As the majority of human
C. burnetii infections cause no or unspecific symptoms,
outbreaks like this likely represent the tip of the iceberg.
Raising disease awareness among physicians and veterinari-
ans, as well as improving detection and reporting of abor-
tions by farmers, would be important steps in reducing the
Q fever risk and disease burden in the human population.
I. Magouras et al.
Acknowledgements
We acknowledge all participating veterinary laboratories
for providing blood samples and abortion material, partic-
ularly the Amt f€
ur Lebensmittelsicherheit und Tiergesund-
heit (canton of Graub€ unden), for contributing the vast
majority of abortion samples. We are highly grateful to:
Franziska Suter-Riniker (Institut f€
ur Infektionskrankheiten,
University of Bern), Thomas Klimkait (DBM-Petersplatz,
Institut f€
ur Medizinische Mikrobiologie, University of
Basel), Gladys Martinetti-Lucchini (Servizio di Microbiolo-
gia, Bellinzona), Olivier Peter (L’Institut central de
l’H^
opital du Valais, Sion) and Martin Risch (Zentrallabor,
Kantonsspital Graub€ unden, Chur), for providing human
serology data. We would like to thank Marion Fasel from
the Health Service for Small Ruminants (BGK, Herzogen-
buchsee) and all farmers for their support in the collection
of abortion material. The GIS maps were created by
Michael Binggeli from the FSVO.
Financial Support
This study was funded by the FSVO. The authors declare
that they have no competing interests.
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