1 Introduction

Q fever is a highly infectious zoonosis typically presenting as an influenza-like illness (ILI) in uncomplicated symptomatic disease [1, 2]. However, most infections are asymptomatic [3]. The disease is caused by the intracellular bacterium Coxiella burnetii, with a large reservoir in both domesticated animals (cattle, sheep, goats) as well as native animals (such as kangaroos and wallabies). People who are exposed to infected animals during work or recreational activities (e.g., farmers, abattoir workers, hunters and veterinarians) are at an increased risk of infection [2, 4]. Given that the pathogen is highly infectious (a single inhaled organism may cause disease) but is largely asymptomatic in infected animals, outbreaks associated with the arrival of an infected herd or flock are common [4]. Unfortunately, as there are many more common differential diagnoses for an ILI (e.g., influenza, COVID), Q fever may not be considered in the first presentation to a primary healthcare worker, even in areas with relatively high prevalence of Q fever and among high-risk occupations.

Consequences of missed Q fever are significant both at individual and community levels. Most individuals with acute Q fever will recover within 2–6 weeks without long-term sequelae, though a few may have serious organ involvement (e.g., pericarditis and meningoencephalitis). Less than 5% of patients progress to chronic Q fever, where endocarditis with associated valvular heart disease and osteomyelitis are known complications [5, 6]. Additionally, 10%–15% of patients may have chronic fatigue syndrome following acute infection [7]. At the community level, undetected or misdiagnosed infections can eventually cause large outbreaks, as once seen in the Netherlands between 2007 and 2010, when > 4000 cases were reported [8]. Though Q fever has been reported in almost every country in the world, the data on the actual burden of disease is sparse, and only Australia has approved a vaccine for use in humans. Therefore, it is a largely neglected topic in infectious diseases, which may translate to poor awareness among the primary healthcare workers who make first contact with ill patients in the community. Once correctly diagnosed, the infection can be easily treated by inexpensive and readily available antibiotics like doxycycline [9]. Thus, removing barriers to timely diagnosis of Q fever will lead to direct and indirect healthcare benefits for at-risk communities.

We previously conducted a seroprevalence study of missed Q fever by testing residual plasma/serum from microbiologically undiagnosed patients with an ILI, living in regional New South Wales in Australia to determine the fraction of missed diagnoses in patients presenting to primary care [10]. However, after testing 542 eligible serum samples referred to NSW Health Pathology Randwick campus from undiagnosed patients between 2016 and 2023, only one missed acute Q fever case was confirmed. During the same period, from the same demographic, 731 samples were referred to the same diagnostic service for Q fever testing, and of these, 70 were positive for acute Q fever. Thus, in this sample, the clinical judgement of general practitioners was considered generally reliable as to when to request Q fever testing. However, there were two main limitations to these observations. Firstly, it is unknown what proportion of patients with suggestive symptoms for Q fever were referred for testing; and secondly, most samples tested for missed Q fever did not necessarily originate from known hotspots for the disease in regional NSW (and hence the missed cases may be underestimated). Thus, this qualitative study sought to investigate how general practitioners (GP) approach a potential Q fever diagnosis to further identify enablers and barriers to making this diagnosis in regional NSW. The interviews explored their knowledge, attitudes and practices in diagnosing, managing and preventing Q fever.

2 Methods

3 Results

Eleven interviews (4 males, 7 females) were conducted between April and August 2024 with general practitioners (n: 10) or GP trainees (n: 1). The duration of their careers as medical doctors since graduation varied from 4 to 35 years (Table 1). They had been in general practice (or in training) from 1 to 30 years. Four participants had completed their undergraduate degrees overseas while the remainder graduated in Australia. Seven participants were within the 20–40 age brackets while all others were in the 41–60-year-old bracket. Four participants were from the Northern regional postcodes while three were from the Western regional postcodes. Two participants each were from Southern and Central Coast postcodes. The frequency of acute Q fever cases diagnosed or suspected by these interviewees in the last 12 months varied from zero to five. The data categories that emerged after the analysis of coded information are summarised in Figure 1. After interrogating these data categories, the following themes emerged.

4 Discussion

This qualitative analysis of general practitioner experiences in diagnosing, managing and preventing Q fever in regional New South Wales, Australia, identified several themes emerging from the data analysis: Q fever is unlikely to be diagnosed on the first visit of an ILI presentation in the absence of risk factors; positive diagnoses are not encountered by general practitioners frequently; almost all diagnoses are based on serology, for which external help is often needed in interpreting test results; the Q fever vaccine is perceived as safe and effective, but there are barriers to its uptake; there is a need for Q fever to be included in onboarding and continuous professional development programs for GPs, at least for those practicing in regional areas.

In a typical ILI presentation, GPs appropriately prioritised common viral infections as differential diagnosis. As some interviewees acknowledged it is not unreasonable to adopt a “watch and wait” approach as most such infections are self-limiting with the caveat that in the elderly or immunocompromised acute influenza or COVID should be diagnosed by RAT or PCR testing and treated with antiviral drugs. Given the difficulty in obtaining a GP appointment a proportion of ILI patients may not even attend a GP practice. Therefore, unless strong epidemiological and occupational risk factors suggest it, testing for Q fever in the first GP visit is unlikely even in regional NSW, where GPs are familiar with the illness. Thus, it is likely that the apparently “low” rate of diagnosed Q fever cases reported by all interviewees may be an underestimate of the true prevalence due to a combination of the above factors. This has implications for diagnostic tests because a C. burnettii PCR test is likely to become negative within 2 weeks after the onset of symptoms [13], and therefore the GPs nominated reliance on serology is appropriate within the context of their practice.

The Q fever vaccine was perceived by interviewees as effective and with limited side effects, but problems were noted in the logistics of service delivery and record keeping. According to those interviewed, not all GPs were experienced in doing vaccinations, presumably related to the time-consuming nature of the pre-testing, the jurisdictional requirement of additional training, and the need for multiple appointments to complete the vaccination process [14, 15]. From the GPs' standpoint, this “specialisation” leads to less waste and cost to practice (and patients), but it may also limit accessibility to those wanting to get vaccinated. It also meant that the GPs who did not do vaccinations were unfamiliar with details of the process and hence would have limited capacity to advise interested patients. The cost of vaccination to patients was considered high when serology, skin testing, and multiple appointments were included. For those who require vaccination due to employment, these costs may be covered by their employer, but otherwise it is a likely a deterrent that prevents high vaccine uptake. The inclusion of the Q fever vaccine in AIR was appreciated by all interviewees doing Q fever vaccinations, but one person (incorrectly) noted that it cannot be used for people without a Medicare card. Thus, clear communication of how this information can be recorded for those without a Medicare card (using an individual health identifier linked to My Health Record) may be worth adding to existing resources such as the training module on Q fever diagnosis and vaccination available via the Australian College of Remote and Rural Medicine (worth 2 CPD points) [16].

Q fever is a neglected but a widely prevalent infection globally [5, 6, 17-21] which is probably underdiagnosed due to a lack of awareness both among patients and medical practitioners [22]. Interestingly, although an effective vaccine is available, Australia is the only country that has approved it for use [23]. Compared to other pathogens that cause an ILI such as COVID, influenza, and RSV, the volume of research on Q fever is limited. It was not possible to find prior qualitative studies that evaluated the perceptions of primary healthcare workers including general practitioners on diagnosing, managing and preventing Q fever to understand the real-life difficulties they face in reducing the Q fever burden. The very few qualitative studies available from literature were only focussed on patients and at-risk occupational groups like farmers or husbandry workers [24, 25]. The only qualitative study that interviewed healthcare workers from Australia included a range of professionals in occupational health, environmental health, and specialists in infectious diseases, but not primary healthcare workers who play a critical role in diagnosing cases in the community [26]. In the public health system in Australia (and in many other countries with similar systems) GPs are the first point of contact for patients and specialists can only be accessed via their referrals (unless in private healthcare or after a hospital admission). Hence, this study addresses a critical knowledge gap in informing how Q fever detection and prevention can be further improved in grassroots community healthcare settings.

This study had several limitations. Qualitative research is context specific, and this work is based on the interviews of GPs from regional NSW, Australia. The context, facilities-related issues, and other logistical issues faced by GPs in other countries or other states of Australia may be different. While this impacts on the generalisability of the findings, it still provides a baseline framework and data that can be compared against for future studies on the same topic. It is likely that the GPs who responded to our request for interviews were those who had a special interest in Q fever, and they may not be representative of all GPs in regional NSW. However, the issues highlighted by them are likely to be relevant to all GPs in regional NSW. The prevalence of Q fever is not homogenous across regional NSW, and the GPs interviewed did not always practice in a Q fever hotspot. Those practicing in high-prevalence settings may be more aware of the illness and diagnose it quickly. Hence, in this study, we asked about the number of cases diagnosed in the last 12 months as a proxy measure of familiarity with the infection, and the numbers were low for all interviewees regardless of the postcode of practice. Finally, as this is a qualitative study, it is not possible to draw any conclusions on the prevalence of Q fever or vaccine uptake from this data.

The findings of this study have implications for clinical practice and future research. In terms of practice, there is an opportunity to engage general practitioners from rural NSW in CPD activities or reintroduce or expand (e.g., eTG) the existing training materials linked to CPD points. Eventually, this may lead to more GPs undertaking vaccinations as they become more aware of the illness and confident in vaccinating. In research, it would be interesting to see if the same findings are true for general practitioners in other states of Australia because the jurisdictional laws, local training opportunities and disease prevalence would be different between the states. Furthermore, qualitative interviews engaging wider representation of the community, including other community and hospital-based healthcare workers, patients, members of the community, and policymakers, will paint a more wholesome picture of enablers and barriers to prevent and manage Q fever in rural Australia.

5 Conclusion

This qualitative exploration of GP experiences in diagnosing, managing and preventing Q fever in regional NSW identified several important themes, including the difficulty of diagnosing Q fever in the first visit as more prevalent differential diagnoses must be prioritised, the need for additional support in interpreting Q fever serology, logistical and record-keeping problems with regard to vaccinations, and the acceptance of the need for continuous professional development activities on the topic. This work fills a critical knowledge gap in improving services to Q fever patients and general practitioners in regional NSW and sets the bar for future qualitative studies of a similar nature in Australia and globally.

Author Contributions

Sachith Maduranga: investigation, data curation, formal analysis. Lok Bahadur Shrestha: investigation, data curation, formal analysis. Braulio Mark Valencia: investigation, formal analysis, data curation. Graeme Horton: methodology, writing – review and editing, resources, supervision. Michelle Guppy: methodology, writing – review and editing, supervision, resources. Heather F. Gidding: conceptualization, methodology, writing – review and editing. Stephen Graves: conceptualization, writing – review and editing, supervision. John Stenos: conceptualization, supervision, writing – review and editing. William Rawlinson: conceptualization, writing – review and editing, supervision. Andrew R. Lloyd: conceptualization, supervision, resources, methodology, funding acquisition, writing – review and editing. Chaturaka Rodrigo: conceptualization, investigation, funding acquisition, writing – original draft, methodology, formal analysis, project administration, data curation.

Ethics Statement

This research was approved by the Human Research Ethics Committee of the Southeastern Sydney Local Health District (2021/ETH10995), and all participants provided informed written consent.

Conflicts of Interest

Andrew Lloyd is a member of, and Heather Gidding has previously contributed to the Seqirus advisory board. The authors declare no conflicts of interest.