Relating increasing hantavirus incidences to the changing climate: the mast connection.

BACKGROUND: Nephropathia epidemica (NE), an emerging rodent-borne viral disease, has become the most important cause of infectious acute renal failure in Belgium, with sharp increases in incidence occurring for more than a decade. Bank voles are the rodent reservoir of the responsible hantavirus and are known to display cyclic population peaks. We tried to relate these peaks to the cyclic NE outbreaks observed since 1993. Our hypothesis was that the ecological causal connection was the staple food source for voles, being seeds of deciduous broad-leaf trees, commonly called "mast". We also examined whether past temperature and precipitation preceding "mast years" were statistically linked to these NE outbreaks. RESULTS: Since 1993, each NE peak is immediately preceded by a mast year, resulting in significantly higher NE case numbers during these peaks (Spearman R = -0.82; P = 0.034). NE peaks are significantly related to warmer autumns the year before (R = 0.51; P < 0.001), hotter summers two years before (R = 0.32; P < 0.001), but also to colder (R = -0.25; P < 0.01) and more moist summers (R = 0.39; P < 0.001) three years before. Summer correlations were even more pronounced, when only July was singled out as the most representative summer month. CONCLUSION: NE peaks in year 0 are induced by abundant mast formation in year-1, facilitating bank vole survival during winter, thus putting the local human population at risk from the spring onwards of year 0. This bank vole survival is further promoted by higher autumn temperatures in year-1, whereas mast formation itself is primed by higher summer temperatures in year-2. Both summer and autumn temperatures have been rising to significantly higher levels during recent years, explaining the virtually continuous epidemic state since 2005 of a zoonosis, considered rare until recently. Moreover, in 2007 a NE peak and an abundant mast formation occurred for the first time within the same year, thus forecasting yet another record NE incidence for 2008. We therefore predict that with the anticipated climate changes due to global warming, NE might become a highly endemic disease in Belgium and surrounding countries.

Evidence-based semiquantitative methodology for prioritization of foodborne zoonoses.

OBJECTIVES: To prioritize an extended list of food- and water-borne zoonoses to allow food safety authorities to focus on the most relevant hazards in the food chain. METHODS: An evidence-based semiquantitative methodology was developed. Scores were given by 35 scientific experts in the field of animal and public health, food, and clinical microbiology and epidemiology to 51 zoonotic agents according to five criteria related to public health (severity and occurrence in humans), animal health (severity of disease coupled with economic consequences and occurrence in animals), and food (occurrence in food). The scoring procedure was standardized and evidence-based as experts were provided, for each zoonotic agent, a same set of up-to-date help information data related to the five criteria. Independently, the relative importance of the five criteria was weighted by seven food chain risk managers. The zoonotic agents were ranked based on overall weighted scores and were grouped in four statistically different levels of importance. RESULTS: The following foodborne zoonotic pathogens were classified as "most important": Salmonella spp., Campylobacter spp., Listeria monocytogenes, and verocytotoxigenic Escherichia coli. A second group of "significant importance" included Toxoplasma gondii, the agent of bovine spongiform encephalopathy, Clostridium botulinum, Staphylococcus aureus, Cryptosporidium parvum, Mycobacterium bovis, Echinococcus granulosus, Streptococcus spp., Echinococcus multilocularis, Yersinia enterocolitica, Mycobacterium avium, Fasciola hepatica, Giardia intestinalis, and Rotavirus. CONCLUSIONS: This methodology allowed to rank 51 zoonotic agents with objectivity and taking account of a combined input from risk assessors and risk managers. APPLICATIONS: These results support food safety policy makers to establish the multiannual monitoring program of foodborne zoonoses. They also enable to identify knowledge gaps on specific zoonotic agents and to formulate key research questions. Principally, this method of prioritization is of general interest as it can be applied for any other ranking exercise and in any country.

Determinants of the geographic distribution of Puumala virus and Lyme borreliosis infections in Belgium.

BACKGROUND: Vector-borne and zoonotic diseases generally display clear spatial patterns due to different space-dependent factors. Land cover and land use influence disease transmission by controlling both the spatial distribution of vectors or hosts, and the probability of contact with susceptible human populations. The objective of this study was to combine environmental and socio-economic factors to explain the spatial distribution of two emerging human diseases in Belgium, Puumala virus (PUUV) and Lyme borreliosis. Municipalities were taken as units of analysis. RESULTS: Negative binomial regressions including a correction for spatial endogeneity show that the spatial distribution of PUUV and Lyme borreliosis infections are associated with a combination of factors linked to the vector and host populations, to human behaviours, and to landscape attributes. Both diseases are associated with the presence of forests, which are the preferred habitat for vector or host populations. The PUUV infection risk is higher in remote forest areas, where the level of urbanisation is low, and among low-income populations. The Lyme borreliosis transmission risk is higher in mixed landscapes with forests and spatially dispersed houses, mostly in wealthy peri-urban areas. The spatial dependence resulting from a combination of endogenous and exogenous processes could be accounted for in the model on PUUV but not for Lyme borreliosis. CONCLUSION: A large part of the spatial variation in disease risk can be explained by environmental and socio-economic factors. The two diseases not only are most prevalent in different regions but also affect different groups of people. Combining these two criteria may increase the efficiency of information campaigns through appropriate targeting.

Surveillance of Infectious Diseases by the Sentinel Laboratory Network in Belgium: 30 Years of Continuous Improvement.

In 1983 the sentinel laboratory network was established because of the need to describe the epidemiological evolution of infectious diseases. During the study period of 30 years (1983-2013), microbiology laboratories reported on weekly basis the laboratory diagnosed cases for a selection of infectious diseases. This resulted in a large longitudinal laboratory based database allowing to provide trends over time and distribution by person and place. During this period, adaptations to data collection were made due to changes in diagnostic methods and public health priorities, introduction and application of digital revolution, and multiple reorganizations of the laboratories. Since the surveillance network is dynamic, it necessitates a continuous evaluation to ensure that, over time, it continues to be representative of the general epidemiological trends in the country. Secondly the aim is to examine the robustness and stability of this surveillance system. Here we demonstrated that the flexibility of the data collection methodology by the sentinel laboratory network is unique and that adaptations do not affect the capacity of the system to follow trends. Therefore, the surveillance by this network is representative of the current epidemiological situation in Belgium. To our knowledge, no such surveillance network with such a long-term follow-up and demonstrated stability for multiple infectious diseases in the general population was earlier described. Furthermore, expected trends due to the implementation of vaccination or other events were accurately detected. The collected data obtained from this network allows interesting comparisons with other national and international information sources.

Spatiotemporal dynamics of Puumala hantavirus in suburban reservoir rodent populations.

The transmission of pathogens to susceptible hosts is dependent on the vector population dynamics. In Europe, bank voles (Myodes glareolus) carry Puumala hantavirus, which causes nephropathia epidemica (NE) in humans. Fluctuations in bank vole populations and epidemics in humans are correlated but the main factors influencing this relationship remain unclear. In Belgium, more NE cases are reported in spring than in autumn. There is also a higher incidence of human infections during years of large vole populations. This study aimed to better understand the link between virus prevalence in the vector, vole demography, habitat quality, and human infections. Three rodent populations in different habitats bordering Brussels city, Belgium, were studied for two years. The seroprevalence in voles was influenced first by season (higher in spring), then by vole density, vole weight (a proxy for age), and capture site but not by year or sex. Moreover, voles with large maximal distance between two captures had a high probability for Puumala seropositivity. Additionally, the local vole density showed similar temporal variations as the number of NE cases in Belgium. These results showed that, while season was the main factor influencing vole seroprevalence, it was not sufficient to explain human risks. Indeed, vole density and weight, as well as the local habitat, were essential to understanding the interactions in these host-pathogen dynamics. This can, in turn, be of importance for assessing the human risks.

Establishment and reinforcement of the national reference centers for human microbiology in Belgium.

BACKGROUND: Microbiology reference laboratories are critical in the development of high-quality clinical and public health services. In Belgium, the reference laboratories performed their activities on a voluntary basis and lacked a legal status. METHODS: Pathogens or groups of pathogens necessitating a national reference center (NRC) were prioritized based on diagnostic and epidemiologic relevance. Terms of reference for each of these pathogens were developed. RESULTS: Recently, 40 NRCs for different pathogens or groups of pathogens have been installed in Belgium to fulfill the following core functions: offering reference diagnostics, collecting reference materials, sharing information and scientific advice, participating in national and international networks, collaborating with research workgroups, and contributing to surveillance activities. CONCLUSIONS: These NRCs are important focal points of the national and international network in public health microbiology.

Human anaplasmosis in Belgium: a 10-year seroepidemiological study.

Human granulocytic anaplasmosis (HGA) is a tick-borne rickettsial infection of neutrophils caused by Anaplasma phagocytophilum. Although the pathogen was known as a veterinary agent as early as 1932, the link with human disease was first established in 1990. In the past decennium, the involvement of HGA as an important and frequent cause of fever with a history of tick bite was increasingly recognized in many regions of Europe. This paper presents a 10-year A. phagocytophilum serosurveillance (2000-2009), wherein 1672 serum samples were tested and 418 were found positive. A total of 111 patients had a history of tick bite, fever, and at least a 4-fold rise in titre and are thus considered to be confirmed cases. These findings suggest that Belgium is a hot spot for HGA infections.

Impact of rotavirus vaccination on laboratory confirmed cases in Belgium.

Rotavirus vaccines were introduced in Belgium in 2006 and recommended in the universal schedule in January 2007. We measured the impact of rotavirus vaccination through an active laboratory-based surveillance system. In 2008, the number of laboratory confirmed rotavirus cases declined by 61.4% (95% CI 60.2-62.6%) compared to the 2005-2006 pre-vaccination period, with the highest decline in children<1 year (80.1%; 95% CI 78.7-81.4%). The rotavirus season was delayed compared to pre-vaccination seasons. Laboratory data provide a crude estimation of vaccination impact, but analysis of in-patient data will be needed to assess the impact on severe disease.

Satellite derived forest phenology and its relation with nephropathia epidemica in Belgium.

The connection between nephropathia epidemica (NE) and vegetation dynamics has been emphasized in recent studies. Changing climate has been suggested as a triggering factor of recently observed epidemiologic peaks in reported NE cases. We have investigated whether there is a connection between the NE occurrence pattern in Belgium and specific trends in remotely sensed phenology parameters of broad-leaved forests. The analysis of time series of the MODIS Enhanced Vegetation Index revealed that changes in forest phenology, considered in literature as an effect of climate change, may affect the mechanics of NE transmission.