What constitutes a fever in children. How to accurately measure body temperature. When should parents seek medical attention for a child’s fever. What are the most effective methods for reducing fever at home. How does fever affect a child’s body and behavior. What are the potential complications of high fever in children. How can parents distinguish between low-grade and high-grade fevers.

Understanding Fever: The Body’s Natural Defense Mechanism

Fever is often a cause for concern among parents, but it’s essential to understand that it’s actually the body’s natural response to fighting infections. A temperature of 100.4°F (38°C) or higher is generally considered a fever. While it can be unsettling to see your child’s temperature rise, it’s important to remember that fever itself is not an illness, but rather a symptom.

Why does the body increase its temperature during an infection? The elevated body temperature helps to:

• Slow down the growth and reproduction of bacteria and viruses
• Boost the production of white blood cells
• Accelerate the body’s immune response

Understanding this natural process can help alleviate some of the anxiety associated with fevers in children.

Accurately Measuring Your Child’s Temperature: Methods and Tools

Accurately measuring your child’s temperature is crucial for determining whether they have a fever and its severity. Different methods and tools can be used, each with its own level of accuracy and ease of use.

Digital Thermometers: The Gold Standard

Digital thermometers are widely considered the most accurate and reliable option for measuring body temperature. They come in various types:

• Rectal thermometers: Provide the most accurate readings, especially for infants
• Oral thermometers: Suitable for older children who can hold the thermometer under their tongue
• Axillary (armpit) thermometers: Less accurate but more comfortable for some children

Other Temperature Measurement Methods

While not as accurate as digital thermometers, these methods can provide a quick estimate of your child’s temperature:

• Temporal artery thermometers: Scan the forehead to measure temperature
• Tympanic (ear) thermometers: Measure temperature inside the ear canal
• Infrared thermometers: Non-contact devices that measure temperature from a distance

Is one method significantly more accurate than others? Rectal temperature measurements are generally considered the most accurate, especially for infants and young children. However, the comfort and cooperation of the child should also be taken into account when choosing a method.

Distinguishing Between Low-Grade and High-Grade Fevers

Understanding the difference between low-grade and high-grade fevers can help parents determine the appropriate course of action for their child’s care.

Low-Grade Fever

A low-grade fever is typically defined as a body temperature between 99°F (37.2°C) and 100.9°F (38.3°C). These fevers are generally not cause for immediate concern and can often be managed at home. Symptoms associated with low-grade fevers may include:

• Mild discomfort
• Slight fatigue
• Reduced appetite

High-Grade Fever

A high-grade fever is usually considered to be a temperature of 103°F (39.4°C) or higher. These fevers may require more attention and potentially medical intervention. Symptoms of high-grade fevers can include:

• Significant discomfort
• Excessive sweating or chills
• Dehydration
• Lethargy or irritability

How should parents respond to different fever grades? For low-grade fevers, monitoring and comfort measures are often sufficient. High-grade fevers may require more aggressive treatment and possibly medical evaluation, especially if accompanied by concerning symptoms.

When to Seek Medical Attention for a Child’s Fever

While most fevers in children are not cause for alarm, there are certain situations where medical attention should be sought promptly. Understanding these scenarios can help parents make informed decisions about their child’s health.

Age-Based Guidelines

The age of the child plays a crucial role in determining when to seek medical care:

• Infants under 3 months: Any fever (100.4°F or higher rectally) requires immediate medical attention
• 3-6 months: Fever of 102°F or higher warrants a call to the pediatrician
• 6 months and older: Fever lasting more than 3 days or accompanied by concerning symptoms should be evaluated

Concerning Symptoms

Regardless of the child’s age, certain symptoms accompanying a fever necessitate medical evaluation:

• Difficulty breathing or rapid breathing
• Severe headache or neck stiffness
• Persistent vomiting or diarrhea
• Signs of dehydration (dry mouth, sunken eyes, reduced urine output)
• Seizures or convulsions
• Unusual rashes or skin discoloration
• Extreme lethargy or unresponsiveness

Do all high fevers require immediate medical attention? Not necessarily. The child’s overall behavior and accompanying symptoms are often more important indicators than the temperature alone. However, any fever that persists for more than three days or doesn’t respond to over-the-counter medications should be evaluated by a healthcare professional.

Effective Methods for Reducing Fever at Home

While fevers play a crucial role in fighting infections, they can cause discomfort for children. There are several effective methods parents can use to help reduce fever and alleviate symptoms at home.

Over-the-Counter Medications

Acetaminophen and ibuprofen are commonly used to reduce fever in children. It’s important to follow dosage instructions based on the child’s weight and age:

• Acetaminophen: Can be given every 4-6 hours
• Ibuprofen: Can be given every 6-8 hours (not recommended for infants under 6 months)

Never give aspirin to children or teenagers, as it can cause a rare but serious condition called Reye’s syndrome.

Non-Medicinal Approaches

Several non-medicinal methods can help reduce fever and increase comfort:

• Cool compresses: Apply to the forehead, wrists, and back of the neck
• Lukewarm baths: Can help lower body temperature (avoid cold baths, which can cause shivering)
• Adequate hydration: Offer plenty of fluids to prevent dehydration
• Light clothing: Dress the child in lightweight, breathable clothing
• Rest: Encourage plenty of rest to help the body fight the infection

Is it necessary to try to break a fever quickly? In most cases, allowing a low-grade fever to run its course can be beneficial for fighting the underlying infection. Focus on keeping the child comfortable rather than aggressively trying to lower the temperature.

The Impact of Fever on a Child’s Body and Behavior

Fever can have various effects on a child’s body and behavior, ranging from mild discomfort to more significant changes. Understanding these impacts can help parents better care for their feverish children.

Physical Effects

Fever can cause several physical changes in a child’s body:

• Increased heart rate and breathing rate
• Flushed skin or paleness
• Sweating or chills
• Muscle aches and weakness
• Decreased appetite
• Dehydration due to increased fluid loss

Behavioral Changes

Children with fever may exhibit various behavioral changes:

• Increased irritability or fussiness
• Lethargy or decreased activity
• Changes in sleep patterns (increased sleepiness or difficulty sleeping)
• Reduced interest in play or normal activities
• Clingy behavior or seeking more comfort from parents

Can fever cause permanent damage to a child’s brain? Contrary to common belief, typical fevers (under 107°F) do not cause brain damage. The body has built-in mechanisms to prevent temperatures from rising to dangerous levels. However, very high fevers or rapid temperature increases can potentially lead to febrile seizures in some children, which, while frightening, are generally not harmful in the long term.

Potential Complications of High Fever in Children

While most fevers in children are benign and resolve without complications, high fevers can occasionally lead to more serious issues. Being aware of these potential complications can help parents recognize when additional medical attention may be necessary.

Febrile Seizures

Febrile seizures are convulsions that can occur in some children with high fevers. While alarming, they are generally not harmful:

• Affect about 2-5% of children between 6 months and 5 years old
• Usually last less than a minute
• Do not typically cause long-term neurological problems

If a child experiences a febrile seizure, it’s important to seek medical evaluation to rule out more serious underlying conditions.

Dehydration

High fevers can lead to increased fluid loss through sweating and rapid breathing, potentially causing dehydration. Signs of dehydration include:

• Dry mouth and lips
• Sunken eyes
• Decreased urine output
• Lethargy or irritability

Ensuring adequate fluid intake is crucial during a fever to prevent dehydration.

Underlying Serious Infections

In rare cases, high or persistent fevers may be a sign of a more serious underlying infection, such as:

• Meningitis
• Sepsis
• Pneumonia
• Urinary tract infections

These conditions typically present with additional symptoms beyond just fever and require prompt medical attention.

How can parents differentiate between a typical fever and one that might indicate a more serious condition? Pay close attention to the child’s overall behavior, energy levels, and any accompanying symptoms. If a child with a high fever appears extremely lethargic, has difficulty breathing, or shows signs of severe pain, seeking immediate medical care is advisable.

Fever Myths and Misconceptions: Separating Fact from Fiction

There are many myths and misconceptions surrounding fevers in children. Understanding the facts can help parents make informed decisions about their child’s care and reduce unnecessary anxiety.

Common Fever Myths

Let’s examine some prevalent myths about fever:

1. Myth: All fevers are dangerous and need to be treated immediately.
2. Fact: Most fevers are beneficial and help the body fight infections.
3. Myth: Fevers will keep rising if left untreated.
4. Fact: The body has internal mechanisms to regulate temperature and prevent dangerously high fevers.
5. Myth: Fever always indicates a serious illness.
6. Fact: Many common, minor illnesses can cause fever.
7. Myth: Children with a fever shouldn’t eat.
8. Fact: While appetite may be reduced, children should be encouraged to eat if they feel up to it.
9. Myth: Cold baths are the best way to reduce fever.
10. Fact: Cold baths can cause shivering, which can actually raise body temperature. Lukewarm baths are more effective.

The Truth About Fever

Understanding the realities of fever can help parents respond appropriately:

• Fever is a symptom, not an illness itself
• The height of the fever doesn’t necessarily correlate with the severity of the illness
• Most fevers in children are caused by viral infections that resolve on their own
• Treating a fever doesn’t cure the underlying cause but can provide comfort

Why do these myths persist, and how can parents get accurate information about fever? Many fever myths are rooted in outdated medical beliefs or exaggerated fears. To get accurate information, parents should consult reputable medical sources, talk to their pediatrician, and stay informed about current medical recommendations regarding fever management in children.

By understanding the facts about fever, parents can approach their child’s illness with confidence and provide appropriate care without unnecessary worry. Remember that while fever can be concerning, it’s often a sign that the body is working effectively to fight off an infection.

Fever 101 – A guide to kid’s fevers

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Posted: May 09, 2022

Fever in children can be a scary thing for parents, often causing them to wonder if a trip to the emergency room is necessary. Le Bonheur Pediatrician Ruth Patton MD, of Pediatric Consultants, shares the advice she often gives parents when their child feels feverish.

“Don’t panic,” says Dr. Patton. “Know that fever is the body’s natural reaction to infection.

Dr. Patton offers three important questions to ask yourself when your child has a high temperature:

1. Is your child’s breathing labored?
2. Is your child drinking less or experiencing decreased urine output?
3. Is your child crying inconsolably?

If you answer yes to any of these questions, it’s best to call your pediatrician’s office, no matter your child’s degree of fever.

Dr. Patton stresses that if you have an infant younger than 2 months with a rectal temperature of 100. 4 degrees Fahrenheit or higher, you need to call your pediatrician immediately. Fever in newborns does require an exam, as newborns have immature immunity and are more susceptible to serious illness.

Even if your child does not show signs of serious illness, a fever can make him or her uncomfortable. To make your child as comfortable as possible, you can provide temporary relief by administering a dosage of acetaminophen or ibuprofen if he or she is 6 months or older. Most children with a temperature lower than 101 degrees Fahrenheit may not need medication, but if you notice that your child is uncomfortable, it won’t hurt to give them an over-the-counter medicine. You should also keep your child dressed in light clothing, keep the house at a comfortable temperature, offer plenty of fluids and make sure they rest.

Knowing your child’s normal behavior and the symptoms that are accompanying the fever is the most important information for you to consider. As long as you don’t notice any of the three red flags, a trip to the doctor’s office probably isn’t necessary. Just remember to monitor your child closely. If the fever has not reduced after 24 hours on medication, call your child’s pediatrician.

What temperature is a fever?

100.4 degrees Fahrenheit measured rectally, orally, temporally (forehead) or tympanically (ear).

What ‘is’ a fever?

Fever is the body’s natural defense against infection.

When should I call the doctor?

Call your pediatrician if you have an infant younger than 2 months with a rectal temperature of 100.4F or if your child is experiencing any of the following:

• Labored breathing
• Inconsolable crying
• Decreased drinking or urine output

You should also call your doctor if you have a child with a temperature higher than 104 degrees Fahrenheit or temperature does not respond to medication.

What should I do if my child has a temperature of 104 degrees Fahrenheit but is acting normally?

If your child is not exhibiting any of the behavioral red flags, give your child a dosage of acetaminophen or ibuprofen if he or she is at least 6 months old. Continue to monitor your child’s behavior and call the doctor if the fever has not gone down after 24 hours with medication.

What type of thermometer and method gives the most accurate temperature reading?

A digital thermometer administered rectally will give you the most accurate temperature.

Authored by:

Ruth Patton, MD

Le Bonheur Pediatrician

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Fever 101: The why, how and what to do for fevers in children

“I don’t feel so good,” your child groans. You put a hand to your child’s forehead, and sure enough, it’s warm to the touch. Fever strikes again!

A fever is not an illness itself – it is actually a sign that the body is fighting off an infection. And while fevers may cause your child discomfort, they are generally not a serious health concern. Fevers usually go away on their own after a few days.

High, medium, low: When is it fever? Though 98.6F is considered a “normal” body temperature, our temperatures actually fluctuate throughout the day. But anything above 100.3F is considered a fever.

Normal body temperature is typically highest in the evening, says Carlos Lerner, MD, UCLA pediatrician. So when your child is sick, that natural increase in body temperature, plus the elevated temperature caused by the fever, means your child may be most miserable during evening and nighttime hours.

“Everything hurts” Common symptoms of fever include:

• Temperature on the thermometer is higher than normal
• Hot, dry skin
• Sweating, shivering and/or chills
• Weakness
• Muscle aches
• Loss of appetite
• Headache
• Dehydration

Three ways to take your child’s temperature Even if you can tell by touch that your child has a fever, it’s a good idea to take his or her temperature, so you have an accurate reading. This is especially important in younger children, because a high temperature may warrant a call to your doctor.

There are three commonly used thermometers you can use to get an accurate temperature. Most should give you a reading within 10 seconds to two minutes.

• Rectal: This is best for infants and has a high level of accuracy. Insert the flexible tip of the thermometer into your child’s rectum, but no further than an inch. Be sure to use this thermometer for rectal temps only. Keep a separate one around for taking temperature by mouth.
• Oral: When children are a little older (around age 4), they can hold the tip of the thermometer under their tongues, with their mouths closed.
• Ear: Insert the thermometer into your child’s ear. This is best for babies 6 months and older because the ear canals in younger babies may be too narrow.

Treating a fever You can’t “cure” a fever, but these steps may make your child more comfortable:

• Dressing lightly
• Drinking plenty of liquids
• Taking a lukewarm bath if they have the chills
• Placing a cold washcloth on the forehead or wrists
• Taking medicine:
  • For children older than 3 months with a temperature of 102F or more, you can give acetaminophen (Tylenol).
  • For children older than 6 months, you can also give ibuprofen (Motrin®).
  • If your child is older than 3 months with a temperature below 102F, he/she does not typically require medication.

A child can return to daycare or school after being fever-free for 24 hours.

When a fever is serious Though you usually do not need to schedule a doctor’s visit at the first sign of fever, you should call your doctor if your child has these symptoms:

• A temperature of 104F or higher
• Fever that lasts more than three days (or more than 24 hours for children under age 2)
• Seizure, irregular breathing, stiff neck, vomiting or not eating/drinking
• Fever 100.4F or higher among children younger than 3 months
• Temperature above 102.5F for children between the ages of 3 and 6 months

These may be signs of a more serious illness and should be addressed immediately.

For your child’s fevers, and any other aches and pains of childhood, make an appointment with the expert pediatricians at Mattel Children’s Hospital UCLA.

Lassa fever – Nigeria

Outbreak summary

Nigeria is currently experiencing a major outbreak of Lassa fever, during which 4702 cases of under vision for the disease, five probable cases and 877 confirmed cases. Among cases with a confirmed diagnosis, 152 deaths were registered (case fatality rate 17%). Lassa fever is endemic in Nigeria and parts of West Africa, where the African polynipple rat is a major reservoir of the Lassa virus.

The implementation of anti-epidemic measures in connection with the current outbreak is hampered by the fact that the country currently has to respond to a number of emergencies at the same time.

The disease is characterized by a wide variety of symptoms, and therefore the diagnosis can be difficult. Most infections (about 80%) caused by the Lassa virus are asymptomatic or mild. However, the infection can cause severe disease with multiple organ dysfunction, with or without bleeding. Therefore, laboratory testing is required to confirm the diagnosis.

Laboratory-confirmed cases of Lassa fever have been reported in states bordering Cameroon (Adamawa, Benue, Cross River and Taraba) and Benin (Oyo and Niger). The overall risk at the regional and global levels is assessed as low because the main route of transmission for Lassa virus is contact with food or household items contaminated with rat feces. There is a low level of human-to-human transmission.

Lassa fever epidemiological situation

Nigeria is experiencing a major outbreak of Lassa fever with 4,702 suspected cases, five probable cases, and 877 confirmed cases between epidemiological weeks 1 and 15 of 2023 (week ending 16 April). Among cases with a confirmed diagnosis, 152 deaths were registered (case fatality rate 17%). The number of cases with a confirmed diagnosis increased by 20% compared to the same period in 2022 (733 cases).

Cases have been reported in 101 Local Government Areas (LGAs) in 26 of 36 states, including the Federal Capital Territory (FCT). Three states have a high concentration of confirmed cases (72%): Ondo (32%), Edo (29%) and Bauchi (11%). Laboratory-confirmed cases of Lassa fever have been reported in states bordering Cameroon (Adamawa, Benue, Cross River and Taraba) and Benin (Oyo and Niger).

Lassa fever epidemiology

Lassa fever is an acute viral haemorrhagic disease caused by the Lassa virus. The virus is most commonly transmitted to humans by direct contact with infected rodents of the genus Mastomys or by contact with food or household items contaminated with the urine or droppings of infected rodents. Accordingly, the virus is transmitted to a person through cuts and scratches or by inhalation of dust particles contained in the air. Person-to-person transmission can occur through direct contact with the blood or body fluids of an infected person, but is rare. Secondary transmission in health care settings can occur when the disease is detected late and treatment is started, and when adequate infection prevention and control (IPC) measures are not followed.

Most Lassa virus infections (about 80%) are asymptomatic or mild, but in about 20% of cases the virus can cause severe disease, sometimes with multi-organ dysfunction with or without bleeding. Without proper laboratory tests, the diagnosis of Lassa fever is difficult due to the variety of possible symptoms of the disease, from asymptomatic infection to multiple organ failure and death.

In patients hospitalized with severe disease, the case fatality rate is typically between 1% and 15%. The disease is particularly severe in the later stages of pregnancy, with rates of maternal death and/or fetal loss exceeding 80% during the last trimester. Maintenance therapy with rehydration and symptomatic treatment in the early stages of the disease is essential to increase the chances of survival. The antiviral drug ribavirin is used to treat Lassa fever, but its effectiveness has not been proven. To date, there is no vaccine against Lassa fever.

The disease was first reported in 1969 in the state of Borno in Nigeria, where it is endemic. Transmission of infection is observed throughout the year. However, large seasonal outbreaks occur during the dry season, usually from December to April.

In 2023, 42 cases were reported among healthcare workers in 11 states during the period from the 1st to the 15th epidemiological week. During epidemiological week 15, 2023 (April 10-16), 141 new cases with suspected Lassa fever, nine new confirmed cases and one new confirmed case with a fatal outcome (case fatality rate of 11%) were reported.

The implementation of anti-epidemic measures in connection with the current outbreak is hampered by the fact that the country currently has to respond to a number of emergencies at the same time. These include outbreaks of COVID-19, diphtheria, meningitis, measles, cholera and ongoing humanitarian crises. In addition, the country is forced to solve security problems, which makes it difficult to carry out anti-epidemic measures in a timely manner.

Public health response

The Nigerian Centers for Disease Control and Prevention (NCDC) and health authorities in the affected states are taking the lead in controlling the outbreak. On January 28, 2023, the National Center for Emergency Situations (ECS) of the NCDC became operational, and Rapid Response Teams (RRTs) were sent to the states of Bauchi, Benue, Ebonyi, Edo, Ondo and Taraba.

Anti-epidemic measures include:

• surveillance: detection, monitoring of cases and outbreaks of the disease and laboratory testing;
• care for the sick;
• preventive measures: educating the public about personal hygiene, food safety and rodent control in the place of residence and work;
• Response: prescribing antivirals, supportive care to confirmed patients, and tracing contracted individuals to identify those who may have been exposed to the virus.

To strengthen the response to the outbreaks of Lassa fever in Nigeria, the NCPC, in collaboration with WHO and other partners, developed a national outbreak prevention and control action plan. This plan includes measures to improve surveillance, increase the efficiency and capacity of national laboratories, increase public awareness and ensure greater access to treatment and care services for patients.

WHO risk assessment

Lassa fever is an acute hemorrhagic fever disease that is endemic in West Africa. Confirmed outbreaks and sporadic cases of Lassa fever have been reported in Benin, Burkina Faso, Côte d’Ivoire, Guinea, Ghana, Liberia, Mali, Sierra Leone, Togo and Nigeria. In some regions, rodents of the genus Mastomys are eaten.

Nigeria is a Lassa fever endemic country and has developed capacity to control outbreaks of the disease, but the overall national risk is currently assessed as high due to several factors:

• increase in the number of confirmed cases compared to the same period in previous epidemic seasons;
• reduced national capacity due to the need to respond to a range of current health emergencies, which has overburdened the country’s health system and limited the availability of medical resources;
• lack of personal protective equipment (PPE), which poses a high risk of spread of healthcare-associated infections;
• delays in transport of biomaterial specimens for laboratory testing in several states resulting in delayed confirmation of diagnosis and provision of treatment and care;
• Poor health infrastructure, poor sanitation and continued presence of virus-carrying rodents;
• insufficient information and education of the public and health care workers about Lassa fever, which can lead to further delays in diagnosis and treatment and increases the risk of infection and the likelihood of death.

Overall regional and global risk is assessed as low because Lassa virus is transmitted to humans primarily from animals and there is low human-to-human transmission.

WHO recommendations

Prevention of Lassa fever involves good hygiene at the community level to control the entry of rodents into homes. Effective measures include keeping grains and other foodstuffs in rodent-proof containers, removing waste disposal sites from homes, keeping homes clean, and keeping pet cats.

When caring for patients in health care settings, regardless of the suspected diagnosis, health care workers should always follow standard infection prevention and control measures. These measures include practicing hand and respiratory hygiene, using personal protective equipment against splashes or other contact with infectious materials, using safe injection practices, and ensuring the safe burial of the deceased.

Healthcare workers caring for patients with suspected or confirmed Lassa fever should take additional infection control measures to prevent contact with patients’ blood and body fluids, and with contaminated surfaces or materials, such as clothing and bedding. When in close contact with patients with Lassa fever (within one meter), healthcare workers need face protection (face shield or surgical mask and goggles), a clean, non-sterile long-sleeved gown, and gloves (sterile gloves are required for some medical procedures).

There are currently no registered vaccines to protect people against Lassa fever. In the early stages of the disease, the antiviral drug ribavirin may be an effective treatment for Lassa fever, but the evidence is conflicting. Evidence on the effectiveness of ribavirin as a post-exposure prophylactic for Lassa fever is not available.

WHO continues to recommend that all Lassa fever endemic countries improve their early case detection and treatment in order to reduce the number of deaths.

Based on available information, WHO does not recommend any restrictions on passenger or trade traffic for Nigeria.

Additional information

• WHO. Health issues. Lassa fever (in English)
• WHO. News bulletin. Lassa fever
• Lassa fever epidemiological summaries, documents on previous outbreaks
• Nigerian Center for Disease Control, Lassa fever outbreak update in Nigeria (in English)

Citation: World Health Organization
(May 1, 2023). News about disease outbreaks. Lassa fever – Nigeria. Available at https://www.who.int/en/emergencies/disease-outbreak-news/item/2023-DON463

Q fever is a natural focal zoonosis | Lubova

1. Kasatkina I. L. Q fever. M.: State. publishing house honey. literature; 1963.

2. Burnet F.M., Freeman M. Experimental studies on the virus of Q fever. // Med. J. Austr. 1937 Vol. 2. P. 299–305.

3. Derrick E.H. Q fever, a new entity fever: clinical features, diagnosis and laboratory investigation. // Med. J. Aust. 1937 Vol. 2. P. 281–299.

4. Cox H.R. Rickettsia diaporica and American Q fever // Am. J Trop. Med. Hyg. 1940 Vol. 20. P. 463–469.

5. Derrick E.H. The Epidemiology of Q Fever // The Journal of Hygiene. 1944 Vol. 43, N5. P. 357-361.

6. McDade J.E. Historical aspects of Q fever // The Disease. Boston: CRC Press. 1990. Vol.1, P.5–21.

7. Georgiev M., Afonso A., Neubauer H., et al. Q fever in humans and farm animals in four European countries, 1982 to 2010 // Euro urveill. 2013. Vol. 18, N8. P. 20407.

8. Dijkstra F., van der Hoek W., Wijers N., et al. The 2007–2010 Q fever epidemic in the Netherlands: characteristics of notified acute Q fever patients and the association with dairy goat farming // FEMS Immunol. Med Microbiol. 2012. Vol. 64. P. 3–12.

9. Whelan J., Schimmer B., Schneeberger P., et al. Q fever among culling workers, the Netherlands, 2009–2010. // Emerge. Infect. Dis. 2011 Vol. 17, N9. P. 1719–1723.

10. Anderson A.D., Kruszon-Moran D., Loftis A.D., et al. Seroprevalence of Q fever in the United States, 2003–2004. // Am. J Trop. Med. Hyg. 2009 Vol. 81, N4. P. 691–4.

11. Cisak E., Chmielewska-Badora J., Mackiewicz B., et al. Prevalence of antibodies to Coxiella burnetii among farming populationin eastern Poland // Ann. Agric. Environ. Med. 2003. Vol.10. P. 265–267.

12. de Alarcon A., Villanueva J. L., Viciana P., Lopez-Cortes L., et al. Q fever: epidemiology, clinical features and prognosis. A study from 1983 to 1999 in the South of Spain. // J. Infect. 2003 Vol. 47. P. 110–116.

13. Chmielewski T., Tylewska-Wierzbanowska S. Q fever outbreaks in Poland during 2005–2011. // Med. sci. Monitor. 2013. Vol. 19. P. 1073–1079.

14. Amitai Z., Bromberg M., Bernstein M., et al. A Large Q Fever Outbreak in an Urban School in Central Israel. // clinic. Infect. Dis. 2010 Vol. 50, N11. P. 1433–8. DOI:10.1086/652442

15. Schneider T., Jahn H.U., Steinhoff D., et al. A Q fever epidemic in Berlin. The epidemiological and clinical aspects. // Dtsch. Med. Wochenschr.1993 Vol. 118, N19. P. 689–695.

16. Yakovlev E.A., Borisevich S.V., Popova A.Yu. et al. The incidence of Q fever in the Russian Federation and European countries: realities and problems // Problems of especially dangerous inf. 2015. V. 4. S. 49–54.

17. On the state of sanitary and epidemiological well-being of the population in the Russian Federation in 2018: State report. – M.: Federal Service for Supervision of Consumer Rights Protection and Human Welfare, 2019. – 254 p. Available at: https://www.rospotrebnadzor.ru/upload/iblock/798/gosudarstvennyy-doklad-o-sostoyanii-sanitarno_epidemiologicheskogo-blagopoluchiya-naseleniya-v-rossiyskoy-federatsii-v-2018-godu.pdf Link active as of March 17, 2020.

18. On the state of sanitary and epidemiological welfare of the population in Primorsky Krai in 2018 year: State report. – M.: Federal Service for Supervision of Consumer Rights Protection and Human Welfare, 2018. – 343p. Available at: http://25.rospotrebnadzor.ru/c/document_library/get_file?uuid=66d89a32-b813-45f4-926a-0224e04a5f4a&groupId=10156 Link is active as of March 17, 2020.

19. Fedorov L. A. Soviet biological weapons: history, ecology, politics. Moscow: Msoes; 2005.

20. Onishchenko GG, Sandakhchiev LS, Netesov SV et al. Bioterrorism: national and global threat. // Bulletin of the Russian Academy of Sciences. 2003. V. 73, No. 3. pp. 195–204.

21. Weisburg W.G., Dobson M.E., Samuel J.E., et al. Phylogenetic diversity of the Rickettsiae // J. Bacteriol. 1989 Vol. 171, No. 8. P. 4202–6.

22. Arricau-Bouvery N., Rodolakis A. Is Q fever an emerging or reemerging zoonosis? // Vet. Res. 2005 Vol. 36, N3. P. 327–349.

23. Pautov VN Phase variation of Coxiella bunettii (theory and practice) // Zh. microbiol. 1989, vol. 9, pp. 97–103.

24. Panferova Yu.A. Molecular basis of pathogenicity of Coxiella burnetii. // Infection and immunity. 2016. V. 6, No. 1. S. 7–24.

25. Willems H., Lautenschläger S., Radomski K.U., et al. Coxiella burnetii: plasmid types. Rickettsia and Rickettsial Disiases at the turn millennium. // Paris: Elsevier. 1999. P. 92–102.

26. Loban K.M., Lobzin Yu.V., Lukin E.P. Q fever. In: Human rickettsiosis. Guide for doctors. M.: SPb.: ELBI; 2002. pp. 393–453.

27. Mediannikov O., Fenollar F., Socolovschi C. Coxiella burnetii in humans and ticks in rural Senegal. // PLoS Negl. Trop. Dis. 2010 Vol. 4, N 4. P. 654.

28. Freilikhman OA, Panferova Yu. A., Saines TV, et al. Infection of ticks with pathogens of infectious tick-borne borreliosis and Q fever in St. Petersburg. // Infection and immunity. 2016.T. 6, no. 3. P.118.

29. Hellenbrand W., Breuer T., Petersen L. Changing epidemiology of Q fever in Germany, 1947–1999. // Emerge. Infect. Dis. 2001 Vol. 7, N5. P. 789–796.

30. Daiter A.B., Rybakova N.A., Tokarevich N.K. et al. Epidemic projection of intraherbal foci of Q fever // Zhurn. microbiol. 1988. No. 11. S. 51–56.

31. Berri M., Souriau A., Crosby M., et al. Shedding of Coxiella burnetii in ewes in two pregnancies following an episode of Coxiella abortion in a sheep flock. // Vet.Microbiol. 2002. Vol. 85, pp. 55–60.

32. Malov V. A., Gorobchenko A.