Ticking on Pandora's box: a prospective case-control study into 'other' tick-borne diseases.

BACKGROUND: Tick-borne pathogens other than Borrelia burgdorferi sensu lato - the causative agent of Lyme borreliosis - are common in Ixodes ricinus ticks. How often these pathogens cause human disease is unknown. In addition, diagnostic tools to identify such diseases are lacking or reserved to research laboratories. To elucidate their prevalence and disease burden, the study 'Ticking on Pandora's Box' has been initiated, a collaborative effort between Amsterdam University Medical Center and the National Institute for Public Health and the Environment. METHODS: The study investigates how often the tick-borne pathogens Anaplasma phagocytophilum, Babesia species, Borrelia miyamotoi, Neoehrlichia mikurensis, spotted fever group Rickettsia species and/or tick-borne encephalitis virus cause an acute febrile illness after tick-bite. We aim to determine the impact and severity of these tick-borne diseases in the Netherlands by measuring their prevalence and describing their clinical picture and course of disease. The study is designed as a prospective case-control study. We aim to include 150 cases - individuals clinically suspected of a tick-borne disease - and 3 matched healthy control groups of 200 persons each. The controls consist respectively of a group of individuals with either a tick-bite without complaints, the general population and of healthy blood donors. During a one-year follow-up we will acquire blood, urine and skin biopsy samples and ticks at baseline, 4 and 12 weeks. Additionally, participants answer modified versions of validated questionnaires to assess self-reported symptoms, among which the SF-36, on a 3 monthly basis. DISCUSSION: This article describes the background and design of the study protocol of 'Ticking on Pandora's Box'. With our study we hope to provide insight into the prevalence, clinical presentation and disease burden of the tick-borne diseases anaplasmosis, babesiosis, B. miyamotoi disease, neoehrlichiosis, rickettsiosis and tick-borne encephalitis and to assist in test development as well as provide recommendations for national guidelines. TRIAL REGISTRATION: NL9258 (retrospectively registered at Netherlands Trial Register, trialregister.nl in in February 2021).

A single dose of doxycycline after an ixodes ricinus tick bite to prevent Lyme borreliosis: An open-label randomized controlled trial.

OBJECTIVES: A single dose of doxycycline after a tick bite can prevent the development of Lyme borreliosis in North America, but extrapolation to Europe is hampered by differences in Borrelia burgdorferi sensu lato genospecies and tick species. We assessed the efficacy of prophylaxis after a tick bite in Europe. METHODS: We conducted an open-label randomized controlled trial, administering a single dose of 200 mg doxycycline within 72 h after removing an attached tick from the skin, compared to no treatment. Potential participants ≥ 8 years of age who reported a recent tick bite online were invited for the study. After informed consent, they were randomly assigned to either the prophylaxis or the no-treatment group. Participants in the prophylaxis group were asked to visit their general practitioner to administer the antibiotics. All participants were followed up by online questionnaires. Our primary outcome was the development of physician-confirmed Lyme borreliosis in a modified-intention-to-treat analysis. This study is registered in the Netherlands Trial Register (NTR3953) and is closed. RESULTS: Between April 11, 2013, and June 10, 2015, 3538 potential participants were randomized, of whom 1689 were included in the modified-intention-to-treat analysis. 10 cases of Lyme borreliosis were reported out of 1041 participants (0.96%) in the prophylaxis group, and 19 cases out of 648 no-treatment participants (2.9%), resulting in a relative risk reduction of 67% (95% CI 31 - 84%), and a number-needed-to-treat of 51 (95% CI 29 - 180). No serious adverse events were reported. CONCLUSIONS: This primary care-based trial provides evidence that a single dose of doxycycline can prevent the development of Lyme borreliosis after an Ixodes ricinus tick bite.

Borrelia miyamotoi infection leads to cross-reactive antibodies to the C6 peptide in mice and men.

OBJECTIVES: Borrelia miyamotoi is a relapsing fever Borrelia, transmitted by hard (Ixodes) ticks, which are also the main vector for Borrelia burgdorferi. A widely used test for serodiagnosis of Lyme borreliosis is an enzyme immunoassay (EIA) based on the C6 peptide of the B. burgdorferi sl VlsE protein. We set out to study C6 reactivity upon infection with B. miyamotoi in a large well-characterized set of B. miyamotoi disease (BMD) patient sera and in experimental murine infection. METHODS: We performed in silico analyses, comparing the C6-peptide to immunodominant B. miyamotoi variable large proteins (Vlps). Next, we determined C6 reactivity in sera from mice infected with B. miyamotoi and in a unique longitudinal set of 191 sera from 46 BMD patients. RESULTS: In silico analyses revealed similarity of the C6 peptide to domains within B. miyamotoi Vlps. Cross-reactivity against the C6 peptide was confirmed in 21 out of 24 mice experimentally infected with B. miyamotoi. Moreover, 35 out of 46 BMD patients had a C6 EIA Lyme index higher than 1.1 (positive). Interestingly, 27 out of 37 patients with a C6 EIA Lyme index higher than 0.9 (equivocal) were negative when tested for specific B. burgdorferi sl antibodies using a commercially available immunoblot. CONCLUSIONS: We show that infection with B. miyamotoi leads to cross-reactive antibodies to the C6 peptide. Since BMD and Lyme borreliosis are found in the same geographical locations, caution should be used when relying solely on C6 reactivity testing. We propose that a positive C6 EIA with negative immunoblot, especially in patients with fever several weeks after a tick bite, warrants further testing for B. miyamotoi.

Ticks and tick-borne diseases in the city: Role of landscape connectivity and green space characteristics in a metropolitan area.

Green spaces in the city are important for human wellbeing, but are also zones in which humans can become infected with zoonotic diseases. Therefore, there is a need to understand how infection risk is related to green space characteristics, wildlife communities and connectivity with rural areas hosting reservoir populations of hosts. Our hypothesis is that wildlife hosts in urban green spaces, and thereby the prevalence of questing ticks and their Lyme disease causing pathogens (Borrelia burgdorferi s.l.), can be partly predicted based on green space characteristics as well as measures of connectivity to known source areas. We sampled ticks in twenty-two green spaces during Spring (2014 and 2016) and Autumn 2016, located along an urbanization gradient in Antwerp (Belgium). More than 18,000 m2 was sampled, with tick densities ranging from 0 to 386 individuals/100 m2. We estimated connectivity using the least-cost algorithm as either the cost distance to the nearest green space, or to a known population of roe deer (Capreolus capreolus), known to be an important tick propagation host. Both connectivity measures turned out to be correlated, reflecting a gradient in green space isolation from the periphery to the urban center. In 87% of plots where ticks were trapped, at least one Borrelia-infected tick was found. The overall Borrelia-prevalence in nymphs was 17.8%, in adults 32.6%. Density of infected ticks decreased with urbanization and increased with connectivity. Nymphs in larger green spaces were more likely to be infected. While density and infection prevalence for adults increased with the amount of neighboring agricultural land, the larval density and nymphal infection prevalence decreased. Interestingly, the proportion of Borrelia genospecies associated with birds or mammals was comparable in rural and (sub)urban areas (bird/mammal: 0.38), suggesting that even in small green spaces Borrelia infections can persist in local host populations.

Cost-effectiveness of a potential anti-tick vaccine with combined protection against Lyme borreliosis and tick-borne encephalitis in Slovenia.

This study assessed cost-effectiveness of a potential anti-tick vaccine that would protect against both Lyme borreliosis (LB) and tick-borne encephalitis (TBE) in a highly endemic setting of Slovenia. A Markov model was developed to estimate cost-effectiveness of a vaccine with potential combined protection against LB and TBE from the societal perspective. The model expressed time in annual cycles, followed a target population through their lifetime, and applied an annual discounting of 3%. A target population entered the model in a susceptible state, with time dependent probabilities to acquire LB/TBE. Disease manifestations were either resolved within one cycle, or a patient developed LB/TBE sequelae. The vaccination consisted of initial immunization and one revaccination. Estimates of LB/TBE direct and indirect costs, and data on natural course of LB/TBE were obtained from Slovenian databases. Effectiveness of the vaccine with potential combined protection against LB/TBE was derived from studies on existing TBE and LB vaccines, while utility estimates were collected from various literature sources. A vaccine with potential combined protection against LB/TBE was predicted to have an incremental cost of €771,300 per 10,000 vaccinated persons, an incremental utility of 17QALYs and a base-case incremental cost-effectiveness ratio (ICER) of 46,061€/QALY. Vaccine cost, effectiveness and discount rates were identified as the most influential model parameters. A wholesale price for a vaccine shot of €9.13 would lead to cost savings followed by health gains for the vaccination strategy. The base-case ICER was below commonly accepted thresholds of cost-effectiveness, indicating that a combined LB/TBE vaccine might be a cost-effective option in Slovenia. With early Health Technology Assessment becoming increasingly important, this analysis still represents a rare example of cost-effectiveness assessment prior to market authorisation. Although obviously in such a situation some key parameters are unknown, our model sets up a tool to analyse pharmacoeconomic criteria that can help development of a cost-effective health technology, in this case a combined tick-borne diseases vaccine.

[Dilemma: to test or not to test for Lyme borreliosis in general practice]. / Dilemma: wel of niet testen op lymeziekte in de huisartsenpraktijk?

There is no such thing as a perfect diagnostic test and the value of a test depends on the situation in which the test is being used. Here, we discuss two options for dealing with the diagnostic process for Lyme borreliosis in general practice. One option is to manage, treat or refer according to clinical signs and symptoms, in accordance with Dutch practice guidelines. The other option is to use laboratory tests to guide further patient management (treatment or referral). The choice depends on currently unknown factors, such as the pre-test probability of Lyme disease in patients presenting to general practitioners. Furthermore, clarity is required about how to proceed after a positive or negative test result. The consequences of a false test result will depend on the patient's status, possible alternative diagnoses and treatment options. Both physician and patient should be aware of the shortcomings of diagnostic tests.

A comparative test of ixodid tick identification by a network of European researchers.

This study reports the results of a comparative test of identification of ticks occurring in Western Europe and Northern Africa. A total of 14 laboratories were voluntarily enrolled in the test. Each participant received between 22 and 25 specimens of adult and nymphal ticks of 11 species: Dermacentor marginatus, D. reticulatus, Haemaphysalis punctata, Hyalomma lusitanicum, Hy. marginatum, Ixodes ricinus, I. hexagonus, Rhipicephalus annulatus, R. bursa, R. rossicus, and/or R. sanguineus s.l. Ticks were morphologically identified by three of the co-authors and the identification confirmed by a fourth co-author who used molecular methods based on several genes. Then ticks were randomly selected and blindly distributed among participants, together with a questionnaire. Only specimens collected while questing and, if possible, in the same survey, were circulated. Because of the random nature of the test, a participant could receive several specimens of the same species. Species in the different genera had variable misidentification rates (MR) of 7% (Dermacentor), 14% (Ixodes), 19% (Haemaphysalis), 36% (Hyalomma), and 54% (Rhipicephalus). Within genera, the MR was also variable ranging from 5.4% for I. ricinus or 7.4% for D. marginatus or D. reticulatus to 100% for R. rossicus. The test provided a total misidentification rate of 29.6% of the species of ticks. There are no significant differences in MR according to the sex of the tick. Participants were requested to perform a second round of identifications on the same set of ticks, using only purposely prepared keys (without illustrations), circulated to the enrolled participants, including 2 species of the genus Dermacentor, 8 of Haemaphysalis, 10 of Hyalomma, 23 of Ixodes, and 6 of Rhipicephalus. The average MR in the second round was 28%: 0% (Dermacentor), 33% (Haemaphysalis), 30% (Hyalomma) 18% (Ixodes), and 50% (Rhipicephalus). Species which are not reported in the countries of a participating laboratory had always highest MR, i.e. purely Mediterranean species had highest MR by laboratories in Central and Northern Europe. Participants expressed their concerns about a correct identification for almost 50% of the ticks of the genera Hyalomma and Rhipicephalus. The results revealed less than total confidence in identifying the most prominent species of ticks in the Western Palearctic, and underpin the need for reference libraries for specialists involved in this task. Results also showed that a combination of certain genes may adequately identify the target species of ticks.

Behavioural responses of Ixodes ricinus nymphs to carbon dioxide and rodent odour.

Many haematophagous ectoparasites use carbon dioxide (CO2 ) and host odour to detect and locate their hosts. The tick Ixodes ricinus (Linnaeus) (Ixodida: Ixodidae) walks only small distances and quests in vegetation until it encounters a host. The differential effects of CO2 and host odour on the host-finding behaviour of I. ricinus have, however, never been clarified and hence represent the subject of this study. The effects of CO2 and odour from bank voles on the activation and attraction of I. ricinus nymphs were analysed in a Y-tube olfactometer. Carbon dioxide evoked a response in the absence and presence of host odour, but did not attract nymphs. Host odour, however, did not evoke a response but did attract nymphs in the absence and presence of CO2 . The current results show that CO2 is an activator, but not an attractant, and that host odour is an attractant, but not an activator, of I. ricinus nymphs, and provide ecological insights into the host-finding behaviour of I. ricinus.

The diagnostic accuracy of serological tests for Lyme borreliosis in Europe: a systematic review and meta-analysis.

BACKGROUND: Interpretation of serological assays in Lyme borreliosis requires an understanding of the clinical indications and the limitations of the currently available tests. We therefore systematically reviewed the accuracy of serological tests for the diagnosis of Lyme borreliosis in Europe. METHODS: We searched EMBASE en MEDLINE and contacted experts. Studies evaluating the diagnostic accuracy of serological assays for Lyme borreliosis in Europe were eligible. Study selection and data-extraction were done by two authors independently. We assessed study quality using the QUADAS-2 checklist. We used a hierarchical summary ROC meta-regression method for the meta-analyses. Potential sources of heterogeneity were test-type, commercial or in-house, Ig-type, antigen type and study quality. These were added as covariates to the model, to assess their effect on test accuracy. RESULTS: Seventy-eight studies evaluating an Enzyme-Linked ImmunoSorbent assay (ELISA) or an immunoblot assay against a reference standard of clinical criteria were included. None of the studies had low risk of bias for all QUADAS-2 domains. Sensitivity was highly heterogeneous, with summary estimates: erythema migrans 50% (95% CI 40% to 61%); neuroborreliosis 77% (95% CI 67% to 85%); acrodermatitis chronica atrophicans 97% (95% CI 94% to 99%); unspecified Lyme borreliosis 73% (95% CI 53% to 87%). Specificity was around 95% in studies with healthy controls, but around 80% in cross-sectional studies. Two-tiered algorithms or antibody indices did not outperform single test approaches. CONCLUSIONS: The observed heterogeneity and risk of bias complicate the extrapolation of our results to clinical practice. The usefulness of the serological tests for Lyme disease depends on the pre-test probability and subsequent predictive values in the setting where the tests are being used. Future diagnostic accuracy studies should be prospectively planned cross-sectional studies, done in settings where the test will be used in practice.

The Presence of Borrelia miyamotoi, A Relapsing Fever Spirochaete, in Questing Ixodes ricinus in Belgium and in The Netherlands.

Borrelia miyamotoi is a tick-borne bacterium that may cause relapsing fever in humans. As this pathogen has been discovered in Europe only recently, only little is known about its local impact on human health and its spatial distribution. In this study, we show the results of PCR screenings for B. miyamotoi in flagged Ixodes ricinus from Belgium and the Netherlands. B. miyamotoi was detected in nine of thirteen, and three of five locations from the Netherlands and Belgium, respectively. These outcomes indicate that B. miyamotoi is more spread than previously thought. The mean infection rate B. miyamotoi was 1.14% for Belgium and 3.84% for the Netherlands.

Borrelia miyamotoi in host-seeking Ixodes ricinus ticks in England.

This paper reports the first detection of Borrelia miyamotoi in UK Ixodes ricinus ticks. It also reports on the presence and infection rates of I. ricinus for a number of other tick-borne pathogens of public health importance. Ticks from seven regions in southern England were screened for B. miyamotoi, Borrelia burgdorferi sensu lato (s.l.), Anaplasma phagocytophilum and Neoehrlichia mikurensis using qPCR. A total of 954 I. ricinus ticks were tested, 40 were positive for B. burgdorferi s.l., 22 positive for A. phagocytophilum and three positive for B. miyamotoi, with no N. mikurensis detected. The three positive B. miyamotoi ticks came from three geographically distinct areas, suggesting a widespread distribution, and from two separate years, suggesting some degree of endemicity. Understanding the prevalence of Borrelia and other tick-borne pathogens in ticks is crucial for locating high-risk areas of disease transmission.

High seroprevalence of Borrelia miyamotoi antibodies in forestry workers and individuals suspected of human granulocytic anaplasmosis in the Netherlands.

Substantial exposure to Borrelia miyamotoi occurs through bites from Ixodes ricinus ticks in the Netherlands, which also transmit Borrelia burgdorferi sensu lato and Anaplasma phagocytophilum. Direct evidence for B. miyamotoi infection in European populations is scarce. A flu-like illness with high fever, resembling human granulocytic anaplasmosis, has been attributed to B. miyamotoi infections in relatively small groups. Borrelia miyamotoi infections associated with chronic meningoencephalitis have also been described in case reports. Assuming that an IgG antibody response against B. miyamotoi antigens reflects (endured) infection, the seroprevalence in different risk groups was examined. Sera from nine out of ten confirmed B. miyamotoi infections from Russia were found to be positive with the recombinant antigen used, and no significant cross-reactivity was observed in secondary syphilis patients. The seroprevalence in blood donors was set at 2.0% (95% CI 0.4-5.7%). Elevated seroprevalences in individuals with serologically confirmed, 7.4% (2.0-17.9%), or unconfirmed, 8.6% (1.8-23%), Lyme neuroborreliosis were not significantly different from those in blood donors. The prevalence of anti-B. miyamotoi antibodies among forestry workers was 10% (5.3-16.8%) and in patients with serologically unconfirmed but suspected human granulocytic anaplasmosis was 14.6% (9.0-21.8%); these were significantly higher compared with the seroprevalence in blood donors. Our findings indicate that infections with B. miyamotoi occur in tick-exposed individuals in the Netherlands. In addition, B. miyamotoi infections should be considered in patients reporting tick bites and febrile illness with unresolved aetiology in the Netherlands, and other countries where I. ricinus ticks are endemic.

Blood feeding on large grazers affects the transmission of Borrelia burgdorferi sensu lato by Ixodes ricinus.

The presence of Ixodes ricinus and their associated Borrelia infections on large grazers was investigated. Carcases of freshly shot red deer, mouflon and wild boar were examined for the presence of any stage of I. ricinus. Questing ticks were collected from locations where red deer and wild boar are known to occur. Presence of Borrelia burgdorferi s.l. DNA was examined in a fraction of the collected ticks. Larvae, nymphs and adult ticks were found on the three large grazers. Red deer had the highest tick burden, with many of the nymphs and adult females attached for engorgement. Most larvae had not attached. The mean number of ticks on the animals varied from 13 to 67. Ticks were highly aggregated amongst the animals: some animals had no ticks, while others had high numbers. Larvae and nymphs were mostly found on the ears, while adult ticks were attached to the axillae. The Borrelia infection rate of questing nymphs was 8.5%. Unengorged wandering nymphs on deer had a Borrelia infection rate of 12.5%, while only 0.9% of feeding nymphs carried a Borrelia infection. The infection rate of unengorged adult male ticks was 4.5%, and that of feeding female ticks was 0.7%. The data suggest that ticks feeding on red deer and wild boar lose their Borrelia infections. The implications of the results are discussed with respect to Borrelia epidemiology and maintenance of a Borrelia reservoir as well as the role of reproductive hosts for Ixodes ricinus.

Diagnosis of human granulocytic anaplasmosis in Belgium by combining molecular and serological methods.

We report here one new, hospitalized case of Anaplasma phagocytophilum in Belgium. The clinical presentation of anaplasmosis, its treatment and the molecular and serological relevant laboratory methods are briefly developed.

[Zoonoses from ticks and fleas in dogs and cats]. / Zoönosen van teken- en vlooien bij honden en katten.

Fleas and ticks may transmit zoonotic diseases. This is an overview of tick- and flea-borne zoonoses where dogs and cats are involved in the epidemiology.

[Flea and tick control in dogs and cats]. / Bestrijding van vlooien en teken bij hond en kat.

Fleas and ticks may cause skin problems in dogs and cats and transmit (zoonotic) diseases. This is an overview about the present situation of the ectoparasites control.

Prevalence of Coxiella burnetii in ticks after a large outbreak of Q fever.

Q fever has emerged as an important human and veterinary public health problem in the Netherlands with major outbreaks in three consecutive years. Goat farms are probably the prime source from which Coxiella burnetii have spread throughout the environment, infecting people living in the vicinity. Coxiella burnetii infection not only spilled over from animal husbandry to humans but could also have spread to neighbouring wildlife and pets forming novel reservoirs and consequently posing another and lingering threat to humans, companion animals and livestock. In these cases, transmission routes other than airborne spread of contaminated aerosols may become significant. Therefore, the role of ticks in the transmission of Coxiella burnetii in the current situation was investigated. A total of 1891 questing Ixodes ricinus ticks and 1086 ticks feeding on pets, wildlife and livestock were tested by a recently developed multiplex Q-PCR. All ticks were negative, except for a few ticks feeding on a herd of recently vaccinated sheep. Coxiella-positive ticks were not detected after resampling this particular herd three months later. Based on these data we conclude that the current risk of acquiring Q fever from questing ticks in the Netherlands is negligible. However, for future risk assessments, it might be relevant to sample more ticks in the vicinity of previously C. burnetii infected goat farms and to assess whether C. burnetii can be transmitted transovarially and transstadially in I. ricinus ticks.

First detection of spotted fever group rickettsiae in Ixodes ricinus and Dermacentor reticulatus ticks in the UK.

A preliminary study was conducted to determine the presence of spotted fever rickettsiae in two species of British tick (Ixodes ricinus and Dermacentor reticulatus). The 16S rRNA gene of Rickettsia spp. was detected in 39/401 (9·7%) of ticks tested, including 22/338 (6·5%) I. ricinus and 17/63 (27%) D. reticulatus. Some positive I. ricinus samples showed 100% homology with Rickettsia helvetica (10/22), and most positive D. reticulatus showed 100% homology with R. raoultii (13/17). Five other Rickettsia spp. were detected exhibiting 96-99% homology. Ticks positive for rickettsiae were collected from various hosts and from vegetation from eight counties across Great Britain. The distribution of R. helvetica in various engorged and unfed stages of I. ricinus suggests that R. helvetica is widespread. R. raoultii was found in questing adult D. reticulatus in Wales and England. This is the first evidence of potentially pathogenic spotted fever rickettsiae in British ticks.

Glycosphingolipids are required for sorting melanosomal proteins in the Golgi complex.

Although glycosphingolipids are ubiquitously expressed and essential for multicellular organisms, surprisingly little is known about their intracellular functions. To explore the role of glycosphingolipids in membrane transport, we used the glycosphingolipid-deficient GM95 mouse melanoma cell line. We found that GM95 cells do not make melanin pigment because tyrosinase, the first and rate-limiting enzyme in melanin synthesis, was not targeted to melanosomes but accumulated in the Golgi complex. However, tyrosinase-related protein 1 still reached melanosomal structures via the plasma membrane instead of the direct pathway from the Golgi. Delivery of lysosomal enzymes from the Golgi complex to endosomes was normal, suggesting that this pathway is not affected by the absence of glycosphingolipids. Loss of pigmentation was due to tyrosinase mislocalization, since transfection of tyrosinase with an extended transmembrane domain, which bypassed the transport block, restored pigmentation. Transfection of ceramide glucosyltransferase or addition of glucosylsphingosine restored tyrosinase transport and pigmentation. We conclude that protein transport from Golgi to melanosomes via the direct pathway requires glycosphingolipids.