Evidence for transmission of the zoonotic apicomplexan parasite Babesia duncani by the tick Dermacentor albipictus

Babesia duncani Pyruvate Kinase Inhibitor Screening and Identification of Key Active Amino Acid Residues

Babesia duncani (B. duncani), a protozoan parasite prevalent in North America, is a significant threat for human health. Given the regulatory role of pyruvate kinase I (PyK I) in glycolytic metabolism flux and ATP generation, PyK I has been considered the target for drug intervention for a long time. In this study, B. duncani PyK I (BdPyK I) was successfully cloned, expressed, and purified. Polyclonal antibodies were confirmed to recognize the native BdPyK I protein (56 kDa) using Western blotting. AlphaFold software predicted the three-dimensional structure of BdPyK I, and molecular docking with small molecules was conducted to identify potential binding sites of inhibitor on BdPyK I. Moreover, inhibitory effects of six inhibitors (tannic acid, apigenin, shikonin, PKM2 inhibitor, rosiglitazone, and pioglitazone) on BdPyK I were examined under the optimal enzymatic conditions of 3 mM PEP and 3 mM ADP, and significant activity reduction was found. Enzyme kinetics and growth inhibition assays further confirmed the reliability of these inhibitors, with PKM2 inhibitor, tannic acid, and apigenin exhibiting the highest selectivity index as specific inhibitors for B. duncani. Subsequently, key amino acid residues were mutated in both BdPyK I and Homo sapiens pyruvate kinase I (HPyK I), and two differential amino acid residues (isoleucine and phenylalanine) were identified between HPyK I and BdPyK I through PyK activity detection experiments. These findings lay foundation for understanding the role of PyK I in the growth and development of B. duncani, providing insights for babesiosis prevention and drug development.

Apparent fatal winter tick (Dermacentor albipictus) infestation in captive reindeer (Rangifertarandus)

The winter tick, Dermacentor albipictus (Ixodidae), commonly infests a wide variety of wild and domestic ungulates throughout North America. This one-host-tick infests animals from October to April, with moose (Alces alces) particularly affected. Animals highly infested may present with anemia, tick-induced alopecia, and alterations in thermoregulation, often resulting in death. Mortality from winter tick infestation has been reported in free-ranging woodland caribou (Rangifer tarandus caribou) and captive reindeer in Alberta, Canada. This historic report raises concern about mortality due to D. albipictus in a wider host range, specifically on translocated caribou. The aim of this report was to describe three cases of winter tick infestation in captive reindeer resulting in severe anemia and mortality likely due to the infestation in New Hampshire, northeastern United States (US). Additionally, ticks were screened molecularly for the detection of tick-borne pathogens. At time of necropsy, all three reindeer showed decreased nutritional status, marked submandibular edema, and had heavy D. albipictus infestation. None of the reindeer exhibited alopecia, which is a common clinical manifestation in moose that die from winter tick infestation. No pathogens were detected via qPCR screening. This report highlights the risk that captive cervids face in areas where winter tick is endemic; therefore, the adoption of preventive control measures should be encouraged to reduce the risk of tick infestation and potential death of these animals.

A Set of Diagnostic Tests for Detection of Active Babesia duncani Infection

Human babesiosis is a rapidly emerging and potentially fatal tick-borne disease caused by intraerythrocytic apicomplexan parasites of the Babesia genus. Among the various species of Babesia that infect humans, B. duncani has been found to cause severe and life-threatening infections. Detection of active B. duncani infection is critical for accurate diagnosis and effective management of the disease. While molecular assays for the detection of B. duncani infection in blood are available, a reliable strategy to detect biomarkers of active infection has not yet been developed. Here, we report the development of the first B. duncani antigen capture assays that rely on the detection of two B. duncani -exported immunodominant antigens, BdV234 and BdV38. The assays were validated using blood samples from cultured parasites in human erythrocytes and B. duncani -infected laboratory mice at different parasitemia levels and following therapy. The assays display high specificity with no cross-reactivity with B. microti , B. divergens , Babesia MO1, or P. falciparum. The assay also demonstrates high sensitivity, detecting as low as 115 infected erythrocytes/µl of blood. Screening of 1,731 blood samples from diverse biorepositories, including previously identified Lyme and/or B. microti positive human samples and new specimens from field mice, showed no evidence of B. duncani infection in these samples. The assays could be useful in diverse diagnostic scenarios, including point-of-care testing for early B. duncani infection detection in patients, field tests for screening reservoir hosts, and high-throughput screening such as blood collected for transfusion.

Short summary

We developed two ELISA-based assays, BdACA38 and BdACA234, for detecting B. duncani , a potentially fatal tick-borne parasite causing human babesiosis. The assays target two immunodominant antigens, BdV234 and BdV38, demonstrating high specificity (no cross-reactivity with other Babesia species or Plasmodium falciparum ) and sensitivity (detecting as low as 115 infected erythrocytes/µl). The assays were validated using in vitro-cultured parasites and infected mice. Screening diverse blood samples showed no evidence of B. duncani active infection among 1,731 human and field mice blood samples collected from the north-eastern, midwestern, and western US. These assays offer potential in diverse diagnostic scenarios, including early patient detection, reservoir animal screening, and transfusion-transmitted babesiosis prevention.

Transfusion-transmitted Babesia spp.: a changing landscape of epidemiology, regulation, and risk mitigation

Babesia spp. are tick-borne parasites with a global distribution and diversity of vertebrate hosts. Over the next several decades, climate change is expected to impact humans, vectors, and vertebrate hosts and change the epidemiology of Babesia. Although humans are dead-end hosts for tick-transmitted Babesia, human-to-human transmission of Babesia spp. from transfusion of red blood cells and whole blood-derived platelet concentrates has been reported. In most patients, transfusion-transmitted Babesia (TTB) results in a moderate-to-severe illness. Currently, in North America, most cases of TTB have been described in the United States. TTB cases outside North America are rare, but case numbers may change over time with increased recognition of babesiosis and as the epidemiology of Babesia is impacted by climate change. Therefore, TTB is a concern of microbiologists working in blood operator settings, as well as in clinical settings where transfusion occurs. Microbiologists play an important role in deploying blood donor screening assays in Babesia endemic regions, identifying changing risks for Babesia in non-endemic areas, investigating recipients of blood products for TTB, and drafting TTB policies and guidelines. In this review, we provide an overview of the clinical presentation and epidemiology of TTB. We identify approaches and technologies to reduce the risk of collecting blood products from Babesia-infected donors and describe how investigations of TTB are undertaken. We also describe how microbiologists in Babesia non-endemic regions can assess for changing risks of TTB and decide when to focus on laboratory-test-based approaches or pathogen reduction to reduce TTB risk.

Babesia duncani multi-omics identifies virulence factors and drug targets

Babesiosis is a malaria-like disease in humans and animals that is caused by Babesia species, which are tick-transmitted apicomplexan pathogens. Babesia duncani causes severe to lethal infection in humans, but despite the risk that this parasite poses as an emerging pathogen, little is known about its biology, metabolic requirements or pathogenesis. Unlike other apicomplexan parasites that infect red blood cells, B. duncani can be continuously cultured in vitro in human erythrocytes and can infect mice resulting in fulminant babesiosis and death. We report comprehensive, detailed molecular, genomic, transcriptomic and epigenetic analyses to gain insights into the biology of B. duncani. We completed the assembly, 3D structure and annotation of its nuclear genome, and analysed its transcriptomic and epigenetics profiles during its asexual life cycle stages in human erythrocytes. We used RNA-seq data to produce an atlas of parasite metabolism during its intraerythrocytic life cycle. Characterization of the B. duncani genome, epigenome and transcriptome identified classes of candidate virulence factors, antigens for diagnosis of active infection and several attractive drug targets. Furthermore, metabolic reconstitutions from genome annotation and in vitro efficacy studies identified antifolates, pyrimethamine and WR-99210 as potent inhibitors of B. duncani to establish a pipeline of small molecules that could be developed as effective therapies for the treatment of human babesiosis.

Comparative analysis of the mitochondrial genome of Dermacentor steini from different regions in China

Ticks are a group of blood-sucking ectoparasites that play an important role in human health and livestock production development as vectors of zoonotic diseases. The phylogenetic tree of single genes cannot accurately reflect the true kinship between species. Based on the complete mitochondrial genome analysis one can help to elucidate the phylogenetic relationships among species. In this study, the complete mitochondrial genome of Dermacentor steini (isolate Longyan) was sequenced and compared with the mitochondrial genes of 3 other Chinese isolates (Nanchang, Jinhua and Yingtan). In Dermacentor steini 4 isolates had identical or similar mitochondrial genome lengths and an overall variation of 0.76% between sequences. All nucleotide compositions showed a distinct AT preference. The most common initiation and stop codons were ATG and TAA, respectively. Fewer base mismatches were found in the tRNA gene of D. steini (isolate Longyan), and the vicinity of the control region and tRNA gene was a hot rearrangement region of the genus Dermacentor. Maximum likelihood trees and Bayesian trees indicate that D. steini is most closely related to Dermacentor auratus. The results enrich the mitochondrial genomic data of species in the genus Dermacentor and provide novel insights for further studies on the phylogeographic classification and molecular evolution of ticks.

Tick species infesting humans in the United States

The data for human tick encounters in the United States (US) presented in this paper were compiled with the goals of: (i) presenting quantitative data across the full range of native or recently established human biting ixodid (hard) and argasid (soft) tick species with regards to their frequency of infesting humans, based on published records of ticks collected while biting humans or crawling on clothing or skin; and (ii) providing a guide to publications on human tick encounters. Summary data are presented in table format, and the detailed data these summaries were based on are included in a set of Supplementary Tables. To date, totals of 36 ixodid species (234,722 specimens) and 13 argasid species (230 specimens) have been recorded in the published literature to infest humans in the US. Nationally, the top five ixodid species recorded from humans were the blacklegged tick, Ixodes scapularis (n=158,008 specimens); the lone star tick, Amblyomma americanum (n=36,004); the American dog tick, Dermacentor variabilis (n=26,624); the western blacklegged tick, Ixodes pacificus (n=4,158); and the Rocky Mountain wood tick, Dermacentor andersoni (n=3,518). Additional species with more than 250 ticks recorded from humans included Ixodes cookei (n=2,494); the Pacific Coast tick, Dermacentor occidentalis (n=809); the brown dog tick, Rhipicephalus sanguineus sensu lato (n=714); the winter tick, Dermacentor albipictus (n=465); and the Gulf Coast tick, Amblyomma maculatum (n=335). The spinose ear tick, Otobius megnini (n=69), and the pajaroello tick, Ornithodoros coriaceus (n=55) were the argasid species most commonly recorded from humans. Additional information presented for each of the 49 tick species include a breakdown of life stages recorded from humans, broad geographical distribution in the US, host preference, and associated human pathogens or medical conditions. The paper also provides a history of publications on human tick encounters in the US, with tables outlining publications containing quantitative data on human tick encounters as well as other notable publications on human-tick interactions. Data limitations are discussed. Researchers and public health professionals in possession of unpublished human tick encounter data are strongly encouraged to publish this information in peer-reviewed scientific journals. In future papers, it would be beneficial if data consistently were broken down by tick species and life stage as well as host species and ticks found biting versus crawling on clothing or skin.

Analysis of the complete mitochondrial genomes of Dermacentor albipictus suggests a species complex

Dermacentor albipictus is a one-host tick broadly distributed across North America. There are two easily recognizable color variants - ornate and inornate/brown - that have been taxonomically synonymized. Based on mt-cox1 and mt-16S data, there is also evidence for two genetic lineages which do not match the color variants. We present for the first time the complete mitochondrial genomes of the two color variants of D. albipictus including representatives of each lineage. The AT-rich genomes are 14,822 bp - 14,865 bp in length and contain 13 protein coding genes, 2 ribosomal RNA genes and 22 transfer RNA genes, arranged in the conserved type 3 metastriate mitochondrial genome order. The overall differences were 10.66% between the mitochondrial genomes of D. albipictus ornate variant lineage 1 and lineage 2, 10.51% between lineage 1 and inornate/brown variant and 5.87% between lineage 2 and inornate/brown variant. The inornate/brown variant did not form a separate lineage and all inornate isolates were found to belong to lineage 2. Ornate variant isolates occurred in both lineage 1 and 2. The high divergence of the mitochondrial genome suggests that D. albipictus may represent a species complex. Other barcoding genes that may help capture the genetic differences between color and lineage variants include nad1, nad2, nad5, cox1 and atp8 loci. The mtDNA data generated in this study are available in GenBank (Accession numbers: OM678457 - OM678459 and ON032564 - ON032573) for future studies on tick taxonomy, phylogenetics and molecular epidemiology.

Fluorescence In Situ Hybridization (FISH) Tests for Identifying Protozoan and Bacterial Pathogens in Infectious Diseases

Diagnosing and treating many infectious diseases depends on correctly identifying the causative pathogen. Characterization of pathogen-specific nucleic acid sequences by PCR is the most sensitive and specific method available for this purpose, although it is restricted to laboratories that have the necessary infrastructure and finance. Microscopy, rapid immunochromatographic tests for antigens, and immunoassays for detecting pathogen-specific antibodies are alternative and useful diagnostic methods with different advantages and disadvantages. Detection of ribosomal RNA molecules in the cytoplasm of bacterial and protozoan pathogens by fluorescence in-situ hybridization (FISH) using sequence-specific fluorescently labelled DNA probes, is cheaper than PCR and requires minimal equipment and infrastructure. A LED light source attached to most laboratory light microscopes can be used in place of a fluorescence microscope with a UV lamp for FISH. A FISH test hybridization can be completed in 30 min at 37 °C and the whole test in less than two hours. FISH tests can therefore be rapidly performed in both well-equipped and poorly-resourced laboratories. Highly sensitive and specific FISH tests for identifying many bacterial and protozoan pathogens that cause disease in humans, livestock and pets are reviewed, with particular reference to parasites causing malaria and babesiosis, and mycobacteria responsible for tuberculosis.

Improving Widescale Monitoring of Ectoparasite Presence in Northern Canadian Wildlife with the Aid of Citizen Science

Simple Summary

Surveying ticks on wildlife hosts consistently over time and across space presents many challenges. In Yukon, Canada, the winter tick, Dermacentor albipictus, is a blood-feeding parasite that can cause significant losses of hair and blood in moose and other wildlife. The impacts of winter tick infestation in wildlife hosts in this northern region are not well documented. To enhance existing surveillance of winter ticks in Yukon, we implemented a three-year citizen science program, the Yukon Winter Tick Monitoring Project (YWTMP) to engage hunters in the collection of underrepresented moose and caribou samples. Social media, participation incentives, and hide-sampling kits distributed to hunters increased the combined number of annual moose and caribou hide submissions almost 100-fold, and the geographical range of samples by almost 500 km, compared with submission numbers in the previous seven years. Citizen science samples were also used to detect previously unknown infection localities on moose in southeastern Yukon that are spatially separate to known infestations found on elk and deer, helping to build a better picture of infection dynamics on different host animals. Engaging with key demographic groups using structured citizen science programs like the YWTMP can significantly expand sampling efforts in remote areas while maintaining systematic sampling methods to monitor parasites of wildlife health concern.

Abstract

Sampling hides from harvested animals is commonly used for passive monitoring of ectoparasites on wildlife hosts, but often relies heavily on community engagement to obtain spatially and temporally consistent samples. Surveillance of winter ticks (Dermacentor albipictus) on moose (Alces alces) and caribou (Rangifer tarandus caribou) hosts in Yukon, Canada, has relied in part on voluntary submission of hides by hunters since 2011, but few samples were submitted. To enhance sampling efforts on underrepresented moose and caribou hosts, we implemented a three-year citizen science program, the Yukon Winter Tick Monitoring Project (YWTMP), to better engage with hunters in hide sample collection. A combination of in-person and social media outreach, incentivized engagement, and standardized hide sampling kits increased voluntary submissions of moose and caribou hides almost 100-fold since surveillance began. Citizen science samples expanded the northernmost geographic extent of existing sampling efforts for moose by 480 km and for caribou by 650 km to reach 67.5° N latitude. Samples also resulted in new detections of winter ticks on moose hides that are spatially separate to those submitted for other cervids in Yukon. Findings from the YWTMP have provided an essential baseline to monitor future winter tick host–parasite dynamics in the region and highlighted priority areas for ongoing tick surveillance.

Establishment of a Transient and Stable Transfection System for Babesia duncani Using a Homologous Recombination Strategy

Genetic modification provides an invaluable molecular tool to dissect the biology and pathogenesis of pathogens. However, no report is available about the genetic modification of Babesia duncani, a pathogen responsible for human babesiosis that is widespread in North America, suggesting the necessity to develop a genetic manipulation method to improve the strategies for studying and understanding the biology of protozoan pathogens. The establishment of a genetic modification method requires promoters, selectable markers, and reporter genes. Here, the double-copy gene elongation factor-1α (ef-1α) and its promoters were amplified by conventional PCR and confirmed by sequencing. We established a transient transfection system by using the ef-1αB promoter and the reporter gene mCherry and achieved stable transfection through homologous recombination to integrate the selection marker hDHFR-eGFP into the parasite genome. The potential of this genetic modification method was tested by knocking out the thioredoxin peroxidase-1 (TPX-1) gene, and under the drug pressure of 5 nM WR99210, 96.3% of the parasites were observed to express green fluorescence protein (eGFP) by flow cytometry at day 7 post-transfection. Additionally, the clone line of the TPX-1 knockout parasite was successfully obtained by the limiting dilution method. This study provided a transfection method for B. duncani, which may facilitate gene function research and vaccine development of B. duncani.

Case Report: A Fatal Case of Babesiosis in a Splenectomized Male Patient from Western India

Human babesiosis is a rare disease, caused by Babesia species and commonly transmitted by tick bite. Although human babesiosis is known to be asymptomatic in immunocompetent hosts, clinical cases of severe babesiosis have been reported from splenectomized or immunocompromised individuals. To our knowledge, only one case of human babesiosis in India has been previously reported. Here, we report a case of severe babesiosis with high parasitemia (∼70%) in a 30-year-old asplenic farmer. The patient presented with fever, yellowish discoloration of skin, oliguria, and anemia; he eventually developed multiorgan failure syndrome and died. Peripheral blood films were prepared and used to confirm the presence of piroplasms by microscopy. Total DNA isolated from blood was used for 18S ribosomal RNA gene fragment amplification by polymerase chain reaction, which was subject to Sanger sequencing. Although 18S sequence indicated that the Babesia species infecting the patient was similar to that of other Babesia species originating from wild mammals, species identification could not be done. Phylogenetic analysis revealed that the patient-derived pathogen is distinct because it forms a separate clade in the cladogram.

Babesiosis and Theileriosis in North America

Babesia and Theileria are apicomplexan parasites that cause established and emerging diseases in humans, domestic and wild animals. These protozoans are transmitted by Ixodid ticks causing babesiosis or theileriosis, both characterized by fever, hemolytic anemia, jaundice, and splenomegaly. In North America (NA), the most common species affecting humans is B. microti, which is distributed in the Northeastern and Upper Midwestern United States (US), where the tick vector Ixodes scapularis is established. In livestock, B. bovis and B. bigemina are the most important pathogens causing bovine babesiosis in tropical regions of Mexico. Despite efforts toward eradication of their tick vector, Rhipicephalus microplus, B. bovis and B. bigemina present a constant threat of being reintroduced into the southern US and represent a continuous concern for the US cattle industry. Occasional outbreaks of T. equi, and T. orientalis have occurred in horses and cattle, respectively, in the US, with significant economic implications for livestock including quarantine, production loss, and euthanasia of infected animals. In addition, a new species, T. haneyi, has been recently discovered in horses from the Mexico-US border. Domestic dogs are hosts to at least four species of Babesia in NA that may result in clinical disease that ranges from subclinical to acute, severe anemia. Herein we review the pathogenesis, diagnosis, and epidemiology of the most important diseases caused by Babesia and Theileria to humans, domestic and wild animals in Canada, the US, and Mexico.

Identification of Rickettsia spp. and Babesia conradae in Dermacentor spp. Collected from Dogs and Cats Across the United States

In the United States, Dermacentor variabilis and Dermacentor andersoni are considered key vectors for Rickettsia rickettsii, the causative agent of Rocky Mountain spotted fever. Through regional surveillance, a wide diversity of Rickettsia spp. have been documented in D. variabilis, and Dermacentor spp. has been suggested as potential vectors for various other pathogens, including Babesia spp. and Ehrlichia canis. To better define the prevalence and diversity of pathogens in Dermacentor spp. across the United States, 848 ticks collected from dogs and cats in 44/50 states in 2018–2019 were tested by PCR for Rickettsia spp.-specific 17 kDa and ompA gene fragments; a subset of Dermacentor spp. was also tested with PCR, targeting fragments of the 18S and large subunit region rRNA genes of Babesia spp. and 16S rRNA genes of E. canis. Rickettsia spp. was identified in 12.5% (106/848) of ticks. Species detected include Rickettsia montanensis (n = 64 ticks), Rickettsia bellii (n = 15 ticks), Rickettsia rhipicephali (n = 13 ticks), Rickettsia peacockii (n = 8 ticks), Rickettsia amblyommatis (n = 3 ticks), Rickettsia cooleyi (n = 1 tick), and unclassified Rickettsia spp. (n = 2 ticks). Ticks with R. montanensis and R. bellii were submitted from every U.S. region; R. rhipicephali was predominantly detected in ticks from the southern half of the United States, and all R. peacockii-positive ticks were D. andersoni that originated from the Rocky Mountain states. Ehrlichia canis was not detected in any Dermacentor spp., and Babesia conradae was detected in two Dermacentor albipictus. Because most ticks had fed on dogs or cats before submission, these findings do not implicate a given Dermacentor sp. as a primary vector of these agents, but in regard to Rickettsia spp., the data do support other published work showing D. variabilis harbors a diversity of Rickettsia species with unknown implications for animal and human health.

The bacterial biome of ticks and their wildlife hosts at the urban-wildland interface

Advances in sequencing technologies have revealed the complex and diverse microbial communities present in ticks (Ixodida). As obligate blood-feeding arthropods, ticks are responsible for a number of infectious diseases that can affect humans, livestock, domestic animals and wildlife. While cases of human tick-borne diseases continue to increase in the northern hemisphere, there has been relatively little recognition of zoonotic tick-borne pathogens in Australia. Over the past 5 years, studies using high-throughput sequencing technologies have shown that Australian ticks harbour unique and diverse bacterial communities. In the present study, free-ranging wildlife (n=203), representing ten mammal species, were sampled from urban and peri-urban areas in New South Wales (NSW), Queensland (QLD) and Western Australia (WA). Bacterial metabarcoding targeting the 16S rRNA locus was used to characterize the microbiomes of three sample types collected from wildlife: blood, ticks and tissue samples. Further sequence information was obtained for selected taxa of interest. Six tick species were identified from wildlife: Amblyomma triguttatum, Ixodes antechini, Ixodes australiensis, Ixodes holocyclus, Ixodes tasmani and Ixodes trichosuri. Bacterial 16S rRNA metabarcoding was performed on 536 samples and 65 controls, generating over 100 million sequences. Alpha diversity was significantly different between the three sample types, with tissue samples displaying the highest alpha diversity (P<0.001). Proteobacteria was the most abundant taxon identified across all sample types (37.3 %). Beta diversity analysis and ordination revealed little overlap between the three sample types (P<0.001). Taxa of interest included Anaplasmataceae, Bartonella, Borrelia, Coxiellaceae, Francisella, Midichloria, Mycoplasma and Rickettsia. Anaplasmataceae bacteria were detected in 17.7% (95/536) of samples and included Anaplasma, Ehrlichia and Neoehrlichia species. In samples from NSW, 'Ca. Neoehrlichia australis', 'Ca. Neoehrlichia arcana', Neoehrlichia sp. and Ehrlichia sp. were identified. A putative novel Ehrlichia sp. was identified from WA and Anaplasma platys was identified from QLD. Nine rodent tissue samples were positive for a novel Borrelia sp. that formed a phylogenetically distinct clade separate from the Lyme Borrelia and relapsing fever groups. This novel clade included recently identified rodent-associated Borrelia genotypes, which were described from Spain and North America. Bartonella was identified in 12.9% (69/536) of samples. Over half of these positive samples were obtained from black rats (Rattus rattus), and the dominant bacterial species identified were Bartonella coopersplainsensis and Bartonella queenslandensis. The results from the present study show the value of using unbiased high-throughput sequencing applied to samples collected from wildlife. In addition to understanding the sylvatic cycle of known vector-associated pathogens, surveillance work is important to ensure preparedness for potential zoonotic spillover events.

An annotated checklist of the eukaryotic parasites of humans, exclusive of fungi and algae

The classification of "parasites" in the medical field is a challenging notion, a group which historically has included all eukaryotes exclusive of fungi that invade and derive resources from the human host. Since antiquity, humans have been identifying and documenting parasitic infections, and this collective catalog of parasitic agents has expanded considerably with technology. As our understanding of species boundaries and the use of molecular tools has evolved, so has our concept of the taxonomy of human parasites. Consequently, new species have been recognized while others have been relegated to synonyms. On the other hand, the decline of expertise in classical parasitology and limited curricula have led to a loss of awareness of many rarely encountered species. Here, we provide a comprehensive checklist of all reported eukaryotic organisms (excluding fungi and allied taxa) parasitizing humans resulting in 274 genus-group taxa and 848 species-group taxa. For each species, or genus where indicated, a concise summary of geographic distribution, natural hosts, route of transmission and site within human host, and vectored pathogens are presented. Ubiquitous, human-adapted species as well as very rare, incidental zoonotic organisms are discussed in this annotated checklist. We also provide a list of 79 excluded genera and species that have been previously reported as human parasites but are not believed to be true human parasites or represent misidentifications or taxonomic changes.

The Global Emergence of Human Babesiosis

Babesiosis is an emerging tick-borne disease caused by intraerythrocytic protozoa that are primarily transmitted by hard-bodied (ixodid) ticks and rarely through blood transfusion, perinatally, and organ transplantation. More than 100 Babesia species infect a wide spectrum of wild and domestic animals worldwide and six have been identified as human pathogens. Babesia microti is the predominant species that infects humans, is found throughout the world, and causes endemic disease in the United States and China. Babesia venatorum and Babesia crassa-like agent also cause endemic disease in China. Babesia divergens is the predominant species in Europe where fulminant cases have been reported sporadically. The number of B. microti infections has been increasing globally in recent decades. In the United States, more than 2000 cases are reported each year, although the actual number is thought to be much higher. In this review of the epidemiology of human babesiosis, we discuss epidemiologic tools used to monitor disease location and frequency; demographics and modes of transmission; the location of human babesiosis; the causative Babesia species in the Americas, Europe, Asia, Africa, and Australia; the primary clinical characteristics associated with each of these infections; and the increasing global health burden of this disease.

Ticks, Human Babesiosis and Climate Change

The effects of current and future global warming on the distribution and activity of the primary ixodid vectors of human babesiosis (caused by Babesia divergens, B. venatorum and B. microti) are discussed. There is clear evidence that the distributions of both Ixodes ricinus, the vector in Europe, and I. scapularis in North America have been impacted by the changing climate, with increasing temperatures resulting in the northwards expansion of tick populations and the occurrence of I. ricinus at higher altitudes. Ixodes persulcatus, which replaces I. ricinus in Eurasia and temperate Asia, is presumed to be the babesiosis vector in China and Japan, but this tick species has not yet been confirmed as the vector of either human or animal babesiosis. There is no definite evidence, as yet, of global warming having an effect on the occurrence of human babesiosis, but models suggest that it is only a matter of time before cases occur further north than they do at present.

The specificity of Babesia-tick vector interactions: recent advances and pitfalls in molecular and field studies

Background

Babesia spp. are protozoan parasites of great medical and veterinary importance, especially in the northern Hemisphere. Ticks are known vectors of Babesia spp., although some Babesia-tick interactions have not been fully elucidated.

Methods

The present review was performed to investigate the specificity of Babesia-tick species interactions that have been identified using molecular techniques in studies conducted in the last 20 years under field conditions. We aimed to indicate the main vectors of important Babesia species based on published research papers (n = 129) and molecular data derived from the GenBank database.

Results

Repeated observations of certain Babesia species in specific species and genera of ticks in numerous independent studies, carried out in different areas and years, have been considered epidemiological evidence of established Babesia-tick interactions. The best studied species of ticks are Ixodes ricinus, Dermacentor reticulatus and Ixodes scapularis (103 reports, i.e. 80% of total reports). Eco-epidemiological studies have confirmed a specific relationship between Babesia microti and Ixodes ricinus, Ixodes persulcatus, and Ixodes scapularis and also between Babesia canis and D. reticulatus. Additionally, four Babesia species (and one genotype), which have different deer species as reservoir hosts, displayed specificity to the I. ricinus complex. Eco-epidemiological studies do not support interactions between a high number of Babesia spp. and I. ricinus or D. reticulatus. Interestingly, pioneering studies on other species and genera of ticks have revealed the existence of likely new Babesia species, which need more scientific attention. Finally, we discuss the detection of Babesia spp. in feeding ticks and critically evaluate the data on the role of the latter as vectors.

Conclusions

Epidemiological data have confirmed the specificity of certain Babesia-tick vector interactions. The massive amount of data that has been thus far collected for the most common tick species needs to be complemented by more intensive studies on Babesia infections in underrepresented tick species.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-021-05019-3.

Preventing Transfusion-Transmitted Babesiosis

Babesia are tick-borne intra-erythrocytic parasites and the causative agents of babesiosis. Babesia, which are readily transfusion transmissible, gained recognition as a major risk to the blood supply, particularly in the United States (US), where Babesia microti is endemic. Many of those infected with Babesia remain asymptomatic and parasitemia may persist for months or even years following infection, such that seemingly healthy blood donors are unaware of their infection. By contrast, transfusion recipients are at high risk of severe babesiosis, accounting for the high morbidity and mortality (~19%) observed in transfusion-transmitted babesiosis (TTB). An increase in cases of tick-borne babesiosis and TTB prompted over a decade-long investment in blood donor surveillance, research, and assay development to quantify and contend with TTB. This culminated in the adoption of regional blood donor testing in the US. We describe the evolution of the response to TTB in the US and offer some insight into the risk of TTB in other countries. Not only has this response advanced blood safety, it has accelerated the development of novel serological and molecular assays that may be applied broadly, affording insight into the global epidemiology and immunopathogenesis of human babesiosis.

Molecular evidence of zoonotic Babesia species, other than B. microti, in ixodid ticks collected from small mammals in the Republic of Korea

The occurrence of tick‐borne infectious diseases, including zoonotic babesiosis, has become a serious concern in recent years. In this study, we detected Babesia spp. using polymerase chain reaction (PCR) amplification of the 18S rRNA of the parasites isolated from ixodid ticks collected from small mammals in the Republic of Korea (ROK). Sequence analysis of the PCR amplicon revealed the presence of B. duncani, B. venatorum, B. capreoli/divergens, and, the most prevalent, B. microti in the ticks. The molecular phylogenetic analysis showed that the four species‐specific18S rRNA sequences clustered in four distinct clades. This is the first study to provide molecular evidence for the presence of zoonotic Babesia spp. other than B. microti in ticks in the ROK.

Evaluation of Winter Ticks (Dermacentor albipictus) Collected from North American Elk (Cervus canadensis) in an Area of Chronic Wasting Disease Endemicity for Evidence of PrPCWD Amplification Using Real-Time Quaking-Induced Conversion Assay

Chronic wasting disease (CWD) is a progressive and fatal spongiform encephalopathy of deer and elk species, caused by a misfolded variant of the normal prion protein. Horizontal transmission of the misfolded CWD prion between animals is thought to occur through shedding in saliva and other forms of excreta. The role of blood in CWD transmission is less clear, though infectivity has been demonstrated in various blood fractions. Blood-feeding insects, including ticks, are known vectors for a range of bacterial and viral infections in animals and humans, though to date, there has been no evidence for their involvement in prion disease transmission. In the present study, we evaluated winter ticks (Dermacentor albipictus) collected from 136 North American elk (Cervus canadensis) in an area where CWD is endemic for evidence of CWD prion amplification using the real-time quaking-induced conversion assay (RT-QuIC). Although 30 elk were found to be CWD positive (22%) postmortem, amplifiable prions were found in just a single tick collected from an elk in advanced stages of CWD infection, with some evidence for prions in ticks collected from elk in mid-stage infection. These findings suggest that further investigation of ticks as reservoirs for prion disease may be warranted.

IMPORTANCE This study reports the first finding of detectable levels of prions linked to chronic wasting disease in a tick collected from a clinically infected elk. Using the real-time quaking-induced conversion assay (RT-QuIC), “suspect” samples were also identified; these suspect ticks were more likely to have been collected from CWD-positive elk, though suspect amplification was also observed in ticks collected from CWD-negative elk. Observed levels were at the lower end of our detection limits, though our findings suggest that additional research evaluating ticks collected from animals in late-stage disease may be warranted to further evaluate the role of ticks as potential vectors of chronic wasting disease.

Sudden Mortality in Captive White-Tailed Deer With Atypical Infestation of Winter Tick

In October 2020, three captive male white-tailed deer, Odocoileus virginianus [Zimmermann] (artiodactyla: Cervidae), were found dead in central Pennsylvania and a fourth was euthanized due to extreme lethargy. The deer presented with high burdens of Dermacentor albipictus (Packard) (Ixoda: Ixodidae) (winter tick). There were no other clinical symptoms and deer were in otherwise good physical condition with no observed alopecia. Winter tick epizootics have been associated with mortalities of moose, Alces alces [Linnaeus] (artiodactyla: cervidae), and more recently elk, Cervus canadensis [Erxleben] (artiodactyla: cervidae), in Pennsylvania, but have not been reported in white-tailed deer. Mild winters are favorable to winter ticks and deer producers and managers should be aware of possible infestations as a result.

Ecology and Epidemiology of Tickborne Pathogens, Washington, USA, 2011-2016

Tickborne diseases are rare in Washington, USA, and the ecology of these pathogens is poorly understood. We integrated surveillance data from humans and ticks to better describe their epidemiology and ecology. During 2011-2016, a total of 202 tickborne disease cases were reported in Washington residents. Of these, 68 (34%) were autochthonous, including cases of Lyme disease, Rocky Mountain spotted fever, tickborne relapsing fever, and tularemia. During May 2011-December 2016, we collected 977 host-seeking ticks, including Ixodes pacificus, I. angustus, I. spinipalpis, I. auritulus, Dermacentor andersoni, and D. variabilis ticks. The prevalence of Borrelia burgdorferi sensu stricto in I. pacificus ticks was 4.0%; of B. burgdorferi sensu lato, 3.8%; of B. miyamotoi, 4.4%; and of Anaplasma phagocytophilum, 1.9%. We did not detect Rickettsia rickettsii in either Dermacentor species. Case-patient histories and detection of pathogens in field-collected ticks indicate that several tickborne pathogens are endemic to Washington.

Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA): 2020 Guideline on Diagnosis and Management of Babesiosis

The purpose of this guideline is to provide evidence-based guidance for the most effective strategies for the diagnosis and management of babesiosis. The diagnosis and treatment of co-infection with babesiosis and Lyme disease will be addressed in a separate Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR) guideline [1]. Recommendations for the diagnosis and treatment of human granulocytic anaplasmosis can be found in the recent rickettsial disease guideline developed by the Centers for Disease Control and Prevention [2]. The target audience for the babesiosis guideline includes primary care physicians and specialists caring for this condition, such as infectious diseases specialists, emergency physicians, intensivists, internists, pediatricians, hematologists, and transfusion medicine specialists.

Ticks and Tick-Borne Diseases of Colorado, Including New State Records for Argas radiatus (Ixodida: Argasidae) and Ixodes brunneus (Ixodida: Ixodidae)

We report 28 species of ticks (Acari: Ixodida) from Colorado (CO). We include the soft ticks (Argasidae) Argas (Argas) cooleyi Kohls and Hoogstraal, Argas (Persicargas) radiatus Railliet, Carios (Alectorobius) concanensis (Cooley and Kohls), Carios (Alectorobius) kelleyi (Cooley and Kohls), Ornithodoros (Pavlovskyella) hermsi Wheeler et al., Ornithodoros (Pavlovskyella) parkeri Cooley, Ornithodoros (Pavlovskyella) turicata (Dugès), Otobius (Otobius) lagophilus Cooley and Kohls, and Otobius (Otobius) megnini (Dugès). We include the metastriate hard ticks (Ixodidae) Dermacentor (Americentor) albipictus (Packard), Dermacentor (Dermacentor) andersoni Stiles, Dermacentor (Dermacentor) parumapertus Neumann, Dermacentor (Dermacentor) variabilis (Say), Haemaphysalis (Aboimisalis) chordeilis (Packard), Haemaphysalis (Gonixodes) leporispalustris (Packard), and Rhipicephalus (Rhipicephalus) sanguineus Latreille. Prostriate hard ticks include Ixodes (Ixodiopsis) angustus Neumann, Ixodes (Phoeloioxdes) baergi Cooley and Kohls, Ixodes (Trichotoixodes) brunneus Koch, Ixodes (Scaphixodes) howelli Cooley and Kohls, Ixodes (Phoeloioxdes) kingi Bishopp, Ixodes (Phoeloioxdes) marmotae Cooley and Kohls, Ixodes (Ixodiopsis) ochotonae Gregson, Ixodes (Phoeloioxdes) sculptus Neumann, Ixodes (Ixodiopsis) soricis Gregson, Ixodes (Ixodes) spinipalpis Hadwen and Nuttall, Ixodes (Phoeloioxdes) texanus Banks, and Ixodes (Ixodiopsis) woodi Bishopp. Argas radiatus and Ixodes brunneus represent new state records. Review of collection reports revealed that inclusion of Ixodes (Multidentatus) auritulus (Neumann), Ixodes (Phoeloioxdes) cookei Packard, Ixodes (Phoeloioxdes) marxi Banks, and Ixodes (Ixodes) pacificus Cooley and Kohls is dubious or unconfirmed and, conversely, that C. concanensis and H. chordeilis have distributions that include CO. We list an additional five species occasionally detected and 13 exotic species intercepted in CO. Tick-host associations, geographical distributions, and medical/veterinary importance are included.

Botanical Medicines Cryptolepis sanguinolenta, Artemisia annua, Scutellaria baicalensis, Polygonum cuspidatum, and Alchornea cordifolia Demonstrate Inhibitory Activity Against Babesia duncani

Human babesiosis is a CDC reportable disease in the United States and is recognized as an emerging health risk in multiple parts of the world. The current treatment for human babesiosis is suboptimal due to treatment failures and unwanted side effects. Although Babesia duncani was first described almost 30 years ago, further research is needed to elucidate its pathogenesis and clarify optimal treatment regimens. Here, we screened a panel of herbal medicines and identified Cryptolepis sanguinolenta, Artemisia annua, Scutellaria baicalensis, Alchornea cordifolia, and Polygonum cuspidatum to have good in vitro inhibitory activity against B. duncani in the hamster erythrocyte model. Furthermore, we found their potential bioactive compounds, cryptolepine, artemisinin, artesunate, artemether, and baicalein, to have good activity against B. duncani, with IC₅₀ values of 3.4 μM, 14 μM, 7.4 μM, 7.8 μM, and 12 μM, respectively, which are comparable or lower than that of the currently used drugs quinine (10 μM) and clindamycin (37 μM). B. duncani treated with cryptolepine and quinine at their respective 1×, 2×, 4× and 8× IC₅₀ values, and by artemether at 8× IC₅₀ for three days could not regrow in subculture. Additionally, Cryptolepis sanguinolenta 90% ethanol extract also exhibited no regrowth after 6 days of subculture at doses of 2×, 4×, and 8× IC₅₀ values. Our results indicate that some botanical medicines and their active constituents have potent activity against B. duncani in vitro and may be further explored for more effective treatment of babesiosis.

Emerging Human Babesiosis with "Ground Zero" in North America

The first case of human babesiosis was reported in the literature in 1957. The clinical disease has sporadically occurred as rare case reports in North America and Europe in the subsequent decades. Since the new millennium, especially in the last decade, many more cases have apparently appeared not only in these regions but also in Asia, South America, and Africa. More than 20,000 cases of human babesiosis have been reported in North America alone. In several cross-sectional surveys, exposure to Babesia spp. has been demonstrated within urban and rural human populations with clinical babesiosis reported in both immunocompromised and immunocompetent humans. This review serves to highlight the widespread distribution of these tick-borne pathogens in humans, their tick vectors in readily accessible environments such as parks and recreational areas, and their phylogenetic relationships.

Global Distribution of Babesia Species in Questing Ticks: A Systematic Review and Meta-Analysis Based on Published Literature

Babesiosis caused by the Babesia species is a parasitic tick-borne disease. It threatens many mammalian species and is transmitted through infected ixodid ticks. To date, the global occurrence and distribution are poorly understood in questing ticks. Therefore, we performed a meta-analysis to estimate the distribution of the pathogen. A deep search for four electronic databases of the published literature investigating the prevalence of Babesia spp. in questing ticks was undertaken and obtained data analyzed. Our results indicate that in 104 eligible studies dating from 1985 to 2020, altogether 137,364 ticks were screened with 3069 positives with an estimated global pooled prevalence estimates (PPE) of 2.10%. In total, 19 different Babesia species of both human and veterinary importance were detected in 23 tick species, with Babesia microti and Ixodesricinus being the most widely reported Babesia and tick species, respectively. Regardless of species, adult ticks with 2.60% had the highest infection rates, while larvae had the least with 0.60%. Similarly, female ticks with 4.90% were infected compared to males with 3.80%. Nested-polymerase chain reaction (PCR) 2.80% had the highest prevalence among the molecular techniques employed. In conclusion, results obtained indicate that Babesia species are present in diverse questing tick species at a low prevalence, of which some are competent vectors.

Challenges in Tick-Borne Pathogen Detection: The Case for Babesia spp. Identification in the Tick Vector

The causative agents of Babesiosis are intraerythrocytic protozoa of the genus Babesia. Babesia parasites are present around the world, affecting several mammals including humans, pets and livestock, hence its medical and veterinary relevance. Babesia spp. detection in its invertebrate host is a main point in understanding the biology of the parasite to acquire more knowledge on the host–Babesia–vector interactions, as increasing knowledge of the Babesia lifecycle and babesiosis epidemiology can help prevent babesiosis outbreaks in susceptible mammals. The aim of the present review is to highlight the newest findings in this field, based on a bibliographic compilation of research studies recently carried out for the detection of the main Babesia species found in tick vectors affecting mammalian hosts, including the different tick stages such as adult ticks, larvae, nymphs and eggs, as well as the detection method implemented: microscopic tools for parasite identification and molecular tools for parasite DNA detection by conventional PCR, nested-PCR, PCR-RFLP, PCR-RLB hybridization, real time-PCR, LAMP and RAP assays. Although molecular identification of Babesia parasites has been achieved in several tick species and tissue samples, it is still necessary to carry out transmission experiments through biological models to confirm the vectorial capacity of various tick species.

Prevalence of Winter Ticks (Dermacentor albipictus) in Hunter-Harvested Wild Elk (Cervus canadensis) from Pennsylvania, USA (2017-2018)

Winter ticks (Dermacentor albipictus) are an aggressive one-host tick that infest a wide-diversity of ungulates. Infestations can result in anemia, alopecia, emaciation, and death. Most notably, the winter tick has caused negative impacts to moose (Alces alces) populations in the northeast United States and Canada. Winter ticks have been identified on other cervid species, including deer (Odocoileus virginianus) and elk (Cervus canadensis), which generally results in low tick burdens and mild or no disease. Recently, however, a wild yearling bull elk in Pennsylvania was found dead as a result of severe winter tick infestation. To obtain baseline data on winter ticks in wild elk in Pennsylvania, we collected 1453 ticks from 190 hunter-harvested wild elk between 2017-2018. Of the 204 harvested elk, 94.3% (190/204) had ticks collected for this study and none of the sampled elk had evidence of winter-tick associated disease. The average tick burden was 7.7 ticks/elk and average winter tick load on all elk was 0.5. Results of this study indicate that winter ticks do infest wild elk in Pennsylvania. However, during the fall months, the tick burden is low and rarely associated with lesions. These data herein serve as a baseline to monitor winter tick populations over time.

First records of Dermacentor albipictus larvae collected by flagging in Yukon, Canada

Background

The winter tick (Dermacentor albipictus) has garnered significant attention throughout North America for its impact on wildlife health, and especially for moose (Alces alces), where high tick burdens may result in host hair loss, anemia, and can prove fatal. The environmental transmission of D. albipictus larvae to a host is a critical event that has direct impact on infestation success, yet in-field observations of this life stage are lacking. In Yukon, Canada, D. albipictus had previously been found on hosts, but its larval life stage had not been detected in the field, despite previous sampling attempts.

Methods

We sampled for D. albipictus larvae using traditional flagging methods in Ibex Valley and Braeburn, Yukon. Sites were sampled repeatedly for D. albipictus larvae by flagging from late August to end of October in 2018 and late August to end of November 2019.

Results

Larvae of D. albipictus were collected throughout Ibex Valley, at approximate densities ranging from 0.04 to 4236 larvae/100 m². Larvae were present primarily on grassy vegetation on south-facing slopes in the Ibex Valley region and in Braeburn. Highest average larval numbers suggest peak questing activity was towards the end of September and beginning of October, as elsewhere in North America.

Conclusions

To the best of our knowledge, we report the first successful collection of the off-host, larval life stage of D. albipictus by flagging, north of 60° latitude in Yukon, Canada. These new observations provide critical information on the spatial distribution of the host-seeking life stage of D. albipictus and confirm that this species is completing its whole life cycle in southern Yukon. Understanding the environmental conditions where larvae spend their vulnerable period off-host in this northern location can inform both management strategies and projections of future range expansion which may occur with a changing climate.

Recent reports of winter tick, Dermacentor albipictus, from dogs and cats in North America

Dermacentor albipictus, a common one-host tick of large animals in North America, is most often reported from moose (Alces alces) and is rarely implicated as a parasite of cats and dogs. From 2018 to 2020, 4 dogs and 4 cats from United States and 3 dogs from Canada were infested with D. albipictus. The specimens were collected and submitted to university diagnostic specialists by veterinary clinics in Indiana, Kentucky, Minnesota, Colorado, Wyoming, Utah, Alberta, and British Columbia between the months of October to February (United States) and April to June (Canada). Six adults and five nymphal D. albipictus were collected in the United States while three adults were collected from pets in Canada, and most often a single D. albipictus was present. Identification of specimens collected in the United States were confirmed by amplification and sequencing of 16S rRNA and ITS-2 gene fragments. Rickettsia spp. were not detected in any D. albipictus collected in the United States by 17 kDa-based PCR. As tick populations continue to increase and expand in North America, correct identification of ticks collected from pets is critical to accurately track the progression and spread of ticks and tick-borne diseases.

Combined Immunofluorescence (IFA) and Fluorescence In Situ Hybridization (FISH) Assays for Diagnosing Babesiosis in Patients from the USA, Europe and Australia

Apicomplexan parasites of the genus Babesia cause babesiosis in humans and animals worldwide. Human babesiosis is a predominantly zoonotic disease transmitted by hard ticks that is of increasing health concern in the USA and many other countries. Microscopic examination of stained blood smears, detection of serum antibodies by immunoassays and identification of parasite nucleic acid in blood by qPCR and fluorescence in situ hybridization (FISH) are some methods available for diagnosing babesiosis. This study investigated the use of a Babesia genus-specific FISH test for detecting Babesia parasites in blood smears and immunofluorescence assay (IFA) for detecting serum antibodies to Babesia duncani and Babesia microti, two common species that cause human babesiosis in the USA. The findings with clinical samples originating from USA, Australia, Europe and elsewhere demonstrate that the parallel use of Babesia genus-specific FISH and IFA tests for B. duncani and B. microti provides more useful diagnostic information in babesiosis and that B. duncani infections are more widespread globally than presently recognized.

A Fluorescence in Situ Hybridization (FISH) Test for Diagnosing Babesiosis

Apicomplexan parasites of the genus Babesia cause babesiosis in humans and animals. The microscopic examination of stained blood smears, detection of serum antibodies by immunoassays, and PCR-based identification of parasite nucleic acid in blood are common laboratory methods for diagnosing babesiosis. The present study evaluated a commercially available Babesia genus-specific fluorescence in situ hybridization (FISH) test for detecting Babesia parasites in blood smears. The FISH test detected Babesia duncani and Babesia microti, two common species that cause human infections in the USA, and other Babesia species of human and veterinary importance in less than two hours. The Babesia genus-specific FISH test supplements other existing laboratory methods for diagnosing babesiosis and may be particularly useful in resource-limited laboratories.

Emerging tick-borne pathogens of public health importance: a mini-review

Ticks are the most important vectors of human pathogens, leading to increased public health burdens worldwide. Tick-borne pathogens include viruses (e.g. tick-borne encephalitis and Powassan); bacteria, such as the causative agents of Lyme disease, spotted fever rickettsiosis and human anaplasmosis; and malaria-like protozoan parasites causing babesiosis. Tick-borne diseases are emerging due to the geographical expansion of their tick vectors, especially in the northern hemisphere. Two examples of this phenomenon are Ixodes scapularis and Amblyomma americanum, which have expanded their ranges in the USA in recent decades and are responsible for the continuous emergence of Lyme disease and human ehrlichiosis, respectively. This phenomenon is also occurring worldwide and is reflected by the increasing number of tick-borne encephalitis and haemorrhagic fever cases in Europe and Asia. In this review, we provide a concise synopsis of the most medically important tick-borne pathogen worldwide, with a particular emphasis on emerging public health threats.

Management strategies for human babesiosis

INTRODUCTION

Human babesiosis is reported throughout the world and is endemic in the northeastern and northern Midwestern United States and northeastern China. Transmission is primarily through hard bodied ticks. Most cases of severe disease occur in immunocompromised individuals and may result in prolonged relapsing disease or death.

AREAS COVERED

We provide a summary of evidence supporting current treatment recommendations for immunocompetent and immunocompromised individuals experiencing babesiosis.

EXPERT OPINION

Most cases of human babesiosis are successfully treated with atovaquone and azithromycin or clindamycin and quinine. Severe disease may require prolonged treatment.

Emerging Tick-Borne Diseases

Increases in tick-borne disease prevalence and transmission are important public health issues. Efforts to control these emerging diseases are frustrated by the struggle to control tick populations and to detect and treat infections caused by the pathogens that they transmit. This review covers tick-borne infectious diseases of nonrickettsial bacterial, parasitic, and viral origins. While tick surveillance and tracking inform our understanding of the importance of the spread and ecology of ticks and help identify areas of risk for disease transmission, the vectors are not the focus of this document. Here, we emphasize the most significant pathogens that infect humans as well as the epidemiology, clinical features, diagnosis, and treatment of diseases that they cause. Although detection via molecular or immunological methods has improved, tick-borne diseases continue to remain underdiagnosed, making the scope of the problem difficult to assess. Our current understanding of the incidence of tick-borne diseases is discussed in this review. An awareness of the diseases that can be transmitted by ticks in specific locations is key to detection and selection of appropriate treatment. As tick-transmitted pathogens are discovered and emerge in new geographic regions, our ability to detect, describe, and understand the growing public health threat must also grow to meet the challenge.

Zoonotic Babesia: A scoping review of the global evidence

BACKGROUND

Babesiosis is a parasitic vector-borne disease of increasing public health importance. Since the first human case was reported in 1957, zoonotic species have been reported on nearly every continent. Zoonotic Babesia is vectored by Ixodes ticks and is commonly transmitted in North America by Ixodes scapularis, the tick species responsible for transmitting the pathogens that also cause Lyme disease, Powassan virus, and anaplasmosis in humans. Predicted climate change is expected to impact the spread of vectors, which is likely to affect the distribution of vector-borne diseases including human babesiosis.

METHODS

A scoping review has been executed to characterize the global evidence on zoonotic babesiosis. Articles were compiled through a comprehensive search of relevant bibliographic databases and targeted government websites. Two reviewers screened titles and abstracts for relevance and characterized full-text articles using a relevance screening and data characterization tool developed a priori.

RESULTS

This review included 1394 articles relevant to human babesiosis and/or zoonotic Babesia species. The main zoonotic species were B. microti, B. divergens, B. duncani and B. venatorum. Articles described a variety of study designs used to study babesiosis in humans and/or zoonotic Babesia species in vectors, animal hosts, and in vitro cell cultures. Topics of study included: pathogenesis (680 articles), epidemiology (480), parasite characterization (243), diagnostic test accuracy (98), mitigation (94), treatment (65), transmission (54), surveillance (29), economic analysis (7), and societal knowledge (1). No articles reported predictive models investigating the impact of climate change on Babesia species.

CONCLUSION

Knowledge gaps in the current evidence include research on the economic burden associated with babesiosis, societal knowledge studies, surveillance of Babesia species in vectors and animal hosts, and predictive models on the impact of climate change. The scoping review results describe the current knowledge and knowledge gaps on zoonotic Babesia which can be used to inform future policy and decision making.

Comparative Microbiome Profiles of Sympatric Tick Species from the Far-Western United States

Insight into the composition and function of the tick microbiome has expanded considerably in recent years. Thus far, tick microbiome studies have focused on species and life stages that are responsible for transmitting disease. In this study we conducted extensive field sampling of six tick species in the far-western United States to comparatively examine the microbial composition of sympatric tick species: Ixodes pacificus, Ixodes angustus, Dermacentor variabilis, Dermacentor occidentalis, Dermacentor albipictus, and Haemaphysalis leporispalustris. These species represent both common vectors of disease and species that rarely encounter humans, exhibiting a range of host preferences and natural history. We found significant differences in microbial species diversity and composition by tick species and life stage. The microbiome of most species examined were dominated by a few primary endosymbionts. Across all species, the relative abundance of these endosymbionts increased with life stage while species richness and diversity decreased with development. Only one species, I. angustus, did not show the presence of a single dominant microbial species indicating the unique physiology of this species or its interaction with the surrounding environment. Tick species that specialize in a small number of host species or habitat ranges exhibited lower microbiome diversity, suggesting that exposure to environmental conditions or host blood meal diversity can affect the tick microbiome which in turn may affect pathogen transmission. These findings reveal important associations between ticks and their microbial community and improve our understanding of the function of non-pathogenic microbiomes in tick physiology and pathogen transmission.

In vitro cultivation of Babesia duncani (Apicomplexa: Babesiidae), a zoonotic hemoprotozoan, using infected blood from Syrian hamsters (Mesocricetus auratus)

Human babesiosis, a tick-borne disease similar to malaria, is most often caused by the hemoprotozoans Babesia divergens in Europe, and Babesia microti and Babesia duncani in North America. Babesia microti is the best documented and causes more cases of human babesiosis annually than all other agents combined. Although the agents that cause human babesiosis are considered high-risk pathogens in transfusion medicine, federally licensed diagnostics are lacking for B. duncani in both the USA and Canada. Thus, there has been a need to develop and validate diagnostics specifically for this pathogen. In this study, B. duncani (WA1 isolate) was cultivated in vitro from Syrian hamster (Mesocricetus auratus) infected blood. We hypothesized HL-1 media with supplements would result in B. duncani propagating at higher levels in culture than supplemented M199 similar to the medium the parasite was originally cultivated with in 1994. We were unable to recreate Thomford's cultivation results with the M199 medium but supplemented HL-1 medium was able to successfully establish continuous culture. We further hypothesized that RBC from species other than hamsters would support B. duncani in vitro. However, rat, mouse, horse, and cow RBC did not support continuous culture of the parasite. Culture stocks of B. duncani were deposited at BEI Resources and are now commercially available to the scientific community to further research. The cultured parasite developed in this study was instrumental in the adaptation of B. duncani continuous culture to human RBC.

Prevalence, distribution, and diversity of cryptic piroplasm infections in raccoons from selected areas of the United States and Canada

The order Piroplasmida contains a diverse group of intracellular parasites, many of which can cause significant disease in humans, domestic animals, and wildlife. Two piroplasm species have been reported from raccoons (Procyon lotor), Babesia lotori (Babesia sensu stricto clade) and a species related to Babesia microti (called B. microti-like sp.). The goal of this study was to investigate prevalence, distribution, and diversity of Babesia in raccoons. We tested raccoons from selected regions in the United States and Canada for the presence of Babesia sensu stricto and Babesia microti-like sp. piroplasms. Infections of Babesia microti-like sp. were found in nearly all locations sampled, often with high prevalence, while Babesia sensu stricto infections had higher prevalence in the Southeastern United States (20–45% prevalence). Co-infections with both Babesia sp. were common. Sequencing of the partial 18S rRNA and cytochrome oxidase subunit 1 (cox1) genes led to the discovery of two new Babesia species, both found in several locations in the eastern and western United States. One novel Babesia sensu stricto sp. was most similar to Babesia gibsoni while the other Babesia species was present in the ‘western piroplasm’ group and was related to Babesia conradae. Phylogenetic analysis of the cox1 sequences indicated possible eastern and western genetic variants for the three Babesia sensu stricto species. Additional analyses are needed to characterize these novel species; however, this study indicates there are now at least four species of piroplasms infecting raccoons in the United States and Canada (Babesia microti-like sp., Babesia lotori, a novel Babesia sensu stricto sp., a novel western Babesia sp.) and a possible fifth species (Babesia sensu stricto) in raccoons in Japan.

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Raccoons in all locations tested were infected with piroplasms.

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Babesia microti-like sp. was commonly found in raccoons throughout North America.

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Babesia sensu stricto spp. were less common throughout North America.

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Four, possibly five, distinct species of piroplasms in raccoons.

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Possible spatial genetic variation within the two raccoon piroplasm species.

Insights into the evolution and drug susceptibility of Babesia duncani from the sequence of its mitochondrial and apicoplast genomes

Babesia microti and Babesia duncani are the main causative agents of human babesiosis in the United States. While significant knowledge about B. microti has been gained over the past few years, nothing is known about B. duncani biology, pathogenesis, mode of transmission or sensitivity to currently recommended therapies. Studies in immunocompetent wild type mice and hamsters have shown that unlike B. microti, infection with B. duncani results in severe pathology and ultimately death. The parasite factors involved in B. duncani virulence remain unknown. Here we report the first known completed sequence and annotation of the apicoplast and mitochondrial genomes of B. duncani. We found that the apicoplast genome of this parasite consists of a 34 kb monocistronic circular molecule encoding functions that are important for apicoplast gene transcription as well as translation and maturation of the organelle's proteins. The mitochondrial genome of B. duncani consists of a 5.9 kb monocistronic linear molecule with two inverted repeats of 48 bp at both ends. Using the conserved cytochrome b (Cytb) and cytochrome c oxidase subunit I (coxI) proteins encoded by the mitochondrial genome, phylogenetic analysis revealed that B. duncani defines a new lineage among apicomplexan parasites distinct from B. microti, Babesia bovis, Theileria spp. and Plasmodium spp. Annotation of the apicoplast and mitochondrial genomes of B. duncani identified targets for development of effective therapies. Our studies set the stage for evaluation of the efficacy of these drugs alone or in combination against B. duncani in culture as well as in animal models.

Human babesiosis

Babesiosis is a worldwide emerging tick-borne disease that is increasing in frequency and geographic range. It imposes a significant health burden, especially on those who are immunocompromised and those who acquire the infection through blood transfusion. Death from babesiosis occurs in up to 20 percent of these groups. Diagnosis is confirmed with identification of typical intraerythrocytic parasites on a thin blood smear or Babesia DNA using PCR. Treatment consists of atovaquone and azithromycin or clindamycin and quinine, and exchange transfusion in severe cases. Personal and communal protective measures can limit the burden of infection but it is important to recognize that none of these measures are likely to prevent the continued expansion of Babesia into non-endemic areas.

Establishment of a continuous in vitro culture of Babesia duncani in human erythrocytes reveals unusually high tolerance to recommended therapies

Human babesiosis is an emerging tick-borne disease caused by apicomplexan parasites of the genus Babesia Clinical cases caused by Babesia duncani have been associated with high parasite burden, severe pathology, and death. In both mice and hamsters, the parasite causes uncontrolled fulminant infections, which ultimately lead to death. Resolving these infections requires knowledge of B. duncani biology, virulence, and susceptibility to anti-infectives, but little is known and further research is hindered by a lack of relevant model systems. Here, we report the first continuous in vitro culture of B. duncani in human red blood cells. We show that during its asexual cycle within human erythrocytes, B. duncani develops and divides to form four daughter parasites with parasitemia doubling every ∼22 h. Using this in vitro culture assay, we found that B. duncani has low susceptibility to the four drugs recommended for treatment of human babesiosis, atovaquone, azithromycin, clindamycin, and quinine, with IC₅₀ values ranging between 500 nm and 20 μm These data suggest that current practices are of limited effect in treating the disease. We anticipate this new disease model will set the stage for a better understanding of the biology of this parasite and will help guide better therapeutic strategies to treat B. duncani-associated babesiosis.