r y

r a
L ib
r e
c tu
L e
TICK-BORNE ENCEPHALITIS
CHANGES OF iTHE n e
n l DISEASE INCIDENCE
O
I D or
C M u t h
S
E by a
@
Institute of Microbiology and Immunology, Faculty of Medicine
Tatjana Avšič Županc
Ljubljana, SLOVENIA
 r y
Emerging vector-borne diseases
r a
L ib
r e
ctu
Le
i ne
n l
O
I D or
C M u t h
S
E by a
@ Kilpatrick AM et al: Lancet 2012,380(9857):1946-55.
Tick borne encephalitis virus - TBEVry
r a
Lib
re


c
Genus Flavivirus, Flaviviridae family
tu
 Spheric form
L e


n
Viral particles: 60-80 nm
i e
n l
O

I D or
Lipid membrane

C M
Positive
u t
strand ssRNAh virus
S
E by a
@
 Tick borne encephalitis virus - TBEVry
r a
L ib
r e
c tu
L e
i n e
n l
O
I D or

M t h
3 structural and 7 nonstructural proteins

C u
S a
 E protein – host cell receptor binding protein; target for NT antibodies


E by
NS5 protein – conserved region; RNA replication; blocks immune system; virulence
factor

@
Tick borne encephalitis virus - TBEVry
r a
L ib
TBEV consist of 3 subtypes:
r e
tu
- European (TBEV-Eu) – Central European Encephalitis (CEE)

c
e
- Siberian (TBEV – Sib) – Russian Spring-Summer Encephalitis (RSSE)
- Far Eastern (TBEV – FE) - RSSE

e L
l i n
O n
I D or
C M u t h
S
E by a
@ Lindquist L, Vapalahti O. Lancet 2008;371:1861-71
Tick borne encephalitis virus - TBEVry
r a
L ib
re
ctu
Le
i ne
n l
O
I D or
C M u t h
S
E by a
@ Fajs L. et al. PLoS ONE 2012; 7(11): e48420
 Natural cycle of TBEV r y
ra
Lib
re
VERTICAL TRANSMISSION
ctu
•
•
Sexual transmission

L e
e
Transovarial (female adult – eggs) - not efficient

n
•

i
Transstadial (larvae – nymph - adult tick)

n l
O
HORIZONTAL TRANSMISSON
•

I D or
Ticks feed on infected rodent hosts

M h
• Cofeeding transmission (uninfected larvae feeds in close

C t
proximity to infected nymphs on a rodent host)
•

S a u
Infected tick stays infected throughout his life!

E by
@
 r y
TBE virus – transmission to humans
ra
L ib
re
ctu


L
Transmitted by Ixodes spp. ticks
e
i n e


n l
Transmission by infectious milk or dairy products

O
I D or
C M u t h
S
E by a
@
Tick borne encephalitis - TBE r y
r a
L ib
r e


c tu
Viral infectious disease involving the central nervous system


L
70-98 % asimptomatic infections
e


i n e
2-30 % simptomatic infections

n l
 Biphasic course (3/4)

O
 Abortive TBE

I D or
 Meningitis, encephalitis, meningoencephalitis or

C M t h
encephalomyelitis
u
S
E by a
@
Tick borne encephalitis virus - TBEVry
r a
L ib
r e
 European (TBEV-Eu) Ixodes ricinus
c tu
L e
- biphasic course; < 2% fatality rate; long lasting sequelae in older patients


i n
Siberian (TBEV – Sib) Ixodesepersulcatus

n l
- less severe; tendency of chronic or prolonged infections; 1 – 3% fatality
rate
O

I D o r
Far Eastern (TBEV – FE) Ixodes persulcatus
-
C M u t h
severe disease; frequent encephalitic symptoms with 5 - 35% fatality rate

S
E by a
@
 r y
Tick borne encephalitis - diagnostics r a
L i b
r e
c t u
L e
i n e
n l
O
I D or
C M u t h
S
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@
 r y
Tick borne encephalitis – diagnostics
r a
L ib
 SEROLOGY:
r e
 Specific IgM and IgG antibodies from sera and CSF
c tu
 Standardized, automated method

L e
e
 Sensitivity (IgM=98,8 %, IgG=99,5 %)


l i n
Specificity (IgM=99,9 % ???, IgG =96,8%)

O
Pitfalls:
n
D or


M I
Cross-reactivity – exclusion of other viral exposure factors (vaccinations, exotic travel),

h
t
neutralisation test, quantitative ELISA

S C u
Post-vaccination TBE – quantitative ELISA
a
E by
 No antibodies in the first phase - PCR

@
 r y
Tick borne encephalitis – diagnostics
r a
L ib
 MOLECULAR Diagnostics:
r e
tu
 I. phase – TBE viremia (no antibodies) – EDTA blood, urin
 II. phase – CSF (fresh or frozen), urin
e c
e L
i n
 Quantitative real-time PCR with reverse transcription and internal controle


n l
Sensitivity (5 copies/reaction)

O
I D or
M t h
10-1

C u
10-2

S a
10-3
10-4

E by
10-5
10-6
10-7

@
 r y
Tick borne encephalitis – diagnostics
r a
Lib
 VACCINATION BREAKTHROUGH
r e
 Exclusion of other flavivirus infection
ctu
 Confirmation of CSF antibody formation

L e
e
 Avidity testing for IgG antibodies


l i n
TBE patients after vaccination have high avidity


O n
IgM antibodies are usually delayed!
Subsequent sera samples for conformation of delayed IgM response, or

D or


M I
an increase in specific IgG antibodies

h
C u t
S
E by a
@
 ry
TBE epidemiology- overview in Europe
a
ib r
e L
TBE notification
tu r
Survey on TBE in Europe

e c
L
 TBE is a notifiable disease in 16
European countries, including 13 EU

n
Member States (AT, CZ, EE, FI, D, GR,

i e
l
HU, LV, LT, PL, SK, SI, SE) and in three

O n
non-EU Member States (Norway,
Russia, Switzerland)

I D or
 TBE is not notifiable in BE, FR, IT, PT,

M h
ES, DK, NL


C u t
In 19 European countries TBE is

S a
endemic (outside Europe TBE is

E by
endemic in Mongolia, China,
Kazakhstan, Japan, and South
Korea)

@
Suss J: Eurosurveillance, Vol 13 (26) 2008 Donoso Mantke O et al: Eurosurveillance, Vol 13 (17) 2008
 r y
TBE case definition
r a
L ib
CLINICAL CRITERIA
r e
tu
any person with symptoms of inflammation of the CNS (e.g. meningitis, meningo-

c
encephalitis, encephalomyelitis, encephaloradiculitis)

e
LABORATORY CRITERIA
e L
i n
At least one of the following five:

n l
 TBE specific IgM AND IgG antibodies in blood
 TBE specific IgM antibodies in CSF

O
 Sero-conversion or four-fold increase of TBE-specific antibodies in paired serum

I D or
samples
 Detection of TBE viral nucleic acid in a clinical specimen

M t h
 Isolation of TBE virus from clinical specimen

C u
S
E by a
Laboratory criteria for a probable case:
Detection of TBE-specific IgM-antibodies in a unique serum sample

@
EPIDEMIOLOGICAL CRITERIA
Exposure to a common source (unpasteurised dairy products)
 TBE cases in Europe 1970-2010 r y
r a
L ib
r e
c tu
L e
i n e
l
Recorded

n
cases of
tick-borne

O
encephalitis,
Europe

I D or
C M u t h
S
E by a
@ Data: S. Randolph; Amicizia, Human Vaccines & Immunotherapeutics, 2013, 9:5, 1163–1171
 r y
TBE cases reported in 16 EU countries, 2000-2010
r a
L ib
r e
tu
3500

3000

e c
e L
n
2500

n l i
Number of cases

2000

O
D or
1500

M I h
t
1000

S C a u 500

E by 0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

@
Year

ECDC: Epidemiological situation on TBE in EU and EFTA; 2012

TBE cases reported in 16 EU countries, 2000-2010
r y
seasonal distribution
r a
L ib
r e
c tu
1500

1250

L e
i n e
l
1000

n
Number of cases

O
750

I D or 500

C M u t h 250

S
E by a 0
Jan Feb Mar Apr May Jun Jul
Month of onset
Aug Sep Oct Nov Dec

@ ECDC: Epidemiological situation on TBE in EU and EFTA; 2012

 r y
a
TBE cases in Europe 1976 - 2007
ib r
e L
tu r
e c
e L
l i n
O n
I D or
C M u t h
S
E by a
@ Suss J: Eurosurveillance, Vol 13 (26)2008
 r y
Tick borne encephalitis - vaccination
r a
L ib
 3 dose vaccination
r e
c
 Vaccination also for children (from 1 year on)
tu
L e
 In Austria a significant decrease due to massive vaccination

i n e
n l
O
I D or
C M u t h
S
E by a
@ Zenz W: Ped Inf Dis J, Vol 24 (10)2005
 r y
TBE annual incidence rate in EU/EFTA (2000-2010)
r a
L ib
r e
ctu
Le
i ne
n l
O
I D or
C M u t h
S
E by a
@ ECDC: Epidemiological situation on TBE in EU and EFTA; 2012
 r y
I. ricinus – current distribution in EU
r a
L ib
re
ctu
Le
i ne
n l
O
I D or
C M u t h
S
E by a
@
 r y
TBD incidence factors
r a
Lib
r e
Human society
tu
Climate
c
L e
i n e
l
Human Tick habitat

n
behaviour
& settlements Host &

O reservoir Ticks

D or
animals

I
Pathogen

M h
transmission

C u t
S
E bTick a
y borne diseases incidence
@
 TBE in Slovenia r y
ra
Lib
re
tu
200-300 cases/year

c
(14/100 000 population)

L e
i n e
n l
O
I D or
C M u t h
S
E by a
@
Average annual incidence of TBE in municipalities (2005-2012)
 TBE in Slovenian ticks r y
r a
L ib
re
tu
Prevalence of infected ticks affects the incidence of TBE

e c
e L
l i n
O n
I D or
C M u t h
S
E by a
@ Durmiši E et. al.:. VBZD 2011;11:659-664
Drivers that have impact on tick biologyry
r a
L ib
re
ctu
Le
i ne
n l
O
I D or
C M u t h
S
E by a
@ Medlock JF et al.: Parasites&Vectors 2013; 6:1.
Ixodes ricinus dynamics in Sloveniary
r a
L ib
r e
50

c tu 90
45

L e 80

e
40 70

i n
35

l
60

No. of patients
n
30
Tick number

50
25

O
40
20

D or
30

I
15
20

M h
10

C t
5 10

S a u 0 0

E by
Jan Feb Mar April May Jun Jul Aug Sep Oct Nov Dec

Patients
Month
Nymphs

@
 r y
Ixodes ricinus dynamics in Slovenia
r a
L i b
120

r e Rakovnik
100
80

c t u
e
60
40
20

e LBimodal seasonal dynamics 

l i n activity
0
Coastal region – unimodal 
May
Jan

April

n
Aug

Sep
Mar

Oct
Feb

Jun

Jul

Nov

Dec

O Influenced by temperature
D or and
140 Črni kal 

I
120
humidity – saturation
M h
100

C t
80
deficit
u
60

S a
40

E by
20
0
Jan

April

May

Sep
Feb

Mar

Jun

Aug
Jul

Oct

Nov

Dec

@ Knap N et al.: Vet Par 2009;164:275-281

 r y
Biology of ticks influences epidemiology of TBEV
r a
L ib
re
ctu
Le χ
TBE

i n e
n l
O
I D or
M h √
Rakovnik

t
120
TBE

C u
100
80

S a
60

E by
40
20
0
Jan

May
April
Feb

Jul
Mar

Aug
Sep

Nov
Jun

Oct

Dec

@ Knap N et al.: Vet Par 2009;164:275-281

 r y
TBE and tick hosts
r a
L ib
re


c tu
Small mammals are numerous in TBE endemic areas
 Important tick hosts
L e
 Viremic transmisson
i ne

n l
Non-viremic transmission
O
I D mouse o r


C M
Yellow-necked
u t h (Apodemus flavicollis)

S
Bank
E by a
vole (Myodes glareolus)

@
 r y
TBE and tick hosts
r a
L ib
r e
tu
Correlation between prevalence of infection in rodents and TBE incidence in humans

e c
e L
l i n
O n
I D or
C M u t h
S
E by a
@ Knap N et al.: VBZD 2012; 12(3): 236-242
 r y
TBE and tick hosts
r a
L ib
 Long lasting viremia
re
tu
 Importance as viral hosts

e c
e L
l i n
O n
I D or
C M u t h
S
E by a
@ Knap N et al.: VBZD 2012; 12(3): 236-242
 r y
TBE and tick hosts
r a
L ib
re
tu
 WILDLIFE

e c
Large mammals (important reproductive hosts for
ticks)
e L

l i n
Abundance is increasing (red deer and roe deer)

O n
I D or
C M u t h
S
E by a
@ Knap N et al.: PLoS ONE 2013; 8(6): e66380
 r y
TBE and tick hosts
ra
Lib
re
tu
 LIVESTOCK
 Low viremia
e c
 No sign of infection
e L


l i n
Excretion of the virus in milk!

O n
I D or
C M u t h
S
E by a
@
 r y
TBE outbreak 2012 - goat milk
r a
L ib
r e
tu
MICROBIAL CONFORMATION

c
CLINICAL LABORATORY VACCIN
PATIENT TREATMENT

e
PRESENTATION TESTING ATION
TBEV ELISA TBEV

L
TBEV NT
IgM IgG RT-PCR

e
1 Biphasic course outpatient 8. May + + + - x

2 Biphasic course

n lin
hospitalization 8. May + + + - x

O
15. May + + + -
3 Abortive form No treatment x
6. June + + + /

I D or
15. May - + + -
4 NO DISEASE √

M h
6. June - + + /

C u t
RNA TBEV was detected in goat sera (1,50x103 copies RNA/ml) and goat milk (1,88x105 copies RNA/ml)

S a
TBEV antibodies in sera of 5/9 goats. Sheep samples (9) were negative.

E by No long term recovery in any of the patients.

Conformation of rare, abortive form of TBE.
Short incubation period – only two days!!! Important for medical history!

@ Hudopisk N et al.: EID 2013; 19(5):806-808.

 r y
Influence of anthropogenic factors
ra
Lib
re
tu
Influence of weather on TBE incidence!

e c
e L
l i n
O n
I D or
C M u t h
S
E by a
@
 r y
Influence of anthropogenic factors
r a
L ib
r e
c tu
L e
 Farmlands – No significant connection

e between decrease of farmlands and

n lin increase of TBE

O
I D or
M h
 Forest – increasing forest arreas

C u t
S a
significantlly influences TBE

E by
@
Predictive maps r y
r a
L ib
re
ctu
Le
i ne
n l 

O
Precipitation
 Elevation

D or


I
Vegetation
 Mean temp. of driest

M t h
period

S C a u
E by
@ Maxent
Factors that influence the transmission of
r y
vector borne diseases
r a
L ib
r e
CLIMATE

c tu
ECOLOGY

e
mean temperature, vegetation, soil moisture,

L
precipitation, humidity, species competition
extreme weather events

i n e
n l
O
TRANSMISSION BIOLOGY SOCIAL FACTORS
sanitation, vector control,

D or
microbe replication/movement,

I
vector reproduction/movement, travel/migration,

M h
microbe/vector evolution behavior/economy,

C t
population/demographics

S a u
E by DISEASE OUTCOME
risk, rate of transmission

@
 r y
What can we do?
ra
L ib
r e
tu
In the present and future:

c
• Need to improve surveillance – homogenous data
•
•
L e
Combined effort of clinicians and PH officials AWARNESS
SURVEILLANCE

e
Uniform use of diagnostic methods for TBEV detection

n
•
i
Use of data from tick and animal surveys
•
n l
Need to develop vaccination recommendations

O
In the presentID
and future: r
M t h o RESEARCH

C
•
u
Understanding the pathogen

S a
• Understanding the pathogenesis of the disease
•
E by
Developing (new) drugs and vaccines