Mapping underestimation in Q Fever: Insights from a major cross-border outbreak in the Meuse-Rhine Euroregion

This thesis is the result of a unique in-depth investigation of a cross-border outbreak of Q fever in South Limburg and the Meuse-Rhine Euroregion. The outbreak’s source, a single large dairy-goat farm, was known to the regional public health authorities from the outset due to a newly introduced veterinary notification mandate, facilitating the mapping of the outbreak’s geographical size and scope in unprecedented detail. The number of individuals and the area affected were much larger than expected based on the relatively limited number of notified human Q fever cases. Missed infections were particularly prevalent in more remote areas and in cross-border areas, probably due to often mild disease manifestation, lack of awareness and low risk perception. Thousands of individuals thus unknowingly incurred Q fever, running a risk of a missed diagnosis of Q fever fatigue syndrome or life-threatening chronic Q fever. The thesis shows that the regional impact of Q fever in terms of human morbidity was severely underestimated. Findings must help public health professionals to adequately inform the public of Q fever risks during outbreaks, so that members of exposed populations can take well-informed decisions regarding their own health and well-being.