PREVALENCIA DE ERRORES DE MEDICACIÓN EN POBLACIÓN

G.Morroy W.van der Hoek Z.D.Nanver P.M.Schneeberger C.P.Bleeker-Rovers J.van der Velden R.A.Cou nho

Epidemiology and Infec on, 2015, 1-10. DOI:10.1017/S0950268815002472.

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SUMMARY

From 2007 through 2010, the Netherlands experienced a major Q-fever outbreak with more than 4000 no fi ca ons. Previous studies suggested that Q-fever pa ents could suff er long-term post infec on health impairments, especially fa gue. Our objec ve was to assess the Coxiella burne i an body prevalence and health status including fa gue, and assess their interrela onship, in Herpen a high incidence village, seven years a er the outbreak began.

In 2014, we invited all 2161 adult inhabitants for a ques onnaire and a C. burne i Indirect Fluorescence An body Assay (IFA). The health status was measured with the Nijmegen Clinical Screening Instrument (NCSI), consis ng of eight sub-domains includ- ing fa gue.

Of the 70.1% (1517/2161) par cipants, 33.8% (513/1517) were IFA posi ve. Of 147 par cipants who were IFA posi ve in 2007, 25 (17%) seroreverted and were now IFA nega ve. Not a posi ve IFA status, but an age <50 years, smoking and co-morbidity, were independent risk factors for fa gue. No fi ed par cipants reported signifi cantly more o en fa gue (31/49, 63%) than not no fi ed IFA posi ve par cipants (150/451, 33%). Although fa gue is a common sequel a er acute Q-fever, we found -in this community-based survey- no diff erence in fa gue levels between par cipants with and without C. burne i an bodies.

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INTRODUCTION

Q-fever is a zoonosis caused by the bacterium Coxiella burne i (C. burne i). In 2007, Herpen, a small village in the south of the Netherlands was heavily aff ected by a Q-fever outbreak [1]. This outbreak was followed by larger outbreaks in 2008 and 2009, in a larger geographical area and culminated in 4107 no fi ca ons na onwide by 2010 [2].

A common sequel of acute Q-fever is protracted incapacita ng fa gue [3-5], o en de- noted as the Q-fever Fa gue Syndrome (QFS) that may con nue ten years or longer[6,7]. Pa ents with QFS may experience severe swea ng, breathlessness, blurred vision, reduced exer on, myalgia, arthralgia, sleeping disorders and mood swings [7, 8], symptoms that re- semble the Chronic Fa gue Syndrome (CFS). The ae ology of QFS is not en rely understood. Dysregula on of cytokines due to persis ng an gens of C. burne i are described to cause chronic s mula on of the immune system [9, 10]. A Post Infec on Fa gue Syndrome (PIFS) [11] may also occur a er other infec ons [12], such as Borrelia burgdorferi [13], Legionella

pneumophila [14], Epstein Barr and Ross River virus infec on [12]. According to several studies,

Q-fever pa ents have an impaired health status, pulmonary disorders and an increased risk of problems in general and social func oning [3-8, 12, 14].

General prac oners (GPs) and the popula on in the Q-fever aff ected area, and the na- onal Q-fever pa ent organisa on, speculated that the number of infec ons and long-term consequences such as fa gue were underes mated. The local municipal health service (MHS) therefore ini ated the ‘Q-Herpen-II’ study in - this small rural village with a stable Caucasian popula on – in order to inves gate the presence of an bodies against C. burne i in rela on to the health status with an emphasis on fa gue.

METHODS

Study design and study popula on

The Municipal Health Service (MHS) “GGD Hart voor Brabant” executed this study as part of the larger ‘Q-Herpen-II’ study. The Medical Ethics Review Commi ee of the Utrecht University Medical Centre, approved the study (protocol 13-367/D Q-Herpen II). For this cross-sec onal popula on study all adult inhabitants (≥18 years of age) of the village Herpen (postal code 5373) were invited to par cipate. The municipal administra on provided demographic data for the 2161 inhabitants. In January 2014, all were sent a le er by mail containing informa on on the study with a par cipa on request, a ques onnaire and an informed consent form. The ques onnaire included ques ons on demographics, smoking, the par cipant’s knowledge or percep on of their Q-fever status, risk factors associated with chronic Q-fever, Q-fever vaccina on status, chronic medical condi ons and medica on use.

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The current health status was assessed with the Nijmegen Clinical Screening Instrument (NCSI), which is a validated method originally developed to measure the health status of COPD pa ents in a clinical se ng [15]. The instrument consists of the main domains: Symp- toms, Func onal Impairment, and Quality of Life. These are divided into eight sub-domains (table 1). Pa ents’ scores are subdivided in “normal”, “mild problems” and “clinically relevant problems”. The only excep on is the sub-domain General Quality of Life that is divided in “normal” and “clinically relevant problems”/“severe problems”. In the univariate and mul-

variate analysis, the NCSI categories mild problems and clinically relevant problems were Table 1. Domains and sub-domains of the Nijmegen Clinical Screening Instrument (NCSI) with their

defi ni on, the instruments on which they are based and number of ques on used.

Domains Sub-domain Defi ni on Instruments

Number of ques ons Symptoms Subjec ve Pulmonary Symptoms Overall burden of pulmonary symptoms PARS-D1 Global Dyspnoea Ac vity, Global Dyspnoea Burden

2

Dyspnoea Emo ons

Level of frustra on and anxiety experienced when dyspnoeic

DEQ2 _{Frustra on,}

Anxiety

6

Fa gue Level of experienced

fa gue CIS3 Subjec ve Fa gue 8 Func onal Impairment Behavioural Impairment

The extent of inability to perform specifi c and concrete ac vi es as a result of the disease

SIP4 Home Management, Ambula on 22 Subjec ve Impairment Experienced degree of impairment in general and in social func oning

QoLRiQ5 General Ac vi es 4 Quality of Life

General (GQOL) Mood and the sa sfac on

with life as a whole

BDI6

Primary Care Sa sfac on With Life Scale

12

Health Related (HRQOL)

Sa sfac on related to physiological func oning and the future

Sa sfac on Physiological Func oning, Sa sfac on Future

2

Sa sfac on Rela ons

Sa sfac on with the (absent) rela onships with spouse and others

Sa sfac on Spouse, Sa sfac on Social

2

PARS-D1

physical ac vity ra ng scale-dyspnoea, DEQ2

dyspnoea emo ons ques onnaire, CIS3

checklist

individual strength, SIP4

sickness impact profi le, QoL-RiQ5

quality of life for respiratory illness ques on-

naire, BDI 6

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