Q fever
Encyclopedia
Q fever is a disease caused by infection with Coxiella burnetii
, a bacterium that affects humans and other animals. This organism is uncommon but may be found in cattle, sheep, goat
s and other domestic mammals, including cat
s and dog
s. The infection results from inhalation
of a spore-like small cell variant, and from contact with the milk, urine, feces, vaginal mucus, or semen of infected animals. Rarely, the disease is tick borne. The incubation period
is 9–40 days. A human being can be infected by a single bacterium. The bacterium is an obligate intracellular
pathogen.
It was first described by Edward Holbrook Derrick
in abattoir
workers in Brisbane
, Queensland
, Australia
. The "Q" stands for "query" and was applied at a time when the causative agent was unknown; it was chosen over suggestions of "abattoir fever" and "Queensland rickettsial fever", to avoid directing negative connotations at either the cattle industry or the state of Queensland.
The pathogen
of Q fever was discovered in 1937, when Frank Macfarlane Burnet
and Mavis Freeman
isolated the bacterium from one of Derrick’s patients. It was originally identified as a species of Rickettsia
. H.R. Cox and Gordon Davis isolated it from tick
s in Montana
, USA in 1938. It is a zoonotic disease whose most common animal reservoirs are cattle, sheep and goats. Coxiella burnetii is no longer regarded as closely related to Rickettsiae but as similar to Legionella
and Francisella
and is a proteobacterium
.
, malaise
, profuse perspiration, severe headache
, myalgia
(muscle pain), joint pain, loss of appetite, upper respiratory problems, dry cough, pleuritic pain, chills, confusion and gastro-intestinal symptoms such as nausea
, vomiting and diarrhea
. The fever lasts approximately 7 to 14 days.
Approximately half of infected individuals exhibit no symptoms.
During the course, the disease can progress to an atypical pneumonia
, which can result in a life threatening acute respiratory distress syndrome
(ARDS), whereby such symptoms usually occur during the first 4 to 5 days of infection.
Less often the Q fever causes (granulomatous) hepatitis
which may be asymptomatic or becomes symptomatic with malaise, fever, liver enlargement (hepatomegaly) and pain in the right upper quadrant of the abdomen
. Whereas transaminase values
are often elevated, jaundice
is uncommon. Retinal vasculitis is a rare manifestation of Q fever.
The chronic form of Q fever is virtually identical to inflammation
of the inner lining of the heart (endocarditis
), which can occur months or decades following the infection. It is usually fatal if untreated. However, with appropriate treatment the mortality falls to around 10%.
, but also abortion and infertility. Severe systemic signs such as anorexia
and fever may occur concurrently.
The pathogenic agent is to be found everywhere except New Zealand
. The bacterium is extremely sustainable and virulent: a single organism is able to cause an infection. The common way of infection is inhalation of contaminated dust, contact with contaminated milk
, meat, wool and particularly birthing products. Ticks can transfer the pathogenic agent to other animals. Transfer between humans seems extremely rare and has so far been described in very few cases.
Some studies have shown more men to be affected than women, which may be attributed to different employment rates in typical professions.
"At risk" occupations include, but are not limited to:
(looking for an antibody
response) rather than looking for the organism itself. Serology allows to detect chronic infection as high antibody levels are found against the virulent form of the bacterium. Molecular detection of bacterial DNA is increasingly used. Culture is technically difficult and not routinely available in most microbiology laboratories.
Q fever can cause endocarditis
(infection of the heart valves) which may require transoesophageal echocardiography to diagnose. Q fever hepatitis manifests as an elevation of ALT
and AST
, but a definitive diagnosis is only possible on liver biopsy
which shows the characteristic fibrin ring granuloma
s.
s is very effective and should take place in consultation with an infectious disease
s specialist. Commonly used are doxycycline
, tetracycline, chloramphenicol
, ciprofloxacin
, ofloxacin
, and hydroxychloroquine
. The chronic form is more difficult to treat and can require up to four years of treatment with doxycycline and quinolone
s or doxycycline with hydroxychloroquine.
Q fever in pregnancy is especially difficult to treat because doxycycline and ciprofloxacin are contraindicated in pregnancy. The preferred treatment is five weeks of co-trimoxazole
.
In 2001, Australia
introduced a national Q fever vaccination program for people working in "at risk" occupations.
The Soviet Union had earlier developed a killed vaccine but its side effects prevented its licensing abroad.
Vaccination of animals is not a current method of control.
The United States investigated Q fever as a potential biological warfare
agent in the 1950s with eventual standardization as agent OU. At Fort Detrick and Dugway Proving Ground human trials were conducted on Whitecoat volunteers
to determine the median infective dose (18 MICLD50/person i.h.) and course of infection. As a standardized biological it was manufactured in large quantities at Pine Bluff Arsenal
, with 5,098 gallons in the arsenal in bulk at the time of demilitarization in 1970.
Q fever is a category "B" agent. It can be contagious and is very stable in aerosols in a wide range of temperatures. Q fever microorganisms may survive on surfaces up to 60 days.
It is considered a good agent in part due to the fact that its ID50 (number of bacilli needed to infect 50% of individuals) is considered to be 1, making it the lowest known to man.
Coxiella burnetii
Coxiella burnetii is an obligate intracellular bacterial pathogen, and is the causative agent of Q fever. The genus Coxiella is morphologically similar to Rickettsia, but with a variety of genetic and physiological differences. C...
, a bacterium that affects humans and other animals. This organism is uncommon but may be found in cattle, sheep, goat
Goat
The domestic goat is a subspecies of goat domesticated from the wild goat of southwest Asia and Eastern Europe. The goat is a member of the Bovidae family and is closely related to the sheep as both are in the goat-antelope subfamily Caprinae. There are over three hundred distinct breeds of...
s and other domestic mammals, including cat
Cat
The cat , also known as the domestic cat or housecat to distinguish it from other felids and felines, is a small, usually furry, domesticated, carnivorous mammal that is valued by humans for its companionship and for its ability to hunt vermin and household pests...
s and dog
Dog
The domestic dog is a domesticated form of the gray wolf, a member of the Canidae family of the order Carnivora. The term is used for both feral and pet varieties. The dog may have been the first animal to be domesticated, and has been the most widely kept working, hunting, and companion animal in...
s. The infection results from inhalation
Inhalation
Inhalation is the movement of air from the external environment, through the air ways, and into the alveoli....
of a spore-like small cell variant, and from contact with the milk, urine, feces, vaginal mucus, or semen of infected animals. Rarely, the disease is tick borne. The incubation period
Incubation period
Incubation period is the time elapsed between exposure to a pathogenic organism, a chemical or radiation, and when symptoms and signs are first apparent...
is 9–40 days. A human being can be infected by a single bacterium. The bacterium is an obligate intracellular
Obligate intracellular parasite
Intracellular parasites are parasitic microorganisms - microparasites that are capable of growing and reproducing inside the cells of a host.-Facultative:...
pathogen.
History
Edward Holbrook Derrick
Edward Holbrook Derrick was an Australian pathologist, best known for his role in identifying Q fever.Derrick was born in Victoria, and earned an M.D. from Melbourne University in 1922. He subsequently worked for a short period of time at the Walter and Eliza Hall Institute in Melbourne, and spent...
in abattoir
Slaughterhouse
A slaughterhouse or abattoir is a facility where animals are killed for consumption as food products.Approximately 45-50% of the animal can be turned into edible products...
workers in Brisbane
Brisbane
Brisbane is the capital and most populous city in the Australian state of Queensland and the third most populous city in Australia. Brisbane's metropolitan area has a population of over 2 million, and the South East Queensland urban conurbation, centred around Brisbane, encompasses a population of...
, Queensland
Queensland
Queensland is a state of Australia, occupying the north-eastern section of the mainland continent. It is bordered by the Northern Territory, South Australia and New South Wales to the west, south-west and south respectively. To the east, Queensland is bordered by the Coral Sea and Pacific Ocean...
, Australia
Australia
Australia , officially the Commonwealth of Australia, is a country in the Southern Hemisphere comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands in the Indian and Pacific Oceans. It is the world's sixth-largest country by total area...
. The "Q" stands for "query" and was applied at a time when the causative agent was unknown; it was chosen over suggestions of "abattoir fever" and "Queensland rickettsial fever", to avoid directing negative connotations at either the cattle industry or the state of Queensland.
The pathogen
Pathogen
A pathogen gignomai "I give birth to") or infectious agent — colloquially, a germ — is a microbe or microorganism such as a virus, bacterium, prion, or fungus that causes disease in its animal or plant host...
of Q fever was discovered in 1937, when Frank Macfarlane Burnet
Frank Macfarlane Burnet
Sir Frank Macfarlane Burnet, , usually known as Macfarlane or Mac Burnet, was an Australian virologist best known for his contributions to immunology....
and Mavis Freeman
Mavis Freeman
Mavis Ann Freeman was an American swimmer who competed in the 1936 Summer Olympics.In the 1936 Olympics Freeman won a bronze medal in the 4x100 m freestyle relay event.-External links:*...
isolated the bacterium from one of Derrick’s patients. It was originally identified as a species of Rickettsia
Rickettsia
Rickettsia is a genus of non-motile, Gram-negative, non-sporeforming, highly pleomorphic bacteria that can present as cocci , rods or thread-like . Being obligate intracellular parasites, the Rickettsia survival depends on entry, growth, and replication within the cytoplasm of eukaryotic host cells...
. H.R. Cox and Gordon Davis isolated it from tick
Tick
Ticks are small arachnids in the order Ixodida, along with mites, constitute the subclass Acarina. Ticks are ectoparasites , living by hematophagy on the blood of mammals, birds, and sometimes reptiles and amphibians...
s in Montana
Montana
Montana is a state in the Western United States. The western third of Montana contains numerous mountain ranges. Smaller, "island ranges" are found in the central third of the state, for a total of 77 named ranges of the Rocky Mountains. This geographical fact is reflected in the state's name,...
, USA in 1938. It is a zoonotic disease whose most common animal reservoirs are cattle, sheep and goats. Coxiella burnetii is no longer regarded as closely related to Rickettsiae but as similar to Legionella
Legionella
Legionella is a pathogenic Gram negative bacterium, including species that cause legionellosis or Legionnaires' disease, most notably L. pneumophila. It may be readily visualized with a silver stain....
and Francisella
Francisella
Francisella is a genus of pathogenic, Gram-negative bacteria. They are small coccobacillary or rod-shaped, non-motile organisms, which are also facultative intracellular parasites of macrophages...
and is a proteobacterium
Proteobacteria
The Proteobacteria are a major group of bacteria. They include a wide variety of pathogens, such as Escherichia, Salmonella, Vibrio, Helicobacter, and many other notable genera....
.
Manifestations
Incubation period is usually 2 to 3 weeks. The most common manifestation is mild flu-like symptoms with abrupt onset of feverFever
Fever is a common medical sign characterized by an elevation of temperature above the normal range of due to an increase in the body temperature regulatory set-point. This increase in set-point triggers increased muscle tone and shivering.As a person's temperature increases, there is, in...
, malaise
Malaise
Malaise is a feeling of general discomfort or uneasiness, of being "out of sorts", often the first indication of an infection or other disease. Malaise is often defined in medicinal research as a "general feeling of being unwell"...
, profuse perspiration, severe headache
Headache
A headache or cephalalgia is pain anywhere in the region of the head or neck. It can be a symptom of a number of different conditions of the head and neck. The brain tissue itself is not sensitive to pain because it lacks pain receptors. Rather, the pain is caused by disturbance of the...
, myalgia
Myalgia
Myalgia means "muscle pain" and is a symptom of many diseases and disorders. The most common causes are the overuse or over-stretching of a muscle or group of muscles. Myalgia without a traumatic history is often due to viral infections...
(muscle pain), joint pain, loss of appetite, upper respiratory problems, dry cough, pleuritic pain, chills, confusion and gastro-intestinal symptoms such as nausea
Nausea
Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...
, vomiting and diarrhea
Diarrhea
Diarrhea , also spelled diarrhoea, is the condition of having three or more loose or liquid bowel movements per day. It is a common cause of death in developing countries and the second most common cause of infant deaths worldwide. The loss of fluids through diarrhea can cause dehydration and...
. The fever lasts approximately 7 to 14 days.
Approximately half of infected individuals exhibit no symptoms.
During the course, the disease can progress to an atypical pneumonia
Atypical pneumonia
Atypical pneumonia aka "walking pneumonia" is a pneumonia not caused by one of the more traditional pathogens, and with a clinical presentation inconsistent with typical pneumonia. It can be caused by a variety of microorganisms...
, which can result in a life threatening acute respiratory distress syndrome
Acute respiratory distress syndrome
Acute respiratory distress syndrome , also known as respiratory distress syndrome or adult respiratory distress syndrome is a serious reaction to various forms of injuries to the lung....
(ARDS), whereby such symptoms usually occur during the first 4 to 5 days of infection.
Less often the Q fever causes (granulomatous) hepatitis
Hepatitis
Hepatitis is a medical condition defined by the inflammation of the liver and characterized by the presence of inflammatory cells in the tissue of the organ. The name is from the Greek hepar , the root being hepat- , meaning liver, and suffix -itis, meaning "inflammation"...
which may be asymptomatic or becomes symptomatic with malaise, fever, liver enlargement (hepatomegaly) and pain in the right upper quadrant of the abdomen
Abdomen
In vertebrates such as mammals the abdomen constitutes the part of the body between the thorax and pelvis. The region enclosed by the abdomen is termed the abdominal cavity...
. Whereas transaminase values
Elevated transaminases
In medicine, the presence of elevated transaminases, commonly the transaminases alanine transaminase and aspartate transaminase , may be an indicator of liver damage...
are often elevated, jaundice
Jaundice
Jaundice is a yellowish pigmentation of the skin, the conjunctival membranes over the sclerae , and other mucous membranes caused by hyperbilirubinemia . This hyperbilirubinemia subsequently causes increased levels of bilirubin in the extracellular fluid...
is uncommon. Retinal vasculitis is a rare manifestation of Q fever.
The chronic form of Q fever is virtually identical to inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
of the inner lining of the heart (endocarditis
Endocarditis
Endocarditis is an inflammation of the inner layer of the heart, the endocardium. It usually involves the heart valves . Other structures that may be involved include the interventricular septum, the chordae tendineae, the mural endocardium, or even on intracardiac devices...
), which can occur months or decades following the infection. It is usually fatal if untreated. However, with appropriate treatment the mortality falls to around 10%.
Clinical signs in animals
Cattle, goats and sheep are most commonly infected, and can serve as a reservoir for the bacteria. Infected animals may show respiratory signs such as pneumoniaPneumonia
Pneumonia is an inflammatory condition of the lung—especially affecting the microscopic air sacs —associated with fever, chest symptoms, and a lack of air space on a chest X-ray. Pneumonia is typically caused by an infection but there are a number of other causes...
, but also abortion and infertility. Severe systemic signs such as anorexia
Anorexia (symptom)
Anorexia is the decreased sensation of appetite...
and fever may occur concurrently.
Appearance and incidence
New Zealand
New Zealand is an island country in the south-western Pacific Ocean comprising two main landmasses and numerous smaller islands. The country is situated some east of Australia across the Tasman Sea, and roughly south of the Pacific island nations of New Caledonia, Fiji, and Tonga...
. The bacterium is extremely sustainable and virulent: a single organism is able to cause an infection. The common way of infection is inhalation of contaminated dust, contact with contaminated milk
Milk
Milk is a white liquid produced by the mammary glands of mammals. It is the primary source of nutrition for young mammals before they are able to digest other types of food. Early-lactation milk contains colostrum, which carries the mother's antibodies to the baby and can reduce the risk of many...
, meat, wool and particularly birthing products. Ticks can transfer the pathogenic agent to other animals. Transfer between humans seems extremely rare and has so far been described in very few cases.
Some studies have shown more men to be affected than women, which may be attributed to different employment rates in typical professions.
"At risk" occupations include, but are not limited to:
- veterinary personnel
- stockyardFeedlotA feedlot or feedyard is a type of animal feeding operation which is used in factory farming for finishing livestock, notably beef cattle, but also swine, horses, sheep, turkeys, chickens or ducks, prior to slaughter. Large beef feedlots are called Concentrated Animal Feeding Operations . They...
workers - farmerFarmerA farmer is a person engaged in agriculture, who raises living organisms for food or raw materials, generally including livestock husbandry and growing crops, such as produce and grain...
s - shearerShearerA shearer is someone who shears, such as a cloth shearer, or a sheep shearer.Additionally, Shearer is the surname of people:-In sports:*Alan Shearer , English footballer*Bobby Shearer , Scottish footballer...
s - animal transporters
- laboratory workers handling potentially infected veterinary samples or visiting abattoirs
- people who cull and process kangaroosKangaROOSKangaROOS are an American brand of sneaker originally produced from 1979 through the 1980s, with a later revival that continues in present. They were notable for having a small zippered pocket on the side of the shoe, large enough for a small amount of loose change, keys, or more recently,...
- hide (tanneryTanningTanning is the making of leather from the skins of animals which does not easily decompose. Traditionally, tanning used tannin, an acidic chemical compound from which the tanning process draws its name . Coloring may occur during tanning...
) workers.
Diagnosis
Diagnosis is usually based on serologySerology
Serology is the scientific study of blood serum and other bodily fluids. In practice, the term usually refers to the diagnostic identification of antibodies in the serum...
(looking for an antibody
Antibody
An antibody, also known as an immunoglobulin, is a large Y-shaped protein used by the immune system to identify and neutralize foreign objects such as bacteria and viruses. The antibody recognizes a unique part of the foreign target, termed an antigen...
response) rather than looking for the organism itself. Serology allows to detect chronic infection as high antibody levels are found against the virulent form of the bacterium. Molecular detection of bacterial DNA is increasingly used. Culture is technically difficult and not routinely available in most microbiology laboratories.
Q fever can cause endocarditis
Endocarditis
Endocarditis is an inflammation of the inner layer of the heart, the endocardium. It usually involves the heart valves . Other structures that may be involved include the interventricular septum, the chordae tendineae, the mural endocardium, or even on intracardiac devices...
(infection of the heart valves) which may require transoesophageal echocardiography to diagnose. Q fever hepatitis manifests as an elevation of ALT
Alanine transaminase
Alanine transaminase or ALT is a transaminase enzyme . It is also called serum glutamic pyruvic transaminase or alanine aminotransferase ....
and AST
Aspartate transaminase
Aspartate transaminase , also called aspartate aminotransferase or serum glutamic oxaloacetic transaminase , is a pyridoxal phosphate -dependent transaminase enzyme . AST catalyzes the reversible transfer of an α-amino group between aspartate and glutamate and, as such, is an important enzyme in...
, but a definitive diagnosis is only possible on liver biopsy
Liver biopsy
Liver biopsy is the biopsy from the liver. It is a medical test that is done to aid diagnosis of liver disease, to assess the severity of known liver disease, and to monitor the progress of treatment.-History:...
which shows the characteristic fibrin ring granuloma
Fibrin ring granuloma
A fibrin ring granuloma is a histopathological finding that is characteristic of Q fever. On hematoxylin-eosin staining, the fibrin ring granuloma consists of a central lipid vacuole surrounded by a dense red fibrin ring and epithelioid macrophages...
s.
Treatment
Treatment of the acute Q fever with antibioticAntibiotic
An antibacterial is a compound or substance that kills or slows down the growth of bacteria.The term is often used synonymously with the term antibiotic; today, however, with increased knowledge of the causative agents of various infectious diseases, antibiotic has come to denote a broader range of...
s is very effective and should take place in consultation with an infectious disease
Infectious disease
Infectious diseases, also known as communicable diseases, contagious diseases or transmissible diseases comprise clinically evident illness resulting from the infection, presence and growth of pathogenic biological agents in an individual host organism...
s specialist. Commonly used are doxycycline
Doxycycline
Doxycycline INN is a member of the tetracycline antibiotics group, and is commonly used to treat a variety of infections. Doxycycline is a semisynthetic tetracycline invented and clinically developed in the early 1960s by Pfizer Inc. and marketed under the brand name Vibramycin. Vibramycin...
, tetracycline, chloramphenicol
Chloramphenicol
Chloramphenicol is a bacteriostatic antimicrobial that became available in 1949. It is considered a prototypical broad-spectrum antibiotic, alongside the tetracyclines, and as it is both cheap and easy to manufacture it is frequently found as a drug of choice in the third world.Chloramphenicol is...
, ciprofloxacin
Ciprofloxacin
Ciprofloxacin is a synthetic chemotherapeutic antibiotic of the fluoroquinolone drug class.It is a second-generation fluoroquinolone antibacterial. It kills bacteria by interfering with the enzymes that cause DNA to rewind after being copied, which stops synthesis of DNA and of...
, ofloxacin
Ofloxacin
Ofloxacin is a synthetic chemotherapeutic antibiotic of the fluoroquinolone drug class considered to be a second-generation fluoroquinolone. The original brand, Floxin, has been discontinued by the manufacturer in the United States on 18 June 2009, though generic equivalents continue to be...
, and hydroxychloroquine
Hydroxychloroquine
Hydroxychloroquine is an antimalarial drug, sold under the trade names Plaquenil,Axemal, Dolquine, and Quensyl, also used to reduce inflammation in the treatment of rheumatoid arthritis and lupus...
. The chronic form is more difficult to treat and can require up to four years of treatment with doxycycline and quinolone
Quinolone
The quinolones are a family of synthetic broad-spectrum antibiotics. The term quinolone refers to potent synthetic chemotherapeutic antibacterials....
s or doxycycline with hydroxychloroquine.
Q fever in pregnancy is especially difficult to treat because doxycycline and ciprofloxacin are contraindicated in pregnancy. The preferred treatment is five weeks of co-trimoxazole
Co-trimoxazole
Trimethoprim/sulfamethoxazole or co-trimoxazole is a sulfonamide antibiotic combination of trimethoprim and sulfamethoxazole, in the ratio of 1 to 5, used in the treatment of a variety of bacterial infections.The name co-trimoxazole is the British Approved Name, and has been marketed worldwide...
.
Prevention
Protection is offered by Q-Vax, a whole cell inactivated vaccine developed by an Australian vaccine manufacturing company CSL. The intradermal vaccination is composed of killed Coxiella burnetii organisms. Skin and blood tests should be done before vaccination to identify preexisting immunity; the reason is that vaccinating subjects who already have an immunity can result in a severe local reaction. After a single dose of vaccine, protective immunity lasts for many years. Revaccination is not generally required. Annual screening is typically recommended.In 2001, Australia
Australia
Australia , officially the Commonwealth of Australia, is a country in the Southern Hemisphere comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands in the Indian and Pacific Oceans. It is the world's sixth-largest country by total area...
introduced a national Q fever vaccination program for people working in "at risk" occupations.
The Soviet Union had earlier developed a killed vaccine but its side effects prevented its licensing abroad.
Vaccination of animals is not a current method of control.
Biological warfare
Q fever has been described as a possible biological weapon.The United States investigated Q fever as a potential biological warfare
Biological warfare
Biological warfare is the use of biological toxins or infectious agents such as bacteria, viruses, and fungi with intent to kill or incapacitate humans, animals or plants as an act of war...
agent in the 1950s with eventual standardization as agent OU. At Fort Detrick and Dugway Proving Ground human trials were conducted on Whitecoat volunteers
Operation Whitecoat
Operation Whitecoat was the name given to a medical research program carried out by the US Army at Fort Detrick, Maryland during the period 1954–1973. The program involved conducting medical research using volunteer enlisted personnel who eventually became nicknamed "White Coats"...
to determine the median infective dose (18 MICLD50/person i.h.) and course of infection. As a standardized biological it was manufactured in large quantities at Pine Bluff Arsenal
Pine Bluff Arsenal
The Pine Bluff Arsenal is a US Army installation located in Jefferson County, Arkansas, just northwest of the city of Pine Bluff. PBA is one of the six Army installations in the United States that store chemical weapons...
, with 5,098 gallons in the arsenal in bulk at the time of demilitarization in 1970.
Q fever is a category "B" agent. It can be contagious and is very stable in aerosols in a wide range of temperatures. Q fever microorganisms may survive on surfaces up to 60 days.
It is considered a good agent in part due to the fact that its ID50 (number of bacilli needed to infect 50% of individuals) is considered to be 1, making it the lowest known to man.
External links
- Q fever at the CDCCenters for Disease Control and PreventionThe Centers for Disease Control and Prevention are a United States federal agency under the Department of Health and Human Services headquartered in Druid Hills, unincorporated DeKalb County, Georgia, in Greater Atlanta...
- Coxiella burnetii genomes and related information at PATRIC, a Bioinformatics Resource Center funded by NIAID