Risk factors for human brucellosis in Iran: a case control study

International Journal of Infectious Diseases (2008) 12, 157 161 http://intl.elsevierhealth.com/journals/ijid Risk factors for human brucellosis in Iran: a case control study Masomeh Sofian a, Arezoo Aghakhani b, Ali Akbar Velayati c, Mohammad Banifazl d, Ali Eslamifar b, Amitis Ramezani b, * a Arak Medical University, Arak, Iran b Department of Clinical Research, Pasteur Institute of Iran, 13164, Pasteur Square, Tehran, Iran c Masih Daneshvari Hospital, Tehran, Iran d Iranian Society for the Support of Patients with Infectious Diseases, Tehran, Iran Received 13 November 2006; received in revised form 13 March 2007; accepted 18 April 2007 Corresponding Editor: Ziad Memish, Riyadh, Saudi Arabia KEYWORDS Human brucellosis; Risk factors; Iran Summary Background: Brucellosis is a zoonotic disease of worldwide distribution. Despite its control in many countries, it remains endemic in Iran. The aim of this study was to determine the risk factors for brucellosis acquisition in the central province of Iran. Methods: A matched case control study was conducted in the central part of Iran. A total of 300 subjects (150 cases and 150 controls) were enrolled in the investigation. Brucellosis cases were defined on the basis of epidemiologic, clinical, and laboratory criteria. Subjects were interviewed using a questionnaire to obtain risk factor information. We used odds ratios and conditional logistic regression models to explore the association between the disease and the variables studied. Result: Significant risk factors for infection were related to the existence of another case of brucellosis in the home (OR = 7.55, p = 0.0001) and consumption of unpasteurized dairy products (OR = 3.7, p = 0.014). Keeping cattle and cattle vaccination were also important risk factors. Conclusions: Pasteurization of dairy products and education regarding fresh cheese must be pursued for eradication of brucellosis. A major risk factor for acquiring brucellosis is the existence of another infected family member. Therefore screening family members of an index case of brucellosis may lead to the detection of additional cases. # 2007 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. Introduction * Corresponding author. Tel.: +98 21 88361922; fax: +98 21 20109550. E-mail address: iiccom@iiccom.com (A. Ramezani). Brucellosis is an infectious zoonotic disease that is associated with chronic debilitating infections in humans and reproductive failure in domestic animals. 1 It is still an important public health problem throughout the world, but principally, and in 1201-9712/$32.00 # 2007 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijid.2007.04.019

158 M. Sofian et al. particular, in the Mediterranean region, including Iran, Turkey, the Arabian Peninsula, the Indian subcontinent, Mexico, and parts of Central and South America. 2 It causes significant economic loss among those keeping domesticated animals as a source of meat and dairy products. 3 Brucellosis can be transmitted to humans through contact with animals or their products; it is an occupational hazard to persons engaged in certain professions (e.g., veterinarians, slaughterhouse workers, and farmers). 4 6 Several variables are significantly associated with the acquisition of human brucellosis. Both direct and indirect transmission such as consumption of unpasteurized milk and dairy products, herding, and lambing have been shown to have significant correlation with this disease. 7 Some authors have reported exposure to aborted homeowned animals and consumption of home-made milk products as risk factors for human brucellosis infections, 4 and others have found a statistically significant correlation between seropositivity for brucellosis and age, sex, and the consumption of fresh cheese and cream made from unboiled milk. 8 Iran is an endemic area for brucellosis. Hasanjani Roushan et al. studied epidemiological features and clinical manifestations in 469 adult patients with brucellosis in the northern part of Iran. They found that the consumption of fresh cheese (22.4%), animal husbandry (11.3%), working in a laboratory (8.1%), and veterinary profession (1.5%) were the main risk factors for brucellosis infection. 9 Identifying the major risk factors for brucellosis is very important for reaching a comprehensive understanding of the nature of the disease and its transmission routes for eradication of human brucellosis. The aim of this study was to explore various risk factors associated with brucellosis in the Iranian population using a case control study. Patients and methods A case control study was undertaken to determine risk factors for brucellosis in Iran. Data were collected during the year 2005. Cases consisted of patients with brucellosis attending 125 health centers from rural and urban regions of Arak City (central part of Iran, Figure 1). Their documents were studied and then case finding was started. Clear definitions of case and control were established. A case was defined as a resident of the district of 1 year or more, who had received a clinical diagnosis of brucellosis on the basis of the symptoms, compatible clinical findings, standard tube agglutination (STA = Wright) test dilution 1:160, and in the presence of 2-mercaptoethanol (2ME) agglutination 20. A control was defined as a neighbor of the case who had been resident in the district for 1 year or more during the study period and who had no history of brucellosis. The controls also underwent STA and 2ME testing and did not meet the clinical and laboratory criteria mentioned above. An infected family member was defined as a household member with brucellosis diagnosed by both interview and laboratory tests. One hundred and fifty cases (67 female and 83 male) were matched with respect to age, sex, and place of residence (rural or urban), with 150 controls. A physician examined and interviewed all the cases. All 300 subjects answered a questionnaire to establish risk factors for brucellosis. Informed consent was obtained from all study participants. Complications were defined as follows: peripheral arthritis was diagnosed by the finding of swelling, effusion, and limitation of motion in an involved joint; epididymo-orchitis was diagnosed by the finding of swelling and tenderness of scrotal skin, testis, and epididymis with confirmation by sonography; meningitis was diagnosed by the presence of headache, neck stiffness, and fever and Figure 1 Map of Iran showing Arak city (central province of Iran).

Risk factors for human brucellosis in Iran 159 Table 1 Characteristics of cases and controls Characteristics Cases (N = 150) % (n) Controls (N = 150) % (n) p Value Sex Male 55.3% (83) 54% (81) Female 44.7% (67) 46% (69) Education Illiterate 29.3% (44) 28% (42) No formal 8% (12) 8% (12) Elementary 37.3% (56) 34% (51) Secondary 21.3% (32) 19.3% (29) Diploma 4% (6) 8.7% (13) College 0% (0) 0.7% (1) Type of animals owned Cattle 16.9% (352) 7.3% (335) Sheep 78.1% (1629) 84.3% (3884) Ewe 0.2% (4) 5.3% (244) Goat 4.8% (101) 3.2% (147) Occupation Farmers 33.3% (50) 21.3% (32) Butchers 0.7% (1) 0.7% (1) Animal husbandry 5.3% (8) 4% (6) Worker 58% (87) 70.7% (106) Farmers and animal husbandry 2.7% (4) 3.3% (5) Positive family history of brucellosis 61.3% (92) 17.3% (26) <0.05 Number of infected members in household 295 44 <0.05 Rate of relapse in family 16% (24) 2% (3) <0.05 Keeping cattle 88.7% (133) 58% (87) <0.05 Cattle vaccination 76.7% (102/133) 86.2% (75/87) <0.05, not significant. confirmed if analysis of cerebrospinal fluid (CSF) showed an aseptic meningitis plus Brucella serological positivity by STA and 2ME in CSF. Statistical analysis The data among study groups were compared with the Chisquare test using SPSS 11.5 program. We calculated the odds ratios and the confidence intervals for the studied variables. A conditional logistic regression model was used to explore the association between disease and risk factors. A p value of 0.05 was defined as statistically significant. Results A total of 150 cases with a mean age 33.37 21.3 years (range 2 86 years) enrolled in our study. Of these, 55.3% (83) were male and 44.7% (67) were female; 85.3% (128) were habitant in rural areas and 87.3% (131) of them kept farm animals. Characteristics of case and control subjects are shown in Table 1. There was no significant difference in age, sex, marital status, area of residence (rural and urban), educational level, consumption of uncooked meat, knowledge about prevention routes of brucellosis, and occupation between Table 2 Risk factors for human brucellosis Risk factors Adjusted OR 95% CI p Value Consumption of unpasteurized dairy products 3.7 1.64 8.3 0.014 Consumption of unpasteurized and pasteurized dairy products 2.9 6.4 14 0.007 Selling cattle 1.9 1.14 3.14 0.0014 Knowledge of the mode of brucellosis transmission 1.14 0.41 3.15 0.8 Knowledge about fresh cheese as a mode of brucellosis transmission 0.44 0.23 0.85 0.01 Knowledge about unboiled milk as a mode of brucellosis transmission 0.48 0.2 1.18 0.11 Knowledge about pasteurized milk for protection against brucellosis 0.94 0.49 1.83 0.87 Knowledge about cattle vaccination 1.63 0.87 3.03 0.13 Infected household members 7.55 3.91 14.61 0.0001 OR, odds ratio; CI, confidence interval.

160 M. Sofian et al. case and control subjects. We could find no correlation between acquisition of brucellosis and abortion or infertility in home-owned animals. Significant risk factors for infection were related to the existence of another case of brucellosis in the home (OR = 7.55, 95% CI = 3.91 14.61, p = 0.0001) and consumption of unpasteurized dairy products (OR = 3.7, 95% CI = 1.64 8.3, p = 0.014) (Table 2). Knowledge about the mode of brucellosis transmission by fresh cheese appeared to be protective against disease transmission (OR = 0.44, 95% CI = 0.23 0.85, p = 0.01). Significant differences were found between case and control subjects with regard to positive family history of brucellosis (61.3% vs. 17.3%, p < 0.05), number of infected members in the household (295 persons vs. 44 persons, p < 0.05), rate of relapse in the family (16% vs. 2%, p < 0.05), keeping cattle (88.7% vs. 58%, p < 0.05), and cattle vaccination (76.7% vs. 86.2%, p < 0.05). When specific animal species were considered, the greatest risk was associated with products derived from sheep as opposed to goats and cattle. The most common symptoms recorded were fever (78.7%), myalgia (66%), and chills (64%). Of our patients, 17.8% showed disease complications including: arthritis (14.6%), meningitis (0.6%), and epididymo-orchitis (2.6%). Complaints and complications of patients with brucellosis are shown in Table 3. Discussion Brucellosis occurs naturally in domestic animals and is transmitted to human beings by direct and indirect routes such as consumption of unpasteurized milk and dairy products, close contact with infected livestock, their tissues or secretions, herding, lambing, and others. 7,10 Several studies have been performed in the Kingdom of Saudi Arabia (KSA), 11 13 Jordan, 14 Gaza Strip, 15 Lebanon, 16 Israel, 17 and in Yemen 18 to determine risk factors for brucellosis. Some authors have emphasized that direct contact with infected animals and their products is more important than ingestion of contaminated animal products for brucellosis transmission. 19 21 Exposure to aborted home-owned animals has been identified as a probable source of human brucellosis infections in some studies. 4 Alballa et al. reported that direct contact with domestic animals and consumption of raw products of animal origin were the main risk factors. 10 In a case control study in Saudi Arabia the greatest risk factor was indirect contact with animals (the consumption of unpasteurized dairy products), as opposed to direct contact with animals. When direct contact with animals was considered, the study found a very high-risk association with assisting in animal parturition but no significant risk associated with other direct (unspecified) animal contact. 11 Other scholars believe that public health programs should focus on educating the population about the risks of consuming dairy products made from unpasteurized milk, such as soft cheeses. 22 Brucellosis is endemic in certain parts of Iran. The prevalence of brucellosis in Iran has been reported as 0.5% to 10.9% in different provinces. In a study in Tehran province the incidence of brucellosis was 17.5/100 000 and the main Table 3 The most common complaints and complications of patients with brucellosis Percentage Clinical complaints Fever 78.7% Myalgia 66% Chills 64% Anorexia 52% Headache 50.7% Malaise 46% Low back pain 44.7% Fatigue 43% Sweating 42.7% Weight loss 34% Arthralgia 34% Paresthesia 18.7% Dyspnea 18% Palpitations 16.7% Nausea 15.3% Rash 12% Dysuria 11.3% Clinical complications Arthritis 14.6% Meningitis 0.6% Epididymo-orchitis 2.6% source of infection was fresh cheese and unboiled milk. Another cross-sectional study in Mazandaran province showed that the main risk factors for brucellosis acquisition were age, sex, and consumption of milk and cheese (data published in Iranian journals). The present investigation determined risk factors for human brucellosis in the central part of Iran using a case control study. According to our survey, the significant risk factors for infection are related to the existence of another case of brucellosis in the household and the consumption of unpasteurized dairy products. There was no statistically significant correlation between acquisition of brucellosis and abortion or infertility in home-owned animals, but keeping cattle and cattle vaccination were significant risk factors between case and control subjects. Our results on the consumption of unpasteurized dairy products are in concordance with the studies published by Cooper, 11 Husseini et al., 7 Cetinkaya et al., 8 Kozukeev et al., 4 and Issa and Jamal, 14 but are in contrast to the report of Serra Alvarez and Godoy Garcia. 23 Our data regarding aborted home-owned animals did not concord with the study of Kozukeev et al. 4 Occupation and educational levels are also risk factors for brucellosis acquisition. 4 A hospital-based case control study in Yemen showed significant risk factors for infection related to occupation and drinking fresh milk and laban. Socioeconomic and educational factors were also independent risk factors. 24 Araj and Azzam from Lebanon concluded that exposure to brucellosis is high among persons in high-risk occupations. 16 Our data showed that occupation and educational levels were not important risk factors and were in contrast with the above findings. One possible explanation could be due to our case and control selection. Case and

Risk factors for human brucellosis in Iran 161 control groups were neighbors and presumably had similar occupations and educational levels, especially in rural areas. Therefore we should not expect to find a significant difference between study groups. A recent study from KSA 25 showed that 63.5% of 137 detected cases in Tabuk district came from rural areas, which is comparable to the result of a study in Palestine 7 that showed 61.1% of the cases being village inhabitants. Our study detected higher cases (85.3%) from rural areas than the above-mentioned studies, but we found similarities in unpasteurized milk consumption and animal keeping and ownership. Familiar antecedents and household members have a significant relation with the seropositivity for brucellosis. 7,22,26,27 We observed significant differences between case and control subjects with regard to a positive family history of brucellosis, number of infected members in the household, and rate of relapse in the family. Therefore, active serological screening of the other household members of brucellosis cases may detect additional unrecognized cases. In conclusion the findings of this study suggest that human brucellosis is still an important public health problem in Iran. However, most of the risk factors for brucellosis acquisition are modifiable. Pasteurization of milk and dairy products and education regarding eating habits must be pursued for eradication of human brucellosis, especially in rural areas. Knowledge about mode of brucellosis transmission by fresh cheese appeared to be protective against disease transmission. Since brucellosis is a zoonotic disease and the vast majority of cases are infected through direct or indirect contact with animals, a campaign to control the infection by animal vaccination would be an important step. In this study we found that the greatest risk factor for acquiring brucellosis is the existence of another infected family member, and it should be emphasized that the exposure of family members to the same epidemiological factors leads to more than one member of the family being infected. Thus the basic principal should be to screen family members once a case is diagnosed. Acknowledgments The authors acknowledge Arak Medical Sciences University for financial support of this study. Conflict of interest: No conflict of interest to declare. References 1. Corbell JM. Brucellosis: an overview. Emerg Infect Dis 1997;2: 213 21. 2. Geyik MF, Gür A, Nas K, Cevik R, Saraç J, Dikici B, et al. Musculoskeletal involvement in brucellosis in different age groups: a study of 195 cases. Swiss Med Wkly 2002;132:98 105. 3. Young EJ. Brucella species. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas and Bennett s principles and practice of infectious diseases. 4th Ed. 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