Karadzinska-Bislimovska et al.

Brucellosis as an Occupational Disease

Macedonian Journal of Medical Sciences. 2010 Sep 15; 3(3):251-256.

doi:10.3889/MJMS.1857-5773.2010.0129
Public Health
OPEN  ACCESS

Brucellosis as an Occupational Disease in the Republic of

Macedonia
Jovanka Karadzinska-Bislimovska, Jordan Minov, Dragan Mijakoski, Sasho Stoleski, Sasho Todorov

Occupational Health Institute of Republic of Macedonia, WHO Collaborating Center, Skopje, Republic of Macedonia

Abstract
Citation: Karadzinska-Bislimovska J, Minov J, Brucellosis, a bacterial disease caused by species of the genus Brucella, is an important zoonosis and
Mijakoski D, Stoleski S, Todorov S. Brucellosis as
recognized as an occupational disease. A high risk of infection with Brucella is associated with certain
an Occupational Disease in the Republic of Mac-
edonia. Maced J Med Sci. 2010;3(3):251-256. workplaces related to direct contact with infected animals or their products. Infection may occur by
doi.10.3889/MJMS.1957-5773.2010.0129. inhalation of infectious aerosols, conjunctival contamination, skin contamination, contact with laboratory
Key words: zoonosis; occupational health; occu- cultures and tissue samples, and accidental injection of live vaccines.
pational risk; preventive measures.
Correspondence: Prof. Jovanka Karadzinska-
Brucellosis is included as an occupational disease in the Macedonian List of Occupational Diseases,
Bislimovska, MD, PhD. Occupational Health Insti- and diagnosis and verification of the occupational diseases, according to the national medical criteria,
tute, WHO Collaborating Center, II Makedonska are realized at the Occupational Health Institute of R. Macedonia. According to the official health
brigada 43, MKD-1000 Skopje, R. Macedonia.
Phone: +389 70 830 881; Fax: +389 2 2621 428.
statistics, in the last two decades in Macedonia as an endemic region, a high incidence of human
E-mail: [email protected] brucellosis has been registered, with more than 300 reported cases per year. In spite of a possible high
Received: 08-Feb-2010; Revised: 03-Mar-2010; occupational risk of infection with Brucella sp in the confirmed cases of disease, during 2008-09 just 12
Accepted: 03-Mar-2010; Online first: 04-Sep-2010 cases of brucellosis (6 stockmen, 5 veterinarians and an agronomist) were confirmed as an occupational
Copyright: © 2010 Karadzinska-Bislimovska J. disease. These data suggest that human brucellosis is underdiagnosed and underreported as an
This is an open-access article distributed under occupational disease at national level.
the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribu- An adequate management of brucellosis with a multidisciplinary approach should provide more
tion, and reproduction in any medium, provided
the original author and source are credited. accurate reported data in occupational epidemiology in the country.
Competing Interests: The author have declared
that no competing interests exist.
There is a need to strengthen joint actions within the health care system, to promote an intersectoral
collaboration and to support the successful realization of national control programme at the community
level.

Introduction it is well controlled in most developed countries. Its

incidence has been decreasing in countries that have
Brucellosis is a bacterial disease caused by spe-
been able to control the disease in animals. However,
cies the genus Brucella. It is an important zoonosis and
every year 0.5 million new cases are recorded, and most
the infection is generally transmitted to people by direct
are caused by B. sp. [1]. Clinical disease is still common
or indirect contact with infected animals or their prod-
in the Middle East, Asia, Africa, South and Central
ucts. Brucellosis can be recognized as an occupational
America and the Mediterranean Basin.In endemic ar-
disease in individuals who work directly in contact with
eas, the reported incidence ranges from less than 0.01
animals.
to more than 200 cases per 100,000 population [1].
Although brucellosis is present in many countries, Human brucellosis is the most common zoonosis in the

Maced J Med Sci. 2010 Sep 15; 3(3):251-256. 251

Public Health

Republic of Macedonia and is still a serious problem, nation, insemination, vaccination, and treatment of ani-
presenting with a high percentage of focal forms, re- mal diseases.
lapses and therapeutic failures in infected persons [2].
Laboratory workers with specific occupational
In the last decade, according to the epidemiologi- exposure to contaminated specimens and Brucella cul-
cal data from different countries, an occupational expo- tures are also identified as an occupational group at high
sure or direct contact with animals or animal products occupational risk. At particular workplace risk of infec-
during professional practice related to the human bru- tion with Brucella are the workers in laboratories where
cellosis were reported with large variations from 18% [3] culturing of Brucella species is performed. Brucella
to more than 90% [4]. The data have shown that brucel- aerosols could be generated by the handling of cultures
losis as an occupational disease is still a present and and their inhalation, as in centrifugation when breakage
future public health challenge. of containers occurs and presents the highest risk. The
processes of preparation and use of live vaccines,
Clinical features of human brucellosis as well as application of diagnostic procedures, and preparation of
its long convalescence suggest that brucellosis is a diagnostic antigens, are also characterized with high
significant medical, economic and social problem with occupational risk.
public health impacts at individual and community lev-
els. Employees engaged in the processing of animal
products, such as slaughtermen, butchers, meat pack-
The aim of this paper is to recognize the occupa- ers, collectors of foetal calf serum, processors of hides,
tional exposure and its importance as one of the main skins and wool, renderers as well as dairy workers may
sources for human brucellosis. On the other hand, the be exposed to Brucella species.
objective is to emphasize the public health point of view
in an integrated, intersectoral and multidisciplinary ap- Workers performing their tasks at the workplace
proach in the prevention of brucellosis as an occupa- are generally infected by inhalation of infectious aero-
tional disease, with particular focus on the Macedonian sols, contamination of conjunctivae, ingestion, skin con-
experience in this issue. tamination through cuts or abrasions, and rarely by
contact with laboratory cultures and tissue samples, and
accidental self-inoculation with live vaccines.
Workplaces and occupational exposure
A high occupational risk of infection with Brucella
species is associated with specific workplaces where Clinical course of Brucellosis
employees are working in direct contact with infected Brucellosis is an acute or sub-acute febrile illness
animals or their products. This includes certain workers, often characterized by an intermittent or remittent fever
such as farmers, stockmen, shepherds, goatherds, ab- accompanied by malaise, anorexia and prostration, and
attoir workers, butchers, dairymen, veterinarians, labo- which, in the absence of specific treatment, may persist
ratory workers, health care workers, and those involved for weeks or months. The acute phase may progress to
in the processing of viscera, hides, skins and wool. The a chronic one with relapse, development of persistent
highest level of occupational risk is assumed at the localized infection or a non-specific syndrome resem-
workplaces where individuals are working with animals bling the “chronic fatigue syndrome” [5].
during abortion or parturition and during other contacts
with infected animals, like shearing, dipping, examina- Brucellosis as an occupational disease is usually
tion, vaccination and treatment as well as during disin- associated with inability for work for a relatively long
fection and cleaning of contaminated premises. period, long and expensive treatment, slow recovery
and very often relapses and possible serious sequelae
One should point out that the way of disease in the musculoskeletal and nervous system.
acquisition in many professionally exposed workers is
almost impossible to determine, and quite often it is a
result of not only one, but more risk activities (different Epidemiology
entry portals at the same time).
The global burden of human brucellosis remains
The occupational risk in veterinarians is the high- enormous; it causes more than 500,000 infections per
est during abortion or parturition of animals, their exami- year worldwide [6]. In Europe, 1,033 human brucellosis

252 http://www.mjms.ukim.edu.mk
 Karadzinska-Bislimovska et al. Brucellosis as an Occupational Disease

cases were reported in 2006 [7]. The annual incidence Those differences in the reported data are related
of human brucellosis in the U.S. is less than 0.5 cases to the degree of endemnicity, level of specific occupa-
per 100,000 persons; approximately 100 cases are tional risk, implementation of specific preventive and
reported annually [1]. In Mediterranean and Middle East control measures, education, information, socioeconom-
countries the annual incidence of brucellosis in people ics, density of cattle, sheep and goat herds, and eating
varies from less than 1 to 78 cases per 100,000 [8]. The habits.
mean annual incidence rate for the population of the
area of North-western Greece was 17.3 cases/100,000
inhabitants [9]. In Spain, brucellosis occurs in epidemic Brucellosis as an occupational disease in
cycles and the peak was in 1984 with 22.7 cases per R. Macedonia – different aspects of the
100,000 population and a total of 596 cases were
problem
registered in 2004 (1.5 cases per 100,000 population)
[10]. In 2004,300 cases of human brucellosis were Brucellosis as an occupational disease has seri-
reported in Macedonia [11]. ous public health consequences such as absenteeism,
work disability, long rehabilitation and socio-economic
In the last few years, numerous epidemiological implications.
studies from different countries have focussed on the
problem of occupational exposure related to human Brucellosis is included in the new List of Occupa-
brucellosis. German studies from 2007 reported direct tional Diseases as an occupational disease [16] and the
contact with animals or animal products during profes- Macedonian List is harmonized with the EU List of
sional practice in 18% of all cases with brucellosis [3]. On Occupational Diseases from 2003, stipulated by the
the other hand, in a Greek study, more than 90% of all Pension and Disability Act. Additionally, a Rulebook on
brucellosis cases referred to occupational exposure [4]. the Confirmation and Verification of Occupational Dis-
eases has been published. This document contains
More than 60% of the patients with brucellosis specific conditions and medical criteria for each occupa-
from the Macedonian study [11] identified occupational tional disease which have to be fulfilled in order to verify
exposure as one of the potential sources of infection. the occupational characteristics of the disease. Diagno-
A serological survey carried out in Bénin in ex- sis and verification of the occupational diseases, ac-
posed workers (workers in slaughterhouses and breed- cording to the national medical criteria, are realized at
ers) showed that the percentage of positive sera among the Occupational Health Institute of the Republic of
exposed workers was 17.7% [12]. The study of the Macedonia, WHO Collaborating Center. When brucello-
epidemiology of brucellosis in Granada province elabo- sis is verified as an occupational disease, a special form
rated that the occupational group with the highest risk is sent to the employer and to the Pension Fund in order
were veterinarians in whom the disease was 31 times to notify them and another one is sent to the Institute of
more common than in the rest of the population [13]. In Public Health for the purposes of registration of occupa-
the study concerning some epidemiological aspects of tional diseases.
the infection by Brucella abortus in high risk occupa- The Occupational Health Institute and its expert
tional groups in the microregion of Araguaína, Tocantins, team are authorized for the preparation of expertise for
Brazil, it was found that 4.1% of serums were positive medical verification of occupational diseases. In order to
among slaughterhouse employees, while the frequency verify and to confirm that brucellosis is an occupational
of positive serums in rural workers was 8.1% [14]. The disease it is necessary to have evidence that a worker
same study showed that individuals born in the country- had been performing his tasks and duties at the workplace
side have a higher probability of being infected with B. where contact with possibly infected animals and animal
abortus than those born in cities and a significant asso- products was present (positive workplace history). Addi-
ciation was found between previous work in direct con- tionally, for the same purpose, brucellosis has to be
tact with production animals and seropositivity. Spinola diagnosed in its acute, subacute or chronic forms and
and Costa in Salvador, Bahia, studied human brucello- diagnosis has to be verified by a doctor – a specialist in
sis in 128 cold storage plant workers under the serologi- infectious diseases. Worker’s contact with Brucella spp.
cal, occupational and clinic perspective. They reported has to be documented and verified. The data obtained
a seropositivity of 10.6% [15]. Regarding rural workers, from veterinary authorities should provide objective evi-
Ramos, et al, in a serological study conducted on 33 dence about the presence of Brucella spp. in the animals
rural workers reported a prevalence of 21.1% [14].

Maced J Med Sci. 2010 Sep 15; 3(3):251-256. 253

Public Health

or animal products. Occupational exposure should be notification of the diseases, including brucellosis as an
considered in the specific case when a worker during his occupational disease.
workplace tasks and duties, had experienced a workplace
contact with seropositive animals or animal products
which were positive on cultures for Brucella spp. It is Preventive measures
necessary to have evidence that the worker was present
at the workplace in the same period and at the same Good workplace practice, safe work, control and
place where Brucella spp. were found in the animals or reduction of risks and protective measures should be
animal products. implemented at any workplace with high occupational
risk of infection with Brucella spp. [5].
During the period 2008-009, 12 cases of brucel-
losis (6 stockmen, 5 veterinarians and an agronomist) The prevention must be based on the elimination
were confirmed as cases of occupational diseases. of direct or indirect exposure to infected animals or their
According to the epidemiological and clinical studies products. But, elimination of the disease from animals is
concerning human brucellosis in Macedonia, brucello- often difficult to implement, especially in endemic re-
sis is underdiagnosed and underreported as an occupa- gions as well as in developing countries. Therefore, the
tional disease. goal is to reduce the risk through personal hygiene,
adoption of safe working practices, protection of the
In order to improve occupational epidemiology at environment and food hygiene.
a national level concerning data on human brucellosis
some steps should be realized in different segments of The personal protective equipment of employ-
the health care system in the country. ees in the workplaces with high occupational risk of
brucellosis includes appropriate protective clothing (coat,
Closer collaboration between medical doctors rubber or plastic apron), rubber gloves and boots, eye
from different disciplines (primary health care, infectious protection, as well as protection of respiratory exposure.
disease, occupational health) should be improved and The work clothes should be disinfected after use (heat
should support the process of verification and confirma- treatment, chemical disinfectants, etc.) and workers
tion of brucellosis as an occupational disease. should wash their hands using a disinfectant solution
Pphysicians should be aware of the possible occupa- and soap and water with special attention to superficial
tional characteristic of the disease, especially in employ- skin injuries.
ees with evidence of occupational risk of infection with
Brucella. The inclusion of brucellosis as an occupational It is also necessary to think about eye protection
disease in the differential diagnosis of the febrile patients due to the possibility of conjunctival contamination.
who belong to high-risk groups could be very important Respiratory contamination by inhalation of aerosols or
from both the clinical and occupational health points of dust derived from infected excreta or tissues should be
view. It is necessary to emphasize the difficulties and prevented by use of adequate respirators with change-
challenges for the doctor to confirm/exclude whether able antibacterial filters.
brucellosis in the patient is an occupational disease in an Adoption of safe working practices and pro-
endemic region. tection of the working environment is a very important
In the context of regular preventive medical ex- step in the reduction of the occupational risk of brucello-
aminations of workers at specific risk of infection with sis. Certain workplaces and working operations with
Brucella spp., occupational health physicians should high occupational risks of infection with Brucella spp.
recognize early signs of the disease and should take require special protective measures and safe working
over all measures of early intervention in affected work- practices.
ers. In the workers with confirmed diagnosis of brucello- Infected animals that are aborting or giving birth
sis, within the medical procedure, the expertise for present specific occupational risks to farm workers and
medical verification of the occupational character of the animal attendants. It is recommended that aborted
disease has to be prepared at the Occupational Health foetuses, placenta and other infected organs and tis-
Institute of the Republic of Macedonia. sues should be collected in special containers and
The new Law on evidence in health in Republic of disposed by incineration. Contaminated premises, used
Macedonia, 2009 [17] should be an additional and vehicles and equipment should be adequately cleaned
important step towards better future registration and and disinfected. An additional problem in the adoption of

254 http://www.mjms.ukim.edu.mk
 Karadzinska-Bislimovska et al. Brucellosis as an Occupational Disease

safe working practices could be nomadic or migratory It is important to stress that in the last decade, a
working conditions of those workers. special preventive programme focussed on various
aspects of human brucellosis (including occupational
Concerning meat processing establishments exposure and high risk groups of exposed workers) has
and rendering plants, it is important to emphasize that been promoted by the Ministry of Health of the Republic
animals infected with Brucella spp. should be slaugh- of Macedonia. This programme offers concrete preven-
tered at specially designated abattoirs and the staff tive measures on different levels and shows the continu-
adequately trained and equipped. Eating, drinking and ous efforts of the government of Republic of Macedonia
smoking must be prohibited at the workplace. Full clean- to deal with brucellosis as a significant public health
ing and disinfection of the premises and the equipment problem in the country.
must be performed at the end of each working day.
Conclusion
Each laboratory should have written procedures
about the use of equipment, disinfection of equipment Brucellosis is an important zoonosis, identified as
and contaminated materials, handling and processing an underdiagnosed and underreported occupational
samples, spill containment and cleanup, and waste disease and represents a serious public health issue in
handling. Bio-safety level 3 is appropriate for handling endemic countries such as the Republic of Macedonia.
Brucella cultures or infected membranes, foetal tissues There is a need to strengthen the joint actions within the
and fluids. health care system between health care workers from
different profiles and disciplines (focussed on occupa-
Medical preventive measures include preven- tional health), between medical associations and or-
tive medical examinations of exposed workers, per- ganizations, the Medical Faculty-School of Public Health
formed by occupational health specialists, according to and the Ministry of Health, through implementation of
the national legislation. In the Republic of Macedonia, specific protective, preventive and promotion meas-
the new Law on safety and health at work [18] empha- ures, supported by new legislation.
sizes that every employed worker should be under
medical surveillance through periodic medical examina- Adequate management of brucellosis with a
tions every 18 months. This Law is an obligation for multidisciplinary approach should provide real epide-
every employer who has to cover expenses for those miological and reporting data on brucellosis as an occu-
examinations. pational disease.

It is necessary to perform pre-employment medi- In order to provide good quality of life in the
cal examinations in individuals who are intending to work workers and productive work in the society it is neces-
with animals or animal products in order to identify sary to promote intersectoral collaboration (health, pub-
workers with diseases or disabilities and to detect vul- lic health, veterinary authorities and agriculture) as well
nerable workers, such as young workers (under the age as to support successful realization of the national
of 18 years) and pregnant women. On the other hand, control programme at the community level.
regular periodical medical examinations should be per-
formed on workers who are already working with ani-
mals or animal products. Within the periodical medical References
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