Vaccination rate and adherence of tick-borne encephalitis vaccination in Germany.

BACKGROUND: Tick-borne encephalitis (TBE) is an arboviral infection of the central nervous system. As there is no causal treatment of TBE, disease prevention by vaccination is especially important. Immunization consists of a three-dose primary vaccination schedule, followed by regular booster doses. In Germany, the Standing Committee on Vaccination (STIKO) at the Robert Koch-Institute recommends TBE vaccination for all those at high risk of contracting TBE. This includes individuals living in, traveling to and/or working in risk areas, and being exposed to ticks. To our knowledge, there are currently no reliable data on TBE vaccination rates in Germany available. METHODS: This retrospective cohort study based on anonymized German health claims data was conducted to determine vaccination rates of TBE primary immunization in 2012 to 2015 by federal state, compliance with the vaccination schedule, and TBE vaccination uptake for the 2011 birth cohort. Vaccination protection rates for each federal state were simulated based on a compartmental model. RESULTS: Vaccination rates of an initiated primary immunization ranged from about 3% in the southern federal states to <1% in the northern federal states. Across all federal states, compliance with the vaccination schedule decreased with each subsequent vaccination. Slightly higher TBE vaccination uptake was determined in the 2011 birth cohort, as compared to the German school entry health examination statistics in 2017. Simulated vaccination protection rates for each federal state ranged from 10% in Hamburg to 51% in Baden-Wuerttemberg. CONCLUSIONS: While there was an overall low vaccination uptake and a discrepancy between areas of high vs. low TBE risk, this study also indicates a concerning decline in vaccination compliance. Vaccinating physicians should address the importance of adherence upon initiation of TBE vaccination.

Research paper on abiotic factors and their influence on Ixodes ricinus activity-observations over a two-year period at several tick collection sites in Germany.

Tick-borne diseases are a public health issue. To predict vector tick abundance and activity, it is necessary to understand the driving factors for these variables. In this study, the activity of Ixodes ricinus was investigated in forest and meadow habitats in Germany with a focus on abiotic factors. Ixodes ricinus adults, nymphs and larvae were caught by flagging over a period of 2 years. Microclimatic and weather conditions were recorded at the collection sites. Statistical models were applied to describe correlations between abiotic factors and tick activity in univariable and multivariable analyses. Tick activity was observed in a broad range of air temperature between 3 and 28 °C, and air humidity varied between 35 and 95%. In general, tick activity of nymphs and larvae was higher in forest habitats than that in meadows. With the exception of a single specimen of Dermacentor reticulatus, all ticks were Ixodes ricinus, most of them nymphs (63.2% in 2009 and 75.2% in 2010). For the latter, a negative binomial mixed-effects model fitted best to the observed parameters. The modelling results showed an activity optimum between 20 and 23 °C for air temperature and between 13 and 15 °C for ground temperature. In univariable analyses, the collection site, month, season, ground and air temperature were significant factors for the number of ticks caught and for all life stages. In the multivariable analysis, temperature, season and habitat turned out to be key drivers. Ixodes ricinus positive for RNA of tick-borne encephalitis virus was only found at a single sampling site. The results of this study can be used in risk assessments and to parameterise predictive models.

Francisella tularensis and other bacteria in hares and ticks in North Rhine-Westphalia (Germany).

Tularemia is a zoonotic disease caused by the bacterium Francisella tularensis. The disease can be transmitted to humans through contact with infected animals such as the European brown hare (Lepus europaeus) and ticks as vectors. The aim of this study was to isolate F. tularensis from ticks and hares in North Rhine-Westphalia using cysteine heart agar to determine their genetic relatedness and to identify other bacteria that grow on this medium. 848 European brown hares and 1556 questing ticks (all Ixodes ricinus) from forests were tested using cultivation and MALDI-TOF mass spectrometry or partial 16S rRNA gene sequencing. The majority of F. tularensis isolates from hares (n=24; 96%) and genomic F. tularensis DNA recovered from ticks belonged to the basal genetic clade IV and subclade B.18. These isolates were sensitive to erythromycin and were assigned to biovar I. Only a single strain isolated from a hare was assigned to basal clade I (B.12/B.35). All isolates were sensitive to tetracycline, doxycycline, streptomycin, gentamicin, chloramphenicol, and ciprofloxacin. Only 4 tick pools were positive for F. tularensis and cultivation was not successful in any of the pools. Most of the other isolated bacteria belonged to the order Bacillales with 36 Staphylococcus isolates, 9 Bacillus isolates and 8 Paenibacillus isolates. Prominent members of Enterobacterales were represented by different genera like Pantoea, Erwinia, Raoultella etc. Several of the bacterial species were soil or plant-associated, but some of the bacterial species were found in I. ricinus for the first time. Our results showed that F. tularensis was detected only in few ticks of an endemic area, but ticks were also infected by several other bacteria with zoonotic potential. Therefore, a wider spectrum of pathogens should be considered if a patient was bitten by a tick.

A Density Map of the Tick-Borne Encephalitis and Lyme Borreliosis Vector Ixodes ricinus (Acari: Ixodidae) for Germany.

The castor bean tick Ixodes ricinus (L.) is the principal vector for a variety of viral, bacterial, and protozoan pathogens causing a growing public-health issue over the past decades. However, a national density map of I. ricinus is still missing. Here, I. ricinus nymphs in Germany were investigated by compiling a high-resolution map depicting the mean annually accumulated nymphal density, as observed by monthly flagging an area of 100 m2 Input data comprise ticks collected at 69 sampling sites. The model domain covers an area of about 357,000 km2 (regional scale). Two negative binomial regression models were fitted to the data to interpolate the tick densities to unsampled locations using bioclimatic variables and land cover, which were selected according to their significance by the Akaike information criterion (AIC). The default model was fitted to the complete dataset resulting in AIC = 842. An optimized model resulted in a significantly better value of AIC = 732. Tick densities are very low in urban (green) areas. Maximum annual densities up to 1,000 nymphs per 100 m2 are observed in broad-leaved forests. The tick maps were verified by leave-one-out cross-validation. Root mean square errors of RMSE = 137 and RMSE = 126 nymphs per 100 m2 were estimated for the two models, respectively. These errors are of the order of the interannual variation of the tick densities. The compilation of a high-resolution density map of unfed nymphal I. ricinus for Germany provides a novel, nationwide insight into the distribution of an important disease vector.

Seroprevalence of tick-borne-encephalitis virus in wild game in Mecklenburg-Western Pomerania (north-eastern Germany).

Mecklenburg-Western Pomerania, a federal state in the north east of Germany, has never been a risk area for TBEV infection, but a few autochthonous cases, along with TBEV-RNA detection in ticks, have shown a low level of activity in natural foci of the virus in the past. As wild game and domestic animals have been shown to be useful sentinels for TBEV we examined sera from wild game shot in Mecklenburg-Western Pomerania for the prevalence of TBEV antibodies. A total of 359 sera from wild game were investigated. All animals were shot in Mecklenburg-Western Pomerania in 2012. Thirteen of 359 sera tested positive or borderline for anti-TBEV-IgG with ELISA and four samples tested positive using NT. The four TBEV-positive sera confirmed by NT constitute the first detection of TBEV-antibodies in sera of wild game in Mecklenburg-Western Pomerania since 1986-1989. This underlines that the serological examination of wild game can be a useful tool in defining areas of possible TBEV infection, especially in areas of low TBEV-endemicity.

Tick-borne encephalitis virus habitats in North East Germany: reemergence of TBEV in ticks after 15 years of inactivity.

The incidence of tick-borne encephalitis has risen in Europe since 1990 and the tick-borne encephalitis virus (TBEV) has been documented to be spreading into regions where it was not previously endemic. In Mecklenburg-West Pomerania, a federal state in Northern Germany, TBEV was not detectable in over 16,000 collected ticks between 1992 and 2004. Until 2004, the last human case of TBE in the region was reported in 1985. Following the occurrence of three autochthonous human cases of TBE after 2004, however, we collected ticks from the areas in which the infections were contracted. To increase the chance of detecting TBEV-RNA, some of the ticks were fed on mice. Using nested RT-PCR, we were able to confirm the presence of TBEV in ticks for the first time after 15 years. A phylogenetic analysis revealed a close relationship between the sequences we obtained and a TBEV sequence from Mecklenburg-East Pomerania published in 1992 and pointed to the reemergence of a natural focus of TBEV after years of low activity. Our results imply that natural foci of TBEV may either persist at low levels of activity for years or reemerge through the agency of migrating birds.

Species determination and characterization of developmental stages of ticks by whole-animal matrix-assisted laser desorption/ionization mass spectrometry.

Matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS) of crude bacterial samples has been introduced as a very cost-efficient and rapid, yet highly informative tool to identify and classify bacteria. The potential of this approach to characterize whole animals, so far preferentially insects, is only evolving. Here, a simple protocol was developed to perform MALDI-MS analysis on extracts from whole ticks of 7 species and 4 developmental stages. Using commercially available software designed for the identification of bacteria, a reference database of spectra was constructed that allowed the species determination of ticks using larvae, nymphs, or adult individuals as starting material. Cluster analysis on the basis of MALDI mass spectra indicated that the primary determinant for the mass spectra was the species, followed by the developmental stages, which formed distinct clusters within the given species. With certain limitations, species identification was also possible using body parts and engorged animals. Spectra of developing Ixodes ricinus eggs showed dramatic changes with time, suggesting that, beyond its usefulness for species determination, MALDI-typing may have applications in developmental biology.

Goats and sheep as sentinels for tick-borne encephalitis (TBE) virus--epidemiological studies in areas endemic and non-endemic for TBE virus in Germany.

The aim of the study was to examine grazing goats and sheep as specific sentinels for characterization of the tick-borne encephalitis virus (TBEV)-related risk in an area by means of serosurveillance tests in the German federal states Baden-Wuerttemberg, Bavaria, Thuringia, North Rhine-Westphalia, Lower Saxony, Schleswig-Holstein, and Mecklenburg-West Pomerania. A total of 3590 sheep sera and 3793 goat sera was collected in 2003 and 2006-2009 and were examined by ELISA screening and confirmed by serum neutralization test. Considerable differences in seroprevalence were seen between single flocks in districts in Baden-Wuerttemberg, Bavaria, and Thuringia with values between 0 and 43% which confirmed the patchy pattern of TBEV foci that can range in size from very small to large. The here described serological screening may be a helpful tool for an early warning system of a potential TBEV risk. Testing of 1700 ticks by real-time RT-PCR in two districts in Baden-Wuerttemberg revealed only one positive tick, thus illustrating the problems of expensive and time-consuming tick collection.

Evaluation of serological tests for detecting tick-borne encephalitis virus (TBEV) antibodies in animals.

Tick-borne encephalitis (TBE) in animals is not well understood yet. TBE virus (TBEV) serology in several host species could be valuable for epidemiological analyses in the field as well as for the detection of clinical cases. However, performance and suitability of the available test systems are not well assessed. Therefore, we evaluated two commercial TBEV-ELISA kits in a pilot study and compared them for their suitability in veterinary applications. For this purpose, we tested 163 field collected goat sera and evaluated the results by serum neutralization test (SNT) as "gold standard". Twenty-eight SNT positive sera (17.2%) were detected. The best suited ELISA kit was used for determination of a species-specific cutoff for horses, cattle, sheep, goats, pigs, mice, dogs, rabbits and monkeys with defined sera from animals without known or with improbable contact to TBEV. The level of non-specific ELISA results does not only differ between animal species but may also be influenced by the age of the tested animals. The number of sera which tested false positive by ELISA was higher in older than in young sheep. In order to obtain defined polyclonal sera as references, two dogs, cattle, goats, sheep, rabbits and pigs each, as well as one horse and 90 mice were immunized four times with a commercially available TBEV vaccine. In conclusion, our results demonstrated that commercial TBEV-ELISA kits are suitable for application in veterinary medicine for both, verification of clinical TBE cases and epidemiological screening. However, positive ELISA results should be verified by SNT. Only a very low number of false negative ELISA-results were found.

Tick-borne encephalitis 2010: epidemiology, risk areas, and virus strains in Europe and Asia-an overview.

Over the past decades, tick-borne encephalitis (TBE) has become a growing public health concern in Europe and Asia and is the most important viral tick-borne disease in Europe. It is also important in the Far East and in other parts of Asia. Vaccination can effectively prevent TBE. It is indicated for persons inhabiting or visiting a TBE endemic area who are likely to be exposed to tick bites. For this purpose, it is necessary to know where TBE virus (TBEV) occurs, where vectors are a potential hazard, and where as a consequence autochthonous TBE cases have been registered. Natural changes in the known TBE foci and the detection of new foci necessitate a summarizing data update to optimize the protection of inhabitants and visitors to TBE endemic areas. The present review includes an overview of the epidemiological data on TBE in Europe and Asia gathered between 1990 and 2009 and describes old and especially new TBE risk areas in Europe and Asia.

Can goats be used as sentinels for tick-borne encephalitis (TBE) in nonendemic areas? Experimental studies and epizootiological observations.

A goat flock grazing year-round on a meadow in a "TBE non-risk area" in Thuringia, Germany, with a history of only isolated human TBE cases was examined repeatedly for TBE virus-(TBEV)-specific antibodies and TBEV RNA between October 2008 and December 2009. Surprisingly, TBEV specific antibodies were detected in one goat, which had never left this area. To compare the results of a natural contact to TBEV with a defined contact to TBEV, two goats were immunized experimentally. Both animals developed TBEV-specific antibodies, one goat however in a delayed and reduced manner. In addition, 177 ticks were collected from the meadow in May and June 2009, and were examined by real-time RT-PCR. However, noTBEV RNA could be detected. The results suggest that goats can be used as TBEV sentinels in defined areas. To verify this observation further investigations with a large number of animals are recommended.

Tick-borne encephalitis in the age of general mobility.

The 11th meeting of the International Scientific Working Group on Tick-borne Encephalitis (ISW-TBE) was conducted under the title of, "From childhood to golden age: increased mobility - increased risk of contracting TBE?" Participants from 26 countries, including the United States of America and China, presented reports on the latest developments and trends in local TBE cases, vaccination coverage and risk factors. In particular, the situation of children and the elderly (the "golden agers") was discussed. As the current evidence suggests, the location and extension of endemic areas for TBE have changed over the last few years, along with global warming and the shift of infected ticks to higher altitudes. The increased mobility of the human population adds to the heightened exposure; outdoor activities and international travel are on the rise also, and especially, amongst the 50+ generation, who are already per se at higher risk of disease manifestation, complications and case fatality. Most Europeans travel within Europe, often without sufficient awareness of endemic areas. Only high immunization rates can ensure low disease rates in the long run. To achieve this goal, public education is the sole effective approach for raising the level of awareness. Overall, the risk of any given person to contract TBE should not be regarded as a fixed entity, but rather it must be estimated individually, on the basis of knowledge of the TBE virus endemic areas and risk factors.

Seroprevalence of tick-borne encephalitis (TBE) in naturally exposed monkeys (Macaca sylvanus) and sheep and prevalence of TBE virus in ticks in a TBE endemic area in Germany.

In a recently published study, a clinical case of severe tick-borne encephalitis (TBE) in a monkey (Macaca sylvanus) was described after natural exposure (tick bite) in a TBE endemic area in Germany, and from the tissue of this monkey the strain 'Salem', closely related to the strain 'Neudoerfl', was isolated and characterized. In this study, it was our aim to test all the available data for characterizing a TBE endemic area like TBE cases in humans and animals, TBE virus (TBEV) in ticks, and TBE-positive sera from animals. Sera from 283 monkeys and 100 sheep as well as 294 unfed ticks were collected at the monkey mountain Salem and its surroundings. A seroprevalence of 2.6% in monkeys and 9% in sheep were found. Furthermore, a new real-time RT-PCR method was established and used, in combination with an already published RT-qPCR, for TBEV genome detection in field-collected ticks, but no TBEV could be detected in the ticks tested.